Sugar, Diabetes and E-mails From Lustig

Do you remember the new study showing that more available sugar in countries is closely followed by more cases of diabetes?

As I wrote this kind of observational correlation does not really prove causation. But the story is slightly more complicated. Dr Lustig emailed me yesterday:

Mail from Lustig

Here’s part of the email:

Andreas, read your blog about our study. Wanted to add something for you and your audience.

While this an ecological study on its face, the statistics are from the field of econometrics, and special care was taken to assure dose, duration, directionality, and precedence. Furthermore, we controlled for poverty, urbanization, aging, total calories, all other calories in the diet, obesity, and physical inactivity. The only signal came from sugar, and sugar was 11 times more potent in explaining diabetes worldwide than was total calories.

While not “scientific proof”, this study satisfies all the criteria laid out by Austin Bradford Hill on “medical causal inference” for sugar as a specific cause of diabetes. This is the same degree of “proof” that implicated cigarettes as the cause of lung cancer back in the 1960’s. The cigarette industry obfuscated these results for decades, to our detriment. No doubt, the food industry will try to do the same here.

I asked Lustig if the statistics implicating cigarettes as the cause of lung cancer did not show a stronger effect. Meaning that a pack of cigarettes a day increases the risk of lung cancer a lot more (compared to a non-smoker) than the increased diabetes risk from a few cans of soda.

Here’s Lustig’s reply:

That’s because the baseline was lower to start with. Same with asbestos. The prevalence is almost zero.

But for diabetes and heart disease there is a significant baseline prevalence in the population to begin with. Much harder to show an effect. But it’s there!

And how about adolescents with Type 2? The baseline there is virtually zero. Of course, the IDF database did not collect that, so it is still an open question. But I can tell you, EVERY adolescent with T2DM that I have ever seen was a soda abuser.

Interesting points I think.

I really like this study. Like Lustig says, while this kind of data is far from perfect it’s similar to the evidence implicating cigarettes as the cause of lung cancer.

The question is, how long are we going to let kids drink all the sugar water they want until they get diabetes? Would we let them smoke all the cigarettes they wanted?

PS

Lustig also pointed out that I still haven’t posted a full review of his new book “Fat Chance”. Guilty as charged. I have a dog-eared copy full of notes though. A review is coming up.

More

Surprise: More Sugar, More Diabetes

Is Your Dietitian Educated by The Coca Cola Company?

21 comments

Top comments

  1. For all readers of this blog, hopefully you'll find this information useful:

    "Chronically elevated insulin won't lead to net fat gain in the absence of a surplus of energy

    And where do you suggest we move where there's not an unlimited supply of food 24-7? Rural Siberia?

    Or did you suggest that people less fortunate than yourself in the weight-gene lottery should just use their willpower and stay hungry forever?

    Read more →
  2. FrankG
    Except that anyone with half a brain who actually listens to Dr Lustig would realise that he never says "fructose is evil"

    ...anymore than Gary Taubes said that ALL carbs are bad or that insulin is the spawn of the devil!

    Way to take a reasonable argument and attempt make it into something ridiculous Brian :-)

    Reply: #16
    Read more →

All comments

  1. 1 comment removed
  2. I agree with this finding - it is a pity that Diabetes NZ (I am from New Zealand) does not agree. Here is a quote from there website "It is important to note that sugar does not cause diabetes."

    To be found on this page. http://www.diabetes.org.nz/food_and_nutrition/healthy_food_choices__a...

    Insane. The information given out to diabetics is nothing short of criminal.

  3. Till
    Here is a blogpost from one of the authors on how their study can be interpreted and what it can show and what not. I guess they were expecting to be misinterpreted.

    http://epianalysis.wordpress.com/2013/02/27/sugardiabetes/#more-1095

  4. I'll be present at
    13 March 2013 - FAB EVENT - Oxford - SUGAR AND THE BRAIN: FOOD CHOICE, ADDICTION AND THE MENTAL HEALTH CRISIS to hear Lustig speak.
    There are PLACES STILL AVAILABLE and as it's getting close to the event maybe if you speak to Fiona O'Fee the event organiser (email or phone) she may extend the FAB members price to non-members but as Registration will close on 8th March 2013 you have to act NOW.
    Reply: #15
  5. Ondrej
    For all readers of this blog, hopefully you'll find this information useful:

    "Chronically elevated insulin won't lead to net fat gain in the absence of a surplus of energy.

    Keep in mind that dietary protein is also insulinogenic, and that the body can store fat in the absence of insulin (via acylation stimulating protein) - two facts that these neo-Atkins types COMPLETELY ignore, either due to genuine ignorance, or to sell books."

    Replies: #7, #9
  6. >>>Chronically elevated insulin won't lead to net fat gain in the absence of a surplus of energy.

    False. With high insulin the body will continue to store fat even with an energy deficit. You can begin to metabolize lean tissue, while storing new fat.

    >>>Keep in mind that dietary protein is also insulinogenic ...

    But the effect is not nearly as pronounced as it is with simple carbs, especially sugar. LCHF (low carb high fat) diet he recommendation is to keep protein intake moderate. Simple carbs immediately raise insulin levels. Protein goes through a complex process called gluconeogenesis, which results in an increase in blood glucose and insulin.

    >>> ... and that the body can store fat in the absence of insulin (via acylation stimulating protein)

    ASP works with insulin, it does not replace insulin.

    >>>- two facts that these neo-Atkins types COMPLETELY ignore, either due to genuine ignorance, or to sell books."

    ASP and protein induced gluconeogenesis are not the cause of obesity. They have minor effects,when and compared the impact of insulin and simple carbs their influence is insignificant.

    ES

  7. For all readers of this blog, hopefully you'll find this information useful:

    "Chronically elevated insulin won't lead to net fat gain in the absence of a surplus of energy

    And where do you suggest we move where there's not an unlimited supply of food 24-7? Rural Siberia?

    Or did you suggest that people less fortunate than yourself in the weight-gene lottery should just use their willpower and stay hungry forever?

  8. LDL-Richard
    Good post Andreas,

    now image if you'd follow your own (newly) enhanced criteria towards epidemiology, you'd probably be blogging about Jeremiah Stamler and his response to Siri-Tarino et al 2010. Stamler showed, that the authors did not look at the most crucial end point of all, the hard fatal CHD. Saturated fat increased the risk of fatal CHD by 32% despite the huge regression dilution bias and the possible sick-quitter effect in the cohorts. Sick-quitter effect is known to attenuate the associations of smoking to cancer mortality towards the null in many studies. Thus, cigarette industry was very delighted about a study published in BMJ in 2003 which showed that cigarette smoking had no association to cancer. Sick-quitter effect refers to the drastic change in lifestyle that people at the most risk of dying usually do. For example, it is widely known that those who are diagnosed with CHD are the first ones to cut their intake of SFAs and dietary cholesterol.

    To make the case even more intriguing, Stamler reported that RRs for the SFA - CHD link of the various sub-studies in the meta-analysis was highly depended on the quality of dietary assessment used. For example, it has been estimated that it requires 22 24-hour dietary recalls to asses the mean consumption of SFAs within 20% accuracy. In addition it is widely known that there's substantial spontaneous intraindividual variation (5 to 10%) of serum cholesterol levels. Because of inadequate number of dietary assessments and cholesterol measurements at the baseline, people were often classified into incorrect categories in older studies and such studies often failed to find an association between SFA and serum cholesterol concentrations; thus null finding of SFAs to CHD was nothing but expected. Stamler showed that out of the 16 CHD studies used, 4 relied on one 24-h dietary recall which is considered invalid dietary assessment method these days; the SFA-CHD RR was >1.00 for only one of these studies. Seven used a food-frequency questionnaire (FFQ); the RR was >1.00 in 3 of these studies. Only five studies used the most modern dietary assesment methods available (dietary history or multiday food record) and the RR was >1.00 in all 5 studies, even though 3 were adjusted for serum or dietary lipids. This is why no one familiar with medicine and nutrition takes the meta-analysis by Siri-Tarino et al seriously. It's like the smoking study published in 2003 in BMJ.

    Diet Heart: a Problematic Revisit
    http://ajcn.nutrition.org/content/91/3/497.full

  9. @ >>>"Chronically elevated insulin won't lead to net fat gain in the absence of a surplus of energy."
    Here is an early example of a low carbohydrate weight loss regime The Raw Milk Diet: A Physician’s Experience With Real Healing Which used 6 quarts of raw milk daily. Each quart of milk = 585 calories x 6= 3516 total calories

    This was in conjunction with High density nutrient feeding is coupled with bed rest 24/7 throughout the diet. so there was no chance of working off excess calories with exercise.

    Richard Nikoley Free the Animal is experimenting with this approach.
    But be aware, before you comment on his site, he doesn't suffer fools kindly.

  10. yuma
    The fact that many diabetics improve their condition on a low carb diet should be evidence of the deadly effects of sugar, and carbs which are converted to glucose (just like sugar) in the body.
  11. Michelle
    'And where do you suggest we move where there's not an unlimited supply of food 24-7? Rural Siberia?

    Or did you suggest that people less fortunate than yourself in the weight-gene lottery should just use their willpower and stay hungry forever?'

    Thank you Andreas. Sometimes I need to remind myself of this.

  12. Brian
    Lustig, the pinup boy of the low carb community...whose "fructose is evil" alarmism is just as unhelpful as the low fat dogma stemming from the 80s.

    http://www.andrewkimblog.com/2013/02/quick-commentary-on-dr-lustigs-t...

    http://www.alanaragonblog.com/2010/01/29/the-bitter-truth-about-fruct...

    Reply: #13
  13. FrankG
    Except that anyone with half a brain who actually listens to Dr Lustig would realise that he never says "fructose is evil"

    ...anymore than Gary Taubes said that ALL carbs are bad or that insulin is the spawn of the devil!

    Way to take a reasonable argument and attempt make it into something ridiculous Brian :-)

    Reply: #16
  14. Galina L.
    Sugar Association's intent to use science to defeat critics uncovered by dentist
    http://www.cbc.ca/news/health/story/2013/03/08/f-vp-crowe-big-sugar.html
  15. rita
    Will this event be recorded and made available online? That would be fantastic for everyone who won't be able to attend!
  16. Brian
    "Anyone with half a brain would realise lustig never says fructose is evil."

    Well my apologies, he only calls it poisonous and a toxin. Oh, and that it has similar effects on the liver as alcohol. He never actually uses the word evil.

    Yes, I feel really stupid now.

  17. Zepp
    "Forget Cholesterol, Inflammation's the Real Enemy"

    http://www.youtube.com/watch?v=AwkBB2Z6914

    Is there somthing going on over there??

  18. FrankG
    Well Brian I did not actually say that you are stupid but you do seem to be going out of your way to confirm my suspicions in that regard...

    Dr Lustig makes it crystal clear that (much like alcohol) fructose is a dose-dependent hepato-toxin. In simple terms (is that all you can manage?): in small amounts (as found in nature) it may be harmless, if not actually beneficial BUT above a given threshold it becomes toxic (just like alcohol). His position (and I agree) is that currently many folks on a western industrial diet are well above that threshold for fructose. What that level is, may depend on the individual: for example an athlete may use fructose as an efficient way of replenishing glycogen stores but as he points out, it is not just (or even) athletes who are drinking the "sports drinks".

    You and your kind seem to find it so much easier to build straw-men arguments based on your own extreme and misleading interpretation of the truth... arguments that fall apart as soon as they are held up to scrutiny. If you want to call that stupid, then why would I argue with you :-)

  19. Brian
    Do you even read what you write frank? "Anyone with half a brain" - that is not implying someone is stupid?

    I don't suppose you even clicked on the links I posted. Lustig has been shown to be wrong about so many key aspects of his hypotheses regarding sugar, fructose etc that he is not taken seriously by anyone who is willing to think for themselves and step out of the low carb echo chamber that exists on the web. Andrew Kim in particular in one of the links I listed earlier has shown that the pathways that fructose undertakes does NOT lead to the formation of fat in the liver in any significant amount.

    From that link:

    "Isotope tracer studies show that fructose is predominantly converted to glucose and lactate, supplying fuel to cells in the periphery. In comparison, the conversion of fructose to fat–via acetyl-CoA–is a minor, and highly energy-consuming, pathway...as is the conversion to glycogen (Tappy & Lê, 2010)."

    Fructose is not a poison at ANY dose in a normal diet (I am excluding trials here where fructose is fed without glucose, since this doesn't happen at any time in the real world, that is unless you can point me to some magical foods that contain pure fructose without glucose). It's laughable to suggest that it is, given the information available, but I suppose you would actually need to read more that just the views and articles that validate your already established opinion to discover that.

  20. Ed
    >>I don't suppose you even clicked on the links I posted.

    The first link is mostly quibbles about interpretation of fine points based on studies of variables in isolation that don't prove or disprove anything related to metabolism of sugars.

    The second link basically says that because one USDA study shows that added sugar hasn't increased, it can't be blamed for the obesity epidemic.

    But, the term "added sugar" as used here (by the USDA) is very misleading. If you sprinkle sugar on your cereal, that's added sugar, but the HFCS the cereal is made with isn't. Syrup on your pancakes is counted as added sugar, but not the sugars in the pancake batter.

    What's key is that total sugar consumption has skyrocketed. The fact that we're putting less sugar in our Iced Tea, etc., shows that people are actually trying to do better. But there is so much sugar in everything we eat (and drink) that our food supply is sabotaging us.

    Also, I don't think you've read Dr. Lustig or even seen his video. Lustig explains very clearly the relationship between fructose and glucose in sucrose and HFCS. You probably should watch the video and play close attention, it might help clear up a few of your misconceptions.

    ES

  21. ribs
    Am a lady of 31 am in love with the man of the age of 47 years.he is diabetes an he is taking a treatment.my worry is that he si drinking alcohol everyday an smoking 2 much.sometimes he not sexual active,he always want to sleep with different woman,he is giving stress cause I feel like am helpless,he don't talk about his diabetes.I love the man,i want to learn more about diabetes now he is using injection an pills.What must we eccept after few years
    Reply: #22

Leave a reply

Reply to comment #0 by

Older posts