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28 Feb 2013 - Still Believe 'A Calorie Is a Calorie'?

by Robert Lustig MD


Are calories from sugar really more dangerous than other calories? New evidence from Professor Robert Lustig and his colleagues suggests that they are - at least in terms of diabetes risks worldwide.  

What do other experts think? Hear from Professor Lustig and join in the debate with some of the UK's leading researchers and clinical specialists at two upcoming events in London and Oxford:

If you do, you fly in the face of mounting and incontrovertible evidence that some calories -- in particular, "sugar calories" -- are jeopardizing both your and your family's health.

Physicians and politicians who cling to the dogma that "all calories should be treated equally" imperil our country's health care system, food supply and standing in the world for the next hundred years.

A calorie is a measurement of energy (a matter of physics), not a value judgment on where that energy goes (a matter of biochemistry). As my book Fat Chance explains, you get sick from inappropriate energy storage (in your liver and muscle), not defective energy balance (bigger love handles). Nonetheless, "a calorie is a calorie" continues to be promulgated by the food industry as their defense against their culpability for the current epidemic of obesity and chronic metabolic disease. But it is as dishonest as a three-dollar bill. Here are just four examples that refute this dogma:

  • Fiber. You eat 160 calories in almonds, but you absorb only 130. The fiber in the almonds delays absorption of calories into the bloodstream, delivering those calories to the bacteria in your intestine, which chew them up. Because a calorie is not a calorie.
  • Protein. When it comes to food, you have to put energy in to get energy out. You have to put twice as much energy in to metabolize protein as you do carbohydrate; this is called the thermic effect of food. So protein wastes more energy in its processing. Plus protein reduces hunger better than carbohydrate. Because a calorie is not a calorie.
  • Fat. All fats release nine calories per gram when burned. But omega-3 fats are heart-healthy and will save your life, while trans fats clog your arteries, leading to a heart attack. Because a calorie is not a calorie.
  • Sugar. This is the "big kahuna" of the "big lie." Sugar is not one chemical. It's two. Glucose is the energy of life. Every cell in every organism on the planet can burn glucose for energy. Glucose is mildly sweet, but not very interesting (think molasses). Fructose is an entirely different animal. Fructose is very sweet, the molecule we seek. Both burn at four calories per gram. If fructose were just like glucose, then sugar or high-fructose corn syrup (HFCS) would be just like starch. But fructose is not glucose. Because a calorie is not a calorie.

Up until now, scientists have shown that sugar is "associated" or "correlated" with various chronic metabolic diseases. For instance, the increase in sugar consumption over the past 30 years paralleled the increase in obesity, diabetes and heart disease. Areas that drink more soda (e.g., the American Southeast) experience higher prevalences of these diseases. But correlation is not causation.

Which direction do the data go? Does sugar cause obesity and metabolic disease? Or do obese people with metabolic disease drink soda? You can't tell, because you only have one point in time -- the snapshot, not the movie. In the February 27 issue of the journal PLoS One, my colleagues Dr. Sanjay Basu, Paula Yoffe, Nancy Hills and I put this issue to rest, because we now have the movie.

We asked the question, "What in the world's food supply explains diabetes rates, country-by-country, over the last decade?" We melded databases from the Food and Agriculture Organization (FAOSTAT), which measures food availability, the International Diabetes Federation (IDF), which measures diabetes prevalence, the World Bank World Development Economic Indicators, and the World Health Organization Global Infobase. We assessed total calories; meat (protein); oils (fat); cereals (glucose); pulses, nuts, vegetables, roots, and tubers (fiber); fruit excluding wine (natural sugar); and sugar, sugarcrops, and sweeteners (added sugar). We controlled for poverty, urbanization, aging, and most important, obesity and physical activity.

Bottom line -- only changes in sugar availability explained changes in diabetes prevalence worldwide; nothing else mattered.

Total caloric availability was unrelated to diabetes prevalence; for every extra 150 calories per day, diabetes prevalence rose by only 0.1 percent. But if those 150 calories per day happened to be a can of soda, diabetes prevalence rose 11-fold, by 1.1 percent (and Americans on average consume the added sugar equivalent of 2.5 cans of soda per day, so that's 2.75 percent!). And this effect of sugar was exclusive of obesity; controlling for body mass index did not negate the effect. Even more important, we showed that the change in sugar availability preceded the change in diabetes (that's cause, not effect); and we showed directionality -- those countries where sugar availability rose showed increases in diabetes, while those where sugar availability fell showed decreases in diabetes. This is a very robust signal, with little noise. While epidemiology can't prove scientific causation, the data allow for objective inference. Sugar drives diabetes worldwide, and unrelated to its calories.

When you do the math, fully one-quarter of the world's diabetes is explained by sugar alone.

The food industry has contaminated the American food supply with added sugar to "sell more product" and thereby uphold their Wall Street mandate to increase profits. Of the 600,000 food items in the American grocery store, 80 percent have been spiked with added sugar; and the industry uses 56 other names for sugar on the label. They know when they add sugar, you buy more. And because you do not know you're buying it, you buy even more.

The outcome: By the year 2050, one-third of all Americans will have diabetes. Trustees of the Medicare program predict that Medicare will be broke by 2024. No health care for you. Yet just six weeks ago, Coca-Cola had the temerity to introduce its two-minute ad "Coming Together," in which they say: "All calories count" because a calorie is a calorie; if you're fat, it's your fault (they claim no culpability); and because they make non-caloric drinks, they're part of the solution. The problem is that a calorie is not a calorie; if non-caloric drinks are the solution, then by inference they're saying that caloric drinks are the problem.

Sugar in excess is a toxin, unrelated to its calories. The dose determines the poison. Like alcohol, a little sugar is fine, but a lot is not. And the food industry has put us way over our limit.

The food industry will summon their spin doctors. They will yet again argue that the statistics are wrong, the interpretation is too broad -- but they will not be able to effectively refute the science. They haven't yet, and they won't succeed now. Sunlight is the best disinfectant, and it's shining brightly on the food industry's practices. They will continue the propaganda, and try to sow the seeds of doubt. But they will be on the losing end of this battle. The UK and Australia have just this past week laid down stricter guidelines for sugar consumption. The people and scientists of the United States are onto them as well. It's just a matter of time before the politicians follow.

Robert H. Lustig, M.D., is Professor of Pediatrics at UCSF, and President of the Institute for Responsible Nutrition (, at which the Doctors' Food Project is the first campaign. He is currently getting his Masters in Studies of Law at UC Hastings College of the Law. His YouTube lecture, "Sugar: The Bitter Truth" has been viewed over 3 million times. His book, Fat Chance: (Harper Collins 2012, Hudson St Press 2012), is in bookstores now.


(1) The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. Basu S, Yoffe P, Hills N, Lustig RH. PLoS One Epub Feb 27, 2013.