Sugar Free - Fighting the Other Pandemic

On my own anniversary of becoming sugar free (7 years today), I am publishing this abstract of the book that started it all for me. In January 2013 I saw Dr. Lustig on TV, touting his new book; I had it downloaded to my Kindle before the end of his interview. I read it carefully. (He’s an endocrinologist; this is not light reading.) Then I bought a paper copy so I could mark it up, and I read it again. 

On March 20, 2013, I emptied my refrigerator and pantry of all foods containing any type of sugar (which goes by 50+ names, you will learn). On March 21 I made sure everything was in place to begin my new life - like shopping for the right foods. On March 22, 2013, I started to eat and drink a completely sugar-free diet. It was a decision for life, and I’ve never enjoyed food more. 

All the credit goes to Dr. Lustig. Unfortunately, I have never met anyone else who wants to take all sugar out of their diet but, just in case you’re out there, here’s a complete abstract of the book to get you started. If you make it through this abstract and are still interested, get the book and start your new life. [All quoted material is, of course, taken directly from Dr. Lustig’s book.]

Abstract of Fat Chance: Beating the odds against sugar, processed food, obesity, and disease, Robert H. Lustig, MD, 2013

1.     OBESITY: The obesity epidemic is not a myth or a theory; it is a fact. “We have an epidemic of obese six-month olds!” The percentage of obese humans has doubled in the past 28 years. “Obesity is a combination of several factors: physics, biochemistry, endocrinology, neuroscience, psychology, sociology, and environmental health.” But obesity is not necessarily a death sentence—it is only a marker for a host of potential unhealthy conditions. In addition, obese individuals can actually be healthy. However, since 1980, the percentage of adults with a BMI (body mass index) above the eighty-fifth percentile has increased 73%. What has changed in the past 30 years?

2.     THIS IS WHAT HAS CHANGED

a.      Increased calorie consumption

b.     Increased use of sugar-sweetened beverages

c.      Lower consumption of natural, high-fiber foods such as fresh fruits and vegetables

d.     Lower rate of breastfeeding

e.      More skipped breakfasts

f.       Fewer family meals (especially the home-cooked type)

g.      More time in front of “screens” and less physical activity

As obesity rates rise, insurance companies and the government continue to lay blame on “personal responsibility,” meaning gluttony or laziness. Even doctors look first to lifestyle explanations and then to biochemistry’s possible explanations. At the same time, food science has made it possible to alter the food supply to provide relatively easy access to cheap foods—and that availability is based on the science of preservatives. Food for the masses is good politics, but it comes at a high health cost.              

The first law of thermodynamics states, “the total energy inside a closed system remains constant,” suggesting an equation: If the number of calories in equals the number of calories out, weight remains constant. Therefore the mantra has been if you eat less and exercise more, you will lose weight, suggesting all calories count the same, are metabolized the same, and are stored as fat the same. Not true. “The quality of what we eat determines the quantity. It also determines our desire to burn it.” Calories simply are not all alike. It is incorrect to say “a calorie is a calorie,” as we will learn.

For six good reasons, obesity cannot be construed as “personal responsibility.” 

a.      Our culture values thinness; no obese individual perceives a personal advantage to being overweight.

b.     “Environmental control is different from personal control.”  Research shows that dietary interventions that succeed usually do so for only the first 3–6 months, and exercise interventions have an even lower success rate.

c.      Obesity is no longer an American epidemic but now a pandemic. Even in underdeveloped countries, obesity and metabolic disease occur. The problem of malnutrition has, in some cases, reversed in 30 years to an obesity problem. Why? “Our fast food culture is now the global diet.”

d.     “Even animals raised in captivity are getting fat.”

e.      The burden on the poor is even greater, for they are denied access to healthful foods in a variety of ways.

f.       The most significant rise in obesity levels is in the youngest patients. “The age group that shows the greatest rate of increase in the last decade is the two-to-five-year-olds.” Surely we cannot argue that they are lazy, gluttonous individuals who are shirking their personal responsibility to maintain a healthy weight!

3.     SO WHO IS TO BLAME? “The obesity pandemic is due to our altered biochemistry, which is a result of our altered environment.”

4.     UNDERSTANDING THE BIOCHEMISTRY—IT’S NOT A CHOICE! “Biochemistry and hormones drive our behavior.” When we eat food, the fats, proteins, carbohydrates, and fiber are metabolized, each in its own proper way. Then amino acids, sugars, and fatty acids are transported to the liver, which absorbs what it can and leaves the rest in general circulation. The pancreas addresses circulating amino acids and fatty acids by releasing insulin. Insulin has one job: to store energy based on the rising level of blood glucose (“blood sugar”). “There is no energy storage without insulin.”  And insulin makes fat! More insulin translates to more fat. Less insulin causes fat cells to shrink: weight loss!

The brain, of course, gathers all the signals and directs the responses. Specifically the hypothalamus controls the process of energy balance, regulating storage vs. expenditure. This is the most complex human function, and it has a “default setting”: energy storage (the creation of fat cells). That is because our bodies have evolved to ensure survival of the species: When in doubt, prepare for starvation, which historically has been a fact of human life.

The hypothalamus is vigilant in seeking evidence about whether your body needs to consume more calories in order to survive. Its two messengers are leptin and insulin. You know what insulin’s job is—to create fat by storing energy. Leptin’s job is to inform your brain that you have had enough—feeling fine, thank you, due to an appropriate appetite and a normal level of physical activity. These two messengers, insulin (“I don’t have enough food”) and leptin (“I don’t need any more food”) convince the brain it should either reduce appetite or increase appetite for the purpose of storing energy.

Well, what if leptin doesn’t work? Or what if you don’t have enough leptin? When this hormone was first discovered in 1994, scientists thought they had found the secret to ending obesity: give them more leptin! But what if all the leptin in the world still fails to send the right message to the brain because either your leptin threshold is too high or the brain can’t decipher the message correctly? Now what? “This is the key to the obesity epidemic… Obese people are not leptin deficient but rather leptin resistant… When the brain can’t see the leptin signal, it interprets starvation… stores more energy, and kick-starts the pancreas to make extra insulin. This… drives nonstop energy storage and nonstop weight gain.”

In addition to storing more energy as fat, a brain that doesn’t recognize leptin’s “all is well” signal will reduce your activity to conserve energy! Biochemistry rules, and it produces the secondary behaviors of gluttony and inactivity. High insulin levels can block leptin signaling at the brain, creating the false signal that the body is starving and must conserve energy and store fat!

Interestingly, obese individuals and starving individuals share similar symptoms: fatigue, malaise, and depression. One has very inadequate leptin and the other is resistant to leptin. That’s why a “starvation diet” such as total fasting for a day actually drives your body to gain weight instead of losing it. And the key culprit is insulin. “The majority of humans, regardless of weight, release double the insulin today that we did thirty years ago for the same amount of glucose.”

What has happened? Can we possibly be addicted to food? Consider the fact that, in the U.S., fast food as a portion of the diet has increased nearly 90% in the past fifty years. And the rest of the world is following suit! “Is the world addicted to food? The biology of addiction is at the center of this question.” Our brains are wired for reward. The primal drive for reward is essential to the perpetuation of the species. Eating must remain one of the most powerful urges in animals and humans to protect the species’ future, and so evolution has made eating a source of pleasure and reward. And that pleasure and reward response is related more to the palatability of a food than to the need for more energy.

It’s all about dopamine, the substance released in the brain when pleasure is felt. When you repeatedly ingest a substance that releases dopamine, your body becomes accustomed to that experience. As a result, you then need more dopamine to feel that same level of pleasure. To get more dopamine, you feel compelled to ingest increasing amounts of the substance, which might be food or a drug.

And here’s something interesting! “If the brain has been wired for addiction, it’s easy to switch              from one substance to another… Dopamine stimulation reinforces the intake of drugs or alcohol and also of food.” People who eat normal amounts of food feel satiated and stop eating because they’ve experienced a satisfactory release of dopamine. When dopamine cannot be fully recognized in the brain, one feels compelled to eat more, driving weight gain. Unfortunately, it is leptin that allows dopamine to clear and the body to return to homeostasis. So, if you are leptin resistant, dopamine isn’t cleared, and you continue to seek reward and pleasure through eating.     

So clearly biochemistry comes first and behavior follows. Insulin resistance leads to leptin resistance. Dopamine is not cleared, and the eating continues when the energy stores are already full. This syndrome leads not only to overeating in general but to seeking out the most palatable foods: those foods high in fat and sugar (preferably high in both!).

5.     FOOD ADDICTION

Most of us like the taste of fast food now and then. It’s full of fat, sugar, salt and caffeine. If one is insulin resistant, wanting fast food would convert to needing it—a physiologic state not unlike that of a drug addict.

Do you know the seven signs of addiction? It is said that, if you meet even three of these seven criteria, you are likely an addict.

a.      Tolerance. You need more to get the same effect.

b.     Withdrawal. Symptoms can be physical, such as tremors, or psychological, including anxiety or depression. 

c.      Bingeing. Eating greater amounts or for longer duration. 

d.     Desire or attempts to cut down or quit. 

e.      Craving or seeking. An intense drive to self-administer drugs. 

f.       Interference with life. Compromising important work, social, or other life activities. 

g.      Use despite negative consequences. Using while knowing you’re only making the problem worse.

Fast food is “high in calories, sugar, fat, salt and caffeine… highly processed, energy dense…highly palatable. The majority of the fiber and a portion of the vitamins and minerals present in the original food have been extracted in processing.” And the most popular fast food combinations cost less than $6 and provide more than 1,100 calories! Fifty percent of Americans consume such a meal at least once a week, consuming 89% of their recommended daily fat intake in one fell swoop.

The salt in fast food is a preservative, increasing shelf life. Processed foods with high fat content almost always contain high levels of starch too. Because that combo (fat and sugar) greatly enhances taste, such foods are more likely to become addictive. Caffeine in and of itself makes a food stand out and feel remarkable to us. It is also well documented as a substance that causes dependence. Combine that caffeine with the sugar of a frappucchino or a mocha or a latte (maybe even some whipped cream), and a “cup of coffee” can have 260 calories and 53 grams of sugar! And taste wonderful! “Caffeine in coffee drinks and soda is part and parcel of the phenomenon of food addiction.”

“Adding soda to a fast food meal increases the sugar content tenfold.” Although nearly half of soft drinks purchased nationwide are diet drinks, 71% of soft drinks purchased at McDonald’s are sugar-sweetened. Clearly fast food eaters drink more sugared sodas. Considering the caffeine most of the drinks contain, our “soda addiction” makes sense. Based on laboratory tests with rodents, which demonstrated sugar addiction, it is clear that sugar is addictive and soda is doubly addictive.

The “gross national happiness index” places Americans, with the highest gross domestic product, only forty-fourth on the happiness index. “Could our unhappiness be related to our food?” Obese people are not happy. This unhappiness could be both a cause and a result of obesity. “Happiness is not just an aesthetic state. Happiness is also a biochemical state” based on serotonin. One way to get more serotonin to the brain is to eat a lot of carbs. Eating more carbs, especially sugar, increases serotonin transport and also substitutes pleasure for happiness for a short while. If one is insulin resistant and leptin resistant, the only way to get pleasure is to eat more and more, ultimately destroying happiness. “Just substitute a little pleasure for a little unhappiness, and presto! Addiction in no time at all.” It is not at all true that all Americans are addicted to fast food, even though most of them consume it, nor is it true that all obese people demonstrate food addiction. What is clear is that fast food is appealing due to its salt and, even more importantly, addictive due to its caffeine and sugar. 

6.     STRESS AND COMFORT FOOD

“Many kids and adults respond to psychological stress by eating.” As the incidence of obesity rises in our society, so do the prevalence and severity of psychological stress. Stress leads to both stress-induced eating and stress-induced fat deposits. The increasing level of stress humans have experienced over the past thirty years correlates directly to the expansion of the human waistline over that time. 

Cortisol, a key hormone released by the adrenal gland, is absolutely critical to one’s ability to handle stress. Cortisol peaks in a stressful situation, such as being chased or being yelled at. It is necessary to survival in small doses and in short bursts, but long-term exposure due to ongoing pressures will kill a person—over time. It raises the blood pressure and the blood glucose level and increases the heart rate. And, according to human research, cortisol also “specifically increases caloric intake of ‘comfort foods’”… and “specifically increases the visceral fat.”

In a British study during the 1970s, researchers were surprised to learn that the lowest-ranking persons in a hierarchical organizational chart, as opposed to their hard-charging bosses, “exhibited the highest levels of cortisol and of chronic disease… Death rates and illness correlate with low social status, even after controlling for behavior (e.g. smoking).” And cortisol kills neurons that help inhibit food intake! No wonder, then, that a child who experiences ongoing stress is at greater risk to become obese in adolescence and adulthood. “Some of the factors associated with lower thresholds for stress and higher ‘cortisol activity’ are low socioeconomic status, job stress, being female, scoring high in dietary restraint [such as chronic dieting] and an overall lack of power and confidence…” Chronic stress induces an unregulated cascade of cortisol, and ultimately the brain is unable to turn the signal off, for reasons science does not understand. But it creates a vicious cycle of more cortisol and more stress.

“Over the years, prolonged cortisol leads to excessive food intake… specifically… caloric intake of ‘comfort foods.’” Stress itself does not make people overeat; the perception of chronic stress causes the intake of comfort foods only in those who react with high cortisol reactivity. How does stress affect food intake? It can reduce sleep, leading to increased cortisol and reduced leptin and increased hunger signals. Food insecurity itself can drive up the cortisol levels and contribute to obesity. And experiments show that people with higher levels of stress and cortisol release are likely to become addicted more quickly to various drugs, and possibly to food as well. “Thus the stress and reward systems are linked, making food addiction among those who eat to manage their stress a fait accompli.”

“When cortisol goes up, insulin does too… Insulin makes you gain weight, while cortisol tells you where to put it… They synergize to make metabolic syndrome worse… There are boatloads of evidence that humans are more stressed today than we were thirty years ago… at home, in the workplace, and at school… Stress (e.g. job stress), depression and excess cortisol are all linked to metabolic syndrome… One of the hallmarks of metabolic syndrome is excessive cortisol due to adrenal gland overactivation…”

The three brain pathways of hunger, reward, and stress drive excess insulin levels, resulting in obesity and metabolic syndrome. By now you know the drill: chronic insulin release inhibits leptin signaling, interpreted by your brain as starvation. This makes you want to move less and eat more, especially the comfort foods high in fat and sugar. The biochemistry of nearly every obese individual has created this vicious cycle that sabotages all attempts at weight loss.

7.  FAT CELLS

Your body fat is the best indicator of your long-term risk for poor health, so what causes us to accumulate fat? According to research completed in the 1970s, the number of your fat cells is determined by the time you are two years old. The more weight your mother gained during her pregnancy with you, the greater your birth weight and the more fat cells you had from the start. And once a fat cell is made, it struggles mightily to remain filled. But fat cells aren’t passive storage lockers. They are active participants in your metabolism and necessary to your health.

“Control over your fat is an illusion promulgated by the weight-loss and fashion industry.” You never had any control over your fat cells. Their number was determined by:

a)    Genetics, but to a very small extent. The 32 genes associated with obesity explain no more than 9 percent of obesity.

b)    Epigenetics, the on-off switches that determine which genes are switched on or off. Because this on-off switching does not change your DNA sequence, you can have an epigenetic defect and never know it. Even more frustrating, these switches are set in utero, between conception and birth. They can be impacted by maternal nutrition and stress levels during pregnancy, setting you up for modified gene expression for life. Even worse, you are almost certain to pass on this new epigenetic pattern to your offspring and they to theirs and they to theirs.

c)     Developmental programming, which occurs again in utero, transmitting to the unborn child signals to prepare for a tough life. This might be caused by the mother’s under-nutrition, overeating, or stress, but it drives the newborn to begin storing extra fat in preparation for a fight to survive, starting immediately after birth. Some babies have been found to be insulin and leptin resistant at birth, with no choice other than obesity and metabolic syndrome. Tiny, premature babies often manifest insulin resistance, as do babies born large for their gestational age. Amazingly, though, this can be prevented. Obese women who underwent bariatric surgery between pregnancies reduced the risk of passing this trait on to the next child. Some babies’ brains, however, will always interpret the “starvation” signal due to developmental programming, making the infant eat more and exercise less right from birth.

d)    Environmental toxins, the possibility that toxins in the environment, called obesogens, increase the fat load due to early fetal exposure, fostering future obesity.

So, are we completely powerless over our fate? Not completely. It’s the filling of the fat cells that causes obesity and impacts your long-term health. Those fat cells are filled when insulin turns sugar to fat and makes your fat cells grow. Block the insulin, and your fat cells simply remain empty. Unfortunately, human bodies overall are now making more insulin than they used to. “Today’s adolescents have double the level of insulin secretion of their predecessors in 1975.” Insulin increases in one of these ways:

a)    Following a meal, particularly one high in refined carbs, your brain signals your pancreas to begin the fat storage process.

b)    Your liver has developed its own unhealthy supply of fat and has become sick, causing your pancreas to make more insulin to try to motivate the liver to perform properly. Insulin levels rise throughout your body, filling fat cells everywhere.

c)     Excess cortisol, due to stress, makes your liver and muscles unhealthily insulin resistant, driving energy deposition into fat. The cortisol might also work on your brain, which tells you to eat more.

One person might experience the above in any combination, but currently society has given us another way to increase insulin and weight gain: medications. We take steroids for inflammation, antipsychotics for our mood issues, and oral hypoglycemic agents to treat our diabetes—and they are notorious for driving up insulin and causing excess weight gain. Often these drugs are the lesser of two evils, although it would be better not to need them in the first place. “Once a glucose molecule is in the bloodstream it has one of three fates: it can be burned (by exercise), it can be stored in fat (by insulin), or it can be excreted in the urine (which eventually kills your kidneys).”

“Your fat is here to stay.” Our early ancestors regularly faced starvation, so the species evolved ways to prepare the offspring for a chance of survival in the face of food scarcity. Fat cells don’t want to give up their stored fat without a fight. When they do get smaller, they stop making leptin, and without leptin the body cannot experience puberty or pregnancy. Fat cells are vital to the survival of the human species. Our only hope is to “reverse the biochemistry. Stop the energy storage. Fix the leptin resistance… We need some version of ‘personalized obesity medicine.’” How do you change your biochemistry? By changing the environment, and that’s not easy.

8.     ARE YOU SICK OR ARE YOU JUST FAT?

Is the overweight individual sick? Not necessarily. First of all, “there is a racial/ethnic overlay to obesity” as well as a genetic component. Asians start to manifest disease when their BMI (body mass index) reaches 25, on average, while Caucasians display the same symptoms at a BMI of about 30, and African Americans at about 35 BMI.

When you step on the scale, what are you really weighing? Four things:

a)    Bone: The more bone you have, the longer you live. African Americans have greater bone density.

b)    Muscle: More muscle is healthier. Muscle takes up glucose and makes better use of your insulin. Bone and muscle help you burn energy rather than store it.

c)     Subcutaneous fat: The visible fat that gives us our curves and bulk makes up 85% of our total body fat and actually contributes to a longer life!

d)    Visceral fat: The “big belly fat” inside your abdomen and inside your organs makes up about 20% of your total body fat. That’s the fat that will kill you.

“You need your fat… the bucket for extra energy to keep you alive and healthy.” The smaller amount of subcutaneous fat (“big butt fat”), the faster you die. So “it’s all about your middle.” The visceral fat within our abdomens constitutes only about 5% of our total fat, but it tends to make a fifteen-year difference in the length of our lives. It drives inflammation and causes insulin resistance, promoting diabetes, cancer, cardiovascular disease, dementia, and the aging process.

The good news is that, when you do lose weight, the first fat you lose is the visceral fat. Your body will struggle to hold onto the subcutaneous fat that gives you a big butt and thick thighs and fat arms because that’s the fat that makes leptin and helps to keep you alive. It contributes very little to disease. So, the fat that makes your jeans tight is probably not the fat to worry about. Body size is irrelevant to health. But your visceral fat, particularly the liver fat, drives disease and shortens lives, yet it is very difficult to measure except by MRI or liver ultrasound. A recent study by Dr. Eric Braverman (who calls BMI “Baloney-Mass Index”) compared the determination of obesity by BMI and by x-ray. The conclusion? Half of all women with a normal BMI and one-fifth of men with a normal BMI are actually “obese” on the basis of their visceral fat. 

But how can you measure visceral fat? Not on a bathroom scale or by having your BMI measured. Your best bet is to consider the circumference of your waist. This is where you come closest to measuring the fat that puts you at risk for disease and death. A rule of thumb is no more than 40 inches for men, 35 for women. The ratio of hip size to waist circumference is also a rough indicator of health. Another place to look, interestingly, is at the back of your neck, your armpits and knuckles. Look for “darkening, thickening and ridging of the skin” or skin tags, all of which can reveal signs of excess insulin affecting your skin.

“Any doctor will tell you that losing weight will improve your health, including me. And it’s a fact—except for two small problems: First, weight loss is next to impossible… And second, it’s only half-true.” Losing subcutaneous fat without building muscle through exercise won’t help your health. When you diet without exercise, you lose as much muscle as fat, keeping your percentage of fat the same. The fat that needs to go is the visceral fat, and it is likely to be the first fat you lose, which is beneficial. But as you lose subcutaneous fat your brain signals starvation, making you reduce your energy expenditure and feel lousy. Your appetite will actually go up, and your body will release extra insulin, trying to store the fat to replace what you lost. 

So what on earth can you do? Depending on what has made you overweight or obese (high insulin levels due to regular overeating or a sick liver or high cortisol levels due to stress), you will have to take the approach that is right for you. You don’t necessarily need to lower your weight, but you do need to get your visceral fat down. 

9.     METABOLIC SYNDROME

“The fatter you are, the quicker you die. At least at a population level.” On an individual level, though, 20% of obese people have normal metabolic health. Forty percent of people of normal weight have abnormal metabolic health. So how do you know where you stand? Obesity itself does not kill, but it brings with it the known killers: diabetes, heart disease, cancer, dementia, hypertension. Together these conditions make up “metabolic syndrome.” If you have three of them, you have the “syndrome,” and you don’t have to be obese to have it.

No matter your weight or BMI, if you are insulin resistant, you are likely to develop metabolic syndrome. How it happens is a long, complex process, summarized something like this:

a)    Energy accumulates, and the excess is stored in the liver and in visceral fat, making the liver insulin resistant and ultimately damaging every organ in the body.

b)    When the liver malfunctions, the pancreas increases insulin release, trying to jump-start the liver. Now more fat is stored, and you gain weight as your insulin levels continue to rise.

c)     The liver tries to export the fat as triglycerides, and you are now at risk for heart disease.

d)    High insulin levels tighten your artery walls, and now you have high blood pressure.

e)    Together, high blood pressure, fatty liver, and insulin resistance put you at risk for heart attack and stroke. 

f)     An inflamed liver becomes scarred, resulting in nonalcoholic fatty liver disease and, ultimately, the possibility of cirrhosis.

g)    Women with insulin resistance and hyperinsulinemia often suffer polycystic ovarian syndrome and infertility.

h)    When the pancreas can no longer keep up with the demand for insulin, you develop type 2 diabetes.

i)      Because insulin is a hormone that causes cells to divide, hyperinsulinemia promotes the growth of cancers.

j)      And some studies show that insulin resistance in the brain can lead to dementia.

That is metabolic syndrome, and there are four specific foodstuffs that contribute to it:

1.     Trans fats, which are synthetic and hard to break down in the body, used to be found in every kind of processed foods. They are still in baked goods and candy bars. “In fact, any food in a wrapper at room temperature that’s meant to sit on a store shelf is suspect.”

2.     Branched-chain amino acids, the levels of which rise in our bodies in direct correlation to the amount we consume, are found in high concentrations in corn. And most of the beef and pork raised in the U.S. is corn fed. The more beef and pork you eat, the more branched-chain amino acids in your body.

3.     Alcohol, which might actually prevent metabolic syndrome when taken in moderation, contributes to metabolic syndrome when taken in increased quantities.

4.     Fructose, the sweet molecule in sugar, is “the Voldemort of the dietary hit list.” Both animal and human data demonstrate correlation and causation between fructose and metabolic syndrome, and every age group, worldwide, has increased its consumption of it in the past thirty years.

No medicine can counteract the effects of these dietary influences. If their consumption continues unabated, “your cells will die and so will you.” However, each of us can slow the process down considerably. You can do this in four ways:

a)    Change your diet

b)    Eat more fiber

c)     Consume micronutrients

d)    Exercise

(Notice that the first three are really all part of “change your diet.”) And those are the four actions that can change your biochemistry, the only way to combat obesity and metabolic syndrome.

10.     THE OMNIVORE’S CURSE

Some of our ancestors were predominantly hunters, others predominantly gatherers. And some were hunter/gatherers. But the cyclic nature of their food supply caused the species to evolve with two completely discrete metabolic processes. Hunters ate fat and protein and had to live off their stored fat when no kill could be made. Based on the supply of energy at hand, the body either burned it or stored it for later use. Hunters did not know what a carbohydrate was. They ate animals, and animal bodies, like our own, are devoid of carbohydrates.

The gatherers ate what grew from the ground—fruits and vegetables and nuts and seeds, basically a vegan diet. The liver would take up all the glucose when energy was in short supply, allow some into the bloodstream when there was excess energy, and signal even higher insulin levels to store fat when energy was in generous supply.

Evolutionarily, the metabolism of fat and carbohydrates developed separately. But both metabolic products meet in the cells, and how much energy the cells must process has everything to do with how healthy the cell is. Because our ancestors found their food on the basis of geographical location and seasons, they rarely ate fat and carbs simultaneously; it was either a hunting season or a gathering period. Thus the liver developed two distinct safety valves to protect it from too much energy, one for fats and one for carbohydrates.

And then society evolved and humans learned how to raise farm animals and irrigate land to grow crops, and they began to eat fat and carbohydrates at the same meal. Do that once or twice—no big deal. But eat like that (and that’s exactly how we were taught to eat, right?) for ten years, and the body can experience some real damage as a result. And how is it we create meals that combine both fat and carbs? By consciously pairing foods that contain them, because very few foods  that occur naturally contain both! Meat and fish have fat but no carbohydrates; grains, roots and tubers are filled with carbs, but no fat. As we strove to eat like gourmets, we consistently paired fat and carbs in our diet, causing serious wear and tear on our cells. Now we have become gourmands, processing foods to contain both fat and carbohydrates in a single food!

Over the years, various “experts” have offered evidence that ill health is variously caused by consumption of fats or of carbohydrates. Ultimately the fats won out as the most dangerous part of our diet, and there was a mad rush toward low-fat foods. This seemed like it might be a good idea: no dietary fat, no LDL (“bad cholesterol”) and no heart disease. 

Unfortunately, it isn’t that simple. Both fats and carbohydrates contribute LDL to the bloodstream, but the LDL contributed by carbs is smaller, denser, and more harmful to the arterial walls. In fact, the 80% of LDL contributed by fats is large and buoyant and does not affect the arteries’ walls! Further, just as “a calorie” is not “a calorie” (because calories are metabolized differently and drive different behaviors), dietary fat comes in seven forms. Some fats are good for our bodies: Omega-3 fatty acids, monosaturates, and polyunsaturates, which come from fish, flaxseed oil, olive and canola oils and vegetables oils, have medicinal value. Saturated fats from grass-fed animal meats and dairy products are fairly neutral in their effect. The fats lower in medicinal value and higher on the “danger” scale come from palm oil, coconut oil, palm kernel oil, farm-raised fish and corn-fed animals, and synthetic or processed foods. So, the only fats we really need to eliminate from our diet are medium-chain triglycerides, omega-6 fatty acids and trans fats (i.e., partially hydrogenated oils.) 

The crusade to remove fat from our American diet has probably done more harm than good, now viewed thirty years down the road. And what result has it produced? No reduction in the incidence of stroke and heart attack. Why? What did we do to our food when we took the fat out? Well, it tasted like cardboard, so the food industry upped the carbohydrate content, specifically sugar! As fat-containing foods dropped to 30% of the American diet, “levels of refined carbohydrates, devoid of their inherent fiber, went through the roof… and thus the obesity epidemic was born.”

About 15 years ago the carbs-restricted diet and the low-fat diet went head to head, and we learned five important lessons about our diet:

a)    Carbohydrate restriction improves glucose control, which is critical to diabetes therapy.

b)    Carbohydrate-restricted diets are as effective as low-fat diets in reducing body weight.

c)     Substituting fat for carbs generally indicates a reduction in the incidence of heart disease.

d)    Carbohydrate restriction improves metabolic syndrome in observable ways.

e)    Carbohydrate restriction provides health benefits even when weight loss does not occur.

One foodstuff contains both fat and carbohydrate. One! It is the true omnivore’s curse, and it is responsible for our human obesity pandemic! Read on…

11.      FRUCTOSE

Consider three popular diets, all of which have their champions and have demonstrated success: the Atkins diet (protein and fat), the Ornish diet (vegetables and whole grains), and the traditional Japanese diet (carbohydrate and protein). Diametrically opposed? Seems so. But consider what they have in common: Sugar restriction! “Every successful diet in history restricts sugar.”

Sugar has been called “empty calories,” but those calories are worse than “empty.” Sugar (sucrose) is half glucose and half fructose—two substances metabolized by the liver in two different ways: one as a fat, the other as a carb! Both metabolic pathways have to work overtime when you consume sugar, and remember, evolutionarily, the human body is designed to metabolize them separately at different times.

“There are now 30% more obese individuals than undernourished ones on the planet.” Americans, specifically, consume, on average, 130 pounds of sugar a year. Compared to 100 years ago, our fructose consumption has increased five-fold. Just in the past thirty years, our fructose consumption has doubled! While the world’s population has doubled in the past 50 years, its sugar consumption has tripled.

Awareness of the toxicity of fructose, particularly purveyed as high-fructose corn syrup (HFCS), has been around for a while. Since 2007, our rate of consumption of HFCS has declined—but our obesity rates have not. Now what?! Is it possible that sugar in any form is toxic? All sweeteners contain fructose because it’s the fructose that gives sugar its sweet taste; glucose without fructose is not a sweetener. So, all of these contain fructose, even if it’s not HFCS: white sugar, cane sugar, beet sugar, fruit sugar, table sugar, brown sugar, corn syrup, maple syrup, honey, and agave nectar.

When glucose exists without the fructose, we have, simply, “starch.” That can be bad for you too. Glucose metabolism depends on insulin release and promotes energy storage in fat cells. But most of it becomes glycogen, which does not harm the liver and does help prevent diabetes. Excess glucose in the liver, however, becomes triglycerides, which promote cardiovascular disease. And, when glucose binds to the proteins in our cells, it can contribute to the aging process and cause tissue damage.

Glucose consumption without fiber, as in pasta and white bread, for example, can cause weight gain but doesn’t necessarily make you sick. Add to those starch calories either ethanol or fructose [e.g., sweetened starch in the form of a cocktail or a donut] and “you get much more of a bang to your liver… For the same number of calories, ethanol (grain alcohol) is more likely than glucose to cause chronic disease.”

What is unique about fructose? For one thing, it does not occur in nature by itself. It is always found with the much more benign glucose. Fructose is seven times more harmful to the body than its sister glucose. Fructose contributes to the Maillard reaction, which is the browning reaction. It’s what turns hemoglobin into hemoglobin A1c, the blood sugar level monitored in diabetics. This reaction is what makes sugary barbecue sauce caramelize meat. Inside your body, fructose is having the same effect on your “meat,” contributing to aging, cancer, and cognitive decline. “You can brown your meat at 375 degrees for one hour, or you can brown your meat at 98.6 degrees for seventy-five years. The result is the same.”

When is something that seems so good for your body really so bad? When you take out the fiber. Consider a glass of orange juice as opposed to eating an orange. The juice contains 120 calories of sucrose, half glucose, half fructose. Only 20% of the glucose will go to your liver because glucose can be metabolized throughout your body. All the fructose will go directly to your liver! A steady diet of this can contribute to gout, heart disease, liver insulin resistance and diabetes, obesity, cancer, overeating due to leptin blocking, cell damage due to the Maillard reaction, and the acceleration of aging and dementia.

The effects of ethanol in the body are easily recognized—alcohol causes observable intoxication. “But sugar flies under the radar.” Soft drinks don’t make you drunk. The two countries with the highest rates of type 2 diabetes, Saudi Arabia and Maylasia, are countries in which alcohol consumption is forbidden! 

In the first decade of the twenty-first century, the worldwide diabetes rate rose from 5.5 percent to 7.0 percent. An ecological analysis of 154 countries sought to determine whether that rise in diabetes was the result of increased caloric intake and, if so, whether any specific aspect of the diet might explain that. Result? Total calories consumed could not explain the rise in diabetes, but “the correlation with the percentage of calories coming from sugar and sugar crops was enormous”: 25 percent!

“Every additional 150 total calories per person per day barely raised diabetes prevalence. But if those 150 calories were instead from a can of soda, increase in diabetes prevalence rose sevenfold. Sugar is more dangerous than its calories. Sugar is a toxin.”

And it gets worse because sugar hooks the starvation-reward cycle of addiction! Just like alcohol, sugar tricks your brain into believing you need more and more of it. Remember blocked leptin signaling? The brain convinces your body it’s starving and needs more. Fructose fits the profile perfectly:

a)    Fructose consumption does not trigger insulin release, so the brain receives no leptin signal of satiety, and one keeps on eating.

b)    Long-term fructose consumption interferes with dopamine clearance, so the reward just keeps coming.

c)     Unlike consumption of most foods, fructose consumption fails to decrease the hunger signal in the stomach (a peptide called ghrelin), and consumption continues.

12.     FIBER IS HALF THE BATTLE

Fiber is touted in our culture as the key to “regularity,” keeping our bowels moving at an agreeable rate. There is a temptation to dismiss fiber as serving only that purpose. But “fiber is half the ‘antidote’ to the obesity epidemic.” Our ancestors actually consumed about 100 grams of fiber per day; we consume, on average, 12 grams! True, fiber is something you can’t digest. It doesn’t give you energy, and it really does end up in the toilet. But there are two types of fiber, soluble and insoluble, that contribute significantly to health. They both eventually get eliminated, the first as gas and the second as stool, but they perform remarkably supportive roles in healthful metabolism of our food. “The two together are an unbeatable pair.”

Soluble fiber, which absorbs water, can be found in oatmeal, apples and oranges, nuts, cucumbers and more. Insoluble fiber, which does not absorb water, occurs in whole grains, barley and brown rice, zucchini, onions, cabbage and more. Together these two types of fiber give the liver a better chance to fully metabolize our food.

Most of our contemporary diet contains virtually no fiber at all. Refined grains have been stripped of their bran and germ, allowing the grain to slip quickly through the digestive system, triggering a quick peak (and then decline) in blood glucose. A whole, unrefined grain forces the intestines to slowly strip away the outside bran, keeping glucose levels reasonable and contributing an earlier feeling of satiety. (But beware: The accepted definition of “whole grain” can be very misleading. If it comes in a box, it probably contains no actual whole grain at all.)

And now you understand why juicing the fruits and vegetables you love is nutritional suicide! When you ingest a whole fruit, the inherent fiber balances the metabolism of the naturally occurring fructose. While juicing does retain some (but not all) of the essential vitamins and minerals in fruits and veggies, it removes the fiber, your liver’s only protection from the blast of fructose.

Fiber fights obesity in five important ways:

a)    It mitigates the presence of fructose by delaying the intestinal absorption of glucose, fructose and fat, limiting the blood glucose peaks and valleys associated with overeating.

b)    Fiber helps lower bad cholesterol.

c)     Insoluble fiber moves your food more quickly through the intestines, signaling satiety earlier. Soluble fiber delays the emptying of your stomach, making you feel fuller faster. The result is lower food consumption.

d)    Insoluble fiber in particular slows the likelihood of insulin resistance (although it causes gas).

e)    Soluble fiber allows some of our nutrients to remain unabsorbed in the small intestine and therefore allow for absorption in the large intestine, feeding the good bacteria that live there, which contribute to health in general and the lower likelihood of weight gain.

Fiber needs to come from our food—bottom line. High-fiber foods have less energy for their relative bulk, bringing in fewer calories, and they move your food more quickly through your digestive system to make you feel satisfied faster. But one type of fiber without the other does not yield the healthful one-two punch. Therefore, taking a fiber supplement such as psyllium in a glass of water does not reduce the chances of developing metabolic syndrome.

In short, the combination of soluble and insoluble fiber reduces both the rate and the dose of glucose, fructose, and fatty acids entering your bloodstream, which keeps your insulin down. At the same time it enhances the workings of the metabolic machinery by feeding the good bacteria in the colon. However, to get the benefits, you have to eat both types of fiber intact, in your food.

13.      EXERCISE – THE OTHER HALF OF THE BATTLE

“Exercise is the single best thing you can do for yourself.” It will help you live longer and improve your life on many levels “except one: your weight.” If all calories were equal, then simply ingesting fewer total calories and burning more of them should translate to weight loss. But all calories are not the same, we now know. Choosing calories wisely can positively impact your weight; the energy you burn does not have a direct opposite effect.

Burning a pound of fat liberates 2500 calories. But a recent scientific analysis showed that an obese individual had to burn 3,977 calories to lose one pound of fat. When you exercise, you build muscle, which is good for you but doesn’t lower your body weight. It’s the biochemistry that drives us. If someone dramatically changed your environment—regulated what you could eat when, and how much, and forced you to exercise at certain times and sleep at others and occupy your time in a particular way, with no room for error—you could definitely lose weight. Until you left that environment. The environment creates the biochemistry that drives the behavior. As a rule, the more energy you expend, the more energy you will take in, because your biochemistry sets you up for that.

Everything we’ve been taught about the relationship between exercise and weight loss has been misleading if not downright wrong. In actuality, physical activity accounts for only 5%-30% of the energy burned in an individual’s day. Just the act of eating and digesting and metabolizing our food can account for a greater percentage of energy burned in a day—on average about 10%. So that leaves about 60% of the energy we burn in a day, and you’ll never guess what stokes that fire: resting! Sleeping, sitting around, or watching TV accounts for the greatest consumption of your energy!

Focus on that “resting energy expenditure” (REE) now, and you will see that it’s not exactly working to help you shed pounds either. For, if you are lucky enough to drop some weight (or unlucky enough to lose pounds due to illness), your REE will adjust itself and burn less! I know—it is so consummately unfair, but your body will always try to stay just the weight it is, with your fat cells struggling to hold onto any fat that’s been deposited in them. Whenever your brain fails to get the leptin signal that all is well, it puts your body right into starvation mode and you become more energy efficient, burning less!

 Let’s focus now on the energy burned by eating—about 10%. This explains why it is important to eat regularly and not starve yourself for any length of time. So, after a full night of sleep (or at least a night without food), a body needs breakfast to get the machinery working again. And “consume some form of protein at breakfast. Protein costs more energy than burning other foodstuffs.” And remember that protein does not stimulate the same level of insulin release that carbs do, so consider a veggie omelet for breakfast.

Individuals of different body sizes and different physical regimens burn calories at dramatically different rates and can therefore eat dramatically different amounts with no change in weight. But ordinary folks, as opposed to Olympic swimmers or long-distance runners, still benefit from exercise. And it still has a positive cumulative effect over time. Why? Because exercise builds muscle tissue, and muscle burns more calories than does fat. The greater the percentage of muscle tissue as opposed to fat, the more energy is burned when you are simply watching your favorite TV show!

“Diet is about weight, exercise is about health. Exercise does the one thing that dietary restriction cannot: it builds muscle.” Exercise develops insulin sensitivity, which does not show on the scale. While exercise will not cure obesity, it can definitely mitigate the effects of metabolic syndrome in these three ways:

a)    By renewing your muscle cells, it makes you more sensitive to the insulin released in your bloodstream.

b)    Over the long term, it reduces the cortisol released by your adrenal glands due to stress.

c)     It improves the liver’s ability to burn energy more efficiently.

Any kind of exercise is good, but the effects are short-lived, so the activity must be frequent and sustained. Within one day, the positive effects on your muscles are no longer in process, and within 15 days of exercise your insulin sensitivity returns to its former level—unless you exercise consistently. Burning energy is always preferable to not burning energy, as long as you remain realistic: exercise without dietary intervention will not reduce your weight. However, fitness overall makes people live longer and feel better. “Irrespective of weight, consistent exercise (even just fifteen minutes a day) is the single best way for people to improve their health.”

14.     MICRONUTRIENTS

“Nonalcoholic fatty liver disease (NAFLD) is now the most common disease in America,” affecting 24–45 percent of the population, fat or thin. Most who have NAFLD have no symptoms. Each year a million Americans die directly from a nutritional disease, not even counting those who die from related diseases such as heart disease, diabetes, etc. These completely preventable deaths are due to both overnutrition and undernutrition. The sugar glut sends excess energy coursing through the liver, causing structural damage to our cells. Micronutritents called antioxidants can detoxify the liver before cells can be structurally damaged or even die from this condition.           

“Cells want to survive. Virtually every biochemical reaction requires one micronutrient or other, whether it is a vitamin, mineral or biochemical compound. If your body has a micronutrient deficiency, it re-allocates significant micronutrients to attend to the short-term, acute threat facing a particular type of cells. The result is that your body, overall, is left with insufficient micronutrients to ensure your long-term health. The aging process is hastened by different toxins, performing differently in different tissues. Therefore our bodies require disparate antioxidants to stave off a variety of chronic diseases.

“But are these micronutrient deficiencies the true cause of disease or just the markers of an extremely bad diet? At this point we just don’t know. We know that altering diet (eating more fruits and vegetables, limiting processed foods and sugar) to deliver more of these compounds is almost uniformly beneficial in improving the signs and symptoms of metabolic syndrome. But when these antioxidants are given as supplements, they usually fail miserably. This could very well be due to the beneficial effects of eating unprocessed foods, where you get both the fiber and the antioxidants as a bonus.”

Micronutrients really do make a difference in our health. The problem is that, in clinical trials, micronutrients taken as supplements didn’t make a difference. “Real food, containing endogenous micronutrients, prevents metabolic syndrome. Processed food causes metabolic syndrome. And nutritional supplements can’t reverse that which has been previously destroyed.” Taking a vitamin raises the level of that vitamin in the body—and that’s all it does.

Replacing what’s missing is easier than removing something excessive. When food is processed, five critically negative things happen to it:

a)    Toxins are added.

b)    Fiber is removed.

c)     With the fiber go many of the micronutrients.

d)    Some antioxidants become so plentiful that they now act as harmful oxidants.

e)    Trying to replace the missing micronutrients means relying on an industry (nutraceutical supplements) that is not rigorously controlled by the FDA.

f)     What we do know works is simple: real food.

15.     “OBESOGENS” IN THE ENVIRONMENT

In 1990 no single state in the U.S. had an obesity rate over 14%. By 2009, every state reported an obesity rate of 20% or more; 36 states had obesity rates of 25% or higher. What could be the cause of such a universal increase? Although the science has not yet confirmed causation, it is widely believed that endocrine-disrupting chemicals called obesogens “insidiously hijack the body’s energy balance system, making energy go places that are detrimental to your metabolic health.” They promote weight gain and obesity, and they are found in the general environment.

The human estrogen receptor (which causes girls to gain weight appropriately in order to enter puberty) will connect with almost any chemical, and estrogens are everywhere. They are in DDT, which was widely used in our country as a pesticide and is still found in pregnant women’s urine. Bisphenol-A (BPA), another estrogen, leeches out of plastic bottles and toys. Genistein, a soy and alfalfa estrogen, causes weight gain in rats—and “it’s in everything we eat.” Carnivores get it in their meat, vegetarians get it in their dairy products, and vegans get it in their soy products.

Other possible obesogens include popular plasticizers called phthalates, pesticides such as atrazine and other organochlorines, a fungicide called trybutyltin, second-hand smoke and air pollution. “These chemicals love to make fat cells, and fat cells love to get filled… Obesogens can alter developmental programming… in utero, and thus change the set point for gaining weight as early as birth.”

16.     THE FOOD INDUSTRY RESPONDS

“Both the Sugar Association and the Corn Refiners Association have gone out of their way in their attempts to exonerate sugar, whatever the source… Soft drinks account for one third of all the sugar consumed. But other foods that never had sugar before are now busting at the seams from the sugar overload (e.g. yogurt, ketchup).” 

Why all the sugar in the U.S.? The Cuban revolution of 1959 cut off our Cuban sugar supply. About 15 years later high-fructose corn syrup (HFCS) was introduced in the U.S., and it cost about half as much as the sucrose we had been accustomed to. President Nixon ordered his Secretary of Agriculture to de-politicize food by keeping prices low and steady, which introduced the corn subsidy as part of the Farm Bill, meaning the government would underwrite the cost of corn, the source of HFCS. In 1980, when Hurricane Allen wiped out the entire Caribbean sugar crop, sending sugar prices through the roof, giant Coca-Cola switched from sucrose to HFCS, and the rest of the food industry quickly followed suit.

What’s wrong with HFCS anyway? It’s no worse for you than any other form of fructose—it just always comes without any fiber, and it’s cheap and easy to produce, so it’s always available. It’s our cheap sugar fix. Sugar adds sweetness to the taste, attractive browning to the visual appearance, texture to baked goods, and longevity to processed foods that would otherwise spoil. Sugar in the form of HFCS is always devoid of fiber, which increases shelf life. “Fiberless food can be frozen, shipped globally, and cooked quickly. But getting rid of fiber has obviated satiety, and exacerbated the negative impact of the carbohydrates, contributing to hyperinsulinemia, obesity, and metabolic syndrome.”

Consider a typical cookie: 30% flour, 30% fat, 30% sugar, 6% protein. That one cookie might be a treat—if you could eat just one. “Sugar is addictive, and sugar plus fat is even more so.” 

It’s true that sugar occurs naturally in food and gives us energy, but that is “irrelevant in terms of our health.” The food industry is powerful; you should be aware of the industry’s messaging in regard to sugar and prepared to regard the message in terms of the scientific facts:

a)    Fructose doesn’t raise blood glucose. True, but fructose is never found alone in nature—it’s always paired with glucose, and that does raise blood sugar via insulin release, while the fructose causes liver fat and liver insulin resistance.

b)    If you substitute fructose for glucose (if you are able), the food would be safe for diabetics. This possibility is currently under study in the laboratory, but remember that “the toxicity of fructose depends on the context.”

c)     The food label is right there! Food labels currently list “total sugars,” not added sugars, which is of no help at all in assessing the relative safety of the actual sugar contained. It’s the “added sugar” that causes the problems. [Note: Just a little more than one year after Dr. Lustig’s book was published, the FDA moved to require “added sugars” on food labels. Food labels might eventually be of some help.] Remember that “fiber is the mitigating factor, not the sugar,” and processing removes the fiber. “Sugar is certainly not an essential nutrient, in the sense that there is not one single biochemical reaction that requires it. Sugar is extraneous, and our bodies certainly don’t need it… Sugar is more toxin than it ever was a nutrient.”

d)    It’s all about supply and demand. The food industry claims it gives the public what the public wants, and that may appear true. However, if one is absolutely besieged by professionally produced advertising created at a high cost, it is likely the public will think it wants what the advertising purveys. That’s how advertising works.

The fast food industry sponsors teams, sporting events and charitable causes—and this only serves to produce more compelling advertising: linking the name of an unhealthy “food” to a healthful physical activity. “And if you think it’s bad in the United States, try Latin America. Consumption of soft drinks doubled in Mexico in seven years. Despite the fact that 75% of Mexican adults are currently overweight, Coca-Cola sponsors more physical activity programs than all other companies put together.”

The food industry helps us assuage our guilt as we become fatter and sicker by using terms like “natural” and “whole wheat” or mentioning added nutrients. “None of these taglines has any meaningful definition, and there is little to no regulation about when they can be used.” So who is really in charge? While you are in charge of your health, if you consume a mainstream diet you are clearly not in charge of your food. So, are you really in charge of your health?

17.     ALTERING YOUR FOOD ENVIRONMENT

“Controlling behavior doesn’t work, because behavior is really just the output of our biochemistry. Controlling behavior is unsustainable.” The goal, then, has to be to get the insulin down, and that starts with what you eat. If you’re going to alter your food environment in a meaningful way, it must begin by altering your relationship with the supermarkets and restaurants from which you get your food.

At any given time, a huge proportion of Americans are “dieting.” When the diet fails (as so many have failed before), you are made to feel you were simply not compliant. But compliance means you changed your behavior, and you can’t sustain changed behavior in an unchanged environment. That’s why the low-fat diet was a dismal failure. Beginning in the 1980s, every health organization in America recommended reducing fat consumption in the diet. But a low-fat diet was tasteless because the flavor was in the fat! Enter carbohydrates! And then followed increased insulin response and weight gain. 

Along with the low-fat mantra came a lot of talk about LDL. Remember that large, buoyant LDL, which comes from fat, floats in the bloodstream and does not harm the arteries. It is the small, dense LDL, which comes from carbohydrates, that sinks and weasels under the blood vessel cells, causing atherosclerosis. Because foods are metabolized differently in different combinations (“A calorie is not a calorie”) it’s not the fat, it’s not the carbohydrate. “It’s the fat and carbohydrate together that cause metabolic problems. Sugar provides just that, and the low-fat diet is rife with it.”

“We need to eat certain dietary fats for our nervous system and immune systems, cell membranes, and to make certain hormones.” A diet that succeeds requires low sugar, high fiber, and fat and carbs consumed together with fiber (e.g., whole, natural foods). “If you eat a vegetarian or vegan diet the way our gatherer ancestors did—eating the food as it comes out of the ground—you’re good to go… Keeping insulin low, eating lots of fiber, and avoiding added sugar. Now you’ve got something.” 

As for the wisdom of using artificial sweeteners, the science has not yet provided conclusive data for making a judgment. Sugar substitutes do provide a sweet taste without calories or fructose. The question is whether that substitution will cause you to adjust your environment in a way that contributes to better eating overall. We do not know:

a)    What a drug does to your body. We know what your body does to the drug, but not the converse operation. “We don’t know what any of these diet sweeteners do to your long-term food intake, weight, body fat, or metabolic status.”

b)    Does the sweet taste of a diet sweetener signal an insulin release, just as sugar does? Can your brain tell the difference? We don’t know.

c)     Artificial sweeteners might alter the composition of our intestinal bacteria—we just don’t know.

d)    If long-term consumption of sugar signals the down-regulation of dopamine, causing you to consume more and more sugar over time to get the same satisfaction, might diet sweeteners act in the same way? This could contribute to the biochemistry that causes sugar-seeking.

e)    The FDA says diet sweeteners are safe. Has science clearly borne that out?

Food labels, as far as they go (without the “added sugars” notation), can be of some help if read properly. But remember that real food doesn’t require a label. Shop to your heart’s content in the produce section and don’t worry about labels. Fresh, whole foods spoil faster than processed foods and take longer to cook. They also cost more, unfortunately. All correct. But they’re still the better value for your health.

If you are going to venture beyond the whole, natural fruits, vegetables, meats and fish, bulk grains and nuts and seeds, into the interior of the supermarket where the processed food is shelved, you’d better be prepared to recognize hidden sugar on a food label. There are 56 known names for sugar! They include the easily recognized “honey” and “agave nectar” and “maple syrup” as well as the less-known “panocha” and “treacle” and “evaporated cane juice.” On a food label the word “sugar” is, itself, combined with many of its source foods, such as “grape sugar,” or with its level of processing, such as “turbinado sugar” and “castor sugar.” It’s all sugar.

Sadly, we introduce sugar to our infants in the form of formula. Isomil, a lactose-free formula, is 10.3% sucrose, almost exactly the sugar content of a Coke.

Three guidelines to reducing your sugar consumption:

a)    Eliminate all sugared beverages and all juices. (Remember, pure fruit juice without its fiber has more teaspoons of sugar per cup than a sugared soda!)

b)    In all recipes, reduce the sugar by a third.

c)     Make dessert a once-a-week special.

What you should actually look for on a nutrition label, instead of “total calories” and “grams of saturated fat”:

a)    If it’s a liquid, it should have 5 calories or less per serving.

b)    If it’s a solid, it should have 3 grams of fiber or more per serving.

c)     If the words “partially hydrogenated” appear on the label, put it back on the shelf. 

d)    If one of the first three words is “sugar” in any one of its 56 forms, treat it as dessert.

You can be fooled! “A standard 6-ounce Yoplait yogurt…has 27 grams of ‘total sugars’... [including] 11 grams of added sugar. So when you consume a Yoplait, you’re [effectively] getting a yogurt plus 8 ounces of Coca-Cola.” Chocolate milk has all the essential nutrients of milk, including lactose. In terms of sugar consumption, the “added sugar” in chocolate milk makes one 8-ounce serving the same as drinking a glass of natural milk immediately followed by ten ounces of sugared Coca-Cola. Learn the names of added sugars; find them on food labels, and avoid them. 

“The goal of the supermarket exercise is to shift your food buying from a high-fructose, high-trans-fat, low-fiber (i.e. processed) grocery basket to a low-fructose, zero-trans-fat, high-fiber (natural) basket.” Buy unprocessed meat, dairy, and produce. “If you eat real food, your weight will take care of itself… All real food is inherently good. It’s what we do to the food that is bad.”

18.     ALTERING YOUR HORMONAL ENVIRONMENT

Sixty million “diet recidivists” are proof that you can’t change your behavior and sustain that change by itself. Hormonal inputs play a crucial role, and if our hormones worked thirty years ago, they can work today. The problem is that they don’t work well in this altered environment. To fix the hormones, we need to fix the environment. The rules are straightforward:

a)    Get the insulin down. Cut back on refined carbs, and reduce your sugar consumption, since this is always fat and carbohydrate combined. To do this, drink water and milk—period. And eat more fiber, opting for brown foods such as lentils, nuts, and whole grains. Finally, improve your muscle insulin sensitivity the only way you can—exercise.

b)    Get the ghrelin down. Ghrelin is the hunger peptide that tells your body to keep eating. The first step is to eat breakfast. Specifically, eat the right kind of breakfast: a high-protein breakfast. Protein better calms the ghrelin than do fat and carbs. And protein actually requires more metabolic work of your body, but it doesn’t generate nearly the insulin response that will ultimately make you hungry again sooner. At the other end of the day, eat nothing after dinner; food consumed in the evening has no chance to be burned.

c)     Get the Peptide YY up. Simply make the food move through your intestines faster to let you know you’re full. How? Eat fiber!

d)    Get the cortisol down. Exercise regularly and consistently over time.

19.     WHEN ALTERING YOUR ENVIRONMENT ISN’T ENOUGH

There is a place for imaging studies and surgery in the treatment of some specific cases of metabolic disease.

20.     PUBLIC HEALTH

The food industry has a vested interest in blocking regulation. Its political action groups aim to convince us of our inalienable right to eat whatever we want, regardless of its calorie content, sugar content, toxicity, or environmental impact. “Unless you grow it yourself, you have only the access the food industry supplies to you.” The University of North Carolina estimates that 80% of the 600,000 food items for sale in the U.S. are laced with sugar. For the poor, the choices are restricted to what is available through WIC and SNAP, “nearly all of which are processed and loaded with sugar for reduced depreciation.”

It seems to be all about the money. Despite the economic downturn that began in 2008, food companies have consistently outperformed the depressed S&P. If the government were to intervene, it could receive a double payoff: The government currently pays $20 billion in corn and soy bean subsidies, and then it pays for Americans who visit emergency rooms with strokes, heart attacks, and diabetes. The Affordable Care Act is based on the premise that preventive health services will save in medical costs. “If we continue to subsidize corn, promote processed food, and espouse personal responsibility for obesity, there won’t be any prevention.”

Ultimately, we will have to choose between strict personal responsibility—“if you get sick, you pay or die”—or a public health movement that promotes some sort of societal intervention that can “tame this beast.” Societal interventions that focus on the food environment rather than on the individual would improve the health of everyone by regulating food nationally and changing food structure and availability. But they would have to garner acceptance by the general population, and they might challenge the electability of politicians. Such movements must be feasible; the pushback from a powerful industry would be tough on an addicted populace. And, of course, the cost would likely be prohibitive.

21.     THE ROLE OF GOVERNMENT

“Our nutritional crisis is the long-term result of the Farm Bill,” originally passed during the Great Depression and the Dust Bowl to save family farms and feed a destitute population. We needed cheap calories that we could store and transport without fear of spoilage. Therefore the bill subsidized all forms of storable carbohydrates, producing a glut of high-glucose foods. Eventually we had to find new ways to use the excess or simply eat more of them. The Bill is “antiquated, unneeded… and… rewards the richest ten percent of farmers.” Still, messing with the Farm Bill, after all these years, can be political suicide.

As reported in Apples to Twinkies: Comparing Federal Subsidies of Fresh Produce and Junk Food, over a five-year period the government allocated $16.9 billion for corn and soy syrups and oils and just $262 million for apples. “At the individual level, that’s $7.36 per year for junk food (worth nineteen Twinkies) and $0.11 per year for apples (worth a quarter of one apple).”

Two-thirds of the Farm Bill is used for nutrition programs such as WIC, SNAP, and the National School Lunch Program. For all these programs, the goal is to use the excess subsidized food to provide cheap nutrition. 

After the FDA designates a food additive as “generally regarded as safe” (GRAS), food manufacturers may add it to food with abandon. In 1958 sugar won GRAS status; in 1983 high fructose corn syrup (HFCS) was rated GRAS. An FDA-commissioned report to support the 1983 decision used data based on the 1980s, when Americans each consumed, on average, 40 pounds of sugar per year. Now we each consume, on average, 130 pounds of sugar per year! And the authors were focused on obesity, not metabolic syndrome. As we know, fructose doesn’t cause obesity; “it turns obesity into metabolic syndrome.” But the FDA upheld its decision in 1996 and again in 2004.

Sugar tariffs are another important part of the government’s role in food manufacturing. Sugar is produced in 18 states and contributes $10 billion annually to our economy. Tariffs keep U.S. sugar prices among the highest in the world—$0.20 more per pound than the rest of the world pays. And yet we consume more sugar than any other country. One reason is our addiction; the other is our cheap alternative to sucrose, HFCS.

American consumers spend about $1 trillion each year on food, contributing nearly 10% of the gross domestic product. Six percent of our exports are food-related, for another $56 billion. And the food industry employs more than 16 million Americans. It’s a hard argument to bring to the federal government! 

By the early 1990s, twenty-three countries had identified sugar as a major contributor to chronic disease. When a 2002 WHO and FAO report (TRS 916) called for limiting added sugar to less than ten percent of the total calories in the diet, a special assistant to the Department of Health and Human Services (HHS) wrote a scathing reply, “rejecting years of research and denying any evidence of a link between junk food and obesity.” Then HHS Secretary Tommy Thompson threatened to withhold the $406 million we annually contribute to WHO, and TRS 916 never saw the light of day.

The more than 20 million American children who eat their lunches care of the National School Lunch Program have “an increased prevalence of obesity, even after race and poverty are factored in.” In 2010, schools were made to limit saturated fat, sodium, calories, and trans fats in these school lunches, with no mention of sugar. In 1983 President Reagan declared that ketchup is a vegetable, and in 2011, told that an eighth-cup of tomato paste is nutritionally equivalent to an eighth-cup of vegetables, Congress declared that pizza is a vegetable.

When McDonald’s was besieged by lawsuits for causing obesity through its fast-food menu, Rep. Jim Sensenbrenner of Wisconsin warned, “Don’t run off and file a lawsuit if you’re fat.” The House of Representatives passed the bill, dubbed the “Cheeseburger Bill,” officially declaring that it’s not the place of the law to protect you from your own excesses.

How useful is the 1990 FDA Nutrition Labeling and Education Act? Currently labels tell us what is in the foodstuff inside the package, but not what has been added to or subtracted from the original food. What if we understood whether the sugar occurs naturally or has been added? Whether the fiber removed is significantly more that the fiber that remains? What if the label told us how much of the sodium occurred naturally and how much had been added? Might we make better choices?

By the way, who put the US Department of Agriculture in charge or our diet? In 2003, in comments printed in the Chicago Tribune, Illinois Representative Peter Fitzgerald remarked, “The primary mission of the USDA is, after all, to promote the sale of agricultural products… So putting the USDA in charge of dietary advice is in some respects like putting the fox in charge of the henhouse.”

It is quite believable that the legislature won’t act because it’s being paid off by the food industry. And the executive branch won’t act because it fears political repercussions. The judicial branch of government has been, to date, blessedly neutral. But what of the taxpayers? Do they still believe “a calorie is a calorie,” or do they really believe in personal responsibility for food choices? Or are they just addicted to sugar? “The bottom has to fall out. And then it’s time for societal rehab. We’re just about there.”

22.     A CALL FOR GLOBAL SUGAR REDUCTION

“The world is dying. Not of the plague, not of influenza, not of Ebola, not of AIDS. Noncommunicable disease (i.e. heart disease, diabetes, cancer, dementia—in other words, the metabolic syndrome) is now a greater threat to the developed and developing world than is infectious disease. This is quite a paradigm shift. The reality is that every country that has adopted the Western diet (now the industrial global diet) has witnessed rising rates of obesity and metabolic syndrome.”

The world has dealt with alcohol and tobacco, but, unlike those two substances, we need food. “In 2003 a landmark book called Alcohol: No Ordinary Commodity laid out the four criteria that the public health community established to justify the regulation of a substance: unavoidability, toxicity, abuse, and costs to society. Alcohol and tobacco easily meet these criteria. But what about sugar?”

Sugar is now unavoidable worldwide, the most ubiquitous foodstuff in the world. It has been added to 80% of the world’s food supply.  Every condition of metabolic syndrome is driven by fructose—it’s toxic enough to actively promote dementia, diabetes, hypertension, accelerated aging, high triglycerides, and insulin resistance. And, because sugar acts on our reward center, we get hooked at an early age and find it harder and harder to kick the habit over time; we abuse sugar. The cost to society? An extra $274 million in jet fuel because airline passengers have become obese. A sinking boat because, although the passenger limit of 48 people was maintained, the average person on board was 25% heavier than the 140 pounds anticipated when the regulation was set. High-ranking military officials have declared a threat to national security because 27% of military applicants are now rejected for obesity-related reasons. There is a cost to society.

Will information and education do the trick? “You can’t change behavior with information alone, especially when you’re talking about addictive substances… Because the biochemical drive will eventually overcome any cognitive attempt to control it. Nope, it’s going to be all about changing the environment, and that means changing availability.”

A 2007 study noted that the average American child sees 30,000 TV commercials each year. During Saturday morning cartoons, a food commercial is aired, on average, every five minutes. When 52 European health ministers met in 2007 to agree to ban the marketing of junk food to children, the U.S. Federal Trade Commission remained mute. It was public outcry that stopped cigarette ads from blatantly targeting children. Today, metabolic syndrome has eclipsed lung cancer as a cause of death. Where is the public outcry?

When San Francisco banned the inclusion of a toy with fast food meals, three states hurried to ban “toy bans.” What will it take? To reduce sugar consumption, we need to limit the upstream supply, because, downstream, demand won’t decrease. Governments limit substance supply by taxation, restriction, and interdiction. Restriction and interdiction didn’t work for alcohol; perhaps taxation is our best remedy. 

“Taxation is a simple and effective, if unpopular, way of reducing consumption of virtually anything.” Worldwide alcohol consumption and alcohol-related harm have fallen dramatically due to taxation. Could we tax sugar to help solve the obesity epidemic? “Want to stop a dialogue in the United States? Utter the phrase ‘soda tax.’” Sugar-sweetened beverages (SSBs) are not the sole cause of the epidemic, but they might be the most promising target. SSBs are a clearly defined category, contribute more calories to the diet than any other single type of food or drink, and have a more clearly marked association with obesity than any other foodstuff. And elevated pricing could make a difference. When a hospital cafeteria increased the price of soda by 35%, they saw a 26% reduction in consumption. But the soda tax remains unpopular. It could work in the public health interests if:

a)    The substance being taxed disproportionately affects the poor. The negative impact of metabolic disease driven by SSBs clearly has the greatest impact on lower-income minorities. 

b)    Proceeds from the tax could be diverted back to lower income neighborhoods to make healthful products accessible.

c)     The tax would be high enough to actually reduce consumption. It is estimated the cost of a soda might have to double to have that impact, despite the example above regarding the hospital cafeteria.

Access to a harmful substance can be accomplished in other ways too. Society could “tighten licensing requirements on vending machines and snack bars that sell sugary products in schools and workplaces… States could apply zoning ordinances to control the number of fast food outlets and convenience stores in low-income communities, and especially around schools.” Efforts could be made to inconvenience the food trucks that gather around schools, and sale of soda could be limited during times that school children are most likely to purchase, such as on their way to and from school. Society could even impose an age limit on the purchase of soda!

“Crop subsidies account for $6 billion per year; of that, $3.5 billion goes to corn… Over the five years from 2006 to 2011, the price of corn has never been higher yet the corn subsidy continues unabated.” If the subsidies ceased and the price of corn (and HFCS) rose dramatically, the government and the poor would ultimately save in medical costs and improved worker productivity. Then there is the possibility of simply imposing an excise tax on the industry, although there is a question as to whether that would alter its business practices.

Interestingly, when crop prices fall, agricultural producers do not respond by reducing the amount of crop. Since the New Deal, they have been paid not to grow certain crops to prevent overproduction. If the U.S. stopped all commodity protection and subsidies, the one food that would be affected would be sugar. With the corn subsidy gone, sugar production would fall by 33%; removing sugar tariffs would cause the price of sugar to fall by 15%. Still, standard economic principles do not apply to an addictive substance: We consume more even at a high price because of sugar’s addictive potential.

“There’s only one answer that the farmers, the food industry, and the populace can live with: differential subsidization. Instead of subsidizing corn and soy (commodity crops that are storable), why can’t we subsidize something green?” That would mean growing local, of course, because green food cannot be easily stored and shipped. “With enough public clamor, tectonic shifts in policy do become possible. Take, for instance, bans on smoking in public, the use of designated drivers, airbags in cars, and condom dispensers in public bathrooms. All unfathomable thirty years ago.”

23.     IT MUST BE A BOTTOM-UP MOVEMENT

While good health dictates that we should eat 1800–2000 calories per day, the American food industry produces 3900 calories per person per day, with about 29% wastage. We simply consume the difference! Our high-sugar, low-fiber diet actually makes us hungrier. For the first time in human history, man is actually able to eat more than a fixed amount. Yet the Farm Bill continues to subsidize the crops that are killing us, and our own government continues to promote our unhealthy diet. “You can’t expect government to do the right thing. You have to coerce it into doing the right thing… A good example is seat belts… It wasn’t until Mothers Against Drunk Driving made such a stink in every statehouse that mandatory seat belt laws started appearing from 1984 through 1993… Public outcry is a powerful force for change.”

In California, the Wellness City Challenge has mobilized the Mayor’s Office, the Chamber of Commerce, the Board of Education, hospitals, the Restaurant Association, supermarkets, and a giant food procurement company to focus on one common goal for one year: Retool every public food venue in two cities (Martinez and Concord) for one year. That means vending machines now sell apples and oranges instead of sugary snacks. And high school students are learning to cook real food—and serve it to their teachers! Amazingly, the kids are now asking for real food too.

The science of obesity is dispassionate. Solving the problem will require public passion and outcry.