>> this is the pat nexen rose garden at the nixon library. it was important because mrs. nixon was instrumental in designing it for the grand opening of the nixon library in 1997. she loved gardening and had a special affinity for roses. mrs. nixon was instrumental in opening up the white house for garden tours in the spring which is a tradition that has continued to this day. this is the pat nixon rose which

was valid in 1972 by a french designer when mrs. nixon was first lady. it is the only rose that will continually grow at the white house. this is the final resting vice of both president and mrs. nexen , only steps away from the president's humble 19 10 farmhouse. there is a great story behind the epitaph on this is nixon's memorial site which she chose herself. she wanted to meet the people that were affected by this devastating earthquake that rocked peru and one of the reporters asked her what good will any of this do if the people you are speaking to cannot understand what you are saying? she replied," even when people cannot speak your language, they can tell if you have love in your heart." >> watchtower program on first lady pat nixon or see it saturday on c-span at 7 p.m. eastern. our series continues live monday as we look at first lady betty ford.

coming up later today, an event honoring women in politics and a white southerner from charleston, south carolina. she became the first american woman to address the legislative body. she spoke about slavery and women's rights before the massachusetts state legislature. the forum was hosted by simmons college and included a panel looking at women in politics. here's a preview. think the word entitlement often has a negative connotation but, really, the goal is for girls and women to operate with a greater sense of entitlement. to say that i am deserving of that opportunity, i am prepared and qualified. all those other nagging insecurities and doubts that often get in the way. was alluding to that earlier but the data says it takes a minimum of seven people to convince a woman to run for

office would you venture to guess how many it takes to convince a man? himself. [laughter] it actually is not a joke. [laughter] say that i was recruited to run for office. that is the case for most women. i was not in some corner politically calculated my political ascension area i had been an aide to senator john kerry for 11 years and prior to that and a tube congressman joseph mcginty the second and enjoyed being the person behind the person. there was reward in that. prior to my being recruited to run, there had never been a woman of color elected to the council. >> how many times did they ask you? >> more than seven. >> you can watch the entire event from seven scholars later today at 1:30 p.m. eastern time and turn 30 a.m. pacific or anytime online at www.c-span.org

>> every weekend since 1998, book tv has brought you the top nonfiction authors includinghannah rosen. >> i think women's identities art tied up with their work in ways we might find disturbing and unnatural. it is in fact true. mayer whok at marissa was chosen to be the ceo of yahoo, when she was visibly pregnant and then was asked how much maternity leave do you want to take and she said none. the fact that such women exist is not the way i would do that. i took plenty of maternity leave. is a kind ofat woman that there can be . the fact that there are some stay-at-home dads who are very happy doing that and don't all live in portland, oregon, that

is ok, too. nationale the only television work devoted exclusively to nonfiction books and throughout the fall, we are marking 15 years of book tv on c-span2. it was shock and awe. i saw it and that look he had on his face, i can close my eyes and see him on the stretcher now. i could see him putting his hand up. i could see his eyes. i can close my eyes and just see it. -- thatever forget that bringing me to reality of what was going on here. after he got into the tent, there was an initial triage and we get the report and we see him and he goes into the tent and everyone starts to work. we got pulled in, myself and my colleague that wrote the forward. we both got pulled in because

the other team wanted us to begin right away. they did not want us to be bystanders. they said you guys have to get involved right away. once they did that, they pulled us in and it was like a joke. it was like wake up, now you have to act. you have to be a doctor, you have to be a surgeon, you have to be a care provider, you have to dismiss your emotion and you have to talk that away what you are feeling and just work now. objective-you have to save this guy's life. you have to stop the bleeding, we have to get him back to him -- back home to his family. in his first book, he talks about his own military experiences to talk about physicians working in afghanistan sunday at 8:00. next, old be city and food policy. city --ob

c-span. now the doctor who did the youtube video "sugar: the bitter truth." he connects sugar, obesity, and food policy. dr. robert lustig is a pediatric endocrinologist at the university of california in san francisco. he spoke to law students earlier this year for an hour and 50 minutes. [applause] >> thank you, david. thank all of you for coming. it is just wonderful to be back now at my alma mater. marsha cohen even gave me a decal to put on my car. i'm fully equipped. i really want to acknowledge so many of my mentors during this past year in the audience, david, pat davidson, marcia, and several other people here, as well, that have done a tremendous job. i have to say it was really an absolutely thrilling year. i wouldn't have given it up for

the world. the homework was another story. [laughter] today, i want to talk to about what got me to law school in the first place, and hopefully, light a fire under all of you. in the way i first felt this as i started researching the topic. it is appropriate that this talk today be done on the 50th anniversary of the march on washington, because we are going to talk about a different form of oppression, one that is a little bit more pernicious. i also have a dream, and that dream is that our food supply would confer wellness, not illness. i have to take care of obese kids. we are losing the battle. the problem is, we are going to continue to lose the battle until we fix the food supply. i'm going to try to explain to you why that is and what we can do about it during the course of this lecture. i hope it won't be so hyperbolic

as to get you all shouting in the aisles. it is not quite a revival, but there is going to be a lot of science. the science should influence the policy. the problem is, politics get in the way. that is where law comes in. with that, let's go ahead and start. first of all, i have no disclosures, no food industry entity is putting me up to this. [laughter] in 2011, just two years ago, u.s. secretary general announced that noncommunicable disease -- that is, type two diabetes, cardiovascular talese -- disease was now a bigger problem not just for the developed world, but for the developing world, than was infectious disease. this was a paradigm shift as to how medicine was going to be conducted from here on in and where the resources have to go. the question is, how do you deal with this? they plan to target tobacco,

alcohol, and diet. tobacco and alcohol, that is easy. we have paradigms that already work for those. we have 15 years of alcohol control policy, for instance, but what about diet? are we going to influence total calories? we have been doing that for 30 years, and look where we are treated are we going to do that with changing fat? we did that for 30 years. red meat, dairy, carbohydrates? what is the factor within our diet? we cannot stop eating. something has to change. what is it? i think all of these are incorrect. i will let will smith tell you what the real answer to this story is. [phone ringing] >> i need some answers.

i can't talk right now. i have a few cases i'm working on. all right. the mosting up. instructive force in the universe is >> sugar. [laughter] >> you know, if hollywood knows this, why don't you? [laughter] anyway, here is the problem. it is very clearly delineated on this slide. this comes from coca-cola's coming together youtube video. they are going to tackle childhood obesity. they say straight up, beating obesity will take action by all of us, based on one simple common sense fact: all calories count, no matter where they come from, including coca-cola and everything else with calories. in other words, a calorie is a calorie. you can get those calories from carrots or cheesecake or coca-

cola or anything else, but the bottom line is, it doesn't matter where it comes from -- a calorie is a calorie. that is based on common sense. well, i don't believe in common sense. i believe in data. the data say something else entirely. what the data say is that some calories cause disease more than other calories, because different calories are metabolized differently in the body. not every calorie is handled the same way. that means a calorie is not a calorie. that is what i have spent the last 16 years figuring out, and i'm not the only one who has figured this out. many other investigators have figured this out. this is now a wave of controversy throughout the endocrine and nutritional literature and at meetings. i just debated the corn refineries association a week ago on exactly this point. so, the question is, if a calorie is not a calorie, could

there be calories that are worse than others? of course, we know there are certain environmental toxins that are bad for you. the question is, what about the stuff over here? is this possible? could this be the problem? i'm going to be referring now to two papaers. -- papers. one is an article written about our research at ucsf, and also our comment last year were we actually called for regulation. in order to regulate an environmental substance, society has said that you have to fulfill four criteria. ubiquity. you cannot get away from it. toxicity -- it has to be dangerous. abuse -- you can't stop using it. finally, externalities or negative impact on society -- how does your use affect me? those are the four. i have to show you that sugar meets every single one of those

four in order to be able to stand up here and talk about it. let's start with an affordability. we are all eating more, no-- on avoid ability. we are all eating more, no arguments. 275 calories in teen boys over the past 20 years. no arguments. we are eating more. what are we eating more of? is it fat? we are told to go low-fat. we are not eating more fat. we are actually eating the same amount of fat as we were before. five grams. if you look at the secular trends of specific food intake, here is a fat -- whole milk, meat and cheese up slightly, milk desserts up slightly. bottom line, it is a wash. we are not eating more fat. in fact, as our percent of calories from fat has gone from 40% to 30%, because we were remanded to back in the 1980s as we were to go low-fat, our

obesity and met a lot -- and metabolic syndrome prevalence has gone through the roof. no, it is not that. what are we eating more of? more carbohydrates. 228 calories, 57 grams in teen boys. here is the trend in carbohydrate intake, all through the roof. that is what we are eating more of. that was the bottom of the food pyramid. specifically, what carbohydrate? beverages. 41% increase in soft drinks, a 35% increase in for drinks, etc. this slide sort of says it all. here is the original bottle of coca-cola, 6.5 ounces, out of atlanta in 1915. if you drink one of those every day for a year, assuming that the formula hasn't changed -- we don't know if the formula has changed, because only three people in the world know the formula, and they are not allowed to ride planes at the same time -- that would be worth eight pounds of fat per year.

in 1955 after sugar stopped being rationed, we got up to 10 ounces. 13 pounds of fat per year. then the ever-ubiquitous 12 ounce can, 16 pounds of fat per year. here we have the current ever- present 20-ounce coca-cola. does everybody know how many servings you get out of the 20 ounces? it is supposed to be 2.58-ounce servings. does anybody know who gets those servings? then you have the 7-eleven big gulp -- 44 ounces, 57 pounds per year if you do that everyday. my friend tells me that down in texas, they have a texas-sized big old. gulp.50 ounces of coca-cola and a snickers bar, all for $.99. you would say, that is the obesity acted -- epidemic). you would be only partially right.

what is this stuff? high fructose corn syrup. our annual consumption is 63 pounds per person. there is a problem. only the u.s., canada, and japan use it. there is very limited exposure in parts of europe, yet the rest of the world as just as much of an obesity metabolic syndrome epidemic as we do. in fact, everybody is so fond of mexican coke, mexico has the highest increase in the rate of obesity in the world today, and they don't have high fructose corn syrup. they have sucrose. here is high fructose corn syrup up here. one fructose. they are free. they are not bound together. here is sucrose. your enzyme leaves this in about a nanosecond. basically, it is a wash.

they are the same. they are the equivalent. all of the studies pitting the two of them against each other show that they are equivalent. they are equivalent to data -- equivalently bad. that is why every other country has the exact same problem we do. here is what u.s. sugar consumption has done is we have developed the ability to refine isolated and market -- to refine, isolate, and market it. we have gone all the way up. you can see the different parts of the curve. here is the growth of the sugar industry in the late 1890s through the early 1900s, and stabilization before world war ii -- here is the dip from rationing -- here is the introduction of high fructose corn syrup and as we were remanded to reduce our fact.-- reduce arafat. you canyou will notice, in the last see how full high things have gone. 5-6 years, there has been a decline, but that decline is nothing compared to the rest of the curve. if you believe that there is a limit to how much sugar you

should consume, and the american heart association has set this threshold, and based on the analogy with alcohol that i have made, this would be the theoretical basis for alcohol right here -- the question is, do these actually work in terms of understanding how disease gets promulgated? here is the emergence of cardiovascular disease as a health risk in the united states in 1931, due to paul dudley white famous treatise on heart disease. we can see, as things went above the threshold, that is when heart disease started to become an issue. here is a 1988 when we started realizing that we have an epidemic of adolescent type 2 diabetes. you can see that the temporal relation between sugar consumption and our two biggest problems in terms of chronic metabolic disease -- heart disease and diabetes -- are at least temporally related to this increase.

of course, temporal relation is not causation. this is a worldwide per capita sugar supply. you will notice the light blue here is how much of the american heart association says you can consume everyday. notice the entire world is darker than that. here we are, 629 calories. the rest of the world is right behind us. now sugar is cheap. the early history of the sugar epidemic was actually nicely delineated in this piece in the "national geographic" this past month, for anybody who is interested in how we got here and the slave trade and all the other things, the political and broglie owes sugar has caused over the centuries. we are going to talk about the last 30 years right now. that is what i have experienced. that is what i'm interested in. that has -- that is what has led to this adolescent type 2 diabetes pandemic that i have to take care of.

that is what i'm trying to fix. let's talk about what happened in these 30 years. this is the perfect storm. it started with the fall of batista and the fact that we could now not rely on cuba for our sugar supply. this caused the increase in sugar production in florida, which actually took over the entire country to the point where now hawaii doesn't even have a sugar refinery. it is now florida. in 1973, richard nixon told his secretary of agriculture, earl butz, that food should never be an issue in a presidential election, that fluctuating food prices caused political unrest. indeed, we know that, it is just five years ago, we diverted some of our chrome -- corn crop to ethanol, and it caused the ouster of the tiling prime minister. whether or not that prime minister deserved to be ousted

was a separate question, but that was the immediate and proximate cause. notice this slide right here. this is the percent of gross national product spent on food per country by "time" magazine. we are the worst. we have only 7% of our gdp spent on food. here is the u.k. at 9%. australia, 11%. we are the three most obese countries. notice the countries in purple they are all greater than 36% of gdp spent on food. they have all had a revolution within the last few years. indeed, fluctuating food prices caused political unrest. nixon had it right. with the advent of high fructose corn syrup that occurred in 1966 and introduced to the american market in 1975, now we have competition for sugar. we always had a sugar terrorist. in fact, it is the second oldest piece of legislation in america dating back to 1789. we always had propped up prices, but when hfcs invaded our

shores, look at what happened. here is the price index. the goal is to keep the u.s. producer price index at 100%. that means price stability. any ups and downs mean fluctuating sugar prices. you can see what happened in the early 1970s -- up and down. this is what nixon was responding to. here is the advent of corn sweeteners. everything settles out at 100%. now there is competition. look what happened on the international stage. here is the london price. they didn't have high fructose corn syrup, but we still saw a stabilization in their prices compared to ours. here is the u.s. retail price for refined sugar -- it was half the price. now the food industry could start putting it in everything, because they could afford to, as it was cheap and admissible, because it was already in the solution. here is the change in high

fructose corn syrup and the change in sugar. this comes from the corn refiners association themselves. they say, it is just a substitution. we are taking something that is cheaper and substituting it for something more expensive. not quite. if you look at the 73 pounds per year here back in the 70s -- the 1970s, this is missing something. does anybody know what is missing from this slide? juice. juice is sucrose. weat is sugar, as well. started making juice like crazy. anita bryant, a day without orange juice is a day without sunshine.-- that is because juicecould be frozen and stored. it became a commodity. fruit is not a commodity, but fruit juice is. here is juice. in fact, we consume right now 120 pounds of sugar per year. the question is, is that over our limit based on the american

the question is, is that over our limit based on the american heart association, based on the analogy with alcohol? we are way over our limits. the question is, is that what is causing the disease? the fourth item -- back in the late 1970s, we were told to go low-fat. why? in the early 1970s, we discovered this molecule in our bloodstream called ldl, low- density lipoprotein. we learned that dietary fat raise our ldl. let's call dietary fat a and ldl b, a led to b. we learned ldl levels of large appellations correlated with coronary -- large populations correlated with coronary disease. the logic was, if a leads to b and b correlates with c, get rid of dietary fats, ldl will go down, and cardiovascular disease will reverse.

is that what happened? not at all. if anything, it got worse. why did it get worse? for a couple reasons. this was the fight going on back in the 1970s. there was a huge nutritional war going on. it was actually quite nasty, a lot of name-calling. over here, we had john yudkin, british physiologist, nutritionists, and physician who said sugar was the bad guy back in 1972. he wrote this missive called "pure, white, and deadly." i realized that i was basically parroting what he said 25-27 -- parodying what he said 25 years ago. i was really quite amazed. here we have keys. he was the inventor of the k ration back in world war ii. he was sort of on the scene nutritionally. he was the one who said saturated fat was the bad guy. let's look at his data. this is his seven countries

study writer could japan, italy, england and wales, australia, canada, and the united date. -- the united states. percent of calories from saturated fat, and here is coronary disease. it looks pretty good. except it wasn't the seven countries study. it was a 22 country study. there is still a minor correlation, but not nearly as good looking as it was before. the question is, why did he cherry pick those seven countries? why is it that he left out countries that actually blew a hole in his -- in his hypothesis? here are indigenous tribes. all they eat is fat. they don't have any carbohydrate -- at all. they have the lowest rate of heart disease on the planet. let's read what keys himself said. this is from page 262 of his own work -- in other words, doughnuts.

[laughter] these guys here eat doughnuts. these guys don't. partial correlation analysis shows that with saturated fats present, there was no significant correlation between dietary sucrose and the incidence of coronary heart disease. when you do a multivariable linear regression, you have to do it both ways. you hold one constant and show that the other one still works. he didn't do it. he only did it one way. the question is, why did he only do it one way? i don't know the answer to that because i don't have his data, and this was before computers. it is kind of hard to check the work. it leaves a major question as to whether or not this was actually correct. nonetheless, the start of the

low-fat craze in america. the content of home-cooked food, you can control the fat. you can decide how much that you're going to put in your own food. low-fat processed food tastes like cardboard. the flavor was in the fat, which meant that you had to do something when he took the fat out. you had to substitute something. carbohydrates. which carbohydrates? sugar. here is snack wells. they are still with us. two grams of fat down, 13 grams of carbohydrate up. which was worse for you, the fat or the sugar? that is the question we are asking today. here is berkeley farms 1% low- fat milk. my daughter brought these two containers home and said, dad, you're not going to believe this. this is 130 calories, 15 grams of sugar, all lactose, and here is berkeley farms 1% chocolate milk. 190 calories, 29 grams of sugar, high fructose corn syrup as the second ingredient.

when you give your kid chocolate milk, you are giving them chocolate milk and a half a glass of orange juice. is that ok to do? the school dietitians say, we've got to get our kids to drink milk somehow. why don't we put the fat back in the milk in the first place? that made it perfectly fine. i drink that my entire young life. number five -- the third worst hurricane in american history, and it never even hit our shows. -- shores. everyone knows katrina and sandy, but this was hurricane allen in 1980. what it did was it destroyed the entire caribbean sugar crop, which really put a fire under u.s. sugar consumption, because now we knew that we needed to have another sugar source aside from a farm. -- foreign soil.

that led to this right here. does everybody remember new coke? we revolted. they brought back coke classic. where did coke classic go? that is coke classic right there. you are looking at it. that is what you are drinking today. as far as i'm concerned, from a ubiquity standpoint, we have had our food supply adulterated right under our own noses and with our tacit approval, because we haven't complained. with the addition of fructose for palatability, and also because it is a browning agent, that is the maillard reaction. that creates hemoglobin a-1 c. it is a sign of cellular aging. if you had orange juice this morning, you are browning faster. and the removal of fiber for shelf life and for freezing, because you cannot freeze fiber, and finally, the substitution of trans fats, which we used as a

hardening agent and increased shelf life vis-à-vis the 10- year-old 20. -- twinkie. we know those are bad. we are removing those did we know those are the devil incarnate. we are trying to get those out of the food supply. there are certainly issues with that, as well, as marcia: and i marsha cohen and i have explored this year. next, toxicity. this is the tough one. i'm going to try to convince you that obesity is not a problem. obesity is irrelevant. obesity is the marker for the disease, not the disease itself. you don't die from obesity. you die from the disease is that travel along with it, which are called metabolic syndrome. those are type two diabetes, hypertension, ardea vascular disease, cancer, dementia, nonalcoholic fatty liver disease, and the list goes on. that is what you die of. we are going to talk about diabetes, because diabetes we've got the best data on. that is where the money goes. that is what is breaking the medical bank, the bank.

-- the health care bank. here is how you need to look at this. here is a venn diagram of the entire u.s. adult population. 72 million obese people, 30%, 168 million people at normal weight, about 70%. everyone thinks these are the bad guys, these are the sick guys, these are the guys costing us the money. 80% of obese people are sick and cost money. usually double the medical expenditures of the general population. everyone assumes these 57 million are the problem, and they are costing us the big bucks. this is incorrect. this is completely incorrect. here is what the real story is. we will start at the beginning. yes, 80% of obese people are sick, but that means 20% of obese people are healthy. they are metabolically normal. a paper came out today showing exactly why they are normal, because they do not have

inflammation. they are metabolically normal. they are just fat. conversely, up to 40% of the normal weight population has the exact same chronic metabolic dysfunction due to inflammation as does the obese. they get type 2 diabetes. they get cardiovascular disease. they get cancer. they get dementia. they get it at a slightly lower rate, but they actually, 40% of 168 million, they actually outnumber the obese. really, what we are talking about is more than half the u.s. adult population. this is not a personal issue. this is more than half of the population. this is a public health problem. in addition, everybody thinks that it is the obese persons fault, because it is convenient to think so. let's hearken back just 30 years to a different public health disaster, hiv.

hiv, 1979, patient zero. 1981, aides got coined as a term aids got coined as a term. 1986, see edgar coop said we everett coop said we have to do something about this. when did hav become a public health crisis? when? does anybody know? 1991. why in 1991 did hav become a public health crisis? because that is when magic johnson got aids. all of a sudden, everybody said, you know what? it is not the gays and the addicts anymore. it is not them. everyone is at risk. it is now us. everybody realized, we needed to do something about this as a society. it became a public health crisis. this is a public health crisis. everyone is at risk, whether you are fat or not. it is not about obesity.

let's talk about what it is. toxicity -- how do we define it? the degree to which a substance can damage an organism. a substance could damage an organism in several different ways, and a nutrient could potentially damage an organism through calories. if i'm going to say that sugar is specifically toxic, i have to show that it is toxic irrespective of its calories, unrelated to its calories and on related to obesity. it does everybody understand? that is my charge. i have to meet that bar in order to make my case. those are the caveats. it has to be exclusive calories, obesity, human data only, because the food industry will say, who cares about animals? it is only about humans. it has to be in doses routinely consumed. it cannot be using doses that are so outlandish that you could basically argue that it is an artifact.

is everybody with me? those are my charges. i have to meet those. here we are. here is the world sugar consumption tripling over the past 50 years, from 50 million tons per year to 150 million tons per year. notice brazil. they used to be so poor they couldn't afford their own sugar. they were always sugar exporters, but they weren't consumers. now they are a bric country. they've got lots of money. now they have the highest rate of increase of type 2 diabetes on the planet. now they are consuming their own sugar. where is diabetes the highest? the middle east, saudi arabia, qatar, uab, malaysia. why them? no alcohol. that's right. no alcohol. they have soft drinks like they are going out of style. why? it is hot. the water supply is a question mark.

no alcohol. this is their reward. i'm going to tell you, alcohol is better than soft drinks. you know why? number one, it is way more fun. [laughter] number two, alcohol, for lack of a better word, is self limiting. you can only drink yourself under the table once a day. i have a little shot glass at home -- beat hangovers, stay drunk. the fact of the matter is, with soft drinks, you can keep doing it and doing it, and that is exactly what is going on in the middle east today. that is their reward. that is their oppression. -- is what it is. this is an analysis called the epic interactive study from europe, and what it shows is that when you adjust for

calories, when you adjust for bmi, and you look for sugar- sweetened beverages against the risk for diabetes, every sugar- sweetened beverage that you consume increases your risk for diabetes by 29% over time. this is in doses commonly used. this is human data. it is correlational data. this is a snapshot in time. the question is, do we have causation of data? that is what we have to meet. that is what we supply. this is a study we published in february this year. it is called an econometric analysis. that is very specific. it actually uses what economists use to predict stock market changes and fluctuations and crashes. we melded for databases together, food and agricultural organizations, melded with the international diabetes federation database which had diabetes prevalence. we looked at total calories, fruits excluding wine, oils, nuts, vegetables, meat, cereals, and sugar, sugar crops, and

sweeteners. we melded that with the world bank world development -- we melded that with the idf and then we melded that with the world bank world development indicators database to control for poverty, urbanization, aging, and physical activity and obesity. we have data for 175 countries. the countries we did not include were not different based on a test. we had a very fancy data monitoring and analysis. that is what an econometric analysis gets you. we had a hazard model to control for selection bias, called the heckman test. in order to show causation, you have to show precedents. you have to show that something occurs before the other thing. in a correlation analysis, you only have a snapshot. you can't tell directionality. you can't tell what caused what.

you can't tell if sugar caused diabetes were diabetics ring -- drink sugar beverages. you couldn't tell that. if you had the whole decade, now you have a movie. now you can determine precedence. we controlled for gdp, obesity, urbanization, aging, and physical activity. we controlled for everything we could control for. here is the data. during the decade, diabetes rose from 5.4% to 7% worldwide. here is the effects model. you will notice it does not cross zero, which is significant. for every 100 calories, diabetes prevalence went up by 0.87%. here is the adjusted association of sugar with diabetes prevalence, a very clearly significant correlator. here's the take home message. only changes in sugar

availability predicted changes in diabetes prevalence, not total calories. total calories were irrelevant. that doesn't mean total calories cannot cause diabetes. that is not what this means. it could. in this study, for every extra 150 calories that every country consumes, it only increased by beatty's by 0.5%. by 0.1%.es prevalence if those 150 calories happen to be a can of soda, diabetes prevalence increased 11 fold. here in america, we do not consume one soda a day. we consume 2.5 sodas per day. that is nearly a 2.4% increase in prevalence. when you consider that diabetes prevalence in america is 8.3%, that means that 29% of all diabetes in america is explained by sugar and sugar alone. that is irrespective of its calories and irrespective of its effect on weight. that is causation.

these data meet what is known as the austin bradford hill standard for causation. we showed a duration, the higher they were exposed, the higher the diabetes rate. we showed directionality -- those countries where sugar went down, and there were a few, showed lower diabetes rates. we showed precedents by three years. whenever sugar cane into a country, diabetes followed in three years in either direction. that is causal medical inference. we estimate that one quarter of all the diabetes in the world today is explained by sugar and sugar alone. if you want something to work on or something that is actionable, here it is. this is direct and causation. this is proximate cause. it has limitations. i'm going to take us through

this very quickly because of time. it is not a raw data analysis. it is not person by person. that would be even better. it is country by country. it has time course and precedents. it could be subject to the ecological fallacy. who says that the people who drink the sodas were the people who got the diabetes? except of course that we know that from other studies where they did have raw data analysis. could the sugar consumers and diabetics be different people? really unlikely. it is food supply, not consumption data, because we don't have consumption data. there is always the concern about wastage. studies have shown 29% wastage across foodstuffs, not anything specific for sugar. leaving u.s. out of the analysis, were we waste the most food, did not change the findings. it was only one decade, but it was a hell of a decade.

not a complete dietary analysis. could micronutrients be important in this? we didn't look at those. that might actually be very important. that is a potential couple -- complicating factor. different techniques used to screen for diabetes in different countries, different diagnostic criteria for diabetes in different countries, and some countries use self-reported data. about two thirds of diabetics don't know they have it. that would make the data even worse. the data includes both type one and type two diabetes. type one has been relatively stable on a percentage basis. this is driven by type two. 90% of diabetes is type two. just so you don't think i am fructose-centric -- [laughter] there are actually four foodstuffs that are metabolized all the same way to cause this same chronic metabolic disease. trans fats do this. trans fats are going down. branched chain amino acids --

these are essential dietary amino acids, and the place to get them, koran-fed beef -- corn-fed beef. that might be a problem, as well. alcohol, a little bit is ok, and a lot is not. same with fructose. and little is ok, a lot is not. the reason that these for travel together is because they are essentially metabolized all the same way and differently from other calories. the liver is the only site for energy metabolism. everything goes to the liver. when your liver gets overloaded, it has to do with the excess. it is not insulin-regular kid. -- insulin-regulated. there is no way to die for the calories into another direction. glycogen is liver starch. it is non-toxic. if you make glycogen, you're helping yourself. that is why marathoners cartload before a marathon race, to up their glycogen. the mitochondria of yourselves,

the energy burning factors, are overwhelmed. all these go straight to the mitochondria. they have no way to stop the onslaught. what the mitochondria do, they turn all the excess into liver fat, and liver fat drives chronic metabolic disease. what this proves is that a calorie is not a calorie. if you believe a calorie is a calorie, number one, you are lost. number two, we are sunk. number three, the food industry wins. if a calorie is not a calorie, that is a place where we can exert some action. abuse -- we will do this really quick. is sugar addictive? yes or no? what do you think? for some people, just like alcohol, lots of people can drink alcohol and be fine, and there is a small minority of people who are clearly alcoholic and addicted. about 20% of the american population is alcohol-addicted.

this is something called addiction transfer. it is probably the same 20% who are addicted to sugar. opera is the world's expert on addiction transfer, ok? the lay public seems to know this. the scientists are having a hard time getting on board with this. if you look at a brain of a controlled patient, you are looking at the dopamine receptors and the reward system dopamine is the feel-good neurotransmitter. when your brain sees dopamine, it goes, i like that. that is good. as long as it has receptors to receive that information, you will get rewarded. notice, here is a cocaine brain. it is a cocaine-addicted were -- adult. the receptors are unregulated greed that is what addiction is. now it means you need more of the substrate, more cocaine in order to get the same level of reward. you have fewer receptors to bind that dopamine.

that is called mass action. this phenomenon is called tolerance. this is the neural anatomic equivalent of tolerance. here is a controlled brain over here. notice there is an obese brain right next-door. what do you see? same thing. in fact, the head of the national institute of drug abuse has said that obesity is a form of food addiction for many patients. i'm not the only one who says this. is there really such a thing as sugar addiction? we have similarities to other drugs of dependence. nicotine, morphing, amphetamine, cocaine. the one i think is the most appropriate is alcohol, because, number one, that is what sugar gets turned into, right? it is called wine. metabolism is the same. number two, it is a market commodity, just like sugar is. number three, it affects the brain in the same way. i'm not the only one who thinks that sugar is a problem.

let's see. i thought i took care of this. why is it not working yet so i thought we had this working. -- why is it not working? i thought we had this working. i apologize. i'm going to have to pass on this. this is eric clapton talking about his addiction to sugar when he was five or six years old. i apologize. i had it working before the meeting started. let's go on. i apologize for that. ok. in animals, here are the criteria for addiction. binging, withdrawal, craving, and cross sensitization with other forms of abuse, meaning that you expose an animal to one drug of abuse for three weeks and you addicted them to the one drug, and then you expose them to a second drug they have never seen before, and they are addicted to that one. the dopamine receptors are the

same. once you down regulate them, you down regulate them for all substances of abuse. that is called cross- sensitization. in animals, we have slamdunk evidence shown -- showing that sugar is addictive. what about humans? it is really hard to determine this in humans. number one, everyone has a baseline. there is nobody who is naïve. number two, we cannot grind up people's brain's. number three, it is very hard to show causation, especially with our current diet. here are the criteria for addiction -- tolerance and withdrawal -- here are all the psychological dependencies great if you read through this, this reads just like obesity. this is what obese patients tell us. the question is, is sugar addictive? has anybody seen this movie? i've got another clip.

i'm hoping this one works. yes. >> [indiscernible] i'm feeling really, really sick and unhappy. we started eating and i over ate. i felt so good, it was crazy. isn't that right baby? >> now, does everybody know the story? morgan spurlock was a vegan because his girlfriend was a vegan chef. he started eating mcdonald's for 30 days nonstop every meal. this is day 18. he just described withdrawal. it can happen to anybody. if you down regulate those dopamine receptors, you're going to need a bigger hit in order to do that. that is called abuse. finally, externality, in negative impact on society. societal intervention says that your abuse of a substance has to affect me in a negative way for us to regulate it.

for instance, nobody is saying we should regulate caffeine. your use of caffeine does not affect me. if you smoke or drink or take drugs, that is bad for me, because of secondhand smoke, car accidents, declining housing prices when your house turns into a coke den. -- crackdown. -- crack den. [laughter] also work productivity and absenteeism. these are the reasons we regulate these substances. how does your obesity affect me? 274 million extra for jet fuel. that doesn't quite do it. discomfort on the subway? sinking of boats due to the weight? 2003, the lake george ferry coded coded for 25 190-pounded else, and the ship capsized.

it ain't going to do it. a $65 billion decrease in work productivity. a 50% increase in health insurance premiums. currently, we are at $2750 per employee for obesity, whether the employee is obese or not. it is breaking the bank. employers know this is unsustainable. we spent $245 billion for diabetes. that is one third of the entire medical budget, for diabetes and dementia. obesity is a threat to national security. 27% of recruits cannot pass the physical education exam -- 27% of recruits cannot pass the physical education. the government pays twice, for corn subsidies and er visits. that is not going to stop. there is no preventative service

for metabolic syndrome. we are going to take 32 million sick people onto the rolls, and we cannot stop the heart attacks or the dementia. it is going to break the bank. medicare will be broke by the year 2026. this is why your obesity affects me. we have toxic substances that are not abused. everything is toxic in the right dose, even water will kill you. here are some substances that will definitely kill you. iron, vitamin d, oxygen, pseudoephedrine, water. these are all toxic substances that are not abused. we don't have to regulate them. we also have abused substances that are not toxic thomas like caffeine. nicotine, until the towers are tars are added. you can buy nicorette gum and walgreens, and it is no problem.

when you have toxic substances that are abused, now you've got a problem, like morphine, heroin, amphetamine, cocaine, and ethanol. guess what? sugar meets all the same criteria for all the reasons i just laid out for you. the question is, what are we going to do about it? the american heart association says, this is a problem. they said -- i contributed to this scientific statement, that we currently consume 22 teaspoons of added sugar per day. we need to reduce that to nine teaspoons per day for males and six teaspoons per day for females. that is a reduction by two thirds to three quarters. is that achievable? can we do that in america today? what does the sugar industry say back to this, what is the politics of this? here we go. what they say is fructose for glucose exchange studies showindifference, and if you look at issa caloric -- were you just change the fructose for the glucose at the same level of -- of calories, you see no change.

that is what they point to. if you look at hyper caloric trials, people over consuming, which is what we all are -- we are over consuming by 275 calories per day -- you start seeing these effects. that is what we are dealing with. what they say is, everybody, eat moderately. the problem is, you cannot eat moderately because it is being abused. we are all addicted. they say it shows no significant difference, but the problem is, oral fructose absorbs poorly. the amount of factors that goats turned into liver fat is quite low. it is not fructose for glucose. it is fructose and glucose. sugar and high fructose corn syrup is sugar -- is fructose and glucose. that matters because when you do the studies with fructose alone, you don't get much.

when you do them together, the liver fat jumps and triples. if you double the amount, it goes up six times. the more sugar you consume, the lower liver fat you make, especially in the hyper-caloric state, which is what we are all in. this is a problem. they also say, fructose doesn't raise blood sugar. it has a low glycemic index. who here knows about glycemic index? so, the glycemic index is the amount of blood sugar rise that 50 grams of carbohydrates will give you. that means the amount of insulin rise that will come with that. fructose doesn't stimulate blood glucose. why? it is fructose. it stimulates fructose instead. the question is, is that dangerous by itself? the answer is, absolutely yes. it causes cardiovascular disease by itself, because it binds to the proteins in your arteries and causes them to become less flexible.

that is what starts the foam cell process. it has nothing to do with your blood glucose. a little fructose has been shown to improve insulin secretion, like alcohol, but that is dose- dependent. as long as you stay under that dose, it is ok. the problem is, we are over that goes by a lot. information on total sugars is available on the food label for everyone to see and for everyone to make their own judgment -- choice. it is the nanny state arguments. that is not really true. here is why. the nutrition labeling and education act of 1990 lists total sugars. that includes glucose, galactose, and fructose, altogether. that is how it works. that is on purpose. the reason is, they don't want to tell you about added sugars. they want to obfuscate what they have added to the food, because they say that that is proprietary. if we told all of our customers

how much added sugar we put in all of our foods, processed foods, our competitors could duplicate our recipes. this is proprietary information. you can't know it. that is a problem. yogurt is a perfect sample. -- example. how many grams of sugar in it, granite yogurt? does anybody -- in a pomegranate yogurt? 19. many of those are lactose and how many of those are added sugar? you can't know. you are not allowed to know. how many grams of sugar are there in a plain yogurt? seven. that means that 12 grams of added sugar to that pomegranate yogurt. that is the same as a bowl of captain crunch. when you have a pomegranate yogurt, you're having plain yogurt plus a bowl of captain crunch. are you ok with that? is that what you bought it to? is that what you expected when you purchased that item? yogurt is supposed to be

healthy. not only that, but there are 56 names for sugar. that is on purpose. they do not want you to know that sugar has been added. yogurt is a perfect example. evaporated cane juice. does anybody know what that is? [laughter] what happens when you evaporated cane juice? you get sugar. evaporated cane juice is not a sweetener by the fda. ecj is not one of them. this is ms. branding could 30% of foods and the american grocery store today are misbranded to keep you from knowing what is going on. here is the list of the 56 names in case you thought i was a little hyperbolic. the question is, where is the sugar, and what foods? how about all of them. one third of the sugar we consume is and beverages. we know about those. 1/6, desserts. that means fully one half of the

foods that have sugar we didn't know had sugar, like salad dressing, yogurt, and mayo sauce, crackers, other products, all things we didn't know. does anybody like wheat thins? check it out. [laughter] and next, they say, we were wrong about that. -- fact. -- fat. we also do, fat was bad, and now you are telling me, it is sugar. what makes you think you are right now? we need more research. indeed, we do. i don't argue that. do you know what that is called? that is called the pessimistic meta-induction theory. look it up on wikipedia. this says that whatever we thought 10 years ago is already wrong and whatever we think today will be wrong 10 years from now. true. i have seen these cycles come and go in medicine.

the question is, why should we do anything if everything is going to be wrong anyway? why should we change anything? do you know what that is? that is moving the goalposts. that means we will never do anything. it means we might as will stick with the dogma of the day, because everything will be wrong. ask galileo. that is what they wanted to do with him. the question is, what level of proof do we need in order to make change? that is the argument for today. how much do you need to know? correlational data is not good enough. you have these questions and other things that might be going on. but when you have causal medical inference which is what we have for sugar and diabetes -- that is what we had with tobacco and lung cancer in the 1960's.

guess what, it is still all we have. we have never done a scientific proof experiment. you would have to take people smoking and starting them for 50 years. do you think anyone will let you do that? that is unethical, immoral, and too expensive. 90% of what we know in medicine today is causal medical inference. the food industry says we need scientific roof to make any change. they know we will never get it. finally, regulation is tantamount to the nanny state. the fact is, we have already been told what to eat. it is too late. everyone says keep your hands out of my kitchen. is, your kitchen has already been invaded. of the 600,000 items in the supermarket, 80% have added sugar. added by the food industry for

their own purposes, not for yours. you've already been told what to eat. this is not about big brother. big brother is here. so the big question is -- who do you want in your kitchen? do you want government, who will take your money and your freedom? or do you want the food industry, who was already taken your money, your freedom, and your health? that is your choice. everything else is a false story. -- anything else is a false choice. and the question is -- how does the food industry stay where they are? well, this is published by michelle simon, a former graduate of uc-hastings, and a former research associate. called, and now a word from our sponsor. and a-n-d -- academy of nutrition and dietetics. are america's nutrition professionals in the pocket of big food? that is who is paying their bill. how about this? co-opting health professionals. i give a talk at the american academy of pediatrics in

october, 2009, and i had this slide. and they said if you show the slide, we will not let you on the dais. i had to take it out, but i'm showing it now. here is what has happened to our food dollars. 1982,, 30 years ago 2012. meat down 10%, because we were told to go low-fat. fruits and vegetables exactly the same. everyone tells us, we need to get more. we are eating all the fruits and vegetables we can. grains and baked goods. up 1%. .not even a big deal. dairy products down from 13% to 10% because we are all lactose intolerant. finally, processed foods and sweets. 22.9%, a doubling in 30 years. that is where the money went.

that is what you are paying for, and that is what is causing the chronic anabolic disease you're looking at. and this is a war, because what is good for them is bad for us. there is no middle ground. it's a war. the question is -- who's winning? here is the stock price of the s&p 500 against mcdonald's, coke and pepsi for the last five years. here is the economic downturn. -- of 2008. mcdonald's, coke and pepsi are doing quite well, thank you. and here is monsanto, conagrea, procter and gamble, kraft, they are all doing better than the s&p. if you want to make money, invest in a food company because they have a winning formula. they have a formula cannot miss, because it is legal and addictive. the problem is, we are all dying in the process. so this paper just came out a couple of months ago in lancet.

profit and pandemics. the prevention of harmful effects of tobacco and processed food. they make the argument, and i subscribe to this, that we use to practice old medicine which was about infected -- infections now the new medicine is something else entirely. it is about chronic disease and the vector is multinational corporations who have figured out how to game the system. now, what are we going to do about? this is a public health problem, and that means we need a public health solution. take a look at all of these solutions. -- diseases. every disease on this list was a personal responsibility issue before the sheer gravity of the problem made it a public health crisis. as we talked about hiv, as an example. how about guns? is that a public health problem? except that it is a personal responsibility problem, isn't it?

depends on who you ask. if you asked the supreme court, it is a personal response ability problem. but it's not. it is a public health problem. and i would put sugar right down there as well. so here we have with the government is doing right now. it is called the let's move campaign. michelle obama's campaign to reduce obesity in a generation. everybody familiar? what she says his focus on individual, focus on the family, and focus on the community. but she leaves government in the -- and the food industry out. now, anybody remember her very first speech after let's move was rolled out in 2010? it was to the grocery manufacturers association of america. and she pointed directly at them, just as i am to you right now, and said, this is your fault. you see this on youtube. and you have to come up with a solution.

she never said it again. not once. why is that? why? she's been muzzled by her own administration because they do not want this fight. and i know because they know they do not because they told me they do not want this fight. sam caste is michelle obama's personal chef and her point person to her obesity task force, and he told me after reading the new york times article, everyone including the president said they are in agreement and they will do nothing about it, not a wink, not a nod, because they have enough enemies. that is what this is about. and you'll notice, anita dunn who founded let's move now lobbies for the food industry. the question i will leave you with our -- can our food environment to change without government or societal intervention, especially for potentially addictive substances? did just say no work?

does education work for substances of abuse? the answer is no. question two -- can we afford to wait when health care will be bankrupted to chronic metabolic disease? we have got 13 years, people, and we have to do something now. not wait for more research. we have the research. we have what we need. policy, what are we going to do? there is called targeted prevention. that is treat the patient, right? treat the obese person. except for one thing. we've just learned that there are more nonobese people who are sick. that is a problem. these are incorporated into medical care. a benefit to risk ratio that is high. the weaknesses is the medicalization of prevention, which is hard.

behavior medication, which is impossible. cost feasibility and limited success across the board. but it is not targeted. it is public health prevention we need. it is radical. it is going to work because we will make it work. it's powerful, because everyone is onboard. environmental modification, fix the environment, not fixed behavior. that is what our data show about obesity, fix the environment. the limitations are the libertarians, -- limitations of acceptability, the feasibility, and cost. what can we do? we could tax and restrict access and intervene. i am not suggesting we intervene. we tried that without alcohol. it was a complete and utter disaster. you cannot have storm troopers invading people's homes for baking an apple pie.

that is just not going to happen. i do not even suggested. because my wife would be the first one they would have to take away. [laughter] what we need to do, like we have with every other substantive abuse is come to peaceful coexistence. we have to find the right amount of legislation, regulation to be able to manage the problem rationally, like we tried to do with tobacco. we can argue about the wisdom of that, especially worldwide, and alcohol. no interdiction but plenty of taxation and restriction of access as needed. so what factors contribute to increased soft drink consumption? price. since the 1980's, the price has only increased 50% versus food. food has gone up higher than sodas have. sodas increased only 20% against fruits and vegetables.

we are supposed to be eating fruits and vegetables. how were we going to do that when sodas are so cheap? sodas are cheap and fruits and nationals keep going up because they are not subsidized. we've allow the serving size to rise. in most developing nations, soda is cheaper and safer than water. until potable water is cheaper than soda, we cannot solve this global health crisis. i totally agree with that. access. it's available worldwide, especially in schools. 50% of flavored milk, that is chocolate milk, is available in schools. marketing. in 2006, food marketer spent $1.05 billion to marketing, half for soda. -- two children and adolescents, half for soda. the question is -- our children a rational target? is that acceptable? why is alcohol so relevant to this question? i think the analogies between sugar and alcohol are very

strong. and we should look to alcohol control policy. and my colleague and i and allen taylor, a visiting professor at georgetown, are planning to write a book on exactly this shortly. both are nutrients, but aside from energy they have no health value. metabolic and the essential pathways in the brain are similar. both are substances that produce health harms when overused. there is little danger from moderate consumption. the problem is what is moderate and how do you keep things moderate when they are abused? and the burden of harm falls disproportionately on the poorest people who can afford the problem least. here are the strategies that have actually been shown not to work. governmental guidelines are useless. we keep saying, let's come up with new guidelines, like every five years. like the dietary guidelines advisory committee. it is garbage.

it is not going to work. public information campaigns have not worked. warning labels on product packaging have not worked. vis a vis smoking. school-based education programs. everyone wants this to work. everybody says, let's cut the money into school-based education. -- put the money into school- based education. all the data so far shows salutary effects almost nonexistent. menu labeling. everyone says, let everyone know what they are eating so you can decide for yourself. let's look at menu labeling. i like this one. here is the adult menu labeling study in new york city. it is a historical, cross- sectional study. we had data before labeling and after. what happened? nothing. nothing happened. mean calories did not change. they went up. three major changes showed very small decreases. 15% of the respondents reported using the caloric information,

and those that did purchase 106 fewer calories than those that did not, but that is all most none of them, because when you go into a fast food restaurant, you were going for taste, and they say so. they may say they're going in for salad, but they by the burger and fries. and there is a reason for that. here is for children. 349 children and adolescents, most accompanied by their parents, and most from racial minority groups, no significant differences in calories purchased before after labeling. 35% eight fast food more times per week. 57% noted the labels. well that is good. at least they had their eyes open. but only 9% reported using the information indeed. and 72% reported that taste was the most important factor. do you think that knowing what is in your food changes what you eat? not at all.

so, education. how are we going to do that? which nutrients will we educate people about? you think the total fat on the label actually matters, because there are good fats and bad fats and they are all crushed in together. -- bunched in together. how are you supposed to know? what about salt. we have had long discussions about salt and whether or not salt matters in the american diet. what is the message? what is the target? if it is about total calories, we are sunk. we will never get past this. that is what we have done for 30 years. the definition of insanity is doing the same thing over and over again and expecting a different result. somehow, somebody in washington still expects a different result. good luck. food labeling. added sugar content. could we put the number of teaspoons in teaspoons on the front of the label and would it matter? maybe labeling has not worked in

new york city. education alone has not worked for any other substance abuse. why would you think this would be enough? i think it is necessary. i think people need to know what they are consuming, but it is not sufficient. necessary but not sufficient. what about strategies that might work? controls on advertising and marketing have been talked about. anyone ever see new york city's man drinking fat commercial. it is on youtube. it is disgusting. it is fantastic. i love it. and it has not changed soda consumption in new york city at all. finally, industry self- regulation. really? in istanbul, 52 european health ministers got together and agreed that we needed to cease marketing of junk food to children. i agree. i approached the fcc director under george w. bush with this exact same issue after this meeting had occurred, and she said "i expect the food industry to police itself,"

which is exactly what they have been doing all this time. it is hands off. the food industry -- hands off. you may remember last year, they tried to rebrand hfcs as corn sugar and the fda told him no. -- then no. they have done it anyway. you know what? they will get away with it. why? because the fda does not have an enforcement arm. the enforcement arm is the department of justice. they got better things to do. they are dealing with the drones and other things. how about on a community level? santa clara and san francisco in 2010 instituted the toy ban? why should you call worse a ce a child into

buying a happy meal for the toy. if you want the toy, by the toy. makes perfect sense. well, since then three states have banned toy bans. let me get rid of that. i don't know why it does that. let's go back. ok. and finally, the campaign to retire -- ronald, which is ever continuing. how about things that are likely to work? pricing strategies are likely to work because people care about price. bundling strategies. controls at the point of sales. government agency action. those are the things that will work. those of the things that worked in the past. the problem is you need people on board. you need government on board in order to be able to enact those. let's talk about pricing. soda taxes. canada and europe already do this. they have the general services tax or they have the value added tax. the price on a can of soda as very small.

everybody understand price elasticity? price elasticity is how much of a change in consumption you will see with the one percent change in price. it does not change much. a 10% prcie increase only increases consumption by 2%. that is not very good. that is what we talk about -- a penny an ounce. existing taxes on soda so far have not resulted in soda consumption. at 3%. this fits this. soda taxes, are they for programs or to reduce consumption? if they are for programs and not consumption, do you know what will happen? soda companies will say, it did not work. worse yet, some unscrupulous politician will take the money and use it for general funds or personal funds and that is what everybody is worried about because that is what we have seen already with tobacco. large taxes are necessary to reduce consumption.

the rand corporation says we need a 36% tax to effectuate a change in consumption. basically what we need to do is double the price of a can of soda. do you think anybody is ready for that? or should we tax the sugar before it goes into the food, rather then tax the food itself? you would need that to be national. you would need congress to do that. only they can levy such taxes. you could not do that state that state, because of commerce clubs. that would be outlandish otherwise. finally, restriction, controls on the point of access. age limits. maybe we should card kits for coke. if their parent wants their kid to have a coke, let them buy it for them. and that would cost nothing. we could do that tomorrow. we do that for beer. licensing and zoning controls over the number of sales. why is there a convenience store within 500 feet of every single school in american?

because the kids are a target. and they know it. how about use permits that control hours of operation? may be the cannot tell so that sell soda between 7:00 and 9:00 in the morning at 3:00 and 5:00 in the afternoon when kids are coming to and from school. in california we had sb19, in the last study said that obesity rates are stable. maybe that is an improvement. maybe it is because of this. we don't know that. and there is the big gulp ban that was struck down by the appellate court in new york state. citing a case in 1986. this case was about public smoking. the thing was it was 1986. in 1990, we learned about secondhand smoke. if borielli have been decided four years later, there was no way it would've been decided in this fashion.

we have the secondhand smoke of obesity and sugar consumption. it is called health care disaster. the fact is, using boreali as a reason to strike it down made no sense. this would ultimately be appealed to the new york state supreme court. here's what happened to sugar sweetened beverage access within schools. you can see it here in terms of purchasing in sixth and eighth grades. look at the arrows. in the schools where sugar sweetened beverage sales have gone down, sales have gone down. that is great, except for one thing. here is the total consumption -- it has not changed. why? they get it on the way home or at home. until we change the entire food environment, concentrating on schools is not going to work. how about bundling. how about differentials differential subsidization. why can't we tax the bad food

and subsidize the good food? could we subsidize broccoli, so that it would be in the best interest of the food industry to promulgate it. we could modify behavior through pricing. we always do. the nordic countries have subsidized low alcohol beers and taxed hard spirits in an attempt to solve alcohol problems. they have been successful in terms of car accidents and cirrhosis of the liver. they have done this over 30 years. differential subsidization. we could discount diet soda and tax sugar soda. i am not sure that diet soda is any better, but it sure is not a whole lot worse. this is the thing to remember. the iron law of alcohol policy says reducing the availability of alcohol will reduce alcohol

consumption and reduce alcohol- related health harms. the same holds for sugar. the problem is -- how do you get there? how about government agency action. regulation in the food industry by congress is a nonstarter. they are not touching this. there is no way in the world anyone in congress will go out on a limb for this. but why can't the farm bill subsidize real food instead of food ingredients? that is what it used to do. food stamps. bloomberg tried to remove food stamps from snap and he was rebuffed by the usda because the usda is in the pocket of the food industry. several other states have applied and the usda has rebuffed them. but the question is why is the usda in charge anyway? that is like the fox in charge of the hen house. the usda sells food, it is hhs's job to keep us healthy. shouldn't this be an issue for them?

not an fda issue. the efsa, the european food safety administration, could influence the court of public opinion to make sugar less appealing. cigarettes went from fashion to filthy habit in a few years when people got on board that there was a problem. the fda could revisit the nutrition labeling education act. instead of total contents, labeling should reflect the degree of processing of the food. so what was added and taken away because all food is inherently good. it is what we do to the food that is not. if we add something, that is a problem. if we take something away, that is a problem. tell us what you did to the food instead of what is in the carton. if we did that, breakfast cereal would disappear. gone. the fta could re-examine their 1986 grasdetermination. generally regarded as safe. one of the reason we're in this

mess is because sugar is generally regarded as safe. this is something determined in 1958 with no data. the results were inconclusive in 1986 that a mean dosage of 50 grams per day. our current dosage is 80 grams per day. we did not do it at that dose. and the issue with -- is intended use. no one intended for sugar consumption to be this high. the sugar industry took that information and so the government gave them a clean bill of health when it was only inconclusive. there are lots of problems with this document. it was based on a 1978 survey at 53 grams, no data on excessive consumption. no data on high fructose corn syrup back then. and fruit juice was considered fruit, not sugar, which it is. so who knows what the real story is? that this is what the 1986 document said, and the person who wrote that document is now a

consultant to the corn refiners association. and there is no dietary reference intake for sugar. there is the nutrition facts label. there is a percent daily value for everything. nothing for sugar. it is not listed. why? sam cast said, why would you need a dri for something that is not a nutrient? something that is not a nutrient? he is actually right, because sugar provides no nutrition. it only provides energy. you do not need sugar to live. there are people who have the disorder in their liver called hereditary fructose intolerance. if they consume sugar, they die. we figured these patients out when they're six months old when they get their first dose of juice, and to become hypoglycemic down to 5. and they are sugar free for the rest of their lives. and they are the healthiest people on the planet and they consume no sugar. why? because sugar is not a nutrient. it is an energy source, but it is not a nutrient.

is alcohol a nutrient? yes or no? it supplies calories. but is it a nutrient? it is a toxin and we treat it as such. same thing here. how about legislative options, advocacy, attempt to apply pressure on the government? good luck. center for science in the public interest is doing that, but nothing has happened so far. legislation has a very long on- ramp. it takes a long time to make anybody do anything in congress. and part of that is due to corporate lobbying. other strategies, so far nothing. how about the farm bill? price subsidies create market distortion. it would be much better to get rid of all the subsidies and let every foodstuff reach it's appropriate market capitalization. that would work nicely.

the problem is, the food industry would have a cow. the question is -- is that ok? is it ok for the food industry to have a cow? i think it is. finally, legal actions. this is the statement that got me to law school. the hyderabad statement. from an indian public health for. all significant advances in public health require and involve the use of law. when i heard that, i went, yes. that is exactly right. and that is why i came to hastings to get my masters. much shorter on-ramp. you can actually make something happen. you can do regulation through litigation. it is the most bang for your buck if you have court support. first question -- who is the defendant? is it the corn refiners or any sugar producer or is it the distributors and the and manufacturers? hard to know. that is a big question. many companies -- theories to ascribe culpability -- market

share, then coke would pay for 29% of the diabetes in the world. take responsibility for a contribution to edit sugar in the environment. these are questions yet to be answered. would you do this to individual plaintiffs or at the state or federal level? they were not successful against tobacco. 845 individual actions brought against big tobacco. only two were successful and both were overturned on appeal. how do you think this would go with something like sugar? it would be even harder. there are so many different defendants. how about class-actions? they were great idea until at&t mobility v. concepcion which said the supreme court does not want to hear these cases anymore. they are not interested, but but there are still 12 states that have this. misbranding is going on in the superior court of california

because there are 56 names for sugar and total sugars are on the label not added sugar. which is what we need. what about liability. this is a big question. is soda a defective product? what do you think? if used as directed, does it kill you? yes or no? what do you think? 11 fold increase in diabetes. what do you think? yes or no? other products contain nutrients, so they would be unlikely to be considered defective. but soda. ain't nothing in the soda you need. everything in it is something you do not. and finally, failure to warn. it turns out latinos are susceptible to this. and they get the worst nonalcoholic fatty liver disease and the worst incidence of diabetes. 50% of california latinos get diabetes. they have a genetic polymorphism that makes their liver susceptible.

they need a warning label on every can of soda, saying, latinos, you will get sick from this, because they will and they do. and i have to take care of them. so where is the label? and finally, the parents parens patriae. the state is the parent. how the mississippi attorney general sued big tobacco. because the state is more than a nominal party. they stand to lose big. they are losing $1.5 billion for diabetes and the state of california every year. there is no requirement for tort liability. all you have to do is show the economic harm. and the state is not a nominal party, which is easy to do. we could recoup medicaid for diabetes and other diseases as well. all sorts of academic papers and more academic papers. and then non-academic. fat chance, which you can purchase today.

this will be out in six days. an e-book that people can use to go into the store and use it to shop properly because it lists the added sugar in each food in the supermarket. and finally, in january, we will be releasing the cookbook. in order to turn this around, people have to learn how to cook again. the question is -- how do they do that and what is it they will make and how do they do it fast? everyone one of these recipes was vetted by a high school student. if they can make it, so can you. and they are good. lastly, we have started a nonprofit organization to provide medical nutritional and legal analysis and consultation to promote personal and public health versus big food.

called the institute for her -- institute for responsible nutrition. responsiblefoods.org. come join, sign up. we will let you know what is going on and you can contact me for more information. i want to thank all of my collaborators at uc-hastings. in particular, david, marcia, john diamond, pat davidson, and my colleague who did the heavy lifting on the statistics on the diabetes study. and kristin kerns who is the person who is basically doing the sugar documents in the same way as the tobacco documents. and stan, who is mr. anti- tobacco, and has realized that noncommunicable disease whatever it be is the problem of the 21st-century. we need to solve it, and we're going to need all of you in the room to get on board and help us do it. with that, i want to thank you all and i would be happy to answer questions. [applause]

>> if you have questions, if you make your way over to the microphone and introduce yourself. >> i answered everyone's questions? that is pretty bad. happy to answer any questions. >> hi. >> go ahead. you bet. >> many questions. try to limit to a couple. so the last, the last piece of information you shared with regards to latinos and a higher likelihood of metabolic disease given exposure.

i wonder if you could talk a little bit more about what we know about that, or where we could find more information about that. we do have a community group here in san francisco interested in health equities impacting latino community, who want more information with regards to that. >> i gave a talk two years ago at the latino health forum on this question. it is a huge problem, especially in san francisco. what we know is that sugar gets converted to liver fat but there are certain things that go on in the liver that can make that worse. there is a gene, pnpla3, it is a gene. and if you have certain polymorphism, which 19% of latinos have, 19%, a little

sugar makes a lot of liver fat. way more than if you have heterozygous or homozygous for the wild type. in addition, there is another polymorphism for another gene, which is one of the molecules that helps the mitochondrial function properly. if you have a polymorphism in that, which latinos carry, you are not going to be able to put enough energy through the mitochondria, which means the backup will get turned into liver fat as well. so both of these are known risk factors for developing nonalcoholic fatty liver disease which is a cause of type 2 diabetes, and latinos are susceptible. the point is that latinos of all ethnicities have to be careful about their sugar consumption. the fact is that latinos are the least careful about the sugar consumption.

they do not even drink water. they drink aqua fresca. they have more names for sugared beverages in spanish than virtually there are in english. and i have actually compose a list of those and published it in the journal of pediatric nutrition in 2012. it is pretty ridiculous. [speaking spanish] the list goes on. it is pretty astounding. kids, they tell us, they drink it because it tastes good. yeah, i know. but this does not mean it is good for you. and we have a real hard time convincing parents, latino parents, of the hazards of this practice. so we have a lot of work to do. >> thank you. i hope there are folks working on that locally. we have a lot of work to do. one more question, since there is not anyone else at the microphone yet.

my name is roberto vargas, i work at the clinical and translational science community and health science program at ucsf. with regards to differential prices, you pointed to the example in nordic countries. subsidization of -- subsidizing beer, heavy taxes on alcohol. do we have any other examples of that? has there been any testing of that with regards to sugar beverages? >> no, there has been no testing. not that i know of. what i can say is that there is one study out of harvard where they change the price in the hospital cafeteria to see whether or not they could get people off sugar sweetened beverages. they had to change the price to significantly. we are about to embark on the study at ucsf that the head of

food services is the principal investigator on, where we will try to do the same thing in a hospital setting, which is very different than the general setting. but hospitals have to start this. the bottom line is -- it used to be the people smoked in hospitals. and now they do not. in fact, hospitals were the first place is to ban smoking entirely. and we will probably have to be the first phase is to ban sugar sweetened beverages entirely, too. >> hi. can you just say a little, a few words about the reversibility of the condition? for instance, what is the duration of exposure for a child at risk? let's say they stop their soda consumption when they turn into, the age of 20, smokers will ultimately go back to the risk for lung cancer over many years. what happens to children -- >> there are two issues.

there is the nonalcoholic fatty liver disease and the diabetes issue. the nonalcoholic fatty liver disease issue, if it is just fatty liver, it is eminently reversible. it can take time, but it is reversible. we are doing a study at ucsf where we are isocalorically taking sugar away and substituting complex carbohydrates for 10 days. i am blinded to the results, so i cannot give you the answer to that, but we anticipate that we will reverse their fatty liver disease during that time, because we have data in adults that 14 days of doing the same thing was effective. 38% reduction in liver fat during that time. if -- sorry? >> what is the duration of exposure that would bring about fatty liver and the child? >> two weeks. two weeks. heavy drinking -- >> of soda.

>> and you get it in alcohol, too. three sodas a day will get you there. in terms of the scarring that occurs, the cirrhosis. once that occurs, that never gets better. once you go from fatty liver to fatty liver plus inflammation, that never improves. five percent of the patients with fatty liver go on to develop cirrhosis over time. you can slow it down by getting rid of the substrate and by using antioxidants, but it is a progressive lesion from that point on, which will ultimately kill you or require a liver transplant. now diabetes is eminently reversible. type ii diabetes is reversible in most patients. problem is, not with our current diet. but people who go on the paleo

diet see all of the medications go, they do not need their medications with in 8 weeks of starting the diet. once they actually change their diet and their composition. so i think that diabetes is eminently reversible. if you do the right thing. >> dr. lustig, what is the role of ethnic communities, what plans do you have for translations in other languages to be able to make it accessible? >> the thing i am most upset about is that there is no spanish version of fat chance. if anybody here is a spanish- language publisher, come talk to me. we have tried to get various publishers interested in in

publishing a spanish-language version. and there are all sorts of problems with that. it is in norway, slovenia, turkey. it is in new zealand, in korea. it is in the u.k. and australia. but that is in english. it is in a lot of countries. it is not in latin america and not in mexico. and the reason is because no spanish language publisher has picked it up and i cannot tell you why. i cannot publish the book, it is copyright, i cannot publish the book myself. that would be really good. we have all sorts of materials that we hand out in our clinic that are in spanish language, very specifically because that is the audience that needs it. we worked very hard to make sure that they get the message. the bottom line is, we do not go home with them. they ultimately do what they do. we do the best we can.

education has never fixed any substance of abuse. >> thank you very much, dr. lustig. the last comment you made, education not fixing an addiction abuse situation. in a stressful society, sugar serves a role. it is comforting, it triggers dopamine. so i am curious about that. is there any possibility of creating -- if you take something away, what will you give them? >> this is like the holy grail. the $64,000 question. if you take something away that gives pleasure, while they search for something else pleasurable instead? could it be that they substitute something even more dangerous in its place?

they go back to smoking, they go to cocaine. these are very concerning. these are worrisome issues. i do not know the answer. i do know that something has to be done because we cannot afford health care associated with this. this is an unsustainable model. if you think about what happened with tobacco, let's talk about tobacco for a minute as sort of the flip side. when did smokers die? average age, 64. that is what the actuarial analysis says. the average age was 64. do you know what happens at 64? you pay in to medicare and pay into social security. and you die. and you do not get anything out. this is actually a sustainable model. in addition, when you got lung cancer, how long did you have before you were dead? 6 months.

how much money could you spend out of your health care dollars in six months of lung cancer? not that much. so, you paid in. you did not get out, and you did not cost society a whole lot. now, we do not smoke. or we have cut down smoking at least by half. so what are we doing instead? addiction transfer. we have chosen an addiction which seems safe, except that it is not. and worse yet, it is causing adolescent type 2 diabetes. and these patients are going to be sick for 20, 30, 40 years before they are dead, and their productivity is going to be nil. and they are going to chew through all of the health care resources of this country and they are not going to be productive. they are going to be on the dole, because they will not be able to work. so the question is -- is this a better model than what we had before?

what i say is, let's get everybody smoking again. [laughter] i say that tongue-in-cheek. >> you said that education alone would not work, but maybe a pricing policy or something more hard, plus an educational model. >> absolutely. for every substance of abuse, we have needed both personal intervention, which for lack of a better word, we can call rehab, and we need societal intervention which we can call laws. for every substance of abuse, we have needed both. rehab and laws. that is what we had for alcohol and nicotine and for cocaine. that is what we have for heroin, etc. for sugar, which meets all the criteria, we have nothing. so the question is, how are we going to do that in order to salvage our health care system? that is the big question. your point is absolutely -- the holy grail. what is going to happen if you

reduce sugar consumption? if that is a matter of pleasure. one thing on that subject. do you remember tolerance? down regulation of the dopamine interception? if you reduce consumption, what happens to that dopamine receptors? they go back up. you get more pleasure. we could find a peaceful coexistence with sugar that would ultimately provide the pleasure and still keep our health care costs down. i say the answer to that is assuredly yes. >> so what is the nature of pleasure? opiodes, oxytocins, how do we substitute goes to create behavioral states. and training that is a societal issue. the anatomy and physiology of medicine but also law. what is responsibility? what is self generation of behavior?

from a legal perspective. >> this is the new ethics of health care. is how do you balance personal responsibility against societal needs? and that is i why went to law school was for exactly that. public health law. jacobson v. massachusetts, 1905. there was a pastor in cambridge who refused to get vaccinated for smallpox. said it was a religious objection. the supreme court said, too bad. you live here, you are getting vaccinated. tough luck. the bottom line is there is a point at which every person responsibility issue becomes a public health one. and the question is -- where is the line and what are the legal doctrines that govern the crossing over of that line? i would submit to you that we have surpassed that for this problem.

yet we have not enacted any societal interventions that are meaningful to try to fix it. that is what needs to change. >> thank you, dr. lustig. i was wondering if you could speak little bit to other disease in addition to obesity, such as autoimmune disease. >> autoimmune disease is a grab bag. this is being televised, taped. and i am about the science. the science on auto immune disease is very much an open question. so i am a little loathe to tell you how all of this might tie into autoimmune disease, other than to say that people are working on it. i am very interested, but i am not willing to go public on it. not until we have hard science. so i'm going to have to beg the question right now.

sorry. >> dr. lustig, i just wanted to make one brief comment about the idea of if you are taking something away, what are you giving? if you take away sugar, what is the reward? >> i have never said take it away. >> i never said take it away, i said reduce exposure. >> reduce availability. to a manageable level. i never said take it away. a lot of people say i say that, but i have never said that. do not put words in my mouth. >> if we reduce the exposure to added sugars, in a very small sample size, mostly middle-aged midwesterners in the united states, i can say one of the main rewards that these people are getting in a health education program i am running on this topic is reduction, and when you reduce your waistline circumference, people start to notice and you start getting a lot of compliments. and people respond to that.