Sugar The Unsweetened Truth and What We Can Do About It

(gentle music) - I'm gonna talk a little bit about some of the work we have going on here at UCSF around sugar, and I wanna start with a graphic just to give you a sense of what the obesity epidemic or pandemic is looking like worldwide. And what I'm gonna show you over a sequence of a few slides is essentially the fattening of our globe. And so the way to read this diagram, everything is being compared to 1980. So, this is a slide of rising obesity worldwide comparing 1980 to 1985. so this is the percentage of any given population that over that five year time period has experienced an increase in obesity rates, and so right here already between 1980 and 1985, you can see China had a 1.6 times increase, okay? So now we're gonna look at the comparison between 1980 and 2000. Now you can see the red, this is a six times increase in obesity rates. So, six times increase in a five year period of the percentage of the population obese. Again China, is really standing out, but also parts of Africa, and now we're gonna compare 1980 to 2015. So here in the United States during that period of time between 1980 and 2015, our obesity prevalence has increased by two and a half times. So, a lot of people look at this slide and they think, "Huh, that really goes against my "kind of cultural narrative around obesity and overweight". You think, well, isn't this a problem of people who just can't, you know, control their appetites? Isn't this a problem of people who are too lazy to run around? But then you have to step back and ask the question, how is it that whole worldwide populations are experiencing the same epidemic? You don't see here, you don't see any countries turning the curve, and going backwards, you don't see any decline in obesity, and in some countries, you're seeing as much as a six fold and plus increase in the rate of obesity. So, people in my field look at this picture, and we say there's something going on here that is much bigger than any given individual. This can't be that we've all suddenly lost our willpower, and as a human species we can no longer control ourselves, there's something going on here that is much bigger than any one of us. And so a lot of the work that we've been doing on sugar is trying to unpack exactly what might that be. Of course, there are a lot of different factors at play but sugar is one of them. Okay, so, So obesity is a driver of a disease that we're seeing increase at precipitous rates, and again, all over the world. Mexico has the highest rates of type 2 diabetes, the United States is coming in second. And we also have very high rates of obesity in both countries. Obesity is a risk factor, a significant risk factor for acquiring type 2 diabetes as well as just poor diet in general. So, my grandmother had type 2 diabetes. She got it when she was in her 70s, she managed it by not eating much sugar, or any, she wasn't supposed to eat any but sometimes she cheated. And at the time, it was called adult-onset diabetes, because type 1 diabetes occurred in children, a genetically driven condition, autoimmune condition, but type 2 diabetes happened in adults much later in life. What's really concerning about what's going on with the diabetes epidemic in the United States, is the fact that we're now seeing this, this has become a disease of children. So, one in 11 American teenagers is prediabetic or diabetic in 1990, today, one in four. Again, you don't see changes like this and think, okay, you know, people, you know, this is an individual problem. You don't see changes across whole populations of humans and assume that this could be about individuals. There's something going on in our environment that is driving this. What's really troubling about diabetes is not so much the disease itself is the complications that come with it, and especially because people often don't know that they're diabetic or prediabetic until they start experiencing complications and they're literally in needing an amputation or having vision problems when they find out that they're diabetic, and by that point it's too late. So, now there... I just wanna show you, again, this is a pretty alarming picture here. This is new, this is the percentage of the US population with diabetes and this is the number of people with diabetes. And as you can see, that over time, the rate, this is time, the rate is just going up, up, up. This coincides quite well with the rise in obesity rates, and again, that makes sense because obesity is a driver of type 2 diabetes. So on top of diabetes, we're also seeing another... And this is actually what kinda got me out of my corner, doing alcohol research and interested in sugar, is that up until I started working in this area, I was not aware that a rising and prevalent cause of cirrhosis of the liver, was that sugar was a potential cause. And, of course, I had studied cirrhosis rates in the populations around the world for many years and had come to understand that, you know, that it's a very good indicator of how much alcohol is being consumed in the country. So I was really surprised to find out that there's a sugar namely fructose, if you take your table sugar, half is glucose and half is fructose. And fructose, it turns out is exclusively or almost exclusively metabolized in your liver, which means that if you're taking in huge doses of it, and you aren't exercising it away in the moment, what can happen is that your liver will lay down fat, it will send some of the fat molecules out through into your bloodstream, causing elevated triglycerides, but some of it will accumulate in the liver and eventually lead to cirrhosis, and so, in our hospitals, as we speak, there are people having liver transplants for non-alcoholic fatty liver disease caused by poor diet, and you know the prevalence is hard to know, because you really do need a liver scan to diagnose it, but the estimates are around 1/3 of adults, 1/3 of us walking around today or have some degree of fatty liver disease, that if we continue with unhealthy habits could progress. So again, there wasn't really a formal name for this condition in as late as 1980. So again, and it coincides with the rise in obesity and the rise in junk food consumption and sugar-sweetened beverage consumption in the United States, but again, it's this kinda canary in the coal mine, okay? Adult diseases happening in children, and then on the other hand you've got whole new classifications of diseases, whole new diagnostic categories that didn't exist before. And so something again is going on in our environment that is driving these factors. They're all connected to sugar and obesity. All right so, I'm actually a sociologist and I was trained to understand the way social environments impact health, and that's what makes this is such an important and interesting area for sociologists to look into. And so I'm gonna talk about the environmental causes of this problem, and make the case that a lot of it is not up to the individual, that it has more to do about our environment than it does our individual choices. So in alcohol and drug research, we have a term that we apply to say, parts of inner cities that are blighted, and where there's deep poverty, San Francisco's Tenderloin is a good example. And we call them alcohol and drugs saturated environments. And what we know from studying these communities where there's just a lot, like everywhere you look, there's a corner store selling alcohol. In front of that corner store, you'll see people shooting up, and people using drugs. And drugs are ubiquitous in these communities, as is alcohol and it's cheap. And it's often sold in really large containers, so it's encouraging consumption. And what we know from studying communities like this, is that no matter who you are, if you grow up in a place Like this, you're more likely to try drugs and alcohol, and if you're more likely to try drugs and alcohol, you're more likely to develop a problem with drugs and alcohol over time. These are communities where there's targeted marketing of people, to people, so depending on who is in that community, the companies that sell alcohol are gonna target those users with advertising, and with particular products, malt beer, malt liquor in big cans and things like that, and make it cheap. And so we know that living in a saturated environment makes you more prone to consuming and therefore having an alcohol and drug problem, and the very same thing is happening in our food environment. And this is the big change that we've seen coinciding since the 1970s, coinciding with rising rates of obesity, rising rates of type 2 diabetes in children, and the growing prevalence of non-alcoholic fatty liver disease. And it coincides with a shift from what we call processed foods to hyper-processed foods. So if you think about, like what I grew up on, my mother, we used to laugh, she cooks with cans, she cooks in boxes, and mixes it all up, and a can of Campbell's Soup goes in and that's the sauce on the pasta and then, right? So those yeah, those were processed foods, but a lot of the processing was really designed to increase shelf life and stabilize the product, make it last longer on the shelf. The difference between that and what we're now feeding our children, is that they're hyper-processed foods. So, a classic example of a hyper-processed food is soda. Essentially a soda, is a some water, a bunch of sugar, some chemicals, two kinds of chemicals, chemicals that add color, and chemicals that add flavor in different combinations depending on what kinda soda, and then what? - [Audience Member] Carbonation. - Well carbonation, carbonated water. What am I missing? - [Audience Member] Caffeine. - Caffeine, an addictive substance. It has... And so what's different here, is that the industrial components that go into making a product like that, or have nothing to do with the actual fruits and vegetables or whatever, they're original sources. So we can grow a lot of corn, and a lot of wheat, and a lot of soy. But what's happening in our food supply, is that those ingredients are being industrially pulled apart, and then recombined adding chemicals for color and flavor, and put into boxes and cans and bottles and sold as food. It's not food, it's industrially produced food and that's very different even from a processed food product where essentially the chemicals are in there mainly to increase shelf life. It's not about actually pulling them apart, the raw ingredients and recombining them in a way, that is designed to make you wanna consume more. A good example is the Dorito chip. It's a classic hyper-processed food. It's got, yeah, it's got some corn in there, but then again, that's been industrially refined, and then mixed with a bunch of flavors and colors and various fats and so forth, but the thing that it's really designed to do, is make you want more of it. It's, literally the people, the food scientists that made the Dorito chip, put people in functional MRI machines, what people in the addiction field use to diagnose people addiction and what goes on in the brain, and to figure out a way to make it even more hyper-palatable, and to intentionally make it such that you don't really get full. So, the ideal hyper-processed food, is industrially produced and rigged to make you wanna eat more and not get full. Sugar-sweetened beverage is another very good example. People down it, people are walking around with whole liters, they drink it in the car, and on an empty stomach you're not gonna feel satiety. And of course, that's delivering a big wallop of fructose to your liver, and a lot of insulin, a lot of sugar for your pancreas to have to manage. So, looking at this situation, if the understanding of the problem is that we have a saturated environment, all of the solutions that we have that we know work, are designed to basically desaturate the environment. So if the food corporations are making foods hyper-palatable, then we need to figure out ways to make them less attractive, whether that's in the case of tobacco, they'll put it in a plain package, can't put a lot of advertising on it, right? That makes it less attractive. So all of our well known evidence-based solutions are essentially trying to rerig the food environment so that it is less saturated, less Likely to drive people to over consume. And the model for this, is the 20th century battle to help Americans stop smoking. Which was an incredibly successful effort to once again desaturate the environment, take it out of the workplace, take it out of the hospital. Yes. - [Audience Member] What year is this? - That's a good question. Well, I'll tell you. It's before 1965 because that's when the Surgeon General released a very impactful report that said, "This stuff causes cancer". And that was the beginning, that is the official launch of the 20th century anti-smoking, some people call it the tobacco war because of course it required people, you'll be hearing from Dr. Glance about this, a true warrior, later in the quarter, but it really meant public health advocates and scientists going to war with the tobacco industry, which denied that their product was addictive, denied that it was, up until, it was found in industry documents that they were lacing nicotine in the cigarettes adding extra nicotine to get us even more hooked. And so, but the model for success is really what was achieved with the 20th century tobacco war. And I just wanna show you this picture and Stan really doesn't like this picture, because he thinks I should be putting heart disease up, because heart attacks, you can literally, if you put a clean indoor air laws into a city, within two weeks you'll see a change in ER visits for heart attacks. That's just because you've decreased smoking in the population, and that reduces the heart attacks. But this is lung cancer. So this is a much longer term disease, it takes a lot more time to come on board and so forth. So what's cool about this picture and why I like to use it, is because you can see that the epidemic in tobacco consumption, just like our obesity curve, and unhealthy diet curve is going up, it peaks. So here's when the Surgeon General's report came out, that's when the war started, and about 10 years later, you see the inflection point in the lung cancer rate. And then plummets. And just think about how many lives, are in that curve? How many people saved? And that's, the blue line is the male lung cancer death rate, and the red line is the female lung cancer death rate. And so this is what I was wanna see happen to diabetes. I wanna see that inflection point, turn, and then it to go down. And in order to make that happen, we need to deal with that black curve, the consumption curve. We need to change that, it's the risk factor that drives the outcome. So, I have a handy term, I refer to this 'cause it's easy for people to remember, I call it The Iron Law of Public Health. And this is the underlying magic of anything that people could do to desaturate the environment, get people to stop smoking, and therefore turn that lung cancer curve. And it goes like this. If you can reduce the availability of something harmful, something that makes people sick and kills people in the environment, that will reduce consumption, and this is in like, it is an iron law. We know this is true for tobacco, alcohol, anything you put in the environment, if you can get it out of the environment, you will reduce consumption. And when you do that, you reduce the harms to health. And so ultimately, it all comes down to reducing the availability of something in the environment. And that can be a tiny, tiny little nudge, or it can be a huge draconian policy like alcohol prohibition. Alcohol prohibition had a lot of problems with it, I don't advocate it. I don't advocate prohibition for anything. It has bad unintended consequences. But the thing that it did do, alcohol problems went way, way down when we prohibited alcohol in the United States. And that's the iron law at play. Fortunately, since then, we learned a lot about what happens if you get too draconian with the public health policy, and so these days, a lot of this is the art of tinkering with multiple different policies all at once, that are sort of gently creating an environment where it's a little less popular, it's a little harder, it's just generally not something that everyone's doing, and therefore, we get this virtuous cycle where the consumption goes down, and then that drives disease outcomes. So, just an example, I walk around with one of these, partly 'cause I'm worried about climate change, and partly because I like to drink water, and this is a convenient way to go. But before I started doing this, and before Janet started, I would come in to give a talk, and there would be a plastic, something here for the speaker. And I often would look at that and I would think, "Okay, well if this was a soda", right? And I was in the middle of talking and so forth or even before and I saw it, it's not like I'm gonna leave the building, go across the street, buy a bottle of water, right? Bring it back, right? That's just too much work, I'm lazy. And so what I would do, is I would drink whatever's in front of me. If this is in front of me, this is what I drink. And so, you know, I'm often asked, "Well, how do people get over food addiction?". "How do people get, you know, quit soda?". And the first recommendation I always make is clean up your personal food environment. Just get it out of your face. If it's not in the cupboard, you're less likely to eat it. It's not that hard. Well, it can be hard for some populations. For us, we have ample resources, it's a lot easier to clean up our personal food environments. So the most effective strategies all follow the iron law. And so if you look like, you know, alcohol control, we have taxes in virtually every country in the world. Alcohol has been taxed for hundreds of years. And it's taxed because we know that it reduces, if you make the price higher, people will consume less, just simple, simple, elegant solution. Controls at the point of sales. So, this can be everything from not having it at the cash register, or the poor mother with the kids screaming in the line in the grocery store, it can be something a prompt that says, "Not good". In fact, Chile, just put little labels on the front of all of their hyper-processed foods, and it's a very simple graphic of three different hexagons, and it's basically telling parents "Stop, go slow", and it's a very simple way to let people know and prompt people to think, "Hmm, I don't know if I really wanna put that thing, "that stuff in my kid, "given that it's got a stop sign on it". Consumption of junk food in the first year went down by 25%. A quarter, just by that little, that little picture. People are smart, you just give us a little bit of a nudge and we often do the thing that's good for health. Counteradvertising, warning labels I just described. Counteradvertising is a really fun strategy that I'm gonna show you some examples of, which is basically using everything that the companies know about how to market things to us, and make them irresistible, only uses it in reverse. We market to make it very unattractive. And then finally you could have, in the case of, SSB stands for Sugar-Sweetened Beverage Zones. And you can have SSB-free zones in workplaces and schools. We have that in California for our secondary schools. I'm gonna show you some data on UCSF's decision in 2015 to stop selling sugar-sweetened beverages everywhere on our campus. I'm gonna show you what the impact was on employee health. There are a lot of ways to skin this cat, We're working across the UCs to try to figure out ways to create SSB-free zones. UCLA took it out the vending machines, there are a lot of ways to do this. Which again, we spend a lot of our day in these environments. It's like cleaning up your home environment. If you're in a place for a long period of time, think consciously and intentionally about what you're bringing into it. And that will be the iron law at play. So, I'm gonna start with taxation. And there are volumes of studies on taxation, why it works, how it works, what its pros are, how to make it more effective. When we first started out, looking at sugar-sweetened beverage taxes, which we now have four of them in Bay Area cities, including San Francisco, and our team at the Clinical Translational Sciences Institute, we were working closely with the Board of Supervisors in San Francisco on this issue, 'cause they really, really wanted to change childhood obesity in the city and especially close the gap between the haves and have-nots, around childhood obesity. And at the time, this was back starting in about 2010 when I just started meeting with supervisor Maher who was in office, now his brother is in office actually, and he said, "Tell me what you think we can do". And so I remember showing him mountains of evidence on alcohol. Because at the time, there wasn't any experience taxing sugar-sweetened beverages and we didn't know that it would work but i said, "Well, you know, "it works like a charm for tobacco, "and it works for alcohol". "And the reasons it works are not gonna be "all that different from soda, "so, I think you should give it a try". Now, we have 40 countries with sugar-sweetened beverage taxes. And lots of evidence from Mexico, and from cities in the Bay Area, very well done studies showing, yep, they do work, they discourage consumption, and all of those proceeds of that tax, are now available to put into communities for chronic disease prevention, clean water, and so forth. So, it's a win for everybody. One of the things that's great about taxes is they're easy and cheap to get going. I always recommend, start with the tax because the proceeds from that tax can then get used for all sorts of good public health stuff like great counteradvertising, media campaigns, and so forth. The evidence shows, and this is kind of an interesting fact, that the heaviest consumers, are the ones that are most impacted. For a long time with alcohol taxes and tobacco taxes they thought, "Well, the heaviest consumers are so addicted, "that the taxes won't work on them", and that turned out to be exactly wrong. The taxes are more impactful on heavier consumers, so they go where the need is in the population. And they can be earmarked for health promotion. Now controls at the point of sales would be for sugar-sweetened beverages. We don't see a lot of this yet, taking it out of public environments and schools, licensing and zoning. So a really sensible thing would be, if you own a store right near a school on, right as kids are going to school and when they're getting out, you don't sell sugar-sweetened beverages. There's simple strategies for that, or even in the case of alcohol, there's a wonderful strategy of just regulating the number of outlets that you can have in any given community, and that desaturates the environment. And you can also control product placements. And then counteradvertising campaigns. The goal here, what we know from the experience with tobacco is that yes, we drove down consumption, but in the process of driving down consumption, we were very careful to at the same time, make it less popular. So if you say, okay, I remember when we started putting smoke-free workplace policies, and at first you just couldn't buy cigarettes at work, then you couldn't smoke inside around your colleagues, and then finally, the poor people who do still smoke, and the majority wish they could quit, are standing outside on, the wall of shame, smoking. And now this is not great if you are a smoker, but the overall population effect, is that you are denormalizing smoking, you're making it less attractive, less popular, and in the process, you are discouraging new users, namely our kids. This is an example of just a really classic counteradvertising campaign was, you know, does that get the message across? Right, you don't need a lot of... There's a great one of a cigarette that goes like that, (speaker and audience laughing) 'cause smoking causes erectile dysfunction. Here's one, the average smoker needs over 5,000, really reminding you this is an addictive product. Now the city of New York launched a really cool... Yeah. - [Audience Member] 5,000 what? - Cigarettes. And I'm sure that's an annual number. I don't know exactly what that... I think that one comes from either the UK or might be Australia. I poked around. This is one of my favorites. The man drinking fat. This comes out of the New York Health Department. I'm gonna see if we can get this going. (audience laughing) (dramatic music) (lighthearted guitar music) Good one, huh? Yeah, that one got picked up in Australia. You wanna see that again? No, no? (audience laughing) Yeah, whenever I present this to kids, they always wanna see it like six times. (audience laughing) And here, this is... Here at UCSF, Dean Schillinger, and folks at the Center for Vulnerable Populations have a wonderful campaign called The Bigger Picture Project, that tries to use counteradvertising and youth poets, to educate young people, especially young people from communities of color, about the junk food and diabetes. And this is actually Canzilla, and they take this to high school parking lots and they put it up when they're there to do assemblies and so forth. And again, you know, it's all about denormalization. We're taking that thing that you've been trained by a soda company to think is this delicious, cool, fun thing, and now we're just reminding you what it does to you, right? And it's strategic reframing of the product. Now, there's some really interesting work that we've got going on here at UCSF, where we're studying the industry, the junk food industry, and the sugar-sweetened beverage industry. We have internal documents from emails, all forms of correspondence between executives and people working in junk food companies. This line of investigation got started because Stan and his group were studying what goes on inside the tobacco companies, and somewhere along the line, we started to think, well, that's a really interesting model to apply to food. Because it allows the public health community to understand a little better what the strategies are for say, targeting minority populations with advertising, or creating sports sponsorships that sell their products, and it allows public health advocates sometimes to anticipate what's coming next. And lo and behold, as we were researching the tobacco archives, somebody figured out that there was, it was literally like somebody emailed me and said, "Hey, you know, I don't know why, "but I'm hearing the tobacco archive "it's like 12 million documents, "and I'm seeing all this stuff on like Kool-Aid, and all these, sugar-sweetened beverages". And I'm like, "Really? "And like how many documents do you think "there are in there?". And she said, "Well, I think about 30,000". And I said, "Wow, that's substantial, "let's look into them". So, long story short, there weren't 30,000. We don't know how many there are. There are hundreds and hundreds of thousands of documents in the tobacco archive about food companies. And the reason is because Philip Morris and R.J. Reynolds, the two giants in the American Tobacco market, in the 80s, bought up General Foods, and another company called Kraft. They bought them as subsidiaries, they merged them to create the largest food corporation in the world at the time. And then they proceeded to train executives in the company and share infrastructure and strategies for targeting kids, for targeting ethnic minority groups, for advertising, for line extensions of products, and it took us a long time to figure out why would tobacco companies be getting into the food and beverage market? Like why would they care? And, now they don't own these companies anymore. They spun them off. So Kraft is now partly Kraft Heinz and partly Mondelez, which is an international company. But it turns out that, it goes back to the colors and flavors. R.J. Reynolds in the 60s, had these labs and they were manufacturing colors, like artificial colors, artificial flavors, to put into cigarettes, like menthol, right? And they had all these colors and flavors that they didn't know what to do with. And we have a quote from one of the company executives saying, "Well, maybe we're not just "in the cigarette business, "maybe we're in the colors and flavors business". And next thing you know, they had bought up a little known small company called Hawaiian Pacific, that really had sort of one product that it sold, which was Hawaiian Punch, and at the time it was being manufactured, let me see if I've got any pictures in here for you. Yeah, here we go. So at the time, Hawaiian Punch was being sold for this purpose. It was an adult cocktail mixer. It was not what we think of today, or even in the 70s. This is an ad from the 70s. In New York Times when this paper got published, they did a wonderful piece on it. If you like old advertisements, Google it and you'll enjoy. They literally have footage of the Kool-Aid Man and all this stuff. But yeah, so R.J. Reynolds, they bought up Hawaiian Pacific and a year later, Hawaiian Punch was closer to the Hawaiian Punch we know of today. It started out as an adult cocktail mixer under R.J. Reynolds ownership, it became a beverage for children. They had only had one flavor back when Hawaiian Pacific owned the company, under R.J. Reynolds immediately it started to come in 25 colors and flavors, and little kid sized containers and on and on. And that's what really smart tobacco executives can do with a sugar-sweetened beverage. They can transform it into something... They were very very keen on, very early on they realized that if you can attract a kid to a particular brand, and make them loyal to that brand, whether or not they even consume the product as a kid, Camel Cigarette, Joe Camel here. If you can do that, when they do become a user, they're gonna be loyal to your brand and you keep 'em for the rest of their life. So the smartest strategy you can come up with is to hook people when they're young. And that we believe is part of why they went after kids with sugar-sweetened beverages when they owned them. As part of the Tobacco Master Settlement Agreement, R.J.R was no longer allowed to use this guy Joe Camel, obviously a cartoon figure, they had to take Joe Camel out of the media, but they still use Punchy. And Punchy is also the same advertising firm, that came up with some of their cigarette cartoon characters came up with Punchy. So, there's a lot to learn about how the industry moves to saturate our environment, and understanding that allows us to be more responsive to strategies and ways to desaturate it. Now, I don't wanna go on too much longer, but I do wanna tell you a little bit about our own efforts here at UCSF to desaturate our own environment. And there was a point when this image, and that image sort of came together in the minds of leadership here. And this idea that we have all these scientists in our university who are studying sugar, and learning about fatty liver disease, trying to understand the diabetes epidemic and so forth, and they're all saying, "Get this stuff out "of the food supply, "or diminish it considerably, "we're all consuming too much". And this idea that, well wait, we're a Health Sciences Campus and we're all about health and treating all these people with diabetes complications in our hospitals, and yet we make money off of soda. And so this idea when it got presented to leadership here, it didn't take people long to see that we needed to kinda walk the talk a little bit on this stuff. And in fact, our medical our Chief Medical Officer at UCSF Health, his reaction when he heard about this, the first thing he said was, "Well, you know, "we don't sell cigarettes in our vending machines", right? Yeah, pretty cool. And so in 2015, we just stopped selling it. Chancellor made an announcement coming out of the, everywhere, hospital meals, vending machines, cafeterias, any retail location. Jamba Juice figured out how to make smoothies with no added sugar, just whole fruit, whole fruit juice. All of our vendors came along voluntarily, because they care about health too, and they wanted to be, in the part of our community, and so it was one of the... It was an interesting process because there had been some hospitals that had tried this, but UCSF was the first sort of whole medical center plus a major university to do it, and we're very large, and we have a lot of locations, and it was happening in the context of passage. A year later, the city voters voted in the second soda tax in America, and so you're really talking about a community of pretty wise leaders thinking about ways to take stuff out of the environment and reduce the harm in the process. And so a lot of people would ask the question "Well, why pick on soda?". And there are a lot of reasons, for one, it's over 1/3 of our sugar consumption in our diet. It is not very satiating, and obviously has no nutritional value outside of maybe the water that you're consuming to hydrate. So, what we did very quickly, because the policy was going into effect very soon, we went to our Human Resources Department, we have, I think about 24,000-ish employees at UCSF across all of our various campuses, and we got a roster of employees, and we drew a sample. And then we surveyed our employees and we also did complete physicals including a fasting blood draw on a subsample of those employees. And we monitored over the coming 10 months to a year, what happened to their health. All right, so I won't get too technical here, I just wanna start by showing you, this is from some of the survey data. So they're about a couple thousand of our employees representative sample, and what you're seeing here is, this is job classifications ranked by income. So, the lowest paid employees at UCSF are our service maintenance police, the highest are some of our medical staff, and what you can see from this picture right away, is that this is a problem that tracks socioeconomic status, right? So, our doctors and academics, people like me and Janet up here, hey, don't worry about it. Four ounces a day, no problem. That's not gonna harm our health. But our service and maintenance folks were consuming almost a liter a day. Like that's a lot of soda, and that is gonna impact their health. So, this is baseline consumption, and now I'm gonna show you what happened to sugar-sweetened beverage consumption and this will be a year after we stopped selling soda, a year later. So these are the declines. And once again you can see, the intervention, actually, it's like precision public health. Some people talk about that. It targets where the need is, just like the taxes target the heaviest consumers. These guys went down by about 25%. So you're really talking about a big impact on their day to day habits just by taking it out of the workplace. You know and they could... And by the way it's... So you can bring in a six pack and put it in the fridge at work, you can walk off campus go buy one, you can, whatever you want. You know, it's just UCSF decided to get out of the business of selling it. And it's not in our environment. And I think what happens after a while, is even if you're gonna fight for your soda, you really love it and you want it, at a certain point, like I said, I'm lazy. We all are, right? At a certain point, you know, it's three o'clock in the afternoon, you got a lot of work on your desk, or you know, you're not gonna walk out for a half an hour to go get a soda, you're just gonna go down and try to find something that you like in the local cafeteria, whether it's a tea or juice or something else, milk, whatever it is. Did somebody have a question? - I did. Did they also support that with (mumbles). - No, no, none of that. Nope, nope. No. - So it was all about (faintly speaking). - I remember fairly soon after we stopped selling soda, and I remember I was giving grand rounds at, I think it was San Francisco General, you know, this is a big, like big group of people and it's like residents and medical students and doctors and people who work at the hospital, and I was talking about this stuff, and just at the beginning I thought, "Hmm, I'm gonna present "some data on this policy, "maybe I should ask if people are aware of it", and I said, "So, how many people in the room noticed "that we stopped selling soda?". And it's like, a couple of hands went up. And that's what makes me really happy. Because, you know, and having brought up the example of alcohol prohibition and, you know, when it's in people's face, it's not a great thing. To my mind, our biggest successes in public health happen when they just become taken for granted. And it's like, "Yeah, I get in the car "I put my seatbelt on no big deal". Nobody remembers what it was like when we didn't have seatbelt laws. Or "Well, I would never..." Oh, you do? Okay, I'm sorry, I'm sorry. - (mumbles) down and landing on my mother's (mumbles) that pushed down on the gas pedal--" - Exactly. Infant car seats. Like I was the first generation of parents, and I was like, "Oh my God, "I can't get this thing in the car", and all that. And by my second kid, I would never let anyone take her anywhere without a car seat. It was just common sense. We don't think about what it was like to fly around in the air trapped in a metal thing with a bunch of people smoking. It was awful. You inhaled a tremendous amount of smoke, it was very unpleasant if you were a nonsmoker. And so the best public health policies are the ones that people just, they just become a new way of life, and it just happens to save a lot of lives, and make people happier and healthier and you get to see your grandchildren and don't complain about we stopped selling soda at your workplace, right? And actually we did, in our sample of employees, we did it ask people. Did they know about it? And if they did, what did they think about UCSF doing this. And we had about 80% of our employee population giving it either, I'm really enthusiastic or thumbs up, it's okay. And so there was a lot of support, I think, even though it never went out for a vote to our employees. It was something that leadership just decided to do. So I wanna show you a little bit of the results from the biomarker study. And this is... So here in this part of the study, we took, we found, we surveyed about 2,000 people a little more than that. And then we found a couple hundred of them that were drinking a soda a day within that group. And we said, called them up and said, "Hey, would you like to come in "and do this other piece of the study?". And so we had a couple hundred employees that we did complete physicals on, before and then 10 months after we stopped selling soda. And so this is a subgroup, and then we randomized some of these folks to an additional little piece, which was a brief intervention where basically we had somebody just say to them, in about a 10 minute conversation, saying, "We think you're consuming too much of this stuff, "would you like to talk about cutting down or quitting?". And so, this is showing you within this 200 people, this is showing you, and they're all heavy drinkers, they're all drinking at least one soda a day. And so what you're seeing here, this is their consumption before we stopped selling soda, and this is their consumption after 10 months after we stopped, for this is a little before 10 months later. And so they're drinking about 35 ounces a day, which is well over a liter, at the beginning. They're drinking 18 ounces a day 10 months later. Big, big drop-offs there. - [Audience Member] Is that in answer to a survey? - Yes, this is self-report. But what's cool, is we also have the biomarkers in the biometrics. So, here is their waist circumference. Now most of these people had overweight... Oh, gotta go back. Most of these people had overweight or obesity. The average waist circumference before the sales ban was 98.7, after it had gone down by... They lost just almost an inch in their waist circumference over that 10 month period. Now that's only 10 months, so you can imagine what might happen if you're living in an environment over years and years takes us a lot of time to put on weight. And the cool thing about waist circumference and this is just a different measure of waist circumference. We actually measured it three different ways. When doctors diagnose something metabolic syndrome, which is argued to be kind of a good way to think about risk for cardiometabolic disease, heart disease, stroke, Alzheimer's, all of that, and stage renal disease from diabetes. They have five things that make up the metabolic syndrome. It's things like, high blood lipids. The most of them, you have to get a blood test to know that you've got 'em. High cholesterol is a good example. It's part of metabolic syndrome. But the only thing that is in the metabolic syndrome criteria that you can figure out on your own, is waist circumference. And if your waist is larger than your hips, we say you probably should go in and get your blood tested to see if you've got other biomarkers for metabolic syndrome, and the reason it's very much, we call it sugar belly, because it's the same basic phenomenon that leads to what we call beer belly. And again, it goes back to the liver, the way that the liver is processing, either ethanol or fructose tends to lead to selective deposition of fat around the waist. And so that's not a good thing. You can be overweight or obese even, and with a fairly small waist, and you're probably not as at risk. I wouldn't wanna say, this is like a population level not an individual level claim, but in the population it's less, waist circumference is an indicator that there might be something going on metabolically. And so that's why we were so excited to see that waist circumference went down. This was the primary outcome for the trial. And here this is showing a couple things. One, that most of the really important effects happened in the overweight and obese group of employees, not in people who were a bit more average weight. And so, you see the big declines are happening again, right? Where we wanna see 'em, in the most at risk in the population. And so that's their sugar-sweetened beverage consumption is going down, and again, you're seeing the waist circumference going down quite a bit. And then here, we're also seeing some other blood biomarkers that changed. So, this is the most important one. That is an indicator of insulin sensitivity. So, if you are prediabetic or diabetic, you are insulin resistant. And so what we wanna see, is in this case is the correlation. So the people who said and this goes back to the astute question about sugar-sweetened beverage consumption, it was self-report, but what we're seeing is, when people said they lower their SSB consumption, their insulin sensitivity got better. So that's a sign that the intervention, the sugar-sweetened sales ban, beverage sales ban is driving this, at least sugary beverage consumption is driving the changes in blood sensitivity. And then, this is a paper that's about to come out. And we did a microeconomic simulation, where we tried to figure out, okay, based on that waist circumference change, what would be the potential savings, cost savings to the healthcare system and to an employer and to an employee, if more organizations followed UCSF's lead and started to stop selling sugar-sweetened beverages? And it's a significant cost savings. And this were... There is a business case for doing this because employees save money. On average about 45 bucks a year for the employer, just by stopping selling soda and 18 for the employee. So, we did some dissemination of this idea, and one day I was just sitting at my desk and I got a call and it was personal with a British accent. And it was somebody at the National Health Service for the United Kingdom. And they said, you know, "We saw in the newspaper "that you guys just stopped selling soda "and we're thinking maybe we should do something like that, "and maybe we should pilot it in like some hospitals", and I'm like, "You guys, "you're thinking about doing it system wide?". So this is like the single payer system for the UK. And, they're like, "Yeah, "great". "Now, like, how did you do it?". And you know, they had a bunch of questions to ask and we wound up doing a little bit of consultation. And then one day I got this in my inbox and this is the telegraph from the UK, and they didn't pilot it in 11 hospitals, they just did it, (speaker laughing) all over England. And so they have 232 hospitals. We have four at UCSF. So, that's a lot of hospitals. And look at the number of employees and patients, and they just did it. And it turned out that they had... The CEO, I guess he is of the NHS just sort of felt like, "If we're gonna it, let's do it", you know? And so, yeah. And so this is really taking off, the other. I was down at UCLA and I was presenting some of the data I just shared with you on the employee data, and sitting in the room by chance, was the guy in charge of human resources for the entire UC system. So all 10 campuses all over California, giant public university, and he came up afterwards, and he said, "Can you give me (mumbles). And he's like, "How can we do this everywhere?". 'cause you can imagine, you know, he's in charge of all of these employees, their families, dependents, retirees, it's a very big health plan, and so the idea that we could do something simple to the environment of our campuses that would affect and of course this diabetes rates are between anxiety and diabetes, healthcare payers are really really suffering. Yeah. - I have a question. I'm sure many of us are wondering. My sugar consumption. Should I cut all sugar out? - Yeah. - (mumbles) all? - No. - And what about sugary fruit? - I'm just gonna sum up and let's get to the questions and answers. You guys here. Let me see if I can get, there we go. Yeah, so it depends on how much you're consuming. The metric for what is considered heavy consumption, one of them that I see in the medical literature is if 25% of your daily calories are coming from sugar, you're considered a heavy user. - [Audience Member] (faintly speaking) sugar too. - Well, that's a different issue, right? And, right, the white carbs are very quickly broken down into glucose, and there are nutrition scientists that I've spoken to who they're kind of a little more, you know, there's more debate around that. Straight up sugar, I mean there are scientists who are funded by the food and beverage industry who will tell you it's no problem, but neutral scientists who are studying the issue will tell you absolutely it's a huge problem. but I'm not a believer in draconian like I said, we all wanna live in this world and enjoy our days, and without harming our health. So the standard recommendation is nine teaspoons a day or less for a man, an adult man, and six for a woman or 38 grams, 25 grams. - [Audience Member] That's a max. - Max. - [Audience Member] Does this include all forms of sugar? - Yes. - Including a fruit? - No. So, the sugars that occur naturally in fruit are different. They come packaged with fiber, they are probably not as efficiently absorbed when they're going through the small intestine, and so that's very different from refined or added sugars. - [Audience Member] So that's where all my sugar-- - Yeah, there's sugar in milk. They're naturally occurring sugar, lactose. There's fructose in fruit. Do not stop eating fruit. It's very, I mean, it's heart-healthy. Fruit is, and I know there's a lot of noise in terms of dietary recommendations, and questions about whether fruit, but the epidemiological studies are really clear. Fruit consumption is good and there's some mechanistic research suggesting that maybe it's the way that, your body maybe has to work harder to get through all the fiber, to get to the fructose, and to extract it and so, as it's moving through your system, there may be less uptake. I mean that's a hypothesis it hasn't been proven yet. - Nine teaspoons (faintly speaking). - Of have added sugar. - Added sugar? - Yeah, and the problem is that sugar is hiding in everything. And I think the best recommendation is if you can avoid anything in packages and bottles and cans, good idea. Cooking at home, and just avoiding the packaged and processed stuff because it's so hard to navigate those food labels, but it is a little easier. We just this year have started implementing the added sugar label, which was one of the biggest, you know, knocked down fights between the public health community and the USDA, and the industry, but it is now on the label and so you can see, but it's in grams, which is harder to calculate for people is like 4.3 grams for one teaspoon. I mean, they don't make it easy. And so, to make make your choices easier, just avoid packaged processed foods, in general there's pretty much, they just can't, from a nutritional standpoint, they can't compete with Whole Foods, and then if you are gonna be consuming things, then you do need to look at how many grams are in there, keep the number 38 in your head, and try to add it up over a given day. Now if I have one, you know, I forget the name of the company, that makes the sugary yogurts, Dannon or yeah, Chobani, one of those. That's almost 25 grams of sugar pretty right there. So, I do that in the morning and I don't have any budget left for the day. So, it's actually pretty easy with added... And you have to watch for things like bread, ketchup, barbecue sauce. Oh, yeah, yeah. Yeah. It's really added to stuff that doesn't taste sweet. It's just added. And I mean, sometimes it's in there as a preservative or kind of a stabilizer, and sometimes it's in there because it makes it more hyper-palatable. I mean, if yeah. So does that answer your question? - [Audience Member] Yeah, and what source information might I check to, - Oh, let me see if I got it. - To find more about-- - Yeah, I'm-- - Personal sugar consumption. - Yeah, I would encourage you, because, as I mentioned, we study the industry. And one of the things we've learned from studying the industry is how many nutrition scientists they pay for, and those nutrition scientists often put out, as a whole, the literature produced by industry-funded scientists, is biased. It's industry friendly findings. And so this is one of the reasons why we're all so confused, right? Because, you know, I go in to testify for a warning label in Sacramento, and there's the industry-funded scientists sitting in front of the American Beverage Association at the next table, and I'm supposed to, you know, and I say, "Oh, this is bad for you". And she says, "This is good for you". And I mean, it's post-truth. And so what I recommend is that you, people be very, very cautious consumers of information online around nutrition. And UCSF created a website for this very purpose. A dozen scientists got together it's called SugarScience. And it's just one word you can just, yeah, you can look it up, and what we did was we tried to get a dozen people from all different, like somebody works on Alzheimer's over here, somebody who works on an endocrinologist, you know, and get people to look at the literature and come up, work with some media people to make it accessible to the public, and come up with, what do we take away? For individual health, what do we take away from this literature? Like what is the right amount for people to have on a daily basis? What is, and it's not tainted, none of those scientists take money from the industry, and we worked with a library here to study, to take industry funding into account, when we came up with conclusions. So that was, and it is really genuinely neutral. But there... And, you know, the American Heart Association is a reasonable source of information in this area, but there are even whole scientific nutrition journals that are paid for by industry. So they're very deep into-- Hmm. - [Audience Member] You can go to the National Institute of Health? - NIH, yes. Like a lot of us here are funded by NIH. We don't consider that a conflict at all. A conflict happens when the entity funding the research, has a vested interest, in the conclusions that the research comes to, and NIH doesn't have any vested interest in what the scientists find. - [Audience Member] That's a wonderful answer to my question. - Oh, good. - [Audience Member] I gave up sugar for 30 days. Why is it so hard? What is happening in your brain that makes you so... I have given up alcohol for six months, it wasn't nearly as hard as sugar. - Yeah. Well, and that might also be because you're consuming it in a different pattern, right? With alcohol at least we may abstain during the day or abstain for whole, you know, longer periods of time. So-- - [Audience Member] (mumbles) but I found it really difficult. - Yeah, people have a similar reaction to caffeine, again, because we have such a standard pattern in our brains and bodies adjust. So, I reviewed some of that literature looking at it from the kind of perspective of an addiction scientist, and I have mixed feelings about it at this point stage of the game. There are people who you will hear from, who know a lot about addiction, and at Yale and at Duke, who will say, "Food addiction, it's real, "we gotta scale the measured in the US general population". And then you'll have people more like me who will say, "Well, I'm not willing to just say that for sugar itself, "and now caffeine when packaged with sugar, "of course is addictive". But, I wanna see when people in the lay public think about addiction, they're not thinking about there are a lot of different concepts in addiction science, habituation, craving, you know, I mean, a million different. But what most of us think about, is dependence. And dependence is a very specific phenomenon. It is defined by psychiatrists using panels of experts. And those criteria that we have global criteria and US-based criteria, the DSM-5, and it is very specific what's in there. And in order to qualify to get into the DSM or the ICD-10 criteria for addiction requires a tremendous amount of science for something to really be defined as addictive. - [Audience Member] (mumbles) one more minute. - One more minute? - One question, real quick. - Yeah, and so, we just don't have the knowledge yet, but I have talked to so many people who will say, "Oh, yeah, I was addicted". And what I would say there is for anyone who feels that way, titrating yourself off is a good way to go. Start simple things like, if you have candy at three o'clock in the afternoon, freeze grapes and munch that using functional equivalents, diet soda, probably to wean yourself off. - [Audience Member] I make my own pasta sauce from my own tomatoes I grow, so-- - Yeah, you're off now. But, you know, you're not alone in feeling like it's addictive, and there are studies to show, it's certainly rats, you can get them hooked. - [Audience Member] Thank you. (audience clapping) (gentle music)

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