Metabolical: The Lure and the Lies of Processed Food, Nutrition, and Modern Medicine

by Robert H. Lustig

Food writer Mark Bittman has said that since food is defined as “a substance that provides nutrition and promotes growth” and poison is “a substance that promotes illness,” then “much of what is produced by industrial agriculture is, quite literally, not food but poison.”

Yes, pesticides are one aspect of food toxicity—but only the tip of the iceberg, maybe about 10 percent of what ails us. The other 90 percent is due to the procedures of the processing, which has morphed what was food into this new slow-acting poison.

Nutrition is not the same as food science. Nutrition is what happens to food between the mouth and the cell. Food science is what happens to food between the ground and the mouth.

Essentially, all you need to know are two precepts, six words total: 1) protect the liver, 2) feed the gut.

Only items that meet both of these criteria qualify as Real Food, i.e., that hasn’t been stripped of its beneficial properties and sprinkled with toxins that will hasten our demise.

The reason for this bottom-to-top and backward-to-forward excursion is to answer these questions: why has our health status declined, our healthcare system devolved, and our climate immolated?

First, the change in food processing, starting about fifty years ago, has fueled a slow but unrelenting medical, economic, and climate vortex downward. It’s picked up speed with time and overwhelmed our medical resources, now evidenced and accentuated by the social disparities of the coronavirus pandemic. It threatens to overwhelm our planetary resources to boot. Second, in today’s society, food is the only possible lever that we can apply immediately to effect change. If you do not fix your food, you continue to court chronic disease and death. If we do not fix our food, we continue to court societal and planetary oblivion. This book explains what’s needed to fix both.

they taught that it was all about calories in and calories out, and I believed what I was told, even though it was the opposite of what I’d learned just one year prior. Hey, these were the doctors, the experts, and my parents were paying a big tuition bill for learning and incorporating the expertise of those doctors.

When I was at the University of Tennessee in the late 1990s, one divisional colleague sent a form letter to outside providers admonishing them for referring such patients, to dispel their belief that an endocrinologist could somehow cure obesity—such sacrilege!—that a doctor could somehow upend the first law of thermodynamics, which espouses a simple mantra: a calorie is a calorie. That mantra, recited with almost religious fervor, has set medicine back at least fifty years, and maybe more.

The science said that not all calories are created equal; and it’s the food quality, not the quantity, that matters. I didn’t know it at the time, but that was my only salvation in terms of my reputation, personal integrity, and sanity. It also set up the second half of my career to be an iconoclast, relegated to the outside of both the medical establishment and the government.

There are two keys to understanding the breakdown of our health and healthcare model. The first key is the one the medical establishment doesn’t want you to know—that their drugs can’t and don’t treat chronic disease; they only treat the symptoms.

But for chronic noncommunicable diseases (NCDs)—such as diabetes, heart disease and stroke, fatty liver disease, cancer, and dementia, which kill more people, at earlier ages, and in the most debilitating of ways (think amputation, dialysis, blindness) and eat up 75 percent of all healthcare dollars—Modern Medicine has gotten it all wrong.

There are eight subcellular pathologies that underlie all chronic conditions—and all of them are nutrient-sensing (Chapters 7 and 8), meaning that they respond positively or negatively to specific components in food; yet none of these are considered diseases themselves. When you look carefully at the science of these eight pathologies, you realize that none are druggable, which is why they don’t respond to our current medications, and why people keep getting sicker despite the doctors’ best efforts. But they are all foodable

the public wants to know—are these eight pathologies exercisable? Not completely; of the eight, only five are responsive to exercise. Physical activity is a useful adjunct, but you can’t outrun a bad diet.

The second key is the one that the food industry doesn’t want you to know—all food is inherently good; it’s what’s been done to the food that’s bad.

ultra-processed food is the cause of other chronic diseases on the upswing, such as addiction, depression, obstructive sleep apnea, and autoimmune disease.

Michael Pollan (full disclosure, he’s a friend), in his now-famous New York Times Magazine article, espoused seven simple words: Eat food, not too much, mostly plants. Three separate clauses, but I think that each clause is misleading. Eat food doesn’t take into account that some people may do better on a low-fat diet, while others may do better on a high-fat diet. Not too much doesn’t say how you are supposed to moderate that, as it doesn’t take into account food addiction or what generates satiety. And mostly plants doesn’t take into account that Coke, French fries, and Doritos are all plant-based.

Andrew Weil espouses the so-called anti-inflammatory diet, which is mostly plants. Seed oils are high in omega-6 fatty acids, which are highly pro-inflammatory; yet omega-3s, found in fish, are anti-inflammatory. It’s not the plants that are important. Furthermore, the low-fat diet, a bastardized version of the plant-based diet, has been a dismal failure, killing more people than cigarettes.

And now we have a new controversy—vegan vs. keto (Chapter 14). Movies like What the Health (2017) and The Game Changers (2018) argue that animal products kill people. Vegan proponents argue that meat is killing people and the planet. Are these arguments based in science? It seems like everyone, from the Lancet Commission to the Intergovernmental Panel on Climate Change, is advocating a plant-based diet for both our health and for the environment. If this were the easy answer, India, which in large part eschews beef, would be healthier. But its diabetes rate is 8.8 percent and growing—the rate in the US is 9.4 percent. By the same token Argentina and New Zealand, which both eat double the meat per capita that the US does, would be fat and sick—but their heart disease, diabetes, and cancer burden are lower than ours.

One of the goals of this book is to help bury the hatchet in this fake diet war by showing that real vegan and real keto can both work, as they have more in common than they realize. As I was writing this book, I thought, “Either I’ll be embraced by both sides because I’ll have validated their view, or I’ll be shunned by both sides because I’ll have validated the opposite view.” I’m not the enemy. Both factions should be allied with me against the real enemy—processed food.

While cows and sheep are indeed methane producers, the methane emissions from the animals (5 percent) turns out to be a pittance compared to the rest of agriculture (10 percent), and compared to industrial methane production (35 percent) and the transportation industry (50 percent). And the climate change impact of the animals is completely dwarfed by the nitrous oxide production resulting from synthetic fertilizer sprayed on all those plant-based products throughout the Midwest grain belt (see Chapter 25).

I propose that Michael Pollan’s seven words for healthy eating can be re-stipulated into these six words: 1) protect the liver, 2) feed the gut. This includes animals.

The healthcare field has been plagued for decades by a philosophical concept known as moral hazard, which denotes a situation where the perpetrator knowingly profits off the victim’s suffering—an economic version of schadenfreude. An example of this is

The deeper I dug, the more I realized that the problem was much bigger; in fact, I am coining a new term—immoral hazard—to denote when the perpetrator specifically rigs the game to create its profit, knowing full well the victim will suffer.

In this book, I will provide evidence for three separate, yet related immoral hazards perpetrated by Big Food, Big Pharma, and Big Government. As people get sicker, Big Pharma benefits from complicity, the food industry is protected from the costs of its actions, and the government profits from tariffs on processed food shipped to other unsuspecting countries. We’ve accepted this as normal. It’s not,

we now know that dietary fat is not toxic (aside from trans-fat), and some fats can be therapeutic. We are beginning to understand the role of the gut and its microbiome in the development of autoimmune and psychiatric diseases.

these two easy precepts: 1) protect the liver, 2) feed the gut.

The US has the best doctors, hospitals, and medical technologies, the most innovative surgeries, the best and newest drugs, and spends the most per capita on healthcare of all the countries on the globe. Are Americans healthier? Do we enjoy better healthcare? Do we live longer? The answer to each of these questions is an unequivocal and emphatic no. In fact, it’s quite the opposite; Americans have the worst health outcomes of any country in the Organisation for Economic Co-operation and Development (OECD; the thirty-seven richest countries). In several of the most lethal chronic diseases, Americans rank among the worst of the developed countries in the world: #1 in diabetes, #2 in Alzheimer’s disease, #5 in cancer, and

There are two main takeaways from this graph: 1) the more money we throw at the problem, the worse it gets—which either means we haven’t addressed the problem at all, or maybe we’re even making it worse; and 2) it wasn’t always this way.

Medical economist Dr. Jay Bhattacharya at Stanford Medicine analyzed millions of medical records, and the factor that most correlated with increasing weight gain in the population was the number of visits to an HMO doctor. Now, that’s correlation, not causation, but you have to wonder. Back in 1970 we spent 6 percent of our GDP on healthcare, and now fifty years later we spend 17.9 percent. Yet the average American’s weight is up, health is down, and wallet is underwater.

in life expectancy, the US ranks only twenty-eighth among the most developed countries in the world, and for the last four years our life expectancy has declined. We’re the only country in the OECD where this is true.

Academics and clinicians nationwide stand by both Modern Medicine and our healthcare system. They feel that investing in areas and “personalized medicine” technologies that “cure” people diagnosed with cancer, cardiovascular diseases, or neurological diseases will ultimately yield better long-term results than focusing on public health measures. This conclusion is wrong, both at the individual and societal levels, and shows at best the misconception of what the real problems are, and at worst a perverse desire of various stakeholders to maintain the status quo at the expense of both lives and dollars. We spend 97.5 percent of our healthcare budget on individual treatment, and only 2.5 percent on prevention.

Here are six clear reasons why we need to rethink Modern Medicine. Let’s use cancer as an example. First, ask yourself which is better: to be cured of cancer or to not get cancer in the first place?

Second, these meager results in curing cancer are matched by a very hefty bill.

Third, those that advocate for Modern Medicine argue that the investment in curing chronic diseases like cancer allows for a better understanding of its causes. I’m not so sure. In the case of cancer, there remains a colossal debate on whether cancer is due to genetics or environment, and whether cancer is in fact a metabolic disease, a by-product of the conversion of food into energy.

please don’t mention “good” and “bad” cholesterol. That’s so twentieth century (see Chapter 2).

Fourth, one would expect that new generations would reap the benefits of the huge advances in Modern Medicine, our supposed ability to diagnose and better understand the causes behind several chronic diseases. Yet, the opposite is true. Only 13 percent of baby boomers—now fifty-four years old—report that they’re in excellent health, compared to 32 percent of people who were fifty-four in 1988 to 1994.

Fifth, our healthcare system is collapsing because we have more people to treat, and the percentage of the population with multiple chronic diseases is growing since treatment often doesn’t result in cure (that is, permanent resolution of disease).

It’s not just more people living with cancer, it’s more cancer every year. And while genetics contribute 10 to 30 percent to cancer development, smoking and diet are the leading factors in 50 percent of cancers.

My Cornell med school colleague and Stanford pediatrician Paul Wise says, “Pediatricians are the ultimate witnesses to failed social policy.” As a practicing pediatrician for four decades, I was supposed to be spared the ravages of treating chronic disease, yet that was what ended up populating my entire clinic.

If doctors and medical professionals made their money with the expectation that they were actually treating or mitigating our chronic disease while disavowing all culpability, that would be prototypical moral hazard—like the insurance industry. But what if they treat us and take our money, knowing full well that they’re not even remotely coming close to addressing the problem? That is immoral hazard—knowing that what they’re doing is nonproductive, generating charges at their and society’s expense, price gouging off the sick, all in direct violation of the Hippocratic Oath.

the solution to this metabolic, economic, and environmental Armageddon is safe, simple, cheap, and green. It’s called Real Food.

People don’t normally think of cancer, autoimmune disease, dementia, and psychiatric disease as food-related. In fact, they are processed food– related.

Cancer is thought to have a genetic basis, or perhaps is a result of environmental exposures causing mutations in DNA. And that’s likely true for cancer initiation, which likely occurs in each of our bodies every day (but the immune system clears those mutations out before they cause havoc). However, cancer promotion is the real issue because that’s how it spreads and grows. And processed food is feeding those mutated cells exactly what they need.

the key to your health is to protect the liver and feed the gut.

Before the advent of packaged and microwavable food, gut bacteria were used to getting what they wanted to eat—fiber

To be clear, better screening, diagnostics, and treatment is what Modern Medicine does; but preventing or reversing NCDs is what Modern Medicine doesn’t do.

Lead toxicity was first described in 1892, but the US government didn’t get the lead out of paint and gasoline until 1982—a ninety-year on-ramp. Other chronic toxic heavy metal exposures, like arsenic, mercury, and cadmium, were also slow to the party, and barely made the Hit Parade.

Before we go any further, I want to do a brief discussion of insulin and its role in NCDs

Insulin resistance is the primary defect in metabolic syndrome, the cluster of NCDs. Insulin resistance manifests itself in a myriad of tissues and ways, which may vary from person to person. You may be overweight, or not. You might have high cholesterol, but maybe it’s normal. You might have high blood pressure, although it could be low. All of these are tissue-specific symptoms of metabolic dysfunction. Previously, doctors only diagnosed metabolic syndrome if you were obese. Now we know better. Even people who aren’t overweight develop metabolic syndrome.