I have suggested the social contract underlying Big Medicine has come unraveled and that we in medicine needed to answer three questions. First, what do we currently do that represents a real improvement in the lives of our people? Second, how can we make these items available to everyone at a cost that is sustainable? Third, how do we expand our and the public’s understanding that healthcare is more than what occurs inside the walls of the hospital or clinic? In this article, I want to focus on an area where we have not been notably successful: the role of nutrition in health and disease.
At first glance, this may seem paradoxical. After all, laymen and specialists alike agree that “you are what you eat,” and terms like the Mediterranean diet, the French paradox, and “blue zones” have entered the public arena. Looking back over the 20th century, you can find examples like the scientific discovery of vitamins and trace elements and the subsequent approaches to eliminating them. For example, vitamin D fortification of milk to address rickets, iodinization of table salt to address endemic goiter, and shoes for children to prevent hookworm infection, thereby eliminating hookworm and its subsequent pellagra due to niacin deficiency come to mind. These instances were so successful that most U. S. physicians have never seen the diseases of vitamin deficiency, and there has not been recent controversy about dietary fortification.
Yet what have we in medicine done? We have changed to a focus on blood levels and pills to “normalize” the blood levels. In my career we have had campaigns looking at folic acid and vitamin D for example, which have had dubious benefits. There is certainly no evidence that widespread use of over-the-counter vitamin preparations has been beneficial in healthy populations. Furthermore, public acceptance of some of these efforts, like fluoridation of water to prevent tooth decay, has always been less than 100% acceptance. My municipal tap water is fluoridated, but there is still one publicly accessible well where the water is not treated. Just this week, the news contained a report of new anti-fluoride efforts.
Another example of mixed success is food safety. Consider pasteurization of milk, which has been the law for decades. But as the FDA notes:
“In recent years, however, a small number of Americans (less than 1 percent) have rejected pasteurization in favor of raw (or unpasteurized) milk, citing a range of taste, nutritional and health benefits they believe are associated with raw milk consumption, as well as a general preference for unprocessed food. Today, 20 states explicitly prohibit intrastate raw milk sales in some form and 30 allow it. While the perceived nutritional and health benefits of raw milk consumption have not been scientifically substantiated, the health risks are clear. Since 1987, there have been 143 reported outbreaks of illness – some involving miscarriages, still births, kidney failure and deaths – associated with consumption of raw milk and raw milk products that were contaminated with pathogenic bacteria such as Listeria, Campylobacter, Salmonella, and E. coli. Because E. coli can spread from one child to another, the risk is not just to the one that drank the milk.” 1
1 https://www.fda.gov/food/buy-store-serve-safe-food/food-safety-and-raw-milk. Accessed 15 September 2025.
The last area is the notion of the proper balance of macronutrients. There have been august pronouncements to “eat this, not that,” food pyramids; various diets: keto, Atkins, paleo, etc., most of which are based on population studies that show areas of the world where exceptional longevity is the rule, tend to be places where diets that are more plant- based. Other studies show the incidence of coronary artery disease is low in Japanese eating a traditional diet, but if the emigrate to the US, the incidence of coronary disease starts to look more like the US than Japan. In my career, I have experienced campaigns against sugar, saturated fats, protein, and now “ultra-processed food,” (UPF), variously defined.
As outlined by Ludwig, 2 the Nova system was proposed in response to the failure of traditional approaches to define “junk” food. In this system, group 1 are foods that are minimally processed, group 2 are foods processed with traditional culinary practices such as sugar, flour, fats, and salt. Group 3 are foods in group 1 treated by addition of group 2 treatments, and everything else is group 4, or UPF. While this seems simple enough, it has proven difficult to put into practice, which is compounded by imprecision in the use of the terms. And there is minimal evidence to support the overall effectiveness of the scheme.
“All known human societies eat cooked foods, and biologists generally agree cooking could have had major effects on how the human body evolved. For example, cooked foods tend to be softer than raw ones, so humans can eat them with smaller teeth and weaker jaws. Cooking also increases the energy they can get from the food they eat. Starchy potatoes and other tubers, eaten by people across the world, are barely digestible when raw. Moreover, when humans try to eat more like chimpanzees and other primates, we cannot extract enough calories to live healthily. Up to 50 percent of women who exclusively eat raw foods develop amenorrhea, or lack of menstruation, a sign the body does not have enough energy to support a pregnancy—a big problem from an evolutionary perspective.” 3
Maybe what we should focus on is more about eating less, particularly nutrient dense foods, processed or otherwise, and increasing physical activity, and reserving dietary prescriptions for those with diseases, like diabetes, morbid obesity, or kidney failure, where we have specific goals patient can get behind. Let’s leave the “eat this, not that” arguments to others, which are hurting our efforts to be cost-effective health advocates. As I have told many people, I have noticed everyone eats and everyone dies, so eating must be bad for your health. Of course, so is not eating.
21 September 2025
2 Ludwig DS. Ultraprocessed Food on an Ultrafast Track. N Engl J Med 2025;393:1046-1049. doi:10.1056/NEJMp2508694. 3 https://www.scientificamerican.com/article/food-for-thought-was-cooking-a-pivotal-step-in-human- evolution/. 26 February 2018. Accessed 15 September 2025.
Further Reading
On the Social Contract, Part 1 Critics of Big Medicine cite mortality statistics where the US is worse than most other advanced countries. We often blame diseases of despair, but a recent retrospective analysis shows survival in the richest US quartile is about the same as the poorest Northern and Western European quartile.
On the Social Contract, Part 2 The social contract underlying Big Medicine has come unraveled, but rather than listing “successes,” I will focus on a problem where we have not been notably successful—substance abuse.
Seasons Seasons are a part of life and we seem to be in both astronomical and sociological winter, so we should expect hazardous driving conditions in both areas.