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Lifestyle as Medicine
A Paradigm-Shifting Expert Interview with Dr. David Katz
Ryan Picarella, ms, sphr and David L. Katz, MD, MPH
truehealthinitiative.org
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October 28, 2015

WELCOA President, Ryan Picarella sat down with Dr. David Katz for an illuminating conversation about what the medical community really knows about disease prevention. If you are confused about what diets are best for health, what lifestyle changes we can make to prevent chronic disease or how you can get involved in the lifestyle as medicine movement, read on to be informed and inspired.

Q1: As someone who is on the frontlines every day watching the declining health of Americans, what would you say is one of the most important things you have learned over the years as you observe this trend firsthand?

Dr. David Katz: There are many valuable lessons, of course, but one that has become more and more salient to me over the years is that knowledge is not power. We like to say knowledge is power, but the gap between what we know about adding years to life and life to years, about preventing disease and promoting health and what we do with what we know belies that wishful thinking. While there are many obstacles to promoting health, I think that is the most important one because it is the most eminently fixable. If you think about many of the challenges we face—Can we cure type I diabetes? Can we cure cancer? Can we develop new antibiotics?—many of them require learning things we do not yet know. Frankly, that is where Nobel Prizes come from, and that is where a lot of the NIH budget goes, and I think that is all for the good.

I would like to live to see a cure for Parkinson’s and type I diabetes and for more cancers, but it does not make any sense to pursue the answers to questions that challenge us while ignoring the answers we already have. I actually completed my second residency in preventive medicine and got my Master’s in Public Health in 1993, and it was in that year, just as I was finishing the training that really was the foundation for everything that followed, that a paper was published in the Journal of the American Medical Association titled, Actual Causes of Death In the United States. And the two authors Bill Foege and Mike McGuiness, two preeminent epidemiologists, really offered us all an opportunity to shift our thinking. We talked about leading chronic diseases as the major causes of premature death in the United States and increasingly around the world; heart disease, cancer, stroke, diabetes, and dementia are on that list. Those are, in fact, the proximal causes of years lost from lives, but the root causes are those things that cause these chronic diseases.

These chronic diseases are not really causes; they are effects. Nearly 80% of all of that mayhem results from bad use of our feet (not being physically active), our forks (not eating well) and our fingers (holding tobacco products). If we did not smoke, ate well and were physically active, we could eradicate up to 80% of all chronic disease in the world today. Since that paper was published 22 years ago, there has been a repetitive drumbeat in the peer-reviewed literature telling us exactly the same thing over and over again with stunning consistency. For the most part, though, modern cultures have failed to turn that knowledge into the power of routine action, and so we still are awash in preventable chronic disease. My hope is to live to see that change.

Q2: We know that a big part of this is, in fact, the foods that we put in our mouths, and I think we can all agree that we need to move more. But there is so much confusion in the market about what we should be eating. What are your thoughts? Do we know whether there is one diet that is really best for our health?

DK: So this is a question that is very near and dear to my heart because it really gets to the very core of this issue of failing to translate what we know into what we do. Nobody is confused about tobacco. Smoking is bad for health; not smoking is good for health. That is quite clear; it is a dichotomous variable. There is a little bit of confusion about physical activity. What’s the best way to do it? Exactly how much is the right amount? But there is not much confusion. I think most people understand that being inactive is bad and motion is good. But there is an enormous amount of apparent confusion with regard to diet. My contention is that it is actually all pseudo-confusion, and it is all about the usual thing in modern culture and that is profit. Unfortunately profit often comes ahead of public health.

There is profit in perennial confusion about diet because, if people do not know what diet is best, you can sell a new fad diet book every week—if not every day. If people do not know what diet is best, you can invent new kinds of processed food and claim they are good and profit from that. If people do not know what diet is best, it populates the airwaves and women’s magazines and men’s magazines and the morning shows and, again, a lot of folks profit. So the status quo is perpetuated because the so-called military industrial establishment benefits enormously from us not knowing what diet is best for health. That pseudo-confusion is propagated by emphasizing areas of disagreement, no matter how trivial. So for example, should we cut fat or should we cut carbs? You can turn that into a big debate and people get to pick one side of that argument, and it seems like one study says one and the next study says the other. Then we hear, “No, it is really not about that anyway. We should just avoid grains; it is all about gluten; it is all about genetic modification; it is all about fructose; it is all about saturated fat. Well, no it is not about saturated fat.”

We have this endless parade of theories all predicated on the my diet can beat your diet notion and routinely populating the bestseller list as well as the media. The reality is if you look without bias at the vast literature on diet and health, spanning intervention trials, basic mechanistic studies, animal research, and observational epidemiology in large real-world populations, the fundamental theme of healthy eating is incredibly clear. Michael Pollan did a very nice job of summing it all up in seven words: eat food, not too much, mostly plants. I did a piece with Frank Hu, a nutritional epidemiologist at Harvard who was on the 2015 Dietary Guidelines Advisory Committee, and we entitled this column in the Huffington Post, Knowing What to Eat, Refusing to Swallow It. And we summed up the state of the science in five words, wholesome foods in sensible combinations, pretty much in agreement with Michael Pollan.

Interestingly, the 572-page report of the Dietary Guidelines Advisory Committee this year reached substantially the same conclusion. It took them a lot more words to say it, but the idea is this: eat a diet of wholesome, foods close to nature, mostly plants (so that would be vegetables, fruits, beans, lentils, whole grains, nuts and seeds) with or without the addition of dairy (and I would argue that the dairy should be low or nonfat, ideally locally sourced and organic), with or without eggs, fish, seafood and lean meat. The important consideration about meat whether it is beef or pork or poultry is that if we are what we eat, what we eat is what it eats. So if you are going to eat animal foods, you want those animals to be well tended, well cared for and well fed, i.e., their native diets. Well, that is the basic theme of healthy eating. So real food close to nature mostly plants, and the evidence to support this comes from an unbelievable, incredibly consistent, diverse literature, spanning populations around the world and every conceivable methodology.

The evidence that I like best is the real world experience in large populations. That is captured in a number of different studies that have looked at the health of populations over time, but my favorite these days is the Blue Zones. The Blue Zones characterizes those populations around the world that live the longest, have the least chronic disease and the greatest vitality. At present there are five Blue Zones characterized by Dan Buettner, who is the author of this work. There is one in Ikaria, Greece. There is one in Sardinia, Italy. There is one in Okinawa, Japan. There is one in Loma Linda, California, and there is one the Nicoya Peninsula in Costa Rica. These are places where people routinely live to be 100, they very rarely succumb to chronic disease, and one night at the end of a 100-year lifespan they go to sleep and just do not wake up. So they live longer, they live better and they die peacefully and that is a consummation devoutly to be wished. We all would like to be in a Blue Zone.

Well, what do they do? They all eat diets of real food close to nature mostly plants but it is not highly prescriptive. In Ikaria, Greece and Sardinia, Italy it is a relatively highfat Mediterranean diet—lots of olives, olive oil, avocado, some fish and seafood and a relatively high intake of overall fat, although most of that fat is unsaturated. In Okinawa, Japan, it is a much lower-fat Asian-style diet with lots of vegetables and a fair amount of starch in the form of rice. In the Nicoya Peninsula in Costa Rica it is an omnivorous diet with some meat, some poultry and some fish and a wide variety of vegetables and in particular yams and other tubers. In Loma Linda, California, it is a vegan diet. That is a Seventh Day Adventist population and they do not eat animal foods at all. So you could say these diets are all very different and we could talk about the differences, and that is what our culture tends to do. But the similarities are what really matter to health.

If you focus on the differences, can we say which of these diets is best? Is an optimal vegan diet better for human health than an optimal Mediterranean diet? Well, then the answer is no; we cannot say which diet is best for health. But if we look at the commonality both among Blue Zone diets and in the literature in general, we absolutely can say what dietary pattern is best for health because what makes the Blue Zone diets alike is actually much more important than what makes them different, and they are all more alike one another than any of them is like the typical American diet. There is no glow in the dark food. There is no highly processed junk food. A diet of mostly plants close to nature prevails, both in all of the intervention studies that show benefits and in these real world populations.

This is a conclusion reached by Dan Buettner in his work, and this is exactly what I found when I wrote a commissioned paper for the Annual Review of Public Health entitled, Can We Say What Diet is Best for Health. That was the question the editors put to me. That is the title of the paper and the question that you are asking now, Ryan. So if we stick with the general theme we absolutely can.

Then the final thing I will say about this is I like the fact that it is a theme rather than a highly prescriptive diet because what that means is you can pick the variant on the theme that actually works best for you and your family and for a lifetime. What that means is that you have an opportunity to choose food, not just that is good for you, but that you actually like. So you can love food that loves you back. That is a mantra for me, and my wife, who offers recipes devoted to that principle at cuisinicity.com.

Q3: Well said. I could not agree more. As President of the American College of Lifestyle Medicine, what do you consider to be the key components of lifestyle as medicine? It sounds like food would a big part of that as well?

DK: Absolutely and in fact, I routinely summarize lifestyle as medicine as a six cylinder engine. The six cylinders are feet, forks, fingers, sleep, stress and love. So feet refers to physical activity, forks refers to dietary pattern, fingers refers to not smoking. Then, there is getting adequate sleep both in quantity and quality, and mitigating stress in our lives. I do not know any way to avoid stress altogether, but people who are healthy deal with it effectively so it is not bottled up and undermining them from within. And by love, I mean strong social connections. It is interesting that in the Blue Zones where people are using lifestyle as medicine—and not because they are working hard as individuals, but because it is what their culture does for them—there is a very strong sense of community. Sometimes it is a faith-based community. Sometimes it is shared spirituality. Sometimes it is an extended family or a village. There are different ways to get there from here. All love is good love. Having a significant other, romantic love is a beautiful thing but really just having friends, people you care about who care about you, is powerfully beneficial. We are social creatures, and unfortunately, the hectic pace of modern living, the dispersal of the family and the increasing reliance on technology get in the way of that. It is really hard to maintain intimate relationships that support that need for social connection. It is a really critical component to health. So that is my six cylinder engine. I have had people suggest we should add mental health, and certainly happiness and purpose belong there, but maybe that fits under love. If you love yourself, love other people, love life, there is a sense of purpose there. Mental health is probably addressed there.

I have also had people suggest that fun should be on that list, and I am tempted to add that one. I have found that over the years working very hard I have had long stretches where I have neglected recreation in my own life, and as you know I am a devoted equestrian and when I got my own horse some years ago I really made a commitment to fitting time into my own schedule for recreation. But I actually had to think about that. I had to commit to recreation. So we may neglect fun and I think that probably costs us something. But fundamentally I would go with those six and say maybe love covers doing what you love and being with the people you love, and that obviously is the source of a lot of happiness. So feet, forks, fingers, sleep, stress and love it is!

Q4: In your experience, what are those factors in our society that are continuing to foster poor lifestyle behaviors? And more importantly, how do we come together to reshape society in such a way that would encourage the behaviors that would improve those six dimensions?

DK: I think everything about modern living that makes it modern does, in fact, conspire against health and vitality. We have done a reasonably good job with tobacco, although frankly I think it ought to be eradicated. It was a huge historical mistake. It has cost us dearly. It is a toxic substance. It is a terrible vice. It intrudes into the lives of other people no matter where you do it. You are injuring people around you with secondhand smoke. Everything about this bad idea really needs to go. So I would love for tobacco to just be banished to the dust bin of history. Again, we have made some progress there. But we continue to subjugate public health to predatory profiteering with regard to diet. It is shocking to me the level of hypocrisy here, but we routinely wring our hands about epidemic obesity in children and the rising rate of diabetes in children, and yet we all look on as we market multicolored marshmallows to kids as part of a complete breakfast and I do not see the righteous indignation. I do not see the outrage. Frankly, there ought to be outrage.

We are willfully marketing to children the very products that are propagating obesity and chronic disease. I do not really understand how any loving parent or grandparent can stand for that. So I think we have to confront the hypocrisy. I also think we have to accept that just because we invent something does not mean we need to use it. We keep inventing more technology to potentially reduce our physically active time, reduce eye contact, reduce our interactions with other people, and invention really has become the mother of necessity as Jared Diamond said and we have to be really careful about that. The good news there is we are now starting to recognize that we can redirect a lot of this inventiveness to solving even the problems of technology. So technology has made us too sedentary, but we are now well into the age of apps and technology that track how active we are, count our steps and goad us to be more active. We are now thinking more and more about standing workstations, standing desks, ways to be active while we are at the computer.

So technology has been one of the problems. It can potentially be a solution. I think we will have to invoke human resourcefulness there, Ryan, because we are not going back to the days before all of this technology. This becomes an if you cannot beat them, join them scenario. How do we take what has been part of the problem and turn it into part of the solution? But fundamentally, I think the main solution here consists of several parts. The first is awareness. I think most people do not realize that we literally could eradicate about 80% of all chronic disease. So 8 times in 10 heart attacks, cancer, stroke, diabetes, dementia do not need to happen simply by using what we already know and have in fact known for decades. I do not think the public really appreciates how luminous the prize is and how accessible it is. We do not need a new Nobel Prize; we need to use what we know. That is step one.

Step two. I think people need to understand how intimate this is. When we talk about an 80% reduction in chronic disease it sounds like I am talking about public health and you do not know who I mean and so you are not all that impressed and I certainly have not brought a tear to your eye. But if I ask you to try and remember a day when you got a phone call about someone you love going to the hospital and getting a diagnosis of cancer or stroke or diabetes or whatever it may have been, I bet you can conjure that memory. Maybe you rode in the ambulance. Maybe you visited them in the emergency room or the ICU or the CCU. If you remember that day, living through it, and then you and I recognize that, if knowledge were power, there are 8 chances in 10 that bad day would not have happened that, that person would not have been sick. We get a different sense of this whole thing. It starts to be obvious that this is up close and intensely personal; we all have literal skin in the game, the skin of people we love. We are also talking about bequeathing to our children, if we so choose, a world where 8 times in 10 those phone calls about some calamitous diagnosis do not happen. Those bad days do not occur. That is what we are talking about. So that is step two: recognizing this is not about an anonymous public, it’s about you, and me, and the people we love.

So one is awareness of how great the prize really is, two is the appreciation that this is up close and personal, three would be getting past pseudo-confusion and, in particular, that pertains to diet. What we know reliably about diet is enough to eradicate up to 80% of all chronic disease. Well, gee, let’s not bog down in the relatively minor differences of opinion like how important is fructose relative to glucose or that kind of thing. Yes, there are some interesting questions there but they are not important enough to divert us from deriving the enormous benefit from a diet of real food close to nature mostly plants. Let’s do that and then answer additional questions rather than pretend we do not know anything and spin around in circles. So getting past pseudo-confusion would be the next step, and I think we need some public health initiatives to clarify to the public that we are not clueless about the basic care and feeding of Homo sapiens, so then the public needs to rally around that.

Then the next step after that—once people know the prize is great, they have got skin in the game, they are not confused—is to either change themselves or change the world. Those are really our two options. So one way to get there from here is to change our culture. Change our environments so that eating well is the norm, that being active throughout the day is the norm, getting enough sleep is what everybody does, a strong sense of community is the cultural norm, mitigating stress is the cultural norm. All of these things are achievable because they already exist in the real world. They are the way the Blue Zones operate, for example, and they can be replicated. But we cannot afford to keep waiting on the world to change either because we do have skin in the game right now. So the other option is to change ourselves to deal more effectively with the world. I describe that as skillpower. It begins with wanting to be healthy and vital and to share that with the people that you love. That is will power. But wanting something and knowing how to implement it are two very different things.

Skillpower is will power’s neglected cousin, and healthy living in the modern world takes skill. So what do I need to know to make good dietary choices wherever I am, whatever I am doing? Well, there is a skillset there. What do I need to know to prepare nutritious, delicious, convenient, economical meals for myself and my family? There is a skillset there. How do I fit physical activity into my daily routine no matter what? There is a skillset there. What is a good sleep hygiene program so I can relax and fall asleep and get a good night’s rest? There is a skillset here. And this is something I write about extensively in my latest book. The emphasis on skill power I think really deserves more attention. Then the good news is if enough of us empower ourselves with a skillset for healthy living, we become the change we want to see in the world because if we all make better dietary choices when we go to restaurants and we go to the supermarket, well, it is not long before that starts to exert a major influence on the food supply. If we are all adamant about being physically active during the school day and the work day, it is not long before that starts to infiltrate the culture of schools and worksites and becomes more of the norm.

So some of us in public health are working to change the world. All of us can work to change ourselves, but when enough of us have changed ourselves, we become a global change. A change in the food demand is the surest path to a change in the food supply for instance. So, in fact, we can think globally about changing the world; we can act locally and change ourselves and our families with skillpower, and then those two things come together. So the sequence is awareness of the prize, recognition that we have got skin in the game, getting past the pseudo-confusion, acquiring the relevant skillpower so that we can get to the prize for ourselves and our families and then being part of a global change: a change in culture and a change in environment so that the mighty wind of culture leads toward health— not away from it.

Q5: I have heard you quote Abraham Lincoln in saying that the best way to predict the future is to create it. It seems those steps certainly feed that perspective in that if we begin the change personally, the future environment will start to model that change. One question that you and I both have been spending a lot of time trying to answer is how to create that kind of movement or ripple effect within communities or other areas of influence. I know you have a new initiative out called GLiMMER, and I would love to hear more about what GLiMMER is, what some of the primary goals are and how you see it being a catalyst of change for those who are part of it.

DK: I am really excited about the GLiMMER Initiative. GLiMMER stands for Global Lifestyle Medicine Movement to Effect the Reform and the core element in this initiative that is innovative is something called the True Health Coalition. This is really predicated on the notion that knowledge is only power if you put it to good use, and that standing between our population, our families, our communities, our nation and frankly increasingly our world and the luminous prize of eradicating up to 80% of all chronic disease is a failure to turn what we know into what we do. So GLiMMER is dedicated to fixing that problem and the True Health Coalition essentially is designed to be a global fusion of perspectives and opinions that rally around the common truths. So for instance in the realm of nutrition, which is the most controversial element to lifestyle as medicine, it would be easy to look at the advice of leading advocates of a vegan diet and the advice from leading advocates of say a Paleo diet and conclude that they are diametrically opposed, that these folks cannot agree.

But I have been doing what I do in health promotion and disease prevention for about 25 years now and in that process have gotten to know most of my colleagues who are prominent in this space around the world. And at one time or another I have actually had a meal with most of them. Little by little I became more and more impressed with the fact that, whatever the rhetoric, when it is time to sit down and eat something and you look what is on their plate, all of the experts around the world from vegan to Paleo put stuff on their plates that looks more alike than different. They really do. So yes it is true that Paleo advocates will choose lean meat or fish along with a variety of plant foods, and maybe they will avoid the grains and maybe they will avoid the dairy if they are being quite fastidious about Paleo. In contrast, the vegans will also avoid the dairy but include the grains and avoid the meat but have otherwise the same wide variety of plant food in their diets. The bottom line is neither of them has anything on their plate that glows in the dark and nobody is eating fast food and nobody is eating junk food.

So it seemed to me that there was this massive agreement about fundamentals and the public knew nothing about it. And I thought well, it would be critical to prove that. So I formed the True Health Coalition and started calling on all of my most esteemed colleagues all around the world whatever their platform from vegan to Paleo and saying look, here is what I think are the core principles of healthy eating: a diet close to nature and frankly mostly plants because that is all that can really work in terms of sustainability in a large population. Some people want to eat game or wild fish, which is absolutely fine, but I think we can all advocate for a diet of mostly plants because we know that is healthy and we know that is more sustainable and it kind of goes on from there. I asked them if they would agree with me, if they would agree with one another. Can we all stand together and own this core set of basic principles of healthy living in public? And, to date, the Council of Directors of the True Health Coalition is nearly 200 of the world’s leading experts and influencers in the area of health promotion and disease prevention representing well over 20 countries. These are people, whatever the tree to which their own career is devoted, willing to come together in public and acknowledge we are all looking at the same forest. That’s a beautiful, powerful thing!

And we continue to grow this council on a weekly basis so there will be many more soon. But it is about 200 people from roughly 24 countries so far including two former surgeons general of the United States, a former commissioner of the US FDA, deans of schools of nutrition, chairs of nutrition departments including the most illustrious such as Harvard, absolute luminaries in the space of the culinary arts including a former chef at the White House and leaders in sustainability and preservation of vital resources such as water, food, biodiversity, conservation, all coming together to rally around these common principles. What is most impressive to me about what we have been able to achieve so far is not just the caliber and the pedigree of the people who are standing together to defend these simple fundamental principles of healthy eating as well as the other principles of healthy living, but it is a team of rivals approach.

You mentioned Abraham Lincoln’s quote, and I certainly like that sentiment. But another thing that Lincoln is well known for is that he oversaw a cabinet that was a team of rivals, and it was a product of the times that he was in, but he needed to manage this diversity of perspectives, people who did not necessarily agree readily with him or with one another, and frankly he managed to elicit from that a hybrid vigor. There is a wonderful book about the Lincoln presidency entitled Team of Rivals. Well, we wanted the GLiMMER Initiative to embody that same power, that hybrid vigor, and so on this same council we have some of the world’s leading advocates of vegan diets and we have some of the world’s leading advocates of paleo diets, and they have come together to say we agree more than we disagree. That is an incredibly powerful thing.

So what we are working to do right now is develop the full scope of this project to grow this council, and then we want to become such an indelible source of unbiased guidance about nutrition because, no matter who your hero is, our hope is your hero will be a member of this council and we would like everybody to start to wonder well, what is the True Health Coalition? What does the GLiMMER Initiative have to say about this? Now the full scope of the initiative will include other things, enhancing medical education, enhancing medical practice, working to support causes such as the Blue Zones Project, which is about changing culture to make it more health promoting. But the initial and innovative contribution here, Ryan, is to take a massive global consensus about the fundamentals of healthy eating and healthy living out of the shadows and show it to the public so that we can all rally around it. Because if you think of getting to health as being the challenge of getting there from here quite literally, the prerequisite to that is agreeing that we know where there is. We got to the moon; but first we had to agree where to find it! You cannot get there from here if you do not know what direction to set off in, and that has forestalled our progress in public health for decades. The GLiMMER Initiative is committed to fixing that.

Q6: I know as soon as people hear this they are immediately going to get excited about the initiative and want to get involved. How do people across the country contribute to the GLiMMER Initiative, and what can they do today to continue building momentum around it?

DK: Thank you—I appreciate that, and, frankly, we wanted to create an opportunity for this to quickly become a movement and for it to benefit from exactly that inclination. If you either Google GLiMMER Initiative or visit glimmerinitiative.org, you can sign up to be a member of the True Health Coalition. And what it asks people to do is to review the basic principles we are working to defend, and, if you agree with those—if you agree that it is vitally important even as we pursue answers to questions that we have not answered that we use the answers we already have; if you agree that we are not clueless about the basic care and feeding of Homo sapiens; if you agree that the basic theme of healthy eating is what we should be acting on rather than bickering and dithering as we contest whose variant on that theme is the best (because maybe nobody’s is); if you agree that it is important to think about diet and health beyond our own skin as something that we can share with the people we love, but also beyond that think about sustainability in the next generation; if you agree with these fundamentals of health promotion and you want that luminous prize of 80% reduced risk of chronic disease in your own life and the lives of the people you love the most— then join us. Because in unity there is strength, and when we can get enough people to sign up as members of the True Health Coalition and we all start communicating with one another routinely, then we can all change ourselves and share relevant skills for healthy living, but we also can become a global force.

We have really seen some impressive natural experiments over the years demonstrating to us all that demand trumps supply. When the Atkins Diet was hugely popular, every supermarket in the United States filled up with low-carb products. Now, they were not necessarily nutritious, which is what the food industry has been doing for decades. Essentially, they have figured out very profitable ways to invent new varieties of junk food. So there is low-fat junk food, there is low-carb junk food. But the important issue there is that we wanted something new, and within a very short period of time they generated it for us. They reformulated, they produced what we were asking for. There is an opportunity through the True Health Coalition to make sure that what we are asking for is genuinely wholesome, genuinely health promoting and that then has the potential to reshape the food supply, to reshape our culture. So go to glimmerinitiative.org, click on the True Health Coalition link and join us. Sign up there and let’s change the world together.

Q7: What is your perspective on the future? Are you optimistic that this initiative and the other initiatives we have been discussing will create change? What do you think the future holds for health promotion and for the state of health and wellness of people in general?

DK: Well, to be perfectly blunt about it, I go back and forth between being quite optimistic and genuinely concerned that we will never get out of our own way. So in my darker moments I think maybe we have not yet run out of ways to eat badly, and we will invent another and another one and another one and keep going around in circles. Maybe the forces of profit over public health are so strong that we cannot win. So every now and then I feel that way and it would be dishonest not to say so. But for the most part I am optimistic. I think we have new and better ways of sharing information with one another. I think we are running out of ways to eat badly. I think we are running out of opportunities to invent new varieties of junk food. I think we are starting to recognize that fixing one thing at a time, like cutting fat or carbs or fructose, and breaking six does not improve a food product—that it is just lipstick on a pig—and I think we have had enough of that.

I think we are starting to focus more on the health of our children, partly because we have no choice. Because epidemic childhood obesity is such a serious public health concern; because chronic diseases that used to occur in mid-life are affecting our kids. Whereas we might be willing to do silly fad diets and irresponsible things for ourselves, we generally are not willing to do that when our kids are involved. So our kids are forcing us to be more responsible and to think about long term and sustainable healthy living. I think more and more people are aware of, and concerned about, the state of the planet from climate change to water supply. We are all realizing that how we eat and how we take care of ourselves has implications for the health of the planet, and it is starting to become a very compelling message that is boxing us in. The best example of that, Ryan, is the 2015 Dietary Guidelines Advisory Committee recommended a mostly plant-based diet for human health because that is what the evidence suggests, but they also said it is essential that we do that for sustainability because we require less water, for instance, to produce plants that we eat than if we use water to produce plants to feed them to animals and then eat the animals.

There was recently a report out of California looking at the water consumption involved in the production of the various agricultural products out in California; to produce a serving of beef requires an order of magnitude more water consumption than to produce almost any of the plant foods that come out of California. So it becomes a relevant issue to us because, aside from health-related factors, we also cannot afford the status quo. The CDC, for example, has projected that, should current trends persist, by about the middle of the 21st century as many as 40% of Americans could be diabetic. Now, we have about 28 million diagnosed diabetics in the US right now. If 40% of us were diabetic we would have 128 million and, frankly, there is no way to manage that or pay that bill.

So we are running out of alternatives. We have to get this right. We have exhausted all of the bad options, we are more aware, we are looking more at the next generation, we are thinking more about the confluence of human health and health of the planet. These are extremely hopeful signs. So all of that I think is coming together and should create a tipping point. And then, frankly, I am very hopeful that an initiative like GLiMMER, which brings together a who’s who in global public health and health promotion, can rally people to these fundamental truths about diet and health so we stop getting distracted with false promises and fads and really do the job of translating what we know into what we routinely do because the potential benefit of that is enormous.

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