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

by Robert H. Lustig

The third thing we’ve learned is that most of us doctors don’t listen to our patients. We talk. In part, because insurance companies tightened the screws, so we only have ten minutes with you. Once we have your set of symptoms and arrive at a provisional diagnosis, we’re on to the quickest and easiest form of treatment, whether it’s the most efficacious or not, and our hand is on the doorknob.

Only 28 percent of medical schools have a formal nutrition curriculum; even fewer than in 1977 when Congress passed the law that created the Dietary Guidelines and called for more nutrition science in the medical classroom. Now, medical students receive on average 19.6 contact hours of nutrition instruction during their four-year medical school careers, about 0.27 percent of the time spent in class. How is your doctor supposed to provide nutrition advice if they never learned it in the first place?

Nutritional epidemiology is fraught with controversy. Recently, there have been calls to curtail nutritional research because it is hard to do properly. For most nutrients, patient recall is the only method for estimating consumption, and people forget, especially about items that they think aren’t good for them. Furthermore, analysis of data is always suspect since correlation is not causation. In order to determine causation in research, you need one of two kinds of studies. The first is called randomized controlled trials (RCTs; this is the gold standard for drug evaluation), but nutritional studies can’t be controlled very easily, because with prospective (following patients over time) studies it’s hard to alter people’s diets for any length of time. When one nutrient goes up (e.g., carbohydrate), another goes down (e.g., fat).

The other kind of study is known as econometric analysis, in which natural history studies of changes in disease rates over time are analyzed, taking into account all other co-occurring factors. This is how we determined that tobacco causes lung cancer—because doing an RCT would get you thrown in jail. Econometric analysis is more conducive to nutritional research, and is how we proved that sugar is causative for type 2 diabetes.

biomarkers (e.g., LDL-C) are not the same as events (e.g., heart attacks) (see

You really can’t blame the public for their nutritional whiplash. We are exposed to a daily barrage of contradictory statements and straw man arguments about basic science (one day “fat is bad,” the next day “fat is good”) coming from physicians and dietitians, while nutritional biochemistry is ignored (i.e., how metabolism works versus calorie counting and body weight). The physicians don’t understand it themselves. If there’s no science or understanding, there’s no imperative to change.

Another reason that patients can’t or won’t alter their diets is that they’re abusing sugar—the food additive that’s most addictive, induces metabolic disease, and reduces longevity.

Astute clinicians are pattern recognizers; they know when they’re seeing the same thing time and again—they know something’s up; they might not know what it is exactly, but they know they need to change something. One such pattern recognizer was Robert Atkins, who rethought human nutrition and metabolism, realized refined carbohydrates were hurting himself and his patients, and wrote a book to explain his change in practice.

Three physicians—Dr. Tim Noakes in South Africa; Dr. Evelyne Bourdua-Roy in Quebec; and Dr. Gary Fettke in Australia—have been formally investigated by their countries’ respective medical boards for promoting low-carbohydrate lifestyle advice. They’re charged with giving “medical advice” on the radio or in lectures that could “mislead the public on low-carb, high-fat (LCHF)/ketogenic diets.”

Noakes went on trial twice to have his medical license revoked, and despite being exonerated with testimony from international experts on metabolism and nutrition, has suffered through waves of negative publicity and censure.

They accused him of “inappropriately reversing a patient’s diabetes.” Really?

And AHPRA slapped a lifetime ban on Fettke for his attempts to try to save diabetic patients’ limbs from being sawed off and their lives from being snuffed out. The good news is that Dr. Fettke, with help from the international medical community, finally won his appeal in 2018.

There are a few branches of Modern Medicine that have recognized both the problems and the importance of nutritional therapy; for instance, integrative and functional medicine and psychiatry. Their charge is to treat the upstream causes of disease, not the downstream symptoms.

the cellular pathways that lead to chronic disease are not druggable, but they are foodable.

The field of modern dietetics was borne out of two concepts, both of which turned out to be false. The first is the idea that a “calorie is a calorie,” which was espoused by the Atwater system, developed by agriculturist Wilbur Olin Atwater in 1916. His claim to fame was that he standardized how much heat energy (i.e., how many kilocalories, or kcal) three specific macronutrients would liberate when burned in a bomb calorimeter (a device that measures heat release of organic substances), and he calculated the ratios, which computes the number of kcal in a given food by its protein (4 kcal/gm), carbohydrate (4 kcal/gm), and fat (9 kcal/gm) content. As fat was the most calorie-dense, Atwater thought it was the most egregious in terms of weight gain.

The Atwater equation neglected to account for the intestinal microbiome and its inherent metabolism of approximately 25 to 30 percent of everything you eat, as well as the role of fiber in altering that percentage

Since fiber doesn’t contribute any calories to your total but alters the percentage of the total that you absorb, the number of calories you eat versus how many you metabolize are completely disparate.

Nowhere is this more true than for nuts such as almonds, where the amount of calories absorbed is a full 30 percent less than those generated from a bomb calorimeter; in fact, some manufacturers are now ratcheting down the labeling of caloric content of their products specifically to reflect this fact. But, of course, we didn’t know the intestinal microbiome even existed...

My hope is that you will see past this fallacy, and that this book will finally kill the calorie, a stake right through the heart of the myth, once and for all.

They also claim it’s what’s in the food that matters—this is clear from their support of the Nutrition Facts label. Except that it’s not what’s in the food, it’s what’s been done to the food, which doesn’t appear on the food label (see Chapter 17). They’ve missed the mark on both counts.

in hospitals where doctors have suggested the removal of sugared beverages from the menu, the hospital dietitians revolted, claiming that this is “cruel and inhuman punishment” (yes, that’s a direct quote).

How can you tell which side a dietitian is on? One question: ask them if you need sugar to live.

Graves was a home economist who was trained and certified as a hospital dietitian. She had plenty of experience dealing with hospitalized diabetic patients and knew that high-protein and high-fat diets were the only effective therapies against hyperglycemia at the time. She even sponsored a 1921 treatise in Modern Hospital called “A high-fat diet for diabetic patients.” Indeed, up to that point, a high-fat diet was the only rational treatment for diabetics; Dr. Frederick Allen, the successor to Dr. Elliott Joslin at the Joslin Diabetes Center at Harvard, argued in 1919 that a 70 percent fat, 8 percent carbohydrate diet was optimal for diabetics. But 1921 was a watershed year for diabetes with the discovery of insulin. And insulin meant that carbohydrate was back on the menu for diabetics, and treatment was now easier to institute than prevention. The high-fat paradigm for treatment of diabetes was destined for the trash heap (at least until ninety years later). Cooper and Kellogg won out, and the low-protein, high-carb diet became codified into dietetic lore.

The good news is that Kellogg’s medical practices are long gone. The bad news is that Kellogg’s dietary practices are still with us, and in greater force than ever.

a sizable portion of the medical establishment pushing vegan diets are Adventists.

While climate change would appear to be a compelling common sense argument to reduce or eliminate meat from the diet, in fact the science doesn’t support this view—I will postpone this argument until later, where I will devote an entire chapter to its debunking

There’s just as much medical evidence for the benefits of the low-carb high-fat (LCHF) or ketogenic diet as there is for the vegan diet. The reasons both work, when they work, is because they: 1) protect the liver, 2) feed the gut

Either diet is a choice, not a mandate. Either diet can be easily co-opted by charlatans and bad influencers. The two factions could learn a lot from each other, because there’s valid science on both sides. But one faction doesn’t talk to the other, in part out of religious fervor. In my opinion, the science of nutrition has been co-opted by the religion of nutrition. The information contained in this book is my attempt to end this usurpation of the science by the “hunters” and the “gatherers.”

Weston Price. Price was arguably the most important and influential dentist in the history of dentistry, but today he’s a (mostly) forgotten man—and not because he was proved wrong. Because he was proved right.

the Brits are back on top (or bottom, depending on your metric), at least in the cavity competition. Why? It’s not because they’re brushing more frequently. It’s because, as a country, they consume less sugar than we Yanks do.

Price abandoned his lucrative practice to travel the world—he spent the decade 1925 to 1935 visiting primitive cultures and industrializing countries, in order to understand the anthropology of tooth decay, heart disease, and cancer. Irrespective of the race of the isolated groups that he studied—be they Inuit, Swiss or Peruvian Indian mountaineers, Australian Aborigines, Kenyan Watusi or Maasai—Price found that they universally maintained near-perfectly aligned teeth and jaws, as well as no dental caries, as long as they followed their traditional diets.

Some believe that the toothpaste industry was responsible for this stance, as Pepsodent advocated this policy as early as 1919, before there was any data in either direction (Big Business strikes again). But even though debunked, it’s one of the reasons that dentists promote the concept of frequent brushing as a preventative for dental caries, a notion that remains with us today. Maybe there is something to it—for instance, frequent brushing was recently shown to be associated with reduced risks for heart failure, just not for dental caries. You

There are three different forms of digestible carbohydrate: 1) monosaccharides (one sugar molecule—glucose or fructose or galactose; high-fructose corn syrup is an example of two monosaccharides at once); 2) disaccharides (two sugar molecules bound together; maltose (e.g., beer) is glucose-glucose, sucrose (e.g., fruit) is glucose-fructose, and lactose (e.g., milk) is glucose-galactose); and 3) starch, which is a string of glucose molecules polymerized together. But only the first two, monosaccharides and disaccharides, can cause dental caries. The reason is that the oral bacteria can only metabolize carbohydrates that are “fermentable”; that is, single free molecules.

Listen, I get it. I like ice cream, and I brush twice a day. Like most people, I hate going to the dentist. But, what if in eliminating most of your dietary sugar, you could avoid the dentist entirely?

similar to Kellogg’s thumb on the scale of nutrition research, the ostensibly positive triumph of fluoride has a darker side, and likely shields an industrial conspiracy driven by politics and profit. The story of fluoride’s transition from industrial contaminant to public health panacea has been the fodder of countless treatises on environmental health over the decades. The original discovery of the “magic” of fluoride was quite serendipitous, first pointed out by dentist Frederick McKay, who noted in 1909 that despite the fact that seven out of eight children residing in Colorado Springs manifested brown indelible stains on their teeth, they nonetheless appeared to be protected from dental caries. McKay isolated the reason to the fluoride in the water supply.

seventy-four cities around the country have followed Portland’s lead and also banned fluoride. Do they know something you don’t? There are a lot of pseudo-reasons for getting rid of fluoride. Some think it boosts the sugar lobby by enabling people to eat more sweets without getting cavities, and some believe that health officials are just plain afraid to stop fluoridation after having supported it for decades.

of course, there were the conspiracy theorists who were convinced it was a Soviet plot for mind control (in Dr. Strangelove [1964], General Jack D. Ripper says, “Fluoridation is the most monstrously conceived and dangerous communist plot we have ever had to face!”).

Sugar restriction is the most effective way of reducing and preventing the modern scourge of dental caries.

In the late 1800s Baptist minister Frederick Gates befriended Baptist philanthropist John D. Rockefeller, and in 1892 they founded the Baptist University of Chicago (which has since become nonsectarian). Gates became Rockefeller’s business advisor, who continued to help rehabilitate his cutthroat business reputation through strategic philanthropy, similar to Andrew Carnegie, and not much different from what is seen by people like Bill Gates (no relation) and Mark Zuckerberg today.

If osteopathy was flawed and dangerous to patients, why are osteopathic schools still thriving? From 2010 to 2016, the number of actively licensed DOs in the US increased by nearly 40 percent, from over fifty-eight thousand to over eighty-one thousand (in my clinical retirement, I teach weekly at Touro University California, a Jewish osteopathic medical college. I can state from experience, DO students are as research-focused as their MD student brethren—the big difference is that DO students are devoted to studying the whole patient, not just the diseased organ. Oh, and they get “Food as Medicine”).

Science is a tool; it’s neither good nor bad. Such value judgments depend on the user. Science should and must be promoted, as it’s a primary driver of societal advancement. However, it’s also clear that the overtly political nature of the Flexner Report, and the effort of Big Business, Big Pharma, and now Big Medicine to capitalize on it, has left a big hole in the profession, which keeps expanding and threatens to engulf us all.

Every single drug company spends more on marketing than on research and development. Some, like Johnson & Johnson, spend double their R&D budget on marketing. The rest of the top ten (Novartis, Pfizer, Roche, Sanofi, Merck, GlaxoSmithKline, AstraZeneca, Eli Lilly, and AbbVie), in the years between 1997 and 2016, doubled their annual marketing budget as well, from $17.7 billion to $30 billion. Schmoozing doctors went from $15 to $20 billion, while direct business-to-consumer advertising increased fourfold (from $2.1 to $9.6 billion). For every $1 spent on “basic research,” Big Pharma spends $19 on promotions and advertising.

As the world’s life span has been expanding consistently over the last one hundred years due to public health improvements and antibiotics, so has the number of older people, both in absolute figures and as a percentage of the population. In the US, people older than sixty-five now account for 16 percent of the population and consume one-third of all prescription medications. In fact, 20 percent of people over the age of sixty-five are taking at least five different medications.

polypharmacy—taking more than five prescription pills a day—is associated with increased mortality risk; and it’s not just because people are old. In fact, the third most common cause of death today is prescription medication.

Mo’ pills, mo’ problems.

Between 2000 and 2008, a total of 667 drugs were approved by the FDA, yet only 11 percent of them were deemed truly innovative; the rest were knockoff analogs in an attempt to bully their way onto the market.

Currently, 70 percent of the US population is taking at least one prescribed medication. Is that because 70 percent of the population is sick? Well, actually yes. In fact, 88 percent of the population is thought to be metabolically ill. But does that mean that medicine is the treatment?

with no governmental regulation, medicines that have been around for a century have tripled in price in just one decade (e.g., insulin). For diabetics, insulin is indispensable; and it’s what the market will bear. For another egregious example, just look at what happened to the price of the EpiPen; kids with anaphylactic allergic reactions were forced to pay four times the original cost, because they had no choice—it’s literally a matter of life or death.

Modern Medicine and Big Pharma remain caught in a vicious cycle: doctors need Big Pharma because they’re taught to treat rather than cure or prevent; but the reason they don’t know any better is because medical education has been co-opted by Big Pharma itself. And so the cycle repeats.

All medicines are selective toxins, poisoning one specific pathway in the body.