Gerald Cox, MD and Silvia Caswell, DO- Beyond the Exam Room: Food as Medicine and the Case for Physician Advocacy (Part 3)

Dr. Gerald A. Cox and Dr. Silvia Caswell join host Dr. Ned Palmer to close out the three-part series on ultra-processed foods with the question that’s been building since episode one: what does a physician actually do about it? They start in the grocery store, where Dr. Caswell offers a test simple enough to hand to any patient — and where both guests push back on treating “processed” as a single verdict. Canned beans, frozen vegetables, and whole grains all sit in that category, and all of them can be the right call for a family shopping on a budget.

From there the conversation gets practical. Kids don’t buy the groceries, so counseling a child without the family rarely works. Ultra-processed food often delivers the most calories per dollar, which makes affordability a clinical question, not a side note. GLP-1s quiet food noise but don’t teach anyone how to eat. The anchor is “add, don’t subtract” — one piece of fruit, one can of beans, one small change a week. Then the guests widen the lens to advocacy: sidewalks and bike lanes, letters to state representatives, food industry lobbying, and the one change each of them would make if they could.

Can you eat well on a tight budget without giving up your whole Saturday to meal prep? Does a GLP-1 prescription let food quality off the hook? What do you say to the parent whose kid only eats the bright orange stuff? And what would it actually take to make the healthy choice the cheap one? Tune in for a conversation about treating food as medicine — without pretending patients live in a world that makes that easy.

Dr. Caswell’s views are her own and do not reflect those of the U.S. Department of Veterans Affairs or the U.S. government.

Here are 5 takeaways from our conversation with Dr. Cox and Dr. Caswell:

1. Ultra-processed food is an environmental problem—not simply a willpower problem

People’s food choices are shaped by what is affordable, convenient, visible, and heavily marketed. Grocery store layouts, brightly colored packaging, product placement, family routines, and advertising all influence decisions before a person consciously evaluates the food. The episode challenges the idea that people simply need more discipline. Instead, it argues that healthier eating becomes more realistic when the surrounding environment supports it. Clinicians should consider what foods are available at home, what families can afford, and how marketing influences both children and adults.

2. Nutrition advice must account for a patient’s financial reality

Healthy eating recommendations are unlikely to work if they ignore income, time, food access, and household responsibilities. Many ultra-processed foods are attractive because they provide inexpensive calories, are easy to prepare, and last longer than fresh foods. The speakers emphasize that nutritious choices do not have to be expensive or complicated. Affordable options such as beans, lentils, canned legumes, frozen vegetables, canned fruit, and whole grains can provide practical alternatives. The important point is to meet patients where they are rather than prescribe an idealized diet they cannot afford.

3. The family—not just the individual—is often the true unit of change

Children cannot control most of the food decisions that affect them. Parents and caregivers usually determine what is purchased, prepared, stored, and offered at home. As a result, treating a child’s nutrition or weight concerns requires understanding the entire family system. Clinicians should explore who shops for groceries, who cooks, what foods are easily accessible, whether the family eats together, and whether treats are being used as rewards or tools for managing behavior. The episode recommends approaching these conversations with empathy instead of blame and involving children in age-appropriate food choices.

4. Food quality affects much more than body weight

The speakers explain that ultra-processed foods may contribute to high intake of refined carbohydrates, inflammation, reduced microbiome diversity, and gut dysfunction. These effects may influence digestive health, cardiovascular risk, metabolic health, and the gut-brain connection. The episode also discusses the relationship between nutrition and mental health. Improving dietary patterns may support improvements in anxiety, depression, and overall well-being. This broader view reinforces the idea that food is medicine—not only for weight management, but for whole-person health.

5. GLP-1 medications can help, but they do not replace lasting behavior change

GLP-1 medications may reduce appetite and decrease what patients often describe as “food noise,” but they do not automatically teach sustainable eating habits. Patients may also stop taking the medication because of cost, insurance changes, side effects, or loss of coverage. For that reason, the speakers recommend combining medication with supervised lifestyle and nutrition support. The medication can create an opportunity for change, but lasting health improvements require gradually developing better food habits. The goal is not to eat unlimited ultra-processed food in smaller portions, but to move progressively toward more whole and minimally processed foods.

Transcript:

Ned Palmer: If we have GLP-1s, do we need to care about ultra-processed foods in the same way?

Silvia Caswell: Yes. We know that ultra-processed foods have a lot of simple, refined carbohydrates. They cause a lot of inflammation in the gut, worsen your microbiome diversity, and cause what we call dysbiosis. That’s very much been implicated across the board. We have pretty good evidence for that now.

NP: Welcome back, everybody, to The Podcast for Doctors (By Doctors). This is the third installment in our series brought to you by the American College of Physicians on lifestyle medicine, ultra-processed foods, and ultimately, today, talking about what can we do about it.

I want to thank Dr. Cox and Dr. Caswell for joining me as our guests today. Our first installment in the series really talked about what are ultra-processed foods and what are the problems. Our second talked about what we could do about it through the interpretation of a clinical nutritionist and a dietitian.

Now we’re going to be talking about what we, as physicians, can be doing every single day about this public health issue from an advocacy standpoint. So I’m thrilled to have Dr. Cox and Dr. Caswell here with me today, public health experts. And as I read out their intros, you’re going to understand why, as an audience, you should be excited to be listening to them as well.

They’re too humble, so let me brag on them.

Today, we are joined again by 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 on 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. His work there focuses on improving patient outcomes, advancing population health, and building better systems of care for some of healthcare’s most pressing challenges.

Thank you, Dr. Cox, and welcome back to The Podcast for Doctors (By Doctors).

Gerald Cox: Always a pleasure, Dr. Palmer.

NP: Thank you. And now, Dr. Silvia Caswell, one-upping the both of us, or maybe three-upping by the time we’re to the end of this. But thank you, Dr. Caswell, for joining us.

She’s, I think, first and foremost, a mother. You said four children?

Silvia Caswell: Three of my own, but there’s five.

NP: But okay, a mother to all. And is triple board-certified in public health and general preventive medicine, lifestyle medicine, and obesity medicine.

She currently serves as a program director for the Preventive Medicine Residency Program at Loma Linda University Health. She earned her Bachelor of Arts in Anthropology from the University of Utah and her Doctor of Osteopathic Medicine from Campbell University School of Osteopathic Medicine in North Carolina.

Dr. Caswell completed her general preventive medicine and public health residency at Loma Linda University Health, where she served as the chief resident while concurrently earning her Master of Public Health degree from Loma Linda University in Southern California.

Clinically, she practices lifestyle and obesity medicine, where she leads innovative, evidence-based approaches to reversing chronic disease through lifestyle interventions at the individual and group level via shared medical appointments.

Her work, much like Dr. Cox’s, focuses on cardiometabolic disease prevention, physician education, and advancing lifestyle medicine in clinical practice. She’s presented nationally and internationally on integrating lifestyle medicine into patient care and medical training, and has contributed to research and public health initiatives addressing maternal health, plant-predominant nutrition, and health equity.

With a strong commitment to physician advocacy and patient-centered care, she brings a practical, evidence-driven perspective to improving health outcomes at both the individual and population levels.

Dr. Silvia Caswell, thank you so much for joining us on The Podcast for Doctors (By Doctors). It’s great to have you here.

SC: It’s such a pleasure. Thank you for having me.

NP: I want to start, as always, by going back. I was taught by my residency program director that interleaving always helps with education. And now that we’re at the third part in our series, I want to go back to really some foundations.

What are ultra-processed foods to you? We read out some dry clinical definitions previously. We looked at the NOVA guidelines. We talked about what they are through a variety of different lenses, but to you, as a professional in this space, what are ultra-processed foods? And then how can we all, as consumers of food, identify them?

Because there’s the clinical definition, but then there’s the grocery eye. So I like to keep it simple: smarty pants, KISS method.

SC: The way that I explain it to patients is anything that is in the middle of the grocery store, anything that’s in the aisles, that’s generally identified as an ultra-processed food.

So anything that comes in a box, anything that has a list, whether it’s three ingredients or 15 ingredients, that has had quite a bit of manipulation to it, right? So we call that an ultra-processed food.

Think, you know, anything from your cookies and your crackers, all the way to anything that’s canned, anything that is dried up or manipulated to some extent. That can be considered processed. There’s different levels of processing. Ultra-processed is probably the worst. It’s the one that’s up there that’s been associated with a lot of the chronic yet preventable disease that we see in the United States.

NP: I love that model of the grocery store, like stay around the outside: your milk, cheese, vegetables, things that come out of an animal and still maybe look like it, or come off the farm and still look like it on the other side.

Well, you mentioned something that we haven’t spent a lot of time on in this podcast, but that there’s differences in levels of ultra-processed foods. Now, we did talk about the NOVA classification, but what are the relative harms and benefits? How broad is that spectrum from minimally processed to ultra-processed? And is there harm across the entire spectrum? Does it quantify? How does the harm align with the level of processing?

GC: Man, that’s really tough. I mean, first of all, Dr. Caswell, it’s so great to be on here with you. It’s heartwarming for us to be in this position.

I just have to say that your thoughts and your description of the grocery food aisle just made me feel like, yeah, that is pretty much what it does break down to.

I actually caught myself walking down one of those mischievous aisles that you described, and I found myself kind of overwhelmed by the sheer color. And we had this discussion about coloring and food dyes and those additives that make it into these ultra-processed foods.

And it had me kind of thinking a little bit about how our company is trying to mimic the color of fruits and vegetables that are in that section, that is plant-based, that doesn’t really come from any animal sources, right? You can get all your great bananas, your bell peppers, all the good stuff.

And I was like, wait, why is Fruity Pebbles trying to mimic that bell pepper, red and green? But it’s ultra-saturated in a way that really just draws my attention. So I feel like I’m being visually manipulated down these aisles.

I kind of walk past with my cart and eyeball it a bit. Is there anything I need down that one? Probably not. Let me keep on going.

But to answer your question, Dr. Palmer, ultra-processed foods in that regard, you can take your simple bread. So that’s going to be significantly processed. But how do we actually separate? Because we’re not going to be telling our patients, you know, don’t eat bread. Basically, just grow your own fruits and vegetables. Who’s going to be able to do that? A select few.

But when we actually start to break down and say we’ve got whole-grain bread, maybe we can actually stick to something that doesn’t strip away all of the nutrients that actually benefit us, even though it’s a processed bread, right?

Maybe we stick to something that’s less processed, stripping all of those nutrients away from it and then adding things back in. So looking at that ingredient label and saying, like, you know, this is enriched, right? This is enriched flour, this is enriched wheat, basically, can help you identify, hey, this is maybe something that’s a little bit further away from what’s going to be making me healthy in the long term.

NP: Love what you’re describing there, Dr. Cox, because we’d spoken previously about this sense of food engineering and nutrition engineering. The additive, not just for shelf stability, which I would argue is probably a good thing. I would argue shelf stability has an element of safety where this started from.

But your Red 40 and your Yellow 7s and all of those things like that, designed to mimic natural products, of course, and also designed to be that color attractiveness, right?

You walk by a bloom of wildflowers or something and you go, like, I have something deep in my lizard brain that’s attracted to that as a pretty color. And they’re trying to mimic that with Fruity Pebbles and try to subvert my expectations and get me to grab a handful of that.

GC: Sounds like you had a similar challenge to what I did, Dr. Palmer. So I’m kind of curious, like, as the pediatrician, because you know that these things are really being advertised heavily to children, and we’ve talked about that too.

So how are you finding ways in which you’re helping steer, particularly children, towards, I’m not going to say away, because we kind of found ways to address this in our last topic. You know, we want to say, how do we add more?

How do we add more nutrients of nutritional value into your lives? So, you know, the best thing is really trying to find them young. And that’s what the beauty is of your specialty.

So how are you incorporating that into your treatment of some of these overweight and obese patients who really struggle with the addiction to some of these ultra-processed foods?

NP: Pediatrics is frankly very challenging. It’s a very challenging area to have these conversations in. I don’t think they’re ever easy, but having these conversations in pediatrics, there’s the added layer of what I understand of obesity as the least trained person in obesity here.

But obesity is heritable. My super superficial understanding is it’s typically genetically and socially heritable. And so when you’re talking about an obese child, or a child with body weight issues, or a child of excessive weight, there’s an element of treating the family, right?

The patient in front of you, it’s not just that they’re the proband of a disease state. It’s most likely happening on a family level.

Now, of course, there’s individual diseases or metabolic syndromes or things like that that can impact children that are approached totally differently, early-onset hypothyroidism or some of these things that are true disease states, as opposed to what I would consider more of obesity through this classical familial, heritable type of illness.

It’s frankly like I’m not great at it. And that’s why I’ve been excited about this. And I’ll fully admit that I’ve not been great at it as a pediatrician and as a hospitalist and have shied away from it because I felt like I didn’t have a lot of room to have that conversation.

I think some of the skills that I’ve picked up and even started using over the last couple of months, since we’ve been frankly doing this together, and I’ve been learning from smarter people, are approaching it at the family level.

Because you can walk into a room and tell pretty quickly whether the kid is suffering from this as a heritable illness. And if it’s at the family level, use those tool sets that we talked about, right?

What do you have at home? What are you giving your child? And some of this is age-dependent. What are you giving your child or what does your child have access to, depending on how old they are and whether they can get things off the cupboards?

What is down low if you’re starting to give your children more free and ready access to foods? Are you using treat foods constantly and using it as a form of manipulation, which we all do?

I’ve looked as a parent. I don’t know if Dr. Caswell mothers everybody. Maybe she might be better than me at it. But we have all tried this. Like, here’s a treat food. Here’s a Pavlovian response to a treat that we’re trying to instill.

Maybe it’s stop crying, maybe it’s be quieter, maybe it’s I just need to finish this car ride or this podcast or something. We just need an hour of quiet. We’re all guilty of it.

And so you have to start by interrogating from a place of empathy.

What is this family’s relationship with food? How is the family engaging with food at every level? Are the parents sitting down and making food together every night? Or is everybody going off and doing things individually with their own little bag or basket of goodies?

Are they shopping together? What is the whole life cycle of this? If they’re shopping together, where are they shopping? Are they going to farmers markets? Are they looking for plant-based food?

And then frankly, this is a whole can of worms that I was going to wait till later in the conversation, but you need to have early, is: What can you afford?

We can’t, from a physician standpoint, be totally blind to the ridiculous food inflation pressures that are happening, along with fuel inflation, especially right now in the fall of 2026. Everything is dizzyingly more expensive over the last six years since the pandemic.

And that has led to people significantly changing their food choices when they’re wandering those aisles and they get drawn into the brightly lit, ultra-processed heart of most grocery stores.

Because to me, and I’m going to put this question immediately back to both of you, this is where I see the most calories per dollar going out the door.

Plant-based foods are great, and I’m obviously, I love them and want everybody to be healthy. But at a certain point, if you’re trying to feed a family of four or five on a relatively fixed income, you need calories per dollar, and that tends to come in the ultra-processed section.

And so there’s a balance there where you have to be understanding and empathetic. Is this being driven from a socioeconomic standpoint?

Because you simply can’t afford to feed everybody salad every night because they’ll still be hungry. And so yet, nobody looks at Cheetos and thinks, well, that’s a natural product. But at the end of the day, it’s probably 1,400 calories in a bag. That’s a lot more than your bag of lettuce down the way.

So I’m going to ask both of you, because that’s a conversation that I struggle to have nearly all the time, that I think we all do in a variety of ways. Can you afford the treatments that medicine wants you to take?

And in this case, food is medicine, as we’ve discussed. So I’d love to hear, Dr. Caswell, kind of how’s your approach to that? Food is medicine. This is important, but there’s an economic trade-off and balance here we need to be mindful of.

SC: Yeah, for sure. So when I think about patients, I think about their whole health, and you’re looking at, okay, what can I do clinically, right?

Twenty percent of somebody’s health are things that I can manage within the clinical walls, right? Medications, surgeries, things like that, right?

Thirty percent of somebody’s health comes from their lifestyle choices, right? So I’ve been trained in motivational interviewing. I’ve been trained in behavioral modification to get them to go from one stage of behavior to the next and make those changes along the lines to where they’re making those changes.

But 50%, so the remaining 50% of somebody’s health, comes from social determinants of health, socioeconomic factors, job stability, and what their income is like. Do they have education? Do they have health literacy? All of those things very much impact somebody’s life.

So when I’m sitting here in clinic and I’m able to do the 50, my clinical and lifestyle behavior change, I still cannot sit there and address the other 50 that they might be having trouble with, right?

And so that is something that I have always at the forefront of my mind when I’m counseling patients.

Now, when I’m counseling adults, that’s usually a little bit easier, quote unquote, right? Because they have a lot of power. They can go grocery shopping, typically. They can typically cook their own meals and things like that.

But when I’m thinking about children, which I have seen periodically, it becomes a family intervention because the child is not cooking, the child is not shopping, the child doesn’t know these things.

They might hear it from school and from their health education classes. And they know that eating a fruit or a vegetable is a little bit healthier than eating a bowl of cereal in the morning, generally speaking. But they don’t have the power, right, to go get the food and prepare that food and so forth.

And so I have to take all of these things into consideration.

When it comes to affordability, it’s become outrageous how expensive eating is. And sure, the cost of groceries has gone up quite a lot in recent years, but going out to eat is even worse, I think.

NP: So, you know, when I sit down with patients and I try to make that assessment of how are things going from the social determinants of health perspective, affordability, and, you know, are the parents working one job? Can they even prepare a meal? Are they so busy that they are literally just throwing what they can on the table to feed their family?

But also thinking about, okay, well, if you’re throwing whatever it is on the table, then do we want to think about what is the cost really if you were to sit and prepare something that’s a little bit quick that came from the grocery store versus actually picking up a meal at a local fast-food place or a restaurant or something?

Because I’m willing to bet that actually that might be a little bit more expensive. Eating plant-based, you don’t have to make it expensive. It can be quite cheap. If you’re buying beans, that is much cheaper than buying meat at this point.

And so I try to drive that into families and say it doesn’t have to be expensive, what you’re choosing. It does not have to be organic. It doesn’t have to be fresh. You can buy canned legumes, you can buy canned beans, you can buy canned fruit because it’s going to last longer. You can buy frozen things because they’re picked at their peak freshness when they’re picked, and then they’re frozen.

And then they’re sold. And so if you need to rely on frozen things so that way you’re not losing food because it goes bad so quickly, rely on frozen things, right?

So there’s so many different ways of making eating healthy so cheap that it’s silly not to try.

And also trying to not make the decisions yourself, right? If you’re a parent, but involving your children in that decision-making and giving them choices too, I think is important. Because if they are the ones that are picking that food, if you’re going to the grocery store and say, hey, look at all this fruit, right? Pick one that looks good to you.

They’re more willing to eat it instead of being told, hey, you need to eat this, right? They usually won’t want to do that. But if they chose it, if they had control over that decision, then they’re more willing to eat those types of foods.

And so there are lots of different ways to work around those adverse social determinants of health. I do this with patients all day, every day. It’s just a matter of sitting down, and you don’t have to overhaul their lifestyle overnight and their choices overnight. It’s literally one small little goal at a time.

And then, over time, those are all going to add up and they can make a huge difference in the long run.

Absolutely. Yeah, Dr. Cox, I’d love to hear your approach as well on that.

GC: That was fantastic. That was awesome. I really love you guys’ answers and what Dr. Caswell was sharing with us.

I think it really breaks down to, really, people are going to say, “Well, Dr. Caswell, isn’t that spinach in the frozen aisle processed?” And you and I would have that discussion with the patient, like, well, yes, it is. But we know that even though they fit that classification, these are better choices.

We have studies that show, despite whole-wheat bread, whole-wheat pasta being processed, these whole grains, vegetables, and legumes, even though they’re in cans and processed in cans, like you’ve mentioned before, we know that by choosing those products rather than choosing the Fruity Pebbles that I might have mentioned earlier, right? Or the Fruit Roll-Ups that have two servings of fruits and vegetables and 10 grams of added sugar, right?

We know that choosing those things is going to be a lot better for the patients. And so sometimes having that discussion, right? Having that discussion that, yes, there is this publicity about processed foods and ultra-processed foods, but it really does sometimes come down to that nutritional element of the choices that are made of those processed foods.

So we can’t just say all these processed foods are bad because people’s TikTok feeds or their Instagram feeds are telling them, “Process, process, process. Go milk your own soybeans to make some soy milk because that’s how you’re going to live a long and healthy life.”

It’s like, no, it’s okay to choose these things. We just want to avoid some of these other things.

And Dr. Palmer, what you shared with your relationships in the pediatric population and adult populations, getting to know the family dynamic, getting to know those interpersonal relationships, it really just helps these patients significantly to actually dive into those networks, right?

Being a bit of a detective or a sleuth and understanding the family dynamics. And Dr. Caswell and I, in our training, we’ve seen so many times that the family being involved, maybe that spouse or significant other needs to be a part of the appointment.

Maybe talking to children, we also need to incorporate another family member who didn’t make it to that appointment to really just understand the dynamic and see how we can fit this in.

You mentioned taking them grocery shopping with you. That’s a beautiful thing. That could be fun. That’s a handoff process.

Teaching your children, or whoever it is that’s inside of your family, how do we select these certain foods and how you’ll be able to do this on your own down the road?

And we’re kind of having this discussion about policy, right? We’re getting into this idea about how we can actually help people with their social determinants of health with regards to how expensive groceries are today.

Dr. Caswell so aptly mentioned if we pick up our can of beans, that’s a lot cheaper than how much beef prices have gone up. And it’s going to be a lot healthier long term with regards to your colon health, your digestive health, your microbiome, your overall physical fitness in terms of saturated fats and deposits around the circulatory system, right?

So additionally, we’re looking at a bit of a challenge as a nation right now. We’re facing this very hard time of rapid inflation and price control, and everybody’s feeling it, whether you’re at the top or the bottom, and some feel it more than others, right? And we know that.

But what can we do as a nation to really kind of direct our health in the right way, right?

And so mental health is becoming a bit of a crisis in addition to everything that we’ve mentioned so far. Since 2020, the pandemic and maybe even earlier than that, but 2020 certainly lit the Bunsen burner, right, to create those catalytic reactions.

If we look at how we can incorporate some of these therapists into these dynamics of family relationships, then we can actually get to a little bit more about what is underneath the surface that’s causing these decisions or these choices to be made. And then we can have a more holistic approach.

Sure, we’re doing a lot of funding right now to help things like depression and anxiety and having those conversations about that, which we haven’t had as public conversations about those as much as we did in the past.

But think that if we can try to formulate a way in which we can have programs where we have mental health specialists also dive into obesity treatment, right?

GC: Can we get some of that involved too? Because we know we got to treat depression and anxiety, but are there underlying things that could be leading to that depression and anxiety, right?

Maybe, you know, my school clothes don’t fit anymore. Now I’m feeling a little depressed or anxious in my social circle because maybe I’m gaining weight.

And can we get more people trained inside of that technique of delivering that kind of care and diving into some of those factors to really help people along this journey too?

So I just wanted to kind of share a couple of those things as well in terms of, as we’re going to this “what can we do about it as a nation” approach.

NP: Absolutely. I love what you were saying there of, like, food is so critical. It’s implicit in other disease states, right? Like, you know, depression, anxiety, or the physical effects, the physical manifestations of food could be having on you.

It can also be the response to disease states as well, as we’ve seen, right? That hyperphagic response to certain illnesses.

And so really getting to understand what’s going on with the patient, their life, like really diving deep to understand what, in this case, is the proverbial chicken or the egg in terms of how this is manifesting and negatively affecting you.

I’m going to throw this one out there. It’s a little bit of a grenade in the room because the other thing that’s come up, just blown up in the last five years, parallel to COVID, not on purpose because of COVID, but are the rise of GLP-1s.

You can’t turn on a TV or flip to a magazine or any advertisement anywhere. There’s somebody selling GLP-1s to everybody, with no visits and, frankly, increasingly fewer prescriptions.

I’m going to ask a question that is leading that I hope everybody knows. I don’t believe, but if we have GLP-1s, do we need to care about ultra-processed foods in the same way?

Yes. Please, Dr. Caswell, I’d love to expound on that because I have heard this rhetoric of, well, I can stay skinny on GLP-1s. I’ll eat whatever I want, right? And that then includes the quality of food from a processing standpoint.

Loving Fruit Loops like Dr. Cox, like it’s Fruity Pebbles, excuse me, Fruity Pebbles. Help me understand, like, at what level are these, you know, frankly, at a molecular level, these foods are having an effect that even if the weight’s not coming on, there have to be negative health impacts.

SC: Yeah. So we know that ultra-processed foods, they have a lot of simple refined carbohydrates. They cause a lot of inflammation in the gut. It worsens your microbiome diversity, right? It causes what we call dysbiosis.

And so that’s very much been implicated across the board. We have pretty good evidence for that now.

And so when people are on GLP-1 agonist medications, right, they are on it to treat excess adiposity, which is a fancy term for fat tissue.

And I don’t want to ever call anybody obese because I think there’s a stigma around that. People have obesity, right? I don’t even call the term overweight either because it doesn’t make sense. It’s based on a BMI system that’s completely flawed.

So I like to call it pre-obesity, right? That’s that overweight status, BMI of 25 to 29.9, however you’d like to call that.

So we treat people with these GLP-1 agonists, depending on what their BMI is, if they have comorbidities, if they have obesity class one, two, or three.

Yes, we’re treating obesity because it is a chronic, relapsing condition that requires long-term treatment. Obesity is a condition. Okay, so we’re using pharmacotherapy to do that.

But these GLP-1 agonist medications, we know that when people, and we saw this plenty in the studies, we know that when people stopped taking them, they regained quite a bit of weight back, sometimes even to their baseline levels.

And so it’s not going to fix your behavior, even though it does work at the brain level. We do have some GLP-1 receptors in the brain, and that’s how it works. That’s why people say, you know, it decreases that “food noise.”

And I hear this all the time from patients, like, “My food noise is gone. It’s great.” And I’m like, perfect. That’s awesome.

But it’s not going to fix that behavior. So if you’re still decreasing the amount of portions, right, because it’s going to make it so you’re not going to want to eat as much, you still can’t say, hey, I’m just going to eat all the ultra-processed food in smaller quantities and expect that that’s going to work for you for the rest of your life, because it’s not.

Because even though we’d love to be able to treat everybody forever with medication, which can be done, sometimes that’s not the case for some people.

Some people lose insurance, some people it goes off of their formularies, sometimes they can’t afford the copay, right? Those are all reasons why people stop taking, or maybe they can’t tolerate it anymore for some reason.

And so they can’t take those medications again. And they can’t just rely on ultra-processed foods to be able to keep their weight loss, right? Because we know that ultra-processed foods have a lot of caloric density to them.

And it’s not going to work for you in the long run if you think that you can just outsmart your diet that way. It’s not going to. And we have plenty of evidence for that now.

And so when people are going through that education process, you know, when they are on GLP-1 medications, they should be supervised by a clinician and they should be undergoing some sort of lifestyle modification intervention to teach them, this is how you should eat.

I’m not asking you to become plant-based by next morning, because that’s unrealistic. But we want to try to get them to go from eating that standard American diet that they might be in at that point, which is why they experience the weight gain in the first place, and slowly walk towards that, eating more whole foods, eating a plant-predominant diet as we can.

Just slowly start walking along that spectrum is what we’re trying to get our patients to do.

Because once they do reach their goal weight, then they’ve had months of experience and it’s become a routine and it’s a habit now for them to be eating better compared to when they were at baseline.

And what I also see a lot in patients, and we do have evidence for that right now, is that when they do start eating better, they do experience improvement in anxiety and depression if that is present at baseline.

And that is because the gut has a lot of serotonin receptors. In fact, 90% of those in our body are in our gut. And we think it’s just in our brain, but it’s not. It’s in our gut. And there’s a gut-brain axis.

So when you’re fixing a lot of the inflammation in your gut by eating better, by reducing your weight, you’re calming down a lot of that inflammation that you already have in your body. You are improving your anxiety and your depression.

It’s really cleaning everything. So food is medicine. And it’s my goal to try to get everybody to understand that. Like food is very powerful in treating not just your weight, but all these other things that might be going on with you as well.

NP: Absolutely. I love your description there. You know, one of the things that we touched on last week with Anafer, our dietitian who joined us, was this idea of adding things. Dietitian counseling is…

NP: It’s never about these extreme restrictive diets or these fads or anything. It’s, you know, the solution to pollution is dilution. And so if you’re overly UPF’d right now, add a salad to it. Don’t take anything away. Just add a salad to the day. Add a piece of fruit to the day.

And over time, those marginal gains, like you’re describing, it’s not about quitting smoking overnight, right? It’s the slow marginal gain. If you can successively add this and make small steps, how much further will you be in six months? How much further will you be in 12 months to an overall much healthier state?

And so I love that description of how clinicians can advise things. Don’t make massive changes overnight because you’ll swing right back. You’ve just got to make one small step in the right direction.

And that’s wonderful in terms of how powerful it can be.

I want us to spend a good chunk of time talking about what we can, as clinicians, do about it. I think we’ve had great conversations about what we can do at the bedside, what we can do with families, how we can counsel.

But as three public health nerds who are coming together to talk about this, what can we do?

Advocacy is a module they teach in med school, and I feel like it’s not particularly well understood, at least from where I went to med school. Maybe you guys went to, I think, much better institutions than I did.

It felt like questions I had to answer on a test, not anything actually practically applicable.

So in this case, up against things like Big Food, some of the largest industries in the country and some of the most entrenched, with powerful lobbyists, how can physicians approach this kind of seemingly insurmountable challenge?

Is it state? Is it local? Is it federal? Like, just what can be done to start feeling like we’re moving the needle at all on this problem?

GC: If we try to do it like a lesson, right, like a lecture, and we’re looking at making things kind of secular, we’ve already kind of talked a little bit about the clinical perspective, just in the physician-patient encounter, right?

And there are things that we can add into that encounter. For example, as Dr. Caswell has mentioned, basically adding more fruits, vegetables, plant-based fibers will be very helpful.

Another aspect would be if we’re looking at trying to add a new cooking method, right? A lot of times people are like, you know, I can do some grilling and basically reduce my carbohydrates and go completely low-carb, right?

But then there’s this whole advanced glycation end products that can really cause that oxidative stress and accelerate that atherosclerosis, giving patients that high cholesterol and increasing their cardiovascular risk for heart attacks and strokes.

So, yeah, another method that we can add to that encounter is like, maybe we steam the food, right? Maybe we can actually steam the fish rather than grilling it. That can actually reduce some of that inflammatory load.

There’s a lot of research coming out that’s been mentioned about aspirin use in colon cancer prevention, right? Mostly because, or at least the theory is, that salicylic acid that we can also get from fruits and vegetables in the shape of a pill as an aspirin that someone can just take in the morning, right?

Because, you know, that’s just a much easier fix for some, in a very busy lifestyle, and can also reduce some of those colon cancer risks.

So that’s one simple way that we can put it into the physician-patient encounter, right? The other thing is looking at the environment.

And so how can we advocate for environmental change? There was a wonderful article, I think it just recently came out. It was ranking different cities, and it was ranking cities based off of a fitness index and basically saying that cities that rank at the top, they’re not necessarily at the top because of one program or one investment.

You know, we have to look at this as a multifactorial approach to building systems that support a healthier lifestyle over time.

So if that means incorporating bike lanes that are safe for people to use, or incorporating more city lights so people feel like they can safely walk along the sidewalks with their children at night, basically giving people that sense of security to be more active, to not have to jump in the car or take an Uber to go these different places.

Of course, that has its own place, but how can we encourage people to take their bike to work? Or ride their bike to get some groceries and ride back?

Just little things in the environment that can make a big difference, right?

And then one thing I really did want to mention, because China’s really doing these kind of weight-loss camps overseas, right? And it’s drawing a lot of attention because, interestingly enough, for 28 days at these locations, you can spend somewhere between $500 and $900 for the month, and it includes the room stay, it includes all of your food, it includes personal training.

You know, it’s just like, wait, but that’s like a two-night stay or three-night stay somewhere, you know? How do you get a month-long stay incorporating food and teaching me how to exercise? That sounds like a better use of my money. Not to mention I don’t have to pay rent.

So, right, there are ways in which that’s being incorporated. So let’s explore this, right? Like maybe this could be state-subsidized. Maybe we can have something at a city level or a state level that provides a pivot of some policy and some funding to actually support people who just really need a little bit of assistance learning the ropes.

Some people don’t feel comfortable going to a gym. Some people don’t feel comfortable because they don’t know what they’re doing. That’s a significant barrier to some exercise.

But if we can have programs that allow for people at a low cost to learn some of these things, then we have different ways to address it.

So that’s kind of looking at things at maybe not an environmental level, but more of a policy level on the state legislative side of things.

So we have different things that we can do in this rainbow to really help support healthier lifestyles. And I think that we should be encouraging, and I think that’s what this podcast is doing. I think that we’re encouraging that discussion and that we’re encouraging thought to be able to provide these things to the people, to be able to say, hey, I think that this would be a great idea. Let me take this to legislative government or local government, or even just something as small as your workplace, right?

GC: To be able to suggest these things can really make a large difference. And I think that we should encourage that.

And I know that the American College of Physicians encourages that. I know that the Annals of Internal Medicine provides a lot of medical knowledge or things for people to look into some of these different practice points.

And I highly encourage people to kind of explore more about how we can actually get more involved, both individually and as a community.

NP: Dr. Caswell, I’d love to hear your thoughts on physician engagement and advocacy in this space, specifically around food, food health, and food as nutrition.

SC: Absolutely. So, yeah, we definitely live in an environment where the healthy choice is not the easy choice.

And it’s very apparent now that our politicians don’t generally support any of these high-level modifications we need to our environment, right? Because we have so much lobbying that’s done.

And the bottom line is always financing.

We know that putting grocery stores in areas where there are none is very difficult because typically the level of income in those areas is very low. And we know that grocers worry about that because they know that the people that live in those areas won’t be able to spend a whole lot of money.

So for them, it’s almost looking at a loss rather than a benefit to their industry.

And then we know that lobbying happens in Washington, DC, and the USDA does a lot of that, which is a lot of the reason why there’s so much around dairy in the dietary guidelines. And I can’t even go into that right now because we could be here all day.

So what I will say is that I think as physicians, we don’t generally learn in medical school how to advocate for things that are of interest to you, right?

And so the best way, I think, to start is by going to your medical organization.

So, you know, for me, I start at my state level. California Academy of Preventive Medicine is at my state level, right? And I go on their website and see what kind of advocacy is going on right now. What are they working on as an organization? And how do I get involved at that level to help pass resolutions that go on to potentially become policy and laws, not just at the state level, but even beyond at the federal level?

And it’s been really fun to be involved in some different resolutions that have come up in the past that I’ve been able to kind of join and help collaborate on. And then I’ve also been involved in writing some of them too, which is really cool.

So I think there’s a lot of power there.

Another thing I suggest is, if you do see that there is opportunity to advocate and write to your own local leaders, they are there to represent you. And as a physician, you don’t have to represent the organization that you work for, but you can represent yourself and say, hey, like I am seeing this in my patient population here in my area. Can you work with me?

You’re writing these to your local representative, and they can take it to the state level. That’s also a great way to get that connection. And I’ve done that as well just within the last year.

So write your letters, write to them, and vote for the people that you want in place to be able to push the things that matter for patient health and population health at a larger scale.

And, you know, if you have the opportunity to go to a day in Washington, DC, with your medical specialty, go do that. You know, there is so much power in numbers, and there’s so many ways to get involved.

Now, let’s say that perhaps you’re interested in the nutrition world and you are a dermatologist, right? Like, I don’t know if dermatology is pushing anything down in terms of nutrition, right? So if you’re not sure where to look, go do a Google search and see what kind of policy right now is going on around the world of nutrition.

And there’s plenty of websites and groups out there that can guide you in the right direction and that you can get on their listservs for. And every once in a while they’ll send out some policy that they’re trying to pass. And, you know, you can sign something that helps push things along.

So there’s so many ways to get involved at that bigger system level that it’s silly not to, because as a physician, you are a leader. We’ve gone through a lot of school, and people see physicians with very high regard. Use that for the benefit of the communities that you serve.

NP: Amazing. I couldn’t agree more. Thank you, Dr. Caswell. That’s fantastic.

I love all those different areas that you can get engaged in, kind of like low, medium, high effort, near to you geographically or even far-term, doing DC advocacy days.

A lot of us belong to medical groups that do those DC advocacy days. So there’s lots of things that are maybe one or two steps away from us that make it accessible, which is important.

So I’m going to ask you both a question, and we’re going to come back to the answer after we do our rapid-fire questions. Okay? So, but I want you to be ready for it.

What is one thing, given all the power to make one simple, straightforward change, that you think would be the most impactful when it comes to getting people to eat more healthily, with food as medicine in mind?

So I’m going to come back to that question. I’ve given you all the power in the world, and you’ve got to meditate on it while I hit you with rapid-fire true-false questions.

I’m going to ask you both the same true-false question. If there’s any disagreement, then I think it means we need to come back for a fourth episode.

Starting with you, Dr. Cox. Food addiction is as real and as serious as alcohol and nicotine addiction.

GC: True.

NP: Dr. Caswell?

SC: True.

NP: Okay. All right. Empathy can change patient outcomes more than any diet.

GC: True.

NP: Natural on a food label is one of the most dishonest words in the grocery store, Dr. Cox.

GC: True. I hope that Dr. Caswell can find a better term that could be more deceiving.

NP: Yeah, it’s very true. Very true. Yeah. I would say it’s up there with organic, forgive me, but as a baseless word that used to mean something.

GC: Yes.

NP: Natural, I think, even less so. Yeah. Have you read Marianne Nestle’s Food Politics book?

GC: No.

NP: No, no. You should. It’s either her book, and/or there’s another one that I was reading about on the fights around certain terms that food companies have used that they’ve had to remove because they were claiming some sort of benefit when, in reality, they actually didn’t have the research or the data to back that up.

And so natural is one of these words that’s actually a very loaded term. It can mean so many things.

GC: I’m sure. It makes total sense.

NP: Okay. Nutrition education should be standard curriculum in med school, Dr. Caswell.

SC: Of course. One thousand percent true.

NP: I don’t think Dr. Cox is gonna disagree with you on that one.

GC: Can’t even try.

NP: Food dye is a lesser concern than sugar and salt content, Dr. Cox. Dr. Caswell?

SC: True.

NP: And lastly, most patients already know what they should be eating. Dr. Caswell?

SC: False.

NP: False. Okay. Dr. Cox?

GC: Also gonna go with false.

NP: Okay. All right. I like that because I think it is different than oftentimes when we discuss the similarities and parallels between addiction medicine. I feel like those oftentimes who have tobacco or alcohol use disorder, or even substance use disorder, there’s a knowledge, right? Like, nobody reaches for a pack of cigarettes anymore and is like, “But these are good for me.” It’s like we’re so far past the “four out of five doctors recommend Marlboros.” And that’s very different than the food world, where there’s still a big education gap.

But I think we as clinicians have an important place then and a gap to fill, right?

Okay, so coming back around, Dr. Cox, what do you think? You’re given the power one day. You get one change to make to fix this.

GC: Again, one change to fix what, exactly?

NP: The problem of inadequate recognition of nutrition as medicine, either from a patient standpoint or from an advocacy standpoint. If the problem is we have a dietary pandemic in this country, an unhealthy dietary pandemic, how do we address that? Because there’s a hundred different ways. So which one are you going to pick?

GC: Biggest thing is that we fail to really understand food as a whole and their effects on the body. So I would say there is a way in which we can spend, and this is gonna be far out there, right? I mean, this is you give me the opportunity to answer this question.

I think personalized medicine. Not everyone responds to food the same way, right?

NP: Let’s go far.

GC: For me, you know, I can have some cheese or some rice and my blood sugar and cholesterol panel goes through the roof, right? Well, my wife might have the same thing and she has very minimal effects, right?

I think that we’re gonna get to this point. I don’t think we’re there yet, but I think there’s a lot of science and artificial intelligence being utilized to try to get there. But I think personalized nutrition is really what’s gonna help us dial in a longevity-focused, long-term approach. And I would love to see us get there, and I would love to participate in anything involving us getting there as well.

NP: Love it. Dr. Caswell.

SC: This is such a hard one because I feel like I’d want to approach it like a thousand different ways. I think lobbying is a massive problem by these food manufacturing companies. Obviously, they want to make as much money as possible. And I think it’s hurting the American public. And I think there is a lot that we need to do there to improve our entire system.

Because there’s only so much I can do at the one-to-one level, which, you know, we’re trained as preventive medicine physicians. We’re trained at one-on-one. We’re also trained at population health. But, you know, like, I can only get to so many people, right?

But if we’re having system-level change at the federal level, I think you can impact a lot more people. And I think food lobbying, I think there’s a lot of issues there. It’s gotten into a lot of guidelines and policies and laws that, you know, it should have never happened in the first place. But because money talked, that’s how they ended up there.

And so I think we need to do a better job as a country and really clean that up. And if I could, I would clean that up.

SC: Love it. Okay. I’m not just going to throw you both out there. I do have one of my own. And so I’m going to follow on from Dr. Caswell, where you were going, because there’s an intersection of, of course, like money and finance in this as well, right? Like we’ve talked about.

I would go for an economically nerdy concept of a negative sales tax on healthier foods. So, in a way, giving basically socially funded discounts back for things that are locally made, plant-based, healthier for you, not the center of the grocery store, so to speak, to go back to your model, Dr. Caswell, and effectively find ways to give rebates.

We already have different taxation levels on things like cigarettes, tobacco, food, marijuana, depending on the state that you’re in, of course. Like, those all have different sales and use taxation limits, of course, different than goods and services and things like that.

And so you could create another category of that, of healthier foods that then have a negative taxation and effectively as a way of subsidizing it without having to go through SNAP or WIC or something that takes even federal programming. That’s something that can be done locally on, like, a state or municipal level.

It’s an idea that I’ve been really interested in recently, this idea of negative taxation as subsidization and as, like, motivation for customers and for all of us who are kind of wandering the aisles with our carts.

So, like I said, I wasn’t just gonna ask you both that, not throw out a, you know, one change on my own.

But look, Dr. Cox, Dr. Caswell, thank you so much for coming to The Podcast for Doctors (By Doctors). This was a fantastic third installment in our obesity medicine and ultra-processed food series. And it was really great having you both as guests. Thank you.

GC: Thank you.

SC: It’s been a pleasure. Thank you.

NP: You can catch The Podcast for Doctors (By Doctors) on Apple, Spotify, YouTube, and all major platforms. If you enjoyed this episode, please rate and subscribe. Next time you see a doctor, maybe prescribe this podcast. See you next time.

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