Balaji Ravichandran: Sugar is the new tobacco

balajiSugar is the new tobacco. It is dangerous, addictive, and toxic, and it cannot be controlled by education or legislation alone. This is a war, between public health and private industry, and one that is best waged through the courts.

These were some of the more dramatic pronouncements heard at what was ostensibly an academic symposium on sugar, obesity, and metabolic syndrome. But then the keynote speaker of the event was Professor Robert Lustig, a paediatric endocrinologist from University of California, San Francisco, known as much for his forthright manner and the theatricality of his presentations as for his academic research. He was the star of the entire conference, the uneasy knowledge of which permeated the words of every other academic on the stage.

The two-day symposium was organised by Food and Behaviour (FAB) Research, a charity that furthers research into the link between nutrition and human behaviour.[1] It was extremely well-attended, especially by people who described themselves as “nutritionists” or “nutritional therapists,” but also by general practitioners, cardiologists and, interestingly, members of the public. Dr Alex Richardson, a founder of FAB, was in no doubt as to who drew the crowds and attracted such media attention. All credit to Dr Lustig, she told me, who achieved fame after his lecture on the health effects of sugar went viral on YouTube.[2]

The opening speaker, Professor Jason Halford of Liverpool, set out the problem. Almost two-thirds of the adult population in the UK was overweight or obese in 2010, and, if this continued, the NHS would soon become overwhelmed, he said. Obesity is traditionally thought of as a problem of energy balance, the difference between what we consume and what we expend. But this equation is at once deceptive and simplistic, he argued. He drew attention to the Foresight Report of 2007,[3] which posited the existence of a constellation of variables that influence our feeding habits and our levels of activity, most of which are outside our control. So, to blame individuals, or to implicate one macro- or micronutrient at the expense of another, was problematic.

In a way, Professor Halford established the dominant theme of the conference. Obesity and metabolic syndrome are not questions of individual responsibility. That is a myth propagated by the food industry and the politicians, who, through their unholy alliance, maintained a toxic environment conducive to the spectrum of disorders that constitute metabolic syndrome. What does it mean to have a choice, every researcher asked, when good, healthy food was out of the hands of most of the general public, especially the poor and the vulnerable, and the available food is designed to trick the hormonal systems of the body into overeating and becoming addicted to sugary, fattening foods?

We already know how powerful the sugar and beverage industries are. Professor Michael Yudkin, son of John Yudkin, recalled how his father’s book Pure, White and Deadly, which argued for a strong link between sugar consumption and metabolic syndrome, was quickly rubbished by the sugar industry, and subsequently forgotten by academic researchers. It was a concerted effort, and the industry spent millions of pounds in recruiting doctors and academics to combat the message of the book. Ancel Keys, the man behind the low-fat diets, and who wanted to blame saturated fats, not sugar, went so far as to describe John Yudkin’s work as “a mountain of nonsense.” It was therefore a matter of great pride to the younger Yudkin that his father’s work has, at the hands of researchers like Professor Lustig, achieved a measure of vindication.

Professor Lustig was greeted on to the stage with rapturous applause from the audience, punctuated with whistles and shouts of approbation. One could see why his manner provoked resentment among some of his academic colleagues. He began by quoting Gandhi: “First they ignore you, then they laugh at you, then they fight you, then you win.” Now, he said, “we’re at the fighting stage.”

Metabolic syndrome, not obesity, is the problem

“I don’t care about obesity,” he then declaimed. “Obesity is not the problem. Metabolic syndrome is.” Why? Nearly 20% of clinically obese were completely healthy, with no health problems. But almost 40% of the population with normal weight had metabolic syndrome, and they presented the greatest threat to public health, he said. The issue of weight was a distraction, one used by the food industry and the politicians to blame the individual rather than the toxic environment to which they in collusion gave birth. It was not surprising, therefore, that we had no uniform definition of metabolic syndrome, as we had used the idea of weight to drive research. Had we defined metabolic syndrome mechanistically, as engendered by insulin resistance, we would have rightly seen obesity as a symptom, not as a disease.

Another declamation soon followed. What caused metabolic syndrome and insulin resistance? A clip from the film Men in Black provided the answer. Tommy Lee-Jones asks Will Smith over the telephone: “Do you know what’s the most destructive force in the world?” Smith responds: “Sugar?”

Sugar was not the only enemy, Professor Lustig was quick to add. Trans-fats, branched-chain amino acids (BCAA), ethanol, and fructose all had a part to blame. But the latter were not subject to regulation by insulin. Yet in being composed of glucose and fructose, sucrose, he said, involved both insulin and fructose at the same time, which is what made sugar particularly unique and problematic. He brushed aside suggestions that fructose and glucose were metabolised in the same way by the liver. The five-member furan ring of fructose was inherently unstable, and at equilibrium, existed in the linear form. When they bound to amino acids, it could result in protein misfolding, which in turn could make insulin receptors scarce in liver cells, thus generating insulin resistance. In addition, while the liver shunted glucose towards the generation of glycogen, fructose was preferentially metabolised to fat droplets, and at high concentrations this resulted in fatty liver.

Worse, he said, fructose was more likely to bind to protein than glucose, and in doing so released reactive-oxygen species (ROS), implicated in ageing and all aspects of metabolic syndrome. He also drew attention to a study in methionine-choline deficient mice, a model for non-alcoholic fatty liver, which showed that sucrose was necessary for steatosis.[4] Most important of all, he said, the downstream effects of fructose in liver cells were such that there were no available drug targets which could stop metabolic syndrome. In other words, we could not design drugs to stop fructose and sucrose from inducing insulin resistance and de novo lipogenesis in the liver.

Sugar as a toxin
Finally, he drew attention to the study he published in PLoS One two weeks ago,[5] which suggested that a quarter of the prevalence of diabetes around the world could be explained by sugar alone, after controlling for other confounding factors. The econometric analysis, he said, in being a repeated cross-sectional study across a decade amounted to a “causal medical inference,” the same level of proof that was used to implicate tobacco as being responsible for lung cancer. Sugar, therefore, was a toxin in its own right. Given that, of the 600,000 items in the American food supply chain, 80% had added sugars, the sugar industry would do everything in its power to fight these findings, he said. “This is a war,” he concluded, in his typical dramatic manner, “and you didn’t even know you were fighting it… This is a war, and I throw down my gauntlet.”

There was not a single reaction in the body, Professor Lustig said, that required fructose. But surely fruits are healthy, and they have fructose, someone asked. Lustig responded by saying that there wasn’t a single sweet substance in nature that was poisonous to us, and that was no coincidence. It was evolution’s way of guiding us to essential nutrients and antioxidants. But nor was there a single substance in nature rich in fructose and devoid of fibre. Indeed, the level of fructose was roughly proportional to the amount of fibre in the fruit, he said. Fibre kept the insulin response and fructose absorption down. The problem, he said, was that food processing removed both the fibre and micronutrients, and left the sugar fully intact.

In his final statement, Professor Lustig said that neither education nor governmental regulation worked on their own in combating obesity, and certainly not fast enough. But, he said, at least in the United States, there was another way: the courts. It worked in the battle against cigarettes, and he was certain it would work just as well against the sugar industry. This, to him, was the best way forward.

Balaji Ravichandran is a freelance writer, DPhil candidate at The Queen’s College, Oxford, and former editor, Student BMJ


1. See
2., 13 March, 2013) Dr Lustig has also published a book on the same topic, called Fat Chance, which he was in part promoting at the symposium.
3. (Accessed 13 March, 2013)
4. Pickens, MK, Yan, JS, Ng RK et al. Dietary sucrose is essential to the development of liver injury in the methionine-choline-deficient model of steatohepatitis. J Lipid Res. October; 50(10): 2072–2082, 2009.
5. Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873. doi:10.1371/journal.pone.0057873
6. Livesey, G and Taylor, R. Fructose consumption and consequences for glycation, plasma triacylglycerol, and body weight: meta-analyses and meta-regression models of intervention studies. Am J Clin Nutr. 2008 Nov;88(5):1419-37.
7. (Accessed 13 March 2013)
8. (Accessed 13 March, 2013)

  • MEEu

    Balaji Ravichandran

    I enjoyed your well done review. And want to give full support to Robert Lustig and emphasize the scope of problem.

    30 years ago it probably was obvious to industry advisors
    that animal research and human population studies strongly suggested two things that Yudkin and Jack La Lanne (youtube “Sugarholic”) were aware of 20 Years before. One… dietary fructose had been triggering at least a 10 fold increase in expression of many chronic diseases since 1900. Two…fructose was somehow causing
    many to eat more and be less active. So if you owned a business related to food, weight loss, exercise or healthcare you might prefer your customers never learned what you knew about fructose. So
    something was needed to take the blame other than fructose. As you know the initial scapegoat was Ancel Keyes’ dietary FAT. This led
    nutritionists to recommend no-fat diets and condemn fast food as our major health problem. Never mind fast food sold the same toxic fructose molecules as expensive slow food and health food
    stores. Never mind that long term women’s health studies showed that women who ate the most fat had the least heart disease. Never mind that just 15 years of following expert’s advice to eat no fat, folks were sicker and more obese. Other scapegoats are “large
    portions”, “poverty”, “processed foods”, sloth, gluttony, not enough fruits & vegetables and of course evil HFCS. I estimate fructose triggers a tenfold plus increase in expression of type one and two diabetes, autism, depression, obesity and many other diseases. In 2010 car marketers recalled 20 million vehicles. If food marketers are concerned with safety of children it might be wise to recall their “fructosis” (google) causing foods. Change is more likely to come
    from informed mothers. Many mothers may want children to
    avoid what is becoming recognized as a toxin. Fructose like alcohol is proving to be adverse before conception, in the womb and as child grows. Pregnant mother, baby, child or students eating lots of what gram for gram may be worse than alcohol is a modern nutrition tradition. Unlike alcohol, students won’t pass out after 60 grams of fructose so it seems alcohol must be worse than sweet fruit sugar God provided. It doesn’t seem possible that fruit sugar can
    be addicting and cause liver failure, cancer and death like alcohol! It is inconvenient I know, but fructose is addicting for many. Fructose is the leading cause of liver disease in USA, not alcohol, not infection. NASH (caused by unhealthy amount of fructose in cells) is second only to hepatitis C as a reason for liver transplantation. Liver disease is only one of many diseases that fructose started before one is born can increases 10 fold or more. 1½ shots (drinks) is 20 grams of alcohol molecules. One medium sized apple contains 10 grams of fructose molecules. A 12 oz soda contains 20 grams. 12 oz apple juice has 24grams of fructose.

    What is significance of only 20grams of alcohol per day? The American Journal of Public Health concludes… (Daily
    consumption of up to 20 grams of alcohol (≤ 1.5 drinks) accounted for 26% to 35% of alcohol-attributable cancer deaths.
    Alcohol remains a major contributor to cancer mortality and Years per
    Life Lost. Higher consumption increases risk but there is no safe threshold for alcohol and cancer risk.) I suspect that if
    there is no safe amount of alcohol, there is also no safe threshold for
    fructose in cells either. It is the alcohol metabolite acetaldehyde that is a carcinogen and triggers liver disease. It is the fructose metabolite
    glyceraldehyde that is a carcinogen and triggers liver disease. Both aldehydes cause toxic advanced glycation end products (TAGE). See …. to understand why both dietary fructose and hyperglycemia cause unhealthy amounts of fructose in cells.

    We live in amazing times when it may be possible for young women who understand what I am saying to personally reduce the probability their children will express mental illness or other genetic disease predispositions by 95%. What are chances of a young women graduating with practical understanding of what is inconvenient to her teachers?

    John Weaver MD

  • As a physician, one who deals with the ‘end result’ of Metabolic Syndrome, most importantly Type II Diabetes…. Dr. Lustig is fighting one of the most important fights in Healthcare. As a woman, whom has lot over 200 pounds and continues to do so over the past decade, I know first hand the “sugar” connection interpersonally, now professionally, clinically, and scientifically. You are fortunate to have been a part of this symposium and very well noted points and summary. Well done !

  • RIchard Feinman

    As somebody who teaches biochemistry to medical students, I am astounded at the utter disregard for biochemistry or scientific thinking, and a rush to judgement that makes Ancel Keys seem like a very careful researcher. From a medical perspective, not the least of the problem is that equating sugar with ethanol and tobacco trivializes these very serious health problems. Whatever you think about risk factors and what Lustig thinks is biochemistry, there is still not a single disease outside of well-characterized inborn errors of metabolism that is clearly attributed to fructose. These wild sounding statements “There was not a single reaction in the body, Professor Lustig said, that required fructose” sounds profound but is meaningless. If he means dietary fructose, there is not a single reaction that requires dietary glucose, either.” If he means metabolites, fructose is everywhere. “War?” and Jenna Vaught thinks that Type II diabetes is more of a risk from fructose than glucose. People with diabetes don’t have fructometers. Fructose is a carbohydrate and is processed like a carbohydrate (open a biochemistry texgt) and reducing carbohydrates is clearly beneficial for diabetes and metabolic syndrome but it is hard to think of an experiment that showed that it was specifically reducing fructose that accounted for the benefit of carbohydrate restriction. Reducing sugar as method of reducing carbohydrates or reducing calories is clearly a good thing but starting another round of hysteria like the low-fat fiasco that is still with us, is sure to hurt. If nothing else, people have common sense and they have experience with sugar. If we equate the incontrovertible evidence on tobacco with the essentially meaningless results in Lustig’s PlosOne study (I provided a comment there that shows how to interpret his data), we will have done a great disservice at the moment when people are looking for guidance on health.

  • rinpochet

    My body is the experiment. My personal experience, and that of my daughter over the past month of reducing carbs and getting rid of sugar in our diets has been nothing short of miraculous! And we are not alone.

    Not only dramatic weight loss with also dramatic drop in blood pressure but improved hearing, vision, thicker hair, more energy, and no more headaches. BTW, those old “liver spots” have gone and my wrinkiles are also filling out. Whole foods are the miracle drug and sugar is the poison. My body, and that of my daughter are just two of many living proofs of this.

    Dr. Lustig’s book literally saved our lives and we will never be able to adequately thank him.

  • rinpochet

    I also lost a good deal of weight and normalized my blood pressure within weeks of starting a program of low carbs and no refined sugar with whole foods. My body and that of my daughter are living proof of the toxicity of sugar in the diet.

    Dr. Lustig will have our continued undying support for his work in fighting the battle against the greatest killer in our communities; sugar. Also the greatest villain in the surge of health care costs in this country!

    Congratulations on your success!! You are an inspiration to many.