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Fat Chance
Robert H. Lustig, M.D., M.S.L
FAT CHANCE
Copyright
First published in Great Britain by
Fourth Estate
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First published by Hudson Street Press, a member of the Penguin Group (USA) Inc.
Copyright © Robert H. Lustig 2012
The right of Robert H. Lustig to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988
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Ebook Edition © December 2012 ISBN: 9780007514137
Version: 2018-08-03
Dedication
This book is dedicated to all the obese patients worldwide who suffer daily, and the family members who suffer with them. The children who will not know a normal childhood, who will endure an inhuman existence, and will die a slow and early death. The parents who are engulfed by guilt. The unborn children, who are already imprisoned by changes in their brains and their bodies. But most of all, I dedicate this book to those of you who are or have been my patients; for it is you who taught me the science of your affliction. You also taught me more than medical school ever did or could; and that each life is valuable, precious, and worth saving. You maintained your dignity in the face of the most adverse circumstances imaginable. You shared with me your misery, and your joy in small victories. We cried and we laughed together. I hope I was of some service and comfort.
This book is my way of returning the favor.
This book is written only for those of you who eat food.
The rest of you are off the hook.
INTRODUCTION: Time to Think Outside the Box
“We just eat too damn much.”
Governor Tommy Thompson (R-Wisc.), U.S. Secretary of Health and Human Services, Today, NBC, 2004Indeed we do. That’s it, thanks for buying this book, you’ve been a great audience, I’m outta here.
Well, that’s what the U.S. government would have you believe. All the major U.S. governmental health agencies, the Centers for Disease Control (CDC), the U.S. Department of Agriculture (USDA), the Institute of Medicine (IOM), the National Institutes of Health (NIH), and the U.S. Surgeon General, say that obesity results from an energy imbalance: eating too many calories and not getting enough physical activity. And they are right – to a point. Are we eating more? Of course. Are we exercising less? No doubt. Despite knowing this, it hasn’t made any difference in the rates of obesity or associated diseases. More to the point, how did this epidemic happen and in such a short interval of just thirty years? People say, “The food is there,” and it is. But it was there before. People say, “The TV is there,” and it is. But it was there before, and we didn’t have this caloric catastrophe. There’s more to this story, way more, and it’s not pretty.
Everyone blames everyone else for what has happened. No way is it their fault. Big Food says it’s a lack of activity due to computers and video games. The TV industry says it’s our junk food diet. The Atkins people say it’s too many carbohydrates; the Ornish people say it’s too much fat. The juice people say it’s the soda; the soda people say it’s the juice. The schools say it’s the parents; the parents say it’s the schools. And since nothing is for sure, nothing is done. How do we reconcile all these opinions into a cohesive whole that actually makes sense and creates changes for the better for each individual and for all society? That’s what this book is about.
Food is not tobacco, alcohol, or street drugs. Food is sustenance. Food is survival. Most important, food is pleasure. There are only two things that are more important than food: air and water. Shelter’s a distant fourth. Food matters. Unfortunately, food now matters even more than it should. Food is beyond a necessity; it’s also a commodity, and it has been reformulated to be an addictive substance.
This has many effects on our world: economically, politically, socially, and medically. There is a price to pay, and we’re paying it now. We pay with our taxes, our insurance premiums, and our airline fares – nearly every bill we receive in the mail has an obesity surcharge that we underwrite. We pay in misery, worsening school scores, social devolution, and we pay in death. We pay for all of it, one way or another, because the current food environment we have created does not match our biochemistry, and this mismatch is at the heart of our medical, social, and financial crisis. Worse yet, there is no medicine for this. There is no edict, ordinance, legislation, tax, or law that can solve this alone. There is no quick fix, but the problem is resolvable if we know what’s really going on – and if we really want to resolve it.
In his 2004 book Food Fight, Kelly Brownell of Yale University talks about obesity and the “toxic environment” we now live in, a euphemism for our collective bad behaviors. I am going a step further. I’m interested in whether there is something actually toxic, I mean poisonous, going on here. Even laboratory animal colonies have been getting fatter over the past twenty years!
Every good story needs a villain. While I am loath to reveal it this early in the book, I won’t keep you in suspense. It’s sugar – the Professor Moriarty of this story, a substance that now permeates nearly all food and drink worldwide. It’s killing us…slowly, and I’ll prove it. Every statement throughout this book is based on scientific study, historical fact, or recent statistics.
I’m a physician. We take an oath: primum non nocere (first do no harm). But there’s a paradox in this statement: when you know the final disposition – that the outcome is going to be bad – then doing nothing is causing harm.
I certainly did not start out as an advocate. I wasn’t looking for a fight. I didn’t come to this controversy with a preconceived agenda. Indeed, I was fifteen years into my medical career before I stepped up to deal with obesity as an issue. Until 1995, like my medical colleagues, I did my best to avoid seeing obese patients. I had nothing to tell them except “it’s your fault” and “eat less and exercise more.” At that time, seeing an obese child with type 2 diabetes was an anomaly. Now it is an almost everyday occurrence. The problem of obesity is now inescapable in medical practice. You can’t avoid it any more.
The concepts elaborated here didn’t just wake me from sleep one day in a divine revelation. This book is the culmination of sixteen years of medical research, medical meetings, academic discourse with colleagues, journal clubs, policy analysis, and a whole lot of patient care. I have no conflict of interest in espousing the information here; I am not a pawn of the food industry or a mouthpiece for any organization. Unlike many authors addressing the devastation of obesity, I don’t have a product line designed to enrich my bank account. I came by these views honestly and through rigorous data analysis. And the data are out there for everyone to examine. I’m just putting them together somewhat differently.
As a scientist, I have personally contributed to the understanding of the regulation of energy balance. As a pediatrician, I get to watch the interaction between genetics and environment that causes obesity play out in my examining room every day. And now, as a fledgling policy wonk, I have seen how the changes in our society have sprouted this global pandemic. It is this panoramic view that allows me to connect the dots for you, and they don’t connect in the way you’ve been told.
To blame obesity on the obese is the easy answer, but it is the wrong answer. The current formulation of gluttony and sloth, diet and exercise, while accepted by virtually everyone, is based on faulty premises and myths that have taken hold in the world’s consciousness. Obesity is not a behavioral aberration, a character flaw, or an error of commission. When we think about the ravages of obesity, our minds often go first to adults. But what about kids? One quarter of U.S children are now obese; even infants are tipping the scales! Children don’t choose to be obese. They are victims, not perpetrators. Once you understand the science, you realize what applies to children also applies to grown-ups. I know what you’re thinking: adults are responsible for their own choices and for the food they give their children. But are they?
An esteemed colleague involved in the obesity wars once said to me, “I don’t care what’s causing the obesity epidemic. I just want to know what to do about it.” I respectfully disagree. In order to pull ourselves out of this ditch, we have to understand how we drove into it. Indeed, our current thinking is based on correlation, supposition, and conjecture. I wrote this book to persuade you, the reader, to take up this cause, for your own health and for our country’s. However, you can’t truly advocate for a cause unless you know what is going on. And you can’t disagree with me until you know all the facts. And that means the science. After you’ve read this book, if you think it’s a crock or that I’m a crank, tell me. I want to know. In fact, I’ll make a promise to you right now: there is not one statement made in this entire book that can’t be backed up by hard science. My reputation in the field is built on the science. It’s also my protection against those who would try to discredit me, including the food industry and, as you will see, the federal government. Indeed, it’s the only reason I haven’t been discredited yet. And I won’t be, because I stick to the science. Now and forever.
However, in four places in the book, I let my imagination run wild. I will try to explain how obesity fits within the process of evolution, how our evolutionary biochemistry works to keep us alive, and finally how our food environment has altered that biochemistry to promote this global catastrophe. These fits of speculation will carry the section heading “Deconstructing Darwin.”
This book is targeted at the patients who suffer, the doctors who suffer along with them, the U.S. electorate who pays for this debacle, the politicians who must take up arms to dig us out of the mess that has been created out of our economy and our health, and the rest of the world, so they don’t make the same mistakes (although they already have).
In Part 1 of this book, I will challenge some of the theories you’re used to hearing in the media, and indeed from the medical profession. Parts 2 and 3 will focus on the science of obesity, and how the body deals with energy burning versus storage. No, you don’t need to be a biology or medical expert to understand the science. I’ve worked hard to reduce it down to its essence, and to keep it interesting, light, and accessible. In Part 2, I’ll also explain how your brain has developed, evolutionarily and in utero, to thwart your attempts at dieting. You truly are hormonal when it comes to the foods you crave, just not in the ways you think. Part 3 will elaborate on the science of fat tissue, and when and how it can make you sick. In Part 4, I will prove that our current environment is indeed “toxic.” I will show how the “American diet,” which is now the “industrial global diet,” is killing us…slowly. I will identify the poison and the antidotes, why those antidotes work, and why they’ve been added to or removed from our diet for the food industry’s purposes. Part 5 elaborates what you, as an individual, can do to protect yourself and your family by changing your “personal environment.” Finally, in Part 6, I argue that governments around the world have been co-opted by the food industry, and I will outline how they must instead partner with the populace and exert influence over the food industry to stop the obesity pandemic before we all reach the medical and financial Armageddon now within sight.
PART I
The Greatest Story Ever Sold
Chapter 1
A Fallacy of Biblical Proportion
Juan, a 100-pound six-year-old Latino boy whose mother is a non-English-speaking farm worker from Salinas, California, comes to my clinic in 2003. He is wider than he is tall. I ask the mother in my broken Spanish, “I don’t care what your kid eats, tell me what he drinks.” No soda, but a gallon of orange juice per day. On calories alone, this accounts for 112 pounds per year of body fat. Of course, some of that is burned off, and it might influence total food intake. I explain to the mother, “La fruta es buena, el jugo es malo (the fruit is good, the juice is bad). Eat the fruit, don’t drink the juice.” She asks, “Then why does WIC [Women, Infants, and Children, a government entitlement program for the poor run by the U.S. Department of Agriculture] give it to us?”
One kid, one mother, one question, my life was changed – and the need for this book was born. Why does WIC give it to them? There is real science behind our worldwide obesity catastrophe. And science should drive policy, but as you will see, the politics get in the way. This is the most complex issue facing the human race this side of the Middle East conflict. And it has become incrementally more complicated over time, with multitudes of stakeholders with set agendas, and bigger than the individual parties involved. Devoid of simple solutions, it has destroyed families and claimed the lives of countless people.
You can’t pick up a newspaper or log on to the Internet without seeing some new statistic on the obesity pandemic. It’s all obesity, all the time. And how many of them have something good to report? You can bet that any tabloid headline is about one of two things – either the statistics are getting worse or another obesity drug was denied or withdrawn by the Food and Drug Administration. I’m sure you’re sick of it. I know I am. And weight loss has turned into a blood sport – just tune in to The Biggest Loser.
In 2001, Newsweek reported that six million kids in America were seriously overweight. We have tripled that number in a decade, and the numbers are now surpassing twenty million. Yet for all the media attention, visibility, discussion, and weight loss programs, even Michelle Obama can’t put the genie back in the bottle.
While we’re getting fatter, we’re also getting sicker. Our risk for illness is increasing faster than the increase in obesity. Indeed, the cluster of chronic metabolic diseases termed metabolic syndrome – which includes obesity, type 2 diabetes, hypertension (high blood pressure), lipid (blood fat) disorders, and cardiovascular (heart) disease – is snowballing by leaps and bounds. And then there are the other obesity-associated metabolic diseases, such as nonalcoholic fatty liver disease, kidney disease, and polycystic ovarian syndrome. Add to that the other comorbidities (related medical conditions) associated with obesity, such as orthopedic problems, sleep apnea, gallstones, and depression, and the medical devastation associated with the obesity pandemic is staggering. Every one of these diseases has become more prevalent over the past thirty years. What’s more, all of them are now found in children as young as five years old. We even have an epidemic of obese six-month-olds![1]
The human damage in this scourge of metabolic syndrome is showing. In 2005 one study showed that despite the increased availability of medical care, our children will be the first generation of Americans who will die earlier than their forebears.[2] The study placed the blame squarely on the obesity epidemic. In the United States, quality-adjusted life years lost to obesity have more than doubled from 1993 to 2008. Emergency rooms are taking care of forty-year-old heart attack victims. Teens with type 2 diabetes used to be unheard of; now they are one third of all new diagnoses of diabetes. In the United States alone, 160,000 bariatric surgeries (to reduce the size of the stomach) are performed per year, at an average cost of $30,000 per surgery. Over 40 percent of death certificates now list diabetes as the cause of death, up from 13 percent twenty years ago.
The loss in American productivity due to time off from work is staggering, the waste in medical expenditures ($147 billion per year) is breaking the bank, and this amount is predicted to increase to $192 billion by the end of the decade. Guess what? There’s no money to pay for it all. The Affordable Care Act (ACA, or “Obamacare”) is going to put thirty-two million sick people on the insurance rolls by 2019. The president says we’ll make up for the costs in savings from preventative care. However, it is unlikely to improve our health in any significant way, as there are no provisions for the prevention of chronic disease, most notably those that attend obesity. How do you prevent all the ravages of chronic metabolic disease when we bust the scales and when the statistics show no sign of improvement? It’s often been said that we wouldn’t need health care reform if we had obesity reform.
It would be one thing if obesity were an isolated problem in America, but it’s happening everywhere. The obesity pandemic has expanded the world’s collective waistline. The World Health Organization (WHO) has shown that the percentage of obese humans globally has doubled in the past twenty-eight years. In fact, obesity’s contribution to the burden of chronic disease has been equal to if not greater than that of smoking. Even people in developing countries are obese. After only one decade, there are now 30 percent more people who are obese than are undernourished worldwide. The WHO reported in 2008 that approximately 1.5 billion adults were overweight and at least 400 million were obese globally[3]; these numbers are projected to reach about 2.3 billion and 700 million, respectively, by 2015. In September 2011 the UN General Assembly declared that non-communicative diseases (diabetes, cancer, and heart disease) are now a greater threat to world health than are infectious diseases, including in the developing world (see chapter 22). Is the whole world now composed of gluttons and sloths? Over the next fifteen years, these diseases will cost low- and middle-income countries more than $7 trillion.[4] People are dying earlier, and national economies are losing billions of dollars in lost productivity while governments pay for the medical expenditures. Millions of families end up in poverty, guaranteeing that the cycle will not be reversed.
For the 55 percent of adults who are overweight or obese, listen up. I’m talking to you, at a doctor-to-patient level, at a person-to-person level. Obesity is not an automatic death sentence. A full 20 percent of morbidly obese persons are metabolically healthy and have normal life spans.[5] As for the other 80 percent, you don’t have to be in poor health; everyone has it within his reach to improve his health and regain those years the actuaries say will be lost. But success in doing so depends on identifying the cause of the problem, assessing your metabolic risk, and changing your biochemistry. Okay, full disclosure: despite your best efforts, you may never lose your stubborn subcutaneous fat (the fat that pads your thighs and derrière). And if you do, you’ll gain it back in short order – unless you become a gym rat, because vigorous exercise is the only rational way to prevent weight regain (see chapter 13). In fact, if you lose meaningful amounts of subcutaneous fat and keep it off for more than a year, I’ll be shocked. Pleasantly so, but shocked nonetheless.
For the 45 percent of adults who are normal weight, pay attention. You either sneer at or pity the other 55 percent of your brethren who take up two seats on the bus. You look down on them as weak, overindulgent, and lazy. You resent them, and you show it financially and socially. You’re indignant that they cost you money. And you think you’re out of the woods and home free. You’ve been told that you’ll live a long and happy life. Whatever you’re doing, it must be right. For those of you who are “naturally” thin, you’ve been told that you have great genes and can consume all the soft drinks and Twinkies you want without gaining a pound or getting sick. Would that it were true. A few years ago, you were the majority of Americans. Now you’re the minority. And you’re losing your percentage year by year.
This means that many of you are flipping – that is, gaining weight and going over to the dark side. Indeed, current projections suggest that by 2030, the United States will be 65 percent overweight and 165 million American adults will be obese.[6] The 2008 movie Wall-E is a prophecy: that’s where we’re all headed. We’ll all be so fat, we’ll have to ride around on little scooters, just like at Walmart. And as you get older, your risk for gaining weight keeps going up. Your genes won’t change, but your biochemistry will. So, if you’re flipping (which more and more of you are), something must be sending you over to the “dark side.” And if that’s not your fate, it will be that of your children. Nobody knows this better than I, because I take care of those children every day.
Here’s the kicker. Being thin is not a safeguard against metabolic disease or early death. Up to 40 percent of normal-weight individuals harbor insulin resistance – a sign of chronic metabolic disease – which will likely shorten their life expectancy. Of those, 20 percent demonstrate liver fat on an MRI of the abdomen (see chapter 8).[7] Liver fat, irrespective of body fat, has been shown to be a major risk factor in the development of diabetes. You think you’re safe? You are so screwed. And you don’t even know it.
The overriding thesis of this book is that your fat is not your fate – provided you don’t surrender. Because people don’t die of obesity per se. They die of what happens to their organs. On the death certificate, the medical examiner doesn’t write down “obesity”; instead it’s “heart attack,” “heart failure,” “stroke,” “diabetes,” “cancer,” “dementia,” or “cirrhosis of the liver.” These are diseases that “travel” with obesity. They are all chronic metabolic diseases. But normal-weight people die of these as well. That’s the point. It’s not the obesity. The obesity is not the cause of chronic metabolic disease. It’s a marker of chronic metabolic disease, otherwise known as metabolic syndrome. And it’s metabolic syndrome that will kill you. Understanding this distinction is crucial to improving your health, no matter your size. Obesity and metabolic syndrome overlap, but they are different. Obesity doesn’t kill. Metabolic syndrome kills. Although they travel together, one doesn’t cause the other. But then, what causes obesity? And what causes metabolic syndrome? And what can you do about each? Read on.
I wrote this book to help you and your kids get healthy and improve your quality of life, increase your productivity, and reduce the world’s waste of medical resources. If you get thin in the process, great. But if that’s what you expect, go find your own diet guru, and good luck with that. Want to get healthier? Want to get happier? Want to get smarter? It’s your visceral (around your abdominal organs) fat and hepatic (liver) fat that’s keeping you down. And getting rid of visceral fat is not as hard as you might think. This is the more metabolically active fat, and there’s plenty you can do to shrink it.
