Ultra-Processed Foods: Concerns, Controversies, and Exceptions

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And now for our final speaker of the conference. He is the founder of NutritionFacts.org, which has over 2,000 educational videos on pretty much any topic on nutrition that you could want. And over the last couple of years, we’ve learned How Not to Die, How Not to Diet, How Not to Age. And today, he is answering a burning question on everyone’s minds. And that is, what is the role of ultra-processed plant-based foods in our diet? Ladies and gentlemen, it is an absolute honor to welcome our final speaker, Dr. Michael Greger.

Hey, hey, hey! Welcome everyone. I love this conference so much. So honored to be here. Alright. There is no conference I’d rather be premiering a new talk for, so let’s do this.

Modern nutrition science began about a century ago in the context of nutrient deficiency diseases. So, there were editorials with titles like “Sugar as Food,” heralding sugar as one of the cheapest sources of calories. For a mere six cents, you could buy three thousand calories. What a bargain!

But the Nutrient Deficiency era gave way to the Dietary Excess era. No longer were we dying of nutrient deficiency diseases, like scurvy, as much as we were dying from nutrient excess diseases, like obesity and heart disease. So, it became more about avoiding too many calories, too much saturated fat, too much sugar, too much sodium, but either way, still focused on nutrients. This allowed food companies to get away with abominations like frosting-filled cereal, because it was fortified with twelve vitamins and minerals, 50% better than the measly eight in Marshmallow Froot Loops. However, food, not nutrients, is the fundamental unit in nutrition. And to their credit, the field of nutrition started moving toward a more holistic view itself.

So, first-generation dietary guidelines emphasized individual nutrients moved on to second-generation food-based dietary guidelines, which largely converged on encouraging diets rich in vegetables, fruits, legumes—which are beans, split peas, chickpeas, and lentils—whole grains and nuts. But an area of emerging importance was the degree of food processing.

What if, when it comes to nutrition and health, it’s not so much the food or the nutrients as much as the level of processing? For instance, a food-based dietary guideline might say something like “Eat more vegetable soup.” Great! But there’s vegetable soup, and then there’s vegetable soup. Are we talking a clean-out-the-fridge vegetable soup? A health-haloed quinoa and kale organic with a heart-stopping 1,200 milligrams of sodium? How about a vegetable soup with more salt than there are vegetables? Or a vegetable flavor soup that has more artificial colors and MSG than it has vegetables. All soup is not the same. The degree of processing matters.

Ultra-processed foods are these industrial formulations which, besides salt, sugar, oils, and fats, include substances that are really not used in cooking, like added flavors, colors, artificial sweeteners, emulsifiers, and other additives used to imitate real foods, like a frosted grape Pop Tart with more grapes on the front of the package than are actually in it, with less grapes than there are salt, but it may artificially taste like grapes and look like grapes because of one, two, three, four, five different food dyes.

Simply put, ultra-processed foods are foods that can’t be made in a home kitchen, because they have been chemically or physically transformed using industrial processes. They typically contain little or no whole foods, are ready-to-consume or heat up, and are fatty, salty, or sugary and depleted in dietary fiber and other nutrients. So, that’s like all the sweet, fatty, salty snacks like potato chips, ice cream, soda, candy, French fries, burgers, hot dogs, chicken nuggets, fish sticks. Basically, everything in a box or a bag. Why not just call them “packaged foods”? Well, they were actually thinking about it, but they were afraid that some consumers would look at, like, a bag of apples and get confused or something.

But what is so revolutionary about this concept of ultra-processed foods? I mean, wasn’t fatty, salty, sugary junk always a bad idea? Why isn’t it enough to just tell people to stay away from junk? Because, Diet Coke.

Diet soda is the perfect example of why a new kind of term like ultra-processed can be so useful. Because it has no calories. No fat. No sugar. So, no problem, right? Well then, why is diet soda consumption associated with premature death, stroke, heart disease, hypertension, diabetes, metabolic syndrome, leukemia? And most studies controlled for body weight; so, it’s not just because heavier people are more likely to drink it.

Health risks are not only related to the nutritional quality of ultra-processed foods but also to the presence of additives. No apparent calories, fat, sugar, or salt, but contains caramel color, which results in the formation of 4-methylimidazole, which is a potential human carcinogen.

And contains aspartame, also recently classified as possibly cancer-causing in humans. And contains phosphoric acid, which is a phosphate additive that may be damaging our health as well. And contains a benzoate preservative. If you remove artificial colorings and benzoate preservatives from the diets of preschoolers, and then randomize them to be slipped a placebo or a hidden cocktail of colors and benzoate, there is a significant reduction in hyperactive behavior when they removed these compounds, and then a significant increase in hyperactive behavior when they got the colorings and benzoate, compared to getting the placebo. Now, of course, it could have been the colors, not the benzoate, but that’s one of the problems. As little as we know about the effects of these individual additives, we know even less what combinations of them can do.

There is a large body of evidence suggesting toxicity from certain food colors, preservatives, sweeteners, and emulsifiers, in part sometimes through our gut microbiome.

Now, industry apologists argue that the Food and Drug Administration carefully evaluates food additives to make sure that they are safe, until they’re not. In fact, to show the system works, they cite the removal of six carcinogenic artificial flavors in 2018. Artificial flavors that had been in the food supply, approved for safety, since 1964. So, we were exposed for more than 50 years before they were banned. And that’s their example of the system working!

Aspartame, NutraSweet, was officially recognized as a potential human carcinogen in 2023, 42 years after the FDA’s own public board of inquiry opposed approval based on it causing brain tumors in animals in the industry’s own studies. This included several FDA scientists who didn’t think it should be approved. The FDA Commissioner, however, rejected these concerns and approved it anyway, before leaving the agency to enjoy a $1,000 a day consultancy position with the aspartame company’s PR firm. And then, the FDA actually prevented the National Toxicology Program from doing further cancer testing. Meanwhile, literally tens of millions of pounds made its way into the food supply.

Remember when the food industry thought partially hydrogenated oils was a good idea? Let’s replace saturated fats with trans fats. Although many countries now restrict their use, trans fats continue to kill an estimated half-million people around the world every year. Of course, saturated fat is also probably killing hundreds of thousands a year, but the point is that trans fats from partially hydrogenated vegetable oil killed people for decades before there were any limits on it. The FDA didn’t ban it until 25 years after the first solid evidence that it increased the risk of heart disease, and meanwhile, every single one of those years, trans fats were killing an estimated 50,000 Americans a year. That is quite the death toll that can be laid at the feet of the ultra-processed food industry.

But they originally thought it was safe! That’s the problem. Any time a chemical company comes up with a new preservative or sweetener or artificial color, we have no idea how it is going to turn out decades later. So, we can start to see the value of this ultra-processed food concept, in which an entire category of products is essentially presumed guilty until proven innocent. This drives the food industry crazy, but look at their track record, look at the trail of bodies they’ve left behind.

If additives are the problem, well then, why not just stick to so-called clean-label foods, made with simple, recognizable ingredients, no matter how the food is processed. But that’s assuming additives are the only other reason that ultra-processed foods may be unhealthy. Harmful additives are just one of many ways ultra-processed foods have been linked to disease.

At least the food additives are listed on the label; so, we could avoid them if we wanted to. Unlisted are some of the sneakier ways ultra-processed foods may be unhealthy. Harmful additives are just one of the ways that ultra-processed foods have been linked to disease. Like advanced glycation end products (AGEs), for example.

Increasing evidence has shown that uptake of dietary AGEs, advanced glycation end products, is closely related to the occurrence of many chronic diseases: diabetes, chronic kidney disease, osteoporosis, and Alzheimer’s disease. In fact, it’s hard to find a single age-related disease not associated with AGEs.

Dietary AGEs are abundant in highly processed food, because thermal treatments are commonly used, but thermal treatment just means heat; so, we can get AGEs from industrial processing or just from home cooking. So, let’s look at some examples.

Canned corn has 20 units of AGEs per serving, compared to corn chips at 151 and corn pops cereal at 373. Rice only has 9, but rice crackers 275, and Rice Krispies has 600. So, you might be at the store and see some a no-salt-added rice crackers or a no-sugar-added puffed rice cereal and be like, “Oh, it’s just straight rice. Perfect—one ingredient.” But no, because of the processing, it’s not just that one ingredient.

A boiled potato has 17 per serving, potato chips 865, and fast-food fries over 1,500. So, ultra-processed plant foods can have nearly 100 times more of these toxins than minimally-processed plant foods. But even raw, unprocessed animal foods start out with high levels and just go up from there.

Instead of the 10 or 20 in cooked whole plant foods, fish, poultry, and meat start out at around 500 or more in their raw state and then jump into the thousands once cooked, which is still considered minimal processing, though processed or ultra-processed meat can exceed 10,000 per serving.

Although these contaminants are not limited to ultra-processed foods, you can see how just considering foods based on their listed ingredients fails to capture how food processing can sometimes transform food at a molecular level. So, it’s clear that just using this kind of clean label strategy of sticking to foods with simple ingredient lists isn’t going to cut it, since you’re never going to read something like AGEs on a label. It’s the processing itself, whether traditional or industrial, that is affecting the healthfulness of the food.

In the latest dietary guidance document from the American Heart Association, they advise choosing minimally processed foods, instead of ultra-processed foods. Now, of course, they’re not telling people to eat a steak, which is considered minimally processed, because they also emphasize that we should eat foods low in saturated fat and cholesterol. But just like there can be unhealthy unprocessed foods, like steak, they suggest there may be some healthy ultra-processed foods, like what about, plant-based milk and meat substitutes?

Admonitions against the consumption of products simply because they are classified as ultra-processed foods may impair society’s acceptance of a plant-based diet—thus preventing any related health advantages from being realized. And indeed, that does appear to be a significant reason why many people avoid these products. Is that a good thing? Is that a bad thing? Are plant-based alternatives healthier than conventional animal products? Let’s find out.

Food Compass is a nutrient-profiling system that rates foods on a scale from 1 to 100, with 1 being least healthy and 100 being most healthy. Eight thousand foods have been scored; so, you can see where your favorite food falls. And when I have my laptop next to me, I ask people to yell out their favorite foods, and we look up to see what the score is, and they’re all disappointed that their raspberries are only 93 or something, but unfortunately, laptop’s in the back. Here are some examples of perfect 100 foods, and foods that score the worst, all the way from kale down to Coca-Cola.

Okay, so the main objective of ultra-processed “fake” foods is to imitate real foods. Like strawberry Pop Tarts trying to mimic real strawberries. When you start with a perfect-100 food like strawberries, the only way to go is down. So, fruit is better than fruity-shaped marshmallows. But when the “real” food is ultra-processed meat, processed meat, or unprocessed meat, or dairy, there is a lot of room for improvement.

Food Compass has scored nine ultra-processed meatless alternatives. Let’s compare them to the closest conventional meat matches. In every single case, the plant-based meat was rated higher, healthier, and sometimes by a large margin. Nearly all scored at least twice as high. Or three times the health score, seven times, 20 times, even 60-fold higher. Other common nutrient scoring systems all found the same general trend.

Now, better than chicken would be chickpeas. And better soybeans than soy burgers—soybeans are another perfect-100 food, but the choice on the Burger King menu is between this and that, not between this and that. (Though, of course, there is a third choice: not ending up at Burger King.)

This was just a few products though, just as an illustration. A 2024 systematic review identified nine studies using nutritional scoring for the assessment of over 2,000 meat alternatives and their meaty matches, and all of the studies, nine out of nine, sometimes found comparable scores, but mostly showed meat alternatives score better.

Based on their nutrient profiles, plant-based meats and milks would be expected to reduce chronic disease risk. When it comes to heart disease, stroke, and cancer, plant-based meats would be expected to decrease risk of these killer diseases by about 3% per daily serving replacement. Now, whole soy foods might take that down an extra 2%, because they’re not weighed down by the sodium issue, but overall, swapping in even just one serving of plant-based meat a day nationwide could potentially prevent more than 100,000 cases of heart disease, stroke, or cancer in the U.S. every year. It’s hard to get everyone to go all kale and quinoa overnight, but a veggie burger should be easy. 100,000 cases prevented every year, with a single daily serving swap of plant-based meat.

Now, that’s just based on their respective nutrient make-up—like how much saturated fat versus fiber they each had. But remember how all the harmful effects of ultra-processed foods are not necessarily captured by their nutrient profile? There are 16 proposed mechanisms linking ultra-processed foods to disease and death, and balance of nutrients is only one of those 16.

And so, using these 16 criteria, normally, when you compare ultra-processed products to the foods they were designed to replace, for example, water vs. Kool-Aid, or fruit vs. fruit-flavored candy, the ultra-processed product tends to do worse, and not just because of the junkier nutrient profile. However, plant-based meats appear to be the exception, better in most ways compared to the foods they were designed to replace.

We already covered nutrient profile, where plant-based meat tended to score healthier than regular meat, based on every study, using every major nutrient profiling system.

I don’t have time to go through all of these right now. For those who want dive a little deeper, I had a paper published this year on the subject, which you’re welcome to download. This Thursday, the 21^st, I’m going to be giving a three-hour webinar on the subject, where I will go into detail through all the rest of those criteria, and I’ve got a book coming out on ultra-processed that will be out in January; so, you’ll have all the references handy. But with limited time, I’m going to skip through a bunch of these, though happy to talk about them in Q&A.

In terms of additives, I’ve been long concerned that Red No. 3 hadn’t been banned from food, given that it was banned over 30 years ago from anything going on our skin, due to cancer risk. But it’s still ok to eat? Thankfully, California passed a Food Safety Act, set to ban Red Dye No. 3 by 2027. So, in 2027, Loma Linda Big Franks will be illegal to sell in Loma Linda, but would still be available to potentially contribute to cancer risk throughout the rest of the country. But the FDA finally decided to ban it from food, 35 years after it removed it from cosmetics, starting in 2027 as well. So, for now, this veggie bacon is considered too toxic to rub on your skin but okay to eat—at least, for the next two years.

Why has the pork bacon industry figured out how to use cherry powder as a coloring before the plant-based bacon industry?

The most harmful additive in plant-based meat, is ironically, really the most traditional, and that’s salt, contributing to the #1 dietary risk factor for death on planet Earth: excess sodium consumption. It is one of the most common ingredients in plant-based meat alternatives. But, also one of the most frequent ingredients used in conventional meat processing, and not just in processed meat. While the #1 source of sodium for kids in this country is pizza, and, in older individuals, bread, one of the reasons the #1 source of sodium for those aged 19 through 50 in this country is chicken is because injecting raw chicken with saltwater is a widespread practice in the poultry industry––something they’ve been doing since the 1970s, resulting in raw chicken breasts reaching as much as 400mg of sodium or more, six times more than they’d naturally have.

When it comes to salt, how does meat and plant-based meat compare?

A systematic review found that the average levels of sodium were not significantly different overall between plant-based and conventional meat, which is not great, but there are some products that are improving. When I created a chart five years ago for UBS, Beyond Meat burgers had 390 milligrams of sodium, which is in the typical 290 to 400 range of a regular American hamburger. But the current version is 20% lower at 310 mg, thanks to the use of potassium salt, potassium chloride instead of sodium chloride, and Impossible now has a beef “lite,” with only 260. Ideally, we would be under 180, meeting the World Health Organization’s recommendation for less than a 1:1 ratio of sodium to calories. All the foods we eat ideally should have less sodium than calories.

Plant-based meat tends to be better when it comes to some additives, like carcinogenic nitrite preservatives; similar with salt and sugar, and worse with emulsifiers, which might be expected to hurt the gut microbiome. But vegetarians who eat plant-based meat actually end up with lower rates of irritable bowel syndrome than those who don’t, which suggests that at least on that metric the emulsifiers don’t seem to be a problem.

In fact, all three studies on the impact of plant-based meat show microbiome benefits; for example, this randomized, controlled trial analyzing stool samples before and after even just swapping out about five meals of meat a week for plant-based meat, confirming that even just the occasional replacement of meat may promote positive changes in the gut microbiome.

In the second trial, the Mycomeat study, people were randomized to replace a few servings of meat a day with the mycoprotein meat Quorn—made from the mushroom kingdom rather than the plant kingdom. This swap not only increases the abundance of beneficial microbes in the gut; it reduces fecal genotoxicity, which is the amount of DNA damage that their feces can cause colon cells. Now, that may just have been because they were cutting down on meat. But on the Quorn, there was a boost in good bacteria, like lactobacillus, which may have benefits, suggesting that the fiber in mycoprotein may have prebiotic potential.

The two-week swap did not seem to be long enough time to affect TMAO levels, though, but in the 8-week Stanford SWAP-MEAT study, in which two or more servings a day of beef, pork, or chicken were swapped out with plant-based beef, pork, or chicken, several cardiovascular risk factors improved, including TMAO, which stands for trimethylamine n-oxide, considered like the smoking gun in gut microbiome-disease interactions.

When we eat meat, dairy, or eggs, the carnitine and choline get turned by certain bad gut bugs into trimethylamine, which is oxidized by our liver into TMAO, which can go on to damage various organ systems throughout the body. So, the cardiovascular harm from eggs and meat is more than just cholesterol and saturated fat. TMAO is linked to some of our deadliest diseases—cardiovascular disease, diabetes, high blood pressure, stroke, cancer. Check out those P values. Those, are my kind of P values. Like six times ten to the negative 21st. That means you’d only get a finding that extreme by chance if you ran the study about a billion trillion times. So, TMAO may also mean time to minimize intake of animal products, which we can do by switching to plant products.

Plant-based meals can also be better for the upper digestive tract. If you randomize people to eat chicken, cheese, fish, and steak, versus tofu, soy steaks, seitan, and soy burgers, you see twice as much heartburn after the animal protein meal than after the plant-protein meal. And stick a probe down their throats, and after the animal products, you see three times as much acid exposure refluxing up from their stomach into their esophagus.

The bottom line is that, unlike almost any other ultra-processed product, plant-based meat appears to be the rare case in which ultra-processed products are actually better, overall, than the foods they were designed to replace.

Now, this probably says less how healthy they are, and more about how really unhealthy modern meat is. Take food safety, for example. In response to a Super Bowl ad placed by a meat-industry-funded lobbying group questioning plant-based meat for its hard-to-spell ingredients, Impossible Foods responded with a parody, questioning an unintentional additive in conventional meat.

Fecal contamination of the carcass in the slaughter plant is considered unavoidable, and though there are methods for removing visible fecal contamination on meat, and even experimental imaging technologies designed to detect more “diluted fecal contaminations,” we’re still left at a retail level with guess what proportion of meat contaminated with fecal bacteria at the grocery store? About 85% of ground beef and turkey contaminated with fecal bacteria, and about half of chicken on store shelves, and a third of pork, found contaminated with Enterococci, which is used as a marker of fecal contamination of food.

But you don’t have to cook the crap out of plant-based meat, because there shouldn’t be any crap to begin with.

Fecal contamination is not just unseemly, but a critical public health issue. Fecal matter is considered the main source of some of our most serious foodborne pathogens, like Salmonella and Campylobacter.

Salmonella is the leading cause of foodborne hospitalizations in the United States, and the #1 cause of foodborne death, and one in four packages of chicken sampled in the United States by the USDA contaminated with Salmonella, one in eight packages of ground turkey, one in 24 packages of pork, and one in 67 packages of ground beef, and one in four packages of retail chicken.

Campylobacter, which sickens more than 800,000 Americans a year, is also found in every one in three, or one in four, packages of retail chicken.

Even just shopping for meat can be risky, as disease-causing fecal bacteria can contaminate the outer packaging of meat. But, the good news is that food-borne illnesses are largely preventable, and the simplest approach to reduce their occurrence is to greatly reduce the consumption of animal products like meat.

They’re intestinal bugs, and since plants don’t have any intestines, we can reduce the risk with plant-based meat––though there are always cases of manure runoff contaminating crops. But the leading causes of large foodborne outbreaks of food poisoning are all meat, and every single one of the top pathogen-food combinations that cause the greatest burden of disease are all animal products, mostly meat.

That second one is toxoplasma, which is a brain parasite that may infect a million Americans a year, making it a leading source of severe foodborne illness in the United States. What may end up in your brain may start in your burger.

Tapeworms in your brain from pork have become an increasingly important emerging infection in the United States. What you think is a migraine may not be a migraine. This is what they found in the brain of our current Secretary of Health and Human Services.

You may even get bladder infections from eating meat––particularly poultry––urinary tract infections or viral hepatitis from pork products—hepatitis E infection. There aren’t any prions in plants either, the cause of fatal spongiform brain diseases, which is why there’s a mad cow disease, but not a mad Quorn disease.

And I didn’t include other meat-borne pathogens, like trichinosis or E. coli O157:H7, which still sickens 50,000 Americans a year, mostly from beef, or the 100,000 sickened by yersinia-infected pork every year. But let’s just stick to the major pathogens, some of which can become antibiotic-resistant.

Consuming contaminated meat with antibiotic-resistant bacteria is considered a severe public health hazard. To help compensate for the overcrowded, stressful, unhygienic conditions, animals raised for food are dosed en masse with antibiotics. Lots of antibiotics. This is in kilos; so, we’re talking 10 million pounds a year of medically-important antibiotics. So, we give farm animals in the United States more than a million pounds of penicillin drugs a year. Four thousand tons of tetracyclines. Millions of pounds of drugs, laced right into their food and water. Antibiotics important to human medicine being fed to cows, pigs, chickens by the ton—by the thousands of tons every year.

And so now in chicken breasts, for example, most of the Salmonella and Campylobacter found is now resistant to at least one class of antibiotics, and about half of the Salmonella is resistant to three or more classes of drugs.

Even organic meat raised without antibiotics can be contaminated with multidrug-resistant bacteria, often because there is cross-contamination in the slaughter plant. It’s funny—in the cover story of Consumer Reports that urged retailers to stop selling meat produced with antibiotics, they noted, some store employee confusion: “An assistant manager at one store, when asked by a shopper for meats raised without antibiotics, responded, ‘Wait, you mean, like, veggie burgers?’” Exactly.

Antibiotic-resistanct genes can also be transmitted through meat, which can then transfer to other pathogens in our gut, as well as residues of the antibiotic drugs themselves––which is itself considered a serious public health threat. You can correlate how much meat people eat; you can just measure the amount of antibiotics flowing out of their urine every day. These drug residues in the meat can cause allergies, nerve damage, liver damage, reproductive disorders, bone marrow toxicity, even increased cancer risk, not to mention what eating antibiotics every day is doing to your gut microbiome. In contrast, the production of plant-based meat involves no guts, no feces, no antibiotics necessary.

In addition to antibiotics, livestock may be fed or injected with hormones. Currently, seven hormone drugs are approved by the FDA to bulk up the production of milk and meat. In Europe, there exists a total ban on all such use. But even without injected hormones, animal products naturally contain hormones because they come from animals.

I already touched on processing contaminants, but there are also industrial contaminants that build up in the food chain, like certain pesticides, PCBs, heavy metals, and flame-retardant chemicals that end up concentrating in meat.

Can’t you just choose organic meat? Surprisingly, the consumption of organic meat does not seem to diminish the carcinogenic potential associated with these industrial pollutants. If you look at the micropollutants and chemical residues in conventional vs. organic meat, several environmental contaminants—like dioxins, PCBs, lead, arsenic sometimes measured at significantly higher levels in organic meat, though cooking does draw off some of the fat where the PCBs are concentrated. Seafood seems to be the exception, though, with steaming, for example, generally increasing the concentration of contaminants like mercury. There is, however, no mercury added to plant-based tuna.

When researchers tested retail meat for the presence of 33 chemicals with calculated carcinogenic potential, like organochlorine pesticides like DDT and dioxin-like PCBs, they concluded in order to reduce our risk of cancer, we should limit our ingestion of beef, pork, or chicken to a maximum of five servings—a month.

Meat presents the only scenario in which ultra-processed products were designed to replace foods that we know cause cancer, in fact, the #1 cancer killer of nonsmokers, colorectal cancer. These are foods in desperate need of replacement. Processed meat—bacon, ham, hot dogs, lunch meat, sausage—is considered a known human carcinogen, leading major cancer centers, like Mount Sinai, Memorial Sloan Kettering, and MD Anderson, to recommend flat-out avoid processed meat.

All in all, plant-based meat is better than animal-based meat in about 40 different ways.

Now obviously, some of these categories are more important than others. The fact that bacon is officially designated as cancer-causing is more important than the fact that it may have a few more calories than plant-based bacon. But cancer is just killer #2. The leading cause of death in men and women is heart disease, and hidden in that nutrient profile, are the three things that raise LDL cholesterol: saturated fat, trans fat, and dietary cholesterol. Yes, there are other factors, like TMAO and sodium. But LDL cholesterol, also known as bad cholesterol, is unequivocally recognized as the principal driver in the development of atherosclerotic cardiovascular disease, our leading cause of death.

Basically, we should try to get our LDL as low as possible. When it comes to LDL lowering for the prevention of heart disease, “Lower for longer is better.” Even if your LDL is “normal”; even if other heart disease risk factors are considered optimal, still, of utmost importance to control it.

So, if LDL is the primary driver of our primary killer, if you could just know one thing about a food, if could just ask one question, it would be “What does this food do to my LDL cholesterol?” So, we’re looking at nutrition labels for saturated fat, trans fat, and cholesterol, since any intake above zero increases LDL cholesterol and, therefore, increases our risk of coronary heart disease.

In terms of saturated fat and cholesterol, animal meats are the main source in the American diet, and with the removal of partially hydrogenated oils from the U.S. food supply, such that these other sources are now banned, animal products are now the leading source of trans fat as well (since meat and dairy naturally contain trans fat).

Online, some bloggers parrot egg industry propaganda that the 2015 U.S. Dietary Guidelines removed its dietary cholesterol limit, whereas if anyone actually bothered to read the guidelines, they’d see that the guidelines actually strengthened their recommendation, telling Americans to “eat as little dietary cholesterol as possible,” as recommended by the Institute of Medicine, the most prestigious medical body in the United States. This advice was reiterated in the subsequent dietary guidelines: “The National Academies recommends that dietary cholesterol consumption to be as low as possible.” While eggs are the most concentrated source of cholesterol gram-for-gram, the greatest cholesterol contribution in the overall American diet is meat, including poultry and fish.

Since cholesterol is present only in animal-derived foods, it’s not surprising that plant-based meat contains little or no cholesterol (unless they have cheese or something added in it). And saturated fat content is usually low in plant-based meat compared to regular meat, averaging to one half and one third. You can see that illustrated graphically here, where the conventional meat is those orange bars across the top, so better across the board, often by a large margin. This is as true in Europe as well as in South Africa and the U.S.—where plant-based meat may only average a third of the saturated fat.

Swapping out meat for plant-based meat significantly lowers saturated fat, but does this translate into lower LDL? That’s really what we care about. Well, you don’t really know, until you put it to the test. Here’s a meta-analysis of 10 randomized controlled trials replacing some or all meat with plant-based or mycoprotein-based meats, and within an average of six weeks, saw a 15-point drop in LDL cholesterol. What does that mean in terms of disease risk?

Maintaining a 15-point drop in LDL for five years would be expected to decrease your risk of heart disease by about 10%, and after a dozen years by more like 15%, and across a lifetime by more like 25%.

And risk reduction is independent of baseline LDL, meaning you get about the same relative risk reduction, even if your LDL is so-called normal, less than 100.

One would also expect the use of egg substitutes to reduce cardiovascular risk, given that eggs are the most concentrated source of dietary cholesterol. What about substituting soymilk for cow’s milk? Based on 17 randomized, controlled trials, drinking soymilk instead of cow’s milk resulted in significant improvements in blood pressure, in cholesterol, in inflammation, an eight-point drop in systolic blood pressure, a five-point drop in diastolic blood pressure, a seven-point drop in LDL cholesterol switching to soy, as well as a drop in C‑reactive protein, so less inflammation as well. Over a lifetime, that seven-point drop in LDL could drop our risk of heart disease by more than 10%, just making a single dietary swap from cow to soy.

Now, the benefit only accrues if your cholesterol stays down. And it turns out, it may even get better. In a four-year study in which diabetics were randomized to swap out half their animal protein for ultra-processed plant protein, their LDL went down year after year, ending up 26 points lower than the control group. Whoa, that could net you a nearly 40% drop in risk, over a lifetime, of our #1 killer, just swapping out half of their animal protein servings.

An estimated 20 million Americans have heart disease, having about 800,000 heart attacks a year. If we started swapping our animal products for plant products, imagine how many lives could be saved by even a 10% drop in heart disease.

Instead of swapping out a burger for a veggie burger, why not just switch to chicken and fish? Because, it doesn’t work. A meta-analysis of randomized, controlled trials that compared the cholesterol effects of beef versus poultry-and/or-fish found no significant difference in terms of LDL.

And an updated meta-analysis of four times as many studies also found no benefit to switching to chicken and poultry, and the beef was actually found to be better than fish, which they attribute to using particularly lean cuts of beef as the comparator, particularly because the beef industry is the one that funded these studies. But even organic, grass-fed beef appeared to be no match for plant-based meat, as shown in the Stanford SWAP-MEAT trial.

With processed meat officially classified as a known human carcinogen, global health organizations flat-out recommend avoid processed meat, but looking at six health outcomes—colorectal cancer, breast cancer, ischemic heart disease, type 2 diabetes, and two types of stroke—the optimal amount of unprocessed red meat may be zero as well, but even a 30% reduction in both types of meat could lead to a million fewer cases of type 2 diabetes, hundreds of thousands of fewer cases of cardiovascular disease, and tens of thousands fewer cases of cancer and premature death over a decade.

Diets high in processed and red meat are also the two single leading causes of diet-related disability in the United States, responsible for more than a million years lived in disability annually—three times more than diets high in sugar-sweetened beverages, for example, and more than two million years of healthy life lost, based on the most comprehensive analysis of risk factors for death and disability in history. Millions of years of lost life every year in the U.S. because people are eating diets high in red and processed meat.

What do they define as high, though? A diet “high” in processed meat is defined as any intake of processed meat. And a diet high in red meat? High as in any intake of red meat. So, millions of years of life lost in the United States, because people are eating more than zero red and processed meat.

Higher intake of meat in general—red meat, white meat, processed, unprocessed— also associated with an increased risk of death from all-causes put together. If people swapped out 75% of their meat, up to 50,000 lives a year could be saved in high income countries. What would happen if the whole world cut out all meat? We would save an estimated 7 million lives a year, and if humanity cut out all animal products, we might annually save 8 million lives. Hanging in the balance!

The bottom line is that veggie burgers are not Twinkies, even though they’re both classified as ultra-processed foods. Now, there are two directions we can go with that fact. We can decry the very concept of ultra-processed foods. Or we can take what I would argue is a better tact: keep the baby; throw out the bathwater. In other words, not deny ultra-processed foods tend to be worse, not deny that plant-based meats are ultra-processed, but rather that despite this classification, plant-based meats and milks are the rare exception in that they compare well with the foods they were designed to replace, in some cases, potentially even saving thousands of lives.

But there is some merit to the argument that the ultra-processed concept is not as useful as many people think. If you look at the three big Harvard cohorts—200,000 people followed for decades. Yes, total ultra-processed foods intake was associated with cardiovascular risk, but if you break it down, the risk is driven exclusively by soda and meat. Sugar-sweetened beverages, a little from artificially sweetened beverages, and the rest from processed meat, poultry, fish. If you exclude soda and meat, the relationship between ultra-processed food and cardiovascular disease disappears completely. So, nutritional advice for cardiovascular health should consider the differential consequences of group-specific ultra-processed foods, and specifically, that means processed meats and soft drinks should be discouraged.

What about mortality? Yes, those who ate the most ultra-processed foods in general had a higher risk of dying prematurely, but it mattered what kind of ultra-processed foods, with ready-to-eat meat, poultry, and seafood products showing particularly strong associations with mortality. The apparent worst ultra-processed food when it comes to dying prematurely in general? Meat/poultry/seafood. The worst when it comes to dying from cancer? Meat/poultry/seafood. The worst when it comes to dying from cardiovascular disease? Meat/poultry/seafood. The worst when it comes to dying from lung diseases like emphysema? Meat/poultry/seafood. The worst when it comes to dying from neurodegenerative diseases? (Ice cream). And the worst when it comes to dying from other causes? Meat/poultry/seafood.

Bottom line, the major factors contributing to the harmful effects of ultra-processed foods on mortality are processed meat, poultry, fish, and soda. So, the negative, life-shortening effects of ultra-processed food is really mostly talking about the negative, life-shortening effect of ultra-processed meat like burgers, chicken nuggets, and fish sticks.

Ideally, we would have a study that specifically looked at meat alternatives. And, here we go: a quarter-million people followed for over a decade, and while the higher consumption of ultra-processed foods in general increases the risk of cancer and cardiovascular disease and diabetes, but that was driven by ultra-processed animal products and soda, not plant-based meats. They specifically studied plant-based alternatives and found no increased risk. And when it comes to diabetes, plant-based meat and milk appears to cut the risk of developing diabetes in half. Animal-based products were associated with more than twice the risk; plant-based alternatives with less than half.

So, when the authors conclude that higher consumption of ultra-processed foods may increase the risk of cancer and other diseases, their data really only show that the consumption of foods of animal origin and soft drinks is associated with such a risk, and indeed, when the authors were challenged to go back and exclude animal foods and beverages, the relationship between ultra-processed foods and multiple diseases disappears.

That’s also what a systematic review and meta-analysis of all such studies showed. The only categories of ultra-processed foods associated with higher mortality were sweetened beverages and meat. So, wait. If the only ultra-processed food that appears to be killing people is meat, then in that case, instead of being a part of the problem, plant-based meats may be the solution to the ultra-processed problem. Let me say that again; instead of being a part of the problem, plant-based meats may be the solution to the ultra-processed problem.

The one other ultra-processed study that separated out plant-based meats looked at telomere length, which is used to measure cellular aging. Their study found that a higher consumption of total ultra-processed foods was associated with a shorter telomere length, a sign of accelerated aging. However, some subclasses of ultra-processed foods were associated with longer telomere length, suggesting slower aging. And, the class of foods associated with the longest telomeres? Vegetarian alternatives: plant-based meat.

The most important question in all of nutrition may be, “Compared with what?” The effects of any given food depend on what that food is being compared against. So, is plant-based meat healthy? Compared to the animal products they were intended to replace? Absolutely. Plant-based meat alternatives are more healthful than the meat they replace, but perhaps less so than whole plant foods, such as legumes and whole grains. Wait, just perhaps less so?

This is how ultra-processed plant meat compares to meat. This, is how unprocessed plants compare to meat. Not only making up for all the shortfalls, but if we add an even better category, whole plant foods do even better, in many categories.

For example, bean-based meat averages five times less saturated fat than their meat comparators, but actual beans have 40 times less: half the trans fat or no trans fat. Five grams of fiber is certainly better than zero, but nine grams is even better.

And there are interventional trials demonstrating the greater benefits. For example, better at fighting insulin resistance and inflammation.

So certainly, whole foods for the win, but plant-based meat alternatives, they are not designed to replace whole plant foods, instead to offer a steppingstone in the transition away from meat. I think of it like meat methadone.

Or, as Professor Gardner put it, “I’m hoping that plant-based meats will be the gateway drug to legumes.” This is how the transition to healthier diets is envisioned, from the global burden of disease, to the global relief of disease, as people use plant-based and mycoprotein-based meats to transition toward a more whole food, plant-based diet.

With the added saturated fat and sodium, plant-based meats are not healthy—but, they are healthier. They are healthier than the foods they were designed to replace. They are better, but not the best.

Yes, nutrition policies and dietary guidelines, the bottom line is that we should continue to emphasize a diet rich in whole plant foods. Indeed, if all meat in high income countries were replaced with whole legumes, we could potentially decrease overall mortality rates by 5 or 6%. That means saving 180,000 lives in the United States every year.

If instead, we replaced meat with processed or ultra-processed plants, we’d only save about 130,000 Americans a year (about a 4% drop in overall mortality). That’s still over 100,000 people saved every year. So, we shouldn’t let the perfect be the enemy of the good. Plant-based meat alternatives are better than the alternative. Or as one study put it, plant-based meat can be considered “meat with benefits.”

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• alcohol
• calories
• cholesterol
• fiber
• fruit
• grains
• hamburgers
• heart disease
• hot dogs
• ice cream
• kale
• legumes
• nuts
• obesity
• quinoa
• salt
• saturated fat
• sugar
• ultra-processed foods
• vegetables