 Welcome to Ancestral Health Today. Evolutionary insights into modern health. Thanks everyone. 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 set 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 percent. Here are the secular trends in specific food intake and here are the fats. Milk way down meat and cheese about the same desserts you know milk desserts about the same bottom line we're not eating more fat and if you can see here from the calories from fat going from 40 to 30 percent 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 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 percent increase in soft drinks 35 percent increase in fruit drinks fruit aids etc. 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 percent 45 percent and down on the bottom is sucrose one molecule of glucose one molecule of fructose joined by an oak glycosidic linkage which is cleaved by the enzyme sucrace in 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 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 percent of our total caloric intake by 1994 we were up to 55 grams or 10 percent of our total caloric intake and currently adolescents average 75 grams a day which is 12 percent of total caloric intake so double that for sugar because it's glucose fructose right so that's 25 percent and 25 percent 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 percent 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 this 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 foods 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 nother 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 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 you which was worse the sugar of the fat I think you know the answer here's my daughter when she was in second grade bringing milk cartons home for me for me from the San Francisco unified school district said dad you're not going to believe this over here is Berkeley farms 1% low fat milk 130 calories was it 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 food stuffs 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 hyper insulinemia 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 the sensibly as a browning agent well you all know that that browning that occurs is the my heart 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 my heart reaction occurs you release a reactive oxygen species which has to be quenched by an antioxidant and if you're antioxidant deficient which processed food is you get cell death you get human death in addition to 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 then squeeze it and freeze it lasts 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 ten most obese states in the United States no surprise to anybody here are the ten 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 ten 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 alright now everyone will say wait a second that's correlation not causation indeed it is why because those are poor states and you know they don't have any money to buy decent food etc etc 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 can't 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 100 to 50 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 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 and you know if you don't have any alcohol you got to get your pleasure somewhere what are these five pictures have in common they're all brown that's the my heart reaction okay it's the non enzymatic application or fructose elation 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 now 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 and 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 sugars 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 the question is is a sugar actually addictive anybody see the 60 minutes piece we just got replayed on Sunday night okay Eric Stice thinks sugar is addictive and he's looking at fmri's in the brain and here's the data this is showing dopamine D2 receptors in red in a controlled brain versus a cocaine brain you can see the down regulation of D2 receptors that's tolerance that's the neuro imaging correlative 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 controlled 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 called 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 in 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, etc. 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 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 there are abuse substances that are not toxic like caffeine and if you take my Starbucks away from me I will kill you and nicotine right nicotine is not toxic right you can buy it at Walgreens right and 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 work productivity I gotta 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 boat was coded for 17 people at 165 pounds 24 people at 190 pounds average and the boat went over 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 4F'd and the government pays twice they pay for the food subsidy and then they pay for the ER visits 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 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 5 years and there's the economic downturn of 2008 you know they're doing very well thank you and here's Monsanto, Archer Daniels Midland, Hormel, General Mills, Conagra, Procter and Gamble and Kraft all doing better than the S&P how come because when we have less money we eat more 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 and 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 Siddharth Faroukis 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 9 for men and 6 for women so here's the bottom line 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 I suppose 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 okay that's just a rational academic argument based on the data right so the taxation restriction of access interdiction no one's proposing interdiction I am not banning sugar I'm not suggesting we ban sugar okay 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 okay 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 who get metabolic syndrome in fact thin 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 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 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 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 they instituted 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 changes showed very small decreases 15% of the respondents reported using the calorie information that consumed 106 calories less problem is it was only 15% and that's about right because about 15% of the US population actually has a brain how about for children 349 children since about age 1-17 69% accompanied by their parent no statistically different changing calories before or after labeling 35% ate fast food six or more times per week 7% 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 okay the Olympics is a perfect example of the disaster okay counter advertising campaigns like for instance the New York City Department of Health anybody ever see the YouTube man drinking fat it's fantastic it's wonderful it's great and you know what it doesn't work okay it's wonderful and it doesn't work how about industries self-regulation so in Istanbul in 2007 52 European health ministers got together and said yes they would see 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 okay pricing strategies always work sadly controls at the point of sales bundling strategies and ultimately government agency action where 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 added tax 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 got to raise the bar really high Roland's Sturm down here at the bottom showed that you have to double the price of a can of soda to reduce consumption significantly the other problem is no one trusts government God knows I don't trust them okay 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 okay we could count 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 the kind of like methadone is to morphine you know 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 of and use like for instance carting kids for coke okay 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 okay 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 okay and or if a parent wants their kid to have a coke let them go buy it for them okay I guarantee you 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 okay hydration screw you and 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 okay 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 dollars riding on this and if we 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 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 it could you know the farm bill was set up because of the dust bowl okay so we needed commodities commodities means storeable food food that wouldn't go bad like Joseph and Pharaoh okay you know the seven years of famine right 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 okay 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 right he was rebuffed right several states have since applied why is the USDA in charge anyway that's like the fox in charge of the hen house they have anything to do with our health but the FDA and the European Food Safety Administration could influence the court of a public opinion if they wanted to they could make sugar less appealing you know 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 context 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 okay 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 and fruit 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 indeed 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 whole bunches of articles here I can post you'll get this on the web okay here are some more you know about and in 2013 you will see this book out on Amazon and everywhere else that chance beating the odds against sugar process food obesity and disease thanks for joining us on this episode of ancestral health today we hope you enjoyed our discussion on how evolutionary insights can inform modern health practices be sure to subscribe to our podcast to catch future episodes