Seminar 33: Healthy, wealthy and wise?

Lustig photo for webOn 11 July 2014, Dr Robert Lustig, professor of paediatrics at the University of California, gave a C3 International Breakfast Seminar on Healthy, wealthy and wise?

  • A longer report of the event is available here >> (pdf)
  • A blog of the event, by Richard Smith, on the BMJ website, is available here >>

There is a worldwide epidemic of non-communicable diseases (NCDs), such as type 2 diabetes, and we need to reallocate resources to prevent it. Addressing tobacco and alcohol misuse makes sense – but what is the best way to tackle poor diet? Focusing on lowering calories or fat has not made a difference to date – and it is time to act. So Robert focused on debunking three myths about NCDs:

Myth 1: It’s all about obesity

  • Obesity per se is not where the money is spent (other than on some orthopaedic procedures): it is the diseases that travel with obesity that are the cost – £61 billion was spent last year on diabetes in the UK. Worldwide, per year, obesity is going up at 1 per cent but diabetes is growing at 4 per cent – and this cannot be explained if diabetes is seen as a subset of obesity.
  • Of the 30 per cent of the population with obesity, 80 per cent are ill with NCDs – and the prevailing view is that if they would only diet and exercise then the health-care crisis would be solved. But the remaining 20 per cent are metabolically healthy and do not cost the taxpayer anything. Among the 70 per cent of the population without obesity, 40 per cent have the same conditions as those with obesity – they are often thin on the outside, fat on the inside (TOFI). The group who are thin and sick is, in fact, a larger group than those who are the fat and sick:  this cannot be about obesity if thin people also get the diseases, and it cannot all be about behaviour change.

Myth 2: A calorie is a calorie

  • If ‘a calorie is a calorie’, it would be irrelevant where the calories come from. But is this really the case? It takes twice as much energy to turn protein into energy as it does to turn carbohydrates into energy – so you use up more energy by metabolising protein than carbs, even when the calories in two foods are the same. And fats can either be healthy (Omega 3s) or unhealthy (transfats). Sugar is the biggest issue – and Robert clarified that this is not about glucose (which our cells use for energy, which we need to live and, if we do not consume it, our bodies make); it is about fructose, which we love because it is sweet, but there is no biochemical reaction that requires it.

Myth 3: It is about personal responsibility

  • To be able to take personal responsibility, you have to have knowledge (but so often labelling is unclear – for example, failing to indicate which sugars are naturally occurring and which are added), access to healthier products, to be able to afford your choice (and society, too, has to be able to afford your choice: can we really afford to unleash a ‘bariatric surgery bonanza’?), and your choice must not harm anyone else (but US employers are now paying over $2750 per employee in insurance every year to cover the cost of obesity, whether each employee is obese or not, and this is inhibiting economic growth).
  • Personal responsibility is a ‘lame concept’: the person exercising the ‘personal responsibility’ is not responsible for the cost, and the concept does not take into account that food has changed significantly. When market forces cannot fix a problem then it is time for society (our elected officials) to step in, as they did with speed limits, seat belts and smoking in public places. We have accepted these restrictions because public education made it clear that it is necessary.

In the 1970s, the food system changed to focus on mass production and low costs. A low-sugar high-fibre diet (‘real food’) is much better for us than the low-fibre and high-sugar diet that our food system is currently constructed to supply – but real food tends to cost more, because we do not subsidise the right things.

Of course, the food industry has to make money: they are in business, and that is what they do. We need to come up with a new food business model because, if the food industry is to change, it needs to be provided with an alternative way forward, for example subsidising healthy options. Regulation is needed if the same rules are to be applied across the board – but governments are reluctant to tackle it, as they have not fully appreciated the link between health costs and the food we eat.

We all need to write to our MPs to say we have had enough! ‘Let’s start a movement, let’s fix this problem, and let’s get healthier together!’

The discussion included:

  • is there a role for sugar in treating depression?
  • sugar taxes – the level at which they should be set and how they could be administered and spent – particularly bringing the money back into the local community;
  • the role of diet sodas;
  • to what extent are sugar consumption and obesity linked to diabetes – particularly referring to a study in PLoS One in 2013 (Basu et al.);
  • the key role of physical activity in weight maintenance – but that diet is also key to tackling diabetes and weight-loss;
  • the problem of mixed-messaging;
  • how and when to work with industry – there are concerns about scientific neutrality, and pressure from shareholders may stymie efforts toward healthier products, and Robert noted that government intervention (such as took place in successful efforts to reduce salt consumption) could provide a level playing field from which to take things forward; and
  • the need for local communities to call on parliament to change the whole food environment.