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The sugar pandemic:policy vs. politics
UCSF Sleep Apnea Symposium, Feb. 15, 2014
Robert H. Lustig, M.D., M.S.L.
Professor, Pediatric EndocrinologyMember, Institute for Health Policy Studies
University of California, San Francisco
President, Institute for Responsible Nutrition
• no disclosures
U.N. General AssemblySept 20, 2011
• Non-communicable disease is now a bigger problemthan acute infectious diseases worldwide
• Plan to target, tobacco, alcohol, and diet
• But exactly what about diet?Total calories?Fat?Red meat?Dairy?Carbohydrate?
U.N. General AssemblySept 20, 2011
• Non-communicable disease is now a bigger problemthan acute infectious diseases worldwide
• Plan to target, tobacco, alcohol, and diet
• But exactly what about diet?Total calories?Fat?Red meat?Dairy?Carbohydrate?
Addictive and hazardous to your health Addictive and hazardous to your health
New York Times,April 17, 2011
Nature 487:27-29, Feb 1, 2012
Criteria for societal intervention for substance control
• Unavoidability
• Toxicity
• Abuse
• Externalities-negative impact on society
Babor T, Caetano R, Casswell S, et al. Alcohol: no ordinary commodity - research and public policy. Oxford: Oxford University Press; 2003.
Unavoidability
The Fiction“Beating obesity will take action by all of us, based onone simple common sense fact: All calories count, nomatter where they come from, including Coca-Cola andeverything else with calories…”
-The Coca Cola Company, “Coming Together”, 2013
• Some Calories Cause Disease More than Others
• Different Calories are Metabolized Differently
• A Calorie is Not A Calorie
The Science High Fructose Corn Syrup
Current US annual consumption:
• 63 pounds per person
Current users:U.S.CanadaJapanParts of Europe (limited use)
High Fructose Corn Syrup is 42-55% Fructose;Sucrose is 50% Fructose
Glucose Fructose
Sucrose
150150
125
100
75
50
25
0
Grams per day
U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010
150150
125
100
75
50
25
0
Grams per day
U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010
Growth ofSugar Industry
StabilizationHFCS +Sugar for Fat
WWII
150150
125
100
75
50
25
0
Grams per day
U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010
Growth ofSugar Industry
StabilizationHFCS +Sugar for Fat
WWII
Theoreticalthreshold based on EtOH
AHA threshold for CVD
150150
125
100
75
50
25
0
Grams per day
U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010
Growth ofSugar Industry
Stabilization
WWII
Emergence of CVD as health issue 1931
HFCS +Sugar for Fat
Theoreticalthreshold based on EtOH
AHA threshold for CVD
150150
125
100
75
50
25
0
Grams per day
U.S. Commerce Service 1822-1910, combined with Economic Research Service, USDA 1910-2010
Growth ofSugar Industry
Stabilization
WWII
Emergence of CVD as health issue 1931
HFCS +Sugar for Fat
Emergence of Adolescent T2DM as health issue 1988
AHA threshold for CVD
Theoreticalthreshold based on EtOH
Worldwide per capita sugar supply, 2007
FAOStat, 2007
Toxicity
Obesity is not the problem
People don’t die of obesity
Obesity is not the problem
People don’t die of obesity
Metabolic syndrome is the problem
In particular, diabetes:
because that’s where the money goes
“Exclusive” view of obesity and metabolic dysfunction
Obese (30%)
Normal weight (70%)240 million adults in U.S.
72 million168 million
Obese (30%)
Obese and sick(80% of 30%)
Normal weight (70%)240 million adults in U.S.
72 million168 million
Total: 57 million sick
“Exclusive” view of obesity and metabolic dysfunction
Obese (30%)
Normal weight (70%)240 million adults in U.S.
72 million168 million
“Inclusive” view of obesity and metabolic dysfunction
Obese (30%)
Normal weight (70%)240 million adults in U.S.
Normal weight,Metabolic dysfunction
(40% of 70%)
Obese and sick(80% of 30%)
57 million 67 million Total: 124 million sick
72 million168 million
“Inclusive” view of obesity and metabolic dysfunction
Basu et al. PLoS One, 8:e57873, 2013
Imperfect correlation between obesity and diabetes worldwide
Obesity is rising at 1%/year, but diabetes at 4%/year Prevalence of diabetes, 2010
Toxicity :
The degree to which a substance can damage an organ ism
• Does not distinguish acute vs. chronic toxicity
Caveats:
• Exclusive of calories
• Exclusive of obesity
• Human data only
• In doses routinely consumed
Romaguera-Bosch et al. Diabetologia 56:1520, 2013
SSB’s and BMI-adjusted risk of diabetes in EPIC-Interact (Europe)
An international econometric analysis of diet and diabetes
Food and Agriculture Organization (FAO); FAOSTATFood Supply data in kcal/capita/day calculation: Food Supply= ∑Supply Elements - ∑Utilization Elements =
(Production + Import Quantity + Stock Variation – Export Quantity) - (Feed + Seed + Processing + Waste).
Only industrial waste factored in.
Extracted Food Supply data for 2000 and 2007:Total Calories Roots & Tubers, Pulses, Nuts, Vegetables Fruits-Excluding Wine MeatOils CerealsSugar, Sugarcrops & Sweeteners
International Diabetes Federation (IDF)2000 (1st ed) and 2010 (3rd ed)
The World Bank World Development Indicators Databas eGDP expressed in purchasing power parity in 2005 US dollars for
comparability among countries Basu et al. PLoS One, e57873, 2013
Total 175 countries; complete data for 154 countrie s (21 not different)
An international econometric analysis of diet and diabetes
Basu et al. PLoS One, e57873, 2013
Total 175 countries; complete data for 154 countrie s (21 not different)
Data monitoring and quality
Generalized estimating equations
Conservative fixed effects approach (Hausman test)
Hazard model to control for selection bias (Heckman selection model)
Longitudinal data to determine what preceded diabetes (Granger causality)
Period effects controlled for secular trends that may have occurred as a
result of changes diabetes detection capacity or importation policies.
An international econometric analysis of diet and diabetes
Basu et al. PLoS One, e57873, 2013
Total 175 countries; complete data for 154 countrie s (21 not different)
Data monitoring and quality
Generalized estimating equations
Conservative fixed effects approach (Hausman test)
Hazard model to control for selection bias (Heckman selection model)
Longitudinal data to determine what preceded diabetes (Granger causality)
Period effects controlled for secular trends that may have occurred as a
result of changes diabetes detection capacity or importation policies.
Controlled for:
GDP per capita % population living in urban areas
Obesity % of population over age 65
physical inactivity
An international econometric analysis of diet and diabetes
Basu et al. PLoS One, e57873, 2013
An international econometric analysis of diet and diabetes
Diabetes prevalence rose from 5.5% to 7.0% for 175 countries 2000-2010
Basu et al. PLoS One, e57873, 2013
An international econometric analysis of diet and diabetes
Diabetes prevalence rose from 5.5% to 7.0% for 175 countries 2000-2010
Sugar
Sugar+controls
Sugar+controls+period
Overall
Model # countries Effect (95% CI)
Basu et al. PLoS One, e57873, 2013
An international econometric analysis of diet and diabetes
Basu et al. PLoS One, e57873, 2013
An international econometric analysis of diet and diabetes
Only changes in sugar availability predicted change s in diabetes prevalence
Every extra 150 calories increased diabetes prevale nce by 0.1%
But if those 150 calories were a can of soda, diabe tes prevalence increased 11-fold, by 1.1% (95% CI 0.03 — 1.71%, p < 0.001)
This study meets the Bradford Hill criteria for Causal Medical Inference:
—dose —duration —directionality —precedence
We estimate that 25% of diabetes worldwide is expla ined by sugar
Basu et al. PLoS One, e57873, 2013
Figure 1. Adjusted Hazard Ratio of the Usual Percent of Calories from Added Sugar for CVD Mortality Among US Adults Aged >20 Years – NHANES Linked Mortalit y Files, 1988-2006
Histogram is the distribution of usual percent of calories from added sugar in population. Lines show the adjusted HRs from Cox models. Mid-value of quintile 1 (7.5%) was the reference standard. Model was adjusted for age, sex, race/ethnicity, educational attainment, smoking status, alcohol consumption, physical activity level, family history of CVD, antihypertensive medication use, health eating index score, body mass index, systolic blood pressure, total serum cholesterol and total calories. Solid line indicates point estimates ; dashed lines indicate 95% CIs. CVD indicates cardiovascular disease; HR, hazard ratio; NHANES, National Health and Nutrition Examination Survey.
Yang et al. JAMA Int. Med epub Feb 3, 2014
Hazard ratio for CV disease based on percent calories as sugarfor US adult population, 1988-2006 Foodstuffs and metabolic syndrome
• Transfats• Branched chain amino acids• Ethanol• Fructose
• Liver is the only site for energy metabolism• Not insulin regulated• No glycogen pop-off• Mitochondria are overwhelmed
A calorie is not a calorie
Abuse
Obesity and reward
Volkow et al. Philos Trans R Soc Lond B Biol Sci. 2008 363:3191, 2008
Dopamine binding correlates with glucose metabolism both in drug addiction and obesity
CTL Cocaine
D2receptors
CTL Obesity
Cocaine
Metamphet-amine
Cingulate
OFC
Is there really such a thing as sugar addiction?
Need to look for similarities to drugs of dependence
• nicotine• morphine
• amphetamine• cocaine• ethanol
Criteria for addiction
Cross-sensitizationIncreased
ConsumptionEnhanced locomotion
BINGEING
WITHDRAWAL
Tolerance
CRAVING
Negative emotion
Anticipation
Avena et al. Neurosci Biobehav Rev 32:20, 2008 (Courtesy Dr. B. Hoebel)
How about humans? The DSM-V criteria for addiction
2 of the 11 following criteria within a 12-month pe riod:
1.Tolerance2.Withdrawal3.Craving or a strong desire to use4.Use resulting in a failure to fulfill major role obligations (work, school, home); 5.Recurrent use in physically hazardous situations (e.g. driving); 6.Use despite social or interpersonal problems caused or exacerbated by use; 7.Taking the substance in larger amounts or over a longer period than intended; 8.Attempt to quit or cut down; 9.Time spent seeking or recovering from use; 10.Interference with life activities; 11.Use despite negative consequences.
Physiologic
Psychologic
Externalities-
Negative impact on society
Societal intervention requires ““““externalities ””””
Societal intervention requires ““““externalities ””””
If you smoke, drink, or take drugs, it ’’’’s bad for me• second hand smoke• car accidents• declining housing prices• altered work productivity and absenteeism
Societal intervention requires ““““externalities ””””
If you smoke, drink, or take drugs, it ’’’’s bad for me• second hand smoke• car accidents• declining housing prices• altered work productivity and absenteeism
How does your obesity affect me?• $274 million extra for jet fuel (?)• discomfort on the subway (?)• sinking of boats due to the weight (?)
Societal intervention requires ““““externalities ””””
If you smoke, drink, or take drugs, it ’’’’s bad for me• second hand smoke• car accidents• declining housing prices• altered work productivity and absenteeism
How does your obesity affect me?• $274 million extra for jet fuel (?)• discomfort on the subway (?)• sinking of boats due to the weight (?)• $65B reduction in work productivity • 50% increase in absenteeism• 50% increase in health insurance premiums• $150B waste of health care resources• Obesity is a ““““threat to national security ””””
• The Government pays ““““twice ””””
Toxic substances that are not abused
• Iron• Vitamin D• Pseudoephedrine (not turned into meth)
Toxic substances that are not abused
• Iron• Vitamin D• Pseudoephedrine (not turned into meth)
Abused substances that are not toxic
• caffeine• nicotine (but the tars in the cigarettes are)
A vicious cycle: Addiction medicine-
Toxic substances that are abused
• morphine• heroin• amphetamine• cocaine• ethanol• sugar
Recognition at the American Heart Association
Circulation 120:1011, 2009
Recommends reduction in sugar intake from 22 tsp/da y to 9 tsp/day (males) and 6 tsp/day (females)
Response of the sugar industry
Response of the sugar industry1. Fructose for glucose exchange studies show no sig. difference
B. Hypercaloric trialsFavors fructose Favors any CHO
0%0.01 (-0.42, 0.44)212IHCLNon-alcoholic fatty liver (NAFL)
0.04 (-0.43, 0.50)
-0.39 (-0.93, 0.16)-0.68 (-1.23, -0.14)-0.64 (-1.19, -0.10)
-0.33 (-0.63, -0.02)0.06 (-0.29, 0.45)-0.27 (-0.67, 0.14)
-0.27 (-0.49, -0.04)-0.46 (-0.95, 0.03)-0.16 (-0.90, 0.58)
0%
31%47%*97%*
0%0%0%
66%*63%*13%
390
352
352352
121598458
172176
57
sBP
dBPMAP
GBPFBGFBI
GBPFBGFBI
18
13
1313
62824
1316
7
Uric acid
Blood pressure 4
Glycemic control in non-diabetes
Glycemic control in diabetes
0%0.01 (-0.42, 0.44)212IHCLNon-alcoholic fatty liver (NAFL)
0.04 (-0.43, 0.50)
-0.39 (-0.93, 0.16)-0.68 (-1.23, -0.14)-0.64 (-1.19, -0.10)
-0.33 (-0.63, -0.02)0.06 (-0.29, 0.45)-0.27 (-0.67, 0.14)
-0.27 (-0.49, -0.04)-0.46 (-0.95, 0.03)-0.16 (-0.90, 0.58)
0%
31%47%*97%*
0%0%0%
66%*63%*13%
390
352
352352
121598458
172176
57
sBP
dBPMAP
GBPFBGFBI
GBPFBGFBI
18
13
1313
62824
1316
7
Uric acid
Blood pressure 4
Glycemic control in non-diabetes
Glycemic control in diabetes
-4 -3 -2 -1 0 1 2 3 4
1.07 (0.27, 1.87)1.41 (0.43, 2.39)
-0.40 (-1.79, 0.98)0.57 (-0.82, 1.96)
1.24 (0.61, 1.85)
Standardized Mean Differences (SMD) with 95% CI
96%*84%*96%*0%
30%
I2
127
59
2828
119
N
TG
TC
LDL-CHDL-C
6
4
22
10
No. trials
Body weight 2
Cardiometabolic endpoint
Lipids in non-diabetes 1.07 (0.27, 1.87)1.41 (0.43, 2.39)
-0.40 (-1.79, 0.98)0.57 (-0.82, 1.96)
1.24 (0.61, 1.85)
Standardized Mean Differences (SMD) with 95% CI
96%*84%*96%*0%
30%
I2
127
59
2828
119
N
TG
TC
LDL-CHDL-C
6
4
22
10
No. trials
Body weight 2
Cardiometabolic endpoint
Lipids in non-diabetesDolan et al. 2010;Sievenpiper et al.Ann Int Med 2012
Response of the sugar industry
2. Fructose doesn’t raise the blood sugar, has low glycemic index• It’s all taken up by the liver, causes insulin resistance• A fructose receptor has been identified on beta-cells
(Kyriasis et al. Proc Natl Acad Sci 109:E524, 2012)
Rizkalla, Livesey
Response of the sugar industry
2. Fructose doesn’t raise the blood sugar, has low glycemic index• It’s all taken up by the liver, causes insulin resistance• A fructose receptor has been identified on beta-cells
(Kyriasis et al. Proc Natl Acad Sci 109:E524, 2012)
3. A little fructose has been shown to improve insulin secretion
• Like alcohol, it’s dose-dependent (50 gm/day threshold)
Rizkalla, Livesey
Response of the sugar industry4. Information on total sugars is available on the food label for each consumer to make his or her own choice
• NLEA of 1990 lists total sugars (glucose, galactose, fructose)• no information of “added” sugars, which is the problem• food industry petitioned FDA; information on added ingredients was “proprietary”
• 56 names for sugar – that’s on purpose
Wilkening, Popkin
Fat Chance
Response of the sugar industry4. Information on total sugars is available on the food label for each consumer to make his or her own choice
• NLEA of 1990 lists total sugars (glucose, galactose, fructose)• no information of “added” sugars, which is the problem
• food industry petitioned FDA; information on added ingredients was “proprietary”
• 56 names for sugar – that’s on purpose
5. We were wrong about fat; what makes you think you’re right now? WE NEED MORE RESEARCH
• Pessimistic meta-induction theory• Moving the goalposts
• What level of proof do we need? Scientific or Causal Inference?
Wilkening, Popkin
Response of the sugar industry
6. Regulation is tantamount to the “Nanny State” • We’re already told what to eat, with lack of access and choice• Of the 600,000 items in the American supermarket,
80% have added sugar
Wilkening, Popkin
And how do they stay that way?Co-opting dieticians
October 17, 2009American Academy of Pediatrics (Washington, DC)
Welcome Reception Sponsored by
And how do they stay that way?Co-opting medical professionals
And how do they stay that way?Co-opting politicians
Washington Post, Dec. 9, 2013
Philpott, Mother Jones 2012 (from Bureau of Labor Statistics)
How our food dollars have been reallocated Who’s wealthy?• Despite the economic downturn of 2008,McDonald ’’’’s revenues and stock price continues to rise; and Coke and Pepsi still fared better than the S&P 500
Pepsi
McDCoke
S&P 500
Stock prices of various food companies comparedto the S&P500 2007-2013
Who’’’’s winning the war?
Archer Daniels Midland Proctor & Gamble
Kraft
Monsanto
General Mills
ConAgra
Hormel
S&P500
Kraft
Old medicine: infections microbes
New medicine: chronic multinationaldisease corporations
Lancet 381:670, 2013
Personal responsibility vs. public health
• Syphilis• Cholera• Lead poisoning
• TB• Food-borne illnesses• Vitamin deficiencies• AIDS• Pollution• Guns?
Personal responsibility vs. public health
• Syphilis• Cholera• Lead poisoning
• TB• Food-borne illnesses• Vitamin deficiencies• AIDS• Pollution• Guns?• Sugar?
The ““““Let’’’’s Move ”””” Campaign
Focus on the IndividualFocus on the Family
Focus on the CommunityBut leaves government and the food industry out
Anita Dunn (founder of Let’s Move) —now lobbying for the food industry
Question 1:
Can our ““““toxic food environment ”””” be changed
without government/societal intervention?
Especially when there are potentially addictive
substances involved?
Question 2:
Can we afford to wait to enact public health measur es
when health care will be bankrupt due to
chronic metabolic disease?
We believe higher taxation on “sugary” food and drinks would be the best option to reduce sugar intake and help fund the fast-growing healthcare costs associated with diabetes type II and obesity.
We have started a non-profit to provide
medical, nutritional and legal analysis and consult ation
to promote personal and public health vs. Big Food
INSTITUTE FOR RESPONSIBLE NUTRITION
www.responsiblefoods.orgPlease let me know if you would like more informati on!
UCSF Andrea Garber, Ph.D., R.D.Patrika Tsai, M.D., M.P.H.Emily Perito, M.D.Jung Sub Lim, M.D., Ph.D.
Touro University Dept. of BiochemistryJean-Marc Schwarz, Ph.D.Alejandro Gugliucci, Ph.D.
SFGH Depts. of Medicine & RadiologySusan Noworolski, Ph.D.Kathleen Mulligan, Ph.D.
Stanford Prevention InstituteSanjay Basu, M.D., Ph.D.
Collaborators
UCSF Clinical/TranslationalScience Institute
Laura Schmidt, Ph.D.Claire Brindis, Dr.P.H.Cristin Kearns, D.D.S.Stanton Glantz, M.D.
UC HastingsDavid Faigman, J.D.Marsha Cohen, J.D.John Diamond, J.D.Patricia Davidson, J.D.
UC Berkeley Dept. of Nutr. SciencesPat Crawford, R.D., Ph.D.Kristine Madsen, M.D., M.P.H.Lorrene Ritchie, Ph.D.Paula Yoffe, B.A.