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Sugar, dietary devil

First: exercise; then: cut sugar and add fibre Frank Armstrong 


Just as the issue of climate change is rarely deemed newsworthy, in a world where consumption is God, the obesity pandemic is seldom recognised. Compared to a terrorist outrage the slow impact of dietary and lifestyle change makes little impact in an increasingly squeezed media focused on impact, and compromised by the advertising buck. That is the difference between news creep and a single dramatic event.

But the cumulative effect of over-consumption is havoc: for the first time since the Industrial Revolution, in the United States parents are likely to live longer than their offspring. Over 40% of US death certificates now list diabetes as the cause of death, up from 13% twenty years ago. The increasingly-prevalent Type 2 diabetes is usually a consequence of ‘metabolic syndrome’: “a cluster of chronic metabolic diseases characterised by energy overload of the mitochondria” usually caused by obesity. The long-term cost in medical bills and lost productivity in the US is staggering. Already $147bn (and rising) in medical expenses clock up each year. This includes 100,000 bariatric surgeries – such as gastric bypasses or fitting gastric bands – at $30,000 a pop.

Robert Lustig may be the most articulate US public health advocate confronting the pandemic. His recent book, ‘Fat Chance: The Bitter Truth About Sugar’, is a triumph of clarity and prescience. His lecture: ‘Sugar: the Bitter Truth’ has been a Youtube sensation, garnering over 3.5m hits. He is a medical doctor steeped in the science but sensitive to his patients’ needs, and, importantly, aware of the economic and social context. As a communicator he has Bill Clintonesque empathy. He closed his book with the words: “I love you all”, and I believed him.

But Big Love is nothing to  Big Food. One member of the Obama administration revealed to Lustig that nothing could be done to help his campaign against sugar. Big Food is too powerful, even for the federal government. The successful legal challenge to New York Mayor Bloomberg’s soda tax reveals the strength of the industry.

It seems the Irish government is similarly cowed, as their unwillingness to introduce a ‘fat tax’ in the latest austerity budget shows. This is despite a recent UCC study which estimated the cost of obesity to the Irish exchequer to be in the region of €1bn. Now even developing countries are contending with increased health expenditure as the US diet spreads.

For Lustig, the ‘Professor Moriarty’ of an admittedly very complicated piece is sugar which, besides offering empty calories, generates hormonal imbalance and toxic overload comparable to the effect of alcohol. It is far from being the only cause for people being overweight and in bad health, but its ubiquity is revealed by the following statistic: “Of the 600,000 food items for sale in the United States, 80% are laced with sugar’’. As a result 20-25% (or 22 teaspoons daily) of all US calories come in refined sugar.


Health and weight

The best policy is to avoid all processed food. As Lustig puts it: “If the food comes in a wrapper, the wrapper has more health benefits than the food. Fast food is the antithesis of real food”.

Body mass index (BMI) is a rather crude measurement of obesity, as it is often not indicative of health, and does not take account of race. Underweight individuals can be just as susceptible to the deleterious effect of poor diet while you can have a high BMI and be perfectly healthy. Brian O’Driscoll may be categorised as obese but much of his weight is muscle, though even highly active people are not immune from the effects of bad diet.

Interestingly, according to Lustig, numerous studies have shown that exercise does not lead to weight loss because once we put it on our body seems to retain a memory of its old weight. So when you leave fat camp – so to speak – the satisfaction of your appetite will return your body to its previous size: “Once the balloon is filled, it doesn’t want to be deflated”.

But exercise is the best thing we can do for our health, and being moderately overweight has even been shown to be healthier than being underweight. That is the flaw with a TV show such as Operation Transformation which uses weight loss as the criterion for success. When weight returns, as it seems to, patients feel discouraged and resume eating pathogenic foods. A message needs to be sent out that you can appear overweight and be healthy so long as you are active and eat the right food.

If the food comes in a wrapper, the wrapper has more health benefits than the food

It is where we store excess baggage that really counts. Visceral fat around our organs (big-belly fat) is very dangerous, but substantial sub-cutaneous (mainly stored in our posteriors) fat actually correlates with longevity. Where we put on weight is determined by the type of food we eat and the effect of cortisol, the steroid hormone we release under stress: “Insulin makes you gain weight, while cortisol tells you where to put it”.

Concentrated fructose derived from sugar cane, sugar beet or high-fructose corn-syrup (they are equally bad) causes a spike in insulin secretion which inhibits the release of the hormone ghrelin that otherwise would tell us we are full. It is also metabolised as fat in the liver, and works in our brain like alcohol or cocaine when it releases dopamine. Humans have not adapted to fructose – a highly refined industrial product which, when encountered in nature, is safely encased in fibre or guarded by bees.


Caveman cravings

Fibre is the great lacuna in the industrial global diet. Paleo-biologists performed DNA footprint analysis of 3-10,000-year-old stool samples from caves in Texas and estimated that these cave dwellers consumed about 100g of fibre per day, yet our median consumption of fibre today is a mere 12g.

Lustig has a simple solution to the deficiency of fibre: “I would propose that all we need to do is eat ‘safe carbs’. That means low sugar to prevent insulin resistance, and high fibre to reduce flux to the liver and prevent insulin hypertension”. Refining grain is a threat to our health.

The main reason fibre does not feature prominently in the modern industrial diet seems to be that it does not preserve well, while sugar actually adds shelf life. Furthermore, high-fibre, unlike sugary, foods promote satiety. Naturally the food industry wants to sell more food, and sugar has the benefit of being something we eat without causing us to feel full, which is great for business.

Sugar is also cheap, owing in large part to the perverse subsidy regime in the United States promoting an artificially low price for maize even though its cultivation is dependent on climate-change expediting fertilisers. Thus: “only 19 percent of all money spent on food in the United States is for the food itself. The other 81 percent is for packaging and marketing”. The Farm Bill originally promulgated by the Nixon administration and now costing $20bn annually was designed to keep the cost of food low, in part to bring political quiescence in the wake of the rambunctious Sixties. It has succeeded spectacularly.

If you eat a vegetarian or vegan diet the way our gatherer ancestors did – eating the food as it comes out of the ground – you’re good to go, although you might need to supplement the diet with calcium and vitamin D

Lustig advocates a complete change in subsidies, to bring down the price of healthy vegetables and fruits. He argues that horticulture is environmentally beneficial due to its low carbon impact and that short shelf-lives militate in favour of local production. That advice has important implications for Ireland where subsidies are devoted almost exclusively to environmentally-egregious livestock production and where fresh local vegetables and grains are a rarity. This healthy food could be much cheaper.

He says: “If you eat a vegetarian or vegan diet the way our gatherer ancestors did – eating the food as it comes out of the ground – you’re good to go, although you might need to supplement the diet with calcium and vitamin D”.

He shows how high meat consumption is tied to metabolic syndrome which is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Many sufferers exhibit a prevalence of branched-chain amino acids – meat from animals fed on corn – in their bloodstream.

Lustig endorses aspects of the so-called ‘Paleo’ diet of foods available to our ancestors before the ascent of agriculture, including meat from grass-fed livestock. But he reckons it leaves a deficiency of vitamin D and calcium and questions the necessity of excluding wholegrains which were present in the pre-agricultural diet: that explains why they were domesticated in the first place. But for him its biggest drawback is expense: “the poor aren’t invited to the Caveman party”. Also, advocates are unwilling to recognise its unsustainability. Perhaps a vegan diet which excluded all refined foods would be the best option: there is substantial evidence that vegans and vegetarians have lower BMIs, and would be much cheaper.


Big Food needs Big Profit

One area that Lustig does not explore is the extent to which our staple grains have been bred for yield as opposed to for nutrition. Lower yielding, ancient varieties often have a superior nutritional profile but. with most farmland devoted to the production of grain as livestock feed. there is little scope for their cultivation. Anyway, there is no rationale for Big Food to produce food we would need to consume less of, and niche producers only reach a limited, generally elite, market.

Lustig’s work shows the futility of proposals by our Minister for Health for restaurant menus to include calorie counts, since there is little benefit to a low-calorie meal high in refined sugar. It is how we metabolise calories that count: the interplay of hormones that different foods generate and the extent to which fibre is part of the meal. Further, calorie-counting menus do not include the drinks which are often high in fructose; Lustig is critical of any calories contained in liquid form such as fruit juices.


No easy answers

Lustig is clear there is no pharmaceutical panacaea for the problems we are facing. He says of the prospect of a wonder drug: “that’s a pipe dream because, first, obesity isn’t one disease, it’s many; second, our bodies have many redundant pathways to maintain our critical energy balance, and one drug can’t possibly be effective for everyone; and third, there’s no one drug that will treat metabolic syndrome”.

He also sees bariatric surgery as being of limited use: “One of the biggest public misconceptions is that bariatric surgery consistently works in the long term…[But] the underlying causes of the obesity…the behaviours of reward and stress…are not remotely alleviated”. Furthermore: “[It] doesn’t prevent you from drinking your calories”.

Lustig acknowledges that exercise is the single most important measure we can take for our health, but, as indicated, this has little or no relevance to weight loss in the long term. “Exercise is the single best thing you can do for yourself. It’s way more important than dieting, and easier to do”. Thus, health rather than weight loss should be recognised as the desired outcome. But health is intangible and difficult to determine, and the delayed pleasure of avoiding disease usually takes second place to the appeal of being able to fit into a dress or pair of jeans. The trick is to incorporate exercise into daily routines as opposed to punishing gym schedules which are invariably abandoned.

One obvious way would be to seriously discourage motor-car usage, though here again vibrant lobbies distort the approach. He believes our urban environments in particular should be arranged so that cycling is given top priority, rather than the current arrangement where safe cycle tracks are a rarity and the absence of contra-flows makes journey unnecessarily long in Dublin’s city centre. With its temperate climate Dublin could be a cycling city comparable to Copenhagen and Amsterdam. Further, it is anomalous that Iarnród éireann charges for all train journeys with a bicycle, unlike in the UK.

Any sugar tax or other measure to curb the consumption of unhealthy foodstuffs obviously has to be carefully considered as it is potentially regressive. Lustig counsels that proceeds should be invested in subsidising wholefoods.


Changing behaviour

We should recognise the obesity pandemic for what it is: a crisis of industrial civilisation comparable and linked to climate change, in the  cynicism of its proponents if  not the longevity of its consequences. Countering an urge to consume highly calorific, unnatural food and live lifestyles of low energy expenditure is a huge challenge for a species that has above all  evolved mechanisms for coping with periodic shortages: storing calories in particular. But how do we regulate our behaviour in this era of plenty?

Alas these questions are not being addressed in our education system, and the abandonment of mainstream religion has removed many constraints on  behaviour of all sorts. Jettisoning much of what has become gospel is essential in this still new millennium.