The Melanie Avalon Biohacking Podcast Episode #99 - Dr. Robert Lustig

TRANSCRIPT

Melanie Avalon: Hi friends, welcome back to the show. I am so incredibly excited about the conversation that I am about to have. It is a long, long, long time coming. I have been a follower of this guest’s work for so long, ever since I originally read his book, Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease. That book took a really hard look at the role of sugar and processed foods and what it's doing to our health and lifestyle. I had a whole obsession with it because I've been haunted by the concept of fructose for quite a while. I've been really torn about actually if it is healthy or not healthy, and I've done a lot of research and it has haunted me. So, this man's work has been really present in my mind.

For today's show, he released a new book Metabolical: The Lure and the Lies of Processed Food, Nutrition, and Modern Medicine. Friends, this book, I honestly mean this, I think this book should be required literature in medical school. The amount of information in it about our current food system, the relationship between Big Food, Big Pharma, the industry, people, personal responsibility, our health, the environment, I can't even express how much I learned in this book. Basically, while I was reading it every single day, I was learning things and telling everybody everything that I have learned. [chuckles] I am so excited about this conversation that I'm about to have. I'm here with Dr. Robert Lustig, Pediatric Neuroendocrinologist and New York Times bestseller. Dr. Lustig, thank you so much for being here.

Robert Lustig: It is my pleasure, Melanie. To be honest with you, I don't know who you're talking about. It doesn't sound like me. [laughs]

Melanie Avalon: [laughs] Well, you've done really, truly an amazing job. We just talked before the show, I sent you over my list of potential questions. The version I sent you was long, but my notes are like 20 pages. So many things I could ask, so many directions we could go in. I think to start things off, I'll just ask a very basic question, which is, why are you so passionate about this focus and the role of processed food in health? What's the big deal here?

Robert Lustig: I don't have a passion, I have the science, I guess the science is my passion. I've had a lot of different experiences within clinical medicine over the last 40 years. I can do a quick one-sentence timeline of 40 years of research. I went from brain tumors, to obesity, to insulin, to metabolic syndrome, to fructose, to public health, to addiction, to technology, to finally, now policy, and they all string together. It's not that I've been a zealot or sort of a bellwether for any of these things. It's just where the science took me. It's been very clear taking care of patients for the past 40 years, that something is very wrong, and the empiric data, the science, not just my science, but everyone science is pointing to ultra-processed food as the problem. I know from my own experience, when we got our patients here at UCSF off ultra-processed food, they got better. We have the data, we've published the data. This book is to make it clear what the problem is. You cannot solve a problem if you don't know what the problem is. Thus far, we have thought calories were the problem, we have thought saturated fat was the problem. We thought a whole slew of different things were the problem, and it's not. It's in fact what has happened to our entire food system over the last 50 years, and we have to undo it.

Melanie Avalon: This is so fascinating. I think particularly with processed food, I think there's a general consensus now people think that either it's bad, or at least it's not healthy or whole foods are healthy, but it's a very vague feeling, I think, about processed food. And you do a really beautiful job of actually looking at what is processed food and the subtle nuance between food and then what has been done to our food. Like for a definition to start with, what is processed food? What makes a food processed, and what's the difference between food as nutrition and food as what you call poison?

Robert Lustig: The new mantra out of everyone's mouth is food is medicine, and that's not quite true. In fact, actually, real food is medicine, because real food is food. The question is, is processed food food? The argument I make in the book is that no, actually processed food is not food. Processed food is poison. Now, that sounds very strident. It sounds very inflammatory and incendiary. I understand that people will be taken aback because after all, you don't want to be putting poisons in your body. There's an inherent defensive reaction that brings up. In fact, when you understand what the difference between healthy and unhealthy is, you understand how processed food is poison. In the book, I very specifically describe the two parameters that have to be met in order for any given thing that you put in your body to be healthy. They are six words, two clauses. Protect the liver, feed the gut.

Any food that does both is healthy. Any food that those neither is poison. Any food that does one or the other, but not both, is somewhere in the middle. That's what the empiric data show. I spend a fair amount of the book explaining how come that works, and why this is actually the definition of healthy that, in fact, not only should we adopt, but in fact, the FDA and the USDA and the FSA, and all the other regulatory agencies should adopt this well. Now, you asked me the question, okay, what is processed food? The answer is, there are different gradations, there are different levels. My colleague and friend, Dr. Carlos Monteiro at the University of Sao Paulo in Brazil, actually came up with a very good food classification system, I think it's very useful to think about, and let me give you an example.

It's called the NOVA system, and it divides all food into four classes of processing. The first class, class one, would be, say, an apple. An untouched apple, nothing done to it. The second would be apple slices. Mechanical dispersion, shall we say, simple processing. It's still apple, it still would give you the same level of nutritional support that, say, a full apple would. The third one would be applesauce. Okay, so complete dissociation of the food matrix, possibly with the addition of a preservative or maybe even some added sugar, although you can certainly buy unsweetened applesauce at the store, and you should. Then finally, the last one would be an apple pie. All right, and that would be an ultra-processed food, where numerous foodstuffs that normally don't exist in nature come together and in fact, added sugar, changes in the fiber content, etc., in part also because of the cooking.

These different classifications confer different risks, and it turns out that when you actually look at the empiric data, it is only that NOVA class 4 group, the ultra-processed food group that confers any significant morbidity mortality. Problem is that that's 56% of all the food consumed in America and 62% of the added sugar is in that class 4. This is the problem, and this is what the food industry is pushing. Their juggernaut, that's their gravy train. They've also learned that the more sugar they add, the more product they sell.

Melanie Avalon: The difference between class 4, that jump from 3 to 4 is additives?

Robert Lustig: Additives, combinations of ingredients that normally are not found in nature. Usually, the addition of sugar and the removal of fiber.

Melanie Avalon: Okay. Historically, when did that first start?

Robert Lustig: Oh, well, it's gone on forever, but it really picked up in frequency back in the 1950s. At the time of World War II, processed food basically meant spam, the original processed food. And that was really for the military in order to be able to carry it off into battle and to be able to get to frontlines and stuff like that. We didn't have a lot of processed food in our diet or in our grocery stores prior to World War II, it really all came after that. There was the breakfast cereals that appeared in the 60s, there was Swanson TV dinners. A lot of these things, people very specifically remember. And then of course, we got the sodas and then the diet sodas adding to that, and ultimately ultra-processed food really took over. And then in 1975, it got even a bigger boost with the advent of high-fructose corn syrup. Then, it got the biggest boost of all in 1977 when the McGovern Commission convened to try to determine dietary guidelines for Americans, and we were all told to eat less fat. Well, you can't eat less fat unless you process it out. When you process the fat out, the food tastes like cardboard, in which case they had to process something else in. What do you think that something was?

Melanie Avalon: Sugar.

Robert Lustig: That's sort of the short history of how we got to where we are today. It's just been sort of gaining steam and it's been a juggernaut ever since.

Melanie Avalon: Yeah, for listeners, I will just say this once and just keep remembering, get Metabolical because if you want the full, full history, it's all in there. A question about that processed food and you talk about this a little bit in the book about all the debates about different diets working for different people, and can all diets work, do you think processed food is the missing piece for why different diets seemingly work? People on a keto diet or people on a vegan diet, maybe it's not so much the macros as people often eradicate processed foods when they adopt those diets?

Robert Lustig: Well, the fact of the matter is people when they talk about the macros, macronutrients, they're talking about protein, fat, carbohydrate. That is a very inappropriate method for thinking about food classification. I make this case in the book umpteen times. First of all, a protein is not a protein, a fat is not a fat, a carb is not a carb, a calorie is not a calorie. To be honest with you, a fiber is not even a fiber, and you'll notice that fiber is not in any of those macronutrients, people think fiber is what you throw in the garbage after you juice the fruit. It turns out, the fiber is absolutely essential, essential. The reason is because the fiber is not for you. It's essential for your bacteria, for your intestinal microbiome, because when your intestinal microbiome is happy, they make you happy. When your intestinal microbiome is starved, they rebel against you. They actually eat the mucin layer right off your intestinal epithelial cells, denuding the inside of your intestine, and making it much more likely that the bacteria in your intestine and some of them are not good guys, some of them are bad guys, will actually lead to perturbation of that intestinal barrier. There are proteins that hold the intestinal cells together called tight junctions.

When those tight junctions become dysfunctional, you end up with a phenomenon called leaky gut, and lipopolysaccharides and cytokines and full bacteria even can get from your intestine into your bloodstream, head straight to your liver, cause systemic inflammation, leading to insulin resistance and starting the chronic metabolic disease process. You have to protect your liver and feed your gut. Fiber is not even on the list of macronutrients, yet it is perhaps the single most important thing you need to do in order to stay healthy.

Melanie Avalon: One of my biggest fears in life is LPS and the release of endotoxins from our gut bacteria, and I'm haunted by gut dysbiosis. Okay, this is sort of an esoteric question, because throughout human history, we've evolved to adapt to different diets that our gut microbiome has likely evolved with us. Processed food, is it possible that our gut microbiome could ever adapt and evolve? Could we adapt to this or is there a reason that we can't adapt to processed foods?

Robert Lustig: Well, that's a good question. I'm going to be very honest with you, Melanie, I don't know the answer to that. Let me tell you what I do know, maybe that'll inform the question, but it's a hard question. Evolution takes a long time. It's not something that happens overnight. Let me give you an example of how this could work. This actually goes to the dental literature. If you look at the DNA fingerprint of dental calculi in fossils from way back, there were certain bacteria, for instance, proteobacteria that used to be in our mouths. Today, those bacteria actually deep down in our intestine. For instance, firmicutes. Firmicutes used to be in the mouth, now it's way down in the intestine, causing problems there. The assumption is that somehow and for some reason, those bacteria migrated. They used to be happy with the environment they found themselves in and now they're not, and they had to go find another place to hide. In the process, they now have set up shop in our intestines and actually end up causing disease.

The bacteria are not necessarily mutating per se, but they are adapting to the environment they find themselves in the same way we adapt to the environments we find ourselves in. The question is, is that good for them and good for us? In this case, I would argue it is not good for us. Could this be one of the reasons for our current epidemic of modern disease, is that the bacteria are not where they belong? Yeah, it's a possibility. Is there a chance that evolution could fix that? Well, I would say probably not very much. That doesn't seem likely, given the fact that this has gone on over millions of years and we haven't figured it out yet. I'm a little loathe to put in the stock in that.

Melanie Avalon: Yeah, that absolutely blew my mind in the book about the changing of the gut microbiome populations and our mouth versus the intestines. It's really scary, actually. I'm hesitant to ask this question, because it's almost a question not-- nobody would be forced to do this, but if you had to choose-- we talk about this a lot on the Intermittent Fasting Podcast, because we see with fasting and calorie restriction that there's a lot of health benefits activated by that. If there was a dichotomy of fasting and calorie restriction, but with processed foods compared to overeating, but normal foods, the potential harm of foods in fasting and calorie restriction and overeating, do you have thoughts on those two options? Not that you have to choose.

Robert Lustig: What you're asking is, which is better for you? Intermittent fasting or eating real food? That's what you're asking.

Melanie Avalon: Yes, thank you. [laughs]

Robert Lustig: Yes. So, the question is, well, okay, first of all, I am a fan of intermittent fasting. I'm not against intermittent fasting. The question is, why does intermittent fasting work? The answer is whether [laughs] you like it or not, and to be honest, I don't know how you feel about this. So, I'm just going to blurt it out. It's in the book. I'm on record. The reason intermittent fasting works is because it gives your liver a chance to burn off the extra energy it has stored as fat. Okay, when you fast, the first thing that goes is the glycogen, right? Wrong. The first thing that goes is the liver fat that's accumulated that doesn't belong in your liver.

Melanie Avalon: The liver fat, before the liver glycogen. On a daily cyclical basis?

Robert Lustig: If you've developed liver fat, and then the question, of course, is where the liver fat come from. Your liver is not supposed to have any fat in it. It is supposed to have glycogen in it. Your liver can store any amount of glycogen that it needs. That's why marathoners carb load before a race is to try to raise their liver glycogen, so that they have a ready source of glucose available during the course of the race. When you overdo it and when your liver is tasked to store extra energy, it doesn't do it as glycogen, it stores it as liver fat. This is a process called de novo lipogenesis, new fat making. This isn’t fat that's being imported from your dietary fat. This is fat that's being made right there in the liver, and the substrate that makes it is sugar, in particular the fructose molecule.

Fructose basically has a limit on how fast it can be burned, and if you exceed the consumption-- if your consumption exceeds your capacity to burn, then your liver has no choice but to take the extra and divert it to liver fat. This is exactly why alcoholics have fatty liver, because they're taking in alcohol faster than their liver can metabolize it too. So, the liver has no choice, but to take the excess and turn it into fat as well. That fat, of course, sets you up for cirrhosis. Well, guess what? Sugar sets you up for cirrhosis. Today, nonalcoholic fatty liver disease is the leading cause of liver transplant in the United States having overtaken hepatitis C. 45% of Americans today have fatty liver disease and don't know it. The reason is their diet, because of the sugar in their diet that they don't know about. We know that because we've measured it.

The bottom line is people are walking around with these fatty livers, and when your liver is fatty, that means it's not working well, and when your liver is not working well, that makes it insulin resist. When your insulin resistant, that means your pancreas has to make extra insulin for the liver to do its job. Okay, pushing on it. That's why the pancreas drains into the liver, not into the inferior vena cava is because the liver is the primary target of insulin action. When your liver sick, your pancreas has to work harder, like the assembly line when somebody basically falls asleep or gets sick on the assembly line, and everybody else has to work harder. Bottom line, you raise insulin levels all over the body and insulin’s the driver of all these chronic metabolic diseases that we've been talking about. So, getting rid of the liver fat is priority one. You cannot fix chronic metabolic disease, until you fix liver insulin sensitivity. If the liver fat is the driver of that liver insulin resistance, then you have to get rid of it first.

Well, turns out intermittent fasting burns that liver fat first, won't burn all of it in one session of intermittent fasting. But if you keep doing it over the course of time, you will likely be able to reverse that process. That's why intermittent fasting is good. The question then comes up, well, why did you have the liver fat in the first place? The answer is it’s your crappy diet. if you ate properly in the first place, you wouldn't have the liver fat that you would have to intermittently fast for. Your question in a way is kind of moot for that reason.

Melanie Avalon: Me and my cohost, Gin, we debate this all the time. She's on the fasting train, and I'm more on the food train. [laughs]

Robert Lustig: Food train is a much easier train to be on, to be honest with you, except if you live in a place where there is no real food, which is unfortunately a lot of urban areas in America, and actually suburbs-- and rural areas in America to be honest with you too.

Melanie Avalon: I'd love to actually go on that train, but some really quick questions about the liver. I'm so obsessed with this topic. The amount of liver fat, like in grams, for example, how much liver fat can the liver store?

Robert Lustig: This is a very important concept and I'm going to spend a minute on it. There's not one fat depot, there are three. They confer different levels of disease. They also have different capacities. To understand how metabolic syndrome works, you really have to understand these three fat depots in detail. The first fat depot is the subcutaneous fat. For lack of a better term, we'll call it the big butt fat. It's the fat you can see, everyone hates that fat the most because after all, everyone wants to get into their size 2 bikini or their speedos. Now, how much subcutaneous fat do you have to gain before you start manifesting metabolic dysfunction and sickness? The answer is, for the most part, most people about 25 to 30 pounds. So, you can carry about 25 pounds of excess subcutaneous fat before you will start showing signs of insulin resistance. Okay, got it?

Melanie Avalon: Does the level of the potential for subcutaneous fat gain determine when a person becomes metabolically ill?

Robert Lustig: Absolutely. By the way, different races have different capacities. For instance, African Americans have a much greater ability to store subcutaneous fat at baseline. Whereas Asians seem to have a much smaller ability to store subcutaneous fat at baseline. That's one of the reasons why when an Asian gains even five to seven pounds, they start manifesting metabolic syndrome. Whereas an African American can gain sometimes even 50 pounds before they'll start manifesting metabolic syndrome. Basically, you have different-sized buckets. When you overflow the bucket, you get into trouble, but everybody's got a different-sized bucket. But the bucket is this what you can see. The second fat depot is your visceral fat or, for lack of a better term, your big belly fat. Now, it turns out your big belly fat is much more dangerous than your big butt fat. Your big belly fat drains right into the liver, it doesn't enter the systemic circulation. So, it's much more likely that if you generate big belly fat, visceral fat, you will become insulin resistant on that basis.

Now, the thing about the belly fat is it is completely unrelated to the subcutaneous fat, so you can actually be losing weight, but gaining visceral fat. The proof of that is clinical depression. People who are clinically depressed, actually lose weight, they don't even want to eat. They have melancholia, they actually have anorexia. They don't want to eat, but their cortisol levels are so high that they are diverting energy into their visceral fat and their visceral fat grows, and you can measure that on magnetic resonance imaging. Increased visceral fat is way worse for you than increased subcutaneous fat. This is the story of the apples versus the pears in terms of the body shape. The question is, how much visceral fat can you accumulate before you start getting sick? And the answer is about four pounds. 25 pounds for subcutaneous fat, 4 pounds for visceral fat. For the most part, visceral fat is the fat you cannot see, because it's inside attached to your organs. You might see it in terms of your waist circumference, or you might not.

Then finally, there's the third fat depot, the liver fat. Now, the liver fat is the worst, because it's right there. Okay, it doesn't have to travel anywhere, it's causing problems right where it lives, right there in the liver. It turns out, you only need 200 grams of liver fat, about half a pound, before you start seeing metabolic dysfunction and insulin resistance. 25 pounds of big butt fat versus 4 pounds of big belly fat, versus half a pound of liver fat. And you can't see the liver fat, or the big belly fat. The only fat you can see is the big butt fat. That's unfortunately the only fat that anybody seems to be concerned about. So, we have a problem because we're not even understanding what's going on and neither does your doctor. Your doctor says if you lose weight, you could take care of this problem. The fact of the matter is, if you could just get rid of your liver fat, you could take care of this problem.

Melanie Avalon: Circling back to the question about the fasting, the liver fat, and the liver glycogen, have they done studies on a person who has full tanks of both liver fat and liver glycogen and then fasting, what gets tapped into first, is the liver fat?

Robert Lustig: Yeah, the liver fat will go first, the glycogen will go too, but the liver fat will go, not that rapidly, but it will go. That's the point is you got to get that down. We showed in our study of kids-- so we took kids with metabolic syndrome, 43 children with metabolic syndrome, Latino and African American with lots of liver fat. We showed that we didn't even have to get them to lose weight. All we had to do is take the sugar out of their diet. In nine days, their liver fat fell by 22%. As the liver fat fell, their insulin sensitivity went up and their insulin secretion from their pancreas went back to normal. In other words, we reversed their metabolic dysfunction just by taking the sugar out of their diet with no change in calories and no change in weight.

Melanie Avalon: When you took out the sugar, the liver fat dropped though, correct?

Robert Lustig: Right. Well, we put in starch in its place, because if you take the sugar out of a kid's diet, they're going to lose 350 to 400 calories a day out of their diet. If you do that for 10 days, they might lose weight. And then, the critics would say, “Well, of course they got better, they lost weight.” We didn't want these kids to lose weight, we wanted them to stay the same weight, or even gain weight. So, we had to replace the 350 to 400 calories in sugar with something else, something equicaloric. We gave them refined starch. Now, I'm not suggesting refined starch is good, but compared to sugar, it's a walk in the park. Refined starch is going to raise your glucose excursion and increasing your glucose excursion would raise your insulin release, and that would potentially cause weight gain. Well, guess what? When we did this maneuver and got rid of the sugar and put in the starch, their glucose and their insulin excursions went down, not up, went down. The reason was because we had so fixed their insulin resistance, their insulin sensitivity improved by 25% in just 10 days. Again, with no change in calories, no change in weight. We basically reversed the metabolic dysfunction unrelated to weight or calories because we got rid of the liver fat.

Melanie Avalon: Okay. I think this is a tiny nuance, but I'm just haunted by this question, this chicken and egg question of weight, insulin, and metabolic syndrome and health and all of that. They didn't lose weight, but they lost the weight of the liver fat.

Robert Lustig: Right.

Melanie Avalon: The root cause between-- and I know what you talk about it in the book, but I just want to talk about right now. The root cause between insulin is issues and energy toxicity, chicken and egg.

Robert Lustig: It's not quite chicken and egg, it depends on the person. One of the reasons this is so complicated is because not everybody's the same. There are people who over release insulin. David Ludwig has demonstrated this. People up in at the University of Laval, there's a Quebec cohort that increase their insulin release in response to a glucose load. These people hypersecrete insulin, their pancreases are primed to over release insulin in response to a carbohydrate load. These people because they're pancreases are sort of, shall we say, twitchy, they have twitchy beta cells, they go boom, and all of a sudden, their insulin levels are super high really fast. They drive energy into fat quickly, and so they get obese very rapidly, because of their carbohydrate consumption, because their pancreases are primed to release insulin.

Conversely, most people, probably 80% of the population, they've got a problem when their liver gets sick, and start storing fat. Now, their liver’s insulin resistant, and now their pancreas has to make more insulin even at baseline to get the liver to do its job. Two insulin problems. A person could have either one or both. The only way to know the answer to this is actually for your doctor to do an oral glucose tolerance test with simultaneous insulin levels. Now, we do that. At UCSF, we do that. The reason we do that is because then we can figure out who's who, and target therapy appropriately. But I guarantee you, your doctor does not do that, because they don't understand this. All right, but this is the point that I'm trying to make to the general public and also to the medical establishment is, it's not like the weight comes first, the insulin comes first. The insulin comes first. We now have numerous, numerous levels of scientific evidence to demonstrate the insulin comes first.

Melanie Avalon: So, like that first situation you just said where the pancreas is over producing insulin, wouldn't it still require excess energy for the problem to manifest?

Robert Lustig: Sure, and the point is that that excess insulin is driving increased food intake at the level of the brain, because insulin blocks leptin signaling, so your brain doesn't know you've eaten, so you keep eating. What we showed in these people who over-release insulin, these insulin hypersecretors, is we can put them on a low-carbohydrate diet and get their insulin down. Now, they won't overeat. In fact, they now eat properly, and they start losing weight, because their food intake has gone down, because now they're leptin works, because we got their insulin down. Insulin blocks leptin. If your brain can't see the leptin, your brain thinks it's starving. So, you're going to eat everything in sight. But when your insulin goes down, now your brain can see the leptin, in which case, now you're going to moderate your portion size, and the kinds of foods you're going to eat much more effectively, like normal.

Melanie Avalon: Yeah. And I guess the reason I'm so haunted by it and thinking about it is this concept of personal responsibility that you talk about in the book and how-- because it sounds like with what you just said, with the insulin, if there's a condition where there's hyperinsulinemia, in theory, if you fought that nail and tooth, it would just be really, really, really hard to follow a calorie-restricted, weight maintenance or weight loss diet.

Robert Lustig: Yeah. First of all, look how well that works, nobody. It's real rare for a calorie restricted diet to be able to work. I mean, you hear about it in anecdotes in People magazine, but short of that, there's no science that actually demonstrates that that works in any meaningful way. Here's the counter, here's the exception that proves the rule that I'm not lying. We have an epidemic of obese newborns. Now, they didn't choose what they got to eat in utero, did they? So, how come they're obese? The answer is because of mom's insulin resistance, because that mom's insulin resistance and her hyperinsulinemia drove excess placental transfer of carbohydrate, particularly glucose and fructose. Everyone said fructose doesn't cross the placenta. Oh, yes, it does and actually causes liver fat in the newborn, in the fetus before the babies even born, and that causes the fetal hyperinsulinemia and that causes excess fat deposition, and we know it because we measure it with DEXA scans in newborns. Okay, four separate studies, Russia, South Africa, Israel, the United States, newborns now weigh 200 grams more on average than 25 years ago. When you look at that 200 grams, it's not muscle, it's fat. Every baby is carrying around a half of pound of fat that they didn't use to carry around.

Melanie Avalon: What type of fat in the babies?

Robert Lustig: Well, it's tends to be subcutaneous, but it can be liver fat too. And everybody thought the Gerber baby is such a good thing. No, it's not. Not even remotely.

Melanie Avalon: Another question about the fat in the liver. When the liver fat fills up, and then if you continue increased carb intake, is there significant fat creation beyond the liver? Or is the majority of the fat gain-- There's the whole argument about de novo lipogenesis from carbohydrate overconsumption and how there's really not a huge amount that you actually can create even in a state of massive overfeeding. When you hit the full liver, like making fat from carbs, do you actually make a lot of fat that you gain weight from? Or, is it just that you are storing all the fat that you eat, because you're topped out?

Robert Lustig: Whether the liver stores it or exports it out, has to do with whether it can package it. We actually have data that shows that the amount of choline in the liver determines that. If you have lots of choline, you'll export it out as triglyceride, in which case then your triglycerides will rise, which is of course, a setup for obesity and heart disease, because your high triglycerides precipitate heart disease. Or, if your choline levels are low in your liver, then you won't be able to package it, because choline is part of phosphatidylcholine, which is part of ApoB-100, which is the export mechanism for fat out of the liver, so you can't get it out. Fat will precipitate in the liver as a lipid droplet, now you’ve got fatty liver disease, and then that puts you as a setup for diabetes, and other phenomena associated with metabolic syndrome. Whether the fat leaves the liver or stays in the liver, it still causes problems, just different kinds.

Melanie Avalon: With the personal responsibility and coming back to the processed food industry, you talk about whether or not what is happening with the processed food industry is an immoral hazard. I was wondering if you could talk a little bit about that, just the role of because-- Okay, I think it can seem conspiratorial, if you think about the government institutions and the processed food industry and intention and what is happening, and if you don't really know what's happening, it can sound really like a conspiracy, that there's really dark things going on.

Robert Lustig: Well, there are dark things. The question is, is it with malice of forethought? That's the question. Are they trying to kill you? The answer to that is they're not trying to kill you. They're just trying to take your wallet, that they are trying to do, and they're all trying to do it, because there's a lot of money involved. It's about the money. They are not trying consciously to kill you. This is not murder. This is more like negligent homicide. They're just callously insensitive. How's that? Does that make sense? [laughs]

Melanie Avalon: Yes.

Robert Lustig: In the book, I discuss the difference between a term called moral hazard and a term I made up for the book called immoral hazard. Now, what's the difference between those two? They sound alike. Moral hazard is the economic version of schadenfreude. Basically, profiting off the misery of others. Schadenfreude is taking delight in the misery of others. Anybody’s who ever seen the musical Avenue Q, there is the most wonderful song and it called Schadenfreude, and everyone should go look it up on Spotify, and you will laugh your head off. It's kind of dirty, but it's very funny.

Now, what the insurance industry engages in is moral hazard. They didn't create your disease, but they sure are happy enough that you got sick. The reason they're happy you got sick is because they get to raise your rates and they can't raise your rates unless you get sick. They raise your rates way higher than any sickness than you ever got. It's the casino model, pay to play and set the rates. They can't make money unless you enter the game. They were really happy when you got sick.

Now, Obamacare, and I don't care if you like Obamacare or don't like Obamacare, it's irrelevant to me. Obamacare did one thing, what it did was it kept insurance company profits at 15%. Now, those insurance companies can't make as much money off you being sick. In fact, now for the first time in their existence, in their 75-year existence, insurance companies actually want you to be healthy. The reason is, because if you're healthy, then they get to keep the difference, since they can't make the money just by raising your rates. They don't even know how, because they've never done it before. So, this is a problem, but that's called moral hazard.

What I'm describing in the book is immoral hazard. The difference is creating the system to be able to profit off the misery of others. That's what Big Food and Big Pharma and big government have all done. In the book, I describe how each of them have done it, because we didn't have these markets before, but we do now. The reason we have them is because each of them saw the profit, and they know what they're doing. And it's only about the profit, it's only about the money. The fact that you die in the process, well, collateral damage.

Melanie Avalon: Do you think the timeline of that historically, with the processed foods and the profit, and the health conditions, the way it is now--- because now I feel like there's the ethos is changing, at least among consumers, like people are looking for organic, people are looking for whole foods, and we see sort of like the commercialization of it all, if you go to like Kroger or Target now they have their brands with their organic lines and their grass fed beef and stuff like that.

Robert Lustig: They see money in it.

Melanie Avalon: Yeah. Do you think that's a good thing? That's something I've wondered. Is the commercialization of the changes that we would want, in theory, a good thing?

Robert Lustig: The question is organic good for you, that's what it comes down to, does it actually do something? The answer is it does a little something, it doesn't do nearly as much as they say it does, but it does something. Basically, organic means no pesticides, no antibiotics, and that's good. I'm not going to tell you that's bad, that's good. The goal is to get to real food, and all of those pesticides and antibiotics basically make your food not real food. All right, you can take a strawberry and turn it into not real food by spraying it with a pesticide. Pesticides are bad, I'm not telling you they're not. On the other hand, they keep the food from being eaten by the locusts, and that's good. But at the same time, those pesticides have effects in your body. If you don't believe me, all you have to do is look at DDT to know that pesticides ultimately are not good for you. They interact with receptors in your body, in particular, the estrogen receptor and the glucocorticoid receptor. Our livers can metabolize some pesticides to some extent, but invariably, they tend to be too greater than our capacity to metabolize them, and so they can make us sick. I'm for getting rid of pesticides in our food for all these reasons.

But when you think about our chronic metabolic disease, and what causes it, and you think about our weight gain, and what causes it, pesticides do contribute, they contribute somewhere between 10% and 15%. But it's really the food itself, the ultra-processing of the food, having nothing to do with the pesticides. There are plenty of things at whole foods that say organic, that are still just as bad, because they are loaded with sugar, and the fibers been removed. Other things have been added, because lots of food additives can be natural. Evaporated cane juice is natural, it's still sugar. So, just because it says organic on it, doesn't necessarily mean it's good for you. If you're buying them at Whole Foods, you're just paying more for the privilege.

Melanie Avalon: What would it take for processed food to be accepted as toxic?

Robert Lustig: Well, [laughs] first of all, there's a whole bunch of people who refuse to go there and think I'm a rabble rouser and a fearmonger. I would argue I'm actually anything but. The point is you have to know what the problem is. You have to identify the problem before you can fix it. The reason I wrote this book is to lay out the argument for why ultra-processed food is the problem. I dare anyone, anyone to argue the science. If you want to argue my rhetoric, fine, but you cannot argue the science, and when you understand the science, you understand that ultra-processed food is at the base of what's going on in our health and healthcare system, and also, in fact, our environment today. The reason people don't understand this, and the reason why I get blowback is because they think the diseases that we are currently experiencing en masse, type 2 diabetes, hypertension, lipid problems, cardiovascular disease, cancer, dementia, polycystic ovarian disease, nonalcoholic fatty liver disease, all these chronic metabolic diseases, they think they are diseases. Have ICD-9 codes, doctors learn them in medical school. There are medicines to treat each of them. So, they think these are the diseases.

The point I make in the book is, no, that's incorrect. These are the symptoms of disease. These are not the diseases themselves. These are the symptoms of disease. In fact, all the medicines we treat these diseases with, they're not fixing the disease. They're just treating the symptom. High LDL, that's the symptom of the disease, not the actual disease itself. The disease itself is underneath, and I'll talk about those in a moment. High blood pressure, it's not the disease, it's the symptom of the disease. The high blood glucose, it's not the disease, it's the symptom of the disease. The low bone mass, osteoporosis, it's not the disease, it's the symptom of the disease. Then, what is the disease if these are the symptoms and all the medicines we use, just treat the symptoms? What is the disease? Well, they are eight separate pathologies, eight processes that go on inside the cell, and they go on all the time. The question is, how well are they running? When they're running well, you'll be 110, playing tennis. When they're running poorly, you'll be 40 years old, in a wheelchair with two stumps, on dialysis waiting for your next stroke. And it's all about the food.

So, here are the eight pathologies. The eight sub cellular pathologies that actually drive all chronic disease. I go through each of these in the book. One glycation. Two, oxidative stress. Three, mitochondrial dysfunction. Four, insulin resistance. Five, membrane instability. Six, inflammation. Seven, methylation. Eight, autophagy. There's no ICD-11 code for any of those. Doctors don't even know most of those. The only one they know maybe is inflammation. When you think about the medicines, none of the medicines that we currently prescribed for any of these “diseases” touch any of these sub cellular pathologists, because they can't get there. They can't get to inside the cell where the problem is. For the most part, most of them, not all of them, but most of the problems I just mentioned, all eight of them, most of them are because of mitochondria. You have mitochondrial dysfunction, and you can't get medicines to the mitochondria. There's no medicine for the mitochondria. They're unreachable. So, all the medicines we throw at it, they're not fixing the problem, all they're doing is fixing the symptoms of the problem. If you only fix the symptoms of the problem, you're not fixing the problem. Problem is going to get worse.

Like the first sentence of the book, there's a wasp in your attic. What are you going to do? Kill the wasp or find the wasp’s nest? You have to work upstream of the problem. If you're going to fix it, working downstream of the problem only fixes the result. You have to fix the cause, and medicine is not fixing the cause. And that's why I wrote the book is to explain that you can't fix the cause, you can prevent the cause, and you can only prevent it with food, real food.

Melanie Avalon: I guess the only pill that would work would be one that would get rid of the food? [laughs]

Robert Lustig: Yeah, get rid of the food. Here's the problem. Remember, we started with protect the liver, feed the gut?

Melanie Avalon: Mm-hmm.

Robert Lustig: Okay, so any food that protects the liver and feeds the gut is healthy. Real food protects the liver and feeds the gut. Number one, it's low sugar, so you're protecting the liver because you're not flooding it. Feed the gut, the fiber in real food. So, take an apple, okay. Apple’s low sugar, high fiber. Apple is healthy. Apple pie is not. We've got our spectrum. Apple, apple pie, not the same. Now, the question is, our processed food environment is high sugar, low fiber. High sugar for palatability, low fiber for shelf life. Well, unfortunately, that high sugar is flooding the liver leading to liver fat and chronic metabolic disease. The low fiber is not feeding the microbiome, causing intestinal inflammation, which leads to systemic inflammation, which also leads to chronic metabolic disease. We have to have food that protects the liver and feeds the gut, but that's not the food we have. And that's not the food the food industry is pushing, because that's how they make their money. Also, because, after all, that's what's being subsidized. Corn, wheat, soy, sugar, all the stuff that kills us.

We have an inherent dichotomy between our biology and our food system. I know why, I know how it happened, I know where it came from. The question is, how are you going to undo it? There are ways you could undo it, and that's what I talk about in the book. I give the roadmap for undoing it at each of the stakeholder levels. Whether it's the patient, whether it's the doctor, whether it's the hospital, whether it's the food industry, whether it's the pharma industry, whether it's government, I basically show how each sector could respond in order to fix the problem if we fix the problem together. However, I'm not that naïve. I'm not that much of a Pollyanna, to believe that that's actually going to happen anytime soon. I'm a practicalist, not a purist. The question is, is there something we could do in the meantime? Is there a way we could take processed food and get it metabolized in the body like real food?

I'm working on that. I'm actually working on that. I'm working with a company. The company is called BioLumen Technologies. What we've done is, we've developed a proprietary fiber that expands in the stomach, that actually sequesters mono and disaccharides, added sugars in the matrix of this proprietary fiber, they’re a little micro cellulose sponges, if you will, that are impregnated with stuff that holds on to the sugar. Therefore, the stuff doesn't get absorbed early, thereby protecting your liver, and it delivers that further down the intestine to feed your gut. In other words, it's taking apple juice and turning it back into apples.

Melanie Avalon: That's so cool. [laughs]

Robert Lustig: Well, we're actually testing it now. If your biohacker listeners want information, I would be very happy to field the information. If you send me an email at rlustig@biolumentech.com, I will be happy to respond to you.

Melanie Avalon: My audience would probably love to do this, because you mentioned before you're pairing it with research with CGMs.

Robert Lustig: Yeah, we're looking for people who are not diabetic. If you're diabetic, we can't do this. We're looking for basically people who have CGMs, who would basically, first thing in the morning, eat a test food and measure their CGMs. Then, the next day, would eat the same test food with the fiber as a pill alongside it, and test their CGMs again to see what their glucose excursions are, and then be willing to share the data.

Melanie Avalon: We can talk more offline about it because I'm not sure when this episode is going to air, but depending on when you want to do this, I can definitely rally. If it's before this episode comes out, a lot of my listeners will probably love to do this.

Robert Lustig: Well, that'd be great. We'd be very happy for that. We could send them the fiber in the mail, and they could test it.

Melanie Avalon: Okay, this is great. This is exciting. Some last few questions because I want to be really respectful of your time. As far as actually implementing change with everything, what was the response on your campus, UCSF, when you guys did a ban on sodas? How did that go down?

Robert Lustig: Because of the science and because UCSF is a leading health institution, we should be modeling for the public. Think about it. Where was the first place that cigarettes were banned? Hospitals. It's a teaching moment. When people enter a hospital, it's a teaching moment as to what their actual behavior should look like. Well, if there's a fast-food franchise in every hospital lobby, and if you can get soft drinks galore at the hospital cafeteria, what are you telling your patients? We decided to put our money where our mouth is. At UCSF, we passed the healthy beverage initiative back in 2015. We got rid of all sugared beverages from the campus, and from all vendors who brought food onto the campus, and at all UCSF sites, and that is still in place. If you come to UCSF today, you can't find a sugared soda. We still have diet soda, we still have juice, although I'm not happy about it, but that's as far as the dietitians would let us go, at least for now.

Bottom line is we studied the effect on the UCSF employees. We looked at 3000 people in terms of questionnaire, and of that we took a subset 214 heavy soda users and saw what happened before and what happened after the campus-wide ban on sugar beverages. What we found was that sugar beverage consumption went down by half, from 35 to 17 ounces per day. In addition, their waist circumference went down by a full inch. Their insulin sensitivity improved, just by taking the sugar beverages out of the vending machines and out of the cafeteria.

Melanie Avalon: Do you think something like that ever in the future could be something we could see in stores?

Robert Lustig: We're doing it in hospitals all over the country. We actually have a toolkit for people if you're interested in that. We can help your hospital go soda free. We're doing that everywhere. The question is, would we be able to do this in larger venues? The answer is absolutely. It would have to be in private venues. Public venues would have a much harder time doing it for all the reasons you can imagine. The ACLU will be breathing down our neck, like crazy. In a private venue, you can do that. Ultimately, if it works in the private venue, it'll end up working in public venues. The bottom line is that policy is still in place five years later, and all we've gotten is positive feedback on it. By the way, it hasn't hurt cafeteria sales at all.

Melanie Avalon: You said people just buy more water basically, [laughs] solves that problem. Something that blew my mind, the generally recognized as safe list is privatized. That means I can't look up the list to see what's on the list?

Robert Lustig: You can look it up. It's just means that the FDA doesn't even know what's on it. For your listeners, G-R-A-S, GRAS, okay, it's not what you smoke. It's Generally Recognized as Safe, it is a list of compounds that the Food and Drug Administration say is safe to put in your food at any level, Generally Recognized as Safe. Now this started in 1958, as a method for trying to unburden the Food and Drug Administration from having to look at every food under the sun for approval. At the beginning, there were 170 items on the GRAS list, when the list was first conceived. Today, there are more than 10,000. Because there are so many-- so the first question is, do you really think there are 10,000 things you can put in your body that won't kill you? That's number one.

Number two, when the number of items started building up and building up and building up, in 1997, the FDA had Congress pass the FDA Modernization Act, also known as was for FDAMA, Food, Drug Administration Modernization Act, FDAMA. What that did was it privatized the list. Basically, any company can put anything they want on the list, all they have to do is convene a scientific committee to basically say, “Yeah, that's safe.” Now it's on the list. There are things that are on the list that the FDA doesn't even know are on the list, because the private company does necessarily have to tell the FDA because it's been privatized. This is a real, real disaster, and just an example of how the Big Government has basically screwed us in terms of this issue. Like I said, and there's a chapter in the book, Chapter 24, and the title of the chapter is, the USDA and the FDA don't actively kill people rather they let them die. It's just callously insensitive.

Melanie Avalon: You said for the GRAS list, that it's safe in any amount or safe in amounts that people would normally consume?

Robert Lustig: If it's on the GRAS list, it's safe in any amount.

Melanie Avalon: So, you probably could make the case for some, if you could show acute toxicity from fructose.

Robert Lustig: Well, our goal is to get sugar, specifically fructose, off the GRAS list. Now the Center for Science in the Public Interest is interested in doing this. It's a heavy lift, to be sure, but it could be done. There are two things that have been removed from the GRAS list, just two in all of its what 60 years of existence, nitrates--

Melanie Avalon: And trans fats, right?

Robert Lustig: And trans fats. Those are the two things that have been removed from the GRAS list. So, the question is, could we turn sugar from a food into a food additive? Because after all, that's what it is. It's called added sugar. It's added because it's a food additive. Obviously, the food industry would fight this tooth and nail because after all, sugar is their juggernaut. It's their gravy train. It's the thing that keeps us coming back for more, because it's addictive. They're not going to be very happy. This is what the science says. The logic shows that sugar and alcohol are metabolized virtually identically in the liver and in the brain. They both have the same hedonic tendencies. Alcohol is not a food. Alcohol is a food additive. Caffeine is not a food, caffeine is a food additive. Why would sugar be different?

Melanie Avalon: Yeah, that was one of my favorite parts of the book, the part that looked at the whole dialogue surrounding what makes the food addictive, and what you just said, the comparisons between sugar and alcohol and caffeine. I get really-- not upset, but there's the whole intuitive eating movement, and people will make the argument that people should be able to moderate their consumption of processed foods and things like that. I just don't know if that's a fair challenge for people because these foods literally seem to hijack our bodies and brains and mind. I don't know if everybody can have a healthy relationship and eat just one situation.

In any case, though, this has been absolutely amazing. I've been looking forward to this interview for so much. Listeners, you've got to get Metabolical, there is just so much information in there. We didn't even remotely touch on-- One of my favorite parts was you talk about the PI3-kinase mTOR and AMPK combinations. That was one of my favorites.

Robert Lustig: Well, good. That's brand-new stuff, and that's not written down anywhere else. This is basically how cancer cells grow, and why sugar feeds it.

Melanie Avalon: I made a whole chart and I've been staring at it. It's amazing. But two of the eight are just hypothetical because some were like AMPK and mTOR were related.

Robert Lustig: Well, AMPK turns off mTOR, so whenever AMPK is on, that means mTOR is off, whether there's a permutation for it or not.

Melanie Avalon: Exactly. And we didn’t even talk about greenhouse gases. There's just so much here, or the role of archaea bacteria in our intestines. So many things. Listeners, get Metabolical. Thank you so much, Dr. Lustig. The last question I asked every single guest on this show, and it's just because I realized more--

Robert Lustig: Better not be what I eat.

Melanie Avalon: It's not. It's completely different. It's because mindset is very important to me, so what is something that you're grateful for?

Robert Lustig: I'm grateful for my family, because they've stuck with me through thick and thin.

Melanie Avalon: That is wonderful.

Robert Lustig: I have abused my family, not physically, but from neglect in many ways to get this work done.

Melanie Avalon: Well, I just imagine also all of the-- just the controversy and everything that you're doing must be--

Robert Lustig: That doesn't help. You know what really doesn't help? What really doesn't help is when my kid goes into a science class, and they show Fed Up and all the kids start teasing my kid because their dad's on the screen.

Melanie Avalon: Oh, man. [laughs] Well, I am forever grateful for everything that you're doing. Any other links that you would like to put out there? We'll figure out the whole thing about the fiber supplement.

Robert Lustig: Sure. My website is robertlustig.com. There's a site for the book, metabolical.com. By the way, I realized I said my email address wrong. It's rlustig@biolumen.tech. I had said, unfortunately, rlustig@biolumentech.com, that's not correct. It's rlustig@biolumen.tech.

Melanie Avalon: Perfect. Well, for listeners, we'll put all of that in the show notes. Thank you so much. I would love to talk to you again in the future. This is amazing. I really look forward to your future work. This is just really, really incredible.

Robert Lustig: It's been my pleasure, Melanie. Thanks for asking such good questions and being so up on this.

Melanie Avalon: Enjoy your day.

Robert Lustig: You too.

Melanie Avalon: Bye.