Is Sugar a Killer?
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Among the least likely viral megahits on YouTube is a 90-minute lecture by the food scold and pediatric endocrinologist Robert Lustig entitled “Sugar: The Bitter Truth.” He delivers it in a windowless room at the Osher Center for Integrative Medicine at the University of California, San Francisco. The talk is simultaneously boring and powerful, combining the gravitas of a national health crisis, the thrill of conspiracy theory, and the tedium of PowerPoint slides. Midway through the talk he scans the hall for approval. “Am I debunking?”
The UCSF extension students mutter “yeah”—most of them, at least. Lustig has a way of seeking validation and pissing off people at the same time. His combined love of showmanship and need for approval led to acting in 12 musical-theater performances during his three years as an undergraduate at the Massachusetts Institute of Technology. His greatest role yet may be as the loudest, most contrarian voice in the public-health debate over why we get fat and what we should do about it.
Lustig is an imperfect front man for abstemious eating. At age 55, his face is puffy. He looks disheveled even in a coat and tie. People love him and people love to hate him, especially after he proposed in the journal Naturethat sugar should be regulated like alcohol and that people who buy soda should be carded. Almost three million people have watched Sugar: The Bitter Truth. Alec Baldwin publicly lost 30 pounds by following Lustig’s rules and giving up toxic foods, even trying to avoid the sugar in a dish his mother calls “love pie.” Still, a leading endocrinologist, who asked to go unnamed, called Lustig an “idiot.”
Public reception of Lustig’s new book, Fat Chance, will likely be just as divided. The book repeats and expands on the main point of contention in the sugar wars: whether our bodies treat all calories the same. The old guard says yes: A calorie is a calorie; steak or soda, doesn’t matter. Eat more calories than you burn, you’ll gain weight. Lustig believes that our bodies react to some types of calories differently than others. Specifically he believes that sugar calories alter our biochemistry to make us hungry and lazy in ways that fat and protein calories do not. As a result, he says, the ubiquity of sugar in the Western diet is making Americans sick, obese, and bankrupt.
But Lustig does not stick to explaining his reasoning and raising public-health awareness. “Education has not worked. Labeling has not worked. And they’re not going to work,” he told me in his characteristically emphatic way. “Education hasn’t worked for any addictive substance.” According to Lustig, we need to accept that America’s obesity problem can’t be fixed by a Puritan resolution by each individual to eat fewer calories. To fix America’s obesity problem, we need a regulatory framework for selling and serving less sugar-laden food.
A morning spent in Lustig’s UCSF Weight Assessment for Teen and Child Health Clinic (next door to Lustig’s endocrinology clinic) puts a person in touch with the Sisyphean absurdity of trying to solve the nation’s weight problem one patient at a time. The exam rooms fill up with fat kids. They empty and fill again. Tucked in a back corner of the second floor of a clinic building across the street from Benioff Children’s Hospital is Lustig’s office, a cramped galley that he shares with two doctors, two nurses, a nutritionist, and a social worker. The computers look vintage, circa 1997.
“This kid is a disaster—an unmitigated disaster,” Lustig muttered one day in October as he read aloud an old case file on the ancient screen. “No breakfast, two lunches, two dinners, eats in the middle of the night.”
He turned to me and asked, “What’s your tolerance for swearing?”
I shrugged. He swore and said, “What a mess.”
In the exam room Lustig encountered an overweight 14-year-old boy dressed in orange and black—it was Halloween and the San Francisco Giants had just won the World Series—with the telltale dark ring around his neck that signals insulin resistance. Lustig high-fived the boy, put down the old leather doctor’s bag in which he keeps his stethoscope and prescription pad, and asked what he was eating. The boy knew exactly what to say. No snacking, no fast food, no soda, no eating after dinner. “That’s good,” Lustig said nonchalantly. Patients’ self-reports of their diets are notoriously unreliable. “You want to know why you’re gaining weight?”
The kid didn’t move.
“Let me tell you what’s happening. You’re not a glutton. You’re not a sloth. But if you eat a lot of carbohydrates or drink those sweetened drinks, the sugar makes your insulin shoot up. You know that ring around your neck? It means your body has chronically high insulin. That’s not good. Insulin steals the energy from your blood and puts it into your fat. Say you eat 1,000 calories. Your insulin grabs 500 of those calories and stores them in your fat tissue. And guess what? You’re still hungry and you feel tired.”
The second patient’s file appeared more promising. When Lustig last saw this boy he’d been doing well, losing weight. But that was nine months ago. Since then the child had skipped four appointments and gained 33 pounds.
“You were doing so fantastically! You were so stable! What happened?” Lustig said when he entered the room.
The kid shook his head.
“Are you going to fast-food restaurants?”
“Are you drinking sweet drinks?”
“No horchata, agua fresca, Jarritos, tamarindo?”
The boy’s trim father jumped in. “This is not really what’s happening. He’s spending more time with his friends”—separating from his parents. “We have a lot less structure.”
And so the morning went: every 30 minutes, a new obese kid, most of them hunched and mumbling, self-esteem crushed under their weight. Lustig walked into each exam room full of vim, with his rap about how insulin works. Yet it’s an endless, uphill battle. For every family he gets to understand the relationship between sugar, metabolism, and weight gain, there are tens of thousands more to help. Lustig’s last patient of the morning was a 13-year-old girl. He high-fived her and set down his leather doctor’s bag.
“Do you eat breakfast?” Lustig asked.
“Do you eat lunch?”
“How do you do in school?”
“As and Bs.”
“You want to get As and As? Eat breakfast.”
“I don’t have time to eat breakfast,” the girl said.
“She’d rather put on makeup than eat breakfast,” the girl’s mother interrupted.
“You want to know something?” said Lustig, trying to contain his ennui and frustration. “Nobody has time to eat breakfast. I don’t have time to eat breakfast. Go to bed 10 minutes earlier and get up 10 minutes earlier. A lot of kids who don’t eat breakfast eat in the middle of the night. Those kids are a disaster. Those kids gain weight the fastest. Eat breakfast. And pack a lunch.”
Lustig ended the appointment slapping the girl on the back and saying, “Breakfast. As and As.”
Out in the hall he said, “If we keep thinking about obesity in terms of personal responsibility, we’re not going to work our way out of it.”
That’s why Lustig is going to law school.
IN MANY WAYS, LUSTIG SEEMS BETTER SUITED to the bluster of the courtroom than the fastidiousness of the lab. His talks and his book are extensions of the truth. (As he writes in Fat Chance, obesity-related “diseases are eating away our health care dollars faster than we can print the money to pay for them.”) He hasn’t done much original research on this topic, which drives his endocrinology colleagues crazy. His sloppy errors leave experts wanting to, as one told me, “stick knitting needles” in their eyes. Lustig’s most prominent role is as an ideas man, a popularizer, a 60 Minutes talking head. When I asked him if he still did musical theater, he said, “Now I give lectures.”
This academic year Lustig is on partial sabbatical from the UCSF School of Medicine and attending Hastings College of the Law. Before he enrolled at Hastings he met with 14 lawyers; all agreed that case law supports using the judiciary to alter public health policy to moderate sugar consumption. “All health debacles were originally categorized as personal travails before they were declared public health issues,” Lustig writes in Fat Chance. “What if our breakfast cereal was laced with heroin by some unscrupulous food company?” Whose fault would it be if people became addicted? “Isn’t it the role of the government to protect us?”
One day this fall I attended a public health seminar at Hastings with Lustig. He had just received his first finished copy of Fat Chance. Still dressed as a doctor, in a sport coat and slacks, he ate a Trader Joe’s wrap for lunch and passed around his hardback, with a blurb by Alec Baldwin on the back cover. Most of Lustig’s fellow law students wore knee-high boots, cuffed jeans, bangle earrings. A few sipped Nantucket Nectars. The teacher was drinking a 16-ounce Coke. The topic of the day was compulsory vaccination. While the other law students cited the assigned reading, Lustig spoke personally, with great authority, as if he considered himself to be more than just a bystander to public health history. “When does a public health message become a public health intervention?” he asked rhetorically. “Happens all the time. I’ve seen it with tobacco: scientists who did not intend to become advocates found themselves in that position.”
Lustig grew up in Brooklyn. He loved Stuyvesant High School and MIT—the brilliant, eclectic students; his musical theater gigs—but hated Cornell Medical College. “The most dehumanizing experience of my life,” he told me. “Wherever you came from, you were supposed to think the same, act the same, study the same. The object was to create 100 carbon copies of the ideal medical student.” This was anathema to Lustig. He likes to stand out.
In 1995, when Lustig was a pediatric endocrinology attending physician at St. Jude Children’s Research Hospital in Memphis, Tennessee, a group of children with brain tumors set him on his career course. Lustig noticed that, after neurosurgery to remove the tumors, the children showed signs of hypothalamic obesity. Their hypothalamuses were damaged, and as a result their bodies started producing too much insulin. All became lethargic and fat. Then Lustig prescribed octreotide, a drug that blocks insulin. With no counseling or any effort at behavior modification, all of the children started eating less, moving more, and losing weight. According to Lustig, elated parents started calling him, saying, “I got my kid back!” A follow-up study, in 1998, showed that insulin suppression using the same medication caused weight loss in 20 percent of obese adults. Lustig concluded that adiposity—fatness—must stem from a hormonal problem, not a behavioral one. In other words, fat people eat too much and gain excess weight because chemical imbalances make them hungrier and lazier than they should be. These hormonal imbalances cause the behavior, not the other way around. So if you want to fix the behavior, you have to fix the biochemistry.
BUT ONE PEDIATRIC ENDOCRINOLOGIST, even one with a taste for grandstanding, cannot fix a nation’s biochemistry en masse. Seventy-five percent of food items sold in the United States have added sugar. According to Lustig, 90 percent are sold by ten conglomerates. Conventional wisdom holds that the federal legislature is useless, paralyzed by a farm bill that is beholden to extremely powerful and wealthy special-interest groups and that underwrites the cost of growing corn, rice, and wheat, even though American would be well served by eating less of that stuff. Voters have not proven useful either. This past November, the city of Richmond, California, shot down a tax on sugar-sweetened beverages. (Philadelphia, along with other municipalities, indicated that they might float similar measures.) In New York, Mayor Bloomberg convinced the city’s Board of Health to enact his big-soda ban. But that ban, while praised by wonks, caught a lot of flack. Comedian Steve Martin tweeted, “Drank 32 oz. soda and now moving on to heroin.” The underlying question is a good one: Is a Big Gulp really anything other than an individual concern?
Lustig believes it is: “If we’re still talking in terms of personal responsibility, Medicaid is going to be broke by 2024.” So he’s searching for ways to pull civic levers. “I want to know what the pressure points are,” he said while sitting on a Hastings library couch during a class break. “I’m looking for the legal precedent for social change. TB, AIDS, teen pregnancy—everything is initially seen as an individual failing. It becomes a matter of public health when enough people are involved.”
For the past six months Lustig has been working with the San Francisco Office of the City Attorney, considering possible mislabeling actions against various food products, kicking the legal tires on failure-to-warn claims. The great white hope—Lustig’s dream—is that sugar policy and litigation will follow the path of tobacco. For many years that path included abject failure. First lawyers tried bringing suits for product liability on behalf of sick individuals. That didn’t work. (Too hard to show cancer was from cigarettes alone.) Then they tried failure-to-warn claims. That didn’t work either. (Manufacturers argued that smokers assumed liability when they lit up.) What finally worked were lawsuits by states arguing that cigarette manufacturers were triggering huge public health costs.
The suits against Big Food have largely been stalled at the failure stage. In 2009 a federal court in California tossed out a case accusing PepsiCo of false advertising, that Cap’n Crunch’s Crunch Berries cereal contain no real fruit. (The judge’s ruling: you’d have to be an idiot to ever think the cereal “contained a fruit that does not exist.”)
But recently lawyers—including Don Barrett and others who landed huge settlements from R. J. Reynolds and Phillip Morris in that successful third wave of tobacco litigation—have been taking a different tack. They’re not suing big manufacturers for making people sick or alleging that junk food is healthy. They’re nailing producers for not following the rules.
One such suit, filed in California in May 2012 and amended a few months later to become a class-action suit, charges Chobani, the yogurt company, with using the term “evaporated cane juice” on its label, despite warnings from the Food and Drug Administration not to use the term. “Evaporated cane juice” is just sugar, and not a juice. “This is a whole lot easier. The law is on our side,” says Barrett. “We don’t have to show causation. I don’t have to hire a bunch of experts or engineers to show what’s deceptive on a label or what it really means. It’s deceptive because the FDA says it’s deceptive. I wish I’d had that with tobacco.”
An optimist could see Chobani’s linguistic weaseling as progress for Lustig. It’s evidence that the message has gained enough traction with consumers that nobody wants the word “sugar” on their labels. But Lustig is not an optimist. “It took 40 years for tobacco,” he said, referring to the decades required to bring the industry to heel.
Might young people help? “Unlikely. They’re often less open-minded than their parents and they were raised on processed food.”
Public health initiatives? Little faith there either. As Lustig sees it, the government is focused on creating a prosperous country, helping people make money. Public health is focused on saving money. The two are not the same. “Plus public health has to spend money before it has any hope of saving money, so the government has little impetus to make public health work.”
Academics? They remain stuck on the dogma that a calorie is just a calorie, and Lustig knows this belief must fall before his argument can really take hold. “Just this past weekend I went to a symposium at the Palo Alto Medical Foundation. All very nice people; all get up and espouse a calorie is just a calorie. Then I get up and throw firebombs into the middle of the room. But by the end of the symposium they were all on board.”
LUSTIG’S MODEST-SOUNDING, MEDIUM-TERM GOAL is to get sugar removed from something called the “Generally Recognized as Safe” list at the FDA. Items listed as GRAS aren’t considered food additives, so manufacturers can include them in any food products in any quantities they wish. Lustig’s plan seems reasonable enough. According to the FDA, “For a substance to be GRAS, the scientific data and information about the use of a substance must be widely known and … establish that the substance is safe under the conditions of its intended use.” When the FDA last reviewed the safety of sugar, in 1986, the agency assumed Americans ate 40 pounds of sugar annually and acknowledged that significantly increased sugar consumption would carry health risks. Currently, the U.S. Department of Agriculture puts annual sugar consumption at more than 90 pounds.
A reasonable person might assume it’s time for a new review. But Lustig, while doing everything in his power to make this happen, isn’t counting on a quick fix. Maybe someday sugar will replace saturated fat as the villain in our diets. If this happens, Lustig will have succeeded in stealing the public health mantle from Ancel Keys, whose landmark Seven Countries Studypinned heart disease on saturated fat and shaped nutrition guidelines in the United States for more than a quarter century. Yet for all his determination, and confidence, Lustig remains pessimistic.
“I’m not a lucky guy,” he said as he headed back to his law school seminar. “I’m smart, but I’m not lucky.”