'A CALORIE IS A CALORIE' IS AN AMBIGUOUS PHRASE. IN ONE SENSE IT IS TRIVIALLY TRUE, AS IN GERTRUDE STEIN'S FAMOUS PHRASE, 'A ROSE IS A ROSE IS A ROSE IS A ROSE'. In another sense it is obviously questionable, because it assumes no difference between the energy produced by burning food in a bomb calorimeter and that generated by metabolic processes. It also assumes that as far as effect on body weight is concerned, fat is bad because fat by itself is calorie-dense per unit of weight, and carbohydrate and protein are good because they are relatively low in calories. It further assumes that in terms of weight gained or lost, there is no difference between diets that include the same number of kilocalories say from rice, greens and fish, or from French fries, burgers and cola, or from Danish pastries, frappuccinos and gin slings.1

Over the last decade, researchers have started looking more closely at assumptions going back more than a century regarding calories and the macronutrients carbohydrate, fat and protein. Most dieters are familiar with calorie counting and long lists of calorie tables for food portions. Indeed, the FDA mandates this information on Nutrition Facts panels and even some dietary supplements have begun to engage in this practice. One problem, as most dieters learn from bitter experience, is that over the long term calorie counting does not work. Other than in starvation mode, a condition under which all calories consumed regardless of their source are metabolized quickly to fill the deficit, the body treats calories from different sources differently and it treats calories according to the combinations in which they are consumed, the time of day, and so forth and so on. Food preparation, meal preparation, dietary patterns, etc., all count. In other words, it is not true that a calorie is a calorie is a calorie.

Eat Fat, Live Longer?
Let's start with an extreme, the effect of a ketogenic diet. In this diet, the preponderance of calories is derived from fats. A University of California, Davis study published early this year, found that a long-term ketogenic diet (89–90 percent of total calorie intake) in a mouse model significantly increased median lifespan and survival compared to controls. Moreover, in aged mice only those consuming a ketogenic diet preserved normal physiological functions (strength, coordination, prevention of age-related markers of inflammation). In short, the ketogenic diet, even though it did not alter the maximal span of life, extended both overall longevity and healthspan in mice.2 How much? There was a 13 percent increase in median life span for the mice on a high-fat versus high-carb diet. In humans, that would be seven to 10 additional years with better health along the way.

Another research team, this time at the University of California, San Francisco and associated aging institutes, discovered that a cyclic ketogenic diet, meaning that it was alternated weekly with the control diet to prevent obesity, reduced midlife mortality without affecting maximum lifespan. The researchers observed that a non-ketogenic high-fat diet fed similarly may have an intermediate effect on mortality. A non-obesogenic ketogenic diet improved survival, memory, and healthspan in aging mice according to these finding.3

Note that there was no attempt in the foregoing studies to determine whether a change in the nature of the carbohydrates fed to the animals in a non-ketogenic high fat diet affects outcomes. However, even without a direct study, evidence abounds from indirect studies. Many carbohydrate sources are close to fiber in their influence on blood sugar levels and, in line with this, promote digestive health and gut probiotic diversity. In contrast, the modern American and common Western diets in general are ultra-processed diets. The healthfulness of ultra-processed foodstuffs is quite different from that of foods processed and prepared more traditionally, including, it turns out, from supposedly unhealthful foods.

Ultra-processed Foods
A few years ago, Harry Preuss, MD of Georgetown University and I wrote a chapter for a medical text on the metabolic syndrome. We began by observing.

Throughout the world, many elements comprising the Metabolic Syndrome (MS) such as diabetes, obesity, hypertension, and dyslipidemias are becoming alarmingly common. Although many etiological factors may be involved in this situation, one hypothesis is that a well recognized increased consumption of sugars and refined carbohydrates (CHO) such as sucrose and high fructose corn syrup (HFCS) plays a pivotal role in the increase of these unwanted entities.4

An Increasing Content of Empty Calories
Food refining, processing and meal preparation techniques favored in the United States and in much of the Western World, including especially fast and convenience foods, have led to dramatic changes in food quality. Definitions of ultra-processed foods provide clues as to why this should be the case. In one study of dietary intakes of 9,317 participants from 2009 to 2010, food items were classified into unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods.5

Ultra-processed foods are formulations manufactured using several ingredients and a series of processes (hence "ultra-processed"). Most of their ingredients are lower cost industrial sources of dietary energy and nutrients, and additives used for the purpose of imitating sensorial qualities of minimally processed foods or of culinary preparations of these foods, or to disguise undesirable sensory qualities of the final product. They are made to be hyper-palatable and attractive by the use of many additives, with long shelf life, and are able to be consumed anywhere, anytime. Ultra-processed foods include but are not limited to soft drinks, sweet or savory snacks, reconstituted meat products, and pre-prepared frozen dishes.

The average content of protein, fiber, vitamins A, C, D, and E, zinc, potassium, phosphorus, magnesium, and calcium in the US diet are decreased significantly in ultra-processed foods, whereas carbohydrate, added sugar, and saturated fat contents are increased. As the degree of ultra-processed food increases as the source of total calories, the overall dietary quality measured in terms of a nutrient-balance-pattern of fiber, potassium, magnesium and vitamin C goes down.

In another study, "ultra-processed foods were defined as industrial formulations which, besides salt, sugar, oils and fats, include substances not used in culinary preparations, in particular additives used to imitate sensorial qualities of minimally processed foods and their culinary preparations." In the 2009–2010 National Health and Nutrition Examination Survey of the US diet, ultra-processed foods were found to constitute 57.9 percent of total energy. The content of added sugars in ultra-processed foods (21.1 percent of calories) was eight times that in processed foods (2.4 percent) and five times that in unprocessed or minimally processed foods and processed culinary ingredients grouped together (3.7 percent). Consumption of added sugars increased linearly as ultra-processed food consumption increased. It went from 7.5 percent of total energy in those in the bottom one fifth of consumption of ultra-processed foods to 19.5 percent in the highest one fifth. A total of 82.1 percent of Americans in the highest quintile exceeded the recommended limit of 10 percent energy from added sugars compared with 26.4 percent in the lowest.6

Consequences of Differences in Food Quality
As populations shift from more traditional foods and food preparations, there can be serious consequences. These consequences include increases in obesity and cardiovascular disease. As an example of the first of these, a study of food consumption in nineteen European countries spanning 1991—2008 found a clear pattern. There was a median average household availability of 33.9 percent total purchased dietary energy for unprocessed or minimally processed foods, 20.3 percent for processed culinary ingredients, 19.6 percent for processed foods and 26.4 percent for ultra-processed foods. The average household availability of ultra-processed foods ranged from 10.2 percent in Portugal and 13.4 percent in Italy to 46.2 percent in Germany and 50.4 percent in the UK. As the percentage of total energy from ultra-processed foods increased, so did the rate of obesity. On average, for each percentage point increase in the household availability of ultra-processed foods there was an increase of 0.25 percentage points in obesity.7 Estimates suggest that merely cutting in half the amounts of processed and ultra-processed foods consumed as components of the overall diet in the UK could result in approximately 13 percent fewer deaths from cardiovascular diseases by 2030.8

Benefits of Traditional Foodstuffs
Ultra-processing is but one issue among several regarding the impact of modern farming, processing and preparation of foods. It does not take into account the benefits of returning to farming practices less dependent on chemical fertilizers, pesticides and fungicides or intensive energy use. It does not take into account the effects of removing genetically modified organisms from the food chain. It does not take into account returning to the use of varietals that produce more protein and minerals per acre and less starch, and so forth and so on.9 Nor does it take into account issues such as the negative consequences of the consumption of ultra-pasteurized and homogenized milk nor the move to A1 milk (the A1 protein is actually a histidine-rich mutated form of casein, and is commonly found in US dairy products).10

Going Organic and Non-GMO
Can such changes be embraced? Much evidence suggests that the answer is "yes" to all points. This includes lower use of pesticides, higher yields in nutrients and experimentally better results from consuming the resulting foodstuffs.11,12,13,14,15,16 A significant finding from a 30-year ongoing trial is that organic farming is not less efficient nor inferior in production for many or even most crops. After a 30-year side-by-side trial, a report by the Rodale Institute found:17,18

  • Organic yields match conventional yields.
  • Organic outperforms conventional in years of drought.
  • Organic farming systems build rather than deplete soil organic matter, making it a more sustainable system.
  • Organic farming uses 45 percent less energy and is more efficient.
  • Conventional systems produce 40 percent more greenhouse gases.
  • Organic farming systems are more profitable than conventional.

Unexpected Benefits of Traditional Foods

In previous Total Health articles, it has been pointed out that a number of "exotic" foods, such as pomegranate, support health in unexpected ways, such as promoting changes in gastrointestinal bacteria. Now, it seems, that food items traditionally found in European cuisines may have similar benefits. For instance, the bacterium Propionibacterium freudenreichii, which is used in the fermentation of Emmentale—the proper name of Swiss cheese, because it came from the Emmental region of Switzerland—benefits health. The bacterium turns lactate into acetate, carbon dioxide and propionate. Acetate and propionate are known to benefit the immune system and propionate supports the health of the lining of the intestinal tract. Other lactic bacteria in Swiss cheese, Weisella koreensis and Weissella cibaria, extend the lifespan by protecting the body against stress and the invasion of pathogens and promoting an anti-inflammatory effect on the immune system.19 Other aged cheese, such as cheddar, blue, brie, Parmesan, Gouda, Gruyère and some forms of mozzarella, also provide longevity and related benefits in a number of models.

Another route by which gut bacteria improve health is the production of a compound known as indole. Indole is produced by many types of bacteria through breakdown of the amino acid tryptophan.20 Indole and its chemical relatives can be found in plants, especially vegetables such as broccoli and kale. However, tryptophan also is found in eggs, cheese, tofu, salmon, turkey and some nuts and seeds. The key for transformation of the amino acid to indole is the gut bacteria, hence success involves more than merely adding this amino acid to the diet. Likewise, balance is the key: many meats supply tryptophan and thus are healthful in appropriate amounts, yet unbalance gut bacteria if consumed in excess.

Putting It Together
In August 2017, a major British cardiologist, Anseem Malhotra, who holds that cardiovascular disease is caused by inflammation rather than by fats,21 put out an interview entitled, "Choose The Pioppi Diet Over Statins To Beat Heart Disease."22 It provides an interesting discussion matching much of the information found above. Here are some of the key recommendations:

  • Don't fear fat. Sugar and refined carbohydrates are the real enemies.
  • Keep moving. Walk as much as possible.
  • Extra virgin olive oil is medicine. Eat some every day. And nuts are important, too. Pioppians eat plenty of hazelnuts, walnuts, and almonds.
  • Get seven hours of sleep a night. Adequate sleep is required for good health.
  • Stop counting calories. What you eat is more important than how much you eat.
  • Eat eggs. Many Pioppians eat 10 a week.
  • Pile on the vegetables. Eat big helpings of fresh, organic vegetables in at least two meals a day.

Long time readers of TotalHealth will recognize that Dr. Malhotra's recommendations based on his study of Pioppi longevity look quite similar to the Okinawan dietary pattern in many respects. Along with an only moderate intake of carbohydrates (much less rice than is typical of the Japanese diet generally) and plenty of fish and eggs, the Okinawans consume bitter melon similarly to how the Pioppians consume extra virgin olive oil, which is to say, routinely or even daily. The evidence is that these types of dietary practices coupled with exercise and other healthful habits reduce most of the elements that we have come to associate—wrongly—with declining health in advancing years.23


  1. Monteiro CA, Cannon G. Calories do not add up. Public Health Nutr. 2015 Mar;18(4):569 .70.
  2. Roberts MN, Wallace MA, Tomilov AA, Zhou Z, Marcotte GR, Tran D, Perez G, Gutierrez-Casado E, Koike S, Knotts TA, Imai DM, Griffey SM, Kim K, Hagopian K, Haj FG, Baar K, Cortopassi GA, Ramsey JJ, Lopez-Dominguez JA. A Ketogenic Diet Extends Longevity and Healthspan in Adult Mice. Cell Metab. 2017 Sep 5;26(3):539 .46.e5.
  3. Newman JC, Covarrubias AJ, Zhao M, Yu X, Gut P, Ng CP, Huang Y, Haldar S, Verdin E. Ketogenic Diet Reduces Midlife Mortality and Improves Memory in Aging Mice. Cell Metab. 2017 Sep 5;26(3):547 .57.e8.
  4. "Potential of Diet and Dietary Supplementation to Ameliorate the Chronic Clinical Perturbations of the Metabolic Syndrome,"h with H.G. Preuss in Nutritional and Integrative Strategies in Cardiovascular Medicine edited by Stephen T. Sinatra, Mark C. Houston. (CRC Press, 2015)
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  6. Martinez Steele E, Baraldi LG, Louzada ML, Moubarac JC, Mozaffarian D, Monteiro CA. Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study. BMJ Open. 2016 Mar 9;6(3):e009892.
  7. Monteiro CA, Moubarac JC, Levy RB, Canella DS, Louzada MLDC, Cannon G. Household availability of ultra-processed foods and obesity in nineteen European countries. Public Health Nutr. 2017 Jul 17:1 .9.
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  10. http://blog.unikeyhealth.com/dos-and-donts-of-dairy-consumption/
  11. Chang K. Study of Organic Crops Finds Fewer Pesticides and More Antioxidants. New York Times July 11, 2014.
  12. Bara.ski M, Srednicka-Tober D, Volakakis N, Seal C, Sanderson R, Stewart GB, Benbrook C, Biavati B, Markellou E, Giotis C, Gromadzka-Ostrowska J, Rembialkowska E, Skwarlo-Sonta K, Tahvonen R, Janovska D, Niggli U, Nicot P, Leifert C. Higher antioxidant and lower cadmium concentrations and lower incidence of pesticide residues in organically grown crops: a systematic literature review and meta-analyses. Br J Nutr. 2014 Sep 14;112(5):794 .811.
  13. Morin R. The Amish Farmers Reinventing Organic Agriculture. The Atlantic October 6, 2014.
  14. Chhabra R, Kolli S, Bauer JH. Organically grown food provides health benefits to Drosophila melanogaster. PLoS One. 2013;8(1):e52988.
  15. Šrednicka-Tober D, Bara.ski M, Seal C, Sanderson R, Benbrook C, Steinshamn H, Gromadzka-Ostrowska J, Rembialkowska E, Skwarlo-Sonta K, Eyre M, Cozzi G, Krogh Larsen M, Jordon T, Niggli U, Sakowski T, Calder PC, Burdge GC, Sotiraki S, Stefanakis A, Yolcu H, Stergiadis S, Chatzidimitriou E, Butler G, Stewart G, Leifert C. Composition differences between organic and conventional meat: a systematic literature review and meta-analysis. Br J Nutr. 2016 Mar 28;115(6):994 .1011.
  16. Šrednicka-Tober D, Baranski M, Seal CJ, Sanderson R, Benbrook C, Steinshamn H, Gromadzka-Ostrowska J, Rembialkowska E, Skwarlo-Sonta K, Eyre M, Cozzi G, Larsen MK, Jordon T, Niggli U, Sakowski T, Calder PC, Burdge GC, Sotiraki S, Stefanakis A, Stergiadis S, Yolcu H, Chatzidimitriou E, Butler G, Stewart G, Leifert C. Higher PUFA and n-3 PUFA, conjugated linoleic acid, α-tocopherol and iron, but lower iodine and selenium concentrations in organic milk: a systematic literature review and meta- and redundancy analyses. Br J Nutr. 2016 Mar 28;115(6):1043.60.
  17. 30 Year Old Trial Finds Organic Farming Outperforms Conventional Agriculture. Permaculture Magazine June 10, 2015 with a link to the full study at http://rodaleinstitute.org/assets/FSTbooklet.pdf
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  20. Sonowal R, Swimm A, Sahoo A, Luo L, Matsunaga Y, Wu Z, Bhingarde JA, Ejzak EA, Ranawade A, Qadota H, Powell DN, Capaldo CT, Flacker JM, Jones RM, Benian GM, Kalman D. Indoles from commensal bacteria extend healthspan. Proc Natl Acad Sci USA. 2017 Sep 5;114(36):E7506 .E7515.
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  22. http://doctoraseem.com/choose-pioppi-diet-statins-beat-heart-disease/
  23. Preuss HG, Mrvichin N, Clouatre D, Bagchi D, Preuss JM, Perricone NV, Swaroop A, Kaats GR. General Lack of Correlations between Age and Signs of the Metabolic Syndrome in Subjects with Non-diabetic Fasting Glucose Values. J Am Coll Nutr. 2017;6(7):556 .64.

Dallas Clouatre, PhD

Dallas Clouatre, Ph.D. earned his A.B. from Stanford and his Ph.D. from the University of California at Berkeley. A Fellow of the American College of Nutrition, he is a prominent industry consultant in the US, Europe, and Asia, and is a sought-after speaker and spokesperson. He is the author of numerous books. Recent publications include "Tocotrienols in Vitamin E: Hype or Science?" and "Vitamin E – Natural vs. Synthetic" in Tocotrienols: Vitamin E Beyond Tocopherols (2008), "Grape Seed Extract" in the Encyclopedia Of Dietary Supplements (2005), "Kava Kava: Examining New Reports of Toxicity" in Toxicology Letters (2004) and Anti-Fat Nutrients (4th edition).

Website: www.dallasclouatre.com