 Thanks, everyone. Can everyone hear me okay? All right. Just for everyone's knowledge, there's going to be a set of seven slides that will appear probably about ten minutes into the presentation. They are very sensitive. They are out at a journal right now. It's been three months since we submitted the data. They've had the external reviews for three weeks, and they still haven't made a decision because this is so hot, so incendiary that they're not sure what to do with it. The point is, please, during the seven slides, and I will announce which slides they are, please do not take any photos. And the cameras crews know not to shoot during those, and they'll be edited out. Please, if they show up on the internet, we're all screwed. Okay? You too, all of you, because you're all in this together. All right? Anyway, let's see. How do I run this thing? This is not running. Okay? All right. First of all, I have no disclosures. Again, no food industry is putting me up to this. Last year, last year at this meeting, I talked about the science and the evolutionary biology of sugar and how it ultimately affects us in several different ways, particularly in terms of the concentration that we are currently consuming in terms of dose and, you know, from various standpoints, from the liver insulin resistance standpoint, from the hedonic standpoint. Ultimately, the science should drive policy, but the politics get in the way. But what we're going to do today is we're going to basically extrapolate that logic from the science to what policy considerations we might put into practice today. Some of you, I'm sure, read the article in Nature that's here on the right. Some of you, I know, have blogged about it. Some of you quite negatively. And I'm here today to try to defend that position in terms of what societal intervention can or should do in terms of our current sugar pandemic and why it's so important. Now, in 2003, Thomas Baeber and colleagues who worked with the World Health Organization established these four criteria for societal intervention of any given substance. Unavoidability that you can't get rid of it. Number two, toxicity. Number three, abuse. And number four, most importantly, negative impact on society. Certainly, alcohol and tobacco satisfy those four criteria. And so we treat those two substances very differently than we do virtually any other substance. We have learned to, quote, peacefully coexist with them. But through legislation, through changes in society that ultimately reduce total consumption and they have had very beneficial health effects. No one can argue with the successive tobacco and alcohol legislation and regulation. So let's talk about how sugar might work within those four confines, purely on a scientific and logical basis right now. First, unavoidability. So, of course, we're all eating more. Everybody will tell you that the reason for obesity is we eat too much and we exercise too little. Right? Wrong. Well, you know, we're eating more of everything, right? Wrong. We're not eating more of everything. We're eating more, certainly here. But we're not eating more fat. We've been told to reduce our consumption of fat from 40 to 30%. Here are the secular trends in specific food intake. And here are the fats. Milk, whey down, meat and cheese, about the same desserts, you know, milk desserts about the same. Bottom line, we're not eating more fat. And as you can see here from the calories from fat going from 40 to 30% over the past 30 years, because of the ADA, the AMA, the USDA recommendations of the early 1980s based on the McGovern Commission, our obesity and metabolic syndrome prevalence has gone through the roof. No, it's carbohydrate that we're eating more of. And obviously, I'm speaking, you know, that's like bringing coles to Newcastle here. Everybody's part of the choir. So here are the secular trends in carbohydrate intake all through the roof. We are not eating more. We are eating more carbohydrate. And what carbohydrate? Well, in particular, beverages, right? 41% increase in soft drinks, 35% increase in fruit drinks, fruit aides, et cetera. And that stuff here in America is this stuff, high fructose corn syrup, where we are currently consuming 63 pounds per person per year on average. But notice the current users are only the U.S., Canada, Japan, and very limited exposure in parts of Europe. Yet the entire world has exactly the same disease as we do, and they're catching up. There is no high fructose corn syrup in Australia. They are the third most obese society on the face of the earth, and they have all the same disease as we do. So what is this stuff? Well, as you know, high fructose corn syrup is up on top. One molecule of glucose, one molecule of fructose, you know, give or take, you know, 55%, 45%. And down on the bottom is sucrose, one molecule of glucose, one molecule of fructose, joined by an oglycosidic linkage, which is cleaved by the enzyme sucracin, about a nanosecond. Bottom line, biologically, chemically, these are equivalent. And all of the studies that pit high fructose corn syrup against sucrose show no different effects, all the same, all bad. That's the problem. It doesn't matter which one it is. And the whole world has shown this. Here's our secular trend in fructose consumption. Our ancestors getting fruits and vegetables out of the ground with the occasional honey got to about 15 grams of fructose a day. Prior to World War II, with the nascent candy and soft drink industries in America, we got up to about 20 grams a day. By 1977, before the glut of high fructose corn syrup in America, we got up to 37 grams a day, which was 8% of our total caloric intake. By 1994, we were up to 55 grams, or 10% of our total caloric intake. And currently, adolescents average 75 grams a day, which is 12% of total caloric intake. So double that for sugar, because it's glucose fructose, right? So that's 25%. And 25% of adolescents today in America consume 100 grams of fructose per day. Double that for sugar. That's 200 grams. Multiply by 4.1 calories per gram. That means 840 calories a day in sugar, which is more than 40% of total caloric intake. So we're not just eating more. This is what we're eating more of. And as you know, cross-sectional and longitudinal studies correlating sugar consumption with energy intake body weight, milk and calcium intake, adequate nutrition, all show significant negative effects in all directions. The disclaimer is that those studies that are funded by the beverages industry show much less of an effect. Wonder why? If you look at mechanistic studies where you actually take the stuff away, so this is the fizzy drink study from James at all, you'll notice that the intervention schools maintain their prevalence of obesity over a course of a year of soft drink restriction, whereas the control schools continue to show increased prevalence. Now, this is where things get a little contentious. Everyone in this room has a pet diet. Some of you are making money off your pet diet. I'm not making money off anything, all right? But the bottom line is they all share two things in common. Anybody know what the two things are? Low sugar, high fiber. And you know what we call low sugar, high fiber diets? Real food. Ultimately, that's what we're really talking about here is food processing. Not specifically sugar, not specifically high carb. We're talking about real food because if you ate real food, you would get a low sugar, high fiber diet. The fiber would mitigate the carbohydrate as we know occurs in terms of the glucose rise, therefore the insulin rise. Keeping insulin down, real food's the story. But in the 1980s, we went on the low fat craze due to the AMA, AHA and USDA recommendations. The point is that the content of low fat, home cooked food can be controlled. You can decide what goes into the food that you make at home. But low fat processed food is a whole other story because it tastes like cardboard. And palatability equals sales. And the food industry knew that. So when they were remanded to reduce the amount of fat in the diet, they had to do something. What'd they do? Up the carbohydrates, specifically the sugar, either with HFCS or sucrose. An example, of course, is snack wells. Two grams of fat down, 13 grams of carbohydrate up, four of which was sugar. So I would post to you, which was worse? The sugar or the fat? I think you know the answer. Here's my daughter when she was in second grade bringing milk cartons home from the San Francisco Unified School District and said, dad, you're not going to believe this. Over here is Berkeley Farms 1% low fat milk, 130 calories, 14 grams of sugar, which is lactose, which is not a problem because the galactose gets converted to glucose in the liver. And here's Berkeley Farms 1% chocolate milk. 190 calories, 60 calories more, 29 grams of sugar, all high fructose corn syrup. So when you drink a glass of chocolate milk in school, that's a glass of milk plus a half a glass of orange juice. And the question is, is that okay? This is, again, highly contentious, but I would pose to you that evolution for foodstuffs, you have one form of energy storage or the other. For meat and for other fatty fruits, for instance, avocado, coconut, olives, you have fat. And for other things that come out of the ground, you have carbohydrate, but you don't usually have both. Only sugar, only sucrose, because the fructose gets converted to fat in the liver through de novo lipogenesis. And of course the glucose is carbohydrate, is both. When glycogen storage, stores are full. That's when de novo lipogenesis occurs. And that's the liver's way of exporting extra energy out of the liver so it doesn't get sick. The problem is it gets stuck. It causes liver insulin resistance and fatty liver, which you know. And that starts the cascade of hyperinsulinemia, insulin resistance, and all the diseases that we know about. And here's the big problem right here. Of the 600,000 food items sold in the U.S. grocery store today, 80% of them are laced with added sugar, very specifically for the food industry's purposes, not for yours. And that's the issue that we're facing today, is you can't eat properly because the food industry won't let you. As far as I'm concerned, we've had our entire food supply adulterated through the addition of fructose for palatability, especially with the decrease in fat, and ostensibly as a browning agent. Well, you all know that that browning that occurs is the Maillard reaction, which is the same thing as hemoglobin A1C, and we know that's bad for you, right? Because that causes glycation of proteins, causing them to have decreased flexibility, causing cellular aging, and every time that that Maillard reaction occurs, you release a reactive oxygen species, which has to be quenched by an antioxidant. And if you're antioxidant-efficient, which processed food is, you get cell death. You get human death. In addition, the removal of fiber, ostensibly for shelf life, right? And also for freezing, because you can't freeze fiber. Go home, take an orange, put it in your freezer overnight, take it out, put it out on the table, and let it thaw, try to eat it, see what you get. What do you get? Mush. Why do you get mush? Because the ice crystals macerate the cell wall of the plant so that when you thaw it, all the water rushes in, turns it to mush. Food industry knows that. So what do you do? Squeeze it and freeze it, last forever. Brings prices down. Okay? Because there's no depreciation. So good for your pocketbook, good for the food industry, bad for your health. Big time. And, of course, substitution of trans fats, but we know that so we're getting rid of those. Okay, now to toxicity. And this is where the seven slides will come in. First of all, here are the 10 most obese states in the United States. No surprise to anybody. Here are the 10 laziest states. What's going on over there in Nevada? I guess you can only burn so much energy going like this. And now you just have to go like this, right? Okay. Well, here are the 10 most unhappy states. No surprise. Well, here's the adult diabetes rate. Here's the adult heart disease rate. Again, no surprise. And finally, here's soda per capita consumption. What do you see? All right. Now, everyone will say, wait a second. That's correlation, not causation. Indeed it is. Why? Because those are poor states and they don't have any money to buy decent food, et cetera, et cetera. And they're pretty unhappy. So what do you think they do? They drown their sorrows in a Coca-Cola. Because after all, if you watch the advertisement, Coca-Cola will tell you if you open a bottle of Coke, you open happiness. Indeed. Right. Here's the problem is it's not just America. It's the whole world. Because here's the worldwide per capita supply of sugar. This was in the Nature article. And we know from the American Heart Association, Missive, from 2009 that we're not to consume more than 150 to 200 calories of sugar per day for cardiovascular health. And you can see how many countries are above that threshold, virtually all of them. And world sugar consumption has tripled over the past 50 years. Notice Brazil, highest per capita consumption. Why? Because they're an exporter. Now they're a consumer because they can afford it. And they now have the highest increase in prevalence of type 2 diabetes in the world. Not the highest prevalence. That is reserved for Saudi Arabia and Malaysia. Saudi Arabia and Malaysia, how do they do this? No alcohol. But they got soft drinks like they're going out of style. Why? Because the water supply sucks. Right? Okay. You know who does the water purification for most countries? Coca-Cola. Right? Okay. And you know if you don't have any alcohol, you've got to get your pleasure somewhere. All right. Here are the seven slides. Please, everybody, turn off your iPads, iPhones, blackberries, crackberries, et cetera. Okay? What do these five pictures have in common? They're all brown. That's the Maillard reaction. Okay? It's the non-enzymatic glycation or fructosellation. Either way, it's why you put barbecue sauce on your meat. So, bottom line is you can slow roast your meat for one hour at 375 degrees, or you can slow roast your meat at 98.6 degrees for 75 years. You get the same thing. Okay? That's aging right there. And I'll show that to you because here's rib cartilage as a function of age. There's newborn rib cartilage and there's 88-year-old rib cartilage. You're all browning even as we speak. Okay? And if you had an orange juice at breakfast, you're browning faster. And here's the data that shows that. This is in vitro data showing the rate of glucose binding to proteins there on the left versus fructose. And this is seven times faster. You can see the rate there. And the number of carbonyls, which are the reactive oxygen species produced, are 100 times greater. Now, this is in vitro, but it's true in vivo as well. This is correlational data, but we actually have mechanistic data in animals showing that the rate of steatosis, the great stage of fibrosis correlate with fructose consumption in a liver clinic in Duke. And this is great of inflammation, great of ballooning, same thing. So, basically, your liver gets sick when you consume sugar. Now, abuse. Everybody seems to know that sugar's addictive, except, of course, the scientists. And I had a big argument with somebody at the American Society of Nutrition back in April over the same issue. Okay? The question is, is sugar actually addictive? Anybody see the 60 minutes piece? We just got replayed on Sunday night. Okay? Eric Stice thinks sugar's addictive, and he's looking at fMRIs in the brain. And here's the data. This is showing dopamine D2 receptors in red in a control brain versus a cocaine brain. You can see the down-regulation of D2 receptors. That's tolerance. That's the neuroimaging correlate of tolerance. And if you have tolerance plus withdrawal, you have addiction. And that's what we see in patients who try to come off sugar is they feel lousy. Here's a control brain. Here's an obese brain showing the same effect. Down-regulation of D2 receptors, because obese people, because they don't get the same level of reward for each molecule of energy that they consume, they have to eat more to get there. And so that's cold tolerance. So is there really such a thing as sugar addiction? Well, we have to look for similarities to other drugs of dependence. So like nicotine, morphine, amphetamine, cocaine. And the one I would suggest is the closest, both metabolically and in terms of commodities, is ethanol, alcohol. And that's what we've done is we've compared fructose to alcohol in our research and our papers. The criteria for addiction in animals are the following. Binging, withdrawal, craving, and cross-sensitization with other drugs of abuse. So in other words, you expose an animal for three weeks to one drug of abuse, say amphetamine, and then you hit them with another drug of abuse, say cocaine, that they've never been seen before, and they'll get enhanced locomotion and increased consumption from the second drug, even though they've never seen it before, because the dopamine D2 receptors are the same, no matter which substrate you use. And that includes, by the way, power, money, gambling, et cetera. How about humans? Here are the DSM-5 criteria for addiction. So tolerance and withdrawal, that's physiologic. And then this list over here of various things. And if you read through that, it sounds like every obese patient that we take care of. The point is that we have toxic substances that are not abused. For instance, iron, vitamin D, they'll kill you, right? Iron, toxicity, vitamin D, intoxication. Pseudofedrine, once it's turned into crystal meth, right? And we have abused substances that are not toxic, like caffeine. And if you take my Starbucks away from me, I will kill you. And nicotine, right? Nicotine's not toxic, right? You can buy it at Walgreens, right, in Nicarac gum. It's the Tars in the cigarettes that are toxic. But when you are both toxic and abused, now you have a problem. So that's morphine, heroin, amphetamine, cocaine, ethanol, and I'm just showing you sugar. And the problem is that when you're toxic and abused, educational efforts alone don't reduce consumption. Did Nancy Reagan's just say no work? Finally, externalities, the negative impact on society. So societal invention requires an externalities. So if you smoke or drink or take drugs, it's bad for me. Secondhand smoke, car accidents, declining house prices, you know, work productivity. I got to do your job. How does your obesity affect me? 274 million extra for jet fuel. Discomfort on the subway. Sinking of boats due to the weight. 2003, Lake George, the boat was coded for 17 people at 165 pounds. They had 24 people at 190 pounds average, and the boat went over. Okay, no, that's not it. 65 billion reduction in work productivity. 50% increase in absenteeism. 50% increase in health insurance premiums. 150 billion in healthcare resources wasted every year. We could balance the medical budget on that clearly. And we could probably balance the federal budget on it. Obesity is a threat to national security because 27% of all conscripts are obese and get foreft. And the government pays twice. They pay for the food subsidy, and then they pay for the ER visits. Okay, and all of that affects you, whether you're obese or not. So, this is a public health problem. This is not a personal responsibility problem. And finally, who's winning the war? This is the S&P 500 in blue compared to the stock price of McDonald's Coke and Pepsi over the last five years. And there's the economic downturn of 2008. You know, they're doing very well, thank you. And here's Monsanto, Archie Daniels Midland, Hormel, General Mills, Conagra, Procter & Gamble & Craft, all doing better than the S&P. How come? Because when we have less money, we eat more. Why? Because that's our pleasure. That's our reward. And ultimately, the more pleasure and the more reward, the unhappier we get. Now, there is debate among scientists. You know, there's honest debate, and that's okay. I'm happy to have that debate. Okay? For instance, here's Luke Tappie's article saying that the science is right, but are we ready for a public health intervention? And we can have that debate. That's why I'm here. And here's Siddhartha Ruki's work from England. You know, she does leptin deficiency saying, is the addiction model convincing? Okay? So, you know, there's real honest to goodness debate, and I'm happy to have it. However, the American Heart Association has reversed its stance from fat to sugar being the issue. And this is the paper that we published, 2009, recommending reduction in sugar intake from 22 teaspoons a day to nine for men and six for women. So here's the bottom line. Personal responsibility versus public health. The libertarians versus the communitarians. Here are a whole bunch of diseases that were personal responsibility until they became too big, too problematic for society, and ultimately public health had to get involved. Well, sugar and obesity and metabolic syndrome fits that as well. You could add, by the way, teen pregnancy and gun control to this list as well. So the question to pose is, can our toxic environment, which we have created, be changed without government or societal intervention, especially when there are addictive substances involved? There are three methods of societal intervention. I am not endorsing any one of the three or any of the three for that matter. The only thing I'm endorsing is reduction in consumption, however we can get there. So everybody who says, oh, he's for taxing sugar. No, I'm not. I've never said I was for it. I said, let's put it on the table and discuss it. That's just a rational academic argument based on the data. So the taxation restriction of access, interdiction. No one's proposing interdiction. I am not banning sugar. I'm not suggesting we ban sugar. Only Michael Bloomberg can do that. I'm suggesting that we have to negotiate a peaceful coexistence with sugar. The same as tobacco and ethanol. Not interdiction, but maybe taxation and restriction of access. We'll see. The point is you can do public health two ways. You can do targeted prevention. The strengths are individual. It's limited to those affected. That sounds good. Easier incorporated into medical care, except for one thing, hasn't worked. Benefit to risk ratio is high. But the weaknesses are big. Medicalization of prevention, that's hard to do. Behavior modification is impossible to do. Costs and feasibility are ridiculously expensive and limited success. How about public health prevention? Here are the strengths. It's radical. It works. It's powerful. Environmental modification. We actually live in a cleaner, safer environment if we take care of these things. Less antibiotics in the meat if we actually ate real food, as an example. The limitations are acceptability, especially to the libertarians. Feasibility. And finally, also costs. Here's the issue. It's not just the obese. It's not just the obese who get metabolic syndrome. In fact, some people get metabolic syndrome. They're just not obese. They have all the same risk factors and they have the same diseases. Assuming an adult population of 240 million, 30% of which are obese, here's how the math works. 80% of obese people have metabolic dysfunction. That means 20% don't. So you can be fat and fit. And you can be perfectly fine and live a perfectly normal, healthy life. And you're just fat. That's 0.8 times 0.3 times 240 million. That's 57 million people. But 40% of normal way people have metabolic dysfunction, as demonstrated by their lab tests or their cardiac or diabetes events. So that's 40% times 0.7 times 240 million. That's 67 million people. So ultimately we're talking about 124 million adults. That's more than half of the US population. So you think you can do that with targeted prevention? Forget it. This is public health. So why is alcohol so relevant? Well, here's the corresponding phenomena for alcohol and sugar. Both are ostensibly nutrients. But aside from energy, they have no health value. Metabolic and CNS pathways are similar. Both legal substances that produce health harms when overused. Little danger from moderate consumption. But the burden of harm falls disproportionately on the low SES groups. And they're the group that can least afford the money to basically take care of their health care. And they are the ones who show up in the emergency rooms. And they are the ones who are chewing through all our health care dollars. No issue. So socioeconomic status. Now here are the strategies that have not worked for alcohol. And there's no reason to suspect that they will work for sugar either. Government guidelines have not worked. Public information campaigns have not worked. Warding labels on product packaging have not worked. School-based education programs have not worked. And ultimately, most recently, menu labeling has not worked. I'll show you the menu labeling. So this was the historical cross-sectional study that was done in New York City when the Department of Health instituted their menu labeling plan. So they look at lunchtime purchases at several fast food chains in 2007, 2009, before and after. The mean calories did not change. Three major chains showed very small decreases. 15% of the respondents reported using the calorie information. Those who used it consumed 106 calories less. Problem is it was only 15%. And that's about right. Because about 15% of the U.S. population actually has a brain. How about for children? 349 children, adolescents, about age 1 to 17. 69% accompanied by their parent. No statistically different changing calories before or after labeling. 35% ate fast food six or more times per week. 57% said they noticed the calorie labels. Only 9% used them to order. 72% said taste was the most important factor in their meal selection, indeed. How about strategies that might work? How about controls on advertising and marketing? We've been talking about this advertising to children forever, forever. The Olympics is a perfect example of the disaster. Counter-advertising campaigns like, for instance, the New York City Department of Health. Anybody ever see the YouTube video, Man Drinking Fat? It's fantastic. It's wonderful. It's great. And you know what? It doesn't work. It's wonderful and it doesn't work. How about industry self-regulation? So in Istanbul in 2007, 52 European health ministers got together and said, yes, they would vote to cease marketing of junk foods to children. In 2007, I approached the Federal Communications Commissioner, Deborah Taylor Tate, under the Bush Administration, and asked her this question, would the United States consider this? And she said, I expect the food industry to police itself, and that is still true today. The Corn Refiners Association rebranded high-fructose corn syrup as corn sugar without FDA approval, and they're still selling it as such. So industry self-regulation, they won't even go with the regulations they got. Santa Clara in San Francisco, the toy ban on happy meals, and I am proud to say that I was part of that movement, and I continue to be proud of it. Because children don't need any more coercion than they've already got to eat a fast food meal. However, since that toy ban, three states have instituted bans on toy bans. And finally, the campaign to retire Ronald, which continues on going. How about strategies that are likely to work? Pricing strategies always work, sadly. Controls at the point of sales, bundling strategies, and ultimately government agency action. So here we get into the taxing. Bottom line is this isn't very new. Canada and Europe already do this, with their general sales tax and value-add attacks. Price elasticity on a can of soda is so huge, it is so enormous, that a 10% increase in price only reduces consumption by 2%. That means you've got to raise the bar really high. Roland Sturm, down here at the bottom, showed that you have to double the price of a can of soda to reduce consumption significantly. That's a problem. The other problem is no one trusts government. God knows, I don't trust them. So are they going to generate money for programs to help the obese or to underwrite farmers markets in local, you know, poor areas? Or are they just going to do a money grab and use the money for their own purposes like so many times? And that's the reason the libertarians are so inflamed by this, is because they consider this a money grab. And indeed, the way government currently operates, they're right. But the bottom line is we still need a public health strategy that works. So let's debate it. Let's have an argument about it that's real, rather than blogging about it in the blogosphere. This is similar to what we saw with tobacco and alcohol. There's really no difference. How about differential subsidization? Could we tax the bad food and actually underwrite the healthy food? So could we modify behavior through pricing? The answer is absolutely yes. In fact, Andreas is, in felt us here, the Nordic countries have state-run liquor stores. And the price of all the alcohol is exactly the same. And they charge less for the low alcohol beer than for the high alcohol spirits, specifically to reduce alcohol-related health harms, which they have shown both in terms of cirrhosis and in terms of car accidents. So they have a policy that actually works and I'm for them. We could discount diet soda to make that more palatable and tax regular soda to get the fructose consumption down. Now I'm not for diet soda. None of you should be for diet soda. But you know what? It's kind of like methadone is to morphine. It's a way of getting off the stuff. You could wean it down if you had to. Ultimately, this is the bottom line, the iron law of alcohol policy. This is absolutely airtight and truly iron. Reducing the availability of alcohol will reduce alcohol consumption, thereby reducing alcohol-related health harm. Same thing would be true for sugar. Could we restrict? How about age limits on purchase and use? Like for instance, carting kids for Coke. I mean, do you want your kid to go into a convenience store after school to buy a Coke? Do you want them to do that? There's a posse of mothers in South Philadelphia who actually barricaded the entrance to the convenience store outside the school to make sure their kids didn't do that. I so applaud them. The point is, why should they have to do that? Why can't a public health directive do that? How about licensing and zoning controls on sales outlets? There are 2.5 fast-food restaurants per thousand square meters in lower socioeconomic neighborhoods, versus 1.5 in affluent neighborhoods. How about permits that control hours of operation? How about we just don't sell soda between 7 and 9 in the morning and 3 and 5 in the afternoon? Or if a parent wants their kid to have a Coke, let them go buy it for them. That's a guarantee that they wouldn't. In California, we have something called sodas out of schools. SB19, the last survey in 2010, showed that school obesity rates were stable. We think this may be why. And ultimately, Michael Bloomberg's big gulp ban, whatever you want to say about it, nobody needs a 32-ounce big gulp. Hydration, screw you. But the problem is, if you just do it in schools, it's a problem because here we're looking at purchasing in the center. And we're looking at 5th grade and 8th grade banning soda only or all-sugar beverages. If you ban soda, you still have just as much consumption because you get it at home. So doing something in schools isn't enough. We have to do it across the board. Another reason for public health intervention. And finally, government agency in action. Now, there's no way in the world Congress is going to regulate the food industry because they're bought off, because 6% of our exports are food. $56 billion riding on this. You can't tell the whole world, you know what? The Western diet, it ain't really so good for you. What do you think would happen? What happened when that one downer cow went from Canada to Washington State back in 2003? That was the end of meat sales to Britain and South Korea for two years. Bottom line, the USDA's job is to protect the food supply. And that includes protecting it from people like me and people like you. That's a problem. Why can't the Farm Bill subsidize real food instead of food ingredients? You know, the Farm Bill was set up because of the dust bowl. So we needed commodities. Commodities means storable food. Food that wouldn't go bad. Like Joseph and Pharaoh. The seven years of famine. They stored grain because you can store grain. Bottom line is we could store real food now because we have the technology to do it. We choose not to, but we need to. The USDA does not have a dietary reference intake for sugar. Why not? Because they don't want you to know that you need to limit your sugar consumption. And finally, food stamps. Bloomberg tried to get food stamps off the USDA list. He was rebuffed. Several states have since applied. Why is the USDA in charge anyway? That's like the fox in charge of the hen house. Do they have anything to do with our health? But the FDA and the European Safety Administration could influence the court of a public opinion if they wanted to. They could make sugar less appealing. Cigarettes went from fashion to filthy habit in just a few years because of David Kessler and the campaign to regulate tobacco. The FDA could revisit the Nutrition Labeling and Education Act. Instead of total contents, we could reflect the degree of processing of the food because all food is really inherently good. It's what we do to the food that's a problem. What we put in or what we take out. Like sugar and fiber. What was added, what was taken away. And finally, we could revisit the 1986 disposition on sugar which said that the data on sugar at the time was quote, inconclusive unquote. Well, it ain't inconclusive anymore. But the FDA has no desire or interest to do this because the food industry runs the FDA. There are plenty of problems with that 1986 document. They were all based on 1978 surveys. Consumption of all sugars at that time was 53 grams. Now the 90th percentile is 104 grams. There was no data on excessive consumption. No data on HFCS. The juice was thrown in with fruit. Not added sugars. That's a problem, okay? Fiber was just a waste product. And the current White House and FDA are not interested. Well, guess what? If the Republicans get in, they'll be less interested. This is the slide I'm going to leave you with. This was from an Indian Public Health Forum called the Hyderabad Statement 2009. All significant advances in population health require and involve the use of law. The legislative and executive branches of government are co-opted. The judicial branch has no horse in the race. And that's how the Mississippi State Attorney General was able to influence tobacco, was through litigation. Now I'm not a for litigation per se, but I am for societal intervention because there's no other way to solve this problem. And you know what? As an endocrinologist taking care of fat kids, we have to solve this problem because that's our future and we are going down the friggin' tubes and you all know it. For further reading, a whole bunch of articles here. You'll get this on the web. Here are some more you know about. And in 2013, you will see this book out on Amazon and everywhere else. Fat chance beating the odds against sugar process, food, obesity, and disease. We have time for some questions, but if anyone's hungry, lunch is officially being served on the same field as yesterday. And we also have some indoor space because we were worried that it would rain. And yes, it's gluten free. We're having local grass fed burgers. So enjoy. Kate Chanahan from Napa. You have to speak up. I'm Kate Chanahan from Napa. And I wanted to say thank you very much for your laser like presentation. I don't want to get on your bad side ever. So I'm going to ask my question that I'm probably going to have to run. No, that's all right. I would actually ask you sincerely, as a human being, to consider maybe rethinking and working with the libertarians because I do believe you, with your power and influence, could gain traction with an organization like that. And what they're saying actually is in total agreement with your last slide where you were saying government regulation is kind of what got us into this Coca-Cola creates the food pyramid structure. Right. The problem, here's the problem. The libertarians are anti-government and they have good reason to be because government has behaved badly. No argument. The problem is we can't solve this at an individual level. We need government for this kind of mass change. Or we can take government out of the way. The problem is you can't expect government to do the right thing. You have to coerce them into doing the right thing. And that's what everyone in this room is about. That's what you're about. That's what I'm about. And that's what we need to do. But the libertarians would say, no, we just need to exclude government. No, we need to include them. And we need to get them on our side. And there are ways to do it. Well, good luck to you. Thank you so much. Hi. Great talk. I just wanted to ask in your study, was there an effect of cereals on diet and stool? No, none. No effect of cereals whatsoever. And if not, why not give them a comparable glycemic index? We did not do it by glycemic index because that data was not available within the food and agriculture organization statistics database. We don't have that data. We did do pulses, nuts, roots, vegetables, and tubers, which would have a low glycemic load because it's high fiber. And that did not have any effect either. And I was actually surprised. I figured that that would actually be protective. It turned out not to be in the model. And I was kind of shocked, but it did not have an effect. We can't do glycemic index with these kind of data. Were you surprised by the cereal results? No, I wasn't. No, I really wasn't because a cereal, glucose, is about insulin secretion. But diabetes is about insulin resistance. And insulin resistance is the big issue in type 2 diabetes. And sugar is the thing that really drives that contrary to what my argument with Dr. Feynman might be. My question is, do you personally eat sugar? No. And how many grams per day? I have dessert two times a year. When I'm in New York, I have a piece of junior's cheesecake. And when I'm in New Orleans, I have bread pudding with whiskey sauce. And that's it. Do you eat fruit? What? Do you eat fruit? I'm not a big fruit lover. I've just never been from when I was even a little kid. It's not my thing. I eat some berries. I'll eat strawberries, blueberries. But I'm not a big apple's peach lover. Just tasting. Yes. You said that sugar explains 25% of the increase in diabetes. Did you analyze the other 75% or do you have any insight into that? No, we have no insight into that. At this point, we have no insight into that. Just completely unexplained. There's a lot of genetics involved. There's other things. I can't tell you at this point. But 25% is pretty darn good. Thank you. Paul Jaminé actually wrote a blog post a while back about what really affects glycemic index. I know it's not as big a focus here. But the point he made actually was that fat is what lowers GI the most versus fiber. Right. Well, in part because of absorption changes with fat. Do you ever promote that or talk about that? I am getting insulin down any way you can. My clinic, for instance, the Weight Assessment for Teen and Child Health Clinic at UCSF. That is our overriding goal. We don't have a multidisciplinary clinic. We have an interdisciplinary clinic because everyone has bought into the same ultimate issue, which is insulins the problem, get the insulin down. And everyone at this meeting has been saying that as far as I can tell since I got here, and there's a thing going on over there and insulin signaling policy at the same time kind of pain in the butt because I would have liked to have been there. But everyone agrees insulin is the bad guy. And we know why insulin is the bad guy because it causes energy storage and it also causes cell proliferation, both of which are bad. So getting insulin down is the answer. And you can do it two ways. You can reduce insulin secretion by restricting glucose, which is basically what the low carb diet is. Or you can reduce insulin resistance by reducing sugar. They're both important. They're both good. Well, you know what? A low processed carbohydrate, low sugar diets called real food. There was also a recent study, and I know this is kind of counterintuitive, but they were showing that if you consumed some amount, not a large amount, but some amount of fructose 30 minutes before a meal, it actually lowered the area under the insulin curve. I haven't seen that. I'll show it to you. If it's fructose alone, it's a problem. Because dietary fructose is poorly absorbed. That's one of the reasons why it hasn't appeared as a sweetener on the market, is because it's so poorly absorbed that the bacteria get it, chew it up, cause extensive gas bloating, diarrhea, et cetera. That's one of the reasons why the food industry hasn't moved to it as a sweetener for just that reason. So if it was a preload of fructose alone, then it's got significant artifactual problems in terms of its interpretation. Yeah, Matt? This is more of a request for your opinion than a question. And please correct me if I'm interpreting this stuff wrong, but there's new information that's come out to show the difference in metabolism in rodents and humans of fructose. And I will preface this in saying that I'm considering the context to be a hypercaloric diet, because let's stick to hypercaloric diet. That's the diet of North Americans. Okay. So in rodents, it seems like the majority of it, maybe 60%, goes to de novo lipogenesis, whereas in humans, it's the reverse glycolysis and it goes into sugar and whatnot. But let me finish before you comment. I look at it and I'm like, okay, so in the rodents, the lipids increase, but then in the humans, once the sugar goes into the bloodstream, the body burns that preferentially for fuel and then the lipids increase. So the end result is the same. What's the big deal and aren't you confusing everybody by saying this because you're making sure you look not as bad as you should? No. I disagree with the premise. Here's why. I agree that the de novo lipogenesis in humans is less than what we see in animals in the hypercaloric situation, but it is still very significant. Now, if you look at de novo lipogenesis as a function of state, that's where we get into the issue. So if you look at the original Parks and Hellerstein paper from JCI 1998, the de novo lipogenesis for an oral fructose load was 3% and everybody said 3% who cares. But then, but the problem is number one, those were normal people who were not calorically overloaded and they were fasting. So they were already glycogen depleted because you already deplete your glycogen by 50% from just the overnight fast. And it was pure fructose. And it was pure fructose so a lot of it didn't get absorbed. So, artifactual issues. Now, if you do that same study, number one, with obese people, number two, insulin resistant people, number three, fed people, and number four, glucose and fructose at the same time, which is what Hudgens and Hellerstein did in JC and M 2011, March 2011, then the de novo lipogenesis increased to 25%, sixfold over what it was in the fasting state. So all of the food industry people say, ah, de novo lipogenesis is nothing. It's irrelevant. It's a non-issue. These are controlled fructose feeding studies. Number one, we're not controlled. That's number one. Number two, we're not underfed. Number three, we're not glycogen depleted. And number four, no one eats fructose alone. So take those and rethink the de novo lipogenesis argument and then now it makes a whole lot more sense. So that's the first issue. You had a second issue too. I was just wondering, in the end, to me, it seemed like it was just going to lead to the same result. So it happens all the time in our community. I present to seminar nutrition. I'm like, yeah, I might get the mechanism wrong, but at the end of the day, the solution is still the same or the end result is still the same. So you don't make as much of a big deal out of that. In both cases, even if the de novo lipogenesis in a human being is lower than that of a rodent, you are still getting increased triglycerides. Yeah, absolutely. It's just a different mechanism. So why are you... For sure. No, I agree with you. I don't understand that. I don't really... Plus, did you see that paper that was in PNAS from... Was it Orlando? That showed that there are fructose receptors on beta cells? Yeah. The point is that normally, the hepatic extraction of fructose in... If you don't drink a 20-ounce coke is relatively complete. You don't get a serum fructose level from a 20-gram fructose load. But if you take a 35-gram fructose load, you get a 6-micromolar fructose level. That's enough to then stimulate the beta cell to over-release insulin, which drives all of this too. The bottom line is we have a limited capacity for fructose absorption, metabolism, and action. And we are over the top by my count three-fold. That's what I'm saying. Excellent. Thank you. I have a policy question. It strikes me that the position of sugar now is somewhat comparable to the position of tobacco in the mid-1900s. Heavily subsidized in terms of the growth of tobacco. Very rich industry. A lot of money into politics. Very socially accepted, popular thing to do. And in a matter of 50 years that turned on its head, was there a defined strategy that turned that on its head, and could that strategy be employed in this debate so that maybe not tomorrow, but over a relative time period that affect in society where an American society, tobacco, is largely a shun activity? Can be brought to bear in this debate also? No argument. That's basically what I'm trying to say, is that that's what we need to do. We need to follow the paradigm of both tobacco and alcohol, and how we did that. The bottom line was this was a bottom-up movement, not a top-down movement in both cases. For instance, mothers against drunk driving made alcohol consumption a problem. Before that it really wasn't, was it? Seat belts are the perfect example. Seat belts started in Australia in 1968. Now, did the Australians know that seat belts would save lives? No, but they thought it was a good public health thing to do, and it had no risk. The big three, now the big two, fought tooth and nail to keep seat belts out of cars until there was a federal mandate in 1979 to have seat belts in every American-made car. Did it save lives? No, it did not. Through the entire 1980s, people continued to get killed in cars. Why? Because there was no mandate to wear them. Mothers against drunk driving made that unacceptable at each state house in the country, and to this day, right now, there is a federal mandate for the inclusion of seat belts in cars, and there are 50 state mandates to wear them. Okay, because of the bottom-up. We can do a bottom-up here, and that's what we did ultimately with tobacco as well. Was it a bottom-up of Grants Well for tobacco as well? Yes, absolutely, absolutely. Thank you. Yes.