A literary review recently asked me to review a book by an eminent paediatric endocrinologist, Dr Robert Lustig, entitled Fat Chance. It is by no means well-written; but then, as the publisher explained to me, Dr Lustig is a doctor, not a writer. At least he always makes his meaning plain.
His main scientific thesis is that it is dietary sugar, particularly fructose, that has caused the world-wide epidemic of obesity, which is now particularly severe in the United States and Britain. Dr Lustig is a follower of Dr John Yudkin, a British doctor and nutritionist, who first drew the world’s attention to the connection between sugar consumption and obesity, hypertension, hyperlipidaemia and diabetes over 40 years ago in his book Pure, White and Deadly. Yudkin, however, was disregarded or pushed aside by forceful proponents of the alternative animal fat hypothesis of coronary artery and cerebrovascular disease, as well as by the sugar industry which led a propaganda war against his views.
In his book, Dr Lustig reminds us that it is not obesity as such that is dangerous; it is its association with metabolic disorder, which does not develop in every fat person. Furthermore, the dangerous metabolic disorder (now called ‘metabolic syndrome’) can develop in people who are not fat. It is the over-consumption of sugar that causes it, or at any rate is the principal cause of it. Heart attacks, strokes and renal failure follow.
Some epidemiologists believe that the epidemic of obesity and metabolic syndrome is so severe that it might actually reverse the long upward trend of life expectancy: that the present generation of children will be the first for much more than a century who may die at an earlier age than their parents.
Whether this is so or not – it has not happened yet, and it may be that the obesity epidemic has reached its peak – it is scarcely disputable that gross obesity is now as common as it was once rare. It has always existed, of course: Prince Hal described Falstaff as ‘this bed-presser, this horseback-breaker, this huge hill of flesh.’ Among my cherished books is Comments on Corpulency by William Wadd, an English surgeon who died in 1829 by jumping out of a moving carriage while on holiday in Ireland; his book was published the same year. Wadd was a talented draughtsman and his pictures of the exceedingly fat men and women might until recently have been regarded as exaggerations: but now there are such people on every bus, train and airliner, quite often next to me. Wadd was also a much more amusing writer than Dr Lustig:
The celebrated traveller, Dr Clarke, alluding to the pyramids
of Egypt, says “the mind, elevated by wonder, feels at once
the force of the axiom, which, however disputed, experience
confirms, – the in Vastness, whatever be its nature, there
dwells sublimity.” Why, therefore, may not the mountains of
fat, the human Olympi and Caucasi, excite our attention? they
fill a large space in society, are great objects of interest, and
ought afford us no small matter of amusement.
Needless to say, this is not a tone that anyone would dare adopt today with regard to a condition that reduces life expectancy (it was not so obvious in Wadd’s day that it did, of course, when everyone’s hold on life was much more precarious than it is today). On every page of Wadd there is something to interest those who are not entirely po-faced on the subject, and I cannot forebear from quoting the following:
… the fat physician, Dr. Stafford, was not allowed to rest in
his grave without a witticism:
“Take heed, good trav’ller, and do not tread hard,
For here lies Dr. Stafford, in all this church-yard.
But let us return to the more serious Dr. Lustig. There is much in his book besides his main scientific thesis, which I am prepared to believe, having no knowledge to dispute it. I think it has long been common knowledge that sugar makes you fat and I have long suspected, ever since reading Yudkin’s book forty years ago, that sugar was bad for the health. At any rate, it never occurred to me that it was good for it. I further suspect that, if you were to ask 100 people whether sugar was good for you, 99 would say ‘No.’
But Dr Lustig has further hypotheses to advance, for example that sugar is addictive and that once people have grown accustomed to consuming it they cannot stop themselves from consuming more of it. That is why so many attempts to lose weight are futile; people return to their sugar as homing pigeons to their nests. And in many cases patterns of consumption are set in childhood: mothers feed their children an unhealthy diet for which the children then have an irresistible craving.
The processed food industry is largely to blame for the epidemic, says Dr Lustig, because it adds large amounts of sugar, particularly fructose, to its products. It started to do this on a large scale (he says) first when President Nixon’s administration tried to find a way of making food reliably cheap and did so by subsidizing corn and therefore high fructose corn syrup; and second when, acting on what seemed the best (though actually the noisiest) nutritional advice at the time, the Department of Agriculture decreed that the American diet should include less animal fat. Fat-free or low fat products are unappetizing, and so the food industry added sugars, particularly the corn syrup that had become cheap, to their products. What it started to do reluctantly it soon enthused over: a bit like mortgage lenders and sub-prime loans.
I pass over in silence what appears to be the undistinguished record so far, at least as described by Dr Lustig, of the federal government in the matter of interference with the food supply and with the diet of average Americans. This is because the past is no infallible guide to the future and it is possible, I suppose, that the next time the government takes up the cudgels on the question of the American diet it will get it right from the public health point of view. Neither truth nor error, after all, is fore-ordained, even if unforeseen consequences are.
What I found almost as interesting in Dr Lustig’s book was what it omitted, an entire dimension of the problem in fact. His book may be summarized as follows (I hope I do not do him an injustice):
Obesity and its associated metabolic disorder has become a major public health problem.
The disorder is largely the consequence of over-consumption of sugar in the diet.
This over-consumption leads to addiction from which it is impossible to escape.
The sugar in the diet is put there by food companies which make a large profit from doing so.
Since individuals are helpless in the face of all the above, action ought to be taken at
governmental level to reduce the consumption of sugar.
As it happens I am not altogether out of sympathy with Dr Lustig’s suggestions. Like him, I can see no reason why corn, and hence high fructose corn syrup, should be subsidized and thereby become cheap but unhealthy food for the masses (no pun intended). He says that food subsidies are more or less inevitable, at least no modern society has done without them, and so, instead of being attached to corn syrup, they might be attached to something healthier, or at least thought for now to be healthier until proved deadly poison: broccoli, I suppose, or artichokes. I am not sure whether this is either practicable or right in economic theory.
He also says that schools should prohibit the sale and consumption of sugary sweet drinks on their premises, and here too I find myself in agreement with him. Schools by definition are in loco parentis and have an obligation to protect children and do their best by them. Pupils are not yet fully autonomous individuals and require guidance: that, after all, is why they are in school. Even if it could be shown that such a ban had no practical effect, there would be a moral obligation to impose it.
But it does not follow from the fact (as Dr Lustig implies by the whole tenor of his book) that if the government and the food companies are either negligent or actively malicious in promoting the consumption of sweet and corn syrupy foods and drinks, that ordinary people are absolved from blame for the current situation. It does not follow from the fact that two legs are bad that four are good, to adapt Orwell’s formulation. Let me illustrate what I mean by quoting one of Dr Lustig’s clinical vignettes, significant because it comes at the very beginning of his book and heads a chapter that is intended to persuade us of the insufficiency of human agency as an explanation of the obesity epidemic (the chapter is entitled A Fallacy of Biblical Proportion:
Juan, a 100-pound six-year-old Latino boy whose mother is
a non-English-speaking farm worker from Salinas, California,
comes to my office in 2003. He is wider than he is tall. I ask
the mother in my broken Spanish, “I don’t care what your kid
eats, tell me what he drinks.” No soda, but a gallon of orange
juice per day. On calories alone, this accounts for 112 pounds
per year of body fat. Of course, some of that is burned off, and
it might influence his total food intake. I explain to the mother,
“La fruta es buena, el jugo es malo (the fruit is good, the
juice is bad). Eat the fruit, don’t drink the juice.” She asks,
“Then why does WIC [Women, Infants and Children,
a government entitlement program for the poor run by the U.S.
Department of Agriculture] give it to us?”
What is interesting in Dr Lustig’s subsequent ensuing chapter is that neither the words ‘ignorance’ nor ‘foolishness,’ let alone ‘stupidity,’ appear. Dr Lustig is committed to the idea that people such as Juan’s mother can do no wrong because they are the mere playthings of governments and large corporations. Four legs good, two legs bad. For Dr Lustig, Juan’s mother is not a full human being like you and me; she is a mere vector of forces acting upon her. But if giving a gallon of orange juice a day to a six year-old child does not qualify a person as stupid, then the word has no application.
It is worth thinking about the causes, origins and maintenance of such stupidity. As Doctor Johnson said of Thomas Sheridan, ‘Such an excess of stupidity is not in nature.’ But Dr Lustig does not think about this difficult and awkward question. For him, there is nothing between the big wicked company or government, often in cahoots, and the ordinary individual. Implicitly, he wants a government so clever that it will not matter if people are stupid.
The population of my own country, Britain, is now among the fattest in the world. About a fifth of British children do not eat a meal with another member of their household more than once a week; in a similar proportion of homes there is no table at which they could do so. The microwave is the only implement of cooking, to heat up prepared meals full of sugars. Such a pattern does not exist in households of Indian immigrants or people of Indian descent. Surely this is worth pondering over when we think about dietary questions.
Dr Lustig talks of food deserts, urban areas where stores carry no fresh vegetables or fruit, as being responsible for obesity. But is food desertification a matter of supply or demand? Is there no cocaine, for example, to be had in food desert areas? I rather doubt it.
Social scientists and epidemiologists are fond of calling the origin of problems ‘multifactorial.’ But they avert their gaze from anything that looks like human failing, in part for fear of appearing ungenerous towards the poor and disadvantaged, and in part because that failing itself may be encouraged by precisely the kind of policies that they have long supported.