How to navigate the food system for healthy eating

Dr. Ellen Beckjord: Stronger communities begin with good health—for everyone. You’re listening to the “Good Health, Better World” podcast, presented by UPMC Health Plan.  

This season, we’re exploring ways to achieve good health in today’s complex world. I’m your host, Dr. Ellen Beckjord. Let’s get started.

In this episode, we're joined by Steve Downs from Building H to talk about the food environments around us and how to make healthy decisions about the food we eat.

Steve, thanks so much for joining us on “Good Health, Better World.”

Steve Downs: Hi Ellen, it's great to be here. Thanks for having me.

Dr. Ellen Beckjord: You know that I'm a huge fan of what you're doing with Building H, and because of the nature of Building H, we could have talked about any number of things on this episode—we’re going to focus on food—but before we dive into that, would you please tell our listeners about the wonderful initiative that is Building H.

Steve Downs: Thank you. So, Building H is a research organization dedicated to making everyday life healthy by design. We're part of the nonprofit Public Health Institute. Building H comes from the idea that it's hard to be healthy today, right? It's hard to eat well, it's hard to get enough physical activity. It's hard to get enough sleep. It's hard to spend enough quality time with friends and family. And part of the reason that it's hard is that we have all of these products and services that are not really part of the health care industry or anything like that, but products and services that we interact with every day, that sort of form what we call this product environment that is often pushing against these healthy behaviors.

We have products, whether that's in the food industry that we'll talk about—but also entertainment industry, transportation industry, housing industry, that sort of collectively make it challenging to get all these healthy behaviors in. And so, our aim is to really shift that environment in a much more health positive direction. And we do that to a large degree by measuring these influences, measuring these impacts, looking at very specific products and services and asking how they affect the health behaviors of their users and doing that analysis.

Dr. Ellen Beckjord: It's such important work. One of the most complicated, if not the most complicated health behavior, I think, is eating. There’s so much, so many contextual layers, one of which—and I’m by no means an expert in this, but [I] have become more familiar with it over the past few years—is the contextual layer of the food system that has a lot of impact on the eating behaviors of the American public. How would you, in your own words, define the food system in the United States?  How is it or is it not governed? And what are some of the challenges that exist within the food system as it relates to most people eating in a way that is aligned with nutritional guidelines?

Steve Downs: When I think of the food system, I think of it really broadly. You know, it's the foods and beverages that are manufactured and sold. It's the restaurants we go to. And I would actually include in that school lunch, school cafeterias, which have been described as America's largest chain restaurant. But I also think about the delivery services like DoorDash and Grubhub and all the grocery stores and supermarkets where we can buy food. But I also think it's in things like our recipes that we either pass down or that we have access to. It's our food culture or actually really many food cultures that we have in the U.S. It's our personal infrastructure—things like the equipment in our kitchens, the refrigerators, the stoves. It's the financial supports provided to help people who are food insecure to be able to purchase food, and also the places that distribute food to people who are food insecure. So there is so much that comes together in terms of what we put in our mouths and how it gets there and sort of the context in which that happens.

You’d asked about how it's governed. And I guess I would say there's a lot in place to make sure that the food that we eat is safe, right? So that we're not going to get food poisoning from it. There's a lot that is done. It’s inspections of restaurants, it’s inspections of food manufacturing, processing plants and all of that, and a whole reporting system and tracking, you know, for this kind of stuff. So that's part of the governance. There is certainly a federal policy around food aid—things like, SNAP, the Nutrition Assistance Program, or WIC, the program that helps women and infants and children with food support.  And there's policies around school lunch, like what qualifies as legitimate stuff to serve for school lunch and how much we subsidize that.

But there's not as much, and I would say a lot less focus, on how we make food healthy for people. And I don't think we have anything that resembles a national goal around making sure that everybody has a healthy diet and doing things to help make that possible. I think we have not succeeded in preventing people from suffering from diseases that are the result of inadequate diets or diets that are unhealthy.

Dr. Ellen Beckjord: One of the things that seems to loom pretty large in the national conversation right now is the idea of ultra-processed foods. I don't think ultra-processed foods are new, but it seems like there's more attention being paid to them, or that term comes up. And in a Building H newsletter from, I think, the second half of 2024, you all did a wonderful sort of commentary on the really interesting tension that is emerging between parts of the food system and the pharmaceutical industry, because as certain medications, GLP-1s in particular, become more common or used more often by folks, it's threatening the profitability of some parts of the food system, because not only are people who take these medications typically eating less, there's evidence that these medications interrupt what can be part of what makes eating certain foods and often ultra-processed foods reinforcing, because of the effect those foods have on the dopamine pathways in the brain.

But one of the things that blew my mind in what was shared in that newsletter is how there hasn't been a super big change in the caloric intake of the average American person over the last 25 years—but of course, over the last 25 years, there's been an enormous change in the prevalence of overweight and obesity—and that one of the reasons that seems to be emerging for that as an explanation is that ultra-processed foods are typically not digested in part by gut bacteria. So, foods that aren't ultra processed, if it was 100 calories, the caloric hit to your system, say, might only be 80 calories because your gut bacteria processed 20 of those calories.

You know, you look at this stuff in a grocery store, and it's just unbelievable that it's being sold. And even our gut bacteria are like, we're going to take a hard pass on that. That doesn't seem like a good idea. So, ultra-processed foods aren't the only or probably even the problem. I don't want to give that impression. But we are hearing a lot about ultra-processed foods, and I wonder if you could talk a little bit about those from your perspective in kind of the broader product environment?

Steve Downs: Yeah. So first I should say I'm not an expert in ultra processed food, I'm not a nutritionist or anything like that. But ultra-processed foods, as you said, have been around for a long time, but their labeling as such, some sort of classification, is relatively new. It's actually a research team out of Brazil that sort of developed this classification.

When we think about ultra-processed foods, we're really talking about the foods that have been produced using all sorts of industrial methods, the kind that you can't try them at home. These are chemical processes. They tend to have ingredients that you can't shop for and wouldn't shop for. There are things that are added into foods, primarily to make them look more attractive. And to be what is called in the industry, “hyper palatable,” so the foods that you crave and crave, and can't seem to get full on.

There's this great work from you nearly over a decade ago by Michael Moss in the book Sugar Salt Fat, I think it was called, where he talked about this idea of the engineered bliss point, which is the sort of optimization of sugar, salt, and fat so that you absolutely felt like you needed to take another bite, and you couldn't really stop.

Dr. Ellen Beckjord: And is it true that some of that kind of triggers, you know, there was a time when if you were a human being and you came upon something that contained sugar, salt, or fat, you might not come upon it again for a really long time and so there's this sort of evolutionary like, eat as much as you can. Now, of course, we can eat as much as we want anytime. But is that part of what's, what the theory or even maybe the science backs, that that's kind of what's getting triggered?

Steve Downs: Yeah, I think that…that we evolved in sort of a low-calorie environment, right? Or an environment in which calories were hard to come by. It sort of took 17,000 steps to acquire these calories to keep you running every day, so it was a lot of work involved in obtaining calories. And to your point, because they were so often unpredictable, we developed mechanisms to sort of eat while you can, because you never know when your next meal is going to be.

One of the issues, I think, with the modern world in general is that our genes have not changed rapidly, but our environment has changed rapidly. So now we're living in an environment where many, many calories are available, at the drive-thru with no physical effort, or at the tap of your phone and DoorDash arrives. There is this mismatch between what essentially our bodies and minds are designed for and the environment where suddenly you can get all the calories anytime you want 24/7, really. So, I think that is part of it.

I think one of the things that actually is sort of shocking about ultra-processed foods is just how pervasive they actually are. So, there's a stat that out there that is, I think, 60 percent of the calories consumed by children and youth in the United States are from ultra-processed foods. So, it's not like there's this weird thing that we're seeing a little of on the edges, but it is the core of our diet.

So, it goes back to the point about how is this all governed? Which is that food to a large degree is designed to be hyper palatable as we talked about, but also designed to be sold at levels that are more than what we need, you know. So if you think about ordering food on an app or going to a restaurant, you're always being upsold, right? They're going to sell you another side dish or a larger drink or a dessert. And so I think there is this problem that we have, that abundance of food, where we're being pushed to have more and more, and it's being exquisitely engineered to be craved. And that, you can imagine, results in more calories, but also to your point about the ultra-processed foods being digested differently, results in this unfortunate kind of epidemiological finding that the overall calories may have stabilized in the last couple of decades, but obesity continues to rise. And that's an issue that, as you say, ultra-processed foods are a suspect in that, but also, I think scientists are really still sort of scratching their heads about it. It's not clear exactly what's driving that.

Dr. Ellen Beckjord: Well, I think this is one of the really wonderful contributions of Building H is that it helps us to think about multiple contextual factors and the interactions between them. You know, if a lot of other things had stayed the same over the past 25 years except for the increased prevalence of ultra-processed foods, maybe it would be a different picture, but it's perhaps the interaction or the coupling of ultra-processed foods with more social isolation and sedentary behavior and just all of the ways that modern American life, in large part in relationship to the broader product environment (you've heard me say this, I think), puts a lot of pressure on us to sit still and consume. That might be food, that might be media, content, whatever.

And you can take it too far in the other direction; I'm a culprit of that. I mean, it's a little bit hard for me to sit still, and it probably would behoove me to sit still a little more often. But there's a lot of excess sitting still and consuming. And there's a lot of evidence that it's not real good for us.

Steve Downs: No, absolutely. And I think that that's in some ways part of why we're trying to sort of look at this product environment as a whole and think about it in sort of a cross-cutting way. You know, a lot of behavioral science is sort of organized by behavior, right? So people focus on nutrition, or they focus on physical activity, or they focus on sleep. Or it's by industry, how do we get this industry to change these kinds of products or whatever? And I think what we're saying is that there is a whole to this. There is a whole that tends to reinforce, or negatively reinforce, these kinds of behaviors. And I think we have to get a handle on it at that level, right, to say there is an overall environment that we need to shift in more positive direction so that these behaviors, the healthy behaviors, come more easily, come more naturally. We create these things like gyms and exercise, you know, because we don't move naturally. And so it has to become an extra thing that you add into your routine.  And what I think we're trying to push more for is, how do we make it so that these kinds of things do happen as a part of your day? Not like a sort of health add-on that you can optionally introduce into your life.

Dr. Ellen Beckjord: Right, and just making it more of the default, which is so often not the case.

I'm curious if you have an experience similar to me, which is, I seem to want to draw a lot of parallels to what's happening with the food industry with what happened previously with the tobacco industry; that there's a product that's being sold and it has known negative health consequences, and the incentives are misaligned because the company designing the product, you know, of course, makes more and more money the more of the product that they sell, but that it’s clearly having a negative consequence. I guess I'm wondering, is there anything that we can take from what we learned about how we navigated—not completely successfully, but I think a lot of success—the sort of fight with Big Tobacco as we move forward with the food industry, or is it just too different and complicated a foe, if you will, because it's just such a more varied, nuanced, complicated industry? It's not as straightforward, and I wonder if that means there's not really much that we can take from the fight against Big Tobacco and bring it to sort of the fight against ultra-processed foods?

Steve Downs: Oof, yeah, I think you've raised a number of key points in that question. There are definitely parallels, as you point out, but there are enough differences that I think we have to think about it differently. It is a product that commercial companies or for-profit companies produce. They have an incentive to sell more volume. They have an incentive to make the foods craved by people. And, you know, a lot of this can be linked to disease. Now, it's not as straightforward, I think, as tobacco and lung cancer and heart disease—which again, I'm not an expert in that, but I think the science was probably a little cleaner—and it's much more complex, right? Because it's often the interaction of different ingredients. It’s not just about, let’s say, getting fat out of your diet. You know, that doesn't work. You replace it with carbs. It’s a very complex field of study. So, I think that's one of the differences.

And then of course, there's the issue that, unless I'm missing something, cigarettes really didn’t have an actual benefit. Obviously, people enjoyed smoking them. Obviously, some people were addicted to smoking them. But you could live a perfectly good life without cigarettes, whereas you do need food. And where you draw the line between something that is, you know, perfectly good at reasonable levels of consumption versus something that is, you know, maybe not so great if you have too much of it versus something that you probably really shouldn't have at all. You know, these are not easily done.

There's another piece of this, though, which was ultimately a big piece that came from tobacco. One was having strong science and being able to start by saying kids should not be harmed by this and let's not market to kids, let's restrict availability to kids. But I think another was that state attorney generals started to be able to calculate harm in terms of costs that states were having to pay, in Medicaid, for the treatment of people who had suffered lung cancer, heart disease, as a result of smoking cigarettes. And so, they were able to say, let's sue the tobacco companies because, you know, they are literally costing us money through this interaction. And so that raises an interesting question then: could that happen in the food industry? And I think in order for that to happen, you'd have to start to get a sense of can you calculate the costs that are associated with the disease burden that is associated with the diet, and then can you sort of figure out a company's share of that?

In many cases when we regulate products, we do so when they cross some sort of line of safety or harm, you know, where we say, like, up unto this line, you can do what you want, sell what you want, whatever, but if it contains too much of X or if X has been shown to, you know, cause this disease, then you can't cross that line. I think with the case of food and I also think the case with things that create sedentary activity, you have to move more to a contribution model, which is not to say that this product is harmful and should be off the market, but to say a certain number of people using a certain amount of this product contributes to an overall population level of behavior that is harmful. And it may be that this product only contributes half a percent of the population's problem on that, but maybe there should be accountability for that half percent contribution. So, I think that's, to me, what's interesting is how do we start developing the methods and the measures to say, here's a food, you know, whether it's a restaurant or a food or beverage manufacturer to say they're contributing X into the food environment and the collective impact of that food environment is something that we can put a cost on and maybe we can start to hold some accountability for that—their share of that. A lot of work to be done on that, but I think that may be one of the areas that we have to get better at.

Dr. Ellen Beckjord: Absolutely. And I think Building H is really leading the way on that work. And it points to something that I think is important to mention just briefly, which is, of course, eating is an individual-level behavior, but as you've pointed out, that behavior is so heavily influenced by system-level factors. And one could argue that accountability is best positioned at that system level, or at least it can't be thought of only as individual level accountability. It has to be thought of as at least both, but with a healthy dose of accountability at the system level.

Steve Downs: 100 percent. You've heard me say this before, but the metaphor we often use to describe the product environment is that people have to swim upstream to be healthy, right? It's a constant struggle because there are all these systemic forces making things hard. And we have to do better than tell people to try harder.

Dr. Ellen Beckjord: That’s right. Yep.

Steve Downs: We have to make it so that it's not so hard. And if you have people who are saying: I'm trying to eat, you know, in moderation and I'm trying to eat healthy foods, but then you have a lot of folks who are sort of PhDs at designing food to be maximally craveable.

One of the things that actually has come out of the GLP-1 battle for the food industry is now using AI to develop food processing that will maximize that craveability. And so, you have this sort of arms race of how do the food manufacturers create things that will even overcome the GLP-1 effect? And when you step back from it, it all sounds kind of absurd, right? You know, and so I think this is an ongoing challenge, but I think we really have to kind of call it out.

Dr. Ellen Beckjord: Yeah. Agree. Well Steve, given your experience having been studying and navigating the product environment, anything you care to share about how that's affected either your own practices related to food, or what advice you might have for listeners who might be seeking to, I don't know, renegotiate their relationship with food and in what we might call a positive way?

Steve Downs: Yeah. I mean, a couple thoughts. And everything depends on someone's individual contexts and their resources, both money and time and other things. But I think when you can, if you can prepare your own food or your own meals, that's a great thing to do. You're going to wind up eating more healthy if you're actually preparing the ingredients or preparing the meals with the fresh ingredients and that sort of thing.

The second thing that I would say is, in terms of navigating the environment, is…be sensitive to when you're being manipulated. And with that sensitivity then choose, when you can, to resist. There are a lot of times when you're being upsold, you know, or cross sold, meaning that you think you know what you want and you order it, and someone's trying to get you to order more on top of that. Recognizing when you're eating something, you're like, wow, this was actually engineered to make me not be able to stop, and say, OK, someone is actually manipulating my behavior. And to sort of say, OK how do I feel about that? Do I want to push back against that? They're doing this for a reason, and they're getting me to do something that I might not ordinarily do on my own. And how do I feel about that?

Dr. Ellen Beckjord: I love that. That's a great contribution and a great thing to keep in mind. Thank you.

My last question for you, Steve, is what are you feeling hopeful about? This work to understand the forces that are pushing against health is so incredibly important, but I imagine that you, like me, can sometimes kind of get into a pretty dark place thinking about only that. And so I'm curious if there are things that you can share that you're feeling hopeful about, because as much as is working against us, I know that people at an individual level, and certainly products and services, are doing incredible things to try to push back against that momentum against health.

Steve Downs: Yeah. So, I think there are a couple of big things I feel hopeful about. One is I think there is much more awareness of and much more attention on the importance of healthy behaviors than ever before. I think people are well aware that diet really matters and that they need to be active. And I think there's so much more attention on things like sleep than there used to be. There's much more attention on the value of social engagement and social connection. And so I think it's fantastic that these things are really much more in the foreground.

The other thing that I always feel hopeful about is the sort of our societal capabilities to innovate and invent and to build amazing things. I mean, one of the things that I've looked at a lot is the sort of the evolution of technology over the last, you know, 50 years, 100 years, and it's sort of a mixed story of unbelievable accomplishment, you know, and we're living in this magic world because of the ingenuity of so many people and the capabilities that we have. And one of the things that I've talked about a lot is how health has not always come with that, because we've in some ways been building things that lead us to eat poorly or to sleep less, or to be less active or less social. But what's not lost in all of that is our capability to accomplish amazing things. And so, for me, the hope is that with more understanding of the importance of helping people be able to have a lot of healthy behavior in their lives and our incredible capability to build things and accomplish the things that we set our minds to, I'd like to believe that we can shift some attention of our builders, you know, to building things that make it easier for people to be healthy. That capability is inherent. It's a question of how we direct it. And so I think that's the thing that I feel hopeful about.

Dr. Ellen Beckjord: Is there anything that we didn't talk about that you'd like to mention to folks listening to the podcast?

Steve Downs: The only thing that I would add in is that it's easy to medicalize food and to think about it as sort of a task of optimizing nutrition, and I don't think we need to sell food that short. Food is nuanced and complex. It is social. It is cultural. The act of preparing food can be a really fun activity in itself if you can find the time. And so, I think it is about encouraging people to think about how you maybe honor and prioritize the role of food in your life. We're so often strapped for time and feel like food is just something we need to get in us quickly, or we go down the rabbit hole of really trying to maximize on certain nutrients and that sort of thing.

So really trying to encourage people to think about it not as purely medicine, although it has a big effect on our health, but to think about it as something to be enjoyed, to be celebrated, to be part of a practice, and to be something that can be very social. So, I guess that's what I would add.

Dr. Ellen Beckjord: I'm so glad that you added that. I love that. Steve, thank you for the ongoing incredible work of Building H, and thanks so much for taking the time to talk with us on “Good Health, Better World.”

Steve Downs: Oh, it's my pleasure, and thank you for all of your ongoing support for our work. I really appreciate it.

Dr. Ellen Beckjord: We hope you enjoyed this episode of “Good Health, Better World.”

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