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Food Literacy For All Presentation

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Michigan State University February 2020

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Food Literacy For All Presentation

  1. 1. Corporate Wealth or Public Health? Robert H. Lustig, M.D., M.S.L. Division of Endocrinology, Department of Pediatrics Institute for Health Policy Studies University of California, San Francisco Adjunct Faculty, UC Hastings College of the Law Adjunct Faculty, Touro University—California Chief Science Officer, Eat REAL Food Literacy for All, U. Michigan, February 4, 2020
  2. 2. Disclosures
  3. 3. If a researcher isn’t willing to follow his data into the policy arena, who will? — Dr. Jeremiah Stamler, “Father” of Cardiovascular Epidemiology The reason I am here today
  4. 4. Agenda • 1. The problem • 2. The three myths • 3. The dark forces • 4. The solutions
  5. 5. 1. The Problem
  6. 6. T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 PROJECTED Projected annualized inflation rate 3.88%
  7. 7. T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 285 MILLION IN 2010 Actual annualized inflation rate 6.55%
  8. 8. T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 422 MILLION IN 2014 Actual annualized inflation rate 10.30%
  9. 9. T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 WTF?? 422 MILLION IN 2014
  10. 10. Over the past 40 years, we’ve traded one disease for another Heart disease Diabetes Khasan, The Atlantic, Dec. 2016
  11. 11. The money is not going to hospitals, physicians, or Big Pharma
  12. 12. The money is not going to hospitals, physicians, or Big Pharma It’s going to chronic metabolic disease
  13. 13. Two inconvenient truths
  14. 14. Two inconvenient truths • There is no rational medical therapy to prevent chronic metabolic disease • There’s just long-term treatment
  15. 15. Two inconvenient truths • There is no rational medical therapy to prevent chronic metabolic disease • There’s just long-term treatment • You can’t fix healthcare until you fix health • You can’t fix health until you fix the diet • And you can’t fix the diet until you know what is wrong
  16. 16. 2. The three myths
  17. 17. Myth #1 It’s about obesity
  18. 18. 1. Which predicts metabolic syndrome best? a.Total body fat b.Subcutaneous fat c. Visceral fat d.Liver fat e.Brain fat
  19. 19. 1. Which predicts metabolic syndrome best? a.Total body fat b.Subcutaneous fat c. Visceral fat d.Liver fat e.Brain fat
  20. 20. Obesity is the problem (?) Basu et al. PLoS One 8:e58783, 2013
  21. 21. Obesity is the problem (?) Basu et al. PLoS One 8:e58783, 2013
  22. 22. Obesity is the problem (?) Basu et al. PLoS One 8:e58783, 2013
  23. 23. Obesity is the problem (?) Basu et al. PLoS One 8:e58783, 2013
  24. 24. Obesity is the problem (?) • Obesity is increasing worldwide by 2.78% per year 1975-2015 Lancet Oct 10, 2017 http://dx.doi.org/10.1016/S0140-6736(14)60460-8 • Diabetes is increasing worldwide by 4.07% per year • 1980-2014 Lancet Apr 6, 2016 • http://dx.doi.org/10.1016/S0140-6736(16)00618-8
  25. 25. JAMA 314:1021, 2015, doi:10.1001/jama.2015.10029 Secular trend in diabetes among U.S. adults, 1988-2012
  26. 26. Secular trend in diabetes among U.S. adults, 1988-2012 25% increase in obese JAMA 314:1021, 2015, doi:10.1001/jama.2015.10029
  27. 27. Secular trend in diabetes among U.S. adults, 1988-2012 25% increase in obese 25% increase in nl wt JAMA 314:1021, 2015, doi:10.1001/jama.2015.10029
  28. 28. Obesity is not the problem People don’t die of obesity
  29. 29. Obesity is not the problem People don’t die of obesity Metabolic Syndrome: where all the money goes (75% of all healthcare dollars)
  30. 30. Obesity is not the problem People don’t die of obesity Metabolic Syndrome: where all the money goes (75% of all healthcare dollars) Diabetes Hypertension Lipid abnormalities Cardiovascular disease Non-alcoholic fatty liver disease Polycystic ovarian disease Cancer Dementia
  31. 31. “Exclusive” view of obesity and metabolic dysfunction Obese (30%) Normal weight (70%) 240 million adults in U.S. 72 million 168 million
  32. 32. Obese (30%) Obese and sick (80% of 30%) Normal weight (70%) 240 million adults in U.S. 72 million 168 million Total: 57 million sick “Exclusive” view of obesity and metabolic dysfunction
  33. 33. Obese (30%) Normal weight (70%) 240 million adults in U.S. 72 million 168 million “Inclusive” view of obesity and metabolic dysfunction
  34. 34. Obese (30%) Normal weight (70%) 240 million adults in U.S. Normal weight, Metabolic dysfunction (40% of 70%) Obese and sick (80% of 30%) 57 million 67 million Total: 124 million sick 72 million 168 million “Inclusive” view of obesity and metabolic dysfunction
  35. 35. Relation between visceral and subcutaneous obesity TOFI (thin on the outside, fat on the inside) Thomas et al. Obesity doi: 10.1038/oby.2011.142, 2011
  36. 36. Histology of (N)AFLD Normal (N)AFLD
  37. 37. NAFLD is a worldwide problem, even in normal weight people
  38. 38. Loomis et al. J Clin Endocrinol Metab. 101:945, 2016 Obese Normal Weight Obese Over Weight Normal Weight Over Weight NAFLD is associated with diabetes, even in normal weight people
  39. 39. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6%
  40. 40. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6%
  41. 41. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24%
  42. 42. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24%
  43. 43. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24% Thin High Liver Fat = 23%
  44. 44. MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24% Thin High Liver Fat = 23%
  45. 45. 48 The key to the kingdom: It’s not about obesity (the fat you can see); It’s about metabolic dysfunction (the fat you can’t see); of which obesity is a result, not a cause
  46. 46. Myth #2 A calorie is a calorie
  47. 47. 2. Fructose increases liver fat by: a.increasing obesity b.increasing visceral fat c. by increasing de novo lipogenesis d.by reducing exercise e.by making the brain think it’s starved
  48. 48. 2. Fructose increases liver fat by: a.increasing obesity b.increasing visceral fat c. by increasing de novo lipogenesis d.by reducing exercise e.by making the brain think it’s starved
  49. 49. The Fiction “Beating obesity will take action by all of us, based on one simple common sense fact: All calories count, no matter where they come from, including Coca-Cola and everything else with calories…” -The Coca Cola Company, “Coming Together”, 2013
  50. 50. • Some Calories Cause Disease More than Others • Different Calories are Metabolized Differently • A Calorie is Not A Calorie – Fiber – Protein – Fat – Fructose The Science
  51. 51. 150 125 100 75 50 25 0 Growth of Sugar Industry Stabilization HFCS + Sugar for Fat WWII U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010 http://ushealthcarespending.gov PROCESSED FOOD
  52. 52. (20%) (80%)
  53. 53. (80%)
  54. 54. (100%)
  55. 55. Sugar is toxic unrelated to calories Lustig et al. Obesity 24:453, 2016 Schwarz et al. Gastroenterology 153:743, 2017 Gugliucci et al. Atherosclerosis 253:171, 2016
  56. 56. Ac CoA* Malonyl CoA Glycerol-P Fatty Acid* TG* De novo Lipogenesis DNL VLDL* Schwarz et al. Gastroenterology 133:742, 2017
  57. 57. Ac CoA* Malonyl CoA Glycerol-P Fatty Acid* TG* De novo Lipogenesis DNL VLDL* LIVER FAT DNL VLDL* 9 days fructose restriction Visceral fat Schwarz et al. Gastroenterology 133:742, 2017
  58. 58. Ac CoA* Malonyl CoA Glycerol-P Fatty Acid* TG* De novo Lipogenesis DNL VLDL* Improved Insulin kinetics LIVER FAT DNL VLDL* 9 days fructose restriction Visceral fat Schwarz et al. Gastroenterology 133:742, 2017
  59. 59. 62 Independent Confirmation
  60. 60. Fructose reduces liver mitochondrial function, while glucose stimulates it Softic et al. Cell Metab 30:735, Oct 1, 2019 "The most important takeaway of this study is that high fructose in the diet is bad," says Dr. Kahn. "It's not bad because it's more calories, but because it has effects on liver metabolism to make it worse at burning fat. As a result, adding fructose to the diet makes the liver store more fat, and this is bad for the liver and bad for whole body metabolism." Dr. C. Ronald Kahn, CEO, Joslin Diabetes Center
  61. 61. Sugar and disease • Causation – Diabetes – Heart Disease – Fatty Liver Disease – Tooth Decay • Correlation – Cancer – Dementia
  62. 62. The American Heart Association knows Circulation 120:1011, 2009 Recommends reduction in sugar intake from 22 tsp/day to 9 tsp/day (males) and 6 tsp/day (females)
  63. 63. Myth #3 It’s about personal responsibility
  64. 64. 3. Who invented personal responsibility? a. The British b. The French c. The founding fathers d. The Supreme Court e. The tobacco industry
  65. 65. 3. Who invented personal responsibility? a. The British b. The French c. The founding fathers d. The Supreme Court e. The tobacco industry
  66. 66. Personal responsibility is an ideology
  67. 67. Knowledge Personal responsibility is an ideology
  68. 68. 56 names for sugar Agave nectar Barbados sugar Barley malt Beet sugar Blackstrap molasses Brown sugar Buttered syrup Cane juice crystals Cane sugar Caramel Carob syrup Castor sugar Confectioner’s sugar Corn syrup Corn syrup solids Crystalline fructose Date sugar Demerara sugar Dextran Dextrose Diastatic malt Diatase Ethyl maltol Evaporated cane juice Florida crystals Fructose Fruit juice Fruit juice concentrate Galactose Glucose Glucose solids Golden sugar Golden syrup Grape sugar High-fructose corn syrup Honey Icing sugar Invert sugar Lactose Malt syrup Maltodextrin Maltose Maple syrup Molasses Muscovado Organic raw sugar Panocha Raw sugar Refiner’s syrup Rice syrup Sorghum syrup Sucrose Sugar Treacle Turbinado sugar Yellow sugar
  69. 69. Why don’t they list “added sugars”? Why is there no Dietary Reference Intake?
  70. 70. Knowledge Access Personal responsibility is an ideology
  71. 71. Knowledge Access Affordability Personal responsibility is an ideology
  72. 72. Personal responsibility is an ideology Knowledge Access Affordability Don’t hurt anyone else
  73. 73. Old medicine: infections microbes New medicine: chronic multinational disease corporations Lancet 381:670, 2013
  74. 74. 150 125 100 75 50 25 0 Growth of Sugar Industry Stabilization HFCS + Sugar for Fat WWII versus US health care spending (% GDP) U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010 http://ushealthcarespending.gov PROCESSED FOOD
  75. 75. 150 125 100 75 50 25 0 Growth of Sugar Industry Stabilization HFCS + Sugar for Fat WWII versus US health care spending (% GDP) U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010 http://ushealthcarespending.gov PROCESSED FOOD
  76. 76. Morgan Stanley Report, The Bitter Aftertaste of Sugar, March, 2015
  77. 77. PROCESSED FOOD
  78. 78. Kearns et al. PLoS Biol 15:e2003460, 2017
  79. 79. 3. The Dark Forces
  80. 80. Ten conglomerates
  81. 81. Methods used by the DARK FORCES • Shoddy science
  82. 82. World Sugar Research Organization critique of WHO proposal to reduce sugar to 5% of total calories June 9, 2014 • 3.1: Sugar is less energy dense than fat; 4 kcal/gm vs. 9 kcal/gm • In a cookie, the sugar is not displacing the fat; it’s displacing the water 1/3 fat 1/3 CHO 1/3 water 39 cal 1/3 fat 1/3 CHO 1/3 sugar 51 cal 9 gram cookie http://www.wsro.org/Portals/12/Docs/public/documents/News/FINAL%20WSRO%20Comments%20on%20Draft %20WHO%20Guideline%20on%20sugars.pdf -2 gm fat +13gm CHO + 34 cal “Snackwell”
  83. 83. The sugar industry says obesity and sugar consumption don’t correlate
  84. 84. Bentley et al. Econ Hum Biol 36:100818, 2020 Matrix of 46 calendar years vs. 75 life ages The sugar industry says obesity and sugar consumption don’t correlate Wisconsin
  85. 85. Bentley et al. Econ Hum Biol 36:100818, 2020 Matrix of 46 calendar years vs. 75 life ages Generational time lag: Obesity in year t at age y is calculated based on obesity in year t-1 at age y-1 Early excesses in sugar consumption in early childhood are compounded over the long term, and register years later as increasing obesity rates The sugar industry says obesity and sugar consumption don’t correlate Wisconsin
  86. 86. Bentley et al. Econ Hum Biol 36:100818, 2020 Matrix of 46 calendar years vs. 75 life ages Generational time lag: Obesity in year t at age y is calculated based on obesity in year t-1 at age y-1 Early excesses in sugar consumption in early childhood are compounded over the long term, and register years later as increasing obesity rates The sugar industry says obesity and sugar consumption don’t correlate time age Wisconsin
  87. 87. Bes-Rastrollo et al. PLoS Med 10(12): e1001578
  88. 88. Schillinger et al. Annals Int Med 165:895, 2016 Food Company Sponsorship Positive Association Negative Association RR; 95% CI; P Yes (n=26) 0 26 RR 34.0 No (n=34) 33 1 [4.9-234.5] P<0.001 60 studies (28 trials and 32 systematic reviews/meta-analyses)
  89. 89. Methods used by the DARK FORCES • Shoddy science • Buying scientists
  90. 90. • Frederick Stare, M.D., Ph.D.
  91. 91. Berger, The Present Illness, Harvard Medical Alumni Bulletin, Jan/Feb 1974
  92. 92. I would add one point which is that if you receive support from industry or the Corn Refiners sponsors the event, that cannot be taken as influence unless the speaker is a representative for that organization. The NIH is, in my view, extremely biased in what they fund but you have to assume that if the authors say that the funding agency is not involved than that's how it is. Otherwise, we have nothing. (Of course, if there is actually evidence of wrong-doing, there are agencies that you can take your case to). —Dr. Richard Feinman, SUNY Downstate, 2012
  93. 93. I would add one point which is that if you receive support from industry or the Corn Refiners sponsors the event, that cannot be taken as influence unless the speaker is a representative for that organization. The NIH is, in my view, extremely biased in what they fund but you have to assume that if the authors say that the funding agency is not involved than that's how it is. Otherwise, we have nothing. (Of course, if there is actually evidence of wrong-doing, there are agencies that you can take your case to). —Dr. Richard Feinman, SUNY Downstate, 2012
  94. 94. James Hill- U. Colorado Gregory Hand- U. West Virginia Stephen Blair-U. South Carolina
  95. 95. Ignores two studies which show proximate cause for sugar and diabetes EPIC-Interact, Diabetologia Apr 2013; Basu et al. PLoS One, Feb 2013
  96. 96. Serodio et al. Pub Health Nutr 2018 doi 10.1017/S136898001700307X The web of Coca-Cola funded research, 2008-2016
  97. 97. Hessari et al. Millbank Quarterly, 2019
  98. 98. It is difficult to get a man to understand something, when his salary depends on his not understanding it. — Upton Sinclair “I, Candidate for Governor: And How I Got Licked”, 1935
  99. 99. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics
  100. 100. Conflicts of Interest
  101. 101. October 17, 2009 American Academy of Pediatrics (Washington, DC) Welcome Reception Sponsored by Conflicts of Interest
  102. 102. Conflicts of Interest
  103. 103. Am J Prev Med epub Oct 10, 2016 Medical, Professional Government Industry Mouthpiece
  104. 104. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics • Weakening government oversight
  105. 105. Federal Trade Commission vs. Sugar Information, 1972
  106. 106. Federal Trade Commission vs. Sugar Information, 1972
  107. 107. The KidVid Debacle (1978-1981) • The Federal Trade Commission initiated the "KidVid" rulemaking in 1978, seeking to regulate TV advertising to children through either a ban on all kid-targeted ads or a requirement that ads for sugared food products be "balanced" with disclosures about health and nutrition. • This rulemaking ignited a political and regulatory firestorm. • The FTC ended the proceeding in 1981. • Congress enacted the FTC Improvements Act of 1980, which imposed important limits on the unfairness rulemaking authority of the commission, essentially “declawing” the agency.
  108. 108. • Istanbul, 2007: 52 European health ministers voted to cease marketing of junk foods to children • Los Angeles, 2007: Federal Communications Comissioner (FCC) Deborah Taylor-Tate: “I expect the food industry to police itself”. • Santa Clara and San Francisco, 2010: “Toy ban” on Happy Meals • Nationally, 2012 3 states passed “ban” on “toy bans”
  109. 109. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics • Weakening government oversight • Market saturation
  110. 110. Environmental Working Group, 2014 Of 1556 cereals, 88% had added sugar Of 181 children’s cereals, all had added sugar Not one of top 10 sugared cereals had lowered its sugar content between 2011 and 2014
  111. 111. Where’s the sugar? 1/3 in beverages 1/6 in desserts ½ hidden in foods that didn’t used to have sugar e.g. salad dressings yogurt tomato sauce, ketchup, condiments crackers, other carbohydrate products
  112. 112. They’ve even saturated medicine!
  113. 113. They’ve even saturated medicine! 28% of U.S. Children’s Hospitals have fast food venues. (Cafeteria in an American Children’s Hospital)
  114. 114. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics • Weakening government oversight • Market saturation • Astroturf groups
  115. 115. Citizens for Health • Non-profit • Funded by the Sugar Association to take down High- Fructose Corn Syrup • Exec. Director George Turner (special counsel to Senate Select Committee on Food, Nutrition, and Health and to the Senate Government Operations Subcommittee on Government Research)
  116. 116. • Government intervention in the market can only be justified if there is a market failure. • Annual sugar consumption in Britain peaked several decades ago. • There is insufficient scientific evidence to label sugar as addictive. • There is insufficient evidence to suggest that a calorie from sugar is more fattening than a calorie from other foods. • There is very little evidence of consumers being limited by choice in the food market. • Some food campaigners may be unhappy about the kinds of choices consumers are making. • Dietary information and sugar content is clearly marked on nearly all food products. • A ban on television advertising for foods that are high in fat, salt or sugar before 9pm would effectively be a form of censorship. • Limiting the availability of fast food outlets stifles competition. • Taxes on food and soft drinks have been shown to be ineffective in reducing obesity.
  117. 117. Similarly, in the United Kingdom, the Institute of Economic Affairs (IEA), an organisation that describes itself to be ‘the UK’s original free- market think-tank’, claims to be independent of any political party, group or organisation. But in 2016, Transparify – which provides ratings of financial transparency of major think tanks – gave a ‘highly opaque’zero score. Malhotra, Schofield, Lustig, JIR 2018
  118. 118. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics • Weakening government oversight • Market saturation • Astroturf groups • Marketing to children
  119. 119. Similarity to Tobacco
  120. 120. Food and SpongeBob Squarepants
  121. 121. M&M’s, Hot Wheels and NASCAR
  122. 122. Educational Toys
  123. 123. Soft Drink Logos on Baby Bottles
  124. 124. The birth of the “Un-Cola”
  125. 125. It’s a global marketing campaign…
  126. 126. …and the effect is global, too
  127. 127. Methods used by the DARK FORCES • Shoddy science • Buying scientists • Co-opting critics • Weakening government oversight • Market saturation • Astroturf groups • Marketing to children • Spyware and threats
  128. 128. 4. The solutions
  129. 129. The good news
  130. 130. Q: What Source of Calories is Most Likely to Cause Weight Gain? (n = 1009) 2011 2018 Sugars 11% 33% Carbs 9% 25% Fat 14% 16% Protein 2% 3% All the same 40% 17% Don’t know 24% 5%
  131. 131. Q: What Source of Calories is Most Likely to Cause Weight Gain? (n = 1009) 2011 2018 Sugars 11% 33% Carbs 9% 25% Fat 14% 16% Protein 2% 3% All the same 40% 17% Don’t know 24% 5% } 38% } 42%
  132. 132. Q: What Source of Calories is Most Likely to Cause Weight Gain? (n = 1009) 2011 2018 Sugars 11% 33% Carbs 9% 25% Fat 14% 16% Protein 2% 3% All the same 40% 17% Don’t know 24% 5% } 38% } 42% A: 1. More people know a calorie is NOT a calorie 2. Processed food is the problem
  133. 133. ADDED SUGARS. Mars supports the DGAC’s recommendation that consumers reduce their added sugars intake to no more than 10% of daily energy intake. Further, Mars supports labeling and educational approaches, including added sugars labeling and off-label nutrition education…. At Mars, we believe it is time for all stakeholders – including industry – to engage in a constructive discussion that focuses on effective approaches to helping consumers manage their intake of added sugars.
  134. 134. And now Coke has too!
  135. 135. Governments are slowly responding
  136. 136. We believe higher taxation on “sugary” food and drinks would be the best option to reduce sugar intake and help fund the fast- growing healthcare costs associated with diabetes type II and obesity.
  137. 137. Conflicts of Interest
  138. 138. Question 1: Can our “toxic environment” be changed without government/societal intervention? Especially when there are potentially addictive substances involved?
  139. 139. Question 2: Can we afford to wait to enact public health measures when healthcare will be bankrupt due to chronic metabolic disease?
  140. 140. Question 3: Can 6-month old obese babies change the medical profession? Or the food industry? Or Washington?
  141. 141. Advancing the public health • Public education about REAL FOOD • Business • Government agency action • Legal recourse
  142. 142. Conclusions This is a public health crisis, because it is an “exposure”, even in normal weight people Processed food is the exposure The food industry has adulterated our food supply for profit The industry has bought off scientists and co-opted critics Most of the checks and balances have been eroded Government has been complacent, and in some cases complicit Our best chances: public education, business, legal action
  143. 143. Proposal #1 UCSF Healthy Beverage Initiative
  144. 144. JAMA Internal Medicine, epub Oct 28, 2019
  145. 145. Proposal #2 Type 2 Diabetes should be renamed: PROCESSED FOOD DISEASE
  146. 146. Proposal #3 Rollback the subsidies for processed food: CORN WHEAT SOY SUGAR
  147. 147. Proposal #4
  148. 148. Proposal #4 Eat REAL The largest fast food restaurant chain in the United States is our public school system. Eat REAL is a nonprofit organization on a mission to fix this. Eat REAL empowers school district food service leaders to make improvements and inspires students, schools, parents, and communities in their real food journeys.
  149. 149. Proposal #5 Take Fructose off the GRAS list Currently under consideration by Center for Science in the Public Interest
  150. 150. Public Resources
  151. 151. SUGARSCIENCE.ORG Curated by UCSF
  152. 152. Office Infographics — at RobertLustig.com

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