Can avoiding certain foods extend your life? This episode explores a recent BMJ paper on diet and health, focusing on ultra-processed foods and their hidden calories. It highlights the links between these foods and obesity, cardiovascular disease, diabetes, and cancer.
Insights from major studies, like the Nurses' Health Study and the Health Professional Follow-Up Study, show how socioeconomic factors and healthcare professionals' behaviors influence outcomes. The discussion also addresses the importance of accurate food intake data and the challenges of long-term studies.
This engaging discussion aims to provide valuable perspectives on navigating evidence-based integrative medicine and making informed dietary choices for better health.
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Can avoiding certain foods extend your life? This episode explores a recent BMJ paper on diet and health, focusing on ultra-processed foods and their hidden calories. It highlights the links between these foods and obesity, cardiovascular disease, diabetes, and cancer.
Insights from major studies, like the Nurses' Health Study and the Health Professional Follow-Up Study, show how socioeconomic factors and healthcare professionals' behaviors influence outcomes. The discussion also addresses the importance of accurate food intake data and the challenges of long-term studies.
This engaging discussion aims to provide valuable perspectives on navigating evidence-based integrative medicine and making informed dietary choices for better health.
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Welcome to the Dr Journal Club podcast, the show that goes under the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Continue your learning after the show at www. d rjournalclub. com. Please bear in mind that this is for educational and entertainment purposes o nly. Talk to your doctor before making any medical decisions, changes, etc. Everything we're talking about that's to teach you guys stuff and have fun. We are not your doctors. Also, we would love to answer your specific questions on drjournalclubcom. You can post questions and comments for specific videos, but go ahead and email us directly at josh at drjournalclub. com. That's josh at drjournalclub. com. Send us your listener questions and we will discuss it on our pod.
Dr. Joshua Goldenberg:Well, as they say, the second you're born, you start dying.
Dr. Joshua Goldenberg:That's right. So this is just a way to kind of speed it up a little bit there. Yeah, it's like come on, come on, we got clock is ticking here. It's like come on, come on, we got clock is ticking here, let's get a little bit faster. What are some delicious things that I can get in my belly to? So, speaking of which, yesterday we were talking about how you have to create an environment to minimize like triggers for like eating garbage, in this case, highly processed foods.
Dr. Joshua Goldenberg:No, what's that?
Introducer:No, not garbage, not garbage, not garbage, just calorically, calorically dense food okay, and um, I noted, and I think you, you had a similar idea, which was that essentially, yeah, you just have to be in one one environment. You have to, like, control your environment, type of thing. Anyway, um, I went up to get a cup of coffee and I immediately grabbed like a handful of trail mix, ultra-processed trail mix and it's just like, as I was eating it, I was like, oh, this is what we were talking about. I should have kept.
Dr. Joshua Goldenberg:But is it ultra-processed? Is it like the planters with M&Ms and whatnot?
Introducer:Oh it's garbage. Oh it's garbage. It just got back from it the kirkland?
Dr. Joshua Goldenberg:is it the kirkland?
Introducer:like yeah, nice oh it's yeah, it's costco garb, like it's like everything and it's like mass. I told theo I was like this is a hell, like this is garbage. I didn't say garbage. This is junk food masquerading as health food. It's like trail mix and it's just straight up, highly processed, like reese Pieces, essentially.
Dr. Joshua Goldenberg:When you see the serving sizes on that and like you actually weigh it out, it's like why even freaking bother?
Introducer:Two tablespoons. I did. I looked it up because I felt guilty and I had to input it in my log and it's not quite two tablespoons. I think it's three tablespoons, which is essentially like three of these little Reese's Pieces cups, which is, of course you have more of those and that's basically your breakfast for the day.
Dr. Joshua Goldenberg:What I've really enjoyed is now a lot of the ice cream companies will do per serving and then per pint, uh-huh, oh yeah. Yeah. For the nutritional labels, because we all know the pint of ice cream is the actual serving size. Like no one's like when the pint says it serves four people, you're like yeah, no, no, yeah, it's like.
Introducer:It's like having two tablespoons worth of ice cream. Yeah, no, even like bags of chips. Now, it's like you know serving size and like, oh, if you actually ate the bag of chips it would be, you know, xyz if you ate the bag of chips and you actually realize it, you're like all right, I'm gonna go cry in a hole now yeah, yeah, I was very tense.
Introducer:I just I had finished a run and I was starving and I was like at a gas station. I was like, oh my gosh, I'm gonna get these cheetos highly processed, ultra processed terrible, it's gonna kill you which we're gonna talk about in a second. Um, but I was like, okay, just kind of curious, like how many calories are we dealing with here? And it was like, oh, like okay, 500 calories, like per serving. And there was like, basically, when you do the math, there's essentially like 1000 calories in this tiny little bag. And I'm just like, oh, dear God, you literally just adjusted the serving size so that the calorie count would be equivalent for a snack, which is just this absurd.
Introducer:Like what is? How do you determine a serving size? It must literally be well, a snack is 150 calories. Therefore, when you have two fingernails width worth of this snack, we're going to call that a serving size. Anyway, you know what this is speaking to. Yeah, this is speaking to our ability to do tangents, which we just got called out on last week. We got to hold our stuff together here, man. We got to stay on task.
Dr. Joshua Goldenberg:Hey, if you're going to call out our tangents and you have a problem, you can just go listen to a different podcast or you can create your own. How about that?
Introducer:Yeah, I was like. So we're speaking, of course, of my father, who is our greatest fan and also our fiercest critic.
Dr. Joshua Goldenberg:Also I'd like to know how you're the one who's always going on tangents like actually I know I did have something to say that's relevant to like our podcast today, but now all of your tangents have actually made me forget it.
Dr. Joshua Goldenberg:Yeah, well I've just you know oh, now I remember what it was. Now I remember if you actually think about it, right, right, if you think about it we used to just have three, three meals a day, or like two meals a day, breakfast and dinner right, like breakfast. It would be huge. You'd go work the fields, you come back dinner and then you're exhausted, you go to bed okay, for the sake of argument, I will agree and not ask for citations.
Introducer:Don't know that that's completely true, but let's just roll with it for now.
Dr. Joshua Goldenberg:And then, you know, then you also have like breakfast, lunch and dinner. But, like, as we became more modern, we then had this whole like snacking industry and we've kind of come up with our like in our minds that, oh, I need a snack, like to bridge me over. And then, or you see the snack, you know, we have this idea like, oh, it's, it's just a snack, like it's just a little little tiny thing, yeah, I deserve it, but they're like these gigantic calorie bombs. So a snack went from hey, just like, go munch on an apple or a couple carrot sticks, to hey, let's go have you know, two Reese's Pieces, king-size cups, which are, you know, ends up being like 400 thousand calorie in a bag nuts yeah, and then that's, and then that's.
Dr. Joshua Goldenberg:That's how it becomes a problem. And then so, like, our entire like expectation is like what a what a snack is changes from you know, we, we have completely lost the idea as to like how much a serving size of a snack is. So like a handful of nuts, even if they're unprocessed.
Introducer:Yeah, I know, ever count out the cashews in a handful. It's like seven or eight and you're over.
Dr. Joshua Goldenberg:You know, the actual handful is like why even bother? It's like four nuts is like three, is like 300 calories, like I'm not even kidding, yeah, it's, it's, it's terrible. That's why everyone was like, oh, I can't lose weight, all I have is a handful of nuts. I'm like, okay, stop eating nuts. And then next thing you know two weeks later that yeah, it's like chipmunk fistfuls. Yeah, because that's what it is. We eat them like chipmunks. You have like a whole handful of nuts.
Introducer:It's not to demonize nuts, but but it's like I got a handful in each cheek and in each hand, yeah.
Dr. Joshua Goldenberg:And then you know you tell someone, hey, all right, well, stop eating nuts. And then like two weeks later they're down 10 pounds.
Introducer:It's like okay yeah well, 20 000 calories a day worth of uh healthy nuts because nuts are so calorically dense.
Dr. Joshua Goldenberg:yes, they're good're good for you All, right now we got to go.
Introducer:This is six and a half minutes. We're talking about nuts and chipmunks. I blame you and I blame you. I may have started it, but you are continuing it, sir All right, so end it.
Introducer:All right, fine, I'll think about it. All right, so wait, no, here's, we need the transition. Here's the transition, as we speak about ultra-processed foods. Now we are going to go into this very interesting BMJ article about how ultra-processed food consumption will kill you Slowly. Well, maybe not slowly. Well, we'll talk about all that. Okay, do you want to start us off with any background or do you want me to jump into all that jazz?
Dr. Joshua Goldenberg:Yeah, let's actually talk about it for a little bit. So I think it's really important first to like get the ideas like what is the definition of ultra processed foods and basically their definition that they use in this paper? Is ready to eat or heat industrial formulations made mostly or entirely from substances derived from foods, including flavors, colors, texturizers and other additives, with little, if any, intact whole food.
Introducer:After you read that, did you just cringe inside you're like, oh my gosh, that's what I've been eating not really.
Dr. Joshua Goldenberg:I'll be honest, I don't really like eat a lot of processed food. So, like I don't know, yeah, I just don't really eat it. So I didn't feel bad about it at all.
Introducer:Well, but describing it that way, which is such a fair way to describe it, it's like wow, this really just is this industrialized product that's peripherally related to food.
Dr. Joshua Goldenberg:That's also kind of dumb because, if you think about it, the milk is processed food, because that's industrialized.
Introducer:Well, I don't know that that would meet these definitions, made entirely from.
Dr. Joshua Goldenberg:Yeah, but yes, it doesn't meet that definition, but from the idea of industrialized food is what I'm saying.
Introducer:Yeah, so this is different, and so I think that's their point is that there's this idea that there is this Okay, there's processed food, maybe there's highly processed food, but we're talking about what they call ultra processed food, which they have a very specific, and I think we all kind of know what we mean. It's the Doritos.
Dr. Joshua Goldenberg:Basically it's a yeah, it's the fancy name for junk food low nutritional quality and high energy density. Um, and in middle income countries, ultra processed foods account for 57 percent of daily energy intake among adults and 67 among youths I just about fell off my chair when I read that.
Introducer:I couldn't believe it.
Dr. Joshua Goldenberg:That's nuts, I mean I could believe it if you.
Introducer:I mean just like take a look outside I know, but like more than 50%, two thirds of all calories, dude, nobody cooks, nobody cooks. I mean, this is, this is I mean I was, I was surprised.
Dr. Joshua Goldenberg:Nobody cooks Like look, go, go onto a college campus Like we're like downing ramen noodles.
Introducer:Well, it does skew lower, that's true, like the younger, younger people are eating more and more of this. But anyway, yeah, I didn't know. I mean, I knew it was a problem, but to two-thirds of your calories coming from ultra-processed foods, that seemed a little scary to me.
Dr. Joshua Goldenberg:I mean it's sad, but that's the reality. I wasn't like, oh my God, I was like, yeah, that's probably correct, sad. But I mean, you know, it's kind of the state of things, but anyway, with it's kind of the, the state of of things, but anyway, with the definition too, they usually disproportionately contribute added sugars, sodium, saturated fats and trans fats and refined carbs to the diet, together with low fiber. So I mean, basically, this is like you're. You know, just walk down an aisle in the, in the supermarket, and it's all those bagged like frozen meals, it's, it's the healthy, or the quote-unquote healthy organic food that's still in a bag and you just pop it in a microwave and in two minutes, there you go, chata masala, and now you think you're eating healthy. But really, if you turn on the back, it's, it's the same garbage. Like, at the end of the day, like, stop trying to deem, like healthify it or whatever, just because it says it's organic or has a label. If it's taking you two minutes to make and there's a 400 ingredients, it's, it's probably ultra processed.
Dr. Joshua Goldenberg:And then, uh, basically, um, there's a a lot of growing evidence from various cohort studies that are showing that these, these diets that are high in ultra processed foods. Um, or just eating processed foods are contributing to a lot of our chronic comorbidities, so obesity, cardiovascular disease, diabetes, cancer etc. Etc. And there was a recent systematic review that showed high ultra-processed food consumption was associated with an increased risk of all-cause mortality, cardiovascular disease, metabolic syndrome, depression and postmenopausal breast cancer. But the issue with some of these studies is that they lack long-term follow-up in their definition for that, meaning they didn't really follow up for longer than 20 years, and so really what this study was trying to do was look at durations of at least 30 years and also using data that was a little bit stronger. A lot of the prior cohorts used weaker data, so they kind of just wanted to expand upon this, both from a temporal standpoint and to see if there's a stronger association with improved data.
Introducer:Yeah, fair enough. Okay, so let's jump. Should we jump into the design then?
Dr. Joshua Goldenberg:Yeah. So what they did was they used data from two really large prospective cohort studies that anyone in who or who does a lot of evidence-based medicine is really aware of these cohorts, because just so much data is derived from them and lots and lots of cohort studies basically use these two data sets. We have the Nurses' Health Study, and that started in 1976 and included basically 120,000 female registered nurses between the age of 30 to 55 from 11 states. And then we have the Health Professional Follow-Up Study, which is essentially the same thing but in male health professionals, and that started in 1986 between the ages of 40 to 75, from all 50 states. And basically with both of these cohorts it's like every year essentially they keep following up with these participants to ask them about their health status, about their habits, keep following up with these participants to ask them about their health status, about their habits, so diet, exercise, smoking status, marital status, socioeconomic status, et cetera, et cetera, and just tons of data is just churned out on a yearly basis using data from these two cohorts.
Introducer:Yeah. So what do you think about it? I agree, like it's an amazing cohort or cohorts and long, long follow up period, but just kind of curious. And then maybe we laugh at that because, like we know, because we are healthcare professionals and we know healthcare professionals, but like this idea that this is not a normal sample of humanity, right, like we're looking now, we're going to ask this question about the association between mortality and ultra processed foods and and their health habits and we're having a population of nurses and doctors.
Dr. Joshua Goldenberg:Well, I would say I mean it was one limitation that they that they certainly did address and they talked about it. I mean it's a it's a gigantic cohort, and I mean some of the things you have to think about is you're working with a cohort of people who, compared to the average, are likely of higher socioeconomic status and so can afford to do healthier things, afford more doctor visits, afford more or live in zip codes that are generally healthier less food, deserts perhaps, less exposure to chemicals and whatnot and then you know they just have a higher education and typically people who have more education tend to be healthier. But I mean, it is a very large sample, so it's somewhat reflective of the US, not a shocker. Healthcare professionals also aren't very healthy.
Introducer:Yeah, that's what I was more curious about. I think you bring up really good points about socioeconomic piece, because that of course has such an impact on health and mortality. I was thinking more about, like, their health behaviors. But then I was thinking, well, maybe they're not all that different than the standard Americans.
Dr. Joshua Goldenberg:Ask a healthcare professional how much sleep they get.
Introducer:Yeah, yeah, no, totally.
Dr. Joshua Goldenberg:You know how much sleep and how much exercise they get, or how many professionals do you know smoke. So I mean, yeah, obviously it's not reflective of a global population, obviously it's not reflective of the general American population, but it's data that we have and data that we can work with. And it's a limitation that the authors addressed and I think that we all have to just kind of recognize too, is that, hey, this is data from healthcare professionals in America.
Introducer:Yeah, so totally true, I was just trying to think it through for a bit. Though. It's a great data set that makes sense. It's maybe not completely analogous to standard American population. However, if you're still looking for the associations, they should still be there and, if anything, I would think health professionals would be better about filling out the data about what they eat, or filling out these questionnaires right Like. At the very least, you could make that assumption perhaps, and so maybe the accuracy or the precision of these instruments might actually be better in this population and we might have a better approximation of like. Okay, if we do see an association, it might actually be real.
Dr. Joshua Goldenberg:So I don't know, I'm I am curious, but I mean, I think there's a couple of things that we also have to take into account. Um, when it comes to like long cohort studies, people just suck at answering the questionnaires.
Introducer:That's one thing too yeah, yeah, well, and questionnaires suck. That's the other. That's the other thing I want to talk about. Yeah, questionnaires suck, yeah, and questionnaires suck. That's the other. Yes, that's the other thing I want to talk about.
Dr. Joshua Goldenberg:Yeah questionnaires suck. Yeah, so questionnaires suck.
Introducer:People suck at answering questionnaires and therefore the data derived from those two things is sketchy.
Dr. Joshua Goldenberg:Yeah, it's sketchy, but it's what we have. Um, and especially when it comes to things like food and exercise, consistently people under report how much they eat and over report how much they exercise. So if anyone's like, oh, I can't lose weight, I'm only I'm only eating 1600 calories, I'm like you're probably eating 25, like 2500, like you're probably way over underestimating and in this case it would be, they would probably be underestimating their ultra processed food intake.
Introducer:Sorry, there'd be. Yeah, they'd be underestimating their ultra processed food intake. Yeah, and so if they see an association, you would argue that would. That would even be more impressive, because if anything, that should bias towards the null.
Dr. Joshua Goldenberg:Right.
Introducer:OK, interesting, yeah, All right, I was just kind of curious about that. And then the other things, just real quick. On study population I just want to touch on was you know, these questionnaires are notorious and so they would throw out questionnaires if, like, there was implausible calorie intakes, like you said. So they tried to have some controls on that. But I guess we're more worried about it wasn't obviously off, like they didn't obviously skip it, or like, no, they didn't have 100 calories that day, like that's unrealistic and no, they didn't have 50,000 calories that day. That's realistic. But it's more the ones that are like, well, maybe they're 30% off or 40% off, or things that like could plausibly be true and would have a huge impact on the data, which is what I worry about. But again, I guess they try to balance that across large population sets.
Dr. Joshua Goldenberg:And then also something that's really important to highlight is that they excluded and this makes sense because you're trying to find an association with these things but they excluded participants at baseline if they already reported a history of cancer, cardiovascular disease, diabetes. I thought that was good Because we're trying again to find the association really with death from those things, so you don't want them to already have it Because it's an incidence. We're trying to find new cases, not existing, which would be prevalence.
Introducer:Excellent, totally agree. And then also there's this other interesting benefit of that, which they talk about later, which is that reverse causation thing, where it's like you get diabetes, you start eating healthy. And then if you measure people that you know and you're like, oh well, healthy eating is associated with diabetes, well, it is, but because the diabetes caused them to eat healthy, not the other way around, right, yeah. And so by sort of excluding that from the in from the get go, and then later with their sensitivity analyses, they kind of um, deal with that as well. But, yeah, perfect, okay, I think that's good for me.
Dr. Joshua Goldenberg:on study population, and then when we looked at the at the food intake, uh, they basically broke it down into four categories to begin with, so they have unprocessed or minimally processed food. I think that's easy like think apple right uh processed culinary ingredients. So I kind of think of like dried spices okay processed food. So I would, I would consider that as like butter, right, because butter comes from milk and you kind of have to break it down okay and then you have ultra processed food.
Dr. Joshua Goldenberg:So you went from milk to butter to now butter product.
Introducer:I don't even know what that would be.
Dr. Joshua Goldenberg:I mean, they they do have like some examples uh in the um, uh in the in the supplement, uh, so like for ultra process, like I said, dairy, so uh, let's see what they have here so like dairy based desserts, so artificially sweetened yogurt, flavored yogurt, ice cream, sherbert yeah yeah, like candy bars, right. So if you went from cocoa bean to cocoa powder to like raw coke, I don't know, twix, yeah, yeah to them on twix, yeah, there you go, boom. And then it's interesting because, like we, have non-dairy.
Introducer:Yeah to the Nutwix. Yeah, there you go, boom. And then it's interesting, because we have non-dairy quote unquote butter for Theo, who's lactose intolerant too, I guess.
Dr. Joshua Goldenberg:That's ultra processed, I'm sorry.
Introducer:That would be ultra processed, right. So that's an interesting thing. You got your milk to your butter. But it's organic but it's organic and healthy because it's non-dairy. Yeah, no, that's a good example.
Dr. Joshua Goldenberg:And it's more expensive and it's in the healthy aisle.
Introducer:It has a little leaf on it, which naturally inspired food.
Introducer:So, that's a great example of ultra processed foods, now I want to highlight that. So I think the buckets make sense, but the way they got this right, so they sent out this semi-quantitative food frequency questionnaire with all the caveats we just talked about, every four years. I just want to underline this once more, the data that we're basing everything we're about to talk about is. They mailed out this really crummy by design questionnaire. I know it's validated, but these things have so many problems every four years. That's going to give us an assumption about how much, how truthfully, how much ultra processed food is in their diet. Now the counter argument is well, josh, if everybody is measuring it wrong and then you stratify by quartiles and you're looking at that difference, which is what they're doing, maybe it balances out. But then I would say no, because the people that maybe are having less of that may be measuring that differently than the people that have more than that. Right, like these, populations may differ in other ways. If you're more health conscious, you may eat less ultra processed foods, but you also may be more careful. You may be more comfortable with logging right, for example, and be more accurate in this reporting.
Introducer:So I just have so many issues. I don't have a better solution. Like I know, you can't have 150,000 person study where you're going in and weighing everyone's food in like a science kitchen. I get that. And like this is just like all everything we talk about in nutrition is based on stuff like this. I'm like it's garbage. It's like, well, we sent out a questionnaire that's highly flawed every four years and now we're looking for associations. I just OK. End of rant Moving on. Hey, josh.
Dr. Joshua Goldenberg:Yeah, you don't remember. We ate on on Friday, may 31st of 2019.
Introducer:I know it's crazy and then tell me how many and what the serving size was, and it's just like okay, so, okay, a continuation of rant. Um, so actually, I think this will be interesting now that we have because you and I are into this, we're tracking our food and stuff and like you've got these, these apps now and they're not quite good enough to take a picture and like, get serving size, but now with, like you just scan your barcode and you know you have a really good ability to log. Now, granted, even that is going to be flawed, but think about how much better that is real time logging compared to asking someone to remember how they ate over a four year period, or or asking them how to eat over a one week period and assuming that's an approximation of the past four years. So it could very well be that we get better. So counter.
Introducer:Yeah.
Dr. Joshua Goldenberg:Slight counter argument to that and this is like this is again end of tangent Is that if you were to then ask people to track food and they're like actually measuring things out, then that does change their dietary patterns, because they're going to.
Introducer:Then of course, eat less take healthier choices.
Dr. Joshua Goldenberg:And this goes back to what we were talking about earlier, where, if you actually knew how much a serving size of trail mix was, you're like you wouldn't eat it. You'd be like this is this is stupid like there's like three, three almonds and two m&ms.
Introducer:I'm not gonna bother, that's 200 calories yeah, or you would put it in the garage until it's brought back in by your son or your wife, and then, yeah, that's there's that issue too right and then, whereas if you're just asking kind of people in general, like what do you eat, you know you're looking again, you're looking for that pattern, you're not looking yeah, that's a good point for the exact amount, because if you ask for the exact, people will change their dietary patterns and the amount that they're eating, so you're getting completely different data.
Dr. Joshua Goldenberg:So that's just something to think about.
Introducer:Yeah, okay, yeah, that's a very good point. No, okay, no, hold on. Okay, I'm taking you seriously now. So that's a super, super valid point. So you're saying these are actually very different measures, because, while I'm saying you might get better accuracy, you're saying okay, yeah, but you're sacrificing precision for bias, because you're now going to change the way that you eat and, even worse, you're going to change the way that you eat in that moment and it's not going to be reflective of the rest of the period that's driving the disease, supposedly. Yeah, that's a really excellent point. So that's a challenge, right? So how do you get accurate reporting that isn't influencing the what you're trying to measure?
Dr. Joshua Goldenberg:that's a hard one yeah, the audacity is not taking me seriously too. Um, okay, so then these four categories of unprocessed uh, processed, culinary processed foods and ultra processed the ultra process were then, um, subdivided into nine categories from there, which makes sense. Um, they then divided it to okay, you have ultra processed foods and then you have ultra processed breads and breakfast foods, fats, condiments and sauces, fats, condiments and sauces being one category. Packaged sweet snacks and desserts. Sugar, sweetened and artificially sweetened beverages. I kind of wish they separated that out.
Introducer:They did later, I think.
Dr. Joshua Goldenberg:They did later Okay. Yeah, I think there's a sensitivity there uh, ready to eat slash, heat mixed dishes and then meat, poultry, seafood based, ready to eat products, for example processed meat. Um, I don't think that that counts as like ground beef, like just 100 ground beef.
Introducer:I think that that is more of that's, more of like salami bologna or or chicken nuggets like if you've got littles, like half of their diet is like chicken freaking nuggets and I'm just like, oh my gosh, what the hell are you eating, dude? I know no. I read this and I'm like we need to change everything that we're doing like now you would.
Dr. Joshua Goldenberg:You would not survive at my, at my apartment. Dude, I have like, I have like no.
Introducer:I think we should. We should have, like a, a intervention where we go to Adam's apartment and learn how to eat properly, or remember how to eat properly. All right, Um, okay. So what else we got? Oh, the, the.
Dr. Joshua Goldenberg:But I do want to talk about um, I just have a pop-up on my screen Tangent alert.
Introducer:It said the Taco Bell brought back the cheesy crunch gordita, as we're podcasting, okay, a, that speaks to your history of searching and now you're outed, and B, clearly the microphone is reporting this to whatever it is Facebook or whatever that is now serving you ads.
Dr. Joshua Goldenberg:AI.
Introducer:Although they're clearly not good enough to know the context in which we speak. Okay, did we talk about I really want to talk about the Alternative Healthy Eating Index. Do you want to touch on that?
Dr. Joshua Goldenberg:Honestly, I don't want to talk about that because it's just kind of like a measure of your diet quality. I don't want to get lost in the weeds with it.
Introducer:Okay, we won to get lost in the weeds with it. Okay, we won't get lost, but I think this is huge. I think this is huge as far as a flaw in the study, which I want to, not a flaw in the study, but a flaw in the interpretation of the study.
Dr. Joshua Goldenberg:So just super briefly so can we, can we hold off on that? Actually, let's, let's wrap up the food, sure okay and then they also said that because alcohol is well studied for premature death and a distinct factor, they did not consider alcohol in the ultra processed foods. They kind of had it as its own separate category altogether and then kind of looked at the data with that in it and without. Makes sense.
Dr. Joshua Goldenberg:And then they also did the same thing with whole grains, because whole grains are just so well established from a mortality standpoint that they looked at it from. If you removed whole grains from ultra processed and then also put them back in, how that would change things. Ok, you can. Now you can talk about your stupid index thing or whatever.
Introducer:So one of the other things they measured is this index of healthy eating, which is a sort of um, somewhat simplified you know, how much of this food do you eat, how much of that food do you eat? But it's going to be really important because I think and tell me that as we read through this, you tell me if you buy my hypothesis or not but I think that you could make an argument that essentially, ultra processed eating, ultra processed foods, is a surrogate marker for this quality index and that essentially, what we're measuring is the mortality associated with the quality of your food, not necessarily ultra-processed food. Now, ultra-processed food is part of that index, but it's not all of that index. So something to consider as we move forward.
Dr. Joshua Goldenberg:Yeah, I would say again and again, it's not the food item, it's the dietary pattern component to it. So I think that if you look at like eating ultra processed foods as the food product and then the AHEI, which is the Alternative Healthy Eating Index, as your dietary patterns overall like if you eat 90% whole foods and like you're very minimally processed and then you add in you know some sweets here and there versus only eating processed foods the dietary patterns is your dietary pattern is mostly healthy. With a couple you know things here and there because you're a human and you enjoy life. With a couple you know things here and there because you're a human and you enjoy life. The other one is a very low AHEI because you're just eating I don't know donuts and muffins all day long.
Introducer:Well, I think that's my point, which is, like you can have people so like they're trying to show that it's specifically this ultra-processed food and then they try to go further, although they weren't super successful in saying it's this specific type of ultra-processed food that's most associated, and what you're saying, and I think what I'm saying, or what I'm saying, and I think what you're saying is no, it's the pattern of people that eat this type of food that is more important. And when we look at the sensitivity analysis, I think that bears out our position more than their position. And you can just imagine someone like a health food nut or like a health food nut, but like someone who works out a lot. You know mostly it's healthy food, but it also has, like that's highly processed, like protein bar, you know pre-workout type of thing and post-workout right, that's ultra processed food, multiple servings a day, but yet super health mindset Otherwise everything else is excellent Would probably score very highly overall on this healthy eating index, but would also score high in a bad way on the ultra process. So anyway, so just a case study to kind of think about there.
Introducer:Okay, so let's. What else did we want to talk about? Oh, you wanted to talk about the missing data points. Should we touch on that now?
Dr. Joshua Goldenberg:I think in one second we can. When they looked at the outcomes, the study investigators were blinded to the exposure status when they were looking at death certificates. So when they were analyzing the data, they didn't actually know if people were eating a healthy diet or not. They were just confirming how they died and they basically used death certificates. Okay, this person died from cancer, this person died from a heart attack, etc. Etc. And they were just confirming that and then looking at the data. So not not to skew things, which is important- yeah, that was good.
Introducer:That's detection outcome. Detection bias issues yeah, very good.
Dr. Joshua Goldenberg:And then some of the covariates that they looked at body weight, marital status, smoking status, smoking status, both in pack years and do you smoke or not, which I think is important, because if you're someone who's like, oh, I socially smoke when I go out to drink and maybe I have one or two cigarettes and I do that on on a monthly basis, like you're gonna have a very low pack year history, but technically you answer yes. Versus someone who's you know, I chain smoke two packs at two, three packs a day is may be a little different.
Introducer:uh, when we're looking at this kind of data, yeah, well, and they, they point that out later that when they compare their results to other studies, that just bucketed it like that very different results. And the fact that they were able to sort of stratify in a more nuanced way, I think is important. Which.
Dr. Joshua Goldenberg:I thought was actually really really cool, because usually what I'm used to seeing is it's as a yes, no.
Introducer:Yeah, ever smoker question yeah.
Dr. Joshua Goldenberg:Yeah, so I do think that this was kind of novel in that standpoint.
Dr. Adam Sadowski:Yeah, so I do think that this was kind of novel in that standpoint.
Dr. Joshua Goldenberg:They also looked at physical activity status, family history of cancer, cardiovascular disease, diabetes. They looked at basically, you know, are people who are basically getting annual exams, are they healthier than those who don't? And then looking at menopausal status and post-menopausal hormone use for women alcohol, like I said earlier. And then, as you said earlier, using the AHEI, when we looked at the statistical analysis, they basically followed people. I think they started. They didn't start at the like official start date of the cohort, they kind of started like when when ultra processed foods came out.
Dr. Joshua Goldenberg:Yeah, yeah, yeah. And then they follow them, um, until they they had the event or until they were followed for 30 years, whichever came first. And that was their cutoff point to to analyze the data, cause at some point you have to stop. And then the primary analysis was basically they pooled everything together, looking at both cohorts together, and then sort of like just ultra processed foods as a broad definition, and then they looked at the data at the second, at each cohort on their own. So they looked at how did this affect basically men and how did this affect women? And then they also looked at specific food trends within the ultra-processed food. So does processed meat have an effect that would be different than processed bread products, et cetera, et cetera.
Introducer:Yeah, and one of the sensitivity analyses or yeah, I think they're calling it a sensitivity analysis which is around that A-H-E-I, that healthy eating index. So they stratified everyone into these four buckets, these quartiles, with their healthy eating index, and then looked at the relationship within each quartile with the lowest highly processed food intake versus the highest. And that's sort of a way of controlling for the healthy index. So people that are super, super healthy index eaters, you take the people and say, okay, these are healthy eaters, but let's take that group and compare the people that have the most ultra processed food to the least and see if there's an association there. And we take the people with the unhealthiest diet and look at the association there. So that's one way to kind of control for this issue that I'm worried about, which is like maybe we're just measuring the quality of the food and it's nothing to do with the or very little to do with the ultra processed food. And then the other thing I had about all these sensitivity analyses that you're touching on is did you see anywhere where they said this was like a priori? Did they publish their protocol on their statistical plan? I mean, that's a lot of subgroups, a lot of specific calls here. I didn't see anything about publishing that ahead of time.
Introducer:Look, the thing is we don't do this for money. This is pro bono and, quite honestly, the mothership kind of ekes it out every month or so, right? So we do this because we care about this, we think it's important, we think that integrating evidence-based medicine and integrative medicine is essential and there just aren't other resources out there. The moment we find something that does it better, we'll probably drop it. We're busy folks, but right now this is what's out there. Unfortunately, that's it, and so we're going to keep on fighting that good fight. And if you believe in that, if you believe in intellectual honesty in the profession and integrative medicine and being an integrative provider and bringing that into the integrative space, please help us, and you can help us by becoming a member on dr journal club. If you're in need of continuing education credits, take our nancyak approved courses. We have ethics courses, pharmacy courses, general courses. Interact with us on social media, listen to the podcast, rate our podcast, tell your friends. These are all ways that you can sort of help support the cause.
Dr. Joshua Goldenberg:And they didn't. Yeah, there's no like statistical method that they said that they use to control for all of these additional testing. And that's important, because if you just test for 100 things, you're bound to find something, and so just by chance you'll probably find something by chance. And for every P statistic that you run or you know analysis that you run, the chance of finding something that's significant incrementally goes up unless you control for that. So your P result would have to be smaller with each analysis that you ran, like when you're controlling for it. So you would want, like, let's say, instead of the typical P equals 0.05 would be statistically significant. When you're controlling for multiple analyses, it then may be like 0.0025 is then considered statistically significant.
Introducer:Yeah, and I think that what you're talking about will address the issue of just like, let's just go fishing and see if we can find something. And that is very true. And I am particularly worried that the way they chose to do things was influenced by a presumed bias of ultra processed foods are bad. Not that there's a huge lobby of people that think that ultra processed foods are bad, not that there's like a huge lobby of people that think that ultra processed foods are good, but, like, if you look at the authors on this paper and where they come from in their previous work, like, and also just reading the introduction, is very, very clear that they believe that ultra processed foods is bad. And I just worry about going in with those sort of intellectual predispositions, even if they make sense. You know, did we say ahead of time how we were going to do these sensitivity analyses and subgroups and statistical analysis and all the things? Because, yeah, I don't know. I just I worry about that sort of thing.
Dr. Joshua Goldenberg:Yeah, and then on the comment that you were alluding to earlier, on their analysis, they carried forward non-missing values from the previous survey to replace any missing data, which can be problematic, because you know. Basically what they're saying is oh, they missed this answer, let's just copy and paste from the previous four years, which is kind of assuming that within four years nobody changed their dietary habits. So perhaps someone actually went from, you know, eating nothing but ultra processed food to then having some sort of intervention where they're like, oh, now I'm going to stop that and only eat healthy. You know, you know how dietary trends happen and you know, post holidayiday people always want to lose 10 pounds or something like that, and so they change their eating habits. And so, on this assumption, it's hey, we're assuming that people are not changing their habits and we're just going to kind of carry forward. Whether they're always reporting a healthy diet, we're just going to kind of move that forward. And then, if they're always eating an ultra-processed diet, we're moving that forward, which at first I kind of had an issue with.
Dr. Joshua Goldenberg:But I also get why they did that Because it would be so hard to, and you don't want them to be like, well, we lost all this data, so now we can't do anything with it. So now we can't do anything with it. If you think about it from like a temporal standpoint, it kind of strengthens the data in a way of like okay, well, if they were super ultra processed food eaters in the past and we're continuing to move this along, then they're temporally exposed to this risk factor that we're interested in for a longer standpoint and you would assume that that would then have, you know, more of an effect on the results that we're seeing. And similarly, then we would also see more of a protective factor if they're eating healthier for longer.
Introducer:Yeah, it's a big question. Like in the methods world, it's highly debated how we deal with missing outcome data. And to your point, you don't want to just throw everything out because it's highly debated how we deal with missing outcome data. And to your point, you don't want to just throw everything out because it's important information. But the question is like the assumptions behind. So basically what they're doing is like I think they sometimes call it like last measurement carried forward in other instruments, right when, basically just take whatever they said last time and you assume it's the same. And you know there are issues with that, because, A, it could be wrong, like you're saying, but B, if the reason for the missing data is connected to either the thing that the exposure so ultra food, ultra processed foods or the outcome, like death or disease, then we have a bias issue, not just a precision issue. And so you can imagine scenarios where it's like I just got diabetes and I'm too guilty to say how much Twickers Snickers I eat and so I'm going to just not answer that one or whatever, and so you can imagine environments where it could be associated, and then you get a bias issue, so anyway. So it is a big issue.
Introducer:Traditionally that's what everyone did, Last measurement carried forward. These days, I feel like there are, you know, people do multiple imputation, like there's. You can do sensitivity analyses, which is how we've dealt with this issue. You say, okay, assuming the worst, or assuming worst plausible, you know, would the results survive, right? So I think, anyway, there's just different ways to do it. But I think your points are valid. We don't want to just throw out the data, but I don't know that less measurement carried forward is the best way to handle that.
Dr. Joshua Goldenberg:And two quick tangents on that. One is this is why, when you when you're because stuff like this is always in the news and it's why you can't just buy the headline you really got to read the study and, like, actually be able to critically evaluate it, to understand there's a lot of nuance going on, and then be able to you know there's data and then it's okay. Well, what do we do with this data? How do we interpret it in the context of all these things biases and study flaws and whatnot, and best available evidence that we have. So you always you kind of have to tie it all together. You can't just say, oh see, this, this is in line with my bias. Therefore, I'm going to agree with it. And it's why, in like in our previous episode, I kind of am critical about things and want people to be critical about things, so that means that you're actually thinking about things.
Introducer:Um, and then the other tangent is well, I forgot it, so it doesn't matter well, I agree with tangent one, and because the the headline here is like ultra processed foods kill you, right? So that's the sexy headline and you're right. There's a lot and we haven't even got into the results yet, and there's a lot of nuance here yeah, yeah.
Dr. Joshua Goldenberg:So, that being said, let's get into the results okay, cool, so let's move.
Introducer:I I don't know that we have to perseverate too much on the results. I think they were pretty somewhat straightforward, but so, basically, we're talking about a median of 34 years of follow-up, so that's outstanding, right? So they have, like I don't know, 120, 130, 140,000 people total studied over three, almost three and a half decades, with median levels. So that is the real advantage of this type of study, as well as, to your point, a lot of nuanced data, even with the caveats that we talked about. And OK, so I want to kind of jump right into the results and then talk about it in line of this healthy eating index. Is there anything you wanted to talk about before we?
Dr. Joshua Goldenberg:we do that um, I do want to kind of give a just a brief breakdown of our, our baseline cohort, like characteristically what we're looking at. So sure, remember, um, one cohort included 122 000 people, the other one included, uh, 51 500 um. In total I think there was what 48 000,000 deaths or something. Yeah, 48,000 deaths Um, total. Uh, of that we had 13 and a half from cancer, 11 and a half from cardiovascular disease, 4,000 from respiratory diseases, so things COPD um, and then 6,000 from neurodegenerative diseases, um, so we started off with what did I say like 160 and 50 died for easy numbers. And then they said that participants with higher ultra-processed food consumption were younger, more physically inactive and more likely to smoke and had higher BMI, lower consumption of alcohol, whole fruits and vegetables, whole grains and a lower AHEI score. But then when we actually look at the data, when we're looking at our quartiles, so quartile one being less ultra-processed food consumption, so quartile one is your healthier diet, if you will. And then quartile four is your more processed, is your least healthy? Yeah, so most processed foods. When we actually look at the age difference there, that's really, it's really like not that different 66 versus 65 from a quartile one to quartile two and that was in the health professionals follow-up study. So that was the male study. In the nurse's health study, 66 versus 64. So really, from a clinical standpoint, like, the age difference there is like is pretty negligible. The majority of participants were white 89% in quartile one versus 92% in quartile four. From a marital standpoint, 67 percent in quartile one versus 68 percent quartile four. When we look at bmi, 25 versus 26 and a half total activity met hours 33 in in quartile one. So healthier people just exercising a little bit more and more vigorously, versus 25 in quartile four. That one was pretty notable. Notable, uh, from an alcohol standpoint. Or again, it's based on alcohol units. So how many grams of alcohol um are are within your your drink, um, so 13, uh in quartile one versus nine in quartile four. Um, so that that was pretty dramatic. You can kind of see that people who are eating worse are actually drinking less alcohol. Just something that's interesting.
Dr. Joshua Goldenberg:And then from an AHEI score I don't know what the max score is, but in people who are eating a healthier diet they had a 53 on average versus a 44 in quartile four, and this is kind of consistent across both groups, meaning the nurse's health study and then the health professional's follow-up study. When we look at those who never smoked, those who ate healthier, 55% were never smokers versus 45% who were in quartile four. And then the mean pack years of smoking. Those who did smoke or were former smokers in the healthier dietary pattern standpoint had a mean pack year history of nine years versus 14 and a half in quartile four.
Dr. Joshua Goldenberg:Um, and then otherwise, most things otherwise were pretty, uh, pretty, um, um, equal across the board. When we looked at mean ultra processed food intake based on servings per week, the people in the healthier dietary habit pattern, um, on average, uh, ate 22 servings of ultra-processed food per week versus 56 in quartile four. So I think that that's pretty remarkable there. Something to note that was for the health professionals follow-up study, so in men and then for women it was 21 servings versus 50 servings.
Introducer:So a nice spread there to look for an association for sure. So if you take okay, drum roll please If you take the lowest quartile of people overall that had the lowest amount of ultra processed foods, which is a median of about three servings a day, and you compare those to the highest quartile, which is about seven and a half servings a day of ultra-processed foods, which is a lot, there was a 4% higher risk of total death. And that's after multiply, adjusting for all the different variables that we talked about, like BMI and smoking and things like that. So basically we're talking about for those, if you compare those that had the fewest amounts of ultra processed foods to those with the most, over like a 35 year period, you're going to see four extra people dead per hundred in the highest ultra processed group than the lowest. One way to think about that sort of and what's the confidence interval on that?
Introducer:1.01. So like barely uh barely there statistically significant, and 1.07 now to as the as the upper bound there. So it's interesting. They say it's a strong positive association. That's speaking to the p value. But actually the magnitude of the effect? I mean it's a strong positive association, that's speaking to the p value, but actually the magnitude of the effect I mean it's quite modest. Right, we're talking about a four percent difference over from the highest group to the lowest group over a 35 year period. So that's, that's one thing that they found. So that's their main kind of take on here increased risk of death, and we're talking about a four percent difference over five years and if we look at sort of like the baseline risk, sorry, 35 years, yeah, if we look at the baseline risk.
Dr. Joshua Goldenberg:Uh, they did an incidence rate per 100 000 person years, which which makes sense because you're having these high numbers, which is essentially the same thing as like okay. Well, if you were to then look at the numbers, like, you can still convert it to a percentage standpoint. So in quartile one, so those who are eating healthier. Basically, your baseline risk of total mortality was 1.47%, so let's say 1.5%. Okay.
Dr. Joshua Goldenberg:Versus quartile four, which was 1.536%, so versus 1.56%, versus so versus 1.56. So then to that baseline risk you add that four percent. You went from a 1.5 risk of mortality to like 1.6 that's a really good way to think about it.
Introducer:That's a really that's a much better way to think about it that's why you have me on this podcast.
Dr. Joshua Goldenberg:This is why you tune in people, I know, I know. So get that, go get that trail mix, joss, and go chomp down. You're not.
Introducer:Well, that's what I was saying. I was like, hey, I'm not, I'm like I'm totally on the bandwagon, like ultra processed food is bad. I was like we're talking about a 4% difference here over 35 years, from the highest to lowest quartiles, and then okay, quartiles, and then okay, and then get this on top of that. Once they controlled for this healthy eating index.
Dr. Joshua Goldenberg:There was zero effect. Oh, hold on, hold on. My dominoes order just came in. Let me go get that from the door while I go crush this bag of doritos and get a tub of ice cream I mean, it's just like it's crazy, it's and, um, yeah, so we have this headline ultra processed foods kills everybody.
Introducer:And again, just to underline this, if this is real and there's all the questions of, like the measurements and all this, we're talking about the best to the worst comparison. You know, 1.5% risk to a 1.54% risk over 35 years. This is what we're seeing. And then, if you control for healthy eating, it's actually not a thing, and so I don't know. It's just like, yeah, like don't eat ultra processed foods, like I don't want you to die, and we're talking about a really minuscule effect size here. And actually the ultra processed foodsed foods themselves may not be the issue. It might be the overall quality of the food, and again that we're measuring a surrogate for overall dietary quality. Like you said earlier, the dietary pattern is the one that matters there.
Dr. Joshua Goldenberg:Yeah, and then when? So that was total mortality. What about mortality from cancer? Yeah, so I don't think they saw an association with cancer right yeah, it was 0.96, so protective, but if we look at the confidence interval, and from 0.91 to 1.0, so yeah, this is really interesting.
Introducer:No association with cardiovascular death, cancer death or respiratory death. That's so interesting. Yeah, so there's something else. So their argument is there's something else that this is doing. It's killing us in other ways. And what I thought was interesting we had to get Heather on the podcast for this is they saw the signal with neurologic disease and she's always talking about ultra processed foods and the microbiome and cognition and neuro, you know, neurodegeneration, which they did see an association with, and so you know that might be the signal here, which is, you know, quite fascinating. I think it's a small signal, but that might be the signal.
Dr. Joshua Goldenberg:And a couple of things too, that I thought were interesting, was all cause mortality seemed to be stronger in participants consuming less alcohol and not smoking say that once more all cause mortality had a stronger interaction oh, excuse me, it seemed to be stronger um in participants consuming less alcohol.
Introducer:So an inverse relationship, and not currently smoking I think that makes sense again in that, like you don't have those other risks for death, and so then the association would be stronger. That's how I make sense of that sentence. Am I thinking about that wrong?
Dr. Joshua Goldenberg:um, I kind of I guess maybe I read it wrong and I kind of interpreted it as they kind of found the opposite of what you would expect, like people who are drinking less and not smoking have a higher incidence of mortality.
Introducer:Oh, I was reading it as like. Once they took that out of the multivariable.
Dr. Joshua Goldenberg:But then there's also that, yeah, which is probably more accurate, which would then mean that, hey, there's a U-shaped curve to alcohol, which is kind of something that has been sort of established of like. There is sort of this health even though alcohol is a toxin. It is a U-shape where too much is bad for you. But we're also seeing that no consumption, or very little consumption, seems to be associated with more health, like adverse health outcomes. But there's a sweet spot there where it's kind of neutral or maybe beneficial, and so is BMI. Bmi is also well known to have a U-shaped curve to it, where people who are very low on the BMI in this study they looked at less than 25, there's actually, you know, an increased risk and those who are like morbidly obese, increased risk. And those who are like morbidly obese there's also an increased risk. But there is this healthy range of like, of like, you know, normal to slightly overweight, where there is actually a neutrality or possible health beneficial effect there.
Introducer:Yep, yep, yep, which totally, which I think makes sense A lot. I think we're learning a lot of things in in medicine and health are have U-shapes, which which totally makes I think makes sense a lot. I think we're learning a lot of things in in medicine and health are have u shapes, which which totally makes sense to me, although maybe not ultra processed foods, I don't know um, you know interesting which goes to that really dumb saying that I hate of everything in moderation, because then you have to find what is moderation yeah, everything to the left of the curve in the U.
Introducer:So okay, I just want to pull up. Oh, we talked about that. We talked about that. We talked about that, okay.
Dr. Joshua Goldenberg:Do you want to break it down?
Introducer:real quick by the ultra-processed food type you can Sure.
Dr. Joshua Goldenberg:Go ahead. Basically the main one that they looked at that did have the strongest association, and one that I did think was actually kind of important was the ultra processed meat, um, with a hazard ratio of 1.13 in that confidence interval. The chicken nuggets, yeah, it was 1.10 to 1.16, so it's smack dab in a narrow confidence interval in that that's pretty high amount, like 13, which ranges from 10 to 16 increased risk yeah, and again, these are relative numbers like, if you were to like make one change get rid of the chicken nuggets like.
Dr. Joshua Goldenberg:What would you do, instead of saying, oh, you can't eat anything. Get rid of the chicken nuggets, get rid of, like you know, know, your sausages, your your bologna.
Introducer:Yeah, totally true. Okay, can I get back on this healthy eating index hypothesis thing? So I called that up, right? So I'm convinced that what we're really talking about here is we're just it's just a surrogate for this healthy eating pattern, right, it's not necessarily the chicken nuggets, although, um, anyway. So when you look at the what goes into this, I just pulled up, like the constituents of this index. So it's like asking people how many fruits and vegetables, whole grains, nuts and legumes, omega-3s, pufas, things like that. And then on the negative side, you know, sugar-sweetened beverages, red and processed meat, trans fats, sodium and alcohol, right? So these are kind of the things that we all kind of assume by consensus are part of a healthy or unhealthy diet. And so, yeah, there's some overlap, which is, when you say red and processed meat, that's going to overlap with the ultra processed stuff. Oh well, the processed meat version, rather not the red meat, which is the unprocessed version, but not totally overlapping. And again, I really think it's just a freaking surrogate for this, which is the overall healthy eating pattern. And, yeah, if you eat healthier, you won't die as much, although the difference appears to be pretty darn small.
Introducer:I don't know, I'm really. I'm like. The more I look at this Adam, like the more I'm convincing myself, like, more I'm convincing myself, like it's not the nuggets, it might be the nuggets, but I'm definitely getting rid of the nuggets. I'm just putting that out there. So the gluten-free dino nuggets that is like a mainstay of our kids diet it's out. It's out today. Um, anyway, I think it's, I think it's really a surrogate for this. I'm just like, more and more convinced, and I think if there's anything novel in this paper, it's this neurodegenerative piece which I think is very interesting and makes sense through the microbiome.
Dr. Joshua Goldenberg:And then the last thing I would say Well, before, you get into that on the context of excluding diet or not diet, but excluding foods within your diet, because I hear this all the time of like, oh, diet sodas and like these diet drinks are terrible for you and that you should just drink the real thing. And then, like you know, quote unquote mexican coke is healthier. Um, when? When they actually further separate out sugar sweetened and artificially sweetened beverages, they found a stronger association for sugar sweetened than artificially sweetened beverages. They found a stronger association for sugar sweetened than artificially sweetened.
Introducer:Wasn't that interesting.
Dr. Joshua Goldenberg:I mean, but like duh right, Because again it kind of goes back down to this like no nutritional value in calorically dense food. If you have something without the calories, you're not going to be getting sort of like the excess caloric intake from. You know, if you're drinking like five actual cokes a day versus five diet cokes, you're getting like an increase yeah, but remember they're controlling for bmi though, right yeah, so that, but yeah, but it's not just a weight thing.
Dr. Joshua Goldenberg:Well, there is that. I mean there's that component which which they did control for, and then when they controlled for that, they still found that the that the artificially sweetened diet cokes or diet beverages were not the actual food of the non-diet had an increased risk versus the diet.
Introducer:Yeah, I thought that was interesting. Just because I constantly hear that it's like chatter of like oh to how terrible dietary or how they're totally counter to the standard yeah, and I mean it's it's so consistent, it's so consistent in the literature about that yeah, it's very interesting, but um, so I want to get, we should get have heather, have like her third appearance.
Dr. Joshua Goldenberg:Heather's wiki, dr's wiki she gets an unlimited amount of appearances yeah, she can make as many darn appearances as she wants. Like that she, she's a standing order. If if she was like hey, I want to be on the podcast, we'll just be like okay, cool, like yeah, standing orders, stat she can get on, that's right.
Introducer:Um, she's got that stat card, um, and so, yeah, I think the neurodegeneration thing is actually in my mind, although they only mentioned it as like a side note, like the most interesting thing to me here and the other quick aside. I wonder why. I wonder if one of the reasons why they didn't see the cardiovascular and cancer association is because they controlled for weight and so you, the whole calorie issue, which of course is associated, is sort of um, netted out in that. Right, they're just looking specifically, not necessarily at the calories, but at the ultra processed foods specifically. But now here's the thing that I wanted to say. This is spin on like good stuff, it's not industry sponsored or anything but like, just look at how I mean the way this was sold, the way they talk about this in some places, like strong association, um, you know well, you know they, actually, they, they controlled it pretty well. Like, if you look at their conclusion in the abstract, they say at the end they said they simmered down.
Dr. Joshua Goldenberg:But I wonder if that was from peer review.
Introducer:They simmered down because I think it's because the yeah, I think it's bmj forced them to simmer down because they're very strict about that sort of thing and I know, you know, some of these authors are just very much into this, which is good, I mean, I agree. Like you know, um, you know, eat whole foods. Totally agree, that's what I do. However, like the association that we're talking about here is minuscule and it goes away as soon as you talk about this index and so, like you know, this idea that it's this massive association, but actually the absolute numbers are like laughably small, the slight increased risk and yada, yada, yada. Anyway, I just find it spin is so interesting, but I think they, the authors, either the authors and or the journal editors, did a good job in tempering that language in the abstract and the conclusion.
Dr. Joshua Goldenberg:Yeah, and I mean it goes back to like yeah, like eat mostly a whole food, like a whole foods diet, but don't ever nutritional shame people for what they eat. First off, you're a jerk if you do that too. Right, like no seriously you are, and then too like it also, like you're allowed to eat these other processed food things and, in the grand scheme of things, it's not going to move the needle not by much, not by much.
Dr. Joshua Goldenberg:Like focus on the bigger things. Like don't be someone who, who, chain smokes two packs a day, but then be like oh, I'm not gonna eat doritos because doritos are bad for you, like it's, you'd probably be better off not smoking did you do a um, did you do?
Introducer:I didn't do like a numbers needed to treat thing here because you had you were better with the absolute numbers here. I am curious, like over 35 years, like how many people would have to eat the lowest level of ultra processed food versus the highest to prevent one death?
Dr. Joshua Goldenberg:I think it would be like really a large numbers needed to treat here well, while I talk about, um, you know, the great benefits of of dr journal club. Why don't you calculate that? And while we run a quick ad, yeah, so where are your?
Introducer:where are the absolute numbers that you came from? You said 1.5 percent, right, where did that come from?
Dr. Joshua Goldenberg:I think it was table two okay, so table two yeah so if you go to Table 2 and then go to Total Mortality, the incidence rate per 100,000 person.
Introducer:Years in Quartile 1 is 1,000. Well, that's the problem. It's person years yeah. So we can't really. I mean, that's the issue is, they're not giving us absolute numbers, like we can't calculate that based on person years. It's probably small, it's probably really freaking small. And I'm suspicious that they don't have some comment about an approximation of what we're talking about here.
Dr. Joshua Goldenberg:Um, but no, we can't actually do that I think I think if you sent them an email or press them or sent like a letter to the editor asking them for that, they probably would be able to do that. Yeah, I feel like it letter to the editor asking them for that, they probably would be able to do that.
Introducer:Yeah, I feel like it should be required. You know, like, for example, for Cochrane reviews, you must have an absolute risk statement. And I think one of the biggest issues with nutrition research is you talk about relative percentages all the time, and even here the relative percent difference of 4% is very small, but I can't even imagine what that would be in absolute terms. Anyway, I was just kind of curious about that. But no, you can't do that from person-year calculation, and I would be interested to know, because it's like they have the number of. Yeah, maybe we could. Well, I don't know, because it's challenging technically because they count them over different periods of time. That's why they do the. Anyway, we're on a statistical tangent, but the take-home is, it's probably pretty stinking small, but it's not medical advice. Don't go out and eat dino nuggets, or if you do, don't blame us. Okay, anything else you want to say last minute before we wrap up, sir?
Dr. Joshua Goldenberg:No, I mean, I still thought it was an interesting study, it was a great study yeah. I thought it was. Yeah, no, I thought it was a great study. I thought it was, I thought there was some stuff here that was really interesting.
Introducer:You know what the issue is.
Dr. Joshua Goldenberg:Nothing really matters, Well it doesn't matter, it's not that it doesn't matter. It doesn't matter. It's not that it doesn't matter. It doesn't matter to the magnitude we want it to.
Introducer:We think we nothing really matters. That's the really word there from metallica I mean, I think, like even this over 35 years.
Dr. Joshua Goldenberg:Are you sure it's metallica and not queen?
Introducer:isn't? Oh, is that queen or metallica?
Dr. Joshua Goldenberg:nothing, it's Queen, it's Queen, it is Queen. Yeah, dude. Nothing really matters what song is that it's Bohemian Rhapsody.
Introducer:That is Bohemian Rhapsody. What am I? Doing Come on dog, I know, I know, I know. Should we keep this or should we call this a?
Dr. Joshua Goldenberg:B-roll. No, we should definitely keep this, so people know we should probably keep this.
Introducer:We should just out me. You're a fraud.
Dr. Joshua Goldenberg:Forgetting Bohemian Rhapsody. You're a fraud. You don't know anything, josh. You don't even know evidence-based medicine. It's all made up. It's like whose line is it anyway? It's all made up.
Introducer:Man, I just conflated Queen and Metallica. I feel like someone just rolled over in their grave. I feel like that is a major. We've lost our entire audience Commandments.
Dr. Joshua Goldenberg:Faux pas.
Introducer:If they're still listening. This is a particularly rambling episode. All right. Should we close it up at this point?
Dr. Joshua Goldenberg:Should we? Let's go on a tangent about I don't know?
Introducer:This is terrible.
Dr. Joshua Goldenberg:Let's tangent about closing out. Yeah, about closing out podcast. Yeah, it's closing time.
Introducer:Okay, now, what's that? Now, is that okay? Is that what's close? Who sings closing time?
Dr. Joshua Goldenberg:I don't know who that is. Is it Creed?
Introducer:I don't know, I don't think so I want to. I want to say Blink 182, but I know it's not blink 182. Don't jump on me. It's um, what is it it was? Weren't they like one hit wonders? Closing time? No idea, closing time song, semi-sonic? Yeah, they were, I don't know. Maybe people will say they're not one hit wonders and that was like their major, their major song semi-sonic, like the semi-quality or semi-qualitative. Okay, I'm cutting it. This is ridiculous. We need to end the podcast.
Dr. Joshua Goldenberg:Okay.
Introducer:Bye everybody. Thank you for listening, if you're still listening. If you enjoyed this podcast, chances are that one of your colleagues and friends probably would as well. Please do us a favor and let them know about the podcast and, if you have a little bit of extra time, even just a few seconds, if you could rate us and review us on Apple Podcast or any other distributor, it would be greatly appreciated. It would mean a lot to us and help get the word out to other people that would really enjoy our content. Thank you, hey y'all. This is Josh.
Introducer:You know we talked about some really interesting stuff today. I think one of the things we're going to do that's relevant. There is a course we have on Dr Journal Club called the EBM Boot Camp. That's really meant for clinicians to sort of help them understand how to critically evaluate the literature, et cetera, et cetera Some of the things that we've been talking about today. Go ahead and check out the show notes link. We're going to link to it directly. I think it might be of interest. Don't forget to follow us on social and interact with us on social media at DrJournalClub. Drjournalclub on Twitter. We're on Facebook, we're on LinkedIn, et cetera, et cetera. So please reach out to us. We always love to talk to our fans and our listeners. If you have any specific questions you'd like to ask us about research, evidence, being a clinician, et cetera, don't hesitate to ask. And then, of course, if you have any topics that you'd like us to cover on the pod, please let us know as well.
Introducer:Thank you for listening to the Doctor Journal Club podcast, the show that goes under the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Be sure to visit wwwdoctorjournalclubcom to learn more.