The Bitter Truth About Sugar with Dr Robert Lustig (Re-release) #616

32:35then you're going to have to eat it and now the storage is primary and the behaviors are secondary the gluttony and sloth are actually because of leptin resistance so we get sick first and then the weight comes afterwards that's right we get sick first and the weight is secondary. That's exactly right. So this is monumental. This is huge. But of course, it goes against everything that we are taught, and it goes against everything that doctors routinely believe. But this was my first aha moment. my second aha moment came in 2006 so i realized that insulin was the bad guy and we started then changing what we did in clinic instead of worrying about weight we worried about insulin we said get the insulin down any way you can and that's what my clinic became it became an insulin reduction clinic.

33:47It wasn't a weight loss clinic. It was an insulin reduction clinic. And when we got the insulin down, then they lost weight. So in 2006, I was asked to give a talk at the NIH, specifically the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina. They were having their 100th anniversary of public health. And it was a two-day symposium. The first day was on their successes, like lead poisoning and pollution and asthma, things they'd figured out and been able to do something for the public health. And the second day was on challenges. And the morning was going to be obesity and metabolic syndrome.

34:30And the afternoon was going to be ADD and autism. Okay. So they asked me to give a talk. What do you think is the single most important environmental exposure that leads to obesity and metabolic syndrome?

34:51And I figured that they probably figured I was going to give a talk about some, you know, like BPA or some other, you know, environmental, you know, toxicant, that's in the water or in the air or something like that. And I thought to myself, how am I going to make this worthwhile? And I thought to myself, all right, wait a second. Let's go backwards here. Children today get two diseases they never got before. Type 2 diabetes and fatty liver disease. Those two. Children never got those before. word now, lots of kids get them. All right. So I looked up type 2 diabetes and fatty liver disease. And of course, you know, I know a lot about both of them, but I very specifically looked for origins and causation.

35:46It turns out that in the old days, you know, back in the 1970s, before this pandemic of chronic disease started, both those diseases were the diseases of alcohol. Type 2 diabetes and fatty liver disease were the diseases of alcohol. But kids don't drink alcohol. So I said, all right, is there something they're exposed to that's like alcohol? So I opened up my Leninger biochemistry textbook from 1974, sitting at this table that I'm at right now. I said, what the hell is like alcohol? And there it was and stared me right in the frigging face, right off the page from 1974. And the answer was fructose.

36:39Fructose and alcohol are metabolized virtually identically. And it makes sense that that would be the case, because after all, where do you get alcohol from? Fermentation of fructose. It's called wine. We do it in Napa and Sonoma every day. Okay, the big difference between fructose and alcohol is that for alcohol, the yeast does the first step of metabolism called glycolysis. For fructose, we do our own first step of metabolism. But after that, what the mitochondria see are exactly the same as tilcoate. It's just a question of which was the substrate. Was it the ethanol or was it the fructose?

37:20But ultimately, they end up with the same fate. so it's very clear all of a sudden right looking at that right there that this is the substrate that is driving both the type 2 diabetes and the fatty liver disease so i put together a talk and i went to north carolina and i said this is what i think's going on and here's why half hour talk and then there was the bathroom break and you know i got my applause and then everyone left the room and they didn't come back. You know, I'm standing there at the podium talking with, you know, this person, that person and no one's coming back for the next session.

38:07And then I had to use the bathroom. So I went out and I actually got tackled in the frigging bathroom of the NIH by a bunch of crazed toxicologists screaming at me saying, oh my God, oh my God, you're right. This makes perfect sense. This is the toxin. You have to tell everyone about this. I guess I'm still doing it. I guess you still are. So, if the toxicologist went berserk, it might be true. Then that was the second aha. And then the third aha was not even my aha. It was my colleague's aha, but I adopted it. So we got very interested in sugar here at UCSF after that. We actually have a group of us, we call the Sugar Hill Gang.

39:12They're actually referenced in the book here. But my colleagues, Kristen Carnes, Laura Schmidt, and Stan Glantz started looking at the paper trail of the food industry back in the 1960s and found the actual paper trail that showed that the food industry paid off scientists to exonerate sugar and finger saturated fat is the bad guy. We actually found their documents that showed the money transfer and the communications, just like what the January 6th committee is doing now, follow the money. And so we actually proved that the sugar industry put their thumb on the scale back in the 1960s to exonerate their product, because there had been data that had been coming out at that point showing that sugar was not good for you.

40:10In fact, that's what John Yudkin found. Remember, pure, white, and deadly. And he had shown that data. And so people were starting to cast a fish eye at sugar. And so they had to go into overdrive mode to PR this problem away. And so they approached the chairman of the Department of Nutrition at the Harvard School of Public Health, Fred Stair, and his associate, Marg Hegstead, who ended up becoming the head of the US Department of Agriculture in 1970, to pay them off$6 ,500 back then, which would be about$50 ,000 today, to write two review articles to appear in the New England Journal of Medicine that basically said, saturated fat's the bad guy, and sugar is no problem whatsoever.

41:01So that's the third aha moment. it's all a scam the whole thing's a put-up job and that's why i wrote metabolically

41:17sugar and alcohol i don't think people commonly would put the two things together people i think like you know joe public i think would would think okay alcohol i know if i drink too much It's not good for me. It's going to cause problems with my liver. I think there's that understanding. And if I drink a little bit, have some days off a week, you know, the odd glass of wine here and there is probably not going to be too bad for me, I think is what most people tend to think. That's true. And if that were the case, that would be true. And that's true for about the 40 % of Americans who are social drinkers.

41:55You know, 40 % of teetotalers don't touch your stuff. Okay. 40 % of social drinkers can pick up a beer, put it down like me. Okay. but 10 % are binge drinkers and 10 % are hardcore alcoholics. Yeah. But I don't think people think of sugar in the same way in terms of what it does for the liver. And I think that's a really, I think, eye-opening comparison for a lot of people. The other thing you said, which I think really beautifully ties into the start of this conversation, is that you started running an insulin reduction clinic. Right. and you know like you i'm very passionate in root causes and right this idea that we've labeled all these so-called separate diseases we get taught about them at medical school as other well separate entities and then for this treatment for this disease you you take this drug and you have this sort of treatment and we look at that downstream pathology don't we but you mentioned mitochondria at the start in terms of what sugar or excess sugar can do to mitochondria and that That mitochondrial dysfunction sits at the heart of so many different conditions, but also insulin resistance, right?

43:04So that insulin resistance, that insulin lowering clinic actually would probably, depending on who was coming in, and I appreciate you're a pediatrician, but if all of us as doctors ran insulin reduction clinics... We would get rid of 75 % of the chronic disease in the world. Exactly. It's that root cause again, isn't it? Yeah, absolutely. I completely agree, which is what I'm trying to bring to medicine. Unfortunately, medicine is provincial. Medicine doesn't respond very well to new ideas. It's a cartel, if you will. You're very critical of modern medicine in the book. you say modern medicine treats symptoms uh you say modern medicine is not the solution i do indeed and i i agree with this it's it's something i'm it's one of my big frustrations in my what now 20 21 year career seeing patients if it's like you know you know i sometimes wonder if doctors honestly ask themselves sometimes at the end of their day and obviously it depends where you work.

44:22I'm not talking about intensive care necessarily. I'm talking about, you know, chronic patients that, and I did this once, Rob, I did this in general practice once. I asked myself at the end of the day, how many patients do you honestly think you've really helped today? And, you know, quite a few years ago, it was 20%. I thought I've only helped 20 % of people. The other 80%, I've done something, I've sent them off for a test, I've, you know, referred them, or I've given them a drug, but I kind of knew they'd be back. I thought I'm not really getting into the heart of this problem. I knew it, and I kind of feel the patient knew it as well.

44:56And that's kind of one of the things that led me on this journey to try and understand that there must be a different way. And, you know, that's why I think Metabolical is such a wonderful book. It outlines the history, it outlines the science, but also gives some really practical solutions. You know, we treat medicine, and unfortunately, medical schools treat medicine like a big game clue. Colonel Mustard in the conservatory with the candlestick, match the symptom card with the diagnosis card with the treatment card and discharge your patient. In fact, in 1980, there was a game that we used to play in residency on Sunday mornings before things got busy in the ER called Intern.

45:44That was what you did. You basically took your symptom card, you got a card, you got a diagnostic card, and you got a treatment card. And once you got the three of them together, you got rid of the patient first, you know, player to discharge, you know, to discharge all their patients won the game, you know, and that's how we treated it. So, you know, these diseases, you know, got a got a meningitis, here's an antibiotic, you know, got a, you know, cancer, here is a chemotherapy, you know, but the fact is chronic disease doesn't, you know, really fit into that. There are, there are eight, count them, eight chronic diseases that have completely taken over modern medicine, eight.

46:30And here they are. Type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, cancer, dementia, fatty liver disease, polycystic ovarian disease, those Those eight now account together for 75 % of all healthcare costs. And none of them have a cure. None of them even have a treatment. But they all have a prevention.

47:04We're not preventing it. we're handing out statins or oral hypoglycemics or antihypertensives like candy, but that's treating the symptoms, the manifestations of the disease, not actually treating the cause. The reason is because those diseases are not really the diseases. What's going on underneath to cause all eight of those diseases are exactly the same. They're just in different organs. And here are the eight things that I outline in the book, what I call the diseases that are not diseases. I call them the hateful eight. And here they are. And these are things that people don't know because they don't have ICD-11 codes.

47:49And doctors don't know what to do about them, so they don't even mention them. So no one's ever heard of them. And they didn't learn them in medical school either. So here they are. Eight. Number one, glycation. Number two, oxidative stress. Number three, mitochondrial dysfunction. Number four, insulin resistance. Number five, membrane instability. Number six, inflammation. Number seven, methylation. Number eight, autophagy. Now, these are all normal phenomena that happen, but they can be speeded up or slowed down by what you eat. And it turns out when you have control over all eight of those things, you will be 110 playing tennis.

48:34And when you don't have control over those eight things, you will be 40 years old in a wheelchair with two stumps on dialysis waiting for your next stroke. And of course, everything in between. so those are the choices those are the options and because none of those eight the hateful eight that i just mentioned any of none of them have a cure none of them even have a treatment they only have a prevention we're not preventing anything and that's why you felt like you were not helping any of your patients because you weren't addressing those eight root causes that you yourself know to be the big problem in medicine.

49:30Yeah, it's like a leaking roof, isn't it? The roof's leaking and you're just putting a bucket there to pick up the water. That's kind of what the drugs are doing. Yeah, it's great. There's no water there on the floor, so you can live a little bit better, but you're not getting to the cause, right? You need to fix the leak in the roof and then actually you no longer need the buckets. Right. And the problem is if you don't fix the leak in the roof, you won't have a house. Yeah. That was one of my favorite parts of the book, these eight processes that are occurring in all of us. And they're either promoting health and longevity, or they're actually the opposite and creating illness and ultimately disease and i really love the way you said that actually medicines aren't really tackling those things and i just want to be really clear for people that anti-hypertensives or um you know drugs in general they have a role sometimes right they can be helpful in certain situations i think you're in agreement with that it's just I'm not against them.

50:42Yeah. Okay, I'm not against them per se. But the problem is that if you don't fix the underlying problem, what have you done? Okay, so it's fine to give a statin to lower an LDL. But what have you done? Have you actually fixed the problem? You haven't done a damn thing about the problem. The problem is still there. Okay. So, you know, the very first sentence of the book, okay, starts like this. You find a wasp in your attic. What do you do? Kill the wasp or find the wasp's nest? You have to work upstream of a problem to solve a problem. working downstream of a problem only fixes the result of the problem the problem's still there and if you don't if you can you can kill the wasp but then the next time you go up into the attic you're going to be stung into submission by all the other wasps because you didn't fix the problem i i think we we really need to i want to make sure everyone listening and watching this has got this, that what you're talking about is really at the heart of pretty much every single chronic disease that's going on at the moment that is afflicting families, it's overwhelming healthcare systems, it's causing disability, it's causing reduction in the quality of life.

52:21And actually, most of them are caused by malfunction in these eight areas. But ultimately, what you're making a very strong case for is that it's actually the modern food environment, this highly ultra processed food that we are consuming in inordinate quantities is actually at the root cause. And unless we deal with that as a root cause, we're going to be struggling, people are going to be suffering, healthcare systems are going to be suffering, and we're not going to get anywhere. Your intro to the book was, it literally was so punchy. Like, we could just do a podcast on the introduction, frankly.

53:00But there's a couple of bits I've underlined, which if you don't mind me reading it back to you, your own book. I so appreciate that you called my intro punchy, because several people on Amazon have said all he did was rant. But I guess it depends on how concerned you are about the problem. Yeah. And this is such a big problem. It's arguably the biggest problem that's going on across the globe at the moment. And you see it in your kids, right? You see kids. I see kids. And when you see a seven-year-old with pre-diabetes, you're like, this wasn't happening 20, 25 years ago. Something is going on.

53:41We can't just give them metformin or whatever. We have to try and figure out what's causing this. Canaries, kids are the canaries in the coal mine. And if you ignore it, you do it at your own risk. It's just that simple. And that's what we're doing. We've done. We've ignored it. The other thing is that everybody right now is completely distracted. They're distracted by this thing called COVID. And I understand why. And it's certainly distracting. However, let's talk about that for a minute. People are dying in droves in every country, UK, US, you name it. Do you know where they're not dying? they're not dying in countries that actually still have real food.

54:28Third world countries actually have a very low death rate. And it's not because they're using masks or hand washing or social distancing. The reason is because they're eating real food. We have the data on mortality rates of the different countries. I can put it up on the screen if you want. But the bottom line is, it's only the developed countries that have the high mortality rates. Now, why is that? So we've identified the elderly and they have immune dysfunction. We understand that. They can't generate the same cytokine response that everyone else should be able to. Okay, let's put the elderly aside for a moment because that's true everywhere.

55:10It was true in Italy too. But the other three things, the other three demographics that were shown to be related to COVID mortality, here they are. People of color, the obese, and pre-existing conditions. Those three. People of color, the obese, pre-existing conditions. What do those three demographics share in common? probably poor socioeconomic conditions, poor diet, lots of highly processed food. Right. Ultra processed food consumption, crappy diet, ultra processed food consumption. So why should your food make a difference as to whether you die from COVID or not? Why is that? Here's why. Three reasons.

56:05Number one, the virus is very smart it wants to attack all your cells and every cell in your body has a receptor that helps regulate water within the cell and that receptor is called ace2 ace2 angiotensin converting enzyme 2 it's an endocrine receptor okay and that's where angiotensin works and it involves water transport. All right. So every cell has it. Turns out the virus uses that protein as its injector point. Well, high insulin increases ACE2 because high insulin causes water retention. And so there are more ACE2s on all your cells. So you are more at risk of being infected when your insulin is high.

56:59and your insulin is high because of processed food. That's one. Number two, diabetes, high blood glucose. High blood glucose, turns out the glucose actually crystallizes around the edges of those ACE2s, holding them open, making it even easier for the virus to inject its RNA. Number three, short-chain fatty acids. Short-chain fatty acids come from fiber consumption. Of course, ultra processed food is devoid of fiber. Short chain fatty acids suppress the cytokine response. And we now know it's not the virus that kills you. It's your cytokine response that kills you because your cytokine response is basically sort of like a nuclear blast that affects even your normal cells.

57:48But it's trying to get rid of the foreign invader. But you have to temper it. You You have to be able to pull it back. You have to be able to minimize it. Short-chain fatty acids that come from the digestion of fiber in the gut are one of the things that improves that cytokine response. That's why fiber is anti-inflammatory and also improves insulin sensitivity. But processed food doesn't have any fiber. It's been, you know, that's been removed for shelf life. So those three demographics, people of color, the obese, preexisting conditions, big ultra-processed food consumers, high sugar, low fiber, processed food, not real food.

58:35The CDC and the NIH and the MRC and everyone in Public Health England, no one is talking about food in COVID. This is the fourth leg of the stool. okay we all talked about masking and hand washing and social distancing garbage fix the food now i think when we're talking about foods i think we need to get clear on terminology for people who are listening and they think okay look i get this highly processed food is at the root cause of many of these chronic diseases over half of what we're consuming as a country as a western in society are these foods. So I guess we need to really help people understand, you know, what are these foods?

59:26There's this part of the introduction where you actually, I've underlined it. You said, what if this slow consumable poison looks like everything else in the store? How do you protect yourself? And that's kind of part of the problem, isn't it? I don't, it's so normalized that I think many people don't really understand anymore. Well, what is a processed food? What is real food? You know, so can you help us try and understand that? Yeah. One of the first questions we ask in clinic, we used to ask is, mom, the mom and the kid come in for the OBC clinic. And we asked, mom, what do you consider food?

1:00:06Do you think Cheetos is food? If you think Cheetos is food, then basically nothing's going to help you. so that's the first thing we do is we disavow them of this concept of this knowledge so what we did in our clinic to be effective and we actually studied this we published on it we validated it as an instrument what we did was we took all newcomers all new referrals to our clinic and we did a teaching breakfast so these kids came in fasting you know so we could get comorbidity in safety labs. They saw the doctor, they got their blood drawn, they got their physical exam, and then they went to the teaching breakfast.

1:00:53Six kids, six parents around the table, one dietician, English and Spanish, different times, so that everybody got a teaching breakfast. And we got a$100 gift certificate from Trader Joe's every month to basically buy the food for the teaching breakfast. And of course, our dietician went out and bought the right stuff, not the wrong stuff. And we would then, she would then narrate for, or he would narrate for an hour why these foods were on the table for breakfast and why the stuff they were buying at home was the wrong stuff. And we would explain insulin and we would show them how much sugar was in each of the things that they were getting at home and versus what was on the table.

1:01:47And four things had to come out of that. and we actually validated this. Four points, four different points that conferred success. Number one, the parent had to see the kid would eat the food. Number two, the parent had to see the parent would eat the food. Number three, the parent had to see other kids would eat the food because they got other kids at home. Number four, we showed them the bill. They had to see they could afford the food. All four. If we got all four boxes ticked, those patients did well. And then there was no going back. So this was a training moment. This was a teaching moment.

1:02:39This was a way we could explain to parents and to kids what was going on and model for them so they can do see one do one teach one we're like we always do in medical school if you tell people what to do they will not do it if you show people what to do and they do it then they'll do it again yeah and not until

1:03:07The term real foods, I like it, you use it, but it does get a bit of pushback from certain academics. And, you know, I saw one, I think on Instagram just a couple of weeks ago, very prominent researcher in obesity in the UK, denigrating the term, saying it smacks a privilege. It's, you know, all kinds of things about it. And here's the thing, you know, my view, Bob, is that I found it to be very useful with my patients. Of course, if my patients don't like it, I'd come up with something else that they understand. But generally speaking, I think the things like, you know, would your grandparents recognize it as food?

1:03:54I think people find it quite helpful. Or does the food packet have more than five ingredients on it or not? as a kind of general rough rule. They're not perfect, but they're all kind of guidelines to try and help people make sense of this ultra processed food environment in which they're living. And I kind of, I wonder why there's so much criticism. It's like, these things are there to help people. If you find it helpful, great. If you don't, fine, use something else. But I don't, like, I find a lot of people, particularly in medicine and academia, look down on these kind of what are considered simplistic terms.

1:04:30Yeah, I've heard those complaints also before, and I've heard about the quote, quote, smacks of privilege also. Basically, what we're saying is real food is food that came out of the ground or animals that ate the food that came out of the ground. That's real food. Okay. As soon as a human touched it, now it's processed. Just a question of the degree of processing also. And, you know, I'm sure you're familiar with Carlos Montero at University of Sao Paulo developed this system called the Nova system for the degree of processing, which I actually think is the right way to go. It's not what's in the food, it's what's been done to the food that matters.

1:05:09All food is inherently good. It's what we do to the food that's not. And that's the point I try to make in the book, and I have an entire section on what we did to the food that actually turned it from food into poison. That classification system is brilliant. And perhaps you could take a kind of readily available simple food and just explain how it can go through these four stages to help people really understand this. Sure. I can do this in one minute. Let's take an apple. Class one on the Nova system would be an apple. Class two on the Nova system would be apple slices. Class three on the Nova system would be applesauce, unsweetened.

1:05:56Class four on the Nova system would be an apple pie. There you go. It turns out that only the class four foods are associated with chronic disease.

1:06:15So we can have minimally... That's really encouraging. So we can have, you know, minimally processed foods that are done to make our life easier a little bit or, you know, but it's when it goes to that extreme where it's actually bears no resemblance to actually what actually came out of the ground in the first place. That's right. And so what is different about that apple pie versus the apple? And the answer is the addition of sugar and the removal of fiber. So the addition of sugar is what basically floods the liver, because the liver, like alcohol, only has an innate capacity to metabolize a small amount.

1:06:56We know how much sugar we can metabolize. And it's not that different from the amount of alcohol that we can metabolize. because the metabolism is virtually the same. Point is you can overwhelm your liver's capacity to metabolize sugar. And when that happens, just like what happens when you over metabolize alcohol, is your liver can't handle the onslaught. And so it has to take the extra and turn it into fat. And there are enzymes in your liver that turn sugar into fat. It's called de novo lipogenesis, new fat making. And there are three enzymes in concert that do this. One's called ATP citrate lyase.

1:07:43The other one's called acetyl-CoA carboxylase. And the last one's called fatty acid synthase. These three enzymes are being driven by excess substrate. And that substrate is fructose then turned into acetyl-CoA by glycolysis. So bottom line, you're flooding your liver. and the goal is protect the liver and when you flood your liver now your liver makes fat and that fat precipitates now you got fatty liver and now you got insulin resistance yeah and now you got chronic metabolic disease so protect the liver second part feed the gut everyone now knows that the microbiome talks to your brain, which is true.

1:08:31It does. So feed the gut. That's what a prebiotic does. So what's a prebiotic? A prebiotic is food for those bacteria that will feed them so that they can grow. And what's nature's perfect prebiotic? fiber fiber fiber is not food for you fiber is food for your bacteria but when we took the fiber out of the food to process it because fiber basically reduces shelf life when we took the fiber out of the food to process it we are now depriving our bacteria of the food they need to be able to live in symbiosis with us. And so those bacteria, the good bacteria are dead. The bad bacteria have taken over.

1:09:26And the bad bacteria is sending all sorts of bad signals, actually suppressing serotonin generation in the intestine, thereby reducing the anterograde transport of serotonin back up into the nucleus tractus solitarius. and that's called depression. Also, because you're not feeding those bacteria, the bacteria are basically stripping the mucin layer right off your intestinal epithelial cells because they can eat that. And that's then exposing and denuding your intestine and making it, all the junk that's in your intestine basically can get through called leaky gut, contributing to inflammation, inflammatory bowel disease, irritable bowel syndrome, and insulin resistance.

1:10:20All because you didn't feed your gut. You didn't feed your microbiome. And that's how the whole thing gets tied together here. Some very simple, but very, very brilliant advice, protect the liver, feed the gut. But the modern food environment, the ultra processing of food is overwhelming the liver with sugar and it's starving the gut through its lack of fiber and then the consequences are the liver could be you know fatty liver type 2 diabetes but the problem when the gut gets starved and as you say leaky gut or increased intestinal permeability sets in then you're opening up for everything autoimmune disease food allergies, Alzheimer's, depression, all these things have been associated with increased permeability in the gut.

1:11:13So it's a very simple maxim, but one that actually, again, going to that nexus of the root cause, it's kind of right there, isn't it? And this is the other thing I really liked, Rob, is that you don't seem to have a preferred diet, very much like me. I'm always like you, it's unprocessed the diet first. Let's just get out the junk, let's get the real food in and then let's see where we are. So how does you feel that like a vegan diet or a low carb diet or a whole manner of diets can fit this maxim of protecting the liver and feeding the guts?

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1:13:59Yeah, I'm agnostic as to the whole vegan keto thing. I, you know, look, if people who want to be vegan, you know, fine, whatever. You want to be vegan? Great. Don't make anybody else feel bad about their choice. But you can feel good about your choice. That's fine. Okay. There are a lot of reasons to be vegan. Animal welfare, religion, cost, coolness, if you will. But metabolic health is not one of them. Okay. And I can prove it. Because Coke, Doritos, and Oreos are all vegan.

1:14:42so you can do vegan right or you can do vegan wrong

1:14:49keto okay i'm not against keto i used ketogenic diets in my patients when their insulin resistance was so severe that nothing else would work where they were where they had insulin hypersecretion and basically we had to control their blood glucose rises in an attempt to try to stave off continued weight gain, either one. So we use the ketogenic diet, and I'm not against that. The problem with the ketogenic diet is not the diet. The problem with the diet is that it's really easy to fall off it. Because as soon as you have even a little bit of carbohydrate, a little bit of carbohydrate is going to raise your blood glucose, therefore raise your blood insulin and therefore stop the ketogenesis because insulin blocks lipolysis at the level of the fat cell and there goes your lack of substrate and so it's been shown that people who are left to their own devices in terms of doing a ketogenic diet they can start with all good intentions and by two months into it they're basically you know not on they're not in ketogenic anymore.

1:16:03They're not making ketones, basically. And then they're on the worst diet because they're on a high-fat, medium-carbohydrate diet, which generates both insulin and loads and loads of LDL. And that's kind of like the worst thing you can be on. So if you're fastidious, then the ketogenic diet is a great diet. If you're not fastidious, then you shouldn't be on a ketogenic diet. So it kind of depends on whether or not you can actually keep it up. And a lot of people, you know, fall prey to, you know, the croissant, you know, that the other guy at work brought in. So, you know, bottom line is I don't have a preferred diet.

1:16:46I don't. I'm agnostic on it. I think there are a lot of ways to skin this cat. I think ultimately we will learn the genetics of who does better with which diet. And it will turn out that certain diets are better for certain people and other diets are better for other people. And I'm very interested and involved in this personalized nutrition concept and movement that's going on right now. So it may be that there are certain people out there who are on a vegan diet who ought to be on keto. And there are certain people who are on a ketogenic diet who probably ought to be on a vegan one. And they don't know it yet.

1:17:22So why would you basically put all your marbles in one goldfish bowl? so i'm for both diets the only diet i'm not for is the western diet

1:17:42and the reality is i think any clinician who has utilized food as one of their tools in their toolbox with their patients which i hope more and more are starting to do although it's clearly not enough you will see that different people thrive on different diets that's you know you you you know i i think real life clinical practice teaches you that well these guys here are literally rocking a low carb real food diet their markers look good their uh bloods look great and all these people here are doing great on a whole food vegan diet as you say the commonality is no processed food or very, very low amount of ultra-processed foods.

1:18:30The commonality is low sugar, high fiber. Both diets work when they're low sugar, high fiber. And so that's why I think those are the two sort of linchpins in this whole story. But unfortunately, that's exactly what processed food is not. You used apples before to demonstrate those four categories of processing, which I thought was a really nice example. where would apple juice fit into that? Because that's something that many people are consuming every day, thinking it's healthy. Hopefully, they might be reevaluating that at the end of this conversation. But yeah, where does that fit in? So what happens with apple juice, whether it's, let's just take apple juice that's not also sweetened, right?

1:19:20Because, you know, sometimes they add extra sugar. Just taking an apple and putting it in the Vitamix. Okay. All right. Let's do that kind of apple juice. Okay. Apple juice that's been Vitamix or the Jamba juice. Okay. People say, that's great, right? Because that's whole fruit. Well, it was whole fruit. Now it's not. So you have to understand the problem of fiber. Now fiber, we've been talking about it like it's one thing. And that's not correct. Fiber is two things. Two. one's called soluble fiber and an example of that would be like inulin or pectins like what holds jelly together hydrogel it's what's in cream cheese and then there's a second fiber called insoluble fiber and that's like cellulose that's like the stringy stuff in celery it's also what's in cardboard.

1:20:17Cream cheese, cardboard, both fiber. Well, it turns out that real food has both. Now, when you put the apple in the Vitamix, you are shearing the the uh the insoluble fiber the cellulose to smithereens you're cutting it up into such little small little fragments that it's not going to be functional after all after what afterward so here's how the soluble and insoluble fiber work together. Imagine a fishnet, all right? So, you know, plastic, you know, matrix, right? With holes in it, right? And when the fishnet is working, okay, what happens is you can catch fish, but then the kelp, the seaweed, is going to plug the holes in the fishnet, and now you're not going to be able to drag it through and catch the fish anymore.

1:21:29You've created a barrier so that the insoluble fiber is like the fishnet itself, and the soluble fiber is like the kelp. Together, they form a barrier. Think of it this way, like a spaghetti colander, a metal bowl with holes in it. You run the water, water runs through. Now take a blob of petroleum jelly, throw it into the center of the colander. Run the water, still runs through. Now take your finger and rub the petroleum jelly all around the inside of the colander. Now run the water. Now the water doesn't run through. You've created a barrier. And you needed three things. You needed the colander, you needed the jelly and lastly you needed the geometry of plugging all those holes all right for the fishnet you needed the net and you needed the kelp together right if somebody came along and took a scissor to that fishnet you know all of a sudden now you don't have a barrier anymore so this is what's going on in your gut the insoluble fiber the cellulose the stringy stuff in the celery, is forming a latticework on the inside of your intestine.

1:22:45The soluble fiber, like the pectins and inulin, they're globular, they're plugging the holes in that latticework. And together, they form a whitish gel on the inside of your intestine. And that gel is a secondary barrier that prevents early absorption of glucose fructose, sucrose, simple starches, so that they don't end up going to the liver, so they don't flood the liver, so that your liver doesn't turn them into fat, so that your liver can stay healthy. So the apple juice, the Vitamix to apple juice, it still has the soluble fiber. And that still has a benefit because that can still go down to your colon and make short chain fatty acids.

1:23:39And that's good. But it won't protect your liver. So you've taken one of the two cardinal phenomena of health, and you've basically thrown it in the garbage can. So apple juice, better than soda, because it has soluble fiber. But not better than soda, because it floods your liver. but soda presumably also floods your liver huge of course yeah and what's the relationship we've we've obviously we're now moving from food into i guess drinks uh although apple juice of course comes from an apple um soft drinks diet drinks these are things which are routinely consumed And perhaps you could talk about the relationship between these drinks and our wider health.

1:24:36Right. So first of all, it's now been shown 50 ways from Sunday that sweetened beverages, sugar-sweetened beverages, soft drinks, are disastrous. They're disastrous for adults, they're disastrous for kids. And we have quantitation on just how many deaths per year occur in both the US and the UK due to soft drinks alone. This has been done by numerous investigators, most notably the ones at Tufts Friedman, like Dariush Mozaferi and his group, Renata Mika, et cetera. No question. So then you say, okay, that's true, but what about diet drinks? They have no fructose. They have no calories. They should work.

1:25:24They should be fine, right? Not so much. So here's why. A couple of studies have now shown exactly why. A couple of years ago, I wouldn't have been able to tell you this, but now we have the data that explains why this is. Number one, you put something sweet on the tongue. Message goes, tongue to brain, sugar's coming. Message goes, brain to pancreas. Sugar's coming, release the insulin. but then the sugar never comes because it was a diet sweetener. What does the pancreas do? Does it say, oh, man, I was waiting for that. I'll just wait till tomorrow. Or does it go, you know, I got all these insulin vesicles sitting here, raring to go, okay, I'm going to go find me some calories to work on.

1:26:22You end up overeating. Turns out it's the latter. We now have the data to show it's the latter. So in fact, all the studies of diet drinks show that caloric intake, total caloric intake does not change. So you think you're doing well by taking 150 calories in sugar out of your diet. But it turns out you end up making up those 150 calories elsewhere in your diet. has been shown in different experimental conditions that basically it sensitizes your pancreas to actually make more insulin those diet drinks this was work from Yanina Pepino when she worked with Sam Klein at Wash U St. Louis and also Tay et al that showed that if you consume diet sweeteners instead of sucrose, you will not consume as many calories in the morning because of the diet soda that you drank in the morning, but you will actually increase your food intake later on in the afternoon and evening.

1:27:30So the total number of calories you ate ends up being exactly the same, which is why diet drinks have not caused anybody to lose weight, because you end up making it up later. That's number one. Number two, we now know that certain diet sweeteners actually alter the microbiome in a negative fashion and contribute to leaky gut, the most famous of which is sucralose, you know, Splenda. And worse yet, we now know that adipocytes, you know, fat cells, have receptors for diet sweeteners. And so if you absorb those diet sweeteners, they go through your bloodstream, end up at your fat cell. They can cause fat deposition in the fat, irrespective of insulin.

1:28:13So the bottom line is diet sweeteners might trick your tongue, but they don't trick your body. Yeah, and it kind of sort of makes sense, doesn't it? If we go back to the fact that our biology, we've been wired over hundreds of thousands of years to respond a certain way to certain things in our environment. We've just changed that so much. And did artificial sweetness exist 100 years ago, 150 years ago? Has our biology learned how to adapt? Of course, it doesn't mean we can't learn. But I know it's a very controversial area, but my advice with my patients has always been, look, I'd be really cautious with this.

1:28:59I don't think you should go to that. I think I'd much prefer water or something else. But I've always taken that more precautionary principle. I know many people vocal on social media will say that there's no problem with artificial sweeteners. But you think it's pretty clear now with artificial sweeteners? Yeah, I think the data are in. There was a paper that came out in the American Journal of Clinical Nutrition about 2017. What they did was they showed, we're using a meta-analysis, that the toxicity of one Coca-Cola equals the toxicity of two diet Coca-Colas. Well, half is bad. That doesn't mean good.

1:29:44That means half is bad. now the problem is okay it's half as bad but people who are drinking diassoda say oh no fructose no calories i'll drink five of them now it's two and a half times as bad we've mentioned sugar as a mitochondrial poison we've mentioned um insulin resistance as a root cause of many of these chronic diseases and we mentioned obesity and weight gain as a symptom rather than the cause. What we haven't quite mentioned yet is thin people who think they're okay because they don't look overweight, yet on the inside there's a very different story. And I wonder if I could just frame that around the statistic which I've heard before, you've written about it in your book, that 88 % of Americans have a degree of metabolic dysfunction.

1:30:41but I also love the way that you describe metabolic syndrome. Maybe you could describe how you say it, because I think it's a beautifully simplistic way of looking at it and then put it in the context of that thin person who thinks they're doing okay. So here's the problem. Everybody thinks that the scale tells the truth. The scale tells you how much you weigh. Who cares? Seriously, who cares? And here's why the scale lies. Because there's not one fat depot. There are three. Three separate fat depots. And they contribute differentially to your health. Here they are. First one, the one you can see.

1:31:38the subcutaneous fat the big butt fat as it were as in do these genes make me look fat and never answer that question bad idea all right turns out the subcutaneous fat fat, while potentially cosmetically undesirable, is metabolically inert. Our subcutaneous fat is there very specifically to store energy for periods of famine. And it has an innate expansive capacity to a certain point before it gets into trouble. In fact, you can basically put on about 10 kilos of subcutaneous fat, about 22 pounds of subcutaneous fat before you will have overexpanded those cells. Those cells will then have choked off and died, will have released their grease into the area, will have recruited macrophages in to clean up the grease, and will then have released cytokines into the bloodstream, which will, by the way, go into the systemic circulation.

1:32:57So you have to have a lot of grease in order to get a concentration high enough to go back to the liver to activate the cytokine response in the liver and cause insulin resistance. So 10 kilos of subcutaneous fat before you get sick. that's depot number one depot number two the visceral fat the belly fat okay the you know beer belly if you will fat right now that fat turns out not to be from beer that fat turns out to be from stress from stress you know a lot about stress that fat in your belly fat okay visceral fat is due to cortisol and cortisol is because our our world is now overly stressful and people are overly stressed like all the time so how do we know that the answer is because we can take patients with clinical depression, endogenous clinical depression, suicidal depression, get admitted to the hospital to keep them from themselves.

1:34:13Put them in a scanner and quantitate the amount of visceral fat. Now they're losing weight because they're not eating. They're losing sub-Q fat because they're not eating, but they're gaining visceral fat because their cortisol is so high. that is metabolically active fat and it drains directly into the liver because it drains into the portal vein not into the systemic circulation so a small amount of visceral fat will generate enough cytokines for your liver to be able to see it because it's concentrated because it's not being diluted over the entire volume of distribution of your systemic circulation So it turns out about five to six pounds of visceral fat before your liver gets sick.

1:35:04So for sub-Q fat, 22 pounds. For visceral fat, five to six pounds. Now, can you see five to six pounds on the scale? Maybe, maybe not. Now let's do the third fat depot, the liver fat. the fat in your liver turns out to be the most egregious because it's right there. It's causing the problem right where the action is right there in your liver. It turns out only a half a pound of visceral fat, I'm sorry, liver fat, half a pound of liver fat, and you will end up with metabolic dysfunction, insulin resistance. Can you see a half a pound on the scale? No. right so three different fat deepers so the question is what makes the liver fat answer sugar because of this phenomenon the de novo lipogenesis that we've been talking about so you are mainlining it right into the organ that is the most susceptible to the problem and you can't even see it on the scale.

1:36:21So there are people walking around with fatty liver and don't know it because they say, well, I'm thin. No problem, except they have a problem. And that's why 88 % of Americans now have some form of metabolic dysfunction because either sugar or alcohol is causing liver fat, irrespective of what it's doing the rest of your body. Yeah. And they don't know it. that's the nugget of truth that people, you know, that doctors are ignoring.

1:36:53Of course, that begs the question, how can people find that out? I will say, because we don't have much long left, I don't want to be respectful of your time, that in your book, there is a whole section on the various blood tests that you should go and get. They're very simple and actually very readily available. And actually, you've had a beautiful section on you know what the actual values are but also what's optimal what we should really be gunning for um obviously there's things like dexter scans there's ways to hit ratios that people can do um but i guess you know from in my culture a lot of people from my ethnicity are walking around we it's quite it was almost a joke growing up like you'd see dads not a joke but you'd see you know dad's friends after they hit a certain age they'd still be thin everywhere, but the belly would just start to go out.

1:37:43But thin arms, thin legs, just that belly. And of course, many South Asians do have an increased risk of toe feed, thin on the outside, fat on the inside and all those sort of things. But I really wanted to highlight this because I think many of us think, oh, it's all right for them. They can eat whatever they want and they don't put on weight. It's like, well, wait a minute. Yeah, cosmetically, they may not be looking, they may look as though they're getting away with it, but they may not be. I also just want to finish off on kids. You just mentioned liver fats. I've heard you say before that you've had to send two children at least for liver transplants, because that is absolutely alarming, from soda drinking.

1:38:27So maybe before we get to the final point, I just wonder if you could, there's many parents who listen to this podcast. And of course, a lot of people can take the advice of themselves, right? I need to have a low sugar diet. I need to have a high fiber, whatever my preferences are. But with kids, like it seems to be quite different. Kids' meals are a joke in most places. It's like the adults can have proper food and the kids have the junk in bars and restaurants, right? It's the same in the US. Chicken nuggets and French fries and a Coke. So what is it doing to kids at this early age when they're having regular juices, regular soda drinks, regular highly processed foods?

1:39:07It's not really necessarily about their weight, is it? It's about, is it setting the tone for later on in life? And then what advice would you give to parents? First of all, sugar down regulates its own receptor on the tongue. So the more sugar, the less sweet. Therefore, you need more sugar. So it becomes a vicious cycle. That's one thing. Second of all, it still causes liver fat accumulation in kids. We now have shown that 20 % of children have liver fat unrelated to obesity. Kids who have died in auto accidents, autopsies, show 20 % of kids have liver fat and it's unrelated to obesity. Where did they get liver fat from.

1:39:55They never had it before. This is where. The bottom line is that this phenomenon is also, you know, the sugar is also causing changes in behavior. Now, we don't have enough time to go into this, but sugar inhibits an enzyme in the brain, in astrocytes, called glutamine synthetase. and glutamine synthetase is necessary to turn glutamate into glutamine, which then will go to GABA. GABA is the inhibitory neurotransmitter. Glutamate is the excitatory neurotransmitter. So there's a balance between excitation and inhibition and sugar basically breaks that balance. And so sugar has been associated with irritability.

1:40:43It's been associated with violent behavior. It's been associated with cognition problems. It's been associated with dementia in adults. It's been associated with changes in the prefrontal cortex thickness. It's been associated with problems in school. It's been associated with all sorts of problems. Now, associations, not causation. We are still working on putting all the causation pieces together. so you know i'm not here to tell you that sugar is poisoning your brain yet but you know there's a lot of data and the data in animals is pretty darn good you know you really want to go this route people and you're not talking about just white table sugar you're talking about the processed food you're talking about the fruit juices right absolutely talking about the capri suns i'm talking about you know the stuff that the the parents are putting in the uh in the lunchbox yeah and that statistic 20 of kids have liver fat that's there could be parents listening to this who think my kids look fine weight wise you know so what's what's the problem with a glass of apple juice a day um that's the problem yeah exactly and so i'm not this conversation is not meant to shame anyone It's just meant to try and raise awareness of something that we both feel could be really, really helpful.

1:42:11Rob, I've got to say that if people want more, and I hope they do, well, at some point, if we can get a second conversation, I'd love that. But the book Metabolical is, it's really thorough, it's really comprehensive. I really would recommend people who want to learn more about this to get a copy. I think it's something you can keep dipping back in and out of over time. I really do think it's a fantastic read. And you cover the planet as well in it, which we didn't get a chance to talk about today. Just to finish off, this podcast is called Feel Better Live More. When we feel better in ourselves, we get more out of our lives.

1:42:47And if you have everything you've said, if you have all your passion about this area, I just wonder if you could just leave my audience with some of your final thoughts and a few top tips that they can think about applying into their lives. Now, the most important thing people have to understand is, and you say it yourself, I'm basically trumpeting what you say. To solve a problem, you have to solve the cause of the problem, not the result of the problem. Doctors don't know how to do that. And I can say that because I'm one of them. okay and i did i didn't understand that going through medical school and i didn't understand that for the first 20 years of my practice i did what i was told i practiced the way they taught me to do i got woke you got woke there are doctors around now who are getting woke and they're starting to make some shall we say noise they're being cast off as you know heretics and rabble rousers and troublemakers and whatever.

1:43:59And some of them have even gone on trial in their respective countries. Tim Noakes in South Africa, Carrie Fetke in Australia, Evelyn Bordour-Roy in Canada. Don't know if there are any in the UK that have had that happen. But the bottom line is, we are undergoing a revolution in modern medicine. We underwent a revolution back in the 1930s, 40s with antibiotics, where we thought a pill could treat everything. Now we're undergoing a revolution where we realized that was a mistake. It's time to rethink health. It's time to rethink health care. You can't fix health care until you fix health. You can't fix health until you fix diet.

1:44:45And you can't fix diet until you know what hell is wrong. And what you thought was wrong was basically propaganda for the last 50 years. We've had to undo that. We've had to basically turn it over. We've had to re-rethink all of modern medicine. And for your audience out there, what I'm telling you is not everything is wrong, but a lot of it is. When I went to medical school in 1976, a very, very famous clinician stood up in front of our class on the very first day, and you've probably heard this yourself wrong, and he said, 50 % of everything we teach you is wrong, we just don't know which 50%.

1:45:36This is the 50%.

1:45:43Robert Lustig you have been doing incredible advocacy for many many years you continue to do it you're helping the lives of hundreds of thousands of people if not millions around the world thank you for joining us on the podcast and hopefully we'll get a chance to talk again in the future it's my pleasure hope to come to the UK and we'll have a beer just one

1:46:09really hope you enjoyed that conversation do think about one thing that you can take away and apply into your own life and also have a think about one thing from this conversation that you can teach to somebody else remember when you teach someone it not only helps them it also helps you learn and retain the information now before you go just wanted to let you know about Friday Five. It's my free weekly email containing five simple ideas to improve your health and happiness. In that email, I share exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I've been consuming, and quotes that have caused me to stop and reflect.

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