Longevity issue Limit calories or not




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3 DR. ROBERT H. LUSTIG THE BITTER TRUTH ABOUT SUGAR How obesity, diabetes and other chronic diseases arise and how we can overcome them Lustig_Zucker_ indd: 10

4 Bibliographic information from the German National Library: The German National Library lists this publication in the German National Bibliography; detailed bibliographic data are available on the Internet at. For questions and suggestions: The author has made every possible effort to provide telephone numbers and Internet addresses that were current at the time of publication. Neither the publisher nor the author accept responsibility for errors or changes made after this book was published. In addition, the publisher has no control over the websites of the author or third parties or their content and assumes no responsibility for them. 1st edition by riva Verlag, an imprint of the Münchner Verlagsgruppe GmbH Nymphenburger Straße 86 D Munich Tel .: Fax: of the original edition: Robert H. Lustig, MD, MSL, The American original edition was published in the USA by Penguin / Hudson Street Pr entitled Fat Chance. Beating the Odds Against Sugar, Processed Food, Obesity, and Disease All rights reserved, in particular the right of reproduction, distribution and translation. No part of the work may be reproduced in any form (by photocopy, microfilm or any other process) or stored, processed, duplicated or distributed using electronic systems without the written consent of the publisher. Translation: Birgit Irgang Editor: Doortje Cramer-Scharnagl Cover design: Verena Frensch Cover image: Tobik / Shutterstock.com Typesetting: Daniel Förster, Belgern Printing: GGP Media GmbH, Pößneck Printed in Germany ISBN Print ISBN E-Book (PDF) ISBN E-Book (EPUB, Mobi) You can find more information about the publisher at: Please also note our other publishers at Lustig_Zucker_ indd: 10

5 Contents Introduction Time to think outside the box l Part 1 The greatest story ever sold Chapter 1 An error of biblical proportions Chapter 2 A calorie is a calorie, isn't it? Chapter 3 Personal Responsibility Versus Obese Babies Part 2 To Eat Or Not To Eat That Isn't The Question Chapter 4 Wolverine And Sloth Hormone-Driven Behaviors Chapter 5 Food Addiction Fact or Fallacy? Chapter 6 Stress and soul food l Part 3 Thoughts about fat Chapter 7 Birth, care and nutrition of a fat cell Chapter 8 The difference between "fat" and "sick" Chapter 9 The metabolic syndrome: The new plague l Lustig_Zucker_ indd: 10

6 Part 4 The "Really" Toxic Environment Chapter 10 The Omnivore's Curse: Low Fat Versus Low Carbohydrate Chapter 11 Fructose The "Toxin" Chapter 12 Fiber Half the Antidote Chapter 13 Exercise the Other Half of the Antidote Chapter 14 Micronutrients: Triumph or Gluttony? Chapter 15 Environmental "Obesogens" Chapter 16 The Empire Strikes Back: The Food Industry Answer Part 5 The Personal Solution Chapter 17 Changing Your Food Environment Chapter 18 Changing Your Hormones Chapter 19 Last Recourse: When Changing Environment Is Not Enough Part 1 6 The healthcare system as a solution Chapter 20 The “paternalistic state”: personal versus social responsibility Chapter 21 The tricks of the government so far Chapter 22 A call for global sugar reduction l Epilogue A movement from bottom to top Acknowledgments Bibliography Glossary Index Lustig_Zucker_ indd: 10

7 This book is dedicated to all of those obese patients around the world who suffer on a daily basis and their family members who sympathize with them. The children who do not have a normal childhood, lead an inhuman life and die a slow, early death. Parents who are plagued by guilt. The unborn children, whose brains and bodies have already been changed. But first and foremost, I dedicate this book to those of you who are or have been my patients because it is you to whom I owe my knowledge of your suffering. They taught me more than any medical school ever did or could, and taught me that all life is precious, precious, and worth saving. Despite the most adverse circumstances imaginable, you have preserved your dignity. You have shared your secret with me as well as your joy at small victories. We cried and laughed together. I hope I have been able to help you a little and offer you some consolation. This book is my way of returning the favor. Lustig_Zucker_ indd: 10

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9 This book is written for those who eat food. It is not intended for anyone else. Lustig_Zucker_ indd: 10

10 Introduction: Time to Think Outside the Box l "We clearly eat too much." Governor Tommy Thompson (Wisconsin, USA), US Secretary of Health for 2001-2005, on NBC's Today program, 2004 That's true. So it is, thank you for purchasing this book, you are a great audience. Then I can go again. Well, that's what the US government is trying to get you to believe. All of the major US government health organizations, the Centers for Disease Control and Prevention CDC, the United States Department of Agriculture USDA, the IOM Medical Institute, the National Institutes of Health (NIH), and the director of the US Public Health Service say obesity is the result of an energy problem. Imbalance is: too high a calorie intake with too little physical exercise. And they are right up to a point. Do we eat more than before? Naturally. Are we doing less sport? No doubt. But although we know this, obesity and the diseases that go with it have not become rarer. It is important to know how this epidemic came about in such a short period of just 30 years. People say, "because we have the food," and that's true. But that was the case before. People say: "Because there is television," and Lustig_Zucker_ indd: 10

11 Introduction: Time to think outside the box 11 that's also true. But it was there even earlier without this calorie catastrophe. There is more to this thing, much more, and that is anything but nice. Everyone blames everyone else for it. In no case is it your own fault! The food company Big Food says it is due to the lack of exercise due to computers and video games. The television industry says the cause is the unhealthy diet. Atkins nutritionist blames carbohydrate excess, while Ornish fans believe we ate too much fat. The juice fraction thinks that lemonades and sodas are to blame, while the lemonade drinkers suspect the juice. The schools blame the parents, the parents in turn blame the schools. And since nothing is resolved, nothing is done either. How do we bring all these opinions under one roof so that a coherent picture emerges and changes are possible that represent an improvement for each individual as well as for society as a whole? That's what this book is about. Eating is not the same as tobacco, alcohol, or drugs. Food is nutrition. Eating means survival. And, what is particularly important: Eating means enjoyment. There are only two things that are more important than food: air and water. The roof over the head takes fourth place. Food plays a crucial role. Unfortunately, food plays too big a role today: food goes beyond what is necessary, is a consumer good and has also been made an addictive substance. This has numerous effects in our world, economically, politically, socially and medically. There has to be a price to be paid for it, and we are paying it now. We pay it with our taxes, our insurance premiums and our airfare. Almost every invoice we receive contains an excess weight surcharge. We pay with misery, poor school grades, social decline and death. We always pay, one way or another, because the diet we created does not match our biochemistry; this imbalance is at the heart of our medical, social and financial crisis. And what's worse, there are no drugs to counteract it. There are no regulations, no Lustig_Zucker_ indd: 10

12 Introduction: Time to think outside the box Laws, no regulations and no taxes that could remedy this problem on their own. There is no quick fix, but the problem can be solved if we know what is really going on and if we really want to solve it. In the 2004 book Food Fight, Kelly Brownell of Yale University speaks about obesity and the "toxic environment" we live in today - a euphemism for our collective bad behaviors. I go one step further. I'm interested in whether something really "poisonous" is going on here. Even laboratory animals have gotten fatter and fatter over the past 20 years! Every good story needs a bad guy. Actually, I didn't want to reveal it in the first pages of this book, but I don't want to keep you tortured any longer. It is the sugar that Professor Moriarty told this story is a substance that is found in almost all foods and beverages worldwide today. Sugar is slowly killing us; I'll prove that to you. Every statement in this book is based on scientific studies, historical facts, or current statistics. I am a doctor. We swear an oath: "primum non nocere" first of all no harm. But there is a paradox in these words: when you know that something is going to turn out bad, you will cause harm if you do nothing. Of course I'm not a lawyer. And I'm not looking for an argument either. I did not approach this controversy with a ready-made opinion. After dedicating myself to my medical career for 15 years, I became increasingly concerned with the topic of obesity. Until 1995 I tried to avoid obese patients, as did my medical colleagues. I didn't know what to tell them other than "This is your fault!" Or "Eat less and exercise more!" Back then it was an exception to see a child with type 2 diabetes. It's almost normal these days. As a doctor, the obesity problem can no longer be overlooked; it can no longer be passed over. The thoughts presented here did not just wake me up one day in a divine inspiration. This book is the essence of 16 years of medical research, medical conferences, academic Lustig_Zucker_ indd: 10

13 Introduction: Time to think outside the box 13 Exchange with colleagues, roundtables, policy analysis and comprehensive patient care. For me there is no conflict of interest in disclosing the information here; I am neither the plaything of the food industry nor the mouthpiece of any organization. Unlike many authors who have made the fight against obesity their goal, I don't have a line of products to replenish my bank account. I came to my views honestly and through thorough data analysis. The data is public so that everyone can see it. I'm just putting them together a little differently. As a scientist, I have personally contributed to understanding the regulation of the energy balance. As a pediatrician, I deal with the interactions between genetics and the environment that lead to obesity in my practice every day. Ever since I've been interested in the background, I've recognized how the changes in our society have triggered this global pandemic. This general overview allows me to establish connections for you and these really do not look the way they have been tried to make you believe up to now. Blaming obesity for obesity is the simplest answer, but it is wrong. Current views on gluttony and indolence, diet and exercise are shared by almost everyone, but they are based on false assumptions and myths that are anchored in the minds of people around the world. Obesity is not a malpractice, not a character weakness and not a mistake of the attending physician. Often times, when we think about the devastating effects of obesity, we think of adults first. But what about the children? A quarter of US children are obese today, and the numbers are also dramatic in Germany and Europe. Even toddlers weigh too much! Children don't choose to be obese. They are victims, not perpetrators. When you understand the science behind it, you will see that what applies to children applies to adults as well. I know what you are thinking now: adults are responsible for their own decisions and for the food they feed their children. But are they really? Lustig_Zucker_ indd: 10

14 14 Introduction: Time to think outside the box A valued colleague who has dedicated himself to the fight against obesity once said to me: »I don't care what causes the obesity epidemic. I just want to know what can be done about it. «Despite all respect, I contradict him. If we are to get rid of this evil, we must understand how it came about. In fact, our reasoning is based on interactions, hypotheses, and speculation. I wrote this book to convince you, the reader, to deal with the topic for your health, that of your children and for the benefit of our country. But you can't really stand up for something if you don't know what is actually going on. And you cannot wrong me before you know all the facts (including the scientific background). If after reading this book you think it's bullshit or I'm a nut, tell me. I want to know it. Here and now, I promise you that this entire book will not contain a single statement that cannot be backed up by hard scientific facts. My reputation in this field is based on science. It is also my protection from those who might try to discredit me, such as the food industry and, as you will see, the government. In fact, that's the only reason I haven't fallen into disrepute. And that's not going to happen either, because I'm sticking to science. Now and in the future too. In four places in the book, however, I let my imagination run wild. I would like to try to explain how obesity fits into the evolutionary process, how our evolutionary biochemistry works to keep us alive, and how our food environment has altered this biochemistry to fuel our global catastrophe. These outbursts of speculation can be found in the chapter entitled "Darwin Newly Interpreted". This book is for the suffering patients, for the doctors who sympathize with them, for the American voters who are paying for this debacle, for the politicians who need to take action to get us out of this dilemma that is due for our economy and health, and for the rest of the world, so that no one makes the same mistakes we do (even if they have already done so). Lustig_Zucker_ indd: 10

15 Introduction: Time to Think Outside the Box 15 In Part 1 of the book, I will question some of the theories that you have come across over and over again through the media and, indeed, through doctors. Parts 2 and 3 focus on the scientific facts related to obesity and how the body deals with burning and storing energy. No, you don't have to be a biologist or medical professional to understand this background. I tried very hard to concentrate everything on the essentials and to keep my text interesting, understandable and easily accessible. In Part 2, I also explain how our brains evolved and evolved in the womb to thwart your dieting attempts. In terms of the foods you want to eat, you are simply hormonally controlled in unimaginable ways. Part 3 of the book deals with adipose tissue from a scientific point of view and with the question of when and how it can make you sick. In Part 4 I will show you that our current environment is indeed "toxic". I will show how the "American diet," which today corresponds to the diet of the industrialized world, is slowly killing us. I'll name the poison and antidotes, explain why these antidotes work, and explain why they have been added to or removed from our menu for the purposes of the food industry.Part 5 deals with the question of what you as an individual can do to protect yourself and your family by changing your "personal environment". Finally, in Part 6, I discuss that governments around the world have been taken over by the food industry; and I will explain how those in power must instead join forces and influence the food industry to stop the obesity pandemic before medical and financial disaster strikes. Because that's what we're headed for. Lustig_Zucker_ indd: 10

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17 Part 1 l The most important story that has ever been sold Lustig_Zucker_ indd: 10

Chapter 1 A Biblical Error l In 2003 I came to my office with Juan, a six-year-old Latino boy weighing forty pounds, whose mother did not speak English and who worked on a farm in Salinas, California. It was wider than it was tall. In my broken Spanish I asked my mother: "I don't care what your boy eats, tell me what he drinks." The answer: no soda, but about four liters of orange juice every day. In terms of calories, that's enough for 50 kilograms of body fat per year. Of course, some of it will be burned, and juice consumption may also have an effect on food intake. I explained to my mother: "La fruta es buena, el jugo es malo." (Fruit is good, juice is bad.) "Eat the fruit instead of drinking the juice." She asked: "Why does the WIC give it to us then? ”(WIC“ Women, Infants, and Children ”is a US Department of Agriculture nutrition program to support the poor.) A child, a mother, and a question that changed my life and led to the creation of this book. Why did the WIC feeding program give people juice? Our worldwide obesity catastrophe can be explained scientifically. And science should steer politics but as you will see, politics actually comes with the Lustig_Zucker_ indd: 10

19 An error of biblical proportions 19 Get in the way of science. This is one of the most complex problems we face today. It has become increasingly complicated over time as there are a multitude of stakeholders with clearly defined intentions. Yes, the problem is now bigger than the individual parties involved. In the absence of easy solutions, the problem has destroyed families and killed countless people. You can't pick up a newspaper or surf the Internet without coming across new statistics on the obesity pandemic. And who has something positive to report in this context? In their headlines, gossip sheets mostly focus on either the increasingly alarming statistics or the fact that a new anti-obesity drug has been rejected or withdrawn by the US Food and Drug Administration. I'm sure you're fed up with this. At least that's the case with me. Losing weight has become a martial art - just tune in to the TV show The Biggest Loser. In January 2016, the World Health Organization (WHO) warned that at least 41 million children under the age of five worldwide were too fat or even obese, that is over 6 percent of all children of this age. There has been a significant increase in this over the past few years. But despite all the media attention, visibility, discussion and diet programs, no government in the world can turn back the clock. As we get fatter, we get sicker too. Our susceptibility to disease increases faster than obesity increases. The amount of metabolic disease known as metabolic syndrome, which includes conditions such as obesity, type 2 diabetes, high blood pressure, lipid metabolic disorders, and cardiovascular disease, is growing rapidly. There are also other metabolic diseases that are associated with obesity, such as non-alcoholic fatty liver disease, kidney disease, and polycystic ovary syndrome. There are also other comorbidities associated with obesity such as orthopedic problems, sleep apnea, gallstones and depression. The health disaster that follows from the obesity pandemic is overwhelming. The frequency of each of these diseases has in the past Lustig_Zucker_ indd: 10

20 20 The most significant story that has ever been sold has increased for 30 years. And besides, they all now appear in children as well, even in five-year-olds. There's even an epidemic of obese six-month-old babies! 1 The consequential damage resulting from the metabolic syndrome is clearly evident. In 2005, a study showed that despite better access to health care, our children will be the first generation of Americans to die earlier than their ancestors. 2 The study placed the blame directly on the obesity epidemic. In the United States, people lost twice as many quality-adjusted life years to obesity in 2008 than in the emergency department caring for 40-year-old heart attack patients. There used to be no young people with type 2 diabetes, but today they make up a third of all newly diagnosed diabetes cases. In Germany alone, at least one bariatric interventions (to reduce the size of the stomach) are carried out each year, in the USA it is annually with an average cost of dollars each. More than 40 percent of death certificates in the US state diabetes as the cause of death 20 years ago it was only 13 percent. In Germany, the number of deaths doubled between 1998 and 2014 for which “obesity and other overeating” was directly stated as the cause of death. Even if it is a doubling at a low level, a clear trend is visible. The loss of productivity due to sick days is high, health costs are exploding: In 2011 they amounted to over 290 billion euros in Germany, that is 11.3 percent of the gross domestic product. It is estimated that around 10 billion euros of this is obesity-related. Just imagine that! There just isn't enough money to pay for all of this. In the USA, the Patient Protection and Affordable Care Act (PPACA or ACA, also known as obamacare), which regulates access to health insurance in the USA, ensures that up to millions of sick people are admitted to health insurance. The US President believes that we will offset the costs with savings in prevention. However, it is unlikely that we will significantly improve our health as a result, as it does not contain any- Funny_Zucker_ indd: 10

21 An error of biblical proportions 21 ne measures for the prevention of chronic diseases are particularly those associated with obesity. How can you prevent all the sequelae of chronic metabolic diseases when we break the scales and the statistics show no sign of improvement? It has been said many times that if there was obesity reform, we didn't need health care reform. If obesity were a problem in the US only, things would be different, but in fact it affects all countries. The obesity pandemic has increased waist size all over the world. The WHO found that the percentage of obese people has doubled worldwide in the last 28 years. In fact, obesity's contribution to chronic disease is at least as large as smoking, if not greater. Even people in developing countries are obese. In a single decade, there are now 30 percent more obese than undernourished people worldwide, the WHO reported that around 1.5 billion adults worldwide are overweight and at least 400 million are obese; 3 It was expected that these numbers would rise to around 2.3 billion and 700 million respectively by 2015. In September 2011, the UN General Assembly declared that non-infectious diseases (diabetes, cancer and heart disease) now pose a greater threat to global health than infectious diseases even in developing countries (see Chapter 22). Does the whole world now consist of wolverines and sloths? Over the next 15 years, these diseases will cost over $ 7 trillion in low- and middle-income countries. 4 People die earlier and economies lose billions of dollars to reduced productivity while governments pay for health care bills. Millions of families fall into poverty, so this vicious circle cannot be broken. The 55 percent of adults who are overweight or obese should now listen carefully. I am speaking to you, from doctor to patient. Obesity is not automatically a death sentence. In 20 percent of morbidly obese people, the metabolism is healthy, so that they have a Lustig_Zucker_ indd: 10

22 22 The most significant story that has ever been sold is normal life expectancy. 5 The other 80 percent need not necessarily be in poor health; it is up to everyone to improve their health and regain those years that insurance statisticians say have been lost. But success depends on knowing the cause of the problem, correctly assessing your risk of metabolic diseases and changing your biochemistry. Okay, to be completely honest, no matter how hard you try, you may never get rid of your stubborn subcutaneous fat, which is the fat on your thighs and buttocks. And if you do, unless you develop into a sports fanatic, you will soon be able to regain it, because exercise is the only sensible way to prevent weight gain again (see Chapter 13). The fact is, if you lost significant amounts of subcutaneous fat and didn't regain it in just over a year, I would be stunned. Pleasantly surprised, but still stunned. The 45 percent of normal weight adults should be careful. They either smile derisively at the other 55 percent of their fellow citizens who take two seats on the bus, or they feel sorry for them. They consider them weak, self-indulgent, and lazy. They get angry with them and show it financially and socially. They are annoyed that they are costing their money. And they think they are off the hook and safe. They have been told that they will have a long and healthy life ahead of them. Whatever you do, it will be right. Those of them who are "naturally" slim have been told that they have great genes and that they can eat lemonade and cream tarts as much as they like without gaining a pound or getting sick. If only that was true! A few years ago, these slim people were in the majority in the United States. Now they are a minority. And the percentage shifts to their disadvantage year after year. This means that many of them will switch to the other camp, so they will gain weight. According to current projections by the WHO, 47 percent of women and 65 percent of men in Germany will be overweight by 2030; obesity will rise to 21 percent (women) and 24 percent (men). 6 The film Wall-E from Lustig_Zucker_ indd: 10

23 An error of biblical proportions 23 The year 2008 is a prophecy: That is where we are going. We will all be so fat that we will drive around on small scooters, as is already the case with us in large supermarkets. And with age, the risk of getting fatter increases. Your genes won't change, but your biochemistry will. So when you move to the other camp (which more and more of you are going to do) there has to be something that does that. And if that's not your fate, it will be your children's fate. Nobody knows that better than me because I take care of these children every day. Here is the problem. Being thin is not a protection against metabolic disease or early death. Up to 40 percent of those of normal weight suffer from insulin resistance, a sign of chronic metabolic disease that is likely to shorten their life expectancy. In 20 percent of these people, liver fat can be seen on an MRI scan of the abdomen (see Chapter 8). 7 Liver fat has been shown to be a major risk factor for developing diabetes regardless of body fat. Do you think nothing can happen to you? You're on the wrong track! And you don't even know. The main thesis of this book is that unless you surrender, your fat is not your destiny. Because people don't die directly from obesity. They die because of what happens to their organs. In the rarest of cases, the coroner or doctor notes on the death certificate "obesity", but rather "heart attack", "heart failure", "stroke", "diabetes", "cancer", "dementia" or "liver cirrhosis". These are the diseases that are associated with obesity. All of them are chronic metabolic diseases. But people of normal weight also die from them. That is the important thing! It's not obesity. Obesity is not the cause of chronic metabolic diseases; it is a hallmark of chronic metabolic disease, also known as metabolic syndrome. It is metabolic syndrome that is killing you. Understanding this difference is essential to improving your health regardless of your size. Obesity and metabolic syndrome overlap but are different things. Obesity doesn't kill. The metabolic syndrome Lustig_Zucker_ indd: 10

24 24 The most significant story that has ever been sold kills. Both go hand in hand, but one does not trigger the other. But what then triggers obesity? What is the cause of Metabolic Syndrome? And what can you do about it? Continue reading. I wrote this book to help you and your children get healthy, improve the quality of life, increase productivity, and reduce the worldwide waste of medical resources. If you lose weight in the process, that's great. However, if that is what you expect, you should find yourself a diet guru good luck! Do you want to get healthier? Do you want to be happier? To look better? It's the fat that builds up around your abdominal organs and liver that gets in your way. And getting rid of belly fat isn't as difficult as you might think. In terms of metabolism, this fat is more active and there is a lot you can do to make it go away. A proverb says: "Even a journey over kilometers begins with a first step." This book introduces you to the functioning of your body. It's a journey into the biochemistry of our brain and our fat cells. It is a journey into evolution, into the imbalance between our environment and our biochemistry. And it's also a journey into the world of business and politics. This journey begins with a single, but very large, step in which we abandon our previous obesity thinking and challenge the age-old belief that "a calorie is a calorie". Lustig_Zucker_ indd: 10

25 Chapter 2 A calorie is a calorie, isn't it? l "If you want to maintain a healthy weight, you have to watch your calorie intake and consumption. Not all calories are created." Governor Tom Vilsack, Iowa, US Secretary of Agriculture at the publication of the 2010 Nutritional Guidelines, January 13, 2011 Wait a minute mal: If people are to be careful about their intake and consumption of calories, why aren't all calories created equal? Is not that a contradiction? That was the first time any member of the US government had suggested that calories are not the same as calories, albeit indirectly in this cryptic cipher. Everyone feels like a nutritionist. Everyone thinks they understand the basics of obesity. But believe it or not, it is one of those diseases that are difficult to see through. Why? Obesity is a combination of several factors: physics, biochemistry, endocrinology (hormonal factors), neuroscience, psychology, sociology and environmental hygiene all contribute to this one problem Funny_Sugar_ indd: 10

26 26 The most significant story that has ever been sold at. The factors driving the obesity pandemic are almost as numerous as the number of people who suffer from it. The Venus von Willendorf is an eleven centimeter statue that was found in Austria in 1908 (see Figure 2.1). Using radiocarbon dating, their age was determined to be around years. The figure consists of the torso of a morbidly obese adult woman. Because of this, we know that obesity occurred long before our fast food. So there are other ways than chips, pizza, soda, and beer to gain weight. The medical literature lists at least 30 diagnoses of which obesity is a symptom.These include problems with the brain, liver, or adipose tissue, genetic disorders, various hormonal imbalances, and the effects of certain medications. But none of these me- Figure 2.1: Fat Venus. The Venus von Willendorf is a 11 cm tall female figure whose age has been determined by means of radiocarbon dating to years before Christ. It was found in Austria in 1908 and can be seen in the Natural History Museum in Vienna. The Venus figure shows that obesity is as old as humanity itself. Lustig_Zucker_ indd: 10

27 A calorie is a calorie, isn't it? 27 Medical Causes explains what has happened to the world's population over the past 30 years. By 1980, only 15 percent of adults in the United States had a body mass index above the 85 percent range, indicating overweight or obesity. Today it's 55 percent. (The body mass index is the ratio of weight to height.) And it is expected that by 2030 it will total 65 percent. 1 Similar developments can be recorded worldwide, including in Germany. Something has happened in the last 30 years but what? The First Law In order to understand obesity and energy balance in general, we need to familiarize ourselves with the first law of thermodynamics, which says: "In a closed system, the energy remains constant." For the math and science freaks among us: U = Q + W where U stands for the internal energy of a system; Q is the heat supplied by the system and W is the work done by the system. In a closed system, the change in internal energy corresponds exactly to the sum of the change in heat and the change in work. Different forms of energy can transform into one another, but energy can neither be destroyed nor "just created". The first law is a law. It's elegant, tough and puncture-proof. If you don't like this, you must complain to Sir Isaac Newton. I sign this first law. However, the basis for our current understanding of the causes and consequences of the obesity pandemic does not lie in the first main sentence itself, but rather has to do with the way you interpret it because, as with all laws, there is ample scope for alternative interpretations. The prevailing opinion about the first law can be summarized in a widespread theorem: A calorie is a ka- Lustig_Zucker_ indd: 10

28 28 The most significant story that has ever been sold is lorie. This means: In order to maintain the energy balance and thus the body weight (the U in the equation), one calorie eaten (the Q) must be compensated for by a calorie burned (the W). The calorie intake can come from any source, from meat to vegetables to cheesecake. The calories burned can be used in any way, from sleeping to watching TV to doing strenuous exercise. And from this opinion the well-known standard interpretation of the first main sentence developed: "If you have eaten the calories, you should rather burn them, otherwise you will store them." With this interpretation, the behavior of increased calorie intake and reduced energy consumption are in the foreground (and will probably be learned); consequently, the weight gain is a side effect. Consequently, obesity is believed to be the natural consequence of these "deviant behaviors." Indeed, as you will see below, all stakeholders in the obesity pandemic have sided with personal responsibility. The seating arrangements at the table of guilt At the top of the table: wolverines and sloths Personal responsibility occupies the largest chair at the table of guilt. The widespread thesis about obesity is that it depends on a personal choice: We control what we eat and how much we move. If you're obese, it must be because you decided to eat more, exercise less, or both. Over the past 25 years, several US government agencies have amassed extensive evidence of increased caloric intake in children and adults. During this time, the US Centers for Disease Control and Prevention has documented that Americans consume 187 kcal more per day compared to 335 kcal for American women. The development is likely to be similar in Europe. The behaviors that go hand in hand with the increase in obesity include increased levels of concentration. Lustig_Zucker_ indd: 10

29 A calorie is a calorie, isn't it? 29 sum of sugared beverages and a decline in the consumption of whole fruits, vegetables and other sources of fiber. On a societal level, obesity is also related to mothers breastfeeding less, skipping breakfast, having fewer family meals and eating more fast food. On the other hand, there is also ample evidence that less physical activity and more time in front of the TV screen (TV, computer, video games and smartphones) play a role in the increase in obesity. It is on this basis that our obesity beliefs arise: gluttony and laziness, two of the original "seven deadly sins." At this point I should note that the other five deadly sins (greed, pride, lust, envy, and anger) are tolerated in the press and in society at large. They are often even praised in the media - just think of reality shows like »big boss« (envy, greed, pride, anger), »Catch the Millionaire« (lust, greed, pride) or »party, brother!« ( all known sins and a few more). We somehow find absolution for almost every vice and sin that one can commit, only not for gluttony and laziness. They defy our society's ability to forgive. Even though so many of us are overweight or obese. Slim people are in the minority today, but our culture continues to punish the majority. The average woman in Germany wears size 44, but in many shops you cannot find anything above size 42. Many women's clothing stores have moved to label larger clothing with a smaller size (what was size 38 in 1950 is now labeled size 34); nevertheless, a large percentage of the population cannot buy suitable clothes in the store. About ten years ago a 24-hour health club in San Francisco featured an alien on a billboard with the slogan, "When they come, they'll eat the fat first." Our society still glorifies being slim, even if it does Seems to be less attainable year after year. People who are overweight or obese are immediately mistaken for wolverines and / or sloths. Obese people are disadvantaged when it comes to assigning jobs because it is assumed that they are just as lazy at work as they are when it comes to caring Lustig_Zucker_ indd: 10

30 30 The most significant story that has ever been sold is your body. They belong to the last groups about which one can make derogatory remarks in public. It is only a small step from that contempt to realizing that obese people became that way because of a behavior disorder. This formulation serves many purposes. Of course, it also satisfies society's desire to blame someone. Even the obese believe in the personal accountability thesis (see Chapter 20). They prefer to be portrayed as a "perpetrator" rather than a "victim". When you are a perpetrator, you are in control and make your own decisions. There is more hope in that than in the other alternative. However, if you are a victim, you have no strength; Obesity is a fate and there is no hope. You're damned that's a lot more depressing. In addition, "personal responsibility" serves as a cornerstone of government and insurance limited support for obese people. Chair 2: Health Insurance Much of the public sees doctors as greedy charlatans who care less about their patients than about their wallets. In fact, we doctors lose money with every patient we treat. While our local general hospital health insurance reimburses an average of 37.5 cents per dollar for pediatric treatment (a starvation wage), our pediatric obesity clinic receives only 29 cents per dollar billed. The reason? The health insurance system refuses to pay for obesity care on the grounds: “Obesity is a behavior, a character weakness, a psychological failure. And we don't pay for behaviors. ”That's why obesity clinics and treatment programs for children across the country are closing despite being busy and more than busy. Insurance has decided that obesity is a lifestyle choice and you don't want to pay for it. And if health insurers do pay, then only the bare minimum. Lustig_Zucker_ indd: 10

31 A calorie is a calorie, isn't it? 31 Insurance hates this obesity epidemic almost as much as we doctors. They are looking for a hiding place to endure a long siege. Why are insurers still refusing to reimburse obesity services? The reason: If they paid for all the services required as a result of today's pandemic, it would skyrocket costs. Instead, they continue to crouch and blame each and every one of them. They know that if they ever admitted that obesity is not the person's fault, they would be in real trouble. Chair 3: The Medical Profession 20 years ago obesity was considered a social problem, not a medical one. At the beginning of my professional career, a colleague in pediatric endocrinology (the study of hormones in children) sent a form letter to the parents of children who were hospitalized for obesity. The letter read: “Dear Parents, Thank you for your interest in our Pediatric Endocrinology Department. Your child was referred to us because of obesity. Obesity is a diet and exercise problem, not a hormonal problem. We encourage you to seek general advice from a pediatrician. ”And despite the undeniable onslaught of referred patients, many of my colleagues still agree. As the problems and the money invested in scientific studies have multiplied, the United States Diabetes Association (ADA), the United States Heart Association (AHA), and countless other professional organizations are now extensively addressing the obesity pandemic. The standard medical establishment mantra about obesity is, "Lifestyle causes obesity, and obesity causes metabolic syndrome." We doctors see our role as alleviating the negative effects of obesity. But for most medical professionals, behavior remains the top priority when it comes to the causes. In her opinion, the fault still lies with the patient. Lustig_Zucker_ indd: 10

32 32 The Most Significant Story Ever Sold Chair 4: The Beneficiaries of Obesity They say, “You are weak. You failed Let us help you. ”They claim to have answers to the obesity problem and offer one solution at a time. They are the beneficiaries of obesity and represent large, important industries, most of which are supposedly trying to "do right" while making a lot of money in the first place. There are, for example, the otherwise honorable weight loss programs like those of Weight Watchers or Optifast 52, which strongly recommend buying their branded products (which often contain a lot of salt) in order to increase their profits. There are also companies that offer nutritional supplements (such as Diet Chef, a new diet concept in Germany from Great Britain) and demand that you buy their products if you want to see results. Gyms that offer special weight loss programs charge entry and renewal fees for membership. And then there are companies that make fitness equipment for the home. Your commercials broadcast at night always show well-trained types stretching a rubber band or exercising in a similar way, as well as the indirect message: "This is how you can look when you train with this fitness article." There are also the "obesity authors" (well, what , I'm one now too!). Some are medical professionals, some have a doctorate, others are journalists, others are media stars, and there are also a few charlatans, although the individual categories are not mutually exclusive. All claim to have the answer to your obesity problem and are in favor of one diet or another. Some of these writers have started their own companies that sell their line of products. And each one provides just enough science and truthfulness to convince the public. Some dieticians and clinics advocate prescribing appetite suppressants or other drugs to aid weight loss, all of which you have to pay for yourself. Some of those doctors are respected and outstanding scientists in medical schools, and they try to make people's lives through obesity research Lustig_Zucker_ indd: 10

33 A calorie is a calorie, right? 33 to save. Some are surgeons who shrink the stomach to relieve the metabolism and the heart, or who suction off the fat for cosmetic reasons. But one or the other carries out such operations on the assembly line, flies from one small town to the next in a small plane to insert as many gastric bands or gastric bypasses as possible. They take money from their victims, do not provide quality control, never see their patients again afterwards, and sometimes leave medical disasters behind. While insurance companies often refuse to pay for this problem, research money is pouring out. The pharmaceutical industry has spent a lot of money to find the "obesity blockbuster", the miracle pill with long-lasting effects that is suitable for everyone. But that is a pipe dream, because firstly, obesity is not a single disease, but a mix of many diseases; second, our bodies always find ways to maintain our critical energy balance so that a single drug cannot be equally effective for everyone; and third, there is no drug that can be used to treat metabolic syndrome (see Chapter 19). All of these individuals and companies have one thing in common: They are trying to turn the US $ 117 billion annually misfortune on the obese. And all of these funds are available in retail stores, so those affected pay them out of their own pockets. There are no insurance reimbursements. No discount. In case you haven't noticed, obese people are actually doing everything they can to lose weight, including throwing their money out of the window for programs that promise them thinning soon. Because of this, these providers take advantage of obesity. Does one of your "solutions" work? Hardly likely! Their reasoning: If customers did what the company asked them to do, the fat would magically disappear. If that doesn't happen, that's the customer's mistake, then they probably didn't get it right! By the way, this is another reason for obese people to fall into depression. Think about it: If any of these books, diets or programs actually work for the entire population - Lustig_Zucker_ indd: 10

34 34 The greatest story ever sold would work if there were only one of them. Whoever makes this discovery is very likely to win the Nobel Prize, retreat to a luxury villa in Tahiti, and be celebrated in the media. Chair 5: The Fat Activists From a social or medical perspective, there is nothing wrong with being fit and fat; that's better than being slim and not moving. But being fat and sick is not okay from a medical point of view. Especially if you have metabolic problems, like 80 percent of all obese people. If you fall into this category, you are costing society money in treating your metabolic diseases because of your reduced productivity and the burden on the health system. Not to mention digging your own early grave! The advocates of the political and social rights of the obese, particularly the National Association to Advance Fat Acceptance (NAAFA) say, “Being fat is an honor. Be fit and fat, fat and proud. «So no discrimination. And I agree with that.But the NAAFA is also trying to stop scientific research on obesity because why should one research a condition that is completely normal? For example, the NAAFA sits on the board of directors of the San Francisco School District and prevents obesity research from being carried out in city schools. Why? The association believes that the question of how much children weigh should not be considered. I find that strange. Allowing your child to be fat and sick is downright paradoxical. Most obese children will have diabetes and heart problems by the time they are 50 years old. The studies that the NAAFA is trying to block are critical to investigating this epidemic and what we can do about it. As a pediatrician, it is my job to protect these children from such inappropriate ideas. Lustig_Zucker_ indd: 10

35 A calorie is a calorie right? 35 Chair 6: The Commercial Food Industry The commercial food industry is responding to the obesity pandemic with two mantras. First: "Everyone is responsible for what they put in their mouth" is that true? What goes into our mouth depends on two things: selection and availability. Second: "Any food can be part of a balanced diet." That is true, but irrelevant, as we do not eat a balanced diet thanks to the food industry. She is the one who created the imbalance. She is the biggest driver of the obesity pandemic because of her actions and the kind of rhetoric she uses to justify those actions. Companies keep preaching one thing, but doing something else. McDonald's is now promoting a healthier menu with lean people in sportswear eating salads. But most of the people who go to McDonalds order burgers and fries instead. And of course McDonalds is aware of that. The latest poster campaign with the slogan "Made for your desires" says it all. The fast food chain Carl s Jr., which is not only active in the USA, but also in Turkey, Brazil and the People's Republic of China, is promoting the Western Bacon Six Dollar Burger, which has impressive calories and contains 55 grams of fat, but forms usually fit and attractive people who enjoy consuming the company's products. Do you really think that if you ate something like this regularly, you would stay slim? Food has become a commodity (see Chapter 21), and food can be stored and traded on the various commodity exchanges almost anywhere. Speculators can rule the market on any commodity from pork belly to orange juice by betting on how far the price will go up or down. And since individual foods are traded as commodities, the effects of the bets on food supplies and, consequently, on food prices around the world can be felt (see Chapter 21). Inexpensive food stands for political stability. There is a need to make food readily available and to keep prices as low as possible. Everyone is for cheap groceries. In 2011, Germans only spent 13.7 percent of their total consumer spending on food. Lustig_Zucker_ indd: 10

36 36 The most significant story ever sold is tel out, which allows the population to buy more DVDs and ipads and go on vacation more often. But for inexpensive food that is full of preservatives so that it lasts longer, you end up having to pay much more than what all your gadgets and vacation trips cost (including interest). Chair 7: The Government The United States government is extremely torn as to its position on the obesity pandemic. In 2003, Richard Carmona, the former US medical inspector, stated that obesity was a national security issue, an attitude shared by current medical inspector Regina Benjamin (although she is obese herself) and shared by the US Army has committed. Government health organizations tell us that we overeat and do not exercise enough. First Lady Michelle Obama's "Let's Move!" Campaign focuses on the idea that childhood obesity can be tackled by planting vegetables in school gardens that encourage children to go outside and exercise, and revised the law on school meals. All of this is required, but it is not enough. The US government is doing everything it can to keep food affordable (see Chapter 16). The US Department of Agriculture has decided not to accept any responsibility for its role in the obesity pandemic and continues to market our western diet worldwide. The U.S. Agriculture Act (see Chapter 21) maintains financial support for food so farmers don't lose their jobs and plant more crops. Farmers owe their profit to the masses. The food processing industry makes high markups and passes them on to the consumer. And the U.S. Department of Agriculture subsidizes nutrition programs for the poor like the UN Food Aid for Low- or No-Income Households (SNAP) and the Women's, Toddler, and Childrens Nutrition Program (WIC), Toddler-Funny_Sugar_indd: 10

37 A calorie is a calorie right? 37 Provides food and health care to low-income mothers and their low-income mothers so that they can survive and be satisfied. The WIC gave in to the pressure of the food lobbyists: The food provided was largely unhealthy and included, for example, white bread and high-sugar juices. The food pyramid, a government nutritional recommendation that was first published in 1974 (see Figure 2.2a), never had a scientific basis. Since then it has been revised every five years in the USA and renamed »mypyramid« in 2004. After numerous medical associations demanded a correction, the food pyramid was discarded in 2011. The German Nutrition Society also designed a food pyramid that had long been carbohydrate-based and was modified in 2005. United States Department of Agriculture and Health Food Pyramid 34 teaspoons additional sugar 64 g additional fats Dietary guidelines recommend limiting the consumption of added sugar to no more than 12 teaspoons per day for a total intake of kcal. They also recommend that fats make up no more than 30 percent of your daily energy intake, roughly 73 grams of added and naturally occurring fats for a total intake of kcal. Use fats, oils and sweets sparingly Dairy products 1.6 servings of meat, poultry, fish, dried beans, eggs and nuts 2.5 servings of dairy products 2 3 servings of meat, poultry, fish, dried beans, eggs and nuts 2.5 servings of vegetables 4 Servings of Fruit 1.4 servings of vegetables 3 5 servings of fruit 2 4 servings of cereals 10 servings of cereal 8 11 servings Adjusted Food Pyramid Source: US Department of Agriculture Economic Research Service Food Pyramid of the US Department of Agriculture and Health Department Figure 2.2a: The ancient pyramids. The US Department of Agriculture's traditional food pyramid, which was in effect around 2005, advised eating more grains and less fats and sugar. Besides, what the Americans actually ate back then looks more like an hourglass than a pyramid. Lustig_Zucker_ indd: 10

38 38 The Most Significant Story Ever Sold Dietary guidelines recommend limiting the consumption of added sugar to no more than 12 teaspoons per day for a total intake of kcal. They also recommend that fats make up no more than 30 percent of your daily energy intake - approximately 73 grams of added and naturally occurring fats for a total intake of kcal. Figure 2.2b: The modern plate model. Under pressure from consumer associations and in response to the new scientific findings, the pyramid was abolished, the US Department of Agriculture published "MyPlate". This model advises us to eat about half a plate of vegetables or fruit, a quarter of high-fiber starch like whole grain rice and a quarter of protein, preferably low in fat. It is too early to say whether this change will have any effect on the eating habits of Americans. "Mypyramid" has now become "myplate" (see Figure 2.2b), and in many other countries, not least Germany today there are alternative nutrition models (DGE nutrition group, Logi nutrition pyramid, etc.). The Advisory Council's Guide to Dietary Guidelines (DGAC), published in the US in 2010, states that obesity is a problem (shocking) that everyone should eat less fat, sugar and salt. We should all eat more fruits and vegetables and less other things. This is nothing new. Don't we already know? Eat less? How? If we could eat less, there would be no obesity pandemic. But we can't. Every obesity pandemic advocacy group sings the same song: “Your obesity is your personal responsibility, it's funny_sugar_ indd: 10

39 A calorie is a calorie, isn't it? 39 your mistake and you failed. "All of these allegations are a variation on the theme based on the one unshakable dogma," a calorie is a calorie. "Calories don't count when it comes time to explore what is going on with them all Because the extra calories happened, the clues as to what really happened are there. In this data we will find the answer to the obesity dilemma. There are three problems associated with the phrase "a calorie is a calorie". First, there is no way we can burn off all of the calories our current food supply provides. A chocolate chip cookie has as many calories as can be consumed by jogging for 20 minutes; and weaning off a Big Mac takes four hours of cycling. Moment! American swimmer and multiple Olympic gold medalist Michael Phelps consumes and burns kcal a day, doesn't he? If that were the case for all of us, diet and exercise should work: we would burn more calories than we eat and lose weight as a result (see Chapter 13). Diet drugs would work too: you take the pill, eat less, and lose weight. But the drugs don't keep their promises: they work for a short time and then the weight loss stops (see Chapter 4). 2 Why? Do the patients stop taking the pills? No. Then why are the drugs no longer working? The answer is: Because the body is smarter than the brain. Energy expenditure is reduced to accommodate the lower calorie intake. So a calorie is not really the same as a calorie because calorie consumption is controlled by your body and depends on the amount and quality of calories ingested. Second, if a calorie was a calorie, then all fats would be the same, since when burned they release nine calories per gram- Lustig_Zucker_ indd: 10

40 40 The most significant story that has ever been sold zen. But they are not all the same. There are good fats (with valuable properties such as anti-inflammatory properties) and bad fats (which can cause heart disease and fatty liver disease, see Chapter 10). All proteins and amino acids should also be interchangeable, as they release 4.1 kcal per gram when burned. But here, too, there is high-quality protein (such as chicken protein) that can reduce appetite, as well as low-quality proteins (hamburger meat) full of branched-chain amino acids (see Chapter 9), which are associated with insulin resistance and the metabolic syndrome (see Chapter 9 ). 3 After all, all carbohydrates should be the same, as they also provide 4.1 kcal per gram when burned. But even that is not true. If you take a closer look at the analysis of carbohydrates, you will notice something interesting: There are two types of carbohydrates, starch and sugar. Starch consists exclusively of glucose, which is not very sweet and can be used as an energy supplier by every cell in the body. And even if there are several other types of "sugar" (glucose, galactose, maltose and lactose), when I speak of sugar in the following I mean the "sweet stuff": cane sugar and high-fructose glucose syrup, both of which contain the molecule fructose . Fructose is very sweet and inevitably is metabolized into fat (see Chapter 11). Fructose is the most important (if not the only) villain, the "darth Vader" who pulls you to the dark side in this wretched story. The third problem with "a calorie is a calorie" is illustrated by former US Health Secretary Tommy Thompson, who warned in 2004 that we are "just overeating," suggesting that we are ingesting too much of everything. But we don't eat too much of everything. We eat too much of some foods and too little of others. And in the word "some" we find the answer to the obesity pandemic. The US Department of Agriculture is observing nutrient disappearance. These data show that total protein and fat intake has remained relatively the same since the obesity pandemic spread. But due to the low-fat diet directive issued in the 1980s by the US Medical Association (AMA), the American Heart Association (AHA) and the Lustig_Zucker_ indd: 10

41 A calorie is a calorie right? 41 United States Department of Agriculture (USDA) was represented, the percentage of fat in the total amount of calories fell (from 40 to 30 percent). Protein consumption remained relatively constant at 15 percent. But if the total amount of calories increases, something else should increase even with the same fat intake. An examination of the carbohydrate data provides the answer: In terms of the total amount of calories, the consumption of carbohydrates has increased from 40 to 55 percent. 4 We actually eat more of both types of carbohydrates (starch and sugar), but our total starch intake has only increased from 49 to 51 percent of calories. And fructose consumption is now 12 percent instead of 8 percent, or in some cases (especially in children) 15 percent of the total amount of calories. As a result, it becomes clear that we are consuming more sugar and especially fructose. In Europe, the development is quite comparable; sugar consumption in Austria has increased twentyfold in the past 150 years! The answer to our global dilemma lies in understanding the causes and effects of these dietary changes. One lesson can be drawn from these three points, which contradict current dogma: Not all calories are created equal. Rather, the phrase "a calorie is a calorie" should be changed to: a calorie burned is a calorie burned, but a calorie consumed is not a calorie consumed. And therein lies the key to understanding the obesity pandemic. The quality of our food determines the quantity. And it determines our energy to burn it. Personal responsibility? Just another myth that real science refutes. Lustig_Zucker_ indd: 10

42 Chapter 3 Personal Responsibility Versus Obese Babies l Sienna is one year old and weighs 20 kilos. She weighed 15 pounds at birth and was born by caesarean section because of her size. Her mother is not obese, but her father is overweight. While she was pregnant, her mother tested negative for diabetes. Sienna has had an incredible appetite since she was born. Her mother could not breastfeed her because it would not have met the baby's nutritional needs. The Average Infant Sienna's Age Consumes About One Liter Of Baby Food A Day. Sienna ate two liters a day. When Sienna was six months old, we advised her mother to start feeding her solid foods. Sienna is constantly eating and screaming when her mother doesn't feed her. She already has high cholesterol and high blood pressure. Is Sienna obese because of her behavior? Was this behavior learned? When should she have learned this behavior and from whom? At the age of one, did she learn how to control her mother so that she can get what she wants? Should she take personal responsibility for her actions? In the dogma "a calorie is a calorie" behavior comes first. Personal responsibility presupposes a choice: A conscious decision leads to behavior. This behavior is based on er Lustig_Zucker_ indd: 10

43 Personal responsibility versus obese babies 43 learned benefits or harms (for example, when a baby puts his hand on the stove and realizes he is hot).But does that also make sense in relation to obesity? With everyone? There are six reasons why "personal responsibility" can be questioned as a cause of obesity. 1. Obesity is not a choice The concept of personal accountability for obesity doesn't always make sense. In today's society one has to ask: Are there people who view obesity as a personal benefit? Something desirable to achieve? In general, in modern western societies nowadays, the slim are valued and the obese are avoided. Obesity is often associated with medical complications; people are more likely to develop heart problems and type 2 diabetes (see Chapter 9). Obese people spend twice as much money on health care. 1 Studies show that obese people have more difficulty finding a partner and getting married, as well as having more difficulties with fertility. They tend to be poorer and earn less than their colleagues, even in well-paying jobs. 2 Now let's ask the same question about children. Did Sienna see obesity as a personal asset? Did she consciously become obese? The quality of life of obese children is similar to that of children undergoing chemotherapy for cancer. 3 They are marginalized and bullied by other children. Many obese children experience low self-esteem, shame, self-loathing, and loneliness. As part of a study, children were shown photos of possible playmates. Each one looked different, and some were physically disabled, disfigured, or were in wheelchairs. The researchers asked the children who they would most like to play with. The obese child came last. Obesity is clearly something that people, especially children, do not aspire to be. But this view of obesity does not necessarily coincide with the view of obese people. You see yourself as the perpetrator, Lustig_Zucker_ indd: 10

44 44 The greatest story that has ever been sold ain't a sacrifice. Often they say that they know they can no longer control their behavior and that this is their own fault. Often times they diet and suffer from the yo-yo effect. They lose weight for a period of time, and when they regain it they blame themselves and consider the relapse to be a character flaw. They often report binge eating, which suggests that nutritional control has been lost to some extent. These experiences of loss of control lead them to believe that they were in control before. But is that really true? 2. Diet and sport do not work If obesity were only about increased calorie intake and reduced calorie burn, reduced intake (diet) and increased consumption (exercise) would have the effect. If obesity were caused by learned behaviors, changing those behaviors would reverse the process and promote weight loss. Certain notable achievements have resulted in behavior and lifestyle changes being considered the cornerstone of obesity therapy. These individual reports include weight loss from celebrities like Kirstie Alley or Oprah Winfrey, who publicly advertise their diets as if they were the latest in handbag fashions. They tell their story on television and convince their viewers that this lifestyle change is possible for them too, and that the weight loss will make them attractive and happy (like adding the latest fall color to their wardrobe). There are reality television shows like The Biggest Loser, which document the weight loss (and many setbacks) of "normal people" through controlled diet and exercise. Advertising, cash prizes and constant attention are often enough to change your own diet and exercise behavior for a short time. And before and after pictures of people who have lost 45 kilos are shown in all magazines and many long-term advertisements for a new weight loss product. Lustig_Zucker_ indd: 10