Blog | Friday, July 6, 2012

Perils of a sugar-coated scapegoat

It has been some time since Dr. Robert Lustig emerged as the messianic nemesis of added sugar, or perhaps specifically fructose. It has been some time since his meme took hold, engaging high-profile adherents and apostles. And it has been some time since I first started expressing my opposition to this "sugar is poison" platform (1, 2, 3, 4).

Consequently, it has been some time since I started receiving a bounty of hostile correspondence that would make my mother pass out, my wife wince, and my children cry. Confronting fervor is ever perilous, and I likely owe the filter of cyberspace for the fact that I have only suffered rhetorical violence.

The fainting, wincing, and weeping notwithstanding, I am sticking to my figurative guns. Excess dietary sugar is harmful, and among the salient liabilities of the modern food supply. Sugar is not poison, however. And yes, I think the distinction matters enough to keep fighting for it. Here's why.

1) The follies of history

I am convinced a fixation on sugar (or fructose) as poison will result in net harm to public health, and quite possibly a lot of it. I am equally convinced that process has already begun.

This is not because we don't consume a large excess of sugar; we do. It's not because that large excess doesn't contribute mightily to our prevailing public health ills; it does. It's not because there are no metabolic differences between fructose and sucrose; there are some, although I don't think they matter all that much in the real world. And it's not because I own stock in Sugar Smacks, or because the sugar cartel is holding my first-born hostage; I don't, and they aren't.

It's because when the truth gets too hyped-up and too dumbed-down, it ceases to be the truth. It turns, instead, into propaganda, or at least fodder for the flames of propaganda. And the food industry will be only too happy to stoke those flames, as history has shown us.

What history?

We decided oat bran was good for us, and saw a wild proliferation of products (including potato chips!) with trivial essence of oat bran in the ingredient list, but great big banner ads about it on the front of the package. This no doubt convinced a lot of shoppers they could have their donuts and Danish and eat their oat bran, too, but it was all marketing hype, exploiting a narrow fixation on a particular nutrient.

The history of our fixation on dietary fat is even more notorious. We didn't start eating more fruits and vegetables, we started eating SnackWell cookies and the like, and all got fatter and sicker.

So we switched to a fixation on cutting carbs, and along with throwing out the baby with the bathwater (I heard a radio DJ once talk about taking the beans out of chili because they were a carbohydrate source ...), we fell victim to the same capacity of the food industry to leverage our tunnel vision. We got low-carb brownies rich in trans fat, and guess what? Since the advent of low-carb eating, obesity and diabetes rates have gone up.

There are many other examples of the dangerous liability of focusing on any one nutrient property at a time, but that should suffice. It is, alas, a well-trod path.

In my opinion, there is a comparable and very grave danger in focusing preferentially on sugar, and that much more so by focusing preferentially on fructose, as our current dietary concern. Perhaps you have already seen some soda and/or ketchup ads noting "now made with pure sugar!" as if sucrose is trading up from high-fructose corn syrup. It is not.

Sucrose is a 50/50 mixture of glucose and fructose; high-fructose corn syrup is, at most, a 45/55 mixture of the same monosaccharides. The notion that a 5% differential in fructose content has much of anything to do with current public health ills is more than a little far-fetched. The net effect of sugar excess is detrimental, no matter the sugar.

As for pure fructose, it doesn't have a big role in the food supply. The only places one tends to find it is in fruits (which all concerned acknowledge are NOT the problem, but let's recall that fruits did get tossed out of diets at the height of the low-carb, low-glycemic frenzy, and we could find ourselves there again if we aren't careful), and in juices made from fruits. Juices are, arguably, a small part of the obesity problem. But I really don't know anyone inclined to blame epidemic obesity or diabetes on orange juice.

Ironically, even while weathering a storm of insults for allegedly being too soft on sugar, the nutrition guidance system I helped develop, NuVal, was criticized by some entity with skin in the game for being too hard on sugar! The system generates deservedly low scores for fruits canned in fruit syrup, among the most concentrated sources of added fructose in the entire food supply, and presumably products Dr. Lustig would love to hate. I can't help but think that if I am allegedly too hard and too soft on added sugar simultaneously, there's a pretty good chance I am actually right in the sweet spot, as it were.

If we now focus public health concerns preferentially on fructose, we will surely see the dawn of the "FRUCTOSE-FREE!" banner ad era, as such proclamations populate the packages of innumerable processed foods that are in many cases new versions of old junk. People getting the message that fructose is bad, and seeing those banners will be led right down the old garden path, through no fault of their own. They'll think they are trading up, while making a lateral move.

And that may not be the whole story. Perhaps we'll see a whole new crop of artificially sweetened starchy foods, boasting they are "now sugar-free!" and belying the facility with which our bodies turn starch into sugar. And maybe, feeling virtuous about eschewing sugar, we'll eat twice as much, and get fatter and sicker.

As someone who has worked in nutrition, public health, medicine and the media for decades, trust me, the food industry is salivating over the "fructose is poison" message. If we get the public totally mesmerized by one nutrient concern at a time, we've created a gaping loophole for a whole battalion of new, high-profit, low-nutrient, just-what-you've-been-asking-for foods. They are already on the assembly line.

My job is to defend against that, and I intend to keep doing it, no matter the weeping, wailing, and wincing. Excess sugar intake, and not just fructose, is one of the great liabilities of the modern diet. But it's just one of them. Until we devise campaigns that leave the industry with no loopholes so their only option is to make and market foods that are actually better for us, and until we educate ourselves to demand the same, we will keep getting fatter and sicker, and the sellers will keep getting richer, presumably while laughing at us.

2) The dose makes the poison

Iron, oxygen, cholesterol and sugar, in the form of glucose, all circulate in the blood. All are essential for life. In the absence of any one of them, we die. And the body manufactures some of them, sugar included.

When sugar levels in our blood dip, our body manufactures glucose in one of two ways. It breaks down a fuel called glycogen, stored in muscle and liver, directly into glucose in a process called glycogenolysis. If glycogen stores are depleted and sugar levels dip, the body manufactures sugar out of any other fuel source, carbohydrate, protein, or fat, in a process called gluconeogenesis.

Iron, which is essential for carrying oxygen, is vital to life, but highly toxic in excess. It, too, might be called a poison, except that we die of oxygen deprivation at the cellular level without it.

And for that matter, oxygen, in excess, is far more virulently toxic than sugar. The harms of excess fructose intake accumulate over years. Exposure to 100 percent oxygen is lethal within hours to days, and this is of practical concern in the hospital setting. But it does not induce us to call oxygen poison; if so inclined, try getting along without it.

Delivery vehicles for fructose include blueberries and cherries. We really can't have it both ways. If fructose is a poison, blueberries are poisonous. If blueberries are not poisonous, fructose is not a poison. Rather, the dose makes the poison, of fructose, or any sugar, or oxygen.

Why fuss about the difference? For the reasons above. The well-traveled path that leads through the garden of dietary good and evil doesn't lead us any place we want to go.

For the many disciples of Dr. Lustig, I hasten to note that his focus on the harms of excess sugar intake did real good up to a point. He was directly involved in getting the American Heart Association to count sugar among its concerns, something I for one felt was long overdue.

I have long railed against the ONAAT fallacy, and the AHA and cardiologists have been perpetrators of it. They worried about saturated fat, while sugar calories were driving an epidemic of obesity that was driving an epidemic of diabetes that was in turn a major driver of trends in heart disease. It made no sense for the AHA to ignore sugar, and thanks in part to the efforts of Dr. Lustig, they no longer do.

But the fact that sugar should be on everyone's list of dietary concerns is a long way from saying that sugar, let alone fructose, should be everyone's entire list of dietary concerns. That leads us right back to the ONAAT fallacy, just through a different door.

We can create new problems by overshooting as we solve old ones, and I give you the food supply and labor-saving technology, the Scylla and Charybdis of the obesity epidemic, as an illustration. Where did they come from? Overshooting!

Throughout most of human history, calories were relatively scarce and hard to get, and physical activity was unavoidable. We are well adapted to that, but it's a daily challenge and inconvenience. So we devoted our large Homo sapiens brains to the task of fixing it, and overshot, devising a modern world in which physical activity is scarce and hard to get, and calories are unavoidable, with epidemic obesity, diabetes, and other ills to show for it.

For far too long, we have diverted public health from the benefits better eating would confer by bogging down in one-nutrient-at-a-time boondoggles. For far too long, we have created monstrous loopholes for a food industry only too happy to tell us what we say we want to hear, while inventing new variations on the theme of junk food. The costs of this have been high.

As the costs of looking for a single scapegoat rather than owning the full scope of our issues are always high. Sometimes, calamitously high.

Added sugar is among the more salient liabilities of the modern food supply, and this requires a remedy. But the ills of modern eating are not due to just one misaligned star, but to a whole constellation of factors we have aided, abetted, invented, and condoned. We must look to ourselves and muster the resolve to fix this comprehensively. Turning one of many dietary concerns into a scapegoat for all threatens to substitute the propaganda and procrastination we've seen with past follies for the genuine progress we urgently need. Let's not go there ... again.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.