Gerald Cox, MD and Anafer Barrera, RDN – Engineered to Crave: How Big Food Hijacked the American Plate (Part 2)

Dr. Gerald A. Cox and registered dietitian Anafer Barrera join host Dr. Ned Palmer for the second installment of the three-part series, moving the conversation about ultra-processed foods out of the abstract and into the exam room. The question is no longer just what’s wrong with the modern food supply. It’s how clinicians can actually talk about it with patients in a way that helps rather than shames.

Dr. Cox and Anafer make the case that every nutrition conversation starts with tone. Before a single recommendation lands, patients need to feel heard rather than blamed, because food is rarely just fuel. It’s routine, reward, emotion, and sometimes an addiction-like pull. The two walk through the NOVA classification that gives “ultra-processed” its precise meaning, from minimally processed foods all the way to the soft drinks, instant noodles, and cured meats drawing the most scrutiny. They dig into the mounting evidence tying these foods to cognitive decline and dementia, whether the risk is dose-dependent, and why food itself can become a source of anxiety when nutrition advice tips into fear.

The conversation also takes on the harder, more practical questions. What does this look like in a high-volume clinic with ten minutes per patient? The guests trade the checklist for a single opening question: how important is diet to you, and what’s your biggest barrier? They champion an “add, don’t just subtract” approach, one that asks patients to eat enough earlier in the day, build in variety, drink water when a craving might be thirst, and stop treating counseling as a list of foods to give up. They also widen the lens to the systems patients live inside, where cheap, marketed, convenient food is the default. Along the way they point to a local program that doubles SNAP dollars at the farmer’s market and the case for subsidizing real food over industrial staples.

Throughout, one idea anchors the discussion: the goal isn’t moderation or willpower. It’s diversity, addition, and empathy. Meet patients where they are, treat food as a tool for support rather than a moral battleground, and the whole conversation shifts from blame to nourishment, from restriction to expansion, from individual failing to structural understanding.

Here are 5 takeaways from our conversation with Gerald Cox, MD and Anafer Barrera, RDN:

1. Lead with empathy, not assumptions

The guests emphasize that conversations about nutrition and ultra-processed foods should start without judgment. Instead of assuming a patient’s body size or eating habits tell the whole story, clinicians should ask open questions and recognize the many factors shaping food choices, including stress, money, access, habits, and childhood experiences.

2. “Convenience foods” are about access and behavior, not just nutrition labels

The episode reframes ultra-processed foods as part of a broader “convenience” pattern: shelf-stable, quick, widely available foods that often show up when someone is tired, stressed, hungry, or short on time. The key point is that the issue isn’t moral failure — it’s that convenience can quietly drive most daily intake when life is hard.

3. Diversity and addition work better than strict restriction

A major theme is that patients respond better to adding nourishing foods than being told to cut everything out. The guests argue for building a fuller food “toolbox” — more water, more meals, more produce, more protein, more variety — so the intake of ultra-processed foods naturally decreases without triggering fear or rebellion.

4. Hunger, fatigue, and sleep strongly influence choices

The episode connects overeating convenience foods to skipped meals, poor sleep, anxiety, and low satiety. When people are hungry or depleted, they are less able to make deliberate food decisions and more likely to choose whatever is fast and rewarding. That makes foundational habits like regular meals and sleep part of the nutrition conversation.

5. The biggest solutions are systemic, not just personal

The guests repeatedly stress that food choice is shaped by systems: food deserts, healthcare time constraints, insurance incentives, and the food industry itself. Their preferred solutions are public-health oriented — subsidizing real food, supporting community programs, and bringing dietitians into care teams — because lasting change requires changing the environment, not just telling individuals to “try harder.”

Transcript:

Anafer Barrera:
If you value nutrition and you’re with your patient and you’ve got 15 minutes, always start with a question: How important is your diet to you? Don’t ever assume that someone in a larger body is eating a lot more convenience food and soda than someone in a smaller body, because that’s not always true.

Ned Palmer:
Hello, everyone, and welcome back to The Podcast for Doctors (By Doctors), brought to you by Panacea Financial. I am so happy to have two guests with me here in the studio today. We’re continuing our series on ultra-processed foods, health, nutrition, the mind-body-gut connection, and everything you can be doing as a clinician to provide better information to your patients as they make nutritional decisions every single day.

I’m thrilled to be here today with my guests, Anafer Barrera, RDN and Dr. Gerald Cox.

Anafer is a registered dietitian nutritionist and Master of Public Health in Health Education and Behavioral Sciences, a certified intuitive eating counselor, certified Body Trust provider, and certified Mindful Self-Compassion healthcare provider. She’s passionate about helping people heal their relationship with food and their bodies through compassionate, evidence-based care. Drawing from both her professional expertise and her own experience overcoming disordered eating, body image struggles, and health anxiety, Anafer empowers others to build sustainable health, reconnect with their bodies, and find lasting freedom from the diet cycle.

Anafer, welcome to The Podcast for Doctors (By Doctors). It’s really great to have you here.

AB:
Thank you. I’m so excited.

NP:
I’m extra glad to be back with Dr. Gerald Cox for our third conversation overall and our second on this particular topic. Reintroducing the one and only Dr. Gerald Cox: a physician, educator, and entrepreneur dedicated to preventing and reversing cardiometabolic disease.

As a specialist in preventive medicine, obesity medicine, lifestyle medicine, internal medicine, and artificial intelligence, Dr. Cox has built his career around the future of preventive care by asking a simple but powerful question: How do we help people live longer, healthier lives?

He serves as an associate professor at Loma Linda University and is the co-founder of Mirror Health and Wellness, where his work focuses on improving patient outcomes, advancing population health, and building better systems of care for some of healthcare’s most pressing challenges.

Dr. Cox, welcome back. It’s great to have you. I am amazed and thrilled to have both of you here today. Reading through your introductions, I think I’m the least qualified person to be here. I definitely have the fewest certifications. Dr. Cox and I joked about this last time—I don’t think I’ve ever seen somebody with more letters after their name.

Gerald Cox:
Nice to see you, Dr. Palmer.

NP:
I think Anafer’s giving you a run for your money, though, and I really appreciate that.

GC:
She should. I think I’m going to have to work alongside Anafer when it comes to treating some patient populations.

NP:
I absolutely love it.

So we’re back talking about our series on ultra-processed foods and what we as clinicians can all be doing about it. That’s why Dr. Cox and I were so excited after our first session to bring in a specialist like Anafer—someone who can really walk us through coaching patients at the bedside when it comes to nutrition, health, and body image. Frankly, it’s something we as physicians either don’t receive much training in or often shy away from because it isn’t really baked into our curriculum.

To date, there are only five medical schools that provide required nutrition education beyond what is mandated by the USMLEs. It’s growing—that number was zero just a couple of years ago—but five out of the 183 medical schools in the United States is still incredibly low.

We’ve known for years that ultra-processed foods have come to dominate the Western diet. Recent literature has really shifted the conversation, though. Last time, we spent a lot of time on the academic side of this. We’re not just talking about calories anymore. We’re also talking about the commercial determinants of health and how they’re tied to the social determinants of health.

We talked about the American Journal of Public Health and how ultra-processed foods have been linked to millions of deaths globally, along with significant morbidity in addition to mortality, including mental health outcomes.

So let’s dive right into the questions.

Dr. Cox, since our last conversation, how would you frame your approach to ultra-processed foods? How do you approach this conversation with your patients as an obesity and lifestyle medicine physician?

GC:
I think when I’m talking to my patients, the hardest part is really creating the right atmosphere for the conversation. One of the easiest ways I’ve found to do that is by acknowledging the elephant in the room. We all understand that food plays a much bigger role than simply choosing what we’re going to have for breakfast, lunch, or dinner.

I often make this joke: if I skip breakfast and then have a really small lunch, by the time I’m leaving work and driving past Chick-fil-A, I’m suddenly thinking, I’ve got to get some chicken tenders and a chocolate shake.

What I try to do is break down the idea that food has a significant psychological component. I also like to make sure my patients are giving me permission to have this discussion with them.

Once we start talking about the psychological aspects of food—how certain foods can become more behaviorally driven and even addictive rather than simply satisfying our body’s need for energy—I use that as a way to ease into the broader conversation about ultra-processed foods and how we can work together to minimize them.

NP:
Anafer, similar question. How do you structure these conversations with your clients? Food is so integrated into life, mental health, physical health, and overall wellness. What’s your entry point that helps you build that clinical relationship?

AB:
Yeah. If you don’t mind, I’d actually like to say a couple of things first, and then I’ll talk about how I approach these conversations with my clients.

First of all, I’m really grateful that physicians are having these conversations among themselves. Ned and I talk all the time about controversial topics, especially when it comes to medicine, science, and lifestyle. One thing I really appreciate about Ned is that he’s comfortable admitting what he doesn’t know.

He mentioned that physicians don’t receive much education in nutrition, and that raises the question: What would healthcare look like if they did? It’s hard to say.

I thought I knew everything after taking my very first nutrition course. I read the textbook cover to cover, passed with flying colors, and that class convinced me I wanted to become a dietitian. Looking back, though, I knew very little. I understood only the tip of the iceberg. All of the complexity was hidden underneath.

So who’s to say what would happen if physicians received more nutrition training? Hopefully, they would rely on dietitians even more because they’d better understand what they don’t know. Or maybe they’d decide this is the field they want to pursue, combining medicine with lifestyle medicine in a really powerful way.

Either way, I truly appreciate that these conversations are happening.

AB:
As you heard from my credentials, I’ve pursued a lot of additional certifications since becoming a dietitian because I really focus on the psychological component of why we eat what we eat.

When I approach a patient—or, in private practice, a client—the first thing I want physicians to remember is to approach them without judgment.

To truly avoid judgment, you have to educate yourself about all of the external factors that influence how people choose food: socioeconomic status, living in a food desert, childhood trauma, growing up with people constantly telling you what to eat, and then later expressing autonomy through food choices. There are so many factors that influence why someone eats the way they do or why they have the body they have.

So first and foremost, approach patients without judgment.

I also always assume they’re doing the best they can, even if they’re eating mostly packaged foods, living in a larger body, or skipping meals altogether. I believe they’re doing the best they can with the education, resources, and support they’ve been given.

AB:
Because of that, every conversation is different. It’s actually difficult to simplify the question, “How do you approach your patients?” because it depends on why they’re seeing you.

Let’s say you have a 22-year-old patient who’s hospitalized with uncontrolled type 1 diabetes. They’re eating mostly ultra-processed foods, not monitoring their blood sugars, and really struggling.

I’d start by asking, “Tell me what you’ve tried in the past.”

I’d acknowledge that managing diabetes is hard, and then I’d ask them to tell me about their diet.

Maybe they say, “I know I shouldn’t be eating three fried chicken sandwiches for breakfast.”

My response wouldn’t be, “You can’t eat fried chicken sandwiches.” Instead, I’d say, “You actually can eat your fried chicken sandwiches, but let’s look at what happens to your blood sugar when you eat three at once. Could we spread them out? Could we adjust the timing with your insulin?”

I don’t want to assume they lack knowledge. They may already know everything they’re supposed to do. Instead, their beliefs or experiences may be influencing their behaviors.

So I listen to what they’ve already tried, validate their experience, and then either refer them to a dietitian when appropriate or help them think through small adjustments by saying, “That’s completely valid. What if we tried this approach instead so your medications can work more effectively for you?”

NP:
I love that framework right off the top. I also think it’s really fair to say that Anafer and I work together. I’m a hospitalist, a Med-Peds hospitalist, and Anafer is a dietitian at the hospital, so we do have some shared clinical context for our listeners joining us.

I love what you’re describing there. If I were to put a word on it, you’re approaching it immediately from a place of empathy.

I think in diet, much like we talked about last time, we spent a lot of time discussing the overlap between diet and addiction and how, frankly, from a clinical standpoint, those were deeply judgmentally treated illnesses for a long time.

What I’m really excited about with the Lancet article—the Lancet tome from a year ago—and then the American Journal of Public Health publication, which was a similar tome from just two months ago, is that it really changes the mentality of clinicians around why this is happening.

Food is often seen as a distinctly personal choice. Through the science and data that’s being presented, I think I’ve grown to completely disagree with that. Humans are making rational choices in that moment.

Why are they eating ultra-processed foods? Probably because it’s the cheapest way to get enough calories in a day, probably because it’s the fastest, and probably because it provides some emotional high or even a dopamine surge, as we learned about through flavor engineering.

NP:
All of these things are playing into it. I think that immediately takes the judgment out of the room and leaves space for empathy.

You can walk into that patient encounter or client interaction just like you described and say, “You’re doing your best.” I think that’s such a valuable framework to approach this from, just like we would with infections, autoimmune diseases, or anything else.

You rarely walk into the middle of an asthma exacerbation and say, “Well, what were you doing breathing air this week?” especially in the middle of wildfire season.

But again, diet and addiction unfortunately breed this kind of mentality among clinicians. I love the idea of approaching it from that space of empathy.

Dr. Cox, I’d love to hear your thoughts and your approach on that. How do you inject that empathy? And how are you taking this information from the Lancet and American Journal of Public Health and using it to create a broader space for your patients?

GC:
I love that Anafer is really speaking to what is an area of focus these days when it comes to treating obesity. The Obesity Medical Association and bariatric associations are really trying to focus on the patient and their backgrounds, while also looking at the clinician and their backgrounds, because a lot of times we bring our own hidden biases into the exam room.

Anafer and I were chatting a little bit before we got started on this podcast. We were talking about how, in 2020, there was this real influx of trying to understand hidden biases within the art of medicine. I think that had its peak around 2022 and 2023.

GC:
But I think what I’m hearing from her, and what I really would like to emphasize, is trying to bring that back.

If we look internally and say, “Well, I don’t have a problem with food. I make the right choices. Why aren’t you making the right choices?” then we kind of have that bias toward that individual, like they’re not doing enough.

And those patients feel that. When you feel like you’re being judged, there’s a feeling, there’s a sensation, and that leads to a lot of guardrails. You’re not able to treat that patient appropriately if those guardrails are up.

GC:
What we really want to try to do, and speaking to what Anafer was mentioning, is bring empathy into the room and see that patient for where they are.

What habits do they have that they don’t recognize? What culture do they live in where food plays such a significant role? What cultural habits are they implementing, and are they doing it to an extent that’s causing them harm?

Then how do we approach that in a framework where we can actually break down their day-to-day lives in a way that can systematically move them toward their ultimate higher self?

GC:
When you start to look at some of these journals that are coming out and some of these articles that are speaking to the nature of public health—which I haven’t heard you mention yet, Dr. Palmer, you have a background in public health and are a public health expert, hence these conversations with you involved—you start bringing these articles and this research to the front of clinicians.

When we start seeing how bias is affecting treatment, and when we start seeing how certain treatments are actually having better effects than others, we’re starting to get into not just theories. We’re getting into theories supported by evidence-based science that really show: hey, maybe we need to take a little bit more of a detour in this direction.

GC:
Maybe we need to have more discussions about ultra-processed foods. Maybe we do need to have more advocacy around our food supply being more monitored or regulated.

Maybe we need to have more policies in place that keep certain restaurants or fast-food restaurants away from schools.

I think that as more of these articles are starting to roll out, we’re getting that permission and that open atmosphere to really address the elephant that’s in the room.

NP:
Absolutely. The advocacy space that you describe there—if that’s where public health is, all of us are public health practitioners. I acknowledge I am one.

I think two of the strongest levers that exist in public health are policy and advocacy, and you’re describing both. Education, of course, is naturally the third.

Clinically, it sounds like we’re trying to emphasize education, and then from a public health standpoint, we’re also working on policy and advocacy. We’re really trying to find ways to make sure that exposure to certain things at certain times, like certain critical moments of development, is addressed.

NP:
I love that. There are foods we’d probably want to keep out of schools. I think we could probably all agree that there are foods we’d want to keep out of schools, or maybe there are certain qualities of food that we’d want available during certain periods of development.

As a pediatrician, the next part of this conversation I’d love to see is the extension of ultra-processed foods across different times of life.

We know it’s a dose-dependent effect. That’s largely what we see. I think that’s why we see many of these diseases accumulate toward the later part of life.

But we’re also seeing massive increases in pediatric obesity, pediatric metabolic syndromes, and other things like that that frankly aren’t yet connected to this whole framework.

NP:
As we increase our knowledge depth around ultra-processed foods, I don’t think anybody is going into this with the assumption that these are good for children.

It’s identifying the magnitude of harm and making sure that we are then, again, going back to our advocacy roots, which we all as providers in different ways hold so dear.

I want to talk about the feature specifically. In July 2026, the American Journal of Public Health published an amazing longitudinal study linking ultra-processed foods to a significantly higher risk of dementia and cognitive impairment in older U.S. adults.

I find this study really fascinating because, going back to this idea of this being dose-dependent, ultra-processed foods have really taken off in the last 20 years.

The study population was 60, 70, and 80 years old. Their actual exposure was probably smaller to ultra-processed foods than maybe even the three of us here from a generational standpoint.

Ultra-processed foods existed when I was born. They’ve been alongside my nutrition the entire time I’ve been alive.

NP:
I was a little concerned about some of the implications here. Is this a dose-dependent thing? Is this something that disproportionately affects the elderly? Maybe ultra-processed foods toward the end of your life lead to more rapid decline.

I’d love to hear from both of you on your thoughts about possible mechanisms. Why is this leading to neurodegeneration?

Recognizing that we’re all just looking at this as more correlation than causation, probably for a while, until we really figure it out.

AB:
I was telling Dr. Cox earlier, nutrition science is like being in the Amazon rainforest. There’s so much going on.

I love that you just said, like, who knows about the difference between correlation and causation with this exact impact on ultra-processed foods?

At the same time, we have shorter attention spans with technology. We’re living in a revolution that’s not just about our nutrition. We’re working differently, we’re always on a screen, and our relationship with technology has changed.

AB:
It’s going to be really hard to tease apart, but there are certain certainties around ultra-processed foods where it’s inevitable. You can’t ignore that these foods don’t happen in nature and that these foods have certain chemicals that are not nutritionally benefiting us.

At the same time, I want to give voice to the fact that we are living in an age of anxiety. I’ve known that in my bones since I was a high schooler.

I remember the first time a friend of mine told me high-fructose corn syrup was bad for you and all these things would happen to us if we had it.

I went to my pantry with my friend, and we started digging through everything, throwing away anything with high-fructose corn syrup.

And that’s just one ingredient.

AB:
After studying nutrition for 15 or 20 years after that, you learn it’s not just one enemy. There are so many things that you can hear once you get interested in nutrition where suddenly everything feels like it’s bad for you.

It’s not just high-fructose corn syrup. It’s not just one ingredient. So how do we move forward as consumers and as people who eat with grace and a little bit more peace, while still knowing, “Hey, this isn’t good for me, but I need to live”?

That’s the extreme place where I found myself at one point in my life, and I found that a lot of my patients also need that clarity and peace of mind.

AB:
First of all, it’s not going to kill you. Like Ned said, it’s dose-dependent. The dose makes the poison here.

How much of your diet is convenience foods? And if that much of your diet is convenience foods, we need to look at different things.

Are you living in a food desert? Are you rebelling from your childhood where maybe you had a parent who only allowed you to eat vegetables and never allowed you to eat processed foods, and now this is what you binge on?

There are so many factors. What’s going on where a significant portion of your nutrition is not really nourishing you?

AB:
As far as anxiety for parents, intuitive eating really preaches—and gut health does too—that you want diversity in your diet.

When you’re looking at it from the lens of gut health, you’re not thinking of ultra-processed foods as a way to improve your gut health, of course.

But if you can provide your children, or even when your child is inside you, with a variety of foods, more than likely they will navigate it imperfectly. It will take so much patience, but they will navigate it and have these exposures that not a lot of kids maybe get.

A lot of kids might be lacking exposure to fresh produce, or on the other end of the extreme, exposure to processed foods.

AB:
That’s where we get a little bit more of, “Then they’re of age, and they’re like, what do I do with this new diet that was never shown to me as a kid?”

That’s not a perfect science, and I am not a pediatric dietitian, so there’s so much more nuance within that.

But I would say don’t be terrified of your ultra-processed foods if you are a parent, provider, or consumer. Make sure that you’re nourishing yourself in other ways. Make sure that you’re eating fresh produce and fresh meats.

And yes, when you’re eating fresh meats and fresh produce, there’s going to be science that’s going to demonize some way that those potatoes are grown or that meat is raised.

AB:
We can really put ourselves in a corner where it’s better to just not eat at all. I’ve heard that from so many people: “What if I just don’t eat at all? Can I just take a pill?”

The last thing I want is for people to fear food that much. And it does happen where they’re not eating.

Let’s go back to Dr. Cox’s scenario where he skips breakfast, has a quick lunch, and then on his way home wants that Chick-fil-A.

Even without all the marketing and without talking about the chemical composition of these processed foods, a hungry person is less capable of making sound nutrition decisions.

AB:
If you’re afraid of eating because nutrition education is leading you to all these corners where you’re like, “I feel like I can’t eat bread, I can’t eat meat, I can’t eat anything,” you’re going to end up hungry.

And when you’re hungry, you’re less empowered to choose a meal that’s going to take you 30 minutes to cook versus the package that takes you three seconds to open.

So go upstream a little bit and say: are you eating enough?

And I’ll get off my soapbox now.

NP:
No, you were invited for your soapbox. Please, please don’t get off it.

I have two quick comments or questions. One is that I love the term “convenience foods.” I feel like, more than ultra-processed foods, that’s something I can immediately identify with.

Can you help put a definition to that for our listeners?

AB:
Actually, I chatted with some dietitians before coming on this week, and it was really hard to define. It always has been hard to define.

When I was in grad school, I’ll never forget my director saying, “All right, let’s define processed foods.” It opened up this whole can of worms.

We were all thinking, “I thought it was so obvious what a processed food was,” but it’s not.

Convenience foods—I don’t know. I think of something that’s shelf-stable, won’t go bad, doesn’t require cooking, doesn’t take extra time, and you can access it at almost any gas station or vending machine. You open a package and it’s ready to go.

Or things like Stouffer’s microwave dinners—that’s also convenient.

But so is an apple, right?

So yeah, it’s hard. Convenience foods are really hard to define. I’ll let you take a stab at it, Dr. Cox.

GC:
Honestly, this is one of the biggest challenges being discussed today.

Out of Brazil came a lot of these studies using what’s called the NOVA classification system. I highly encourage our listeners to do a quick Google search of the NOVA processing system or classification system.

You’ll see foods broken down into at least four different categories. Now, it’s not perfect by any means, but right now it’s kind of the gold standard being referenced in a lot of the literature.

GC:
Group one would be those minimally processed foods, like Anafer was mentioning: fruits and vegetables, raw meat, eggs, things like that. Foods that are essentially one ingredient.

Group two would be more about culinary processing, like things such as vegetable oils or butter.

Then you have group three, which includes more processed foods like canned fruits, canned vegetables, and baked bread.

Then you have group four, which is typically the ultra-processed category. That’s soft drinks, instant noodles, reconstituted meats, cured meats, and things like that.

Those group four foods are where a lot of the controversy is today.

GC:
Going back to that study you were referring to earlier, Dr. Palmer, regarding dementia, I think one of the biggest things that came out of it was the cognitive impairment without dementia.

Anafer, you were making reference to this before too. I found that to be a really interesting category because I think all of us have experienced some form of cognitive impairment at some point in our lives.

Maybe it’s just feeling a little groggy in the middle of the afternoon. Or here’s a good example: maybe you just had lunch while watching a World Cup match, and you find yourself waking up from a deep nap thinking, “Wow, I did not prepare for that. I didn’t realize I was that exhausted. What time is it?”

GC:
Or even our children. Dr. Palmer, you and Anafer were mentioning how we’re starting to see a lot of behavioral conditions like anxiety becoming a bigger issue today, especially since the pandemic.

These little cognitive impairments without dementia don’t fit into the category of dementia because they don’t meet the criteria for it.

But I thought this study showing a 46% increase in those individuals who consume large amounts of ultra-processed foods was a significant finding. That’s something we need to look at more closely.

To me, one of the interesting things was the association with processed meats, like bacon and cured meats.

And it doesn’t mean, like Anafer was mentioning, that I can never have bacon again. I can’t have my bacon and eggs, or my cream of wheat in the morning. It doesn’t mean that.

GC:
The question is: how do we change our lives? Part of this is identity. Food is connected to our routines and who we are.

But if something becomes almost like a prescription drug, where you’re having bacon and eggs two or three times a day every day, then it becomes more of an issue.

I think we have to look at the diversity of food, like Anafer was mentioning. We have to introduce biodiversity for our gut health, our mental health, and our physical health.

You can even take that further into spiritual wellness and other areas, but we have to look at diversity because that helps limit our exposure to the same insult over and over again.

GC:
For example, with alcohol, we talk about how there is no safe amount of alcohol. But we also know we can’t just tell people, “Don’t drink ever again for the rest of your life.”

They’re going to say, “Okay, Doc,” and then go meet their friends at the bar to watch the FIFA game.

We want to be able to connect with these patients. Maybe we shouldn’t have three beers a night or five beers a night. Maybe we can regulate that.

Maybe you have a glass of wine with dinner on a weekday afternoon. If we can space things out and space out some of these things we know may not be good for us, then we can still have them and eat them.

It’s still okay—just in moderation.

GC:
I think what our listeners really have to understand is that you don’t have to eliminate everything.

We know there are certain associations, and there are going to be findings about everything. Like Anafer mentioned, you’re going to have someone say there is an issue with potatoes because now there’s arsenic and lead in potatoes.

Then people think, “I can’t even have a baked potato.”

No, you probably shouldn’t have baked potatoes for breakfast, snack, lunch, snack, and dinner every day.

But space things out.

If we don’t, and if we see that we’re getting those repetitive insults, then we’re getting more into that education component that you were mentioning, Dr. Palmer.

How do we make people aware that certain foods—maybe Peeps, or I was looking at a Moon Pie at CVS the other day and was surprised they still make them, or even something like mouthwash that has Blue 1 in it—can all be sources of exposure?

It doesn’t mean it’s an unhealthy level of exposure, but there is exposure.

So recognize that and try to space it out with the diversity of your choices, what you put into your body, and what you bring into your household.

AB:
I love that. Dietitians always like to think about food as, “What can I add?” or “What can you, as the patient, add to your diet?”

Versus if it scares you to think, “I can’t eat my ice cream anymore,” the question becomes, “Well, what can we add?”

Maybe we have a meal first so your hunger can tone down. Your body can respond with, “Hey, my glucose levels are higher,” and then your hormonal cascade says, “That ice cream isn’t going to nourish me right now.”

That’s coming from your biology versus willpower.

AB:
I love that you mentioned alcohol as well because I became really fascinated with people’s relationships with alcohol after learning all about our relationship with food.

There are so many questions I still have about addiction, our relationship to these things, and compulsive behavior.

I saw this myself. I dated someone who was an addict, and I remember he said, “I can’t get dinner until I get my cigarette.”

And I was like, “I think you’re hungry.”

That was the dietitian part of my brain. But I genuinely thought he was hungry.

I told him, “Let’s eat first,” and he was able to express that the feeling of needing the cigarette really toned down once he ate.

He said, “I think you’re onto something, Anafer.”

And I said, “Thanks. I’ve got about 15 years of studying this stuff.”

AB:
But it is interesting because, similar to what I was saying about stopping at Chick-fil-A, sometimes it feels like an impulse or something you can’t control.

But when we’re hungry, and when we look at our relationship to pleasure, we have to ask: are we getting pleasure and play in our lives? Are we exercising? Are we nourishing ourselves?

All of these things can help tone down that dial for needing that extra beer or needing that extra candy.

Pleasure, play, exercise, and nourishment can be the foundation. Then the other things—like a drink, a peppermint patty, or a Moon Pie—can come on top of that base.

But you have to build that foundation first.

NP:
Yeah, I mean, going back to basic sciences, where Dr. Cox and I spent our first two years of this whole journey, I think about the advancements in the last 10 to 15 years since going through those courses.

Our understanding of the connection between satiety, orexin pathways, ghrelin pathways, things that link to growth hormones, IGF-1, and then of course how that’s all tied deeply into your lizard brain in the dopamine context.

The one other big thing that we haven’t quite mentioned yet, but is deeply tied to all of these things, is sleep.

Increasingly, as we understand orexin, ghrelin, satiety, and this very poorly understood pathway—even though we’re starting to create drugs that act on that pathway substantially—the sleep, anxiety, feeding, and addiction cycle is all tightly intertwined.

NP:
From a clinical context, some things that have really helped me remove the judgment associated with this is recognizing how many other large, complex, and incredibly poorly understood things exist in this space as neighbors to disordered eating, disordered sleeping, and mental health disorders.

The more we pull these apart clinically, the less we know.

Even with genomics, the rise of AI-driven data, and better datasets, the more we know, the less we know every single time.

Especially with incredibly complex, Amazonian-level complex things like food.

NP:
The other thing I was thinking about as you guys were talking about this is an age-old adage: the solution to pollution is dilution.

So if you are going to go have your Moon Pie, tie that back to what Anafer is saying as a dietitian. What could we add to that?

You had the Moon Pie. Okay, we can’t take that back out of the world. We’re not going to ask you to be bulimic about your Moon Pies.

What we’re going to ask you to do is find other ways to add things either before or after, so that you can kind of neutralize some of that and dilute it in a way.

NP:
Dr. Cox, you mentioned moderation, which I think is a fascinating word, largely because I think this idea of moderation is due for a rebrand.

When I hear moderation, I hear “drink Budweiser responsibly.”

That moderation campaign came as a result of many civil litigation suits brought against alcohol and tobacco companies, where they had to basically do brand recognition as moderation.

It did nothing to curb the actual intake of alcohol, cigarettes, or foods, but it massively increased brand recognition and people’s emotional engagement with those brands.

Brilliant from a marketing standpoint, but truly devastating from a public health standpoint, as alcohol, cigarettes, and food are probably three of the biggest detrimental factors to public health in this country.

NP:
So I hear what you’re saying when you’re saying moderation. I agree with you from a definitional standpoint, but emotionally I go to a place where I like the diversity framework a lot better.

Because they’re really the same thing. What you’re saying is that, with moderation, you don’t concentrate on one area.

Very similarly, we’re saying: diversify, add, and diversify.

To me, that’s an amazing clinical framework that you could bring into a room to try to encourage people.

GC:
Couldn’t agree more, Dr. Palmer.

That’s why I love Anafer’s viewpoint because it’s that diversity of adding different foods that allows for moderation.

The example she used with one of her significant others who felt the need to have cigarettes—by adding food, that toned down the drive for a cigarette. That already allowed for a reduction in how many cigarettes were being consumed.

Another example: when Anafer mentioned that, I thought, “This does exist.”

Sometimes at the end of the night I find myself thinking, “You know what? I like to have a beer, unwind, and watch a little Netflix.”

But then I realize, “I’m actually kind of thirsty. Why don’t I just get a glass of water?”

I have a glass of water, and I don’t need that beer anymore.

What is that?

GC:
So yes, I agree with you. Let’s change the framework from, “Okay, you can still go have that Chick-fil-A in moderation. You can have those sodas in moderation.”

Why don’t we add having more water? Why don’t we add a snack between breakfast and lunch, or a snack between lunch and dinner?

Maybe that would allow for less consumption of whatever that next choice is.

I completely agree with you guys. I think that’s really where we can flip the script and allow the patient to ultimately reach their goal.

AB:
I found the same thing with alcohol as well.

Once your needs are met—and sometimes it’s a biological need like water, and sometimes it’s an emotional need—the desire for those things changes.

I never told myself I couldn’t have alcohol. I’ve never done something like a sober January.

But I have noticed my desire for more or for that drink.

During COVID, when my mental health was horrible, I had already built that relationship with my body where I was like, “I don’t think that glass of wine is what I need.”

And it wasn’t because of a rule I had created for myself, like, “You shouldn’t drink wine.”

It was more that I had built this relationship with how my body feels with different things, and I realized that wasn’t actually going to satisfy what I was really looking for.

AB:
So increase your toolbox. Have a variety of things that you can do and see how you feel with different tools.

How are you getting pleasure and play? Are you exercising? Are you nourishing yourself?

All of these things can help tone down that dial for needing that extra beer or needing that extra candy.

Pleasure, play, exercise, and nourishment can all come at the bottom of that pyramid.

Then the other things, like a drink or a peppermint patty—or whatever you were just saying, the Moon Pies—they can come on top of that base.

But you have to get that good foundation.

NP:
I think that toolbox is something that we often talk about from the clinical side of things when we’re trying to give our patients these tools.

Especially as we start to talk about how you bring this clinically to the bedside, we’ve talked about opening, setting the stage, and some of these frameworks that we can use in analyzing these issues for clinicians.

But in reality, if I think about my brethren in primary care, they’ve got maybe 40 slots in a day, 15 minutes per patient.

Your screening has to be laser-focused and fast. Your ability to connect emotionally and empathetically also has to already be there to have a therapeutic relationship.

So what frameworks can we inject into these moments, even going back to Anafer, where you opened up with doing a quick “sick or not sick” assessment?

Something we’re trained very commonly with: sick or not sick.

Sick? Go see a specialist. Or recognize the limitations of what I can do.

What are some frameworks and tools that clinicians can bring into that room and that encounter?

Anything from screening, interventions, diagnostics—what can they bring on top of lipid panels and A1Cs that they’re already going to have in front of them?

AB:
Well, first of all, we’re talking about larger systems that are against us.

We’re talking about the food industry as a system that’s against us, but also the workload on primary care or hospitalists. It’s a systematic issue.

The answer that I’m going to give you isn’t going to be the most satisfying because it’s within a system that is not ideal, to say the very least.

While we’re talking to doctors, let’s advocate to change that as we already are. Dietitians have always been advocating to change the food industry, the lobbyists, and all of that.

But if you value nutrition and you’re with your patient and you’ve got 15 minutes, always start with a question.

AB:
How important is your diet to you?

That’s one question.

Or: How often are you eating convenience foods? How much of your diet is convenience food?

Another one: What’s your biggest challenge when it comes to eating a healthy diet?

A lot of people are going to say time or money.

When they say time, that’s an indicator they might be eating a lot of convenience food, or they might be skipping a lot of meals and then becoming really hungry and eating a lot of convenience food.

AB:
Start with a question. Never assume.

Also, don’t ever assume that someone in a larger body is eating a lot more convenience food and soda than someone in a smaller body, because it’s not always true.

It’s really hard.

Use your dietitians. Talk about this in your own clinics and hospitals. Bring the dietitian to the table.

Say, “Hey, I’ve got 15 minutes. What does this look like with our patient population? What are you seeing when we refer to you?”

Because in Aspen, Colorado, it’s very different than when I was seeing patients in Houston.

I would have loved to be invited to the table in Houston with primary care providers or hospitals and have that conversation:

“Here’s the dietitian’s patient load. We’re saturated. You can continue to refer to us, but if you really want to intervene, here’s when you should intervene during your visit versus when you should refer to us.”

GC:
I have a couple of questions for you, Anafer.

It’s funny because I’m hearing you speak, and I’m thinking, “You’re so right. The system is totally against us.”

How are you going to dive into literally everything we’ve talked about over the last several minutes in a 15-minute clinical encounter?

Obviously, it took us this long just to have the conversation with our listeners. So how are we going to do that in a clinical encounter?

And by the way, the next patient is waiting.

That’s challenging.

GC:
I have a couple of questions.

First, do you find yourself and some of your peers using some of these assessments?

I know that the CDC has things like a barriers-to-exercise assessment, where a patient can fill out questions and it can tell you, “Okay, a lack of motivation seems to be the issue,” and here are some things to address.

Do you find yourself using some of these assessments to expedite the time?

And second—and probably the one I’m even more interested in—is what changes do we want to see in a system where I can spend 15 minutes with one complex patient and bill the insurance company the same amount that it would take me to spend an entire hour with a patient of similar complexity?

The system you’re describing focuses on seeing sicker patients in less time rather than spending more time with sick patients.

So I’m curious about those two things: your assessment of some of the intakes that you do, and what system changes we need to see implemented to help these patients.

AB:
So the first question is about my screening and assessments that I use.

I’ve never used any of those tools that I’ve been provided as a dietitian, and I don’t think I’m better for it. I just think that I operate differently, and that’s not my strength.

I think there are likely dietitians who do use those tools, and maybe that is their way of getting to where they want to go.

I think we need a variety of different dietitians practicing in different ways.

I use more of a counseling style. It’s more like, “Let me get to know you,” and then I trust my gut about where I shouldn’t start asking questions.

Good or bad, I don’t know. Probably not ideal if you ask my Master of Public Health professors.

AB:
In terms of what changes we’d like to see in the system, I think there are going to be way smarter people in the room who are going to have to put their heads together to figure out how we’re going to combine capitalism and healthcare and do it in an effective way.

That’s so hard.

I’ve got so many friends who are doctors, surgeons, and veterinarians. We’re all up against this money industry that we all work in, and yet it’s not that it doesn’t align with our values. It just sometimes competes with our values to help the patient or the dog.

These are much bigger ideas that we could record another podcast on just talking about, but I don’t believe that I have the solutions.

I want to believe that there are smarter people out there who do.

GC:
Well, I believe that you’re incredibly intelligent.

What I gather from that is that when it comes to assessments, they can lead to the patient feeling like there’s already some bias, right?

If you’re introducing a questionnaire that’s saying, “What are your barriers?” the patient is going to be able to tell from the questions that they’re being assessed for their barriers to exercise.

That could be off-putting.

What I’m hearing is that you take more of a personalized approach by just having the conversation and starting it that way.

GC:
And as for assistance, you mentioned it clearly. I don’t know if everyone is aware, but we’re starting to see research showing a lot of private investment inside of healthcare, a lot of venture capitalism inside of healthcare, and we see that outcomes can be worse once that venture capital starts making its way through.

We are in need of a new system, especially as we’re starting to see reimbursements decline inside of a structure that really does harp on seeing sick patients very quickly.

NP:
Completely.

Anafer, what you mentioned about keeping it local and bringing in the teams that you have available is a great first step.

Who else is in your clinic? Every clinic has some multidisciplinary component to it, even if it’s nurses, MAs, or other people with a diversity of degree types.

If you’re actually in a multispecialty clinic or a larger mixed medical-surgical clinic, there are often associated dietitians or people who are more affiliated with the lifestyle side of things, kind of like you, Dr. Cox.

It’s just getting those groups together and starting the conversation.

As always, one of the maxims of public health is: start the conversation. Get people thinking about it. Get people talking about it in the communities that you can, and let it be focused on your community.

I think they’ll feel better that way.

NP:
You avoid that sense of what you’re describing, Dr. Cox, of that implicit bias in some of these surveys.

The CDC is great, truly a wonderful organization. I couldn’t think more highly of the CDC. I have family members who’ve worked there for decades.

But they design things for 340 million people.

That means it has to work in Houston, it has to work in Aspen, it has to work in Loma Linda, and it has to work here in Detroit.

That doesn’t mean it’s going to work perfectly in any one of those places, but it is going to work in every single one of those.

There’s something kind of wonderful about something that works everywhere.

But does that mean it’s the right tool?

What can we create that’s more local and more specific to the patient population that we serve?

NP:
Listeners to this podcast know that one of the other places I frequently work is on a Native American reservation.

It’s a completely different cultural aspect, completely different cultural components, completely different access to food and nutrition, and a completely different sense of what a food desert truly is.

All of those things bring this hyper-locality to something as essential as food.

I actually really genuinely believe what you described, Anafer, is brilliant.

It has to be grassroots in a way, as opposed to something that starts top-down from the Centers for Medicare and Medicaid Services, where they push out some new biochemical test or the next version of metabolic screening instead of something that’s truly local and actually works for your community.

GC:
I really could not have said that better.

NP:
Well, we’re building toward—I don’t want to get too far over our skis here—but we’re building toward this third session together, where I’m really excited to talk through what we can do at the advocacy level and the systems level.

I often feel that same frustration that you described, Anafer, of big systems and big monolithic systems being in tension with one another.

Maybe not purposefully, but they’re certainly not incentivized to necessarily be aligned.

Again, all three of us work in public health.

If we’ve seen anything in the last six years, we’ve seen the erosion of public health as an ideal, the erosion of public health from a source of funding, from a source of financing from the federal government, and even from a source of focus.

NP:
These big systems are shifting. They change over time. They respond to macroeconomic conditions and, frankly, administrations that change and bring in new values and priorities.

But that doesn’t mean that we’re left without solutions.

It just means we go back to the pillars of true change.

Grassroots can be just as powerful as top-down.

You can start with those same pillars of advocacy, policy, and education.

Those are all things we’re really going to dive into and sink our teeth into on the next one.

So, last questions for both of you to round it out.

We’ll start with Anafer.

If there’s one systemic change that, after reading the American Journal of Public Health and the Lancet series, you would want to vocally support, what would it be?

AB:
The one systemic change we can definitely advocate for is subsidizing real food versus just the corn, the wheat, and the soy.

NP:
One of my favorite experiences way back in med school in northern Michigan was a program where they doubled your SNAP dollars if you used them at a farmer’s market.

So SNAP, WIC, and EBT.

It was a brilliant, brilliant program, and it was community-led.

The federal and state governments weren’t doing that. It was community-led.

I remember immediately, even as a med student, thinking, “Yes, that is the right incentivization.”

That was municipal investment into the community where food was being created.

It was one of my favorite things.

So what you’re describing is near and dear to my heart.

All right, Dr. Cox, as a learner today, learning from Anafer, what’s the very first thing you’re going to change about how you approach nutrition counseling in your clinic tomorrow?

GC:
Can I answer by saying getting Anafer involved in my practice? Is that an option?

I feel like she has so many great things to say.

For me, one of the things I really want to take home is trying to introduce more ways to help people increase diversity in what they’re consuming.

I have patients come in and say, “I think my problem is that I don’t eat enough. But how do I eat more when I’m struggling with overweight and obesity?”

And it’s like, well, we do need to eat more because, like we said, you’re skipping breakfast, you’re skipping lunch, and then you’re driving to Chick-fil-A after work because you’re tired and hungry.

As we’ve already discussed, when you’re tired and hungry, it’s harder to make challenging decisions.

There’s another saying: never go grocery shopping when you’re hungry.

I don’t know if any of you have done that, but I just walk in to try to get a handbag and somehow that sucker is in the cart.

GC:
I think I would like to focus more on introducing foods to help people moderate some of the more addictive foods that may make it into their diet.

I think that’s what I’d like to take away from some of the conversations today and start to implement.

NP:
I love it. Replacement therapy.

It works for methadone, so I think it’s a fantastic framework.

I want to thank you both so, so much for coming on The Podcast for Doctors (By Doctors).

It’s been truly wonderful having this conversation with you and learning from you both.

We hope our listeners did as well.

Thank you again for joining us.

AB:
Thank you so much for having us. That was really fun.

GC:
Always a pleasure, Dr. Palmer and Anafer. Just as much of a pleasure.

NP:

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