Review of recent study published in Cell Metabolism:
Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake.
Kevin D. Hall 5 Alexis Ayuketah Robert Brychta Hongyi Cai Thomas Cassimatis Kong Y. Chen Stephanie T. Chung Elise Costa Amber Courville Valerie Darcey Laura A. Fletcher Ciaran G. Forde Ahmed M. Gharib Juen Guo Rebecca Howard Paule V. Joseph Suzanne McGehee Ronald Ouwerkerk Klaudia Raisinger Irene Rozga Michael Stagliano Mary Walter Peter J. Walter Shanna Yang Megan Zhou
Published:May 16, 2019
Comments by Dr. Robert Lustig
A calorie is a calorie is a calorie; eat less and exercise more; any calorie can be part of a balanced diet. These are the mantras of the processed food industry. But are they real or fake news?
Hall and his NIH group attempted to answer this question with a 2-week crossover demand feeding study comparing the effects of real food (NOVA system class I, developed by Monteiro et al at the University of Sao Paolo) with ultra-processed food (NOVA system class IV). Hall locked up 20 subjects at the NIH Clinical Center, threw away the key, and fed them in random order and for 2 weeks at a time an ad lib processed food diet (more carbohydrate, less fiber) or an ad lib real food diet (less carbohydrate, more fiber). The two diets were matched for presented calories, sugar, fat, fiber, and macronutrients. Hall tracked food intake, body weight, energy expenditure, and baseline and glucose-stimulated hormonal parameters.
The ultra-processed food diet resulted both in weight gain and 508 calories per day greater intake (mostly carbohydrate) than the real food diet, which resulted in weight loss. The only things that distinguished the ingestion patterns were higher carbohydrate and less fiber in the ultra-processed diet. Finally, body weight changes correlated with changes in energy intake.
Bottom line: like other studies which preceded it (eg, the DIETFITS study), this study shows that real food works, and processed food doesn’t — take it to the bank. Real food resulted in fewer calories consumed, but we can’t infer that the effect was due to increased fiber (fewer calories absorbed); decreased energy density; reductions in carbohydrate; reductions in insulin and changes in leptin signaling; feeding the microbiome; and/or increased satiety.
And what about the food industry’s real versus fake news? Can we discern if, and which, macronutrients are the bad guys? What really reduced caloric intake? Unfortunately, this study was not designed or powered to assess whether certain macronutrients (like starch, fat, fructose) altered food intake apart from its caloric equivalent. Hall is a thermodynamics guy—and a calorie is always a calorie. So, don’t expect any other seminal answers out of this one.
Commentary originally published in PracticeUpdate!
Lustig RH. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of ad Libitum Food Intake. PracticeUpdate website. Available at: https://www.practiceupdate.com/content/ultra-processed-diets-cause-excess-calorie-intake-and-weight-gain/84403/65/8/1. Accessed July 11, 2019
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Join me at the
AAOSH 2019 Scientific Session
“Practicing Complete Health: Turning Science into Action”
October 17-19, 2019 | Gaylord Opryland Resort | Nashville, TN
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I’m speaking –
“Clinician Confidential: How industry hacked the health professions”
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You’ve been lied to.
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Tobacco Industry Involvement in Children’s Sugary Drinks Market: Cigarette Giants Bought Food Companies, Used Cartoon Characters, Colors, Flavors to Boost Sales of Sweetened Beverages, UCSF Study Shows
Tobacco conglomerates that used colors, flavors and marketing techniques to entice children as future smokers transferred these same strategies to sweetened beverages when they bought food and drinks companies starting in 1963, according to a study by researchers at UC San Francisco.
The study, which draws from a cache of previously secret documents from the tobacco industry that is part of the UCSF Industry Documents Library tracked the acquisition and subsequent marketing campaigns of sweetened drink brands by two leading tobacco companies: R.J. Reynolds and Philip Morris. It found that as tobacco was facing increased scrutiny from health authorities, its executives transferred the same products and tactics to peddle soft drinks. The study publishes March 14, 2019, in the BMJ.
“Executives in the two largest U.S.-based tobacco companies had developed colors and flavors as additives for cigarettes and used them to build major children’s beverage product lines, including Hawaiian Punch, Kool-Aid, Tang and Capri Sun,” said senior author Laura Schmidt, PhD, MSW, MPH, of the UCSF Philip R. Lee Institute for Health Policy Studies. “Even after the tobacco companies sold these brands to food and beverage corporations, many of the product lines and marketing techniques designed to attract kids are still in use today.”
Fruit Juice, Sports Drinks Linked to Obesity, Metabolic Disease
American youth currently consume an average of 143 calories a day in sugary beverages, according to the Centers for Disease Control and Prevention. These calorie-dense drinks do not provide the satiety of foods and are associated with obesity and metabolic syndrome, a cluster of conditions that increase the risk for heart disease, stroke and Type 2 diabetes.
Sugary beverages include most fruit juices, sports and energy drinks, soda and other beverages sweetened with added sugars, including honey, fructose, glucose, sucrose, dextrose, corn sweetener, malt syrup, corn syrup, brown sugar and raw sugar.
The new papers, which are available in the UCSF Truth Tobacco Industry Documents Library, a subset of the UCSF Industry Documents Library, reveal connections between the tobacco and food industries.
Tobacco giant R.J. Reynolds led the transition to sweetened beverages in 1963 when it purchased Hawaiian Punch from Pacific Hawaiian Products Company, according to the documents. The beverage previously had been promoted to adults as a cocktail mixer, but R.J. Reynolds sought to beef up the drink’s “Punchy” mascot – a counterpart to the “Joe Camel” cartoon character the company used to promote cigarettes – and featured it on toys, schoolbook covers, comics, tumblers, clothing and TV commercials. Punchy became the “best salesman the beverage ever had,” according to tobacco industry documents.
In the ’60s and ’70s, the company conducted taste tests with children and mothers to evaluate sweetness, colors and flavors for Hawaiian Punch product line extensions. The children’s preferences were prioritized, the authors noted.
By 1983, R.J. Reynolds introduced the nation’s first juice box, marketed as a “handy little carton that comes with its very own straw.” This innovation was largely responsible for a 34 percent jump in sales, according to industry documents.
Kool-Aid Joins Marlboro
Meanwhile, tobacco competitor Philip Morris had acquired Kool-Aid, via General Foods, in 1985. The company flipped its marketing audience from families to children, created its “Kool-Aid Man” mascot, and launched collaborations with branded toys, including Barbie and Hot Wheels. It also developed a children’s Kool-Aid loyalty program described as “our version of the Marlboro Country Store,” a cigarette incentives program.
“The Wacky Wild Kool-Aid style campaign had tremendous reach and impact,” said first author Kim Nguyen, ScD, MPH, who is also with the UCSF Philip R. Lee Institute for Health Policy Studies. “Lots of kids in the ’80s dreamed of getting swag from the Wacky Warehouse. What is really ‘wacky’ is that the Kool-Aid kid program was modeled after a tobacco marketing strategy designed to build allegiance with smokers.”
By 2004, Philip Morris had developed at least 36 child-tested flavors to its Kool-Aid line, of which some – like “Great Bluedini” – integrated colors with cartoon characters. The tobacco giant also acquired Capri Sun and Tang, and used similar child-focused integrated marketing strategies to drive those sales.
Most sweetened beverage manufacturers claim to limit marketing to children of unhealthy foods and drinks. The industry launched both the Children’s Advertising Review Unit, to promote responsible advertising to children through industry self-policing, and the Children’s Food and Beverage Advertising Initiative, which states that it devotes 100 percent of “child-directed advertising to better-for-you foods.”
“The industry claims that these tobacco-inspired marketing strategies are not actually targeting children and should be excluded from these industry-led agreements” said Schmidt. “But the evidence cited in our research shows that these product lines and marketing techniques were specifically designed for and tested on children.”
The authors conclude that, given the current high rates of childhood obesity, there is a clear need to replace current industry-led voluntary standards with well-enforced government regulations on marketing sugary beverages to children.
“Parents do play a significant role in what their kids eat and drink,” Nguyen said. “However, we cannot underestimate the influence of these beverage corporations and their marketing. They intentionally develop marketing campaigns that appeal to kids by making the drinks fun and exciting.”
The UCSF Industry Documents Library was launched in 2002 as a digital portal for tobacco documents. Today, the library includes close to 15 million internal tobacco, drug, chemical and food industry documents used by scientists, policymakers, journalists and community members in their efforts to improve and protect the health of the public.
Co-Authors: Stanton Glantz, PhD, from the UCSF Center for Tobacco Control Research and Education; Casey Palmer, MS, RN, from the UCSF Philip R. Lee Institute for Health Policy Studies.
Funding: Laura and John Arnold Foundation, CrossFit Foundation, the National Cancer Institute.
Disclosures: No conflicts of interest.
About UCSF: UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals – UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – as well as Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children’s Physicians and the UCSF Faculty Practice. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. UCSF faculty also provide all physician care at the public Zuckerberg San Francisco General Hospital and Trauma Center, and the SF VA Medical Center. The UCSF Fresno Medical Education Program is a major branch of the University of California, San Francisco’s School of Medicine. Please visit www.ucsf.edu/news.
For additional information, Contact:
UC San Francisco
Stories about this research:
How Big Tobacco Hooked Children on Sugary Drinks, New York Times
The fiber in real food is of two kinds: soluble, which is globular (e.g. beta-glucan, pectin, inulin, etc.); and insoluble, which is stringy (e.g. psyllium, cellulose, chitin, etc.). You need both, as they do different jobs. The insoluble fiber forms a latticework (like a fishing net) in the duodenum, and the soluble fiber plugs the holes in that latticework. Together they form a secondary barrier on the inside of the duodenum, which prevents early absorption of mono- and di-saccharides, as well as other readily absorbable nutrients.
Psyllium is an insoluble fiber. Alone It could form the latticework, but not plug the holes. Beta-glucan is a soluble fiber. It can swell and absorb water, but could not lay down the scaffolding. To get the benefits on delay of absorption, you would need both. Real food has both. Ingestion of either psyllium alone or beta-glucan alone could not form the secondary barrier. You need both. Could you put both into one pill? Perhaps. But the side-effects would be highly problematic.
Psyllium is not compressible, so in order to lay down the latticework for creation of the duodenal barrier, you would have to take a high dose of psyllium. Furthermore, psyllium leads to loose stools, which is not disastrous, but is not pleasant. Beta-glucan swells with exposure to water and does not release the water causing severe bloating, distress, and diarrhea. It does not absorb macronutrients, just water. Furthermore, neither fiber gives up the water it absorbs, resulting in problematic and persistent GI distress.
Intact fiber – as a whole food – has many benefits. Not just the short-chain fatty acids (SCFAs). In the processed food industry, the “germ” of the grain (the nucleic acids, flavinoids, polyphenols) is removed with the fiber. Keeping the fiber also means keeping the germ intact.
Dr. Aseem Malhotra addressed the European Parliament on February 26, 2019 – see the video recording to on the left side of this screen. You may view his powerpoint here as well.
“The science of reversing type 2 diabetes with a low carbohydrate diet (and overcoming opposition from vested interests)”
Dr. Aseem Malhotra
Honorary Consultant Cardiologist, Lister Hospital Stevenage
Academy of Medical Royal Colleges Choosing Wisely Steering Group
King’s Fund – Member of Board of Trustees
(With special thanks to Professor Sir Muir Gray, Dr. Robert Lustig, Professor Simon Capewell, Dr. Kevin Hall, and Dr. David Unwin)
Dr. Malhotra pulls no punches.
“This evening I had the honor of speaking In parliament to a packed audience of MPs, lords, healthcare practitioners, and members of the public including Dr. Michael Moseley. There were no holds barred in calling out dietary misinformation coming from the establishment including Public Health England, ignorant scientists and the British Dietetic Association. Evidence based medicine has been hijacked by commercial influence but we have the solutions to fix this broken system and we must. It was also a pleasure to meet with a very receptive and friendly Secretary of State for health who was delighted to receive a copy of the Pioppi Diet. He also promised he would watch my talk and that of Dr. Zoe Harcombe that has been recorded by Ivor Cummins for you all to see soon. Special thank you to Tom Watson and Keith Vaz for making this happen!”
-Dr. Aseem Malhotra
Intro by MP Tom Watson
Two Presentations with Dr. Lustig offered by the New Jersey Academy of Pediatric Dentistry and the American Academy of Pediatrics, New Jersey Chapter offered April 12, 2019 in East Brunswick, NJ
Tooth Decay and Liver Decay
Mountain Dew Mouth has been the scourge of dentists for decades. But there’s a new disease which affects even more people: Mountain Dew Liver. Non-Alcoholic fatty liver disease (NAFLD) wasn’t even discovered until 1980; and now up to 1/3 of Americans suffer from it. Especially children – 13% of autopsies in children show NAFLD; and 38% of of obese children. Both tooth decay and non-alcoholic fatty liver disease rates have increasing. And excessive sugar consumption explains both.
Dietary sugar is composed of one molecule each of glucose and fructose. It is the fructose that is the primary driver of both diseases. While glucose contributes to the oral biofilm, fructose doesn’t. It is metabolized by oral bacteria into lactic acid, which readily diffuses though the biofilm and into the tooth. Alternatively, fructose gets turned into fat in the liver mitochondria, which drives NAFLD, which is the leading cause of liver transplantation now, surpassing alcohol. And yet who is most susceptible to both diseases? Children, because they are the biggest sugar consumers.
Doctors and dentists must be united in supporting public health measures to reduce chronic disease. Altering our diet is where public health prevention starts.
The Hacking of the American Child
Everyone is looking down. But especially kids. There is something unnatural about a 15 month old using an iPad to soothe himself or herself. Everyone assumes this is just the natural progression of our “tech society.” But what if this is doing harm to us, and to our brains? And what if children are more vulnerable than adults? Numerous politicians are calling for “reigning in” of the internet. Is this necessary?
We will answer five questions:
1) Is there such a thing as Tech Addiction?
2) Is it similar to or different than drug addiction?
3) Does technology lead to depression and suicide?
4) Have our minds been hacked?
5) Are children more at more risk?
The answers to these questions provide us a blueprint to harness technology for good, and not for ill.
“In youth-onset type 2 diabetes, the major modifiable risk factors are obesity and lifestyle habits of excess nutritional intake, low physical activity, and increased sedentary behaviors with decreased energy expenditure, resulting in the surplus of energy being stored as body fat.”
Worst yet, the authors are my Pediatric Endocrine academic colleagues. They should know better. I’m supremely disappointed in them.
The Guardian enters “The Butter Battle 2.0”. More heat than light.
Here are the 10 things everyone need to know to navigate this minefield.
- LDL-Cholesterol (LDL-C) levels (from dietary fat) correlate (but poorly)
with CV mortality.
- Triglyceride levels (from dietary sugar) correlate (much better) with CV mortality.
- LDL particle number (LDL-P) is the right measure for CVD, and higher is worse. But a standard lipid profile measures LDL-C, not LDL-P. Wrong test.
- Dietary fat raises LDL-C, but not necessarily LDL-P, while sugar raises triglyceride levels.
- Red meat is associated with increased CVD. But maybe not because of its saturated fat. In fact, dairy saturated fat is protective against CVD.
- If you have a super high LDL-C (over 200), then you probably also have a high LDL-P, and you might need a statin.
- If your LDL-C is between 70 and 200, maybe your LDL-P is high, but maybe it is not. Statins are not prescribed based on LDL-P; they are prescribed based on LDL-C. This is a bad idea, yet doctors do it all the time.
- 4/5 of the people taking statins were prescribed for high LDL-C. But this is the wrong reason. And 20% of statin takers get side-effects.
- That doesn’t mean you should stop your statin. But it also doesn’t mean you can eat butter without abandon.
- A doctor who knows what they are doing can figure your situation out. But most don’t know what they are doing; they do as they’re told.
There are two kinds of fiber. Soluble (e.g. pectins, inulin), and insoluble (cellulose). You need both. When you have both, 6 good things happen:
- The insoluble fiber forms a latticework in the duodenum, and the soluble fiber plugs the holes in the latticework to create an impenetrable secondary barrier. This limits simple carbohydrate absorption in the duodenum, thus preventing the liver from receiving all that carbohydrate at once, tamping out the tsunami of carbohydrate.
- This also reduces the glycemic excursion in the blood, so that the insulin response will be attenuated.
- If the carbohydrate isn’t absorbed in the duodenum, it goes to the jejunum, where the microbiome is, promoting microbial diversity and gut health.
- Grains are covered in insoluble fiber (the husk). If you consume them whole and non-pulverized, the enzymes in the intestine have to strip that covering off before the starch is released. That takes a lot of time, and so it happens later in the intestine, so the the bacteria can get to it.
- The soluble fiber can be fermented by intestinal bacteria to make short chain fatty acids, which also suppress insulin release and improve gut health.
- The insoluble fiber acts like little “scrubbies” on the inside of your colon to remove old and damaged cells, thus reducing risk for colon cancer.
The best fiber is where there is both soluble and insoluble. That’s everything that comes out of the ground — before it’s processed. As soon as it’s processed, it loses many of these six properties.
Photo credit: Fancycrave, Unsplash