all right so I recognize that you guys
are the choir and you know um you're not
the guys who need to be shall we say
turned or flipped you're already there I
get that but at the same time your job
is to flip everyone else and the only
way you can do that is with the science
so there is going to be a little bit of
science in this and I apologize for
those of you who are not biochemists or
physiologists or physicians but you know
I think it'll be pretty self-explanatory
what I've learned in my 40 years is that
the motto of UCSF is absolutely true
the motto is in god we trust' everyone
else has to produce the data so in order
for me to be able to do my job to train
the trainer's as it were I have to
produce the data so that's what you're
going to see today and you're gonna see
how the data ultimately impacts now I
will say that I as I've mentioned in my
comment I agree with everything that dr.
Keeley told you today about the
diagnosis but once you have seen the
data and once you've seen the politics
it is my hope that you will understand
why I have think that there is a shall
we say a different solution so that this
is an honest debate okay so first of all
I do have some disclosures I did write
these two books for the general public I
also am NOT the chief science officer of
a non-profit located here in the Bay
Area called eat real by the way real is
an acronym responsible epicurean and
agricultural leadership we basically
praise the good we offer a trust mark
like LEED certification or Fairtrade for
restaurants cafeterias hospitals school
districts that procure market and sell
real food
because real foods the answer processed
food is the enemy okay Hippocrates said
let thy food be thy medicine while
Hippocrates never met McDonald's
ultimately I would like you all to
change that model that that that
syllogism okay that is good food is
medicine bad food needs medicine aim
they are not the same and that goes for
breakfast too in addition I am also the
chief medical officer of a new
for-profit startup in San Francisco
called bio luminal a and
method for solving the obesity metabolic
syndrome diabetes heart disease pandemic
I'm not talking about any of that today
and none of it relates to any of the
work that I'm going to show you so the
reason that I am here today on this
slide
Jeremiah Stambler one of the fathers of
cardiovascular epidemiology famously
said if a researcher isn't willing to
follow his data into the policy arena
who will so that's a my job is to
translate the science into rational and
effective policy this is from the New
England Journal of Medicine a couple of
years ago and what it looks at is the
preventable causes of death in the
United States what you'll notice is
smoking down blood pressure down
cholesterol down physical activity up
even before CrossFit does a
collectivities up we should be reaping a
health benefit we are not we have
suffering from a health deficit because
obesity is up and diabetes is through
the roof and not just here in America
but in fact all over the world obesity
and diabetes are not the same I will
show you that in a few moments now
type-2 diabetes is increasing around the
world and you know that but I want to
show you the data this is a paper that
came out in 2001 and what it did was it
looked at the numbers of diabetics and
in the year 2000 151 million and it
projected that one decade later the year
2010 we would be at 221 million
that would be a 3.8 eight percent
annualized inflation rate however that's
not what we saw what we saw instead was
that there were two hundred and eighty
five million at 2010 for an annualized
inflation rate of six point five five
percent which is a doubling in the rate
of acceleration and in by the year 2014
we're up to four hundred and twenty two
million for an annualized inflation rate
of ten point three percent and this is
all while the obesity epidemic and all
the different things and CrossFit were
in fact doing its thing trying to fix
the problem it's only getting worse
w.t.f
okay I could make a very good case that
CrossFit causes diabetes of course
that's not true now if you look at the
health care costs this is modeling going
into the future and if you look at
hospital in red physician costs in green
and pharma costs and purple they do not
add up to the total costs because the
rest of it is going to the care and
treatment of chronic metabolic disease
which is breaking the bank of this
country and every other country point is
there are two inconvenient truths that
are not being addressed the first is
that there is no medicalised prevention
for chronic metabolic disease there are
treatments but those treatments are
treating the symptoms of the disease not
the disease itself so we have statins
for high LDL we have any you know any
hypertensive drugs for hypertension
we have oral hypoglycemic agents for
hyperglycemia but they are not treating
the underlying metabolic dysfunction
which we call metabolic syndrome and
this is a data that shows that in fact
lifestyle could make a difference in
terms of diabetes or metformin could the
problem and you can see the relative
risk assessment is below one meaning
they are protective but here's the
important number
number needed to treat 25 an NT of 25
you have to treat 25 people to prevent
one case we currently have a diabetes
rate of nine point four percent think
about how many people you have to treat
in order to get that number down it's
not possible can't be done
the second inconvenient truth is you
cannot fix healthcare until you fix else
you can't fix health until you fix diet
and you can't fix diet until you know
what the hell is wrong and we have
gotten it wrong and we've gotten it
wrong for very specific political
reasons as dr. Keeley elaborated to you
and I completely and totally espouse and
support that view in order to debunk
this problem we have to dispel the three
myths that surround chronic disease and
we do that with the science so the first
myth is it's about obesity you get sick
I saw you get fat you get sick and it's
the fat person's fault
and you'll see why that's a problem in a
minute so obesity is the problem so they
say is that true on the slide we have
obesity prevalence country-by-country on
the x-axis and diabetes prevalence
country-by-country on the y-axis you
would look at these data and you would
say well very clearly dr. Lustig there
is a correlation and indeed there is no
argument there is a correlation but
correlation is not the same thing as
concordance because there are countries
that are obese without being diabetic
such as Iceland Mongolia Micronesia
other countries that are diabetic
without being obese such as India
Pakistan and China India and China today
have a an 11 percent diabetes prevalence
and they're not fat we the fattest
nation on earth have a nine point four
percent diabetes prevalence if obesity
is the problem how come countries that
are less obese than us have more
diabetes than us problem number one
problem number two obesity is increasing
worldwide at the annualized annotation
rate of two point seven eight percent
per year yet diabetes is increasing
worldwide at the amortization rate of
four point zero seven percent per year
if diabetes is just a sub population of
the larger group of obese persons and
how could you explain that well you
can't because it ain't true number three
here are the second here's the secular
trend in new diabetes diagnosis for
going from 1988 to 2012 in the United
States on the left you see total and on
the right it's stratified by weight
category and you'll notice that there is
a 25% increase in incidence in diabetes
year by year amongst the obese but
there's also a 25% increase in the
normal weight population if obesity is
the cause of diabetes how come the
normal way people are getting diabetic
just as fast as the obese people makes
no sense the reason is because obesity
is not the problem people do not die of
obesity obesity isn't even included on
the death certificate what is included
on the death certificate are all the
diseases of metabolic syndrome the
metabolic dysfunction that attends
obesity but is actually separate from
obesity and this is the list and
diabetes of course being the Sentinel
disease the primary disease that has
just shot up like crazy yeah this is the
way you need to think about this problem
on this slide I have a Venn diagram of
the entire United States population 240
million 30% obese BMI over 30 70 %
normal weight BMI under 30 everybody got
it so everyone's in the in the world and
the country is in one of the two circles
and you know who you are in this room
you're all in the blue circle I got it
okay
except me
okay the standard mantra from the
doctors and the dietitians and the
Institute of Medicine and the National
Institutes of Health and the Surgeon
General and White House and Congress and
the food industry is the following 80%
of those obese people 80% of those 30%
those 72 million people that's re there
those 57 million people they're sick
they're fat and they're sick and they're
sick because they're fat and if we could
only just get them to diet and exercise
we could solve this problem that's what
they say
garbage total complete trash how come it
sounds right
I'll come it's on the slide it is true
that 80% of 30% are metabolically oh I
don't argue that that's true that means
20% of 30% or not they're metabolically
healthy we have a name for these people
they're called ma chose metabolically
healthy obese we study them to try to
figure out how come they didn't get sick
what's different about them that they
didn't get sick even though they're
obese conversely and there's the
important thing 40% of the normal weight
population have the exact same diseases
as did the obese normal weight people
get type-2 diabetes hypertension lipid
problems cardiovascular disease cancer
and dementia - but their normal weight
and if their normal weight that means it
can't be about obesity Kanon well if
it's just diet and exercise then how
come they have just they don't have as
much because it's 40% rather than 80% so
clearly obesity is a risk factor and I
don't argue that obesity is a risk
factor but it's not a cause because
normally people get it - and when you do
the math on 40% of 70% of 168 million
get 67 million there are more thin sick
people than there are fat sick people
calling them
problem and when you do the math on the
two of them together it's more than half
the u.s. population which is why
Medicare is going broke and will be
broke by the year 2026 not because of
the obese sick people but because of a
thin sick people and I'll prove it to
you on the side we have a CT scan
through the abdomen of two equally
weighted people notice drunk fat 12.8
equally weighted ones healthy ones sick
which ones sick air be a year a DME nope
bee bee bee a sick hey he's just got big
love handles something to hold on to
these got fat all around his organs okay
we have a name for this it's up on the
top tophi tof i said on the outside fat
on the inside real medical term 1500
MEDLINE citations coined by dr. Jimmy
Bell a neuro imager at University
College London so when you see a normal
weight person walk into your gym for the
first time the first question you should
ask is not is this person normal weight
is the question should be is this person
ain't OFI now you're not Toph ease
because you are the choir what's going
on in tophi is very interesting we now
know that it's not even the subcutaneous
or the belly fat it's the liver fat that
matters so on the Left we have normal
liver nice sinusoidal canaliculi and
cooked for cells and no macrophages just
normal liver and on the right you see
fatty liver disease okay fatty liver
disease you see the fat vacuoles you can
see the macrophages moving in the
lymphocytes and you start the seeing the
beginning of scarring the problem is you
don't know what the substrate is that
caused it prior to 1980 if you saw this
under a microscope
the alcohol no question about it
alcoholic fatty liver disease baffled
today its methyl non-alcoholic fatty
liver disease in fact non-alcoholic
fatty liver disease is now the leading
cause of liver transplant in the United
States having taken over from Hep C the
question is what's the substrate and
that's where I come in so it turns out
Nathalie is not just a u.s. problem it
is a worldwide problem even in normal
weight people because you can seen apple
prevalence in BMI less than 25 all
around the world and you can see on this
slide stratified by weight male versus
female on the left you'll notice that in
the overweight category there's plenty
of napple and on the right it's diabetes
versus no diabetes and you can see even
in normal weight people
there's nephal as well everybody see
that so this is not I mean yes
obesity makes it worse I'm not arguing
that obesity exacerbates it but it's
there
question is what's causing metabolic
dysfunction globally in everyone
irrespective of weight so here's how you
should look at this and this is you know
the visual if you will this is called an
MRI that fraction map okay lighter means
more fat okay so here's a metabolically
healthy obese person there's lots of
love handles but take a look at that
guy's delivered dark 2.6 percent fat
that's normal
metabolically healthy obese now this is
what you'd normally expect to see this
is metabolic syndrome
there's obesity and take a look at this
guy's liver 24% liver fat okay this
guy's got metabolic syndrome this guy's
got non-alcoholic fatty liver disease I
think a look at this guy
notice no love handles to take a look at
his liver 23 percent that guy's just as
sick as the guy in the middle so we've
got thin the sick on the right fat sick
in the middle fat healthy on the left
so it's not about obesity is it so the
key to the kingdom is it's not obesity
it never was
it's about metabolic dysfunction and
anyone can get it and obesity is not the
cause of the metabolic dysfunction it is
a result of the metabolic dysfunction so
you can have metabolic dysfunction with
or without obesity now when you think of
it that way then you have to ask the
question okay so what's causing the
metabolic dysfunction if it's not
obesity that's where myth number two
comes in because a calorie is not a
calorie despite what they tell you know
again the other choir you know that the
question is do you know why you know
that that's what we're gonna talk about
now is the science of how a calorie is
not a killer
so who watches football it's still
socially acceptable this year maybe not
next year we'll see this was in 2013 a
two-minute video that was played on
every single football telecast in the
entire country every single week
sponsored by coca-cola called coming
together you can still watch it on
YouTube don't do it now but this is a
direct quote from it said 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 so
according to them huge calories from
carrots being huge calorie is from
Cheesecake engage calories from
coca-cola where you get your calories
from kumquats
doesn't matter if you eat more than you
burn you will gain weight if you eat
less than you burn you a lose weight
therefore it's about energy balance
therefore it's about calories in
calories out therefore it's about two
behaviors gluttony and sloth therefore
if you're fat it's your fault
therefore diet and exercise therefore
any calorie can be part of a balanced
diet therefore don't pick on our
calories go pick on
else's calories all that comes from this
simple common-sense fact that all
calories count because a calorie is a
calorie that you just total up the
calories well I don't believe in common
sense I believe in science I believe in
data right show me the data because the
science says something completely
different what it says is that some
calories are metabolized differently
than others
because different calories have
different metabolic pathways in the body
which do different things and can cause
different diseases because a calorie is
not a calorie and I can prove it to you
so who here likes almonds almonds are
okay right there paleo yeah okay you eat
a hundred and sixty calories in almonds
how many of those calories do you absorb
you absorb 130 so not not much it's
actually the majority but it's still not
the whole yeah 8 160 absorbed 130 how
come the soluble and insoluble fiber in
the almonds and you need both not
either/or you need both and that's what
real food has is both soluble and
insoluble fiber together form a gel on
the inside of the duodenum a whitish gel
you can see it on electron microscopy
and what it does is it sets up a
secondary barrier that prevents early
absorption of mono and disaccharides and
probably some fatty acids straight from
the duodenum into the portal vein so
that it doesn't go straight to the liver
keeping your liver healthy that liver
fat you saw is from the liver having to
deal with the tsunami of of processed
carbohydrate refined carbohydrate and
particularly sugar and we'll show you
why in a minute well what happens if you
don't absorb them in the duodenum well
they go further down the intestine to
the jejunum and what's in the jejunum
that's not in the duodenum the
microbiome the bacteria now you have 10
trillion cells in your body but you have
a hundred trillion bacteria in your
intestine they outnumber you tend to one
you are just a big bag of bacteria with
legs well they gotta live well what do
they eat well they eat what you eat the
question is how much did you get
versus how much did they get and if you
supply them with a greater percentage of
what you ate because you didn't absorb
it early that means they get a
free-for-all so you are feeding your
bacteria you are protecting your liver
and feeding your gut all at the same
time so even though you ate it you
didn't get it so the fact that you ate
160 calories and almonds is irrelevant
it matter how many calories you absorbed
and to be honest with you it doesn't
even matter how many calories you
absorbed because depends on what those
calories were and that's where the other
two come in protein
so protein is made up of amino acids
amino acids build muscle but amino acids
can also be burned for energy if you're
not building muscle so turns out in
order to take the amino group off an
amino acid so that you turn it into an
organic acid so it can enter the
metabolic pathways for energy metabolism
it costs twice as much energy to take
that amino group off as it does to
phosphorylate a carbohydrate to brender
it susceptible to that same metabolic
energy pathway in other words there is a
net deficit of energy in turning amino
acids into energy then there is
carbohydrate into energy getting the
same numbers of ATP out but you had to
invest a couple of ATP in so calorie is
not a calorie because if it came from
protein it is less efficient number
three fat so we have over here Omega
threes heart-healthy anti-inflammatory
save your life over here we got trans
fats consumable poison okay without
question it will kill you they're both 9
calories per gram one will save your
life one will kill you physic calories
not a calorie and finally the big one
the one I've worked on most of my career
fructose versus glucose now doctor
Keeley will recognize this statement
since it was his
okay putting nutrition claims to the
test and he said if the sugar hypothesis
is correct it will stand the testing if
not it deserves to be rejected
so dr. Keely I'm going to ask you at the
end of this portion if you will accept
or reject the hypothesis so on this
slide we have what's happened to our
sugar consumption from four pounds per
year 200 years ago our ancestors getting
fruits and vegetables out of the ground
up to now 100 pounds of sugar per year
per person in the United States it was
actually higher than that went up to 120
pounds it's come down because the
obesity epidemic but you'll notice this
is the growth of the sugar industry in
the eighth and the 1800s with you know
Texas and Louisiana Hawaii CNH and
Domino etcetera and we got stabilization
the before World War two and cost
equaled demand price equals supply and
then finally we have some World War two
rationing as you can see there and then
it came back up to the same level and
then we got two things number one we had
the advent of processed food actually
three things processed food which is low
situated there number two we had high
fructose corn syrup which was cheaper
not worse just cheaper than sucrose
because it was a homegrown
and also the dietary guidelines which
said to eat less fat it also said eat
less sugar but when you take the fat out
of food it tastes like crap they ended
up adding sugar even though they were
supposed to say we if they said we
should eat less because otherwise
there'll be nothing to eat okay
everybody got that so there was this
huge increase yet again now here and
simple diagram is what the liver does to
a molecule of glucose what it ends up
with is that most of the glucose ends up
being metabolized elsewhere 20% of it
will hit the liver and most of it ends
up going to glycogen liver starch which
for lack of a better word
is safe metabolically inert in terms of
disease okay because we have kids with
glycogen storage disease type 1a
come on gear keys disease that I have to
take care of as an endocrinologist
they got livers down to their knees
they're hypoglycemic like all get out
but they don't get liver failure because
glycogen is a non-toxic storage form of
glucose and the liver
that's why marathoners carb load before
marathons whether they should or not is
not the issue
now I've likened sugar to alcohol you'll
notice that if you consume alcohol most
of it not 20% but 80% ends up in the
liver and you'll notice it doesn't go to
glycogen comes down here to mitochondria
via acetate mitochondria have to process
it but you overwhelm the mitochondria
the rest of it gets thrown off as
something called citrate exits the
mitochondria through a process known as
the citrate shuttle and then acts as a
substrate for these three enzymes a CL a
CC and FAS ATP citrate lyase stl
carboxylase one fatty acid synthase this
is how you turn carbohydrate into fat a
process called de novo lipogenesis new
fat making this is how alcohol gets
turned to fat and while you get fatty
liver with alcohol consumption everybody
with me
now take a look at fructose the sweet
molecule in sugar hey you see a lot of
arrows don't you okay arrows are not
good okay so even if you don't
understand the biochemistry just count
the arrows
what you'll notice is you don't go to
glycogen either comes down to the
mitochondria does the exact same thing
as alcohol plus a few extra tricks as
well and we've actually discovered a new
trick which I'm going to show you in
just a minute
bottom line is all the diseases of
metabolic syndrome hyperglycemia hepatic
insulin resistance hypertension muscle
insulin resistance to slip anemia
obesity and also leptin resistance which
makes your brain think you're starving
so you end up eating more all come from
how the liver processes this
one molecule now there's a lot of data I
could show you about prospective
correlation and econometrics analysis I
don't have time because I got other
stuff to show you but I'm gonna just
mention the three papers that we've put
out so far from a study that we
performed on inner-city Latino and
African American kids with metabolic
syndrome
we called the study Sucre su CRE which
stands for sugar comorbidities race and
ethnicity but really it was because my
colleague jean-marc Schwartz from
Switzerland Kosuke is sugar and French
okay what we did in a cartoon is we took
43 kids with metabolic syndrome and we
took the sugar added sugar out of their
diet for ten days okay we figured out
what they were eating at baseline we
studied them at baseline and then we
reduced their consumption of added sugar
from 28% of calories to 10% of calories
we gave them fruit but nothing else
we kept their fat content the same their
protein content the same their fiber
content the same and their total
carbohydrate content the same but we
took the added sugar out now if you take
the added sugar out of a kid's diet
you're reducing their caloric intake by
350 to 400 calories a day in which case
after 10 days they might lose weight
because you are starving them well we
didn't want them to lose weight we
wanted us dead them to stay the same
weight so we had to replace the 350 to
400 calories that we were taking out
with something else that was equivalent
we gave them refined starch we did a
starch for sugar exchange we did a
glucose for fructose exchange in the
vernacular we took the pastries out we
put the bagels in we took the sweetened
yogurt out we put the baked potato chips
in we took the chicken teriyaki out we
put the turkey hotdogs in everybody got
it
so we can give them good food we gave
him crappy food okay we gave him
processed food we gave him kids
we bought it at Safeway okay we didn't
go by you know the the the gourmet stuff
okay
we bought the crap we gave him ruffles
okay got it we didn't give him good food
we get me but it was no added sugar food
and we gave him a scale and every day we
tell him well call him up in the phone
would you weigh and if they were losing
weight eat more to keep their way
constant over the 10 days and then we
studied him again so a baseline they had
lots of fat in their liver high
triglycerides high VLDL and crappy
insulin kinetics nine days of fructose
restriction isocaloric fructose
restriction take the sugar out with the
starch in okay and the liver fat went
down 22%
the dnl got cut in half the VLDL fell by
46% and most importantly the enzyme
kinetics went back to normal
we reversed their metabolic syndrome
without any change in calories and
without any change in weight because we
got rid of the sugar and we now have
independent confirmation from another
lab in fact from new C which you heard
about earlier today we're a study that
came out in JAMA from Jeff Schwimmer and
Miriam Voss from UCSD and Emory that
basically did the exact same thing in a
slightly different way but basically did
the same thing and got the same answer
so we have now validation of this and
they had an external control group we
had several internal controls they had
an external control and now we have even
more data and you are the own the first
people to see these new data because we
just got the paper accepted yesterday so
I'm very excited to show it to you so
the reason that the liver makes fat is
because it diverts carbon fragments
away from being oxidized and the enzyme
in the cell that does that is called MP
kinase MP kinase takes information about
the energies sufficiency or deficiency
within the cell and that determines
whether or not more has to be burned or
whether it should go to storage
ambi kinase is the switch the fat switch
in the cell and it's controlled by these
things that are relevant to how we take
care of patients here's what a MP kinase
does when it's working
you get glycolysis that is burning beta
oxidation that is mitochondrial function
nitric oxide synthesis mitochondrial
biogenesis so you make more mitochondria
to burn more energy which is good you
get more glucose uptake to keep your
blood sugar normal and you also get a
toffee G which keeps your cells healthy
by clearing all the crap up so that's
the good stuff
right and it's doing all those things at
the same time it's inhibiting all these
other things
it's inhibiting protein synthesis
through the mTOR pathway it's inhibiting
gluconeogenesis so you're not putting
out more glucose into the bloodstream
it's inhibiting cholesterol synthesis
and it's inhibiting that de novo
lipogenesis so basically it's making you
burn your energy to completion is what
iymp kinase does so if you take a mouse
and you give it a gain-of-function ampie
kinase okay so they amp you guys that's
always turned on you get a liver that
can't get fat it's unfathomable
cause that ampie kinase is working
overtime all the time
alright everybody got that so mpk is
pretty darn important enzyme so when you
look at a MP kinase turns out it's got
three subunits and that gamma subunit
has the active site for a MP that's
where a MP fits in and there are three
arginines in there that are potentially
blockable well turns out fructose makes
a substrate
sorryi metabolites and intermediate
metabolites on the
that is very special it is called methyl
glyoxal for glyoxal right here I'm going
to show you in a minute what that is and
it goes into that active site so this is
what methylglyoxal is there's the
formula on top and what it is is it's an
aldehyde and a reactive ketone all at
once so you know that glucose binds to
proteins and causes the Browning
reaction
it's the reason bananas brown right
that's why you paint your ribs with
barbecue sauce to brown them to
caramelize them that's the Browning
reaction known as the mired reaction now
glucose does it fast but fructose
because of its the stereochemistry of
the molecule does it seven times faster
well because the glucose so glucose has
an aldehyde group and fructose has a
reactive keto group
well nothing axial has both so it is 250
times better at causing this browning
reaction and causing it to bind to
arginines than either glucose than
glucose and 35 times more than fructose
and when you up your methylglyoxal you
get inflammation protein cross-linking
problems in gene transcription and
cellular death so fructose comes down
here to dihydroxyacetone phosphate which
makes its methylglyoxal and then
methylglyoxal can enter that active site
and in poison the ANP kinase now what's
interesting is methylglyoxal can be
detoxified there's a set of enzymes in
the liver called glyoxal ace 1 and 2
which will turn methylglyoxal into d
lactate now you're all exercise
physiologist you know what l lactate is
d lactate has nothing to do with L
lactate they are unrelated to each other
l lactate is what your muscles make when
you incompletely burn energy and they
released D light aid is a specific
metabolic byproduct of methylglyoxal
and you can measure you can measure D
lactate separate from a lactate if you
have the methodology which we do so we
measure D lactate in obese kids getting
and isocaloric fructose restriction so
we did that we look for that so it turns
out it's 52 percent higher
you know obese people probably because
of their sugar consumption but we don't
know that from this study but this is
the study that just got published in
press I'm very excited and you can see
that the D lactate levels went down and
have all of our kids significantly 38%
reduction and the change in D lactate
correlated over that 10-day period with
the change in Denova lipogenesis and
with the change in insulin sensitivity
in other words as the deal act a went
down meaning the methylglyoxal went down
the kids got better and the fructose was
the driver of the D lactate which we
have proven so we think the fructose
goes to methylglyoxal methylglyoxal
poisons that MP kinase to drive to Nova
lipogenesis gluconeogenesis
therefore insulin kinetics get worse
cholesterol biosynthesis and stop all
the other things and that's why you get
the fatty liver disease now the American
Heart Association recognizes that sugar
is a problem and in 2009 I was part of
this panel we recommended that we reduce
our consumption of sugar from 22
teaspoons per day down to 6 per women or
9 for men and 3 for children and it was
more recently zero for toddlers and
infants 0 below age 2 how's that for
added sugars added sugar so how'd I do
dr. Keely thank you all right number
three myth number three it's about
personal responsibility well if it's
about die and exercise then it's about
personal responsibility isn't it
as a true so your personal
responsibility is an ideology it's not a
law it's not a rule it's an ideology who
invented personal responsibility it's it
in the Constitution I think it's very
American you know take the risks suffer
the consequences personal responsibility
right it's in the Constitution
is it in the Declaration of Independence
is it in the Magna Carta is it in any
legal document No
so who invented personal responsibility
the tobacco industry in 1962 because
they were getting killed on the science
doll or no no doll they were getting
killed on the science and they had to
come up with another reason for you to
smoke well nobody put that cigarette in
your mouth nobody lit it for you
personal responsibility nobody else's
fault your own fault now there are four
caveat to being able to say that
something is personal responsibility the
first is you have to have the knowledge
okay you cannot exercise personal
responsibility if you don't have the
knowledge of what the consequences are
so the five-year-old who accidentally
shoots his brother with a loaded gun is
not guilty because he did not know what
he was doing he thought it was a cap gun
or whatever right well there are 56
names for sugar and the food industry
uses all of them alright and here they
are and on the food label on the news on
the Nutrition Facts label they can use a
different sugar for number five Number
six number seven number eight number
nine when you add them up its number one
and you don't know what these are and
they don't tell you what they are in
addition if you look at the Nutrition
Facts label there's a percent daily
value there in purple for every single
thing in the friggin canned bottled jar
or whatever except for one thing
sugar how come
because there's no need for sugar so
therefore there's no percent daily value
oh great so you're kept from the
knowledge access so you have to have
access to be able to exercise personal
responsibility so imagine you own a
house on the top of Love Canal and you
know that the water tables under your
house are poisoning your water and
everyone else around you and they're all
getting cancer okay but the problem is
everyone else knows it too and you can't
sell is it your fault you live there is
it person responsibility that you can't
get out so if they have access
affordability you have to be able to
afford your choice and society has to be
able to afford your choice and lastly
most importantly your choice can't hurt
anyone else
that's called externalities so for
tobacco we have secondhand smoke for
alcohol we have drunk driving okay those
are things you didn't visit upon
yourself other people visited upon you
so the question is what's the
externality to someone else's sugar
consumption the answer is no health care
no health care because Medicare will be
broke by the year 2026 and to be honest
with you I'm gonna be 69 in the year
2026 and I want my friggin Medicare cuz
I worked for it and you did too and it
won't be there for you or for me because
of this you okay with that so here's how
our food dollars have been reallocated
because of this disaster 1980 to 2012
meats down 10% because we're all told to
go low-fat fruits and vegetables exactly
the same no change now we're always told
we don't need enough fruits and
vegetables and that is true I don't
argue that but we never did ain't new
and we didn't have this problem in 1982
but we sure as hell have it now because
it's not about the fruits and the
vegetables grains and baked goods
percent that's the refined carbohydrate
and refined carbohydrate needs glucose
and glucose means insulin and insulin
means weight gain so that is definitely
part of the obesity equation no argument
and that is not good
dairy products down two and a half
percent because we're all now lactose
intolerant okay in fact turns out dairy
saturated fat is different from red meat
saturated fat dairy saturated fat is
protective against type-2 diabetes and
heart disease because it's an odd chain
fatty acid which has a different pathway
of metabolism and a phospholipid
signature that confers metabolic health
work from Dairy schmoes F Aryan and
finally processed foods and sweets
doubling in the span of the 30 years
there's the Big Kahuna that's what's
changed now this is the sp500 in blue
over the course of 2007 to 2012 and what
you'll notice is that even with the
economic recession of 2008 which you can
see there in the center the stock price
for McDonald's Coke and Pepsi did just
fine thank you why because when people
are in trouble they eat more right
because this is their reward it's the
only thing they can't afford and there's
Hormel ADM General Mills Kraft ConAgra
and PNG all against the SNP for the same
period of time want to make money invest
in a food company but things have
changed in 2013 this paper came out
profits and pandemics okay what it says
that when dr. Keeley and I went to
medical school we learned the old
medicine which was about infections and
the vector was microbes today our
colleagues have to learn the new
medicine which is all about chronic
disease and the vector is multinational
corporations and just like bacteria they
learn resistance
which is exactly what we are seeing I'll
show you how so remember this slide I
showed you the advent of processed food
in 1965 on this slide now I am going to
superimpose the percent of GDP spent on
healthcare for the same period of time
everybody ready are you saying
when processed food entered our world
that's when health started to disappear
and take a look here this is from morgan
stanley a global investment bank looking
at this question they modeled into the
future what economic productivity will
look like based on a high sugar case in
blue versus a low I'm sorry a low sugar
case in blue versus a high sugar case in
gold and you'll notice by the year 2035
on the high sugar case which is what we
have today our economic productivity in
the United States will be zero point
zero percent now who is that good for is
that even good for the industry so
basically they are shooting themselves
in the foot and shooting all of us in
the head all at the same time now the
reason is because of money the question
is how do they do it what are the
mechanisms what are the methods that's
where we're going so here are the
perpetrators if you will everybody in
the middle and they control ninety
percent of the world's food supply how
do they do it well they do it with
shoddy science here's an example they
said well sugars less energy dense than
fat because after all sugars 4 calories
per gram versus fat which is 9 calories
per gram so they said snack Wells right
so here's a 9 gram cookie here's a 9
gram snack well cookie what happens is
the carbohydrate that they had to add
when they took the fat out of the cookie
isn't replacing what isn't replacing fat
it's replacing water that's called water
activity that's why we have chewy
cookies rather than crispy cookies is
because of water activity so the reason
that
this makes no sense is because you're
not replacing the fat you're replacing
the water in fact you're going up 34
calories from a standard cookie
yes lower fat more calories to make the
same cookie in addition this is
extremely important to my criticism of
dr. Keeley's thesis he says government
is it should not be doing science that
private industry should be doing science
or foundations should be supporting
science well what the industry says is
that the data on sugar and disease is
inconclusive that's what they say
they don't sugar and disease is
inconclusive and if you look at the meta
analyses of sugar and disease they are
inconclusive and the reason they're
inconclusive is because there's a whole
lot of shitty data that the food
industry has produced and this is my
colleague Dean Schillinger having
analyzed those data based on 28 trials
and 32 systematic reviews and
meta-analyses 60 studies total looking
using the variable of whether a food
company sponsored the study or not and
what he found was that there was a
positive association between sugar and
chronic disease in zero of the 26
studies that were funded by the food
industry zero okay whereas if you look
at the independent studies it's the
exact opposite way everybody see that
now if you look at the meta analyses
done by either the food industry or the
scientists that take money from the food
industry they never include the food
industry sponsorship as one of the
variables on purpose because the food
industry is diluting the data in the
literature so that then they can point
to it basically if you pollute the water
supply you have a cesspool
they have polluted the scientific
literature so now it is unreadable but
when you tease it out and you separate
the two it's very clear what's really
going on they buy scientists funny about
that here's the first scientist they
really bought Fred Astaire
chairman of the department of nutrition
of the Harvard School of Public Health
he was a PhD he got his MD eventually I
think um he defined the four basic food
groups and said everything in moderation
he wrote the book beyond the cholesterol
scare quitter mock sighs the American
Heart Association for scaring the public
about cholesterol which is interesting
he came out against butter though said
everybody should drink a cup of corn oil
a day
took money from many food industries and
the tobacco industry he funded 30 papers
from his department from 52 to 56 alone
based on sugar industry funding in 1960
he accepted a 1 million dollar gift from
General Foods for kool-aid and tang he
endorsed coca-cola as a healthy between
meals snack he extolled the virtue of
sugar as a quick energy food put a
teaspoon in your coffee or tea three to
four times a day he funded he organized
a white paper funded by the food
industry but they didn't say so-called
sugar in the diet of man an 88 page tome
exonerating sugar as a cause of any
disease funded by the industry but the
volume neglected to mention it and was
the primary subject of the documentary
the professor's on the take and here are
all of his associations you can see them
okay this is interesting this is from
the Center for Consumer Freedom which is
a nonprofit set up in Washington DC to
basically do the food industry's bidding
the high fructose corn syrup people the
Corn Refiners Association hired them to
find out what the sugar Association was
doing because they had a big fight over
market share and here's what it says
this is from basically the food
industry's mouth
pease the sugar Association hired a
company called the academic network to
organize an external scientific advisory
committee to aid in the scientist er
Association scientific endeavors
including differentiating fructose from
sugar the academic networks president
explained he could provide access to
researchers that influence health care
policy and consumer opinion under these
blue squares these are redacted are the
name of one of my colleagues whom I know
very well I'm not going to tell you who
he is I'll tell you it's a heating how's
that that's all I'm telling you sugar
Association recognized that a viewer
from review of fructose research would
bolster their position it worked with
the academic network to provide grant
money to dr. X to write a review article
in the text of that dr. X wrote that it
was supported by a grant from the
academic network not the sugar
Association so they're hiding the ball
it's like three-card Monte Brian Wansink
professor at Cornell a professor of
marketing of all things became the head
of nutrition at the USDA for five years
turns out all of his work has now been
discredited and he has been fired from
Cornell and this one you know recently
this is the global energy balance
network that was fought in part by
CrossFit so kudos to Greg basically an
uh-oh no hado Connor outed this three
scientists at three major medical
schools around the country who basically
were paid by coca-cola 1 million dollars
to say that it's about exercise it's
about physical activity it's not about
food or sugar here's a debate that went
on at the in diabetes care
Dietary sugar and body weight two sets
of people by the way this guy here is
the was the head CEO of the American
Diabetes
Association but we're gonna talk about
the other guy John Sivan Piper for a
minute okay here's this funding
this is list of funding calorie Control
Council coca-cola company pulse Canada
International tree nuttin Council
nutrition research educational
innovations all food industry concerns
International Life Sciences Institute
that's the food industry Brazil a post
Canada is Dr Pepper Snapple coca-cola
unpaid scientific advisor to LC etc and
his spouse is an employee of Unilever
who of course makes all the ice cream
interestingly they ignored the two
studies that showed proximate cause of
sugar and diabetes which are listed
there in fact this paper came out a
couple of about a year ago looking at
the web of coca-cola funded research
that was not disclosed on the paper
because ultimately coca-cola had to put
all of its stuff in a transparency list
that's online now so they matched up the
transparency list with the papers and
found all of these that weren't ref
where coca-cola wasn't referenced and
there Stephen Piper down here including
a couple other colleagues of mine this
again CrossFit had a major role in this
disappeared in the Milbank quarterly
public meets private conversations
between coca-cola and the CDC and you
may know that Brenda Fitzgerald had to
give up her position as head of the CDC
not because of coca-cola butter because
of her tobacco holdings but the fact is
before she was head of the CDC
she was a paid adviser to coca-cola and
said solving childhood obesity requires
movement another global energy balance
network Mima well the fact the matter is
we've known for years that sugar was bad
for you but it was buried and it was
buried by of all people the sugar
Association itself because my colleagues
Kristin Karns Laura Schmidt and Stan
glance found the paper trail that
demonstrated that the sugar Research
Foundation actually fought sponsored its
first coronary disease research project
in 1965 a literature review
England Journal of Medicine from that
Harvard School of Public Health by the
way which singled out fat and
cholesterol as the dietary causes of
coronary disease and downplayed evidence
that sucrose consumption was also a risk
factor the answer I've set the reviews
objective contributed articles for
inclusion and received drafts the SRS
funding and role was not disclosed it's
all been a lie the whole thing's been a
lie
and if we didn't have government funding
like mine we wouldn't know that it was a
lie would we it is difficult to get a
man to understand something when his
salary depends on his not understanding
it I was Upton Sinclair the author of
the jungle and it was because of his
investigative reporting of the
meatpacking industry in Chicago that we
even have an FDA co-opting critics turns
out the Academy of Nutrition and
Dietetics are paid off by big food
because that's where they get their
money Michelle Simon basically fingered
them for all the money that they've been
taking I gave the keynote speech at the
American Academy of Pediatrics meeting
in 2009 and this was my slide and they
would not let me get on the podium until
I removed it so I am showing it to you
now since then the head of the AAP
happens to be a friend of mine and she
recognizes the problem and they have
divested their interest in coconut with
Coca Cola American Academy of Family
Physicians their first alliance was with
Coca Cola this is a paper that came out
showing the 96 separate public health
supports that coca-cola and Pepsi
together have done and you can see
medical professional government and
industry mouthpiece all of these are all
things that Coke and Pepsi have
sponsored and under written in order to
get the public health community
to not finger their product in fact the
rest of the world knows this because the
International Diabetes Federation went
to the g20 in 2015 and told them they
needed to tack sugar to save lives and
money yet diabetes UK just took a five
hundred thousand pound grant from Pepsi
Cola just a month ago
the American Diabetes Association and
the Diabetes Association of Britain are
the two organizations that say that
carbohydrate does not cause diabetes
sugar does not cause diabetes take as
much carbohydrate you want just take
enough insulin to cover it the rest of
the world has the IDF the problem is
their countries the member countries are
too poor to be able to afford that they
can't even record the refrigerator put
the insulin in nevermind the insulin
itself they have to be for prevention
and they know this is what's causing it
so this is about money this is about
farm this is about co-opting scientists
and physicians weakening government
oversight the Federal Trade Commission
in 1972 actually took sugar information
a public mouthpiece of the sugar
Association down because of these
advertisements you'll read sure as quick
energy can be the willpower you need to
eat less at that time of day you're
really hungry and ready to eat two of
everything here's how sugar can help
sugar just might be the willpower you
need to curb your appetite sugar can be
the willpower you need to under eat well
the FTC tried to regulate kids food and
they try to regulate kids television
back in 1978 which created what is known
as the kid vid debacle well the food
industry went berserk
and basically lobbied every member of
Congress and they ended up decoying the
FTC with the FTC improvement it's act of
1980 which is why you never hear from
the FTC anymore because they have no
regulatory authority anymore because
Congress took it away from them because
they actually tried to do something
in 2007 52 European health ministers
voted to cease marketing junk foods to
children yet one month after they did
that I was at a meeting where the
keynote speaker was Federal
Communications Commission or Deborah
Taylor Tate and I asked her what did the
u.s. plan to do and she said to me I
expect the food industry to police
itself now here in California we are
relatively progressive in 2010 we passed
a toy ban from McDonald's so they
couldn't market the toy with the Happy
Meal you had to pay an extra 10 cents
for the toy because the toy should not
be the inducement for the Happy Meal two
years later three pet states had passed
bans on toy bans this is from Blanche
Lincoln who used to be the head of the u
of the Senate Committee on agriculture
nutrition and forestry and you'll notice
in 2004 and 2010 when she was running
for re-election where did her money come
from and it's both sides of the aisle
the first event Cory Booker attended
after he was elected senator was on the
fan Houle's yacht in Key Biscayne they
are the ones who make heads of us sugar
and it's going on all around the world
this just from BMJ making China safe for
Coke how coca-cola shaped obesity
science and policy in China because it
turns out their nutrition is the food
industry their nutrition regulation is
the food industry market saturation so
we have things like this Honey Smacks
56% okay here are the 10 worst
children's cereals there is 56 percent
fruit loops by the way at 40 1.4 not
even bad and I say that tongue-in-cheek
of course and the fact is that here we
are eight years later and there's not
one change that's been made to any of
those cereals not one and you'll look if
one third of the sugar is in beverages
one sixth is in desserts but half of the
sugar is hiding in foods you didn't know
had it like salad dressing you know
barbecue sauce hamburger buns hamburger
meat bread etc thing so even if you cut
all the things you knew had it you'd
still be over your limit and they've
saturated medicine this is from a
hospital in the United States in Chicago
and this is one in Fort Worth sir eats a
lot and Grill my favorite astroturf
groups
so here's Citizens for Health okay
there's supposed to be a grassroots
organization trying to promote health
it's funded by the sugar Association to
take down high fructose corn syrup and
it's run by the exact special counsel to
the Senate Select Committee on food
nutrition and health em7 senate
government Operations Committee on
government research this one dr. Keeley
should take a quick look at this is from
the Institute of Economic Affairs in
Britain they wrote one called sweet
truth okay and here's what they said
government intervention in the market
can only be justified if there is a
market failure well there is a market
failure because there's a market failure
with all hedonic substances and that's
because they're hedonic because you can
raise the price and consumption won't go
down there's a market failure with all
hedonic substances annual sugar
consumption in Britain Peaks several
decades ago doesn't matter because of
all the things I told you are it's
considered consumption peaked decades
ago too so we went from four times over
our limit to three and a half times over
our limit big deal there's insufficient
evidence to label sugar as addictive
we're coming out with a paper in a major
journal very shortly to show exactly why
that is not true there's insufficient
evidence to suggest a calorie from sugar
is more fattening than a calorie from
other foods that is true it's not the
calorie from fructose it's the insulin
rise that attends the glucose but it's
the insulin resistance that causes the
fatty liver that ultimately leads to the
generalized insulin resistance there's
little evidence that consumers are being
limited by choice in the food market
that's not true because 74 percent of
all of the items in the grocery store
have been spiked with added sugar for
their purposes not for yours some food
campaigners may be unhappy about the
kinds of choices consumers are making
the
because some of them are now opting to
do otherwise dietary information in
sugar content is clearly marked on
nearly all food products I've already
shown you that as a complete and utter
falsehood a ban on television
advertising for foods that are high in
fat solar sugar before 9 p.m. would
effectively be a form of censorship well
to be honest with you I don't know why
they're allowed to market this at all do
you get to market cocaine do you get to
market heroin do you get to market
tobacco any more on TV limiting the
available fast-food outlets stifles
competition what are you talking about
that's all there are now is fast-food
outlets take a look at basically in food
deserts taxes on food and soft drinks
have been shown to be ineffective at
reducing obesity and that is also not
true because now we have the data from
Berkeley to show that that is indeed not
the case so all of that is just total BS
we have written a paper called the
science against sugar alone is
insufficient in tackling the obesity and
type 2 diabetes crises we must also
overcome opposition from vested
interests and we very specifically call
out the Institute for Economic Affairs
because as transparent or transparency
of organizations they say the more
lobbyists try to hijack the think tank
label and attempt to mask their paid-for
spin as research driven advocacy the
more important it becomes for the think
tank expect the sector to as a whole to
fight back the best weapon to in that
fight is transparency and transparency I
gave the IEA a score of 0 for
transparency they won't tell who their
donors are we know Taylor Lyles one of
them marketing to children I'll go
through this quick you've seen this
you've seen this you seen this this that
oh this is my favorite drinks are on us
publics are rewarding top grades with
free apple juice and soda students we
salute your thirst for knowledge how
about this and this and this and this
and this and this too well the fact that
matter is we are making some headway
because the I effect the international
food information council that's the food
industry said in their most recent
evaluation dr. Lustig mantra
no not all calories are created equal
appears to be resonating with more US
consumers with one third of Americans
now believing sugars are the cause of
calories most likely to cause weight
gain by the way I never said that
compared with just 11% in 2011 and here
is that analysis and you can see that
sugar went from 11 to 33% and whether
all the same went from 40 to 17% so the
message is getting out slowly more
people now know a calorie is not a
calorie and the processed food is the
problem
Mars knows it's a problem because they
support the Dietary Guidelines and said
that all stakeholders including industry
need to engage in a constructive
conversation in order to manage sugar
intake and guess what no Coke says so -
they support the guidelines governments
are slowly responding this is from the
Economic Times reporting on the fact
that they the government of India s
Pepsi to cut their sugar content and
Indra Nooyi from Madras India had a very
invested interest the problem was she
wanted to do it with good-for-you snacks
like hummus and pretzels and chia seeds
and what-have-you and they fell flat on
their face they lost 349 million dollars
in one year and they called for her head
on a plate she survived but the last
thing in the world she was going to do
was to touch the flagship product so
even though her own government asked her
to moderate and mitigate the metabolic
damage of diabetes in India by changing
the formulation they did not another if
you want to know what's really going on
don't ask the doctors because they're
all biased I agree with dr. Keeley
they're they're all biased they come in
with a set of rose-colored glasses if
you want to know what the real story
asks the banks because they are 100%
transparent they have only one goal make
money and they don't care what anyone
says they're gonna figure out for
themselves what the right answer is and
here's what Credit Suisse Research
Institute said we believe higher
taxation on sugary food and drink would
be the best option to reduce sugar
intake and help fund the fast growing
health care costs associated with type-2
diabetes and obesity a global investment
bank is calling for taxation
and indeed we now have sugar taxes
around the world now I'll be honest with
you I think sugar taxes are the third
tax the first tax is the subsidy the
corn and the sugar subsidy because when
you subsidize one thing that means
you're taxing everything else and
everyone's paying that number two
there's the fee for health care because
every employer is paying two thousand
seven hundred and fifty one dollars per
employee for obesity related health care
costs whether the employee is obese or
not which means your premiums are going
up so you are paying a fee not a tax but
it doesn't matter it's the same thing
and then lastly then there's the tax
it's the sugar tax itself so it's really
three taxes when you could get rid of
all of them by just getting rid of the
subsidy and that's something that even
libertarians could get on board with
because where were they when the food in
this plane that when the food industry
was changing our diet in the first place
were they complaining then so ucsf we've
gotten rid of all sugar beverages we
have the healthy beverage initiative you
are not allowed to sell a sugar beverage
on campus if you want to bring one from
home that's your business
but you can't buy one and no vendor can
bring one on to campus because we have
to role model for the public because
where was tobacco first banned hospitals
were supposed to role model for the
public okay we are I think we should
rename type 2 diabetes and you've
probably seen that there's a CrossFit
video of me basically saying let's call
type 2 diabetes processed food disease
because that's what it is let's roll
back those subsidies corn wheat soy
sugar and and finally my nonprofit that
I mentioned eat real an attempt to try
to raise the bottom as opposed to lower
the top get everybody on board that real
foods the real answer to this problem
not what the food industry is peddling
and not what they're saying and not even
what most scientists are saying because
they're paid off also so for real
information missus UCSF curated sugar
Science org you can refer your clients
and patients to this
that up a documentary came out in 2014
about how we got to where we are today a
documentary called sugar-coated from
Toronto 2015 about why we got to where
we are today they're not the same how
and why and a PBS video that we did call
sweet revenge turning the tables on
processed food which is even in Spanish
for the public to be able to understand
the difference because if you think
Cheetos is food you will never get
better ever with that I'll stop and take
any questions
the fact the matter is that virtually
all of these agencies suffer from what
the economist calls elite capture
whether it's the USDA with Monsanto
rotating through or the FDA with Big
Pharma rotating through the bottom line
is all of these are no and now the EPA
especially here they're all now
suffering from a lead capture and I
totally agree so we need a different
system and we need something that
approximates real science but what's
happening right now is that industry is
controlling all the science and the only
science that is there to battle the
industry are people like me
romantic at all
the fact is hedonic substances are
hedonic okay right and if you let the
market basically have its way with
hedonic substances okay we'd all be dead
you know that's actually an
extraordinarily important and very
impression to question okay I I get it I
do I started talking publicly because I
was taking care of obese patients and
for every patient that I treated ten
more showed up at my door
okay this was just not viable and I
recognized that I had to basically cut
the problem upstream which meant that I
had to get involved in policy otherwise
I'd probably still be sitting in my you
know my clinic over at UCSF I actually
tell us the story of one kid in fat
chance the first book about a kid who
comes in he's six years old and he
weighs 100 pounds he's wider than he is
tall and I take the history from the mom
and she's a migrant worker in Salinas
who speaks only Spanish and she tells me
no soda but a gallon of orange juice a
day and I tell her the fruit is good the
juice is bad because of the fiber eat
the fruit don't eat the juice and she
says then why does what give it to us
right why does WIC give it to us so that
actually changed my life that one
statement changed my life I have never
gone beyond the science as loud and as
noisy as you might think I am I've never
said a word that I can't back up with
hard independent science and you can
speak as loud as you want or need to as
long as you stick within the science the
minute you go beyond the science okay
they can't wait for you to
go pass the science get to stick your
neck out because then they'll cut your
head off and that's what's happened to
many people who have preceded me is that
they have gone beyond the science and
they've gotten discredited in fact you'd
get went beyond the science and he got
discredited I have not gone beyond the
science and I am still standing so that
would be my argument to you is no the
science you have to be able to interpret
the science and the most important thing
is when you read a paper okay everyone
looks at the abstract I look at the
funding source that's the first thing
you should look at is the funding source
because if the funding source is a
private for-profit entity there's a
reason why they funded it know that
