 Hello everybody. Welcome to Book Club with Jeffrey Sachs and Professor Robert Lustig Rob. So great to be with you today. Thank you for joining Book Club. Today we're talking about the book we see over your shoulder and that I have in my hand a wonderful and important new book by Professor Robert Lustig called Metabolical and we're going to take an hour together that I think will help everyone understand a very, very important and complicated topic and that is what is going on in our bodies when we eat what should we be eating and why is something clearly not going right in the United States and in a lot of the world regarding how and what we eat. Professor Robert Lustig is one of the world's leading authorities, also a good friend and I admire his leadership in this area. He's a great scientist. I'm going to try to hold you speaking on the level we can understand because you understand a lot of the very deep mechanics and biochemistry of all of this. For us we're trying to make sense of what's happening in our bodies and what we should be eating. Professor Lustig is a emeritus professor of pediatrics at University of California, San Francisco. He's an endocrinologist. I'm going to ask him to explain what that means because that's very important for our story and he's a best-selling author and he has written extensively about food and health and diet and the food industry. His book before this one is a marvelous bestseller called Hacking of the American Mind. It's about topics that we're going to talk about today, how our food affects how we think, which affects how we eat, which affects how we live and how healthy or unhealthy we are. Metabolical has a subtitle, The Lure and the Lies of Processed Food, Nutrition and Modern Medicine. It takes on a very big topic and that's where I'd like to start Rob. First, maybe you could explain what an endocrinologist is so we know what it is you do for a living, what it is, the kinds of patients you've been seeing for decades and how that relates to your advocacy for healthy food. First of all, Jeff, thank you so much. I got to tell you, I've been doing a lot of podcasting lately because of the book being coming out. I have had this highlighted right around it for the last two months, so excited. I cannot tell you what a joy it is to be here. Now, you want to know what an endocrinologist is? Maybe I'll explain that when you tell me what an economist is. I'm going to give you a secret which you know also is I'm actually married to an endocrinologist. I think I know 41 years of happy marriage, but I think you should let the rest of us know. And love to see them. So an endocrinologist is a doctor who studies the hormones of the body. And in particular, the system that has come to the fore is obesity. In 1994, we discovered a hormone called leptin. And leptin is a hormone that goes from your fat cells to your brain and tells your brain, you know what? I've got enough energy on board to engage in normal, expensive metabolic processes. I can burn energy at a normal rate. I can feel good. I can go through puberty. I can go through pregnancy. It is essential for the survival of the species. However, when leptin is not working, your brain says, wait a second, where's all that energy? I must be starving. Therefore, I better ratchet my energy expenditure down. I better sit on the couch. And while I'm at it, I better eat the Doritos in order to be able to actually create more leptin. So it is this phenomenon of inability to see one's leptin that has led to this obesity pandemic. As an endocrinologist, my job was to figure out what's the cause of that. And so that's how I got into this food issue and trying to understand exactly what the metabolic parameters were that surrounds our current obesity epidemic. And in the process, what I learned was that this non-communicable disease pandemic of type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, cancer, dementia, failure of disease, polycystic ovarian disease, these eight diseases will go inexorably and faster than obesity is going up. What is the link? And so I have basically spent the last 25 years trying to put this all together. Rob, if there's a lot of word wealth that I would like everybody to learn and to accumulate in this. So one key phrase you just used is non-communicable disease. I think that's really important for people. We're living in the COVID-19 pandemic. That's a communicable disease. It's a disease that spreads from one person to another. What is non-communicable disease and how does it relate to this story? So non-communicable disease are the diseases of the environment. So things that don't necessarily spread through an infectious route, but through an environmental route. So non-communicable disease means that you don't necessarily give it to your neighbor or to your family member directly through secretions or through the air. But ultimately, you're all exposed to the same thing. So the way to think about this is basically dissecting obesity. So if you look at the obese population of the United States, 240 million adults in the United States and 30% of them are obese. So BMI over 30. Explain quickly, BMI. BMI is weight over height squared. It's a method for being able to take people's adiposity and put it on an index that makes sense. And if in the scale you're over 30, you're classified as obese and over 25, typically you're called overweight. Correct. And if you're under 15, you're actually in big trouble in the other direction. So 15 to 25 is the normal range. We unfortunately now have a mean BMI in this country of about 27. We used to have a mean BMI in this country of about 22. So we are on average five BMI points higher than we used to be. And there are a whole lot of people that are skewed to the right with BMI's way over 30. And we know that as you, BMI increases, your risk for disease increases. And however, in your prime percent, I was going to say, since you were pediatric endocrinologist, you were seeing kids coming in obese as well. So this is an epidemic, meaning this unusual explosion of some phenomenon of this illness that was affecting young kids as well as adults. And why? Kids are always the carry in the coal mine. Well, you know, my colleague Wyse at Stanford famously said, the pediatrician of the witnesses to failed social policy. And in fact, that's exactly right. This obesity epidemic that has affected everyone has affected kids the worst because kids were never obese. We now actually have an epidemic of obese newborns. Now, they don't diet and exercise. How come we have an entire cadre of obese newborns? And we know that because the mean birth weight in Israel, Russia, South Africa, U.S. have increased by 200 grams. Okay, so that's basically half a pound over the past 25 years. And when you do dexa scanning to determine body composition on those newborns, it's all fat. Wow. So how come newborns are being born with a half pound extra fat? That can't be from behavior. That has to be from exposure. It's just not an infection. It turns out the exposure is the food. And that's what I've been studying for the past 25 years. And just to explain to everybody, because in Metabolical, you emphasize that I think I have the term right that you say obesity is actually a biomarker. The disease is not necessarily obesity. Obesity is a reflection of disease. And so too is the higher rate of dementia. So too is the cardiovascular disease. In other words, we're seeing an epidemic, not just of people who are overweight or obese, but we're seeing an epidemic of a very wide range of diseases saying something in our body is going amiss. And this is, it's happened in timescale relatively recently from the 1970s onward. Somehow this has soared out of sight. And that's the puzzle. You actually call it a game of clue. What is going on here? That this remarkable epidemic, and that is the mystery that you have been trying to unravel in several books now. And they are all pointing at and more and more this this book describes in great detail. A basic point that when you started as a doctor, the answer you would have given to this is not the answer you would give now. Maybe you could go in that direction. What did we think it was? Or what did you think it was at the beginning? For sure. So, you know, I've watched this that mean this has all happened on my watch. You know, I entered medical school in 1976. And back then, only 2.5% of the adults over age 65 had 2 diabetes. Today, it's 9.4% of the entire population, rather than just the aged. And one out of every three new diagnoses of diabetes in children is type 2. This is a disease we never saw before 1980. And by the way, wasn't a type 2 diabetes, which is not from a pancreatic failure, but somehow acquired from the environment, as you say, was called adult onset traditionally, if I'm correct. So, this is now seen in children. That whole term makes no sense because it's happening in children, not just in adults. And that's why the term changed for exactly that reason. Point is that back in 1970, if you saw a patient with type 2 diabetes, if you saw a patient with fatty liver disease, which by the way, is the other huge epidemic, because 45% of American adults now have fatty liver disease that they just don't know it, because it doesn't necessarily manifest until much later as cirrhosis. And then you need either a liver transplant or you're dead. When children get these diseases, okay, which they never got before, you know, something's got to be wrong. Well, prior to 1980, those two diseases, type 2 diabetes and fatty liver disease were the diseases of alcohol. So if you saw a patient with fatty liver, that was an alcoholic until proven otherwise. Today, by the way, I thought cirrhosis of the liver, that's an alcoholic, but exactly, not anymore. Not anymore. That's the point. And today, 20% of children, normal weight children have fatty liver and 40% of obese children. So these were the diseases of alcohol, but kids don't drink alcohol. So the question is, what could be affecting their bodies in such a way as to cause these diseases? So what we've learned over the past 40 years is that these are not just the diseases of aging. These are not just the diseases of alcohol. These are the diseases of mitochondria. Now mitochondria are the little energy burning factories inside all of our cells. And our cells have to make a chemical energy called ATP in order to power the cell. The only cells that don't make ATP are the cells that are dead. Every cell makes ATP, it is crucial for survival. And what we've learned is that we now in order, because of this epidemic, we've learned that we have components of mitochondrial dysfunction. Our mitochondria not working like they should. They are not burning energy like they should. And in the process, we are laying down fat and we're laying down fat in places we never laid them down before, such as, for instance, the liver and also the pancreas. And they are now contributing to these chronic metabolic diseases, type 2 diabetes, lipid problems, fatty liver disease, et cetera. Fatty liver disease plays such an important role in this story. Could you explain what it is? What does it mean to have fatty liver disease? And what is the liver supposed to do? And what doesn't it do when you have fatty liver disease? Right. So normally, your pancreas tells your liver what to do. And it does it by releasing the hormone insulin. Insulin goes from the pancreas to the liver. Now normally, other hormones, when they're released from their organs, they go into the vena cava to the heart. But insulin's different. Insulin goes from the pancreas to the liver because the liver is the primary target of insulin action. So when fat builds up in your liver, your liver gets sick. It doesn't work right. It doesn't process nutrients like it's supposed to. And there's a reflex that tells the pancreas, you know what? Just like you would have on an assembly line if you had workers that were out. You'd have backup. And so things slow down. And the pancreas ultimately makes more insulin to try to make the liver do its job. This raises insulin levels all over the body. And so you end up with a phenomenon called hyperinsulinemia. And it turns out insulin is a growth factor. So it is true. It helps shunt energy into cells for utilization. It helps shunt energy into fat cells for storage. But it also is a growth factor. It causes cells to divide. Like for instance, coronary artery muscle cells to divide. And when they divide, you know what happens? Your coronary artery is narrow. And you know what happens then? You get a heart attack. It also causes breast cells to divide. And what happens when breast cells divide? You get breast cancer. And so insulin is the linchpin that connects our food to all of these chronic metabolic diseases. And so the question is, where is this liver fat coming from? Why is our insulin so high? Because when we solve those two questions, we will be able to mitigate this pandemic of chronic metabolic disease. By the way, when I go to the doctor and get a routine blood test, I don't, I may be wrong, but I've never heard of my insulin level being tested. Am I wrong about that? No, you're absolutely right. But I think that's the first thing they should test. Now, I will be very honest with you. The American Diabetes Association right on their website says, don't draw a fasting insulin on people. And they say it for two reasons, both of which are disingenuous and untrue. Here's the reason they say that. They say that the insulin assay is not standardized across all laboratories. Therefore, it's inconsistent. That's true, but it's true for a different reason. Turns out our pancreas, when they are stressed, when they are working so hard, they don't have a chance to process the insulin molecule correctly because they're trying to push it all out as fast as they can because our livers are so sick. And so what happens is there's a piece of the insulin molecule that has to be cleaved out. It's called C-peptide in order to turn pro-insulin into insulin. So you end up secreting pro-insulin as well as insulin, and that gets picked up in the insulin assay. And it turns out pro-insulin only has 5% of the activity of the actual insulin molecule. So the more the pancreas works, the worse the stuff that comes out of it, but it still gets picked up in the assay. So unfortunately, cheap assays don't distinguish those two species. So that's irrelevant. That sounds like a solvable problem, by the way. Well, it is a solvable problem, but it's a moot problem, too, because your levels are high, your levels are high. The second reason they say don't draw an insulin level is because insulin levels don't correlate with obesity. That's right, they don't. They correlate with chronic metabolic disease. And there are thin people who have chronic metabolic disease. 40% of the normal weight population have the exact same diseases as do the obese. They get type 2 diabetes, hypertension, lipid problems, cardiovascular disease, cancer, dementia also, but they get it at a normal weight. So yes, it's true. Fasting insulin does not correlate with BMI. It correlates with disease. So I think the fasting insulin is the most important. And that's what we did in our clinic for 20 years to basically ferret out who was sick and why. So it's such a different story from the story that we normally hear or that our doctors tell us. And I don't think that it is a mainstream idea that Americans are sick with liver disease. Again, it's not something that you normally hear, but just to make sure that I understand and help everyone to understand, the argument you're making with all of the science behind it, of course, is that when the liver has this fatty liver disease or cirrhosis, it causes a cascade of malfunctions in the body. And the most notable one is that there's insulin resistance of the liver. And because of that, the normal thermostat of insulin production, if I could mix metaphors, but the normal control isn't working. And so the pancreas is pushing out more and more of this hormone. And that affects the whole body, because the insulin has all of these powerful biological effects, causing growth of tissues or causing other kinds of disease outcomes. And so a sick liver can show up as cardiovascular disease that can show up as type two diabetes, not adult onset diabetes. It can show up as dementia. It's incredible. But the point is that insulin is such a central part of overall metabolism that when it's dysfunctional, so many things become dysfunctional in the body. And one of the things you point out, and again, I want to make sure I understand this, is that this hyperinsulinemia is also part of what makes that appetite signaling go wrong. Did I get that right? That it actually blocks the brain's uptake of the leptin, which is what you started by telling us keeps our appetite under control. So there's a side effect that we're now going to eat even more. That's exactly right. So this basically is a vicious cycle. Because your leptin doesn't work, your brain thinks you're starving, so you need to eat more. So we started with the question, well, what causes that leptin resistance? What is preventing the leptin signaling from working in the brain? And it turns out the answer is insulin. Insulin blocks leptin signaling. And you'd say to me, well, why should that be? What's the selective advantage in nature when you see this kind of thing? There's always a selective advantage. And the answer to that is, there are two times in your life when you actually don't want your leptin to work perfectly. And they are puberty and pregnancy. Because if your leptin always worked right, you couldn't go through puberty. And if your leptin always worked right, you couldn't carry a baby to term. So it's essential for the survival of the species that you be able to block leptin signaling so that you can gain the weight to be able to go through puberty, to be able to carry a baby to term twice in your life. But then when puberty's over or when the baby's out, you need to be able to revert back to where it was before. The point is that we now have leptin resistance 24-7365 all the time. And the reason is because we have high insulins 24-7365. And the question is, why do we have high insulins? Because our livers are sick. And why is our liver is sick? Because there's fat in the liver. And why is there fat in the liver? Because mitochondria are not working. And why are there mitochondria not working? And the answer is... That's where we're getting to. Right. And the... What is the answer? The two-word answer is processed food. And the one-word answer is sugar. Okay. Please explain. Because that's important. And we like sugar, so... Well, we do. How could the cascade go from something so good as sugar or something so tasty as sugar to... Now, if I got it right, from sugar to the mitochondria to the fatty liver to the insulin and to all of the problems that cascade from there, sugar. My God, what is that about? Right. And why the liver? Why the liver? Right. So it turns out that the food industry has been telling you for 50 years now that sugar is energy. And you need sugar to live. Neither of those things are true. Okay. Those are distinct falsehoods. They are eminently disprovable. And in the book, I, you know, lay out the entire argument as to just how fallacious both of those terms, those statements are. Sugar is energy. That's true. But that doesn't necessarily make it a food. So can you name an energy source that is energy? It's got calories. But there's no biochemical reaction in the body that requires it. That when consumed in excess, it is toxic to cells, to humans and causes death. And we love it anyway. And it's addictive. The answer is alcohol. So alcohol is energy. It's seven calories per gram. But alcohol is not a food. There's no dietitian on the planet who would call alcohol a food, even though it's energy. Okay. It damages cells. It damages humans. It causes death. And it's addictive. And it's addictive. So just because something has energy doesn't mean it's okay. Not that there's no biochemical reaction in the body that requires alcohol. None. Okay. So we have now debunked the idea that energy equals food. Well, it turns out sugar is metabolized exactly like alcohol. And alcohol damages mitochondria. Well, guess what? Sugar damages mitochondria. A metabolite of sugar, which we've now isolated, called methylglyoxyl, actually poisons mitochondria at three separate places in the mitochondrial life cycle. And so we now have the data to show that sugar induces mitochondrial dysfunction even in children. And when your mitochondria don't work, guess what? Neither do you. And this is the basis of why sugar is not a food. In fact, sugar is a poison. Now, our livers have a capacity to metabolize poisons, but only up to a certain point. So just to say that the analogy with alcohol is not merely an analogy. It's a metabolic parallel. And it's a metabolic parallel also in the how it implicates the liver, because both of them lead to liver disease, both alcohol and sugar. And that's why children now get cirrhosis for just that reason. So it's not just a metabolic parallel in terms of its metabolism. It's also a metabolic parallel in terms of its addiction capacity. And it's also parallel in terms of how it's marketed. Yeah. So a basic point not to divert us too much, but there's sugar and there's sugar, as I understand from the book. So there's glucose, there's sucrose, there's fructose. What am I to make of all of this? And what is the takeaway of this? Because if I understand correctly, it's not all sugars, but a particular kind of sugar. That's right. So there are monosaccharides, there are disaccharides, there are starches. This is where things get a little bit complicated from a biochemical point of view. And the food industry uses that complicated paradigm to confuse and obfuscate the truth. So I will make it very clear in what I'm saying. Dietary sugar is not blood sugar. Blood sugar is glucose. Dietary sugar is glucose fructose. Two different molecules join together to form something called sucrose, table sugar, cane sugar, beet sugar, the crystals you put in your coffee. However, if those are separate and not bound together, we call that high fructose corn syrup. Right. No difference. There are two molecules, one glucose, one fructose. The only difference is are they joined or are they free? That's the difference. So people say high fructose corn syrup is the evil one. No, they're all evil. The difference is high fructose corn syrup is cheaper. Because it's cheaper because it's home grown, because we have a steady supply of it. Also because it's miscible, because it's already in liquid, it's a syrup, it doesn't precipitate out, it doesn't crystallize out. This is what gave us Chips Ahoy Chewy Cookies. The bottom line is the food industry, because it was half the price of sugar and because it didn't crystallize out and because you could ship it around the world in big tubs, it basically took over from sugar for quite a while. And so our consumption went straight up. And it is that increase in total sugar because of that fructose molecule, and we'll talk about that in just a minute. The increase in our sugar consumption, because it became so cheap, that basically unraveled and unleashed all of these chronic metabolic diseases since the 1970s when high fructose corn syrup first came to our shores. Now the question is what is going on with that fructose molecule? So glucose, that other molecule which is in starch, it's in bread, it's in pastas, it's in rice, it's in potatoes. That's just straight glucose. Now it's not that glucose is good per se, it causes an insulin response, then we've just learned that high insulin is bad and it is. But compared to fructose, glucose is a walk in the park. Fructose, there's no biochemical reaction in the body that requires it, is completely vestigial from human life, it is a leftover remnant from our plant ancestors way back in the evolutionary tree before we all split off prokaryotes from eukaryotes, you know, as far back as, you know, the evolutionary goes. It's a storage form of energy for plants. It acts differently. It is not our energy source, glucose is. And because it's not our energy source, only the liver has the capacity to metabolize it, only the liver has the glucose transported that transports fructose too. And there's a limit to how much your liver can process, just the same way there's a limit to how much alcohol your liver can process. Once you exceed that amount, you get spillover, guess what, then it goes to your brain and now you're drunk, right? With fructose, you don't get drunk, you get irritable instead. So that's the big difference. But in terms of what your liver sees and what your liver does with it, it's pretty much the same. And so when your liver is overwhelmed by the fructose tsunami from say a soft drink, your liver has no choice but to take the excess and do something with it, it turns it into liver fat. And then that liver fat precipitates as a lipid droplet in the liver. And now you've got fatty liver disease. And now you've got the start of all of the chronic metabolic diseases that we've been talking about this whole hour. So fructose sounds like fruit. Fruit does like it. Is fruit bad for us? So fruit is glucose and fructose just like table sugar, cane sugar. The difference is number one, there's not that much sugar in fruit. Yes, it's sweet, but it's not that much. And the antidote is there as well, the fiber. So it turns out fiber is the nutrient you don't absorb. And the reason is because it's not the nutrient for you, it's the nutrient for your bacteria in your intestine, your intestinal microbiome. This is the work that's really gone on in the last 10 years in medicine is understanding the role of the gut microbiome. And it turns out that microbiome. We have trillions, trillions of microbes, all of us, as many or more microbes in our gut as ourselves in our body, if I understand correctly. 10 times as many. So they got to eat. So the question is, what do they eat? Well, they eat what you eat. The question is, how much did you get versus how much did they get? When you consume an apple, that is glucose and fructose with fiber, turns out that most of the glucose and fructose never actually made it into your circulation. It was blocked from being absorbed early on in the duodenum, the first part of the intestine, by the fiber. The fiber sets up a gel on the inside of the intestine that blocks early absorption. That keeps your liver from getting the tsunami. So it stays healthy. And what it also means is that more of that sugar goes further down the intestine to where the bacteria are. And then the bacteria chew it up for its own purposes. So when you eat the apple, you're feeding your bacteria. And that's a nice thing to do. And that's a good thing to do. When you drink the apple juice, where the fiber has been removed and stripped out, now you're flooding your liver. So you have basically turned something that was healthy into something that was poisoned just by processing it. So apples, okay, or good, apple juice. That's right. So there are different levels of processing. So there's an apple, then there's, say, a sliced apple de-stemmed and de-seeded. That's a level of processing, which doesn't affect things very much. The skin is still there. The fiber is still there. It's still intact as a matrix. Next level would be, say, apple sauce. Now you've disrupted the fiber. You've actually sheared a lot of it to smithereens. You might have added sugar in the process because there's sweetened applesauce. There's unsweetened applesauce. So that's going to have a different metabolic effect. And finally, then you have either apple juice or an apple pie. It's all apple, except from a metabolic standpoint, they couldn't be more different. And by the way, as you emphasize, the old mantra was a calorie is a calorie. And it's almost exactly the opposite, as you've just explained. Exactly right. A calorie isn't a calorie. It's how we got here. All right. And unfortunately, most of the medical and dietary professions still espouse that. And you know, Einstein's theory of insanity, doing the same thing over and over again, expecting a different result. This is what is wrong. This is what has to change. My self-appointed job is to kill the calorie. The fact that the calorie even exists on the nutrition facts label is an egregious affront to science. And this is what has to go. And unfortunately, it means a lot of people in the field have to be put out to pasture. Because as you explained, even the way that the calorie is measured and obviously it doesn't do service of its metabolic effects, it doesn't measure what we actually absorb of those calories. Because when it's measured, if I understand correctly, it's if you burn the food, how much energy do you release? But we don't operate that way like a bomb calorimeter. So it doesn't even say what our body actually does with what is on that label. That's right. Well, so there's the calorie. So you measure a calorie at the mouth. Who cares? What you care about is number one, how many calories did you absorb? And when you consume the food with fiber, you absorbed way less. You absorbed about 35% less. And also then what happened to the food once it got metabolized? So if it turns out that those calories were sugar, that's liver fat. Whereas, for instance, if it was a protein or even a fat, that would not be liver fat. And so different foods convey different disease potentials. And none of this has anything to do with calories. And if anyone in the audience has any problem with that concept, all they have to do is think about alcohol and trans fats. Trans fats are like any other fat in terms of bomb calorimeters. But trans fats are the devil incarnate. We know that because our cells can't metabolize them. So what happens is they just line our arteries and we know the trans fats are consumable poison. The fact that they have nine calories per gram is irrelevant. They are consumable poison. And we know that and that's why they're coming out of the food. So the caloric equivalent and the metabolic equivalent of any given food have nothing to do with each other. Therefore, calories are worse than useless. They are detrimental. And we need to kill them. Rob, what would happen if I don't know if it's possible? Because I don't know what I'm about to say. But could you bake with glucose rather than fructose? Or could you basically have the kind of sugar that isn't going to kill the liver? Sure. So basically, glucose alone is like kerosirup or molasses. Now, can you bake with molasses? Sure. You know, they're molasses cookies, right? But you know what? They're not that sweet. They have a very different flavor. And you know, it doesn't do the same thing to your reward system. They don't sell that well. If you want to make profits, get into the addiction business. That's right. And fructose, as it turns out, activates that reward center in the same way alcohol does. And in the same way cocaine, heroin, nicotine also do. So the fact of the matter is in the extreme, fructose is addictive. And we have the data to demonstrate how that works and why. Well, guess what? Food industry knows that. But it's legal. You know, if they could put cocaine in the food, they would. But you know, they can't. So they do this instead, and it works just as well. And as we know from history, when the Europeans discovered that you could make sugarcane in the Caribbean or in other colonies at mass scale, the sugar addiction in Europe was so overwhelming that it created the empire's slavery, ruthlessness of empire. The motivating factor of sugar is what we know in the 20th century of a different kind of, quote, energy of oil. It led to wars, slavery, and so forth, because the addiction was so powerful from a sociological point of view. Indeed, addiction has driven much of what's gone wrong in the world. We can go all the way back to the, you know, opium wars of the 1800s in China. We can talk about oil, you know, and what it's done to our economy. And, you know, now, you know, sugar being, you know, the one that's ultimately impacting our individual metabolisms and ultimately basically train wrecking modern medicine and healthcare around the world at the same time. So if I want to summarize accurately, is it right to say when you introduced the problem of processed foods as the two words and sugar as the single word, processed foods are foods with added sugar and taking away the fiber? Is that the main two facts that combined are making them particularly dangerous? So processed food is a lot of things, but if I had to sum it up in, you know, in a simple, you know, sentence, I would say processed food is high sugar, low fiber food. Now there are other things too. There's branched chain amino acids, there's glyphosate, there's pesticides, there's, you know, a whole host of various things, none of which are good for us metabolically. And I go through them in the book. There's an entire, you know, part of the book that is dedicated to explaining what all of those ingredients are on the side of the package and how they are affecting your body's metabolism and particularly your mitochondria. But by far and away, the big kahoonas in the story are the amount of sugar and the lack of fiber. And if we lived in a normal world, what happened yesterday, interestingly, to go back to the oil analogy for a moment, there had to be a shareholder revolt against Exxon, Chevron, and there was a lawsuit against Shell. So three events happened recently in which this oil industry, which is doing so much damage to the world, was confronted because even though we know that the CEOs know about the damage, they said, well, that's not our problem, we're making money. So naively, I would have thought that by the time the United States arrived at an obesity epidemic, a fatty liver disease epidemic, a cardiovascular disease epidemic, a dementia disease epidemic, and the science was pointing more and more that this sudden change from the 1970s onward has a common factor. I would have thought, stupidly, but let me just say it, that the CEO of Coca-Cola and PepsiCo and Kraft and others would say, oh my God, what are we doing? This really dangerous, Dr. Lustig, what should we be doing? Is that how the story goes? So no, unfortunately, that's not how the story goes and it's just the same thing as what happened with tobacco and what's happening now with the oil industry. The pressure is coming from the outside, not from the inside. So in the book, I actually talk about three separate people who have tried to change the industry from the inside, who recognized the problem. Indra Nui, CEO of PepsiCo, realized I'm making my own home country diabetic. Which is amazing because that's a case where in India, there's a lot of diabetes, in other words, a lot of metabolic syndrome, but it doesn't show up as obesity. It shows up as these other diseases that you've been pointing out have the same roots. India has an 11% diabetes rate. Ours is 9.4. They have a higher diabetes rate than we do and they're not obese. Again, pointing to the fact that this is not about obesity. This is about metabolic derangement and it can happen anywhere, including India. So Indra Nui tried, she even hired Derek Yack away from the WHO and he was Mr. Anti-Tobacco in an attempt to try to fix the problem from within and in 2011, she lost $349 million and Wall Street called for her head on a spear because she quote took her eye off the ball. She tried, she failed. Denise Morrison, CEO of Campbell's Soup, tried to fix it. She ended up being fired and most recently, Emmanuel Faber at Denone actually was able to reduce the portfolio, the total consumption of a portfolio of sugar in the Denone line by 14%. Now, whether that's good or bad, we can discuss. The point was he was making an effort and he's gone too. So the fact of the matter is this can't happen from the inside because it's about the money. This is going to have to happen from the outside, just like it did with tobacco and just like as you showed yesterday, as you talked about yesterday, with the oil companies coming from the outside. Same thing with the opioids, by the way. So bottom line, anything that's addictive has to come from the outside. Look, tobacco, sugar, exactly the opioids and the Sackler family, which was producing opioids knowing that these were addictive and leading to suicides, leading to such unhappiness and yet they persisted. And till today, they're trying to save their billions, which is disgusting because why should you have any return on this other than disgrace after deliberately putting addictive products into the bodies of the public? Well, Jeff, I'm going to basically usurp your line as an economist. It's all about the money. It's always been about the money. And unfortunately, we're dying for it. Where in this story has Coca-Cola been? Because this is probably the most iconic single brand in the world. You've been making this point through so many important scientific discoveries and then bringing this to the attention of the public as in this wonderful book. And what does the industry say to you, if other than trying to ignore you somehow or wishing you would just go away? Well, like Gandhi said, first they ignore you, then they laugh at you, then they fight you, then you win. We're in the fight now. The fact is, Coke has tried to discredit me and not just Coke. I mean, it's multiple vendors, not just Coca-Cola, but Coca-Cola is sort of the prototypical 2,000-pound gorilla in this. The fact is, they continue to this day to hold on to this notion of calories. And the reason is because that's the only thing they can hide behind. And what we're doing is we're basically stripping that veneer away and demonstrating that metabolic health is really the important thing here. It's not about calories, it's not about obesity, for all the reasons we've discussed already. And people are starting to understand that and Coke sales without question have gone down. In fact, off-drink sales over the world. Maybe something for listeners to understand because it took me a long time. I went from Coke to Diet Coke. And you explain why that's not such a swift move and it doesn't solve this problem. Could you just spend in our closing minutes just a word about that because I'm sure a lot of listeners are saying, I get it, I get it, I don't drink sugar beverages, but I do drink Diet Coke or something else. And that is not an answer. Right. So I'll make it really, really, really quick. It's about the insulin. Turns out diet sweeteners make your insulin go up too. Yeah. Whoa. Why? Basically, you put something sweet on the tongue and your insulin goes up. Because your brain doesn't know it actually activates a nerve called the vagus nerve that sends a message to your pancreas to release extra insulin anyway, even though there were no calories involved. So bottom line, we need to de-sweeten our lives. But by the way, the process food is the antithesis of that. A Diet Coke would not raise what some of us follow the glycemic load because you wouldn't get the blood sugar going up, but you wouldn't get the insulin going up. Is that correct? And that's the point. And that's why glycemic index and glycemic load are not the issue. The insulin response, glycemic index and glycemic load are proxies for the insulin response. And it is, in fact, diet sweeteners that actually undo that argument, both fructose, which doesn't raise your blood glucose, it raises your blood fructose, which is way worse. And diet sweeteners, which don't raise your blood glucose, but they raise your insulin because of this metabolic pathway, the neural pathway I just mentioned. So bottom line is the glycemic load is not what we should be looking at. What we should be looking at is components of metabolic health. And the insulin response is the best arbiter of that currently. The oil companies are being sued right now for the damage that they've done. And some of these cases are winning in the Supreme Court of different countries. Could you sue the food industry till it gets on the case? We are. We already are. There have been several cases, and I've expert witnessed for some of them. You may notice, if you go into the store today, that raisin bran is now not healthy. There was a lawsuit against Kellogg's and there was a lawsuit against Post, both of which were won by the plaintiffs. There are current lawsuits, which I won't mention right now because they're in process. But these have to do with advertising and deceptive advertising, rather than actual faulty product, defective product or strict liability. Or for that matter, behavior, like for instance, racketeering or whether or not states are out money, like parents' patriot, I like what happened with the tobacco litigation back in 1994. These are all things that are in process. They're happening, but these are very slow slogs for obvious reasons. And ultimately, no one wants litigation from the bench. No one wants regulation from the bench. Ultimately, it behooves the food industry to understand that they can actually make more money doing the right thing. The problem is that right now, they're addicted to the food subsidies. And until we get rid of the food subsidies and get the food industry recognizing that they can actually make money by selling real food rather than process food, we will not find our way out of this. And that's where government comes in. And that's where people like you and I come in. Rob, in the remaining moments, can we ping you for some advice for our individual health? What should we be doing in the midst of all of this right now? What lessons should we take in terms of how we're eating so that we can avoid all of this story that is so powerfully told in this book? So in the book, I have a chapter. What does healthy really mean? And that's what it all comes down to. How do you know if any given food is healthy, whether you should put it in your mouth or not? And I basically narrow it down to two precepts. Six words, two precepts. Okay. One, protect the liver. Two, feed the gut. Any food that does both is healthy. Any food that does neither is poison. Any food that does one or the other, but not both is somewhere in the middle. Now, if you understand what you're trying to protect the liver from, protect it from the onslaught of simple sugars, refined carbohydrate, glyphosate, iron and heavy metals, that's what you're trying to protect it from. You'll choose appropriately. If you realize you have to feed the gut, well, what does the gut like to eat? Well, the gut likes to eat fiber, but it needs to eat both soluble and insoluble fiber. So fiber one bars are not the answer because they are only soluble fiber. But if you recognize that food that came out of the ground has its inherent fiber, you know, you're good to go. Basically, it's called real food. Real food does not have a label because it doesn't need a label because nothing's been done to it. So what you need to realize is if a food has a label, it's a warning label. And that's how you have to approach it. Rob, we have come to the end of an hour you've covered. Well, this book Metabolical covers a remarkable body of science, so much of which you have led and partnered with to help us understand what is going on in our society and around the world that is leading to this epidemic, multiple epidemics of non communicable diseases. You have shown us how to take on the food industry, which is you and I and others are going to continue to do that. And I'm sure many people listening in are already engaged in that it is like taking on big oil or big tobacco or the other poisoners that operate on greed rather than on the common good. And you've also thank you for giving us six words, protect, deliver, feed the gut. I'm going to say that you protect the public and you feed the mind. And I'm really grateful for that. I'm sure I speak on behalf of all of the listeners for thanking you for this new tremendous book and for all of the insights and guidance we needed. We are in a struggle to save the planet and to keep ourselves healthy and well and have the kind of the world that we want and you're playing a great role for that. Thank you so much for being together with us. Thanks to all of the listeners. Metabolical Professor Robert Lustig's tremendous new book. Thank you for joining Book Club with Jeffrey Sachs. Can I just say that Jeffrey you have been an inspiration to me for decades and it has been the greatest pleasure to get to know you and call you my friend. Wonderful. I feel the same way. Thank you so much. Thanks for being together and thanks to everybody. We'll see you all soon. Great.