FoodGate: The break-in, cover-up, and aftermath. Robert H. Lustig, M.D., M.S.L. Cristin Kearns, D.D.S., M.B.A. Laura Schmidt, Ph.D., M.P.H., L.C.S.W.
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1 FoodGate: The break-in, cover-up, and aftermath Robert H. Lustig, M.D., M.S.L. Cristin Kearns, D.D.S., M.B.A. Laura Schmidt, Ph.D., M.P.H., L.C.S.W. Osher Mini Med School for the Public, Mar 6, 2018 Decrease in U.S. Deaths from Heart Disease offset by Type 2 Diabetes and they re not dying! Ford et al, NEJM 356:2388,
2 T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, MILLION IN 2010, up 8.9% per yr 2
3 T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, MILLION IN 2014, up 11.7% per yr T2DM increasing around the world People with DM (in millions) for 2000, projection for 2010, and % increase Zimmet et al. Nature 414: 782, 2001 WTF?? 3
4 The money is not going to hospitals, physicians, or Big Pharma The money is not going to hospitals, physicians, or Big Pharma It s going to chronic metabolic disease 4
5 Two inconvenient truths Two inconvenient truths There is no medicalized prevention for chronic metabolic disease There s just long-term treatment 5
6 Two inconvenient truths There is no medicalized prevention for chronic metabolic disease There s just long-term treatment You can t fix healthcare until you fix health You can t fix health until you fix the diet And you can t fix the diet until you know what is wrong
7 2001 Epidemiology 7
8 Nothing about fruit, vegetable, or fiber consumption 8
9 Trends in macronutrient intake and obesity Carbohydrate Fat Obesity (BMI>30) Protein Based on NHANES data. Int J Obes 1998;22: JAMA 2002;288:1723. MMWR 2004;53: Trends in macronutrient intake and diabetes Carbohydrate Fat Diagnosed DM Protein Based on NHANES data. MMWR 2004;53: Diabetes Care 2004;27:
10 Prospective Urban and Rural Epidemiology (PURE) Dehghan et al. Lancet epub Aug 29, 2017 The animal-based food effect on T2DM goes away after you control for iron/heme intake Talaei et al. Am J Epidemiol DOI: /aje/kwx156,
11 Branched chain amino-acids or choline in red meat may contribute to insulin resistance and inflammation Trimethylamine Oxide (TMAO), a bacterial metabolite of dietary choline, appears to be pro-inflammatory Newgard et al. Cell Metab 9:311, 2009 Zhu et al. Circulation 135:1671,
12 Blood levels of dairy saturated fatty acids correlate with protection from T2DM Yakoob et al. Circulation 133:1645, 2016 Surrogate markers 12
13 LDL correlates with CVD, but not all that well 5/12/ ( ) Ravnskov et al. BMJ Open 6:e010401,
14 Hypertriglyceridemia is a better CVD risk factor In Meta-Analysis (univariate risk) 46,413 Men (16 studies) 2445 Events 8.4 yr f/u 10,864 women (5 studies) 439 events 11.4 yr f/u holds up in mutltivariate analysis Austin et al, Am J Cardiol 81:7B,
15 Atherogenic dyslipidemia It s not about LDL cholesterol, it s about LDL particle number Cromwell et al. J Clin Lipidol 1:583, 2007 The lipoprotein continuum VLDL IDL LDL A large buoyant PATTERN A HDL LDL A-B intermediate PATTERN B LDL B small dense Total LDL won t tell you particle number - There s more LDL B than LDL A at the same total concentration 15
16 TG and HDL change with LDL sizing Rizzo and Berneis, Quart J Med 99:1, 2006 Randomized Clinical Trials 16
17 Conclusions: A dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD or stroke. Howard et al. JAMA 295:655, 2006 LDL-C lowering as primary or secondary prevention of CVD Randomized controlled trials (RCTs) of drug (41) or dietary (3) interventions No overall benefit on mortality Most of these trials did not reduce CVD events Some of the drug studies reported harm DuBroff, Evidence-Based Medicine.;22:15,
18 A high intake of omega-6 fats (vegetable oils) has not been proven as beneficial for our health and trans-fats have been shown to have negative health effects. The higher intake of vegetable oils and the increase in carbohydrate consumption in the last years are the two leading factors behind the high rates of obesity and metabolic syndrome in the U.S. Saturated and monounsaturated fats are not. 18
19 AM National Health Trust, UK RR Editor-in-Chief, JAMA Int Med PM Editor-in-Chief, BMJ Open Heart Malhotra et al. Br J Sports Med April 26, 2017 doi: /bjsports
20 Nature 487:27-29, Feb 1, 2012 New York Times, April 17, 2011 Histology of (N)AFLD Normal (N)AFLD 20
21 MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% 21
22 MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24% MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24% 22
23 MRI Fat Fraction Maps Obese Low Liver Fat = 2.6% Obese High Liver Fat = 24% Thin High Liver Fat = 23% MRI Fat Fraction Maps Fat Healthy Low Liver Fat = 2.6% Fat Sick High Liver Fat = 24% Thin Sick High Liver Fat = 23% 23
24 Sugar and Diabetes (Causation) Sugar is toxic unrelated to calories Lustig et al. Obesity 24:453, 2016 Gugliucci et al. Atherosclerosis 253:171, 2016 Schwarz et al. Gastroenterology 153:743,
25 Glycerol-P De novo Lipogenesis DNL TG* Ac CoA* Malonyl CoA Fatty Acid* VLDL* Glycerol-P De novo Lipogenesis DNL TG* Ac CoA* Malonyl CoA Fatty Acid* VLDL* 9 days fructose restriction 25
26 Glycerol-P De novo Lipogenesis DNL TG* Ac CoA* Malonyl CoA Fatty Acid* VLDL* 9 days fructose restriction LIVER FAT DNL VLDL* Visceral fat Glycerol-P Ac CoA* De novo Lipogenesis DNL Malonyl CoA Fatty Acid* TG* VLDL* Improved Insulin kinetics 9 days fructose restriction LIVER FAT DNL VLDL* Visceral fat 26
27 Sugar and disease Causation Diabetes Heart Disease Fatty Liver Disease Tooth Decay Correlation Cancer Dementia Lustig, JAMA Pediatrics 171:212,
28 PROCESSED food is high-sugar, low fiber PROCESSED food is high-sugar, low fiber REAL food is low-sugar, high-fiber 28
29 PROCESSED food is high-sugar, low fiber REAL food is low-sugar, high-fiber All diets that work are REAL food High fat or high carb doesn t matter; it s processed food that matters (DIETFITS) Conclusions: Real food led to weight loss, in either a high-fat or highcarb diet. Processed food doesn t. Gardner et al. JAMA 319:667,
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