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The 2014 film Fed Up is an advocacy documentary. Its message:

There is a worldwide epidemic of obesity.

It is endangering our children.

Increased sugar consumption is responsible.

The food industry is responsible for our increased sugar consumption because it puts hidden sugar in processed foods, bombards us with advertising, favors profits over health, and lobbies against regulation.

The government is responsible because it has failed to control the food industry.

The film has received mostly positive reviews and has been called the Inconvenient Truth of the health movement. It was written and directed by Stephanie Soechtig, whose earlier films attacked GMO foods and the bottled water industry, and narrated by Katie Couric, who “gave anti-vaccine ideas a shot” on her talk show in late 2013.

The film shows families struggling with childhood obesity and “experts” expressing their opinions. Their selection of “experts” is heavy on politicians and journalists and light on nutrition scientists.



Is sugar really the cause of the obesity epidemic?

Between 1971 and 2000, the prevalence of obesity in the United States doubled. During that time, fat consumption decreased, carbohydrate consumption rose, and average calorie intake rose (from 2450 to 2618 for men, and from 1542 to 1877 for women); the film blames sugar, but one could argue that total calorie intake was to blame.

Correlation is not causation, even when there is a strong correlation like the one between the rise in autism diagnoses and the rise in the sales of organic food. There is no such strong correlation between sugar consumption and obesity, much less any convincing evidence of causation.

Sugar consumption has actually decreased around the world even as the rate of obesity has continued to climb. Between 1999 and 2008, American consumption of added sugars decreased from 100 g/d to 76 g/d, mainly due to a reduction in soda consumption.

This webpage lists per capita sugar consumption by country, and it clearly does not correlate with rates of obesity in those countries. Countries with higher per capita sugar consumption than the US include Argentina, Australia, Austria, Belarus, Belgium, Brazil, Chile, Denmark, Estonia, France, Georgia, Germany, Iceland, Malaysia, Malta, Mexico, Morocco, Netherlands, New Zealand, Norway, Poland, Slovakia, Sweden, Switzerland, Ukraine, UK, and Venezuela. According to this source there are 17 countries with higher rates of obesity than the US. Not a single one of those countries has a higher per capita sugar consumption than the US.

There are other sources with different numbers, and these statistics don’t tell us much, because there are so many possible confounders such as lifestyle, total calorie intake, fiber, the type of sugar, hidden sugar in prepared foods, consumption of an otherwise nutritious diet, etc. The point is that it’s premature to make the kind of definitive pronouncements that the film makes about the role of sugar.

Gary Taubes makes a strong case for low-carb diets both for weight loss and health, but he admits that his hypothesis has not yet been properly tested. Chris Voight did an informal test of its exact opposite, a carbs-only diet: he ate nothing but potatoes for 60 days. According to Taubes’ low-carb theories he should have gained weight and raised his blood sugar, but instead he lost 21 pounds and lowered his blood sugar. His cholesterol and triglyceride levels dropped; he felt well and had plenty of energy.

The sugar/obesity hypothesis has not been properly tested either. There are plenty of examples of people who eat a lot of sugar and processed foods and don’t gain weight. In fact, one obese boy in the film complains that his brother eats the same way he does but doesn’t gain weight. There are plenty of examples of people who have lost weight and kept it off by reducing calorie intake and increasing exercise. We know some of the factors involved in successful weight loss, and eliminating sugar is not on the list.

Restaurants contribute to obesity by providing high-calorie food choices, large servings, and super-sized drinks. Fast food restaurants get a lot of blame, but John Cisna lost 56 pounds in 6 months while eating all his meals at McDonald’s. He counted calories and stuck to a 2000 calorie a day limit.

We don’t know that eliminating sugar from the diet is an effective strategy by itself. A family in the film eliminated sugar from their diet (they said they were “detoxing”!) and lost weight, but that could have been because they ate fewer total calories, and we don’t know that they would have lost any less weight if those fewer calories had included some calories from sugar. And the teenage boy lost weight but then gained it right back. What went wrong?

Colin Campbell of the Center for Nutritional Studies points out that the evidence showing sugar to be a major factor in obesity is relatively weak and is confounded by total calorie intake and other factors. He says:

I know of no evidence that were we to eliminate all sugar from our diets, presumably leaving the rest of the diet the same, we could rid ourselves of disease and restore our health.

The film gets a lot of things wrong

I was going to do some further fact checking, but Google saved me the trouble. I discovered that two writers at Food Insight had already analyzed the claims in Fed Up and shown that the filmmakers got many of their facts wrong. They give these examples:

“This year for the first time in the history of the world, more people will die from the effects of obesity than from starvation.” Not true: three times as many die of starvation.

“For the first time in 200 years, the current generation of children are expected to live shorter lives than their parents.” Expected by whom? According to the CDC and the Census Bureau, life expectancies are on an uninterrupted upward trajectory that is expected to continue rising until at least 2020.

While fitness club memberships more than doubled, the obesity rate also doubled. A meaningless comparison that is intended to suggest that we are helpless to do anything about our weight.

It rejects the concept of energy balance, but the scientific evidence clearly shows that it is possible to lose weight by decreasing calorie intake and increasing calorie expenditure.

Dr. Robert Lustig gets a lot of screen time. He says that there is “really good data” that “a calorie is not a calorie,” in that the “toxicity” of sugars is an inherent and unique contributor to obesogenicity. “When your liver gets that big sugar rush… it has no choice but to turn it into fat immediately.” His language is inflammatory, demonizing sugar as toxic and addictive. Lustig’s views are inconsistent with mainstream scientific opinions based on all the available evidence. Dr. David Katz of the Yale Prevention Research Center characterizes Lustig’s theories as “humbug” and explains why.

“Between 1977 and 2000, Americans have doubled their daily intake of sugar.” Not true: Americans are eating more total calories but have not doubled the calories from sugar.

“Over 95 percent of all Americans will be overweight or obese in two decades.” No, obesity prevalence has leveled off since 2003 and the forecasted trend-line is virtually flat.

It claims that consuming a single soda per day increases one’s risk of diabetes by 22 percent. Sugar doesn’t cause diabetes; the film presents a simplistic caricature of the relationship between sugar and diabetes.

The film says the pledge of food companies to remove 1.5 trillion calories from the marketplace amounts to “nothing,” a mere 14 calories a day per person. Actually, they have already removed 6.4 trillion calories, ahead of schedule and more than 400 percent of the original goal. The resulting reduction of 78 calories a day per person is probably more than enough to meet the Healthy People 2020 target for obesity reduction.

This review concludes by saying the central claims of the film are shadings of the truth, sins of omission, and outright fabrication. It says the film’s “obsessive focus on a single nutrient actually could cause more harm than good, in that overconsumption of any macronutrient can lead to overweight and obesity.” It offers credible evidence and provides links to additional resources.

At Reason.com, Baylen Linnekin points out that the film overwhelmingly features supporters of increased food regulation, and non-supporters are treated unfairly. David Allison is asked for his opinion on the contribution of sugar-sweetened beverages to obesity, and when he asks for a moment to collect his thoughts, the editing cuts him off and makes him look foolish.

In the film, Senator Tom Harkin asks how the food industry executives can sleep at night. I find that ironic. He supported farm bills that pay billions of dollars in subsidies to farmers in his home state Iowa, which leads the nation in high fructose corn syrup production. Harkin is a major advocate of alternative medicine who has been instrumental in legislation such as creating the NCCAM , a travesty and a waste of taxpayer dollars. He is so ignorant of how science works that he complained that the NCCAM has been disproving things rather than doing its intended job of “seeking out and approving.” He has been characterized on this blog as “waging a war on science.” I wonder how Harkin can sleep at night.

What can be done to improve the American diet?

I think we can all agree that the typical American diet is not healthy. It provides too much processed food, convenience food, sodas, red meat, salt, sugars, and calories; and it is deficient in fruits, vegetables, and fiber. Sugar is only one part of the obesity problem, a part that may be due to its contribution to total calorie intake rather than anything inherently bad about sugar. No one would argue that we shouldn’t try to reduce sugar consumption; the question is how to accomplish that.

The film’s comparison to tobacco is interesting. For a long time, the tobacco industry misled the public about the dangers of smoking. Tobacco advertising dropped when equal time was required for anti-smoking information. Societal attitudes changed rapidly for tobacco thanks to public information campaigns. Legislation has contributed to a decrease in smoking, but I would argue that legislation would not have been possible without a change in public perceptions.

I think the general public is well aware of the need to control weight, and instead of trying to control their eating habits by passing laws to control the food industry, we might do better to educate them about how to eat a healthier diet. There is so much they don’t understand. The film shows tearful families unable to lose weight and trying so hard — but their efforts include things like switching from regular Hot Pockets to a low-fat version. There are many flavors of Lean Pockets, but the very first one I looked up contained the equivalent of 3-4 tsp of sugar and a whopping 655 calories. Obese teenagers are shown lamenting their inability to lose weight while gorging on cereal, finishing large bags of potato chips to “savor the flavor,” and choosing hamburgers and fries for lunch at school. One is shown making what he thinks is a “healthy lunch” to take to school: a peanut butter and jelly sandwich! These people desperately want to adopt healthier eating habits, but they have no idea how to go about it. How can we best help them?

People complain that they weren’t able to lose weight by reducing calories, but some of them don’t realize that they never actually reduced calories enough to get results. I once had an overweight 13-year-old boy as a patient. I asked what he usually ate for lunch, and we calculated that his daily cheeseburger, fries, and milkshake added up to over 1000 calories. I asked if he would consider bringing a lower calorie sack lunch from home, and he enthusiastically agreed. He had never even thought of that option. I had an adult patient who couldn’t understand why she hadn’t lost weight when she was eating mostly yogurt. She thought yogurt was “diet food” so she could eat as much of it as she wanted. When I asked her to read the label, she was astounded to learn that each container of yogurt had 240 calories.

Efforts are already underway to improve school lunches and remove junk food vending machines from schools. That’s a step in the right direction. Agatha Raisin, a character in a delicious series of mystery novels by M. C. Beaton, brags that she loves to cook, but her idea of cooking is sticking a TV dinner in the microwave. A lot of our young people grow up with similar ideas about what it means to cook. Why not require Home Ec. classes in our schools? They could teach nutrition, menu planning, and meal preparation from scratch with fresh ingredients. Students might learn to think of healthier options when it comes to planning what to do for dinner.

To my mind, it’s not just a matter of educating children, but of educating the parents who buy and serve the food their children eat at home, educating the parents who think you can lose weight by switching from Hot Pockets to Lean Pockets. Just as information campaigns educated the public about smoking, they could educate the public about healthy food choices, hidden sugars, and calorie content of various foods. Even without legislation, a public outcry and grass roots movements would be enough to change food manufacturing. The food industry exists to please its customers and has provided us with easy, timesaving, attractive options that are hard to resist. What if the general public learned to buy less processed food, to read labels, to avoid hidden sugars, to be aware of how many calories they are ingesting, and to enjoy cooking at home? If they did that, market forces would make the food industry adapt. If companies wanted to keep profits up, they would have to be creative about providing healthier products. Just think how quickly they responded to public enthusiasms like gluten-free and low-carb.

People naturally tend to eat the way their parents ate, the way their culture eats. It can be hard for them to even imagine other ways of eating. My parents grew up on farms and ate the way their own parents and grandparents had always eaten. I grew up thinking the ideal meal was meat, potatoes, a green vegetable, a yellow vegetable, bread and butter, a sugary dessert, and milk for a beverage. Last night I cooked dinner from scratch, using several ingredients that never crossed the threshold of my mother’s kitchen, including red quinoa, chickpeas, collard greens, olive oil, yogurt, and limes. I used to see items like those in the grocery store and pass them by; it never would have occurred to me to cook with them because I had no experience with them and wouldn’t have known what to do with them. We can’t expect people to think outside the box of the traditional American family dinner table and the fast food restaurant without some help. My horizons have been hugely expanded by subscribing to the Blue Apron program, which has me cooking from scratch with a variety of ingredients like heirloom vegetables and exotic foods from other cultures (many of which I had never even heard of) and trying out new cooking techniques. Blue Apron is expensive and is not something that could be recommended for everyone, but I can see how school programs and media campaigns might be able to accomplish something similar.

I favor education over regulation. I’m not against regulating the food industry, but I would like to see proposals tested before they are widely implemented. Providing nutrition information on menus seemed like a great idea, but it has had minimal impact on food choices in real-world settings. Many thousands of young people were put through abstinence-only sex education programs before we realized they were ineffective and might even be doing more harm than good. We can’t just assume that any proposed remedy for the obesity epidemic will work. No matter how slam-dunk it sounds, it must be tested using scientific methods.

Conclusion

The film’s thesis, that sugar has caused the obesity epidemic, is not well supported by evidence. It is a partial truth that the filmmakers have dogmatically represented as the whole truth, with nary a hint of nuance. And it’s not fair to demonize the food industry. It has done a lot of good by providing a greater variety of safer food to more people for lower prices. We must share the responsibility for their shortcomings, because their less healthy offerings were created in response to public demand, and large numbers of people have chosen to buy those products because they don’t know any better.

The film will undoubtedly do some good by helping raise public awareness of childhood obesity and of hidden sugars in processed foods. I only wish it could have done so without misrepresenting the facts and without the bias and hype in support of the filmmakers’ political agenda of increasing food regulation. I try to eat a healthy diet, but I enjoy an occasional sugary treat and fast food meal, and I appreciate the convenience of packaged, processed foods when I don’t have a lot of time to shop and cook. I see no compelling reason to think it is impossible for people to lose weight on a diet that is overall nutritious and calorie controlled but that allows small amounts of even the “worst” foods.