Sugar!

Sugar!

October 24, 2019 0 By Jose Scott


MARCIA DAY CHILDRESS:
Good afternoon. I’d like to welcome you to
today’s Medical Center Hour. I’m Marcia Day Childress from
the Center for Biomedical Ethics and Humanities,
which brings you these weekly medical
center hours. We’re delighted to see
all of you here today. Our program is titled “Sugar!” with an exclamation mark. This title, short and
sweet, is intended to cover a lot of territory. Yes, sugar is this
intensely sweet stuff for which humans are said to
have evolved a dedicated tooth. But it’s much more. Sugars of many types
fuel life’s engines at micro and macro levels. Sugar is a driver micro
and macro economically. Its production and
trade having shaped nations and colonial empires,
its lack or surfeit figuring in nutritional policy,
dietary guidelines, and defining household and
social economies alike. So why do Americans eat so
much sugar and to what effect? Sugar gives us energy. It pleases our palates, sweetens
our tea and our chocolate, and so much more. It ends our meals
on a high note. It sparkles at our
celebratory occasions. And why does this matter
especially to personal health and also to medicine
and public health? The answers aren’t hard, and
yet they are complicated. Sugar rots our teeth. It adds calories to our diet. It ups our blood glucose
and hemoglobin A1C numbers. It’s one culprit in the
present public health epidemics of obesity and type
2 diabetes in 21st century America. And all these facets of
sugars crystalline presence in our lives raise a
bewildering array of questions. So this Medical
Center Hour offers dual perspectives
on the sweet stuff and what it does to us
and in us and on a few of its many meanings in
history and for health. We are happy to welcome
today UVA assistant professor of history David Singerman
and UVA physician associate professor of medicine
Jennifer Kirby. Together– and they didn’t
know each other really before this presentation
invitation presented itself, so it’s been an
interesting dynamic as they have tangled with
their respective expertises in shaping this
dual presentation. Together they’ll
introduce us to sugar in what may be some
new and eye opening ways as they look at sugars
impact on the body past and present, historically,
socially, physiologically, nutritionally. And I’ll just mention
this is the last of our history of the
health sciences lectures for this academic year. We gratefully acknowledge
our ongoing partnership with historical collections
in the Health Sciences Library for these history
minded Medical Center Hours that also look acutely
at things that matter today. So now without
further ado, “Sugar!” David. [APPLAUSE] DAVID SINGERMAN: This OK? People can hear me? Thanks everybody for coming. Thanks to Marcia and Jenn
for making this possible. I’m looking forward
to this conversation that we’re going to have. So my talk today is called
What Story Does Sugar Tell? We all know that modern
Americans eat a lot of sugar, but as I was doing the
research for this actually– and I mostly study
the 19th century– I wanted to know
how much is a lot. And it turns out that
a lot is really a lot. So you can see here we consume
about 175 pounds per person. Amazingly as Jenn
will talk about, that’s down from its
peak in the mid 90s. And you can see at the
bottom of the chart that refined sugar has
gone down a little bit from its mid century peak
of 100 pounds per person or so, and that’s
been more than made up for by high frequency– high
fructose corn syrup, excuse me, corn sweetener. And then just at the top are the
tasty ones like honey and maple syrup. Compared to the
rest of the world, we are a huge outlier, about
three times the global average it turns out. So one question is where
does all of that sugar go? So here’s one answer. [VIDEO PLAYBACK] [MUSIC PLAYING] Just watch– – If I give you these four here. – Right. – What I would like you to do– DAVID SINGERMAN:
This is an iced bun. – –a diagonal line about
3/4 of the way through. DAVID SINGERMAN: It’s got icing
on it, and sugar in the dough. – Diagonal line– – Below the icing? – Yes. – Open up the fingers and pipe
in a generous amount of cream. – You’ve made a few
of these in your time? – I’ve done a few
of these in my time. – Finish by piping a line of– DAVID SINGERMAN: Jam over the
cream on the ice sugar bun. – –and top with a dusting– DAVID SINGERMAN:
And then some sugar. – There you go, some
classic ice buns, filled with cream
and a line of jam. [END PLAYBACK] DAVID SINGERMAN: I can’t even
imagine eating one of those. OK. So that’s where the sugar goes. And after today, I
suspect that if any of you are fans of Bake Off, or
any of its affiliated shows, you’ll still want to watch them. I love the show. But you won’t watch it in
quite the same way anymore. So that’s one explanation
for where the sugar goes. It’s in everything. When I tried to cut out
refined sugar for a month, the thing that surprised me
the most was that it was in– bags of Rold Gold pretzels
have sugar in them. So I couldn’t have those. So that’s where it goes. Where does it come from is what
I want to talk about today. The trouble is that you
actually can’t often ask the sugar itself. So, sugar in the raw,
which many of you will know from
Starbucks and stuff, says it’s natural cane
sugar from Hawaii. It’s actually no
longer from Hawaii. This packet is a
couple of years old. The last Hawaiian
sugar mill closed down about two years ago. These other packets tell
us a little bit more. The one in the middle has
a vaguely tropical vibe. And it says it’s fair trade,
and it says it’s cane sugar, so you know that it’s
from the sugar cane. But the one on the right,
which any of you who have been to a conference or
anything like that will know, because it’s the generic Cisco
corporation sugar packet, just says sugar on it. It could be from anywhere. And so this idea that
sugar is from anywhere, and is all the same, is what
I want to talk about today. We can contrast that to coffee. If you think about your
normal hipster coffee shop, there are these big, artsy
black-and-white photos of sugar farmers somewhere,
holding the beans in their hands. Sugar is single origin,
but single-origin sugar doesn’t really exist. A couple of years ago, I
was on vacation in Italy and at a roadside cafe. I picked up a
little sugar packet, and it said on it, “Every
coffee tells a story.” And it’s impossible to
imagine that for sugar. We just don’t have
that interest in it, or we don’t think
about it that way. And the question is why. So, this is one of my
very favorite books about sugar in the Caribbean
called Cuban Counterpoint Tobacco and Sugar, by the
great Cuban anthropologist and sociologist Fernando
Ortiz, from 1940. And what he did in this book was
he analyzed the history of Cuba through the histories of
these two commodities. Tobacco, he says, is
very individualistic, and sugar is very
collectivized and corporatized, and it was the vehicle
for foreign domination of his country. And there’s a line in this
book that I think really speaks to the question
of where sugar comes from and why we don’t know. He says, “Sugar comes into
this world without a last name, like a slave.” And so that relationship between
sugar status and its history, and what’s visible and what’s
invisible, is really important. Because one way to think about
the modern history of sugar– and as I tried to compress
the modern history of sugar into a 20-minute
presentation for today, what kept coming back to me was
that it’s a constant struggle between, on the one
hand, efforts to expose sugar’s origins, and
on the other hand, efforts to keep those
origins hidden– for purposes of profit, mostly. And so there’s three themes that
I think will bring this out. The first is violence,
the second is state power, and the third is
ecological damage. So first, violence. Sugar cane isn’t
native to the Americas. It comes originally
from somewhere in the region of South Asia. But it spread over the
centuries to the Mediterranean. And this is a somewhat
fanciful description, from 16th-century Sicily,
of a small sugar factory. At this point, sugar
is very expensive. It was a drug, and
it was a luxury. It was not the kind
of thing that you could put in your coffee. But because it was so
pricey and so valuable, it was something that, if you
could grow it on large scale, you could make a lot
of money out of it. That was the kind of
thinking at this– around 1500 or so. And so, actually,
Columbus himself– not a generic, oh, Columbus
like the Spanish conquistadors, and the invasion– Columbus himself brought
it on his first voyage to the Americas. And his son actually set up a
sugar plantation on Hispaniola for himself. But mostly, in the New
World, sugar cultivation was on a small scale for
the first century and a half after the Colombian exchange. And it’s important– at some
point, early on in every talk that I give about sugar, I
have to explain how it’s made. And so I’m going to try
to do that in 30 seconds. The basic features of making
sugar from the sugar cane are that you grow the sugar
cane, and then you cut it down. That’s happening on
the right, there. And then, all the
way on the left, you crush the sugar cane
to release the juice. And then, in the foreground,
you boil the syrup slowly, while removing impurities
to grow crystals out of it. Or crystallize the sugar
out of the solution. This is obviously, again, not
drawn from life in the way that we now would expect
illustrations to be. It’s more demonstrative. And, again, from
about 1600 or so. But by the middle of the 1600s,
this scale of sugar production really started to change. And a series of technological
innovations began in Brazil, and spread across the Caribbean
from island to island. And I’ll talk about that
spreading in a moment, also. These innovations
of various kinds made it possible to have much
larger plantations than before, that earn really vast profits by
selling sugar to a wider market than had ever been possible. In 1650 for instance,
Barbados, which you can see a
contemporary map of here, was the most advanced
sugar-producing country on Earth. And you can see,
down at the bottom– you can’t really read it,
but all of those names are the list of sugar
planters who have established plantations along the coast. It was hugely profitable. Really unheard-of
wealth accumulated by private citizens. Because it wasn’t
aristocrats who were leaving England,
in this case, and coming to Barbados to
start a sugar plantation. It was various kinds of
ne’er-do-wells, or whatever. Commoners, essentially,
who would come and make their fortunes in Barbados. If any of you were
here about a year ago for James Delbourgo’s
talk on his biography of Hans Sloane, the founder
of the British Museum, you’ll have learned that
Sloane’s fortune, which enabled him to
purchase and acquire the collection from around
the world of curiosities and oddities that then
became the foundation of the British
Museum, was derived from his wife’s fortune made
as a sugar-planting family in Jamaica. And if any of you have
seen 12 Years a Slave, you’ll have some sense
of the conditions of what sugar slavery were like. The film begins
where Solomon Northup spent much of his time,
which is on a sugar plantation in Louisiana. [MUSIC – “MY LORD SUNSHINE”] And sugar plantations were
known as the most vicious, brutal working conditions
in the Americas. They had high death
rates, even compared with the tobacco
plantations that we’re more familiar with here
in mainland North America. And statistics vary, but
about 80% of Africans brought to the
Americas as slaves went to work on sugar plantations. So mostly not,
again, to Virginia and the east coast
of North America, but to the Caribbean and Brazil. So, as part of this
technological revolution that I talked about,
mills became much bigger– you can see here– so they
could just absorb more sugar. The boiling houses where
slaves stood and worked over these cauldrons became
increasingly proto-factories. Hot, and humid, and noisy. Part of the suffering came
from the tempo of the work, because once the sugar
cane is cut down, the juice starts to ferment. And so to maximize the profit,
and the profitable crystals that you could get out of it,
mills ran around the clock during the harvest. Day and night. One thing that sugar planters
didn’t really like to admit, though, was that they actually
didn’t know how to make sugar. The people who knew how to
make sugar were the slaves. So one planter from Antigua
wrote in the 18th century that, quote, “The
art of boiling sugar is generally least understood,
either by overseers or their masters,
but trusted wholly to the skill of negro-boilers.” And actually, especially skilled
slaves, called sugar masters, would test the syrup by
dipping their fingers in, by stretching it between their
fingers, and listening to it crackle to know when it
was ready to be transferred from one cauldron to another. But at the same time that
they actually didn’t know, really, what was going
on, these planters were presenting all these new
technologies and inventions to the Royal Society in London,
and other learned societies in Europe, to get the
scientific prestige that came with being the
discoverer of something, or the inventor of something. But the truth is, actually, that
mostly the enslaved people were the ones who first of all came
up with these innovations, and second of all
spread them from island to island in the Caribbean,
as I mentioned earlier. But this was kept invisible
because, for reasons you can imagine, racial
theories and gentlemanly codes made it unthinkable
to credit these slaves with their accomplishments. So after their production of
sugar on these plantations, it was packed into massive
barrels, called hogsheads– that you can see here– which weighed hundreds if
not thousands of pounds, and was then loaded
onto ships to be sent to Europe, where consumers
could put it into their tea and into their coffee. As Britain in particular
went from a farming nation into a factory nation, sugar’s
energy, as Marshall was saying, made the industrial
workers’ diet possible. That’s the famous argument that
the anthropologist Sidney Mintz makes in this book, which I–
it’s in the additional readings and I encourage you
all to have a look at. And you can see this
growth of this argument about the growth
of the sugar market in The Great British Bake Off. How many people have
watched the show, or have seen some episodes? OK, yeah. Enough of you. So you’ll know that
there’s two kinds of things that they bake on the show. There’s the aristocratic
patisserie tradition, and those often have
some segment in a castle. And then there’s the
working-class cake, and pastry, and bun tradition,
like the one that we saw. So the violence that I’ve
talked about was hidden, but there were voices
speaking out against it, and one image in particular
came to symbolize the inhumanity of sugar slavery. So on sugar
plantations, as I said, the cane got fed into rollers. And so slaves
would feed the cane into these spinning
rollers that were powered by animals, or water, or
wind, or sometimes by humans, as you can see in this picture. And what would happen is
that limbs and clothing would get snagged. So a kind of integral part of
every sugar mill, in addition to what you might think of as
the machinery of the mill– a crucial part of it was
also a hatchet, or a machete, that was always
kept close at hand to chop off an arm or limb
before a whole person got sucked in. Now, for the planter, this
was as much about– more, in fact– about saving
the expensive equipment as it was about saving a life. And the amputee slave became
a common rhetorical symbol for abolitionists. So in Voltaire’s
Candide, they’re wandering in the Caribbean,
and they encountered a slave who’s missing a hand and a leg. And they ask him how he’s come
to be injured in this way, and he says that he lost
his hand in the mill, in the way that I’ve
described, and his leg was cut off by his master
when he tried to escape. And what he tells
the protagonist is, this is what it costs you
to eat sugar in Europe. Or here’s a British
political cartoon from the late 1700s attacking
the barbarities of the West Indies. A member of parliament
had told a story about a slave who got submerged
as punishment in boiling sugar, for a few quarters of
an hour, and so that’s what happened in this cartoon. And in the upper right, you
can see an amputated arm that’s been nailed to the wall. So abolitionists called for
a boycott of sugar and rum from the West Indies. This pamphlet said, “If
we purchase the commodity we participate in the crime.” And he calculated that in
every pound of sugar used, we consume two ounces
of human flesh. And instead, people
were encouraged to use sugar from other
parts of the world, mostly what we
now know as India, where sugar was not
produced by slaves. Not under great conditions,
but not by slaves. And so those who participated
in the boycott were encouraged to advertise their
opposition by using sugar bowls like this, which says,
“East India sugar not made by slaves.” So you were encouraged to
serve this to your guests and make them feel
uncomfortable, and participate in
the boycott with you. So in the late 1700s, about
this period that abolitionism is beginning in England, the
most valuable and profitable sugar colony on Earth
was the French island of Saint-Domingue. But in 1791, the slaves
of Saint-Domingue, as hopefully you
all know, rose up and threw off European empires. First the French, and then
the British and Spanish, who tried to reconquer it. And so this brings us
to my second topic, which is state power. So the French empire
under Napoleon found itself suddenly cut off
from the main source of sugar, plus it was being blockaded
by the British Navy, and so it had limited
access to foreign sugar from other places. And so Napoleon,
pretty desperate, turned to a new
invention in hopes of satisfying the
domestic appetite that had been generated by centuries
of cheaper and cheaper sugar. And this invention was
called the sugar beet. I call it an invention
because that is really what it was like. I always think of it as
Frankenstein’s monster, because it was sort
of jolted to life in this Middle-European lab
at around the same time. But the real point here
is that nobody had ever gotten the substance
called sugar from anything other than sugar cane before. Nor would anybody
have even thought to. Sugar was what came
out of the sugar cane, and that’s just the way it was. But this German
apothecary painstakingly crystallized a substance from
his local humble vegetable, and concluded through
microscopic observation and what he called it “strong,
sweet taste,” that it was– I’m quoting here–
“not merely a substance approaching sugar but, in fact,
a true and perfect sugar which has complete resemblance with
the familiar sugar extracted from the cane.” So this is exactly
what Napoleon needed. He funded and subsidized
beet sugar factories throughout his European
empire, but, as you might be able to tell,
the idea of beet sugar didn’t make a lot of
sense at the time, and so it was widely mocked. And here’s a cartoon
that I really like. This is from 1811. And so on the left, you see the
nurse telling Napoleon’s son to suck on the beet because
“your father says it’s sugar,” and on the right is
Napoleon trying to squeeze a beet into his coffee. And you know it’s Napoleon
cause he has a big N on his hat. So this government-funded and
government-subsidized beet sugar spurred the development
of huge new machines that would transform
the way sugar was made everywhere, not just
in the temperate climates where beets were grown. Things like steam-powered mills,
for grinding much more sugar cane more quickly,
vacuum-sealed chambers, where it could be
boiled more efficiently, and centrifuges that
dried tons of sugar, like in huge salad
spinners, basically. And so older sugar
mills and boiling houses that looked like this gave
way to giant industrialized factories across the Caribbean. And there’s a
complex relationship with industrialization
in the end of slavery that we can talk
about in the Q&A. And as a result of this
mechanization, sugar got even cheaper and
more widely available. And you can see here
that it goes from– in 1830, this is– US per capita consumption
goes from 10 pounds in 1830 all the way up to
80 pounds in 1910. So fortunately, despite
the high statistics I showed at the beginning,
it hasn’t continued, or we’d be eating a
ton of sugar a person. What happened as
a result of this, incidentally, was that
there was a tariff on imported sugar,
which was designed to protect American refiners. And because sugar
imports were spiking, this tariff became a huge
source of government revenue. So, as Marshall reminded
me earlier, in the 1880s a sixth of the federal
government’s whole budget came from sugar taxes. So sugar was important
in that way to the state, and it was also important
because sugar refiners became the biggest employers
in American cities, and as a result
of both of these, they became very
politically powerful and had presidents and
senators in their pocket. So here is a political
cartoon from 1894 satirizing the political
power of a monopoly called the Sugar Trust, which
controlled about 90% of American sugar production. And what’s happening here
is that the Sugar Trust, in a chariot shaped
like a barrel, is pulling President
Cleveland in chains after passing a
favorable tariff bill. Favorable to it, that is. As you can tell from this,
sugar refiners weren’t popular. They were accused, for instance,
of adulterating their sugar with all sorts of
poisonous substances. The caption here says,
“Look before you eat– and see if you can discover
any adulterated food,” and he’s got this device
into a sugar bowl. In response, refiners drummed
up fears against foreign sugar. Not slavery this time, or
not only slavery this time, but other fears
about contamination. So this is a contemporaneous
ad from the late 19th century for refiners, but it poses
a kind of infomercial. This sugar mite, which you
can see blown up on the left, was this horrible insect that
caused itching and disease. There were supposed to
be tens of thousands in every pound of raw
sugar, and there was a widespread scare about this. It is totally made up,
as far as I can tell. I was a little bit concerned,
when I read about it and I couldn’t find
any site of sort of contemporary or
present-day information one way or the other,
and then I found a letter from one sugar chemist
to another in the 1920s. One of them says, remember that
sugar mite scare of the 1890s? That was so funny. I can’t believe
anybody fell for that. But so this all
sort of testifies to the political power of sugar. And one last piece
of evidence for that is if we look at a map of where,
in the early 20th century, cane sugar came from,
for the United States. So there’s Cuba, and
there’s Puerto Rico, and there’s the Philippines. And you may notice
that all of these are places that America happened
to seize in a war with Spain from 1898. And the other place is Hawaii,
where a coup by sugar planters was supported by the US
government, which then went on to annex it as a territory. So the way to think
about sugar this period, or for the hundreds
of years before it, is similar to the
oil industry now. Immense geopolitical
significance. And this brings me to my
third and final topic, which is ecological damage. And I’ll be considering
ecology a little broadly. I’ll put it that way. So boiling all of that
sugar takes a lot of fuel. And one result of this is that– sorry, back up for a second. You recall earlier that I said
that these kind of technologies of sugar plantations spread
from Brazil through islands of the Caribbean. One reason that
kept happening is that islands would get rapidly
deforested, by the need to cut down all of the
trees to burn for fuel. And that’s another reason that
these new technologies became adapted in the 19th century. Because the cost of
wood fuel became so high that it was necessary
to develop new machines that could burn
the dry cane stocks as fuel, which weren’t as
efficient or as readily available. It took a little
bit of manipulation to dry them out enough so that
they could work in a boiler. But wood fuel was
so expensive, and it was too expensive
to ship coal there, that these new machines
became not only profitable but necessary. And these huge sugar
factories of the late 19th and into the 20th century
that I’ve talked about were, as you can just see,
devastating to the landscape. What’s visible here is that
clear-cutting from miles around. But also, the infrastructure
for these factories was incredibly damaging. You can see the
railroad lines going in, and those railroad ties
came from somewhere. So here is a section
of the forest in Cuba that’s been felled
for railroad ties. And if you look at a
historical map of the sugar industry in an island
like Cuba, which over the 19th and
early 20th centuries increasingly became the leading
sugar producer of the world, it goes from pretty much the
western half of the island eastward, into newer, and newer,
and newer virgin territories, because of this demand for fuel. It was also just
dirty and polluting, as many Victorian and early
20th-century factories were. And you can see that here– not
just the railroads, but just the grime and smoke that’s
covering the environment. And this is captured
really well, I think, in a painting
from a Puerto Rican artist from the early 1900s called El
genio del ingenio, which means, roughly, the spirit
of the sugar factory, or the temper of
the sugar factory. And this painting
captures obviously the violence against
human beings, but also the clear-cutting
of the landscape, and the pollution of the
air, and even the pollution of the soil itself in
the blood that’s pooling. And so I said I was going to
treat ecology a little bit more broadly, and so I’ll
ask the question of what did sugar due to its eaters. Well, let’s ask the
sugar industry in 1950. This is a pamphlet, produced by
Quaker Sugar of Pennsylvania, and the message of this pamphlet
is, sugar is good for you. And if it says, under where
it says sugar is a food, it notes that if
you ate only sugar, you could get all of your
calories for $30 a year. Under “these goodies
are good for you,” there’s something
called jam cake pudding, which maybe will be
on the next season of Bake Off. And– here’s a blown up bit–
it says, “the high dietary value of sugar is
universally recognized by scientists and physicians.” Jen can confirm this. It is vitally necessary
for you to have a goodly amount of
sugar in your diet, and important
medical authorities tell us that for
health and enjoyment, there is no
substitute for sugar. So this is bad enough. Recently, scholars
have found something that we might consider
more insidious, which is that internal sugar industry
documents from the 1950s and ’60s show that
sugar companies modeled their political strategy
on tobacco, funding and publicizing studies that
supported sugar and attacked other dietary components. Meanwhile, labor in the sugar
industry in the United States itself, well into the 20th
century, was still horrible. In the 1940s, the US Sugar
Corporation in Florida was actually prosecuted by
the United States government for slavery. Prosecutions for slavery
are kind of rare, but this corporation
was prosecuted for it. And as late as the
1990s, this company was still bringing in
so-called guest workers from the West Indies
and forcing them to work in what were essentially
plantation conditions. After exposés like this
one in The New Yorker, which is also in the show notes,
the company rapidly mechanized its harvesting. But the environmental
damage still goes on. The companies that make up
so-called Big Sugar in Florida dump fertilizer-rich
runoff into Lake Okeechobee and into the Everglades. Florida’s algae bloom,
in the fall and summer, was at least partly blamed on
this politically influential industry. And this is the weirdest
thing I found in my research for this talk– it’s from an article
in Vanity Fair– that in the Starr
Report, Ken Starr mentions that when Monica
Lewinsky and Bill Clinton are talking at one point,
he gets a call from one of these politically powerful
Florida sugar growers, and says he has
to take the call. The current story that’s
become interesting to me, as well, is the battle between
these Florida growers, who are rebranding themselves
as organic, and sugar beet farmers in the US West, who have
been using GMO crops for quite a while. And because of consumers’
desires for organic produce, rather than GMO produce, the
price of these two commodities has actually diverged. So those are the
three themes that I think capture this
tension between the hidden and the exposed in
the history of sugar. And I want to end on a note
that I think captures the way that, despite its very
sordid history, as I’ve tried to outline here, the
sugar industry actually has had quite good PR. We don’t think of it as
being a very popular industry these days, but they’ve been
good at publicizing themselves for about 500 years. So thank you very much and
I will leave you with this. [MUSIC PLAYING] Sorry, I shouldn’t
just drop that– this is a commercial
from the year 1950 from the Tate &
Lyle sugar company, which was under threat
of nationalization. So they produced
this infomercial explaining that, in
fact, it’s important. You can stop it. JENNIFER KIRBY:
So if it’s OK, I’m going to wander a little
bit, because I don’t like to be tied behind a stand here. But thank you, David
I actually loved it, and I think it sets up
a really nice discussion about the involvement
of sugar in disease. And so when Marsha initially
reached out to us, she said, Jen, I really need to have
you come and tell everybody that sugar is so bad,
and it’s the cause of diabetes and obesity. And I was like, OK, well,
but we don’t know that. And she said, oh, well, then
you need to tell them that, too. And so I put this slide
in as the question. What is the role of
sugar in disease? And I think David
has nicely laid out– we have a sordid
history with sugar. And I think we continue to have
a sordid present with sugar. And so I’m going to
elucidate a little of that, and hopefully muddy the waters
a little more about the role of sugar in our diet and the
role of sugar in disease. And so, I think it’s
important to define sugar. So I know there’s probably
a lot of non-medical people in the audience, but we
throw these terms around. Sugars, carbs. Everybody’s low-carb, keto. So sugar, which
is defined really as table sugar, which is what
has been refined from both the sugar cane and
the sugar beet– they really were sucrose,
which is table sugar. And it’s what’s called a
disaccharide, meaning two sugars, glucose and fructose. Sugar is found everywhere. It’s in our bananas. It’s in our apples. It’s in many of our vegetables. It is just part of our diet. And so there is, I
don’t think, anything inherently bad about it. I think a lot of what
we’re talking about is a definition of something
called added sugars. So the extra that we
put into our diets is really where, I
think, gives us pause. So like what David had talked
about, our consumption of sugar has increased
significantly, mostly around what he was talking
about– these added sugars. High fructose corn syrup, corn
syrup, corn sugar sweeteners, and just refined sugars. And so this was derived
from a really great article in The Washington
Post, and I encourage you guys to take a look at it,
it’s got a nice little graphic. I probably should have
just used the graphic because it was nicer than mine. But really, we talk about
sugars and sweeteners, and this really sets
up a definition. So partway down we’ve
got our refined sugars. These are fructose and glucose. Remember, sucrose, which
is just table sugar, is that disaccharide of
glucose and fructose. We’ve got high
fructose corn syrup, and this is kind of a
contentious part of our diet in that, in the 1970s, under
Nixon, corn subsidies were invented to help
the local US farmer, and one of the things
that they produce is high fructose corn syrup. The name is a bit of a misnomer
because it’s not all fructose. There’s a couple different
varieties of high fructose corn syrup. There’s 55 and 42,
and all that refers to is that it’s about 55%
fructose versus 42% fructose. The remaining of it is glucose. So it’s still both
fructose and glucose. But you can also see
these sweetness factors. So maple syrup and,
oddly enough, honey is a little less sweet
than table sugar, although it’s got a
lot of sucrose in it. Stevia– anybody heard
of stevia, right? It’s the “natural sweetener.” So it comes from a plant and
it’s actually really sweet. It doesn’t have calories. So there’s this appeal– we’ve got a natural sweetener
that is not caloric, doesn’t add to our waistline,
and we’ll circle back on that. There are the sugar alcohols. These are things that you see
in your sugar-free candies. So the story I like to tell
is, yeah, these are great. They’re sweet, roughly about the
same sweetness as table sugar. They’re not calorie-free,
they’re sugar-free. And if you eat a lot of
it, you get diarrhea. So that’s a negative. So the story I tell is my poor
patient, who had diabetes, and he was desperately
trying to quit smoking. And so he found that these
sugar-free peppermints were the way that he kept
himself from smoking. The problem was, he was
going through a bag a day. So one, he had a
lot of diarrhea. And two, he also
was gaining weight, because they’re not
calorically deficient. So just keep an
eye out on those. So the sugar alcohols are not
necessarily a replacement. And then the artificial
sweeteners– and these have really come under fire
for a lot of different reasons. But you can see the significant
difference is their sweetness factor. Hugely sweet. You have receptors
on your tongue– you have taste receptors,
actually, in your gut as well– that detect this sweetness. And one of the things
that has been thought is that when you have
this level of sweetness, you actually bypass your brain’s
ability to feel satiated, or to feel full. And so there’s an
argument, on one hand, that adding these sweeteners
bypasses your body’s ability to be like, I’m good, I
had my two lumps of sugar in my coffee, and I’m OK,
versus my Splenda, and I’m like, oh, I’m going to
go eat that muffin. So that’s debatable and
that data is very mixed. But the other piece of this also
is, because they’re artificial, there’s been a lot of
concerns around things like risk for cancer, and
heart disease, et cetera. And again, these are
difficult studies to do and we’ll talk a
little bit about that. So, sugar is everywhere. When we talk about sucrose,
it’s in a lot of our foods. So this is the breakdown
of what’s in a banana. So when I have
patients who are like, I really shouldn’t be eating
fruit, because sugar is bad. And I’m like, well maybe not. So part of this is
the context of what you’re getting with
your sugar, and I think that that actually is a
very important piece of this. So bananas have
potassium and magnesium. They’re a good source of
some vitamin C and B6. But they also have fiber, and we
know that high fiber diets are actually really important for
reducing our risk of heart disease and diabetes. And so in this context,
these aren’t bad sugars. And the other piece about
this– so the sugars here is about half-and-half
glucose and fructose. The other part
about this, too, is that it’s really hard to
tell what the sugars are when you read labels. How many of you
guys look at labels when you’re buying foods? Yeah. We’re all talking, you’ve
got to look at the label, how much sugar is in there? So can you tell, if you didn’t
know that this was a banana– if I just showed you
this label, and I said, how many added sugars
are in this food product? You can’t tell. So this could be a yogurt. It’s not, but it
could be a yogurt. And you wouldn’t
be able to tell. So yogurt– there’s a lot
of added sugars to foods that are otherwise
probably pretty healthy. And so this is a
challenge, and I think one that the industry
is wrestling around, is should we be putting labels
for added sugars on things? So let’s talk about
the nitty-gritty. How is sugar related
to the things that we are concerned about? So we know that
there is an epidemic of diabetes in this country. We talk about 31 million
patients with diabetes. A lot of them don’t know
that they have diabetes. What’s even scarier is the
nearly 90 million people with prediabetes. About 85% of those patients
don’t know that they have it. So, I have prediabetes. It pains me to say it. It’s a genetic thing. My mom has diabetes, and
so I’ve assessed my risk and I have prediabetes. But there it is. And so this is not uncommon. And so there’s a lot
of patients out there that you wouldn’t think of
having risk for diabetes who potentially do. That doesn’t necessarily
mean that I’m guaranteed to get
diabetes, but I have an increased risk of
things like heart disease, and lifetime risk of diabetes. About 9 and 1/2% of our
population in Virginia have diabetes,
concentrated a lot in our southwestern
part of our state, as many of you guys
are aware, as well as on the eastern shore. Often socioeconomic places. This is a great graph
from Lancet last year. It was a little brief article
and this is NHANES data. So NHANES is a great source
of epidemiologic data that we get as physicians,
and epidemiologists, and public health folks looking
at the prevalence of obesity in the United States over time. And what you’ll see– there is a very clear
inflection point. Right about 1975. Our rates of obesity in this
country started going up. And this is independent
of sex, age, race– every population is affected. And one of the key pieces from
this article that I really liked is that clearly
there’s something going on, epidemiologically. You can see the inflection. The problem is, we
don’t know what it is. There’s been lots of postulates
about what’s driving this. But one of the key
aspects, I will say– and I love there’s
a quote in this line that they basically say, is– this has not been due
to a collective failure of willpower. This is not about us
losing our ability to say no to food
and exercise more. So one of my roles
and one of the hats is that I’m an obesity
medicine specialist. And I think one of the biggest
things that I fight against is weight bias. And this idea is, you just need
to eat less and exercise more. And that is really, really,
a very inaccurate picture of overweight and
obesity in the world. So what’s changed? What’s driving that
inflection point? And there’s been a lot of
proposed drivers of this. Many of you guys
have been around through the low-fat craze. So the American Heart
Association was– and Big Sugar was in part
driving some of this– but it was like, oh fat’s bad. Whoa, fat’s bad. And so everybody went down to
removing the fat of their diet. And so how many of
you guys remember like the SnackWell’s and
the 100-calorie snack packs, low-fat? So what did they
replace it with? Carbs. Sugar. Absolutely. And so there’s a
lot of suggestion that that low-fat craze drove
the obesity epidemic, which is also driving diabetes. And the problem
is, is that’s not been consistent
with the evidence, meaning that you see this
little dip that, in the slides that David showed you of
our consumption of sugars and carbs– and it’s actually dipped. And yet obesity has
not slowed down, and we’re continuing
to see rises, particularly in the
higher ends of BMI. I mentioned the corn subsidies
from the 1970s and the increase in high fructose corn syrup. So it’s interesting from
a biochemistry standpoint. Fructose is
processed differently in the body than glucose. Remember sucrose,
or table sugar, is a disaccharide of
glucose and fructose. And there’s a lot of fructose
out in our diets as well, and fructose is metabolically
different in the way it’s processed. But how we understand
that has been really difficult to tease out. So I remember sitting in my
first-year biochemistry class in medical school, and I was
like, oh, this is how it works. There’s Krebs, and there’s a
TCA cycle, and there’s glucose, and there’s where fructose goes. There’s some overlap, we get a
little lipid stuff over here, and we get a little
ATP over here. Well, it turns out it’s
actually a little more complex than that. And so it’s very difficult,
because of those overlaps between these how these
things are metabolized, is that you can actually
get some fructose that gets converted to glucose. And then you kind of
have to figure out, well, where did that fructose go? Is it in glucose? Or is it going to the lipids? And so it’s challenging. But one of the things
that is out there is that it’s the high
fructose corn syrup. But again, some of the
data is not very clear, and also our consumption
of some of these have gone down over time,
and yet our obesity rates are going up. Our diabetes rates are going up. Our fatty liver disease
rates are going up. We’ve certainly
seen an increase in processed and
ultra-processed foods. So ultra-processed meaning
is that everything is kind of chopped up, and then brought
back together to make some semblance of a food item. Chicken nuggets are a
great example of that. And so it resembles chicken,
protein, meat, but not really. There’s also been– so the
sugar industry was also big, and actually the sugar-sweetened
beverage industry has really been pushing this
idea– well, it’s just really because
we’re all sitting around. You can drink your Coke as long
as you go out and have a run. It’s OK. Which is not true. So as I say to my patients,
and I say when I’m lecturing to students, and
residents, and Fellows, and everybody else is that
you cannot outrun your fork. Exercise does not
drive weight loss. It is really good for
everybody, and everybody should be out there doing
it, but it is really not the key to weight loss. But, I will say, when you
are an avid exerciser– so, anybody who’s seen
ex-athletes, who have spent many,
many years doing a lot of physical
activity, and then they go from being a
professional athlete to retirement? Often associated
with weight gain. So that reduction
in physical activity absolutely does have
an impact on weight, but it’s not the sole cause. All right, so as we mentioned,
sugar intake over time has increased. It plateaued or reduced during
the Depression and World War II, which we knew because–
for reasons of production. It peaks again in
the 1990s, but it’s been reducing since 1996 in
terms of our refined sugar intake, as well as things like
that high fructose corn syrup. So I don’t think it completely
explains our difficulty with obesity and
diabetes in this country. I will say that
probably the data around sugar-sweetened
beverages is probably the best in terms of associative
data, in terms of weight gain. So we know that
sugar-sweetened beverages are really problematic. And, interestingly enough,
they’re widely available. And we talk a lot about things
like food swamps and food deserts, where you
can have access– so I love the quote from the
sugar industry is, you can you can eat all of
your calories as sugar and not spend more
than $30 in a year. Yeah, but that’s probably
not a great idea. You get off on any exit, on
any highway in this country, and what do you find? Highly over-processed,
ultra-processed foods that’s really calorically dense,
got a lot of added sugar in it. You cannot find an
apple to save your life. I love– I was at a
hockey game with my son up in northern Virginia, and I
went to get gas at the Sheetz next to the rink. And I was walking through
to get a cup of coffee, and I was just perusing. Wow. Is there really any food there? So when you talk
about nutrition, there was really nothing
of nutritive value, minus the few
really brown bananas and Red Delicious apples that
were at the front of the store. Which, if anybody knows, Red
Delicious is really a misnomer. They’re not the most
red, delicious of apples. I digress. All right, so
there’s been a swing. There’s been a swing from, oh,
fat is bad, to, oh my gosh, sugar is bad. And the real question is,
is it inherently dangerous? Is sugar in itself toxic? Is it causing problems? Or is it that we are having
an increased intake of it, and the increased intake
is causing weight gain? Which it does. If you eat all of your
calories as sugar, you’re going to be in trouble,
because you’re not really just going to eat all
those calories of sugar. You’re going to
eat more than that. But is the sugar itself
inherently dangerous? And that data is really,
really hard to get at, and it’s not there. It’s not like sugar
doesn’t cause diabetes, sugar doesn’t cause
heart disease. We just don’t have it. So is it a yea or a nay? I can’t say, because we
just don’t have the data. But the American
Heart Association has really tried
hard to say, well, we want to come up with
good recommendations. And so 2009 they
published this– and I love their daily
added sugar limit, and I went back to look at this
because I’m trying to figure out– how did they get to
this idea that I’m only supposed to have 25 grams
of added sugar a day, and David gets to have 36? Like, not fair. But the way they came up
with this is they said, OK, average American woman,
average American man. What are their caloric needs
to get their daily requirements of nutrients minus
how much they need to eat to maintain their weight? And those are your fun calories. Woo-hoo! And so the average American
woman gets about 200 extra “fun” calories a day. If I’ve eaten just enough
to get all my nutrition, and I’m maintaining my weight,
I get 200 extra calories to spend as I wish. So half of them I get
to do is added sugars. So this is how this
data came about. And so it’s really not entirely
scientific because anybody– who has tried to lose
weight in this room? Yeah. You get those apps. I’m a 48 year woman, I
weigh so many pounds. I’m not telling you. I want to lose 10 pounds
I’m going to plug it in– OK, I get to eat this
many calories a day. And I methodically go, and
I do this, and turns out those predictors are really
not that good for everybody. So you may be on this
end of the scale, where you may lose a ton of
weight without many calories because you actually need
more calories per day. Or I may be the person
who’s way down here. I can’t eat nearly
that many calories. And I’m metabolically
challenged, and that stinks, but that’s life. So those calculations
are actually not great, but there they are. What does sugar do? I think you can
safely say, in a lot of cases, that added
sugars, depending on what you’re eating, can
increase triglycerides. This is a surrogate
marker for heart disease. This is not the slam
dunk, this is the cause. It may reduce your healthy
cholesterol, your HDL, it may raise your LDL. Again, that data
is very limited. Certainly, there is a concern
about glucose and insulin. I’m going to do that
one in a minute. This one’s a bigger association. But again, it’s an association
based on epidemiology data. But certainly, beverages. The sugar sweetened beverages–
just get rid of them. Drink water. This change in our
hedonic pathway activation and how we view satiety. So if you sit down and have an
omelet compared to a honey bun, how full do you feel? And the risk– and this is a
big one, I think, amongst kids– if you’re eating
a bunch of crap, you’re not getting
healthy stuff, to the exclusion of
the healthy stuff. And that’s the real
risk, and I think it alludes to what
David was talking about in these
environments, where if you’ve got the local
bodega that only offers chips, and soda, and highly
refined foods, you’re not getting the
things that you need. This is the conventional model
thinking about weight gain, that we overeat, and we have
reduced energy expenditure, and so we’ve got
increased metabolic fuels, and we’ve got increased fat
storage and we gain weight, and we have diabetes, and we
have overweight and obesity. This is a more
contentious model, the carbohydrate-insulin model,
but it’s one that’s out there, and I think it’s
worth addressing. Because this really does get
at the sugar piece, which is that by eating the
carbs, which is a sugar, you actually drive
higher insulin secretion, which makes you store fat, which
makes you have perceived lower circulating fuel sources. So your body thinks,
hey, I’m starving. And then it says,
hey, I’m hungry. And so it’s the eating of the
carbs that actually drives the hunger that
drives the weight gain and drives the reduced
energy expenditure. And this has not been
proven, but is out there. I love the fact that
we had the same slide. The sugar industry is not
passive players in this. So the question is–
here we are, it’s 2019. We’ve been dealing with
sugar for hundreds of years. Why do we not know the answer? And the bottom line is, these
studies are really hard to do. Nutrition studies are
incredibly costly. They’re hard to do long-duration
studies, in part because, do you choose endpoints that
are surrogate versus clinical? Are you looking
at triglycerides, or are you looking at
people having heart attacks? Heart attacks take 30
years to investigate. Are we doing
epidemiologic studies? Historical versus a
prospective trial? Historical has been
very easy to get data, but it’s also
riddled with problems like, Megan, what did you have
for breakfast this morning? Or what did you have for
breakfast 10 years ago? What have you been eating
for the last 20 years? Really, really hard, versus
the cost of providing people dedicated meals to eat day
in and day out for a year. So, bottom line
is, I don’t think we have a good problem
solved yet for this. But what is my take on sugar? So here’s my anti-bias side. If you see a person who has some
extra weight, versus somebody who’s thin, don’t assume
that the person who has the extra weight is eating
crappy food and not exercising. Because I don’t eat very well. I exercise a lot. I’m working on my food. But the thin person is also not
always the healthier person. We all know those people
who drink sodas every day. They’re thin. They’re of the 15% who
were genetically thin, and will not have problems
with overweight and obesity. So the bottom line
is– so what do we do? What do I tell patients? How do we deal with sugar? I’m like, well I love
the Michael Pollan quote. Eat food, real food. Real food if you can get it,
if you’re in an inner city and you don’t have money,
and you can’t get access to fruits and vegetables, we’re
in trouble in this country for that reason. But eat food, real
food, not too much. Portion control. Mostly plants. Including fruits. This was advice given to a study
that was published last year. It was really good– if you
guys get a chance to look at it, DIETFITS, and I’ll end here– their advice was,
they randomized people to low-carb and low-fat. Two different groups. They gave some specific
advice, but they gave all of this advice to
everybody in the group, which was maximize your
vegetable intake, minimize your added sugars,
your refined flours, and your trans fat. That’s pretty simple advice. Shop around the periphery of a
grocery store, get whole foods, make it at home, don’t go out
and buy stuff from McDonald’s. It’s still not going to be
the cure for the obesity and diabetes epidemic, but will
be a heck of a lot healthier. And I will stop there. Thank you guys. I know a lot of you
guys have to leave, but David and I can stick
around for questions. MODERATOR: We have time maybe
for one or two quick questions from the audience that we
can capture on the recording, and then again,
both Jen and David will be here to talk with you. Who is here with a question? Or a comment. OK, coming up to you. AUDIENCE: I’m Sally Telford,
and I just have a comment. As you ended, Jennifer– I could make some
other comments, but– I was part of the
Women’s Health Initiative from the very beginning
in Atlanta in 1993, and I’m still part of it,
but not in the same way. And I am amazed
when you finished. One of the things that
impressed me about that study was its dietary advice
that was given to all of us as participants, and it
comes out pretty much where you ended,
in terms of diet. And for me it’s worked
many, many years. It was focused in the beginning,
of course, on oils and fats. And that was its primary focus. But it was really
done wonderfully well, and a lot of money was
invested in that study, and so I was glad to
see where you came out. JENNIFER KIRBY: From a
medical professional, the Women’s Health Initiative
has given us a ton of data across a wide range of topics– AUDIENCE: Yes, they have. JENNIFER KIRBY: –and so I think
that these studies are really important to do. They’re expensive, and
they’re hard to do well. But it is interesting. We sort of come
back to some basics. The problem is, is that
recommending this and following this are very different. So when you look at clinical
trials or clinical nutrition studies where they
recommended specific diets– so if you look at the DIETFITS
study, which is a great study– it’s a free living study, so
they follow people for a year, they said hey, go do this– they don’t track
what people eat. People were recording it, but
they weren’t given the food. And so there wasn’t
that control. But really, at the end of the
day, what that study showed was like a lot of other
nutrition studies, with some people lose
weight, a lot of people lose a little bit of weight,
and some people gain weight. And so in my world
around treating obesity and overweight, is that– you’ve got to tell
me which diet. I kind of say, well, we’ve got
to find the one that you’re going to stick with. If you like eggs
and cheese, and I’m sitting there telling
you to be a vegan, you’re not going to do it. So I think we have to– there are keto diets
that work for people. There are a lot of
people who hate that you can’t do the keto diet. So I think it’s really
a balanced approach. And for a starting point,
yeah, let’s try to get rid of those added sugars. But it is hard. And the industry
doesn’t make it easy. Yeah. So it’s a great question,
or a great comment. MODERATOR: I think
what we’ll do is close the formal portion of
the recorded program. But again, if you would
like to come and talk to Jen and David for a
few minutes afterwards, we’d encourage that. Please join us next week. I know it’s UVA
spring break, but we are doing a program
in partnership with the School of Nursing with
Roshi Joan Halifax from New Mexico, in a program entitled
Edge States as Opportunities for Courage and Compassion. And we will look forward
to seeing you all then. Please join me in thanking
David Singerman and Jen Kirby for a global tour of sugar. Thank you.