Über Gewicht – Gespräch mit Prof. Dr. Robert Lustig (englisch)

(Dieses Transkript wurde automatisiert erstellt.)

DR. LAURA WEISENBURGER Diesen Monat ist ja unser Spezialmonat bei der Dosis Wissen mit unserem Deep Dive zu Adipositas. Wir haben uns in vier Folgen jetzt angeschaut, welche Gründe es für Adipositas gibt und was sich eigentlich tun müsste, gesellschaftlich, medizinisch, politisch – sehr, sehr viel. Und dazu haben wir aber auch mit einer Menge spannender Expertinnen und Experten gesprochen. Und für alle, die jetzt noch nicht genug von dem Thema haben, gibt es diese Woche, wie versprochen, die Interviews in voller Länge. Heute starten wir mit Professor Dr. Robert Lustig, er ist Endokrinologe und hatte das mit der “Kalorie eben nicht gleich die Kalorie” gesagt, falls Ihr euch erinnert. Dennis Ballwieser hat mit ihm gesprochen und sie haben sich getroffen in einem Museum in London. Also, deshalb klingt das auch so’n bisshen anders hallig. Das Gespräch ist komplett auf englisch, wenn ihr wollt könnt ihr es aber auf deutsch nachlesen. Wir verlinken euch dazu unseren Apotheken Umschau Artikel in den Shownotes.

SPRECHER ‘ne Dosis Wissen – der Podcast für Health Professionals.

DR. LAURA WEISENBURGER Und damit guten Morgen und willkommen bei ‘ne Dosis Wissen. Heute ist Montag, der 25. August 2025 und mein Name ist Laura Weisenburger. Von mir hört ihr heute aber gar nicht so viel, sondern eben mehr von Dennis und Robert Lustig. Und dabei jetzt viel Spaß.

SPRECHER Ein Podcast von gesundheit-hören und Apotheken Umschau Pro.

(Interview)

DR. DENNIS BALLWIESER Dr. Robert Lustig from California, San Francisco, thank you for sitting in with me to talk about food, nutrition, health and obesity.

DR. ROBERT LUSTIG My pleasure, Dennis.

DR. DENNIS BALLWIESER Thank you for being here. I was thinking, you grew up in New York City in the 1960s, so in your childhood I imagined a lot of pizza, hamburgers, hot dogs, peanut butter and jelly sandwiches. Is there a comfort food from your childhood?

DR. ROBERT LUSTIG So, first of all, my mother worked two jobs. So I was a latchkey kid and so I had to heat up a lot of Swanson TV dinners.

DR. DENNIS BALLWIESER So those are the microwavable?

DR. ROBERT LUSTIG There was no such thing as a microwave.

DR. DENNIS BALLWIESER Not in the 1960s. Of course.

DR. ROBERT LUSTIG But things like Salisbury steak or fried chicken, there was quite a bit of that. In terms of comfort food, probably just the usual ice cream. And my mother had a weight issue. She vacillated up and down, and we put a big sticker on the refrigerator. Put brain in motion before moving mouth. I remember that from my childhood very well.

DR. DENNIS BALLWIESER Okay, so 30 years or so forward, what did you tell your kids when they grew up? What comfort food would look like? What was the Lustig household in San Francisco?

DR. ROBERT LUSTIG So, the good news is that I kind of put two and two together in terms of the food and the chronic disease / obesity epidemic before my kids got too far along. And so, my wife and I did a pretty clean sweep of the house. I'm not going to tell you there were no treats, there were, I'm not going tell you, there was no such thing as chocolate, there was, but, you know, we, shall we say, we were, we were much more careful. Prior to 2001, my wife and I probably ate about two to three times a week, because we both had jobs, and we were tired at the end of the day, a nd you know, we did what pretty much everyone in America did. Once we had kids, you know we had to be a little bit more circumspect about them, and so we cut back significantly. And it was around that same time that I started realising- the food was the problem. And so we started cooking at home pretty much routinely. We would eat out maybe once a month. And so my kids grew up in a very different household than I did, you know... 40 years earlier.

DR. DENNIS BALLWIESER A very different household than most American kids grow up, right?

DR. ROBERT LUSTIG Pretty much, yeah, at that point. In San Francisco, we have a good, shall we say, food tradition. We understand what real food is in California, and we have access to it. So I wouldn't say that it was that different for my kids than, say, other kids in the neighbourhood. But it was certainly different from what I was used to.

DR. DENNIS BALLWIESER How far does your Deformation Professionelle go? Are you able to enjoy a food or a meal without thinking about nutrition?

DR. ROBERT LUSTIG Oh yeah, absolutely. But I have to sort of give way to it, and it has to be a good meal. It has to something special.

DR. DENNIS BALLWIESER When you're travelling, travelling makes eating healthy and eating real food especially hard, and you're travelling a lot. How do you deal with that?

DR. ROBERT LUSTIG You keep your eyes open. It's not easy at all. The best thing to do is focus on meat, fish, and vegetables. That's kind of what you can do. And of course, you know, restaurant food is usually heavy-handed, starch, carbohydrate, and other, you now, and sweets. So you have to be very careful. But one rule I have is when I'm on vacation. No dessert.

DR. DENNIS BALLWIESER That's the easy one. So you just said that prior to 2001, you lead a pretty normal life food-wise in your household. What made you switch your focus? You were almost three decades into your career before you took a turn to food and nutrition.

DR. ROBERT LUSTIG So I got into the obesity business late. I started my career in paediatric endocrinology in the mid-80s looking at sex differentiation of the brain, you know, hormones affected the brain. Why boys were boys and girls were girls from the neck up. But I had this idea about what might be the cause of obesity and I didn't have the opportunity initially to be able to act on it until I moved to St. Jude Children's in Memphis, Tennessee, in 1995. And at that point I was presented with a cadre of about 40 children who had brain tumours who survived their tumour due to either the surgery or the radiation or the chemotherapy, only to become massively obese. And so I was charged with trying to help these children.

DR. DENNIS BALLWIESER Obesity wise, that was the question posed at you.

DR. ROBERT LUSTIG And these were kids who were 350, 400 pounds, enormous. And they had lost all interest in life. They basically sat on the couch, ate Doritos and slept. And the parents would come to me complaining, saying, this is double jeopardy. My kids survived the tumour only to succumb to the therapy. And I had to do something about it. As a neuroendocrinologist, I knew there was a medical literature about lesioning the area of the brain that controls energy balance, called the hypothalamus, and I knew that you could stop the obesity from that lesion by cutting the nerve that leads from the brain to the pancreas, called the vagus nerve. They got to me would stop that process, but I'm not a surgeon. And I had to do something that would do the same thing as that they got it. Without a surgery. And it turned out there was a drug that could limit insulin release from the pancreas. And so we tried that in these children and low and behold, they started losing weight. But they didn't just lose weight. That was amazing enough. Because these were kids who basically gained weight on 500 calories a day. It had been shown 30 years prior that, you know, these kids would rather store it than burn it.

DR. DENNIS BALLWIESER So the metabolism completely changed.

DR. ROBERT LUSTIG Exactly.

DR. DENNIS BALLWIESER Burning the calories was not an option. Storing everything was what the body did.

DR. ROBERT LUSTIG Right and we had learned in the meantime about this hormone that your fat cells make that goes to your brain called leptin that was discovered in 1994 and so I hypothesised that these kids could not see their leptins because that area of the brain was damaged. So the question is what is downstream of leptine and turns out that vagus nerve was downstream of that. And so could I impact? On the output of that vagus nerve. Well, we gave this drug that suppressed insulin. And sure enough, the patients lost weight, but more importantly, they started exercising spontaneously.

DR. DENNIS BALLWIESER Without you intervening.

DR. ROBERT LUSTIG I didn't tell them to do anything, they just did. The first patient, it was remarkable, this was patient number one, a patient with pineal germinoma, 220 pounds, 100 kilos. And I told the mother, look, I've never used this drug before, I know what it does, but this is new for me, I want to hear from you in a week. She calls me up in five days screaming on the phone. Lusting, something's happening. Oh my god, you know, adverse event, you know, shut down the study, go to jail, I'm waiting for the other shoe to drop. What, what, what happened? She says, well, normally we would go to Taco Bell and she would eat five tacos and an Enchirito and she'd still be hungry. We just went to Taco Bel and she ate two tacos and she was full. And she just vacuumed the house.

DR. DENNIS BALLWIESER Eating changed and exercise changed both.

DR. ROBERT LUSTIG And then we did eight patients and the same thing happened. I said, this is really remarkable. So we did a double blind placebo control trial in a new set of patients. And we built in a quality of life questionnaire with physical activity as part of it. And sure enough, when we did the analysis on this double blind, placebo control, trial, yes, the weight went down, but the physical activity went up. And so what this showed me was that the two behaviours that we associate with obesity, the gluttony and the sloth, are actually biochemically determined. And that really changed the way I viewed the entire question of obesity, and it also changed how I treated my patients. I turned my obesity clinic into an insulin reduction clinic. Get the insulin down any way you can because insulin is driving energy into fat cells

DR. DENNIS BALLWIESER But help me out here, because I am a massively obese male in his 40s, I didn't have a brain tumour. What is happening inside my brain that makes me obese? I grew obese as a kid in my teenage years. What happened there without the brain tumour?

DR. ROBERT LUSTIG There are two different insulin problems. One is called insulin hypersecretion, and that's the one that this drug treats, this hypothalamic obesity problem. And by the way, 20% of normal obese adults have this same problem, and also respond to this drug the same way.

DR. DENNIS BALLWIESER Without being obese.

DR. ROBERT LUSTIG They're obese, but they don't, without a brain tumour.

DR. ROBERT LUSTIG But that means that 80% don't respond and don't get better. And so the question is what's going on with the 80% because that's where the real quote money is. What I can say is that those patients are not insulin hypersecretors. They're not releasing too much insulin from the pancreas. Those patients are insulin resistant, insulin resistant. Now, what is that? So when you're insulin resistant your pancrease makes insulin but then your liver does not respond to it very well. And so your pancreates has to make more to make the liver do its job. And that raises insulin levels all over the body. And because the fat cell is still insulin sensitive, that high insulin drives energy into fat. So the only way to fix that problem is to fix the problem at the level of the liver. So then you have to know, okay, what's going on at the levels of the livers? Well, we have this new disease that started being... Recognised in the early 1990s, which we called non-alcoholic fatty liver disease, or NAFLD, which now has a new name called MASLD, metabolic associated steatotic liver disease. I hate that name.

DR. DENNIS BALLWIESER And what it is for patients is your doctor does an ultrasound of your liver and tells you there's fat in your liver that doesn't belong there.

DR. ROBERT LUSTIG That's right, exactly right. And what that fat is doing is it's interfering with the ability of insulin to do its job. And so you have to clear the fat.

DR. DENNIS BALLWIESER That makes me more obese faster because my liver doesn't do its job.

DR. ROBERT LUSTIG Correct. Okay, so you have to attack the liver where the problem is. So then the question became, okay, if that's the case, what's the cause of the liver fat and how do we get rid of it? And that's when, shall we say, the you-know-what hit the fan. In 2006, I was asked by the National Institutes of Health to give a talk at their 100th anniversary of the National Institute of Environmental Health Sciences. And the question posed to me was, what did I think was the most important environmental To the obesity epidemic.

DR. DENNIS BALLWIESER What did you say?

DR. ROBERT LUSTIG I thought a lot about it, and they thought I was going to come up with some chemical like bisphenol A or PFAS, things that definitely are obesogenic.

DR. DENNIS BALLWIESER They are not the main ingredients of our food, right?

DR. ROBERT LUSTIG Exactly. They're there, but they weren't, shall we say, the primary driver, and they weren't there at the beginning of the obesity epidemic, they came in sort of later. And so I sat down and I said, all right, look, I'm a paediatrician. Children today get two diseases they never got before. Type 2 diabetes and fatty liver disease.

DR. DENNIS BALLWIESER Early in their life.

DR. ROBERT LUSTIG Early in their life, at age five. This is not normal. They are the canaries in the coal mine. They are being exposed to something now that they weren't before that is driving this phenomenon. And type 2 diabetes and fatty liver disease are the manifestations of it, and obesity comes along with it. That I was sure of. The question was, what is that something? Those two diseases, type 2 diabetes and fatty liver disease, they used to be, when I entered medical school, they used be the diseases of alcohol. But kids don't drink alcohol. At least five year olds don't.

DR. DENNIS BALLWIESER Absolutely.

DR. ROBERT LUSTIG So, I opened up my biochemistry textbook from 1974, and I opened it to the alcohol page, and I looked at the metabolism of alcohol, and said, yeah, okay, I remember that. And then I turned the page, and there was this other molecule called fructose, which is the sweet molecule in sugar, in table sugar. So, table sugar sucrose is two molecules, one glucose. And the other fructose. Now glucose is not very sweet. Glucose is what's in molasses. You don't see people chugging molasses, yeah it might be good in a cookie but you know not too much, okay. Corn syrup, you know like you know, like Tate and Lyle's corn syrup. You don't see people abusing that but fructos is very sweet and people do abuse that.

DR. DENNIS BALLWIESER And then we are at high fructose carcinoma.

DR. ROBERT LUSTIG And now we have high fructose corn syrup on top of that. Not so much in Europe, a little bit, much more in America, Japan, Canada, a few other places. Bottom line, that fructous molecule is metabolised in the liver just like alcohol. Does the same thing, and causes the same diseases as alcohol, including type two diabetes and fatty liver disease. And so I put this talk together for the NIH, saying I think that the driver of the metabolic syndrome, obesity, fatty liver disease, epidemic.... Is the consumption of sugar, especially in youth.

DR. DENNIS BALLWIESER Wasn't it a little bit late in the late 19th, late 20th century, so that the disease showed itself very late because fructose and sugar has been introduced into our food way earlier than that.

DR. ROBERT LUSTIG And, in fact, we've seen the onset of chronic metabolic diseases go slowly initially for just that reason. Example, the first documentation of a change in metabolic status in the human population due to environmental issues was 1924.

DR. DENNIS BALLWIESER What happened in 1924?

DR. ROBERT LUSTIG Haven Emerson, Commissioner of Health of New York City, published a paper showing a seven-fold increase in the incidence of diabetes in the New York city population.

DR. DENNIS BALLWIESER That was grown-ups, not children.

DR. ROBERT LUSTIG Right, in grown ups. The point was that when you compared the increase in frequency of type 2 diabetes and the increase in sugar consumption. If you compare the increase of type two diabetes in the general population and the increased sugar consumption, they parallel each other beautifully. And, of course, things just got worse from there.

DR. DENNIS BALLWIESER And then something must have happened policy-wise in terms of how we use sugar in producing our food, right?

DR. ROBERT LUSTIG No, not really. All that happened was that in the 1930s in America we had two phenomena go on at the same time. We had the depression and we had the Dust Bowl.

DR. ROBERT LUSTIG So, first of all, food became inordinately expensive. And second of all we had a destitute population in the American Southwest. And we had to get food from the Midwest and the Northeast, where it was being produced, down to the American South West where it could be consumed. The problem is, if you took real food and put them on railroad cars and ship them, by the time they would arrive there, it would go rancid. That's when processing started. That's where we started turning wheat into 10-pound bags of flour and shipping them by railroad car and baking it up on site. We solved a catastrophe, a nutritional catastrophe, based on this concept of processing. And then came World War II, and we needed it yet again. And you know the K ration, you know 12,000 calories in a little tin box that soldiers could carry into battle. You couldn't do that without food processing. So food processing became a matter of survival for the United States all the way through World War II. And so, various policies that encouraged food processing were placed... You know, into the American zeitgeist.

DR. DENNIS BALLWIESER And that changed how food was being made after World War II as well.

DR. ROBERT LUSTIG Well, so after World War II, we didn't need those policies, but the food industry figured out they can make money at this. So they doubled down. And so it only got worse. And so we ended up, you know, generating processed food across the board. And then it started entering, you now, grocery stores and became sort of diet staples. And that's when breakfast cereal started appearing on the shelves. And that sort of hit in the mid-60s. And then, of course, we had the advent of high fructose corn syrup in 1975, which wasn't added to the food supply until really 1980. The reason was because Hurricane Allen destroyed the entire Caribbean sugar crop, and so America decided we needed a homegrown sweetener. And so that's when high frructose corn syrup sort of took over.

DR. DENNIS BALLWIESER And that has never gone away, so it's still a year and still put in the process.

DR. ROBERT LUSTIG And here we are.

DR. DENNIS BALLWIESER But the learned perception, which I learned in medical school as well and which is basically how everybody sees obese people, is it's a lifestyle choice. You are a sedentary person, you're lacking the willpower to eat differently and to exercise more, and you're saying that is not the point.

DR. ROBERT LUSTIG That is, it's not even true, okay, it is not even true.

DR. DENNIS BALLWIESER This is important for obese people, I think.

DR. ROBERT LUSTIG Oh, absolutely. Absolutely. And this is the reason I wrote my first book, Fat Chance, because obese people needed to understand it's not their fault. The behaviour is really biochemistry. I can take anyone and make them eat more if I make them insulin resistant. If I raise their insulin in any way, shape, or form, they will eat more. If I take a thin person. And stick an IV in and inject them with insulin, they will eat more. So the question is what's causing the increase in insulin? Well, the answer is this phenomenon, hepatic or liver insulin resistance. So how do you clear that? How do you fix that? And the answer if you get the fat out of the liver, you become insulin sensitive and then you don't want to eat more

DR. DENNIS BALLWIESER How do you get the fat out of the liver?

DR. ROBERT LUSTIG Ah. For that you need to come to my clinic and pay some money. No, I'm only kidding. Only kidding. The fact is that the primary driver of the insulin resistance is the fat in the liver and the primary drive of the fat in liver is the sugar in the diet.

DR. DENNIS BALLWIESER So you take the sugar out of the...

DR. ROBERT LUSTIG Take the sugar out of the diet and the fat goes away. And we proved it. Well, sort of.

DR. DENNIS BALLWIESER How do I do it in the supermarket? It seems to be.

DR. ROBERT LUSTIG It seems to be a problem there. Indeed. So we did a study at UCSF, a 43 children out of our obesity clinic, Latino and African-American, all with metabolic syndrome, all high-sugar consumers. And what we did was we studied them on their home diet. And then, for the next nine days, we catered their meals. No added sugar. We took the percent calories as added sugar from 28% of their calories down to 10% of the calories.

DR. DENNIS BALLWIESER So you cap the calories that the children were fed.

DR. ROBERT LUSTIG We gave them the same number that they were eating all along, because the goal here was not weight loss. The goal was to actually maintain their weight. Because if the patients lost weight, the naysayers, the critics would say, well, of course the kids got better, they lost weight. We needed them to stay the same weight, or even gain weight for that matter.

DR. DENNIS BALLWIESER Or change the metabolism.

DR. ROBERT LUSTIG But change the composition of the diet. So, we took their percent calories as added sugar from 28 down to 10%. Now, if you do that, you're gonna lose 335 to 400 calories per day out of the day. And if you did that for 10 days, you might lose weight. We didn't want them to lose weight, so we had to give them more food. And we had replace those 335-400 calories with something that was equicolor. That was the same number of calories just not sugar. We gave them the starches. In other words, in the vernacular, we took the pastries out, we put the bagels in. We took the sweetened yoghourt out, and we put in the baked potato chips. We took out the chicken teriyaki, and put the turkey hot dogs in. So we didn't give them good food, we gave them crappy food. We gave them processed food. We gave kids food. Food kids would eat.

DR. DENNIS BALLWIESER It is possible with processed food to eat healthier than...

DR. ROBERT LUSTIG Oh absolutely, yes and we'll talk about that in a little bit as to what the food industry could do to fix this problem just to that point. In any case these kids ate the same number of calories because they did not lose weight for 10 days and then we studied them again 10 days later. Every aspect of their metabolic health got better. Their blood glucose went down by five points, their blood pressure went down five points. They had a lactate level at baseline. And you as a physician know that if you have a lactating level at base line, you're sick. Because that means your mitochondria are not working. So you were either post exercise or you have a mitochondrial encephalomyopathy which is like really bad for you, or you've cancer.

DR. DENNIS BALLWIESER We have to explain, I think, what mitochondria are doing for our bodies.

DR. ROBERT LUSTIG Indeed. We will get there. Bottom line, every aspect of their metabolic health improved and the reason was because we took the offending agent out of their diet. And even though they ate the same number of calories, even though they didn't lose weight, they became metabolically healthier. Every aspect of the metabolism, their lipids got better And guess what? They're fatty liver disappeared.

DR. DENNIS BALLWIESER So what this means in terms of me standing in the supermarket aisle is I have to exchange foods that are high in fructose with either processed or non-processed foods that are low in fructose. Is it as simple as that?

DR. ROBERT LUSTIG Well, that's a good start. I'm not going to tell you it's that simple, because everyone's different, okay? And there are other reasons for fatty liver, like alcohol, okay, but the fact of the matter is that's where it starts. Our food has basically been contaminated by the added sugar that the food industry has put into it. Now, if you think that sugar is just calories, then you would say... Why sugar, maybe it's fat, or maybe it is protein, or maybe is something else. It's just the amount you eat. If you believe that every calorie is the same, that a calorie is a calorie. I think that my work and the reason I have written books and the reasons I have published papers and the reasoning I'm sitting with you right now discussing this is because I think I've made it painfully obvious. That a calorie is not a calorie.

DR. DENNIS BALLWIESER What does it mean for me as an eating human being?

DR. ROBERT LUSTIG The food industry would have you believe that all calories are the same.

DR. DENNIS BALLWIESER They're saying I'm responsible for the mix of my food.

DR. ROBERT LUSTIG And indeed, if a calorie were a calorie, that would be true, if that were the case. And they want you to believe that because if a calories is a calorie then there is no individual food that is problematic which gives them licence to be able to purvey anything they want, and it becomes your personal responsibility. To watch your own diet. This assuages their culpability for the composition of the food that they provide on the shelf. If a calorie were a calorie, but it's not.

DR. DENNIS BALLWIESER And what does that mean?

DR. ROBERT LUSTIG Let's talk about what a calorie is first. So a calorie's not a unit of biology. It's a unit physics. That's right. It is how much energy do you have to apply to one gramme of water to raise the temperature one degree centigrade. That's a calorie. A unit of physics. Now, in 1902, a scientist by the name of Wilbur Atwater (?) discovered- If you place fat in a bomb calorimeter and blow it up to smithereens, it will release energy and it will released nine calories per gramme of fat. If you put protein into the bomb calorimiter and you explode it to smitherenes, it will releases four calories per grammes of protein. And for carbohydrate, four calories per gramme carbohydrate.

DR. DENNIS BALLWIESER Carbohydrate would be sugar.

DR. ROBERT LUSTIG Sugar would be within carbohydrate, yes. So based on that experiment, the assumption was, and Atwater's assumption, and everybody's assumption since that time, is that because fat is more energy dense, therefore fat must be more fattening.

DR. DENNIS BALLWIESER That brought the fat-reduced yoghourts.

DR. ROBERT LUSTIG Yes, absolutely. The point is that that assumption has never been documented. That has never proven, not once, never. In fact, we now have data to show that that was a big lie.

DR. DENNIS BALLWIESER But a lot of dietary recommendations are still based on that assumption, right?

DR. ROBERT LUSTIG To this day, by many dietetic associations around the country, around the world, still believe that. And the question is, why do they believe that? And the reason is because if you blow it up in a bomb calorimeter, you can do the math on the calories.

DR. DENNIS BALLWIESER What happens if you blow it up in the human body?

DR. ROBERT LUSTIG You don't blow it up in the human body. You metabolise it in these little organelles inside each of your cells called mitochondria. And mitochondria are not bomb calorimeters.

DR. DENNIS BALLWIESER So they use the energy in a different way.

DR. ROBERT LUSTIG Calories generate heat. Mitochondria generate a chemical called ATP.

DR. DENNIS BALLWIESER That's the energy that we are burning, right?

DR. ROBERT LUSTIG The energy of ourselves. It is essential. It's the goal of cells to basically produce the ATP they need to survive, thrive, and do their job. And without ATP, they're dead. And so are you. Just that simple. The question is, does ATP generation... Correlate with calories, and the answer is not even close. They are not the same. Example. If you take a certain amount of energy and explode it in a bomb calorimeter and you take that same amount of energy and put it in cells that have mitochondria, 40% of the energy will go off as heat from the cells. 60% will be turned into ATP as opposed to 100% which will be generated as heat in the bomb calorimeters. So those are not the same, okay? On the other hand... If you change what that food is in terms of its matrix, like for instance, adding fibre, like real food, turns out you didn't absorb 25 to 30% of those calories. They never even made it into your bloodstream. They stayed in your intestine and the microbiome chewed it up. And so you didn't even get it, even though they passed your lips, even though they registered as a calorie here at your lips at your intestine, they didn't.

DR. DENNIS BALLWIESER But the nutrition effects on my supermarket label tell me different.

DR. ROBERT LUSTIG Well, indeed, and that's part of the problem. So calories are not calories if they came with fibre. Calories are not calorie if they are protein, because protein getting converted to energy, actually you have to invest energy to be able to turn that protein into energy. So there's a net loss of calories.

DR. DENNIS BALLWIESER Why nuts for example are better for you to eat as a snack than anything else

DR. ROBERT LUSTIG Absolutely.

DR. DENNIS BALLWIESER Because they are high in protein and you metabolise only a certain percentage of it.

DR. ROBERT LUSTIG Even high in fat, but they're still better for you and they don't generate the insulin response that a carbohydrate does. And it's that insulin response that actually drives the energy into fat. And what we've learned is that because of that leptin problem that we talked about at the beginning. That driving of energy into that fat cell should generate a leptin response, but if your brain can't see it because of the high insulin and insulin blocks leptins signalling at the brain, then your brain doesn't know you ate, and so you eat more. So insulin is the bad guy in the story, both in terms of driving energy into fat peripherally to drive the weight gain. And also to block the effect of leptin at the brain in order to keep you eating. So if you look from the outside, it looks like gluttony and sloth because you're not burning the energy and you're eating more, but that's the result of the biochemical process of the leptin resistance, which was actually because of the insulin.

DR. DENNIS BALLWIESER So that makes me think about me standing in the supermarket aisle again because now my psychology kicks in. I know all that. I consider myself a little bit educated on the topic.

DR. ROBERT LUSTIG Well, you better be. You are physician.

DR. DENNIS BALLWIESER Why am I having such a hard time to change my habits?

DR. ROBERT LUSTIG So, number one, there's this thing called ultra-processed food addiction. About 20% of the population has it. It's actually easy to determine who's who. You just ask one question and say, oh, I have a horrible sweet tooth. That's sugar addiction to improve another voice. And sugar addiction and ultra-processed food addiction are basically the same thing because that's where the sugar is, is in the ultra- processed food. Because if the sugar weren't in the ultraprocessed food, you wouldn't eat it. Just that simple. Why are some people addicted and some people are not addicted? We do not know. Why are people addicted to alcohol and others are not? Why are they addicted to nicotine and others aren't? We don't know. To this day, we have looked for the genetics of addiction and have not found it. So this is a question mark, and I'm not going to tell you I know the answer to that. But I do know that there is a phenomenon called ultra-processed food addiction, of which sugar is the primary driver, and we have the data to demonstrate that. We are actually petitioning the World Health Organisation to create a new diagnosis for ultra- processed food addictions right now.

DR. DENNIS BALLWIESER What do we have to change in order to change this addiction in the patients?

DR. ROBERT LUSTIG It has to change the food.

DR. DENNIS BALLWIESER How can we do that?

DR. ROBERT LUSTIG Because the food industry has to come along and the problem is they don't want to come along because sugar is their gravy train it's their hook it's the thing that changed food company's annual profit margin from 1% per year to 5% per year because of the addition of sugar that started in the early 80s and has continued to the present day.

DR. DENNIS BALLWIESER Wouldn't things like the UK shoulder tags work if they were applied in more countries?

DR. ROBERT LUSTIG Yes, so we have data now to demonstrate that there are first of all 28 countries that have instituted a sugar tax, which is the low-hanging fruit in terms of regulation. I'm actually giving a talk on this here in London next week on exactly this topic.

DR. DENNIS BALLWIESER So Great Britain is leaning by example.

DR. ROBERT LUSTIG Yes, definitely, and Mexico and several other countries. In America, six cities have adopted a soda tax, local soda tax not sugar tax, San Francisco being one of them. And so we actually have the five-year data on whether or not, not only did it change consumption, but did it change health? And the answer is absolutely it did, in both cases. It reduced consumption and it improved health. In fact, since the advent of the San Francisco soda tax, which was instituted in 2018, gestational diabetes mellitus, which is now a huge problem, 14% of all pregnancies. While they're being pregnant, has been reduced by 77% since the advent of the San Francisco soda tax as an example. So we have the data to demonstrate both changes in consumption and changes in efficacy. This actually conforms to the iron law of public health, which states that reducing availability of an offending agent will reduce consumption, which will reduce health harms. So a soda tax is a way, not the only way, but a way to basically alter societal behaviour on the basis of price. There are other ways too, but ultimately the concept that we have to have some sort of societal intervention to go along with the personal intervention has been necessary for all addictive substances. Think about it. What we have that's addictive. Tobacco. We have personal intervention. We have societal intervention. Okay. Rehab laws. Okay? For alcohol, we have personal intervention, we have societal intervention, opioids, we have personal internvention and we have societal intervention. Ultra-processed food is addictive in the same way. It's toxic and addictive, it's ubiquitous, and it has negative impacts on society. It meets all the criteria for societal intervention, yet we have nothing for it, other than the few places that have instituted a sugar tax.

DR. DENNIS BALLWIESER So there is a new player in town for a few years now, people turn to it, it's a new class of medication, the GLP-1 agonists. What are you thinking about those class of drugs? Because for the first time really for obesity there seems to be a medical solution on the horizon.

DR. ROBERT LUSTIG I wouldn't call it a solution. I would call it a Band-Aid.

DR. ROBERT LUSTIG It's not fixing the problem, it's band-aiding the problem. Let me explain why and how. I wear three hats, okay? I wear the clinician hat, I wear the scientist hat, and I wear the public health advocate slash policy wonk hat, okay. Let me take each of those in turn. When I wear my clinician hat I'm glad they're here because they work and I'm not saying they don't work, okay, semaglutide 16% mean weight loss, terzepatide 20% mean weight loss that is not chicken feed, that's real. There are patients who have failed virtually every other modality, who have comorbidities like type 2 diabetes, heart disease, etc., and they need these or they will die.

DR. DENNIS BALLWIESER So it's an option for them to take them.

DR. ROBERT LUSTIG Absolutely, and I am for that, so I am not against these medications. New had- My scientist had, why do these medications work? They work in two places. First place they work is here at the brain. And what they seem to do is reduce the noise, the food noise, the addiction. That food noise is the addiction.

DR. DENNIS BALLWIESER You are treating the addiction of the patient.

DR. ROBERT LUSTIG That's right. And so it's making it much easier for people to be able to walk away from that ice cream or that chocolate cake.

DR. DENNIS BALLWIESER So it makes it easier to have the right choice made in the supermarket eye.

DR. ROBERT LUSTIG And that sounds very good. Having said that, the way it's working is by reducing the reward signal. Whenever you reduce the reward, you're changing people's internal emotions. You're basically changing their relationship to the world. You are inducing a form of depression.

DR. DENNIS BALLWIESER So it's basically a psychiatric drug.

DR. ROBERT LUSTIG To some extent, and psychiatrists are starting to use it as such, and they're starting to use it for all forms of addiction, not just food addiction, but in fact, alcohol addiction, opioid addiction, and so this may end up being very, very important as a modality for trying to undo addiction. The problem is we've seen this movie before. In 2006, there There is a drug available in Europe, never in America, in Europe. Called Romanabant, okay, trade name Accomplia. And this was an endocannabinoid antagonist. This was the anti-marijuana drug. This was anti-munchies drug. Yeah, as soon as the drug was approved, there were 21 suicides within two months and Sanofi had to pull the drug from the market.

DR. DENNIS BALLWIESER But we are not seeing that effect in that manifestation right now with the GLP-1 agonist, right?

DR. ROBERT LUSTIG We're seeing the change in mood. We are not seeing suicides. So we have to monitor this much more.

DR. DENNIS BALLWIESER You have to be careful and you have to take that into account, it has to be monitored by physicians who know what they are doing.

DR. ROBERT LUSTIG Exactly right.

DR. DENNIS BALLWIESER And there seems to be a bit of a problem there in some countries at least.

DR. ROBERT LUSTIG Well, some places are compounding, and we don't even know what they're taking. And yes, there are non-physician providers that are dispensing this. It's highly problematic, to say the least. So that's one place it works. The second place it work is on the GI tract, on the intestine, and the stomach in particular. And what it does is it delays the gastric emptying, delays the stomach from moving the food through to the intestine. And that's why you don't want to eat because your stomach's still full, right? Well, you know, that is a good reason to not want to to eat, but unfortunately it's also a good reason for getting bloating and distention and vomiting and pancreatitis and most importantly gastroparesis, stomach turns to stone, okay? Now if you get pancreatitus or gastroparsis, you're not gonna be very happy.

DR. DENNIS BALLWIESER Yeah, absolutely. It's painfull.

DR. ROBERT LUSTIG And you're going to have a whole lot of side effects and some of those are going to land you in the hospital and there have already been a few deaths from gastroparesis and there is actually a class action lawsuit in America over gastroparsis because it's not even on the label that this can occur. 3.4% of all patients who take a GLP-1 agonist end up gastroparesis. This is a problem. That's a big issue. In addition, when you look at the weight loss that occurs, and it's not insignificant, it's real, it turns out to be equal amounts of fat and muscle. Now you want to lose the fat, but you don't want to loose the muscle. Losing muscle actually means earlier demise. Muscle is important for longevity. And if you're losing equal amounts of fat muscle, that's not necessarily in your best interest. Do you know something else that causes equal amounts of loss of fat and muscle? Starvation and that's how it works because you're starving. Yeah, this is not good. Okay, all right, and Also only one-third of patients who take these drugs actually respond.

DR. DENNIS BALLWIESER Have the effect...

DR. ROBERT LUSTIG So the companies actually report out only the responders, not the intent to treat. And that's a problem. And one third of the patients who go on within a year are not on them anymore. And they gain all their weight back plus some.

DR. DENNIS BALLWIESER That's the main question, what happens if I have to stop taking it, because it's all out of pocket expense for all the patients.

DR. ROBERT LUSTIG Exactly, and all the weight comes rushing back because you haven't solved the problem you've band-aided it.

DR. DENNIS BALLWIESER That's not a long-term policy that societies might...

DR. ROBERT LUSTIG And it only keeps working as long as you keep taking it which is great for the company, but not great for you. And then finally, let me put my last hat on- The policy hat. Now these drugs do work 16% weight loss for semaglutide, 20% for terzapotide. That's not small. It's real. Okay in America if everyone in America who qualified for GLP-1 analogue. Got it. That would be $2.1 trillion U.S. Dollars to the healthcare system. Right now our healthcare system is $4.1 billion. That will be a 50% surcharge over what we're currently paying and we can't afford that because Medicare will be broke by the year 2029 as it is, notwithstanding this addition. Conversely, that's for a 16 to 20% weight Conversely... If we just got added sugar in our diet, down to rational USD A guidelines...

DR. DENNIS BALLWIESER By changing policy for food manufacturing.

DR. ROBERT LUSTIG Correct!

DR. ROBERT LUSTIG By getting sugar consumption down to 12 teaspoons of added sugar per day, which is still plenty, but about half as much as we're currently consuming, we would see a 29% weight loss, so better weight loss and save $3.0 trillion with no side effects. So which makes more sense to you?

DR. DENNIS BALLWIESER Us to the, I think, biggest elephant in the room. We are always talking about the individual and what the individual could do or should do or has to do. We're not talking about what society needs to do with the environment around the person in order to make it possible.

DR. ROBERT LUSTIG Well, the reason for that is because the food industry doesn't want to engage in that discussion because that's bad for them. But it doesn't have to be. They want you to believe a calorie is a calorie because then what's different about their food than anybody else's food. So they assuage their culpability. So they are married wedded to the notion that a calorie's a calorie except a calorie it's not a calorie. And it matters what you consume because not all calories are equal. But the minute you agree to that, the minute that you say yes to that that means you have to start reformulating policy. And they don't want to do that because this is their gravy train. This is where they get on in terms of their profits. But it doesn't have to be.

DR. DENNIS BALLWIESER And this seems to be the fight politicians and physicians have to pick, right?

DR. ROBERT LUSTIG Let me tell you about a little experiment that's going on in the Middle East. This is a company, a ultra-processed food company, it's like the Nestle of the Middle East, Kuwaiti Danish Dairy Company, KDD. They make flavoured milks, they make frozen yoghourt, they makes ice cream. Confectionary tomato sauce. High sugar and all processed, okay? Because you can't grow any food in Kuwait. You can't raise any cows in Kuwait. So all of this is manufactured, ultra-processed from ingredients that are imported from elsewhere. Kuwait has an 18% diabetes rate and an 80% obesity rate. The chief executive officer and founder of the company, Sir Mohammed Jafar, who's a Kuwaiti national but actually raised in the UK, knighted Sir Mohammed. How many Sir Mohammeds you know?

DR. DENNIS BALLWIESER Not many.

DR. ROBERT LUSTIG He came to me in 2020 during the pandemic and said, we understand that we are part of the problem. We want to be part of a solution. Can you help us re-engineer our entire portfolio to be metabolically healthy?

DR. DENNIS BALLWIESER Is it possible?

DR. ROBERT LUSTIG It is not only possible, they are already doing it. It's taken five years, three years of analysis and two years of implementation, but they have turned over 10% of their portfolio. We have tested those products to actually demonstrate their metabolic health. And so these are on the market in Kuwait today. Now the reason we could do that is because KDD is privately held. The only owners are Sir Mohammed and his sister.

DR. DENNIS BALLWIESER So he can decide or they can decide.

DR. ROBERT LUSTIG They can take the long view. Now, the problem is most other food companies are not privately held. They have quarterly reports. And stakeholders and stockholders that have to be placated, and it's all about the profit. It's all the next quarter's profit. If that's your goal, you can never fix the problem. So we need government to help intervene at this level to be able to get companies all on board together. And this can be done. It was done right here in the UK for salt back in 2003. The Blair government convened the entire UK food establishment in a secret meeting in 2003 and said hypertension and stroke are up 40 percent in the UK because of the sodium content of ultra-processed food. So everyone in this room is going to play by the same rules and everyone is going reduce the sodium contents of each one of their products by 10 percent per over a course of three years to a reduction of 30% and most importantly we are going to watch we're going to regulate. Everyone will play on the same playing field so that there's no competitive disadvantage and most importantly, we're not going to tell the public.

DR. DENNIS BALLWIESER Which might be a problem if you're not going to tell the public what you're doing, right?

DR. ROBERT LUSTIG Well, they did it. And guess what.

DR. DENNIS BALLWIESER It worked?

DR. ROBERT LUSTIG It worked and hypertension and stroke in the UK fell by 40% and a paper in the British Medical Journal in 2011 documented the change. So, public health intervention is doable.

DR. DENNIS BALLWIESER The rationale being always, if everybody has to do it, there's only one loser, in the one picture being the salt industry and the other picture being in the sugar industry, but all the other companies would still benefit from what they are selling.

DR. ROBERT LUSTIG Indeed. And the fact of the matter is the sugar industry knows because they're getting out of it. Look at Tate and Lyle. They know they've got a problem.

DR. DENNIS BALLWIESER It seems to be a little bit like we used to talk of meat and tabaco bevor.

DR. ROBERT LUSTIG Absolutely. It's the same thing all over again.

DR. DENNIS BALLWIESER And it makes sense that that would be the case. But we're still having a hard time. I think we should have learned something from the tobacco discussions.

DR. ROBERT LUSTIG Well, except that the tobacco, except the tobacco industry controlled the food industry. Look at Philip Morris, you know, and Altria, you know, they owned Kraft and General Foods and R.J. Reynolds owned Nabisco and they brought their addictive portfolio to the food industry back in the 1980s to 2000s and it hasn't been undone. So in fact, the food the street knows what it's doing.

DR. DENNIS BALLWIESER So here's my last question. What gives you hope for the next years, nutrition-wise?

DR. ROBERT LUSTIG [So a very good question. What gives me hope is that the public is starting to recognise the problem. Three out of four people in America today want to cut their sugar consumption. And this is not my data. This is actually generated by the food industry itself. And we're seeing the food industry moving toward non-nutritive sweeteners such as allulose or tagatose or stevia or erythritol or monk fruit, etc. They're trying to get away from what brung them, as it were, number one. Number two, there's a market now for better food, okay, and you know. We have a non-profit, for instance, in the Bay Area that is getting real food into K-12 in public schools in the United States.

DR. DENNIS BALLWIESER So where children have to eat.

DR. ROBERT LUSTIG Exactly. So this is what gives me hope- We can change the construct. And this is not crazy. We've done this before. Think of it this way, Dennis. In the last 30 years, we have seen four cultural tectonic shifts around the world. And here are the four. Bicycle helmets and seatbelts, smoking in public places, drunk driving. Condoms and bathrooms. Four cultural tectonic shifts. 30 years ago, if a legislator stood up in a state house or Congress or Parliament or the Duma or anywhere else in the world and proposed legislation for any one of those four, it would have gotten laughed right out of town. Nanny state, liberty interest, get out of my kitchen, get outta my bathroom, get out of my car. Today they're all facts alike. We have new things to bellyache about, like vaccines, but those four are settled signs. No one's bellyaching about any of those. And if you, as a father, pull your car out of the driveway and you haven't buckled your seatbelt, your kids will scream at you. They will tell you. How'd that happen? And why'd it take 30 years? We taught the children. The children grew up, and they aboded, and the naysayers are dead. That's why this is a generational shift. And all of these cultural tectonic shifts are generational, and this is why. We're seeing this change in food now. Okay, we're about, I would say, 10 years into it. So it's coming. It's unstoppable, and this also gives me hope.

DR. DENNIS BALLWIESER Thank you so very much for your insights, your thoughts, and your personal history with food and nutrition, and thanks for being here with us, Dr. Robert Lustig.

DR. ROBERT LUSTIG My pleasure. Thank you.

DR. LAURA WEISENBURGER Das war das komplette Gespräch. Wie schon gesagt, in den Shownotes verlinken wir euch nochmal den Artikel auf deutsch dazu, wenn ihr da nochmal Dinge nachlesen möchtet. Morgen geht es weiter mit dem Interview mit Professorin Marion Nestle und ab dem 01.09., da kommt dann wieder ganz normal unser werktägliches Gesundheitsupdate in kompakten 10 Minuten. Bis dann!

SPRECHER Ein Podcast von gesundheit-hören und Apotheken Umschau Pro.