Fat Chance was published in 2013 and I know is not the most recent book by Robert Lustig, MD (@RobertLustigMD), a pediatric endocrinologist at UCSF. As I’ve said previously, I’m still catching up 🙂 .
The book was a recommendation by Mark Cucuzzella MD at West Virginia University School of Medicine.
It continues to explode the idea that a calorie is a calorie (“the dogma should be restated thus: a calorie burned is a calorie burned, but a calorie eaten is not a calorie eaten”) and exercise is a weight loss strategy (“Donâ€™t get me wrong; thereâ€™s nothing bad about exercise (although it may not provide all the effects you expect). Exercise is the single best thing you can do for yourself. Itâ€™s way more important than dieting, and easier to do. Exercise works at so many levelsâ€”except one: your weight.”)
Biochemistry of Obesity and Stigma
I understand how hormonal feedback pathways work, however I am not an endocrinologist so this part is very detailed and complicated. Probably not as suitable for a non-health professional but very helpful for me.
The clinical vignettes presented are on the horrific side, and explain what motivates a physician to change the way we think about food (which is why we’re here anyway, see below).
What I have in common with Lustig is the sinking feeling that I also got when I saw obesity become medicalized in the early 2000’s.
I certainly did not start out as an advocate. I wasnâ€™t looking for a fight. I didnâ€™t come to this controversy with a preconceived agenda. Indeed, I was fifteen years into my medical career before I stepped up to deal with obesity as an issue. Until 1995, like my medical colleagues, I did my best to avoid seeing obese patients. I had nothing to tell them except â€œitâ€™s your faultâ€ and â€œeat less and exercise more.â€
Lustig, Robert H.. Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease (p. xiii). Penguin Publishing Group. Kindle Edition.
…and the same sinking feeling of where we’ve arrived at today, where medical students harbor explicit biases against obese people that are greater than those against LGBTQ people. Explicit, meaning, openly expressed to anyone who will ask:
Across the board, modern Western societies today value the thin and shun the obese.
Lustig, Robert H.. Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease (p. 23). Penguin Publishing Group. Kindle Edition.
Insulin, Atherogenic Dyslipidemia, NAFLD, and the Low-fat Diet
High insulin is responsible for perhaps 75â€“80 percent of all obesity.
Lustig, Robert H.. Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease (p. 82). Penguin Publishing Group. Kindle Edition.
The idea of the single marker, calculated LDL, as the determinant is addressed (I posted on this previously: Just Read: Challenging the role of LDL vs Insulin Resistance in predicting heart disease, via Kaiser Permanente data )
The reason the low-fat diet is a dismal failure is explained by the science in chapters 10â€“12. Itâ€™s not the fat, itâ€™s not the carbohydrateâ€”itâ€™s the fat and the carbohydrate together that cause metabolic problems. Sugar provides just that, and the low-fat diet is rife with it. The lack of fiber in the processed low-fat diet means that the rate of flux of both fat and carbohydrates to the liver is heightened, putting your poor liver under even more stress. The epitome of failure.
Lustig, Robert H.. Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease (p. 186). Penguin Publishing Group. Kindle Edition.
The approach to food here is to eat real food (if it has a nutrition label on it, it’s probably not real), avoid sugar, and promote fiber. Mostly similar to what others in this area are recommending, with some different prioritization. Reminder that a low-fat diet is essentially a high carbohydrate diet, which means that replacement is with fat, not with protein.
The issue of Non-Alcoholic Fatty Liver Disease (NAFLD) seems alarming to me and yet, I just did some CME through my specialty society (American Academy of Family Physicians- Mildly Elevated Liver Transaminase Levels: Causes and Evaluation – American Family Physician) and I’d say the concern expressed regarding NAFLD in pieces like this is probably less than it should be. I will explore this further.
Physicians as leaders, we came to health care to change everything
This book more than others approaches the policy and market environment promoting a high-insulin and high-stress-hormone milleu that perturbs people’s biochemistry as much if not more than the personal choices they make. From the U.S. dietary guidelines to the recommendations of people in my profession:
When the American Academy of Pediatrics still recommends juice for toddlers, and the American College of Obstetrics and Gynecology still recommends juice for pregnant women?
Lustig, Robert H.. Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease (p. 230). Penguin Publishing Group. Kindle Edition.
And legacies like this
(To really blow your mind, check these out: Document Dive: Whatâ€™s Inside the Sugar Industryâ€™s Filing Cabinets? â€“ Mother Jones)
The impacts were impressive, and they were effective, in a bad way, as I covered in this post from a recent trip to the Library of Congress (@LibraryCongress): More from my trip to the Library of Congress and incredible US News and World Report photo collection: 1968â€™s Harried Housewife Preparing Convenience Foods (and how her diet was re-engineered to be carbohydrate-rich)
As I have said previously on this blog for many issues (environmental stewardship, LGBTQ equality), our generation of physicians came here (wherever that is) to change everything, society shouldn’t expect less.
These are a few international health professional groups creating change: Nutrition Coalition | Nonprofit advocacy organization working to strengthen national nutrition policy, Health Professionals Supporting Change to Canada’s Food Guide, Public Health Collaboration â€“ Informing Healthy Decisions.
And my own real food photo
(apparently I also enjoy taking pictures of food)