ALSOBYGARYTAUBES

WhyWeGetFat:AndWhattoDoAboutIt

GoodCalories,BadCalories:ChallengingtheConventionalWisdomonDiet,WeightControl,andDisease

BadScience:TheShortLifeandWeirdTimesofColdFusion

NobelDreams:Power,Deceit,andtheUltimateExperiment

THISISABORZOIBOOKPUBLISHEDBYALFREDA.KNOPFANDALFREDA.KNOPFCANADA

Copyright©2016byGaryTaubes

Allrightsreserved.PublishedintheUnitedStatesbyAlfredA.Knopf,adivisionofPenguinRandomHouseLLC,NewYork,andinCanadabyRandomHouseofCanada,adivisionofPenguinRandomHouse

CanadaLimited,Toronto.

www.aaknopf.com

Knopf,BorzoiBooks,andthecolophonareregisteredtrademarksofPenguinRandomHouseLLC.

PortionsofChapter8originallyappearedinMotherJones,(November/December2012),as“SweetLittleLies,”coauthoredbyGaryTaubesandCristinKearnsCouzens.

LibraryofCongressCataloging-in-PublicationData

Names:Taubes,Gary,author.Title:Thecaseagainstsugar/byGaryTaubes.

Description:Firstedition.|NewYork:AlfredA.Knopf,2016.|Includesbibliographicalreferencesandindex.

Identifiers:LCCN2016018147|ISBN9780307701640(hardback)|ISBN9780451493996(ebook)Subjects:LCSH:Sugar-freediet—Casestudies.|Sugar—Physiologicaleffect—Popularworks.|

Nutritionallyinduceddiseases—Popularworks.|BISAC:HEALTH&FITNESS/Nutrition.|SCIENCE/Chemistry/General.

Classification:LCCRM237.85.T382016|DDC613.2/8332—dc23LCrecordavailableathttps://lccn.loc.gov/2016018147

CoverphotographanddesignbyDavidDrummond

EbookISBN 9780451493996

v4.1_r1a

http://www.aaknopf.comhttps://lccn.loc.gov/2016018147

ToGaby,forkeepingthefamilytogether

Weare,beyondquestion, thegreatestsugar-consumersintheworld,andmanyofourdiseasesmaybeattributedtotoofreeauseofsweetfood.

TheNewYorkTimes,May22,1857

IamnotpreparedtolookbackatmytimehereinthisParliament,doingthisjob,and say tomychildren’sgeneration: I’msorry,weknew therewasaproblemwith sugary drinks, we knew it caused disease, but we ducked the difficultdecisionsandwedidnothing.

GEORGEOSBORNE,U.K.chancelloroftheexchequer,announcingataxonsugarybeverages,March16,2016

CONTENTS

CoverAlsobyGaryTaubesTitlePageCopyrightDedicationEpigraph

Author’sNote

INTRODUCTION WhyDiabetes?

CHAPTER1 DrugorFood?

CHAPTER2 TheFirstTenThousandYears

CHAPTER3 TheMarriageofTobaccoandSugar

CHAPTER4 APeculiarEvil

CHAPTER5 TheEarly(Bad)Science

CHAPTER6 TheGiftThatKeepsOnGiving

CHAPTER7 BigSugar

CHAPTER8 DefendingSugar

CHAPTER9 WhatTheyDidn’tKnow

CHAPTER10 TheIf/ThenProblem:I

CHAPTER11 TheIf/ThenProblem:II

EPILOGUE HowLittleIsStillTooMuch?

AcknowledgmentsNotes

Bibliography

ANoteAbouttheAuthor

AUTHOR’SNOTE

Thepurposeofthisbookistopresentthecaseagainstsugar—bothsucroseandhigh-fructosecornsyrup—astheprincipalcauseofthechronicdiseasesthataremost likely to kill us, or at least accelerate our demise, in the twenty-firstcentury.Itsgoalistoexplainwhythesesugarsarethemostlikelysuspects,andhowwearrivedatthecurrentsituation:athirdofalladultsareobese,two-thirdsoverweight,almostone inseven isdiabetic,andone infour to fivewilldieofcancer; yet the prime suspects for the dietary trigger of these conditions havebeen, until the last decade, treated as little worse than a source of harmlesspleasure.

Ifthiswereacriminalcase,TheCaseAgainstSugarwouldbetheargumentfortheprosecution.

INTRODUCTION

WHYDIABETES?

Mary H—an unmarried woman, twenty-six years of age, came to the Out PatientDepartmentoftheMassachusettsGeneralHospitalonAugust2,1893.Shesaidhermouthwasdry, that shewas“drinkingwaterall the time”andwascompelled to rise three tofour times each night to pass her urine. She felt “weak and tired.” Her appetite wasvariable; thebowelsconstipatedandshehadadizzyheadache.Belchingofgas,a tightfeelingintheabdomen,anda“burning”inthestomachfollowedhermeals.Shewasshortofbreath.

ELLIOTTJOSLIN’Sdiabetes“caseno.1,”asrecordedinthecasenotesofhisclinic

ElliottJoslinwasamedicalstudentatHarvardinthesummerof1893,workingasaclinicalclerkatMassachusettsGeneralHospital,whenhedocumentedhisfirst consultation with a diabetic patient. He was still a good three decadesremovedfrombecomingthemostinfluentialdiabetesspecialistofthetwentiethcentury. The patient wasMary Higgins, a young immigrant who had arrivedfrom Ireland five years previously and had been working as a domestic in aBostonsuburb.Shehad“asevereformofdiabetesmellitus,”Joslinnoted,andher kidneys were already “succumbing to the strain put upon them” by thedisease.Joslin’sinterestindiabetesdatedtohisundergraduatedaysatYale,butitmay

havebeenHigginswhocatalyzedhisobsession.Overthenextfiveyears,Joslinand Reginald Fitz, a renowned Harvard pathologist, would comb through the“hundredsofvolumes”ofhandwrittencasenotesoftheMassachusettsGeneralHospital, looking for information that might shed light on the cause of thediseaseandperhapssuggesthowtotreatit.JoslinwouldtraveltwicetoEurope,visiting medical centers in Germany and Austria, to learn from the most

influentialdiabetesexpertsoftheera.In1898,thesameyearJoslinestablishedhisprivatepracticetospecializein

the treatment of diabetics, he and Fitz presented their analysis of the MassGeneralcasenotesattheannualmeetingoftheAmericanMedicalAssociationinDenver.Theyhadexaminedtherecordofeverypatienttreatedatthehospitalsince1824.Whattheysaw,althoughtheydidn’trecognizeitatthetime,wasthebeginningofanepidemic.Amongtheforty-eightthousandpatientstreatedinthattimeperiod,ayearshy

ofthree-quartersofacentury,atotalof172hadbeendiagnosedwithdiabetes.These patients represented only 0.3 percent of all cases atMass General, butJoslinandFitzdetectedaclear trendin theadmissions: thenumberofpatientswith diabetes and the percentage of patients with diabetes had both beenincreasing steadily. As many diabetics were admitted toMass General in thethirteen years after 1885 as in the sixty-one years prior. Joslin and Fitzconsideredseveralexplanations,buttheyrejectedthepossibilitythatthediseaseitself was becoming more common. Instead, they attributed the increase indiabetic patients to a “wholesome tendency of diabetics to place themselvesunder careful medical supervision.” It wasn’t that more Bostonians weresuccumbing todiabetesyear toyear, theysaid,but thatagreaterproportionofthosewhodidweretakingthemselvesofftothehospitalfortreatment.By January 1921, when Joslin published an article about his clinical

experiencewithdiabetesforTheJournaloftheAmericanMedicalAssociation,his opinion had changed considerably. He was no longer talking about thewholesometendenciesofdiabeticstoseekmedicalhelp,butwasusingtheword“epidemic”todescribewhathewaswitnessing.“OnthebroadstreetofacertainpeacefulNewEnglandvillage there once stood three houses side by side,” hewrote, apparently talkingabouthishometownofOxford,Massachusetts. “Intothese threehousesmoved in succession fourwomenand threemen—headsoffamilies—andofthisnumberallbutonesubsequentlysuccumbedtodiabetes.”Joslinsuggestedthathadthesedeathsbeencausedbyaninfectiousdisease—

scarlet fever, perhaps, or typhoid, or tuberculosis—the local and state healthdepartmentswouldhavemobilizedinvestigativeteamstoestablishthevectorsofthediseaseandpreventfurtherspread.“Considerthemeasures,”hewrote,“thatwouldhavebeenadoptedtodiscoverthesourceoftheoutbreakandtopreventarecurrence.”Becausediabeteswasachronicdisease,notaninfectiousone,andbecause thedeathsoccurredoveryears andnot in the spanof a fewweeksor

months, theypassedunnoticed. “Even the insurance companies,” Joslinwrote,“failedtograsptheirsignificance.”

—

We’vegrownaccustomed,ifnotinured,toreadingabouttheongoingepidemicofobesity.Fiftyyearsago,one ineightAmericanadultswasobese; today thenumberisgreaterthanoneinthree.TheWorldHealthOrganizationreportsthatobesity rates have doubled worldwide since 1980; in 2014, more than half abillion adults on the planet were obese, and more than forty million childrenunder the age of five were overweight or obese. Without doubt we’ve beengetting fatter, a trend that can be traced back in the United States to thenineteenth century, but the epidemic of diabetes is a more intriguing, moretellingphenomenon.Diabetes was not a new diagnosis at the tail end of the nineteenth century

whenJoslindidhisfirstaccounting,rareasthediseasemighthavebeenthen.AsfarbackasthesixthcenturyB.C.,Sushruta,aHinduphysician,haddescribedthecharacteristic sweet urine of diabetes mellitus, and noted that it was mostcommon in the overweight and the gluttonous. By the first century A.D., thedisease may have already been known as “diabetes”—a Greek term meaning“siphon” or “flowing through”—when Aretaeus of Cappodocia described itsultimate course if allowed to proceeduntreated: “Thepatient does not survivelongwhenitiscompletelyestablished,forthemarasmus[emaciation]producedis rapid, and death speedy. Life too is odious and painful, the thirst isungovernable, and the copiouspotations aremore thanequaledby theprofuseurinarydischarge….Ifhestopforaverybriefperiod,andleaveoffdrinking,themouthbecomesparched,thebodydry;thebowelsseemonfire,heiswretchedanduneasy,andsoondies,tormentedwithburningthirst.”Throughthemid-nineteenthcentury,diabetesremainedarareaffliction,tobe

discussed inmedical textsand journalarticlesbut rarelyseenbyphysicians intheir practices. As late as 1797, the British army surgeon John Rollo couldpublish“AnAccountofTwoCasesoftheDiabetesMellitus,”aseminalpaperinthehistoryofthedisease,andreportthathehadseenthesecasesnineteenyearsapart despite, as Rollo wrote, spending the intervening years “observ[ing] anextensiverangeofdiseaseinAmerica,theWestIndies,andinEngland.”Ifthemortality records from Philadelphia in the early nineteenth century are anyindication,thecity’sresidentswereaslikelytodiefromdiabetes,oratleastto

havediabetesattributedasthecauseoftheirdeath,astheyweretobemurderedortodiefromanthrax,hysteria,starvation,orlethargy.*1

In1890,RobertSaundby,aformerpresidentoftheEdinburghRoyalMedicalSociety, presented a series of lectures on diabetes to the Royal College ofPhysicians in London in which he estimated that less than one in every fiftythousanddied from thedisease.Diabetes, saidSaundby, is “oneof those rarerdiseases”thatcanonlybestudiedbyphysicianswholivein“greatcent[er]sofpopulation and have the extensive practice of a large hospital from which todraw their cases.” Saundby did note, though, that the mortality rate fromdiabeteswasrisingthroughoutEngland,inParis,andeveninNewYork.(Atthesametime,oneLosAngelesphysician,accordingtoSaundby,reported“insevenyears’practicehehadnotmetwithasinglecase.”)“Thetruth,”Saundbysaid,“isthatdiabetesisgettingtobeacommondiseaseincertainclasses,especiallythewealthiercommercialclasses.”William Osler, the legendary Canadian physician often described as the

“fatherofmodernmedicine,”alsodocumentedboththerarityandtherisingtideofdiabetesinthenumerouseditionsofhisseminaltextbook,ThePrinciplesandPractice of Medicine. Osler joined the staff at Johns Hopkins Hospital inBaltimore when the institution opened in 1889. In the first edition of histextbook, published three years later, Osler reported that, of the thirty-fivethousandpatientsundertreatmentatthehospitalsinceitsinception,onlytenhadbeendiagnosedwithdiabetes.Inthenexteightyears,156caseswerediagnosed.Mortality statistics, wrote Osler, suggested an exponential increase in thosereportedlydyingfromthedisease—nearlydoublingbetween1870and1890andthenmorethandoublingagainby1900.By the late 1920s, Joslin’s epidemic of diabetes had become the subject of

newspaper and magazine articles, while researchers in the United States andEuropewereworking toquantifyaccurately theprevalenceof thedisease, inawaythatmightallowmeaningfulcomparisonstobedrawnfromyeartoyearanddecadetodecade.InCopenhagen,for instance, thenumberofdiabetics treatedin thecity’shospitals increased from ten in1890 to608 in1924—asixty-foldincrease.WhentheNewYorkCityhealthcommissionerHavenEmersonandhiscolleagueLouiseLarimorepublishedananalysisofdiabetesmortalitystatisticsin1924,theyreporteda400percentincreaseinsomeAmericancitiessince1900—almost1,500percentsincetheCivilWar.

THEBEGINNINGSOFANEPIDEMIC?

Diabetesadmissions,PennsylvaniaHospital,Philadelphia

Despite all this, the disease remained a relatively rare one. When Joslin,working with Louis Dublin and Herbert Marks, both statisticians with theMetropolitanLifeInsuranceCompany,examinedtheexistingevidencein1934,heagainconcluded thatdiabeteswasrapidlybecomingacommondisease,butonlyby thestandardsof theday.Heconservativelyestimated—basedonwhatheconsideredcarefulstudiesdoneinNewYork,Massachusetts,andelsewhere—thatonlytwotothreeAmericansineverythousandhaddiabetes.

—

Timeshavecertainlychanged.In2012,thelatestyearforwhichtheCentersforDisease Control (CDC) have provided estimates, one in every seven to eightadultsinthiscountryhaddiabetes—12to14percent,dependingonthecriteriaused to diagnose it. Another 30 percent are predicted to get diabetes at somepoint during their lives. Almost two million Americans were diagnosed withdiabetes in 2012—one case every fifteen to sixteen seconds. Among U.S.military veterans, one in every four patients admitted to VA hospitals suffers

fromdiabetes.The great proportion of this tidal wave of diabetics—perhaps 95 percent—

havewhatisnowknownastype2diabetes,theformofthedisease,asSushrutawouldhave saidover two thousandyears ago, that associateswithoverweightandobesity.Asmallproportionhavetype1,typicallychildren.Thisistheacuteformofthedisease,anditkills,ifuntreated,farmorequickly.*2Bothtype1andtype 2 diabetes have been increasing in prevalence for the past 150 years; inboth,theincreasehasbeendramatic.Those afflicted with diabetes will die at greatly increased rates from heart

diseaseorstroke,fromkidneydisease—thediseaseisnowconsideredthecauseofmorethan40percentofcasesofkidneyfailure—anddiabeticcoma.Withoutappropriate treatment (and occasionally even with), their eyesight willdeteriorate(oftenafirstsymptom);they’llsuffernervedamage;theirteethwilldecayandfallout;they’llgetfootulcersandgangrene;andthey’llloselimbstoamputation. Six in every ten lower-limb amputations in adults are due todiabetes—someseventy-threethousandofthemin2010alone.Adozenclassesofdrugsarenowavailabletotreatthedisease,andthemarketfordiabeticdrugsand devices in the United States alone is over thirty billion dollars yearly.Drugstore chains now offer free tests to customers to check levels of bloodsugar,hopingtosellhome-testingkitstothosewhosebloodsugarmighthappentoshowupborderlineorhigh.The obvious questions are:Why have things changed so? How did we get

here?Whatforcesofnatureorenvironmentor lifestylehave led todiabetes inoneoutofeveryelevenAmericans,childrenandadultstogether?Onewaytoavoidansweringthisquestionistoassumethathistoricaltrendsin

diabetesprevalenceconstituteunreliableevidence.Whoknowswhatwasreallygoingonfiftyorahundredyearsago?And,indeed,it’ssurprisinglydifficulttoquantifywithanyconfidencethechangingprevalenceofachronicdiseaseinapopulation. Such issues as the criteria by which it’s diagnosed, how muchattention physicians, the public, and the media pay to it, the availability oftreatmentandhowwellthosetreatmentswork,thelongevityofthepopulation,and whether the disease is more common with age will all confound anyauthoritative attempts to establish reliably how the actual occurrence of achronicdiseasehaschangedwithtime.It’saverygoodbet,though,thathadoneinelevenAmericansbeenafflictedwithdiabetes in thenineteenthcentury, thehospitalinpatientrecordsofthoseeraswouldhavelookeddramaticallydifferent,

aswouldthenumberofdeathsattributedtodiabetes.AsSaundbywrotein1901,“Diabetes is in all cases a grave disease….Life seems to hang by a thread, athreadoftencutbyaverytriflingaccident.”For the past century, the observation that diabetes is increasing in the

population—transitioning from a rare disease to a common one and now to ascourge—has remained a constant theme in the medical literature. In 1940,Russell Wilder, the leading diabetologist at the Mayo Clinic, reported thatdiabetes admissions had been increasing steadily at the clinic for the previoustwentyyears.“Theincidenceofdiabeticmorbidityisunknown,”hewrote,“buttheindicationsthatitisincreasingareveryclear.”Tenyearslater,Joslinhimselfreferred to the “appalling increase in diabetes,” which he now considered aninescapablefactoflife.In1978,KellyWest,theleadingAmericanauthorityondiabetesepidemiology—thestudyofhowdiseasesmovethroughpopulations—suggestedthatdiabeteshadalreadykilledmorepeopleinthetwentiethcenturythan all wars combined. “Diabetes mellitus has become one of the mostimportant of human problems,” he wrote, calling it “a significant cause ofdiseaseanddeathinallcountriesandallmajorraces.”Epidemicincreasesintheoccurrenceofdiabetes,asWestsuggested,werenot

a localized phenomenon. Diabetes was virtually unknown or at leastundiagnosed in China, for instance, at the turn of the twentieth century. OneBritish physician reported seeing only one case of the disease among twenty-four thousand outpatients in Nanking, although “all drawn from the lowerclassesofsociety.”Anotherreportedonlytwocasesamongthetwelvethousandinpatientstreatedinhishospital.Inthe1980s,theprevalenceofdiabetesintheChinese population at largewas still estimated to be approximately 1 percent.Thelatestestimatesarethat11.6percentoftheadultpopulationisdiabetic—oneinnine,morethan110millionChineseintotal.AlmosthalfabillionChinesearebelievedtobepre-diabetic.Theprevalenceofbothdiabetesandpre-diabeteswasconsideredvanishingly

smallamongInuitinGreenland,Canada,andAlaskathroughthe1960s—“EightAlaskanEskimosarenowknowntohavediabetes,” reportedonearticle in theJournal of theAmericanMedicalAssociation in 1967.By the 1970s, diabeteswasstillrare,butresearcherswerenowdocumentingtheincreasingappearanceofapre-diabeticcondition,glucoseintolerance.Inrecentstudies,diabetesratesin the Inuit arenowat 9percent—one in every eleven individuals—similar tothelevelsinCanadaandtheUnitedStatesasawhole.

The same epidemic patterns have been observed in NativeAmerican tribes(particularly thePimapopulation inArizona, aswe’ll discuss later) and in theFirstNationsPeopleofCanada.Inmanyofthesepopulations,oneoutofeverytwoadultsnowhasdiabetes.Insomecases—theOjibwaCreepeopleofSandyLakeinnorthernOntario,forinstance—diabetes,ifitexisted,wasundiagnosedinthepopulationaslateasthe1960s.In1974,whenKellyWestexaminedtheavailabledataondiabetesinNativeAmericanpopulations,heconcludedthatthedisease had been rare to nonexistent prior to the 1940s—both civilian andmilitaryphysicianshadcarriedouthealthsurveys—andyet,by themid-1960s,research,includinghisown,wasdocumentingpreviouslyunafflictedpopulationsinwhichoneinfouradultswasdiabetic.(Whenresearcherschartedthenumberofcasesdiagnosedeachyear in theNavajofromthe1950s through the1980s,the resulting graph looked almost identical to that on this page fromPennsylvaniaHospital in Philadelphia a century earlier.) Similar patterns havebeen observed in Polynesians, Micronesians, and Melanesians in the SouthPacific;inaboriginalpopulationsinAustralia;inMaorisinNewZealand;andinpopulations throughout the Middle East, Asia, and Africa. In fact, anywherepopulationsbegineatingWesterndietsandlivingWesternlifestyles—wheneverand wherever they’re acculturated or urbanized, as West noted in 1978—diabetesepidemicsfollow.Sowhat happened?What’s happening? Something changed dramatically in

our diets, our lifestyle, or our environment to trigger these unprecedentedepidemicsofdiabetes;butwhat?AsJoslinobservedundersimilarcircumstancesat a far earlier stage in this epidemic, had this been an infectious disease, therelevantboardsofhealth,theinsuranceagencies,thenewspapers,thecountryasa whole, would be demanding answers. The CDC and the World HealthOrganizationwould have established panels of expert investigators to pry intoeverycreviceofourassumptionsaboutthecauseofthisdiseasetoseewherewemighthavemisunderstooditsetiology.Suchisnotthecase.

—

Prior to the 1970s, public-health authorities and clinicians commenting on therisingtideofdiabetesinthepopulationstheystudiedfrequentlysuggestedwhattothemseemedliketheprimesuspect—sugarconsumption.Herewasadiseaseof carbohydrate metabolism that was becoming increasingly common aspopulations began consuming sugar—a kind of carbohydrate—at levels that

werevirtuallyunimaginableacenturybefore;insomecases,justtwentyorthirtyyearsbefore.AssugarconsumptionexplodedintheUnitedStatesandtheUnitedKingdom

with the industrial revolution; with the birth of the confectionary, cereal, andsoft-drink industries;andwith the increasingavailabilityofchocolatebarsandice-cream treats, so did diabetes begin its inexorable climb.When sugar andsugar-rich products spread around the globe, so did diabetes. When peasantfarmersthroughoutAfrica,India,Asia,andCentralandSouthAmericamigratedto towns and cities to becomewage earners, and changed their dietary habitsaccordingly—no longer eating locally grown cereals, starches, and fruits, butinstead buying sugary drinks and sugar-laden treats in shops and markets—diabetesmadeitsinevitableappearance.AsKellyWestsaidabouttheemergingepidemicsofdiabetesinNativeAmericanpopulationsin1974,“Somehadbeennomadic hunters and meat eaters…while others had derived a substantialmajorityoftheircaloriesfromfats….Sugarconsumptionhasbeenincreasinginmost,ifnotall,oftheUnitedStatestribesinwhomdiabetesrateshaverecentlyincreasedprecipitously.ThissameassociationhasbeenobservedinEskimosofAlaska,Canada,andGreenlandaswellasinPolynesians.”And on those very rare occasions when sugar consumption declined—as it

did, for instance, during World War I, because of government rationing andsugarshortages—diabetesmortalityinvariablydeclinedwithit.“Risesandfallsin sugar consumption,” wrote Haven Emerson and Louise Larimore in 1924,“are followedwith fair regularity…bysimilar rises and falls in thedeath ratesfromdiabetes.”In1974,whenthesugarindustryhiredpollsterstosurveyphysiciansfortheir

attitudes toward sugar, most of those physicians said they thought sugarconsumptionacceleratedtheonsetofdiabetes.(Oneadvertisingexecutive,laterasked if his children ate a particularly sugar-rich cereal for which he hadmodeled the ad campaign on Snoopy and the Red Baron, admitted that theyneverdid:“Youneedaninsulinshotifyoueatabowlofthat,”hesaid.)In1973,Jean Mayer of the Harvard School of Public Health, probably the mostinfluentialnutritionistoftheera,wassuggestingthatsugar“playsanetiologicalroleinthoseindividualswhoaregeneticallysusceptibletothedisease.”Suchastatement,ofcourse,raisestheobviousquestionofwhetheranyoneevergetsthedisease who isn’t genetically susceptible (with the rare exceptions of thoseindividuals who sustain injuries or tumors that affect pancreatic function).Nonetheless, at scientificmeetings on sugar and other sweeteners, researchers

andclinicianswoulddebatewhetherornotsugarcauseddiabetesoronlyhelpeditalonginthosesomehowpredisposed.By the late 1970s, though, sugar hadmostly vanished from the discussion.

Dietary fat had been implicated as a cause of heart disease. Nutritionists andpublic-health authorities responded by rejecting the idea that sugar could beresponsible for the diseases that associatedwith heart disease,which includedbothobesityanddiabetes.Researchershadalsocometoembraceapairofrelatedassumptionsthatwere

poorlytestedandmightormightnotbetrue.Thefirstisthattype2diabetesiscaused by obesity, because the two diseases are so closely associated, both inpopulationsandinindividuals,andobesitytypicallyappearsfirst(althoughmorethanoneineverytenindividualsdiagnosedwithtype2diabetesisneitherobesenoroverweight).Thesecondassumption,astheWorldHealthOrganizationputsit,is:“Thefundamentalcauseofobesityandoverweightisanenergyimbalancebetweencaloriesconsumedandcaloriesexpended.”“TheonlytroublewiththeAmericandiet,”asFredStare,thefounderandheadofthenutritiondepartmentatHarvardUniversity, said in 1976 on national television, is that “we eat toodamn much.” The overeating was accompanied by a decrease in physicalactivity,attributedtochangingmodesoftransportationandthemechanizationoflabor.Public-health authorities have considered no investigations necessary to

explaintheobesityanddiabetesepidemics,becausetheyhaveassumedthatthecauseisobvious.AttemptstopreventdiabetesintheUnitedStates,Europe,andAsia,andamongpopulationsworldwide,arealmostinvariablyaimedatgettingthese populations to eat smaller portions and fewer calories, perhaps to avoid“fatty foods,” as particularly dense sources of calories, and to increase theirphysicalactivity.Meanwhile,thelatestsurgeinthisepidemicofdiabetesintheUnitedStates—

an800percentincreasefrom1960tothepresentday,accordingtotheCentersfor Disease Control—coincides with a significant rise in the consumption ofsugar.Or,rather,itcoincideswithasurgeintheconsumptionofsugars,orwhattheFDAcalls“caloricsweeteners”—sucrose,fromsugarcaneorbeets,andhigh-fructosecornsyrup,HFCS,arelativelynewinvention.After ignoring or downplaying the role of sugars and sweets for a quarter-

century, many authorities now argue that these are, indeed, a major cause ofobesity and diabetes and that they should be taxed heavily or regulated. The

authorities still do so, however, not because they believe sugar causes diseasebut,rather,becausetheybelievesugarrepresents“emptycalories”thatweeatinexcessbecause they tastesogood.By this logic, since refinedsugarandhigh-fructosecornsyrupdon’tcontainanyprotein,vitamins,minerals,antioxidants,or fiber, they either displace other, more nutritious elements of our diet, orsimply add extra, unneeded calories to make us fatter. The Department ofAgriculture,forinstance(initsrecent“DietaryGuidelinesforAmericans”),theWorldHealthOrganization,and theAmericanHeartAssociation,amongotherorganizations, advise a reduction in sugar consumption for these reasonsprimarily.Theempty-caloriesargumentisparticularlyconvenientforthefoodindustry,

whichwouldunderstandablyprefernottoseeakeyconstituentofitsproducts—alltoooften,thekeyconstituent—damnedastoxic.Thesugarindustryplayedakeyroleinthegeneralexonerationofsugarthattookplaceinthe1970s,asI’llexplainlater.Healthorganizations,includingtheAmericanDiabetesAssociationandtheAmericanHeartAssociation,havealsofoundtheargumentconvenient,having spent the last fifty years blaming dietary fat for our ills while lettingsugaroffthehook.The empty-calories logic allows companies that sell sugar-rich products, or

productsinwhichallthecaloriescomefromthesesugars,toclaimthatthey,too,are fighting thegoodfight.Theycanprofessandperhapsbelieve that theyarefightingthescourgeofchildhoodobesityanddiabetes—thattheyarepartofthesolution,nottheproblem—byworkingtoeducatechildrenonhowtoeatless,besatisfiedwithsmallerportions,andexercisemore, justasCoca-Cola,PepsiCo,Mars,Nestlé,Hershey’s, and a few dozen other companies did in 2009whenthey joined up with the Grocery Manufacturers Association, the AmericanDieteticAssociation(nowtheAcademyofNutritionandDietetics),andtheGirlScouts of the USA to found the Healthy Weight Commitment Foundation.Embracing the notion of empty calories is politically expedient as well. Anypolitician running forpublicoffice isunlikely tobenefit fromalienatingmajorconstituentsofthefoodindustry,particularlycompanieswithpowerfullobbies,such as the sugar and beverage industries. “This is not about demonizing anyindustry,” as Michelle Obama said in 2010 about “Let’s Move,” her much-publicizedprogramtocombatchildhoodobesity.This book makes a different argument: that sugars like sucrose and high-

fructose corn syrup are fundamental causes of diabetes and obesity, using thesame simple concept of causality that we employ when we say smoking

cigarettescauseslungcancer.It’snotbecauseweeattoomuchofthesesugars—although that is implied merely by the terms “overconsumption” and“overeating”—but because they have unique physiological, metabolic, andendocrinological(i.e.,hormonal)effectsinthehumanbodythatdirectlytriggerthese disorders. This argument is championed most prominently by theUniversityofCalifornia,SanFrancisco,pediatricendocrinologistRobertLustig.Thesesugarsarenotshort-termtoxinsthatoperateoverdaysandweeks,bythislogic,butones thatdo theirdamageoveryearsanddecades,andperhapsevenfrom generation to generation. In other words,motherswill pass the problemdowntotheirchildren,notthroughhowandwhattheyfeedthem(althoughthatplays a role), but throughwhat they eat themselves and how that changes theenvironmentinthewombinwhichthechildrendevelop.Individualswhogetdiabetes—theonesinanypopulationwhoareapparently

susceptible,whoaregeneticallypredisposed—wouldneverhavebeenstrickenifthey (and maybe their mothers and their mothers’ mothers) lived in a worldwithoutsugar,oratleastinaworldwithalotlessofitthantheoneinwhichwehavelivedforthepast100to150years.Thesesugarsarewhatanevolutionarybiologist might call the environmental or dietary trigger of the disease: therequisite ingredient that triggers the genetic predisposition and turns anotherwisehealthydietintoaharmfulone.Addsuchsugarsinsufficientquantitytothedietofanypopulation,nomatterwhatproportionofplantstoanimalstheyeat—asKellyWestsuggestedin1974aboutNativeAmericanpopulations—andthe result eventually is an epidemic of diabetes, and obesity aswell. If this istrue, then tomakeheadwayagainst thesedisorders—toprevent futurecasesofobesityanddiabetesfrommanifestingthemselves,andtoreversetheepidemicsthatarenowongoing—wemustshowthesesugarsand thebusinesses thatsellthemforwhattheytrulyare.

—

Theimplicationsofthecaseagainstsugargofarbeyonddiabetes.Thosewhoareobeseordiabeticarealsomorelikelytohavefattyliverdisease,andthis,too,isnow epidemic in Westernized populations. The National Institutes of HealthestimatethatasmanyasoneinfourAmericansnowhavethedisease,unrelatedtoalcoholconsumption.Ifuntreated,itcanprogresstocirrhosisoftheliverandeventuallytheneedforalivertransplant.Thosewhoareobeseanddiabeticalsotend to be hypertensive; they have a higher risk of heart disease, cancer, and

stroke,andpossiblydementiaandevenAlzheimer’sdiseaseaswell.These chronic diseases—the diseases that ultimately kill us in modern

Western societies—tend to cluster together in both populations and individualpatients. Diabetes, heart disease, cancer, stroke, and Alzheimer’s account forfiveofthetoptencausesofdeathintheU.S.Aconservativeestimateisthattheycost the medical system and our society, in lost work and productivity, onetrilliondollarsayear.Togetherthey’reoftenreferredtoasdiseasesofWesternlifestyles,ordiseases

ofWesternization.Thisclusterhasledcancerresearcherstosuggestthatobesityis a cause of cancer. It has led some Alzheimer’s researchers to refer toAlzheimer’sastype3diabetes.Allofthesediseaseshavenowbeenlinkedtoaconditionknownas“insulin

resistance,” a phenomenonwewill examine in depth. Insulin resistance is thefundamentaldefectpresentintype2diabetesandperhapsobesityaswell.Soit’sareasonablepossibilitythat thesamethingthatcausesoneof thesediseases—type2diabetesinparticular—causesallofthem.It’swhatscientistswouldcallthenullhypothesis,astartingpointforresearch,discussion,andstudies.Ifsugarand high-fructose corn syrup are the cause of obesity, diabetes, and insulinresistance, then they’re also the most likely dietary trigger of these otherdiseases. Put simply: without these sugars in our diets, the cluster of relatedillnesseswouldbefarlesscommonthanitistoday;likewiseotherdisordersthatassociatewiththeseillnesses,amongthempolycysticovarysyndrome(PCOS),rheumatoid arthritis, gout, varicose veins, asthma, and inflammatory boweldisease.Ifthiswereacriminalinvestigation,thedetectivesassignedtothecasewould

start from the assumption that there was one prime suspect, one likelyperpetrator,because thecrimes(all theaforementioneddiseases)aresocloselyrelated. They would only embrace the possibility that there were multipleperpetrators when the single-suspect hypothesis was proved insufficient toexplain all the evidence. Scientists know this essential concept as Occam’sRazor.When IsaacNewton said, “We are to admit nomore causes of naturalthingsthansuchasarebothtrueandsufficienttoexplaintheirappearances,”hewassayingthesamethingthatAlbertEinstein,threecenturieslater,said(orwasparaphrasedassaying):“Everythingshouldbemadeassimpleaspossible,butnosimpler.”Weshouldbeginwiththesimplestpossiblehypothesis,andonlyifthat can’t explain what we observe should we consider more complicated

explanations—inthiscase,multiplecauses.This is not, however, howmedical researchers and public-health authorities

havecome to thinkabout thesedisorders.Despite their faith in thenotion thatobesitycausesoracceleratesdiabetesandthattherefore(inwhatIwillargueisamistaken assumption) both are diseases of overconsumption and sedentarybehavior, theywill also defend their failure to curb the ongoing epidemics ofthesediseasesonthebasisthattheseare“multifactorial,complexdisorders”or“multidimensional diseases.” By this they mean that so many factors areinvolvedinthegenesisandprogressionofthesediseases—includinggeneticsforsure,epigenetics(themodificationofhowgenesareturnedonandoffincells),how much we eat and exercise, perhaps how well we sleep, toxins in theenvironment, pharmaceuticals, possibly viruses, the effect of antibiotic use onthe bacteria in our guts (dysbiosis, as it’s now commonly called, ormicrobialimbalance)—that to identifyoneultimate trigger, or one critical componentofourmoderndiets,istobenaïve.Thecounterargumentissimple:Lungcancerisalsoassuredlyamultifactorial,

complexdisease.Mostsmokerswillnevergetlungcancer,andatleastatenthofallcasesoflungcancerareunrelatedtosmokingcigarettes,andyetit’swidelyaccepted—forverygoodreasons—thatsmoking is theprimarycause.Whetheror not obesity and diabetes and their associated diseases are multifactorial,complex disorders, something has to explain their connection with modernWesterndietsandlifestylesandtheepidemicsthatarebothongoingandalmostubiquitousworldwide.Whatisit?Weareclearlydoingsomethingdifferentfromwhatwedidfiftyyearsago,or150yearsago,andourbodiesandhealthreflectit.Why?Thegoalofthisbookistoclarifytheargumentsagainstsugar,correctsomeof

the misconceptions and preconceptions that have dogged the debate for thehundredsofyearsduringwhich it’sbeenongoing,andprovide theperspectiveandcontextneededtomakereasonabledecisionsonsugarasindividualsandasa society. People are dying today, literally every second, from diseases thatseemedvirtuallynonexistentinpopulationsthatdidn’teatmodernWesterndietsor livemodernWestern lifestyles.Something iskilling themprematurely.Thisbookwilldocumentthecaseagainstsugarastheprimeculprit.

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In my two previous books on health and nutrition, I discussed the evidence

implicatingallhighlyprocessedandeasilydigestiblecarbohydratesingeneral—grainsandstarchyvegetables—aswellassugarandhigh-fructosecornsyrup.Isuggestedthattherewassomethinguniqueaboutthosesugarsthatthenmadetheother carbohydrate-rich foods a problem as well. So the treatment of theconditions they caused—particularly obesity and diabetes—often requiredrestrictingsomeorallofthesecarbohydrates,notjustsugar.Inthisbook,thefocusisspecificallyontheroleofsugarinourdiet,andthe

likelypossibilitythat thedifferencebetweenahealthydietandonethatcausesobesity,diabetes,heartdisease,cancer,andotherassociateddiseasesbeginswiththesugarcontent.Ifthisistrue,itimpliesthatpopulationsorindividualscanbeattheveryleastreasonablyhealthylivingoncarbohydrate-richdiets,evengrain-richdiets,aslongastheyconsumerelativelylittlesugar.Assugarconsumptionrisesandpeopleingestitoverdecades,andacrossgenerations,itcausesinsulinresistanceandtriggerstheprogressiontoobesity,diabetes,andthediseasesthatassociatewiththem.Oncethisprocessstarts,easilydigestible,carbohydrate-richfoods aid and abet it. If the argument is correct, the first necessary step inpreventingoravoidingthesediseasesistoremovethesugarsfromourdiets.This argument also serves to censure the last century of advice on obesity,

diabetes,andnutrition,notwithstandingthebestintentionsofthosewhogaveit.Despiteacentury’sworthofevidenceimplicatingsugarasthecauseofinsulinresistanceanddiabetesandmany,perhapsall,ofthediseasesthatassociatewiththem, the researchers working in these fields, and the health organizationsfundingthisresearch,chosetoignoreitorrejectit.Invariably,theydidsoonthebasis of ill-founded assumptions and preconceptions about what other factorsmight be responsible—dietary fat, or the simplistic idea that eating toomanycaloriesofanykindmakesusfat.HereI’llbediscussingthescienceasmuchastheerrors in judgment thatweremadeduring this time. It’sone thing toclaimthat sugar is uniquely toxic—perhaps having prematurely killed more peoplethancigarettesor“allwarscombined,”asKellyWestsaidaboutdiabetesitself—buttodosoconvincinglywehavetounderstandwhythisconclusionhasnotbeencommonwisdom.In the process, I’ll be looking at the key scientific issues with a decidedly

historical perspective. History is critical to understanding science and how itprogresses.Inmanyscientificdisciplines—physics,forexample—thescienceistaughtwiththehistoryattached.Students learnnotonlywhat isbelievedtobetrueandwhichconjectureshavefallenbythewayside,butonthebasisofwhatexperiments and what evidence, and by whose authority and ingenuity. The

namesofthephysicistsresponsiblefortheadvancesinunderstanding—Newton,Einstein,Maxwell(forhisequationsofelectromagnetism);Heisenberg,Planck,and Schrödinger, among others, for their work in understanding the quantumnatureof theuniverse;andmanymore—areaswellknownasmanyhistoricalfiguresinpoliticsandotherfields.Medicinetoday,though,aswithrelatedfieldssuch as nutrition, is taught mostly untethered from its history. Students aretaughtwhat to believe but not always the evidence onwhich these beliefs arebased,andsooftentimesthebeliefscannotbequestioned.Andmedicalstudentsarenottaught,asphysicsstudentstypicallyare,toquestioneverythingthathasnot demonstrably survived the trial-by-fire process of rigorous, methodicaltesting. Students of any science need to know why they are being asked tobelieveaparticularidea,orwhynot,andonwhatgrounds.Withoutthehistoryoftheidea,there’snowaytotelland,byimplication,noreasontoask.Thisiswhyauthoritiesondiabetestodaywilloftenarguethatsugardoesnot

cause diabetes but will do so based on little or no awareness of how thatconclusion was ultimately reached and on what evidence. It’s why theprovenanceof the idea thatwegetfatbecauseweconsumemorecalories thanweexpend is littleknown,evenby thosephysiciansandresearcherswhohavebeen(orstillare)itsdie-hardproponents.It’swhytheexistenceofacompetinghypothesisofobesityasahormonaldisorder is littleknown, letalone that thishypothesis iscapableofexplainingthedataandtheobservations inawaythatthe“energybalance”notionisincapableofdoing.Inwritingthisbook,Ihopetocontinuetorestorethishistorytothediscussion

ofhowourdietsinfluenceourweightandhealth,andtodosointhecontextofthevitallyimportantquestionofsugarinthediet.

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Iwanttoclarifyafewfinalpointsbeforewecontinue.First,I’mgoingtoconcedeinadvanceakeypointthatthosewhodefendthe

roleofsugarinourdietwillinvariablymake.Thesugarindustryandpurveyorsof sugar-rich products are right when they say that it cannot be establisheddefinitively,withthescienceasitnowstands,thatsugarisuniquelyharmful—atoxinthatdoesitsdamageoverdecades.Theevidenceisnotasclearwithsugaras it iswith tobacco.This isn’t a failure of science but, rather, an issue of itslimits.Withtobacco,researcherscouldcomparesmokerswithnonsmokersandlook

for the difference in incidence of a single disease—lung cancer—that innonsmokers,atleast,isveryrare.Thesestudieswerefirstdoneinthelate1940s,and the difference observed in these comparisons was so dramatic—heavysmokershad twenty to thirty times the riskof thosewhohadnever smoked—that itwas effectively impossible to imagine any reasonable explanation otherthancigarettes(notthatthetobaccoindustrydidn’ttry).With sugar, thebest researchers cando is compare individuals all ofwhom

haveconsumedtremendousamountsofsugar,atleastcomparedwiththelevelsofconsumptioninnonindustrializedsocieties.Iftheycomparesugarconsumerswiththosewhoabstain,they’relookingatindividualswhohavevastlydifferentphilosophies about how to lead a healthy life and so will differ in manymeaningfulways other than just howmuch sugar they consume.They’re alsolooking at differences in rates of what are now all-too-common diseases,althoughwhetherthediseaseswouldbecommoninaworldwithoutsugaristhequestion.Thestudyofsugarconsumersversusnonconsumersentailsissuesandchallengesthatsimplydidn’texistinthestudyofcigarettesandlungcancer.Onewaytotacklethisproblemistocomparepopulationsthathadnoaccess

tosugar,orvery little,with those thathadplenty—often thesamepopulationstwenty,fifty,orahundredyearslater.Still,thedifferenceinsugarconsumptionis justoneof themanydifferences thatmightexplain thedifferences inhealthstatus.It’spossibletoassembleacompellingargumentwiththismethod(justasagoodprosecutor cancreate a compellingcase fromcircumstantial evidence),but that is not sufficient to establish definitively what is causing the healtheffectswe’reseeing.Whetherwecanassemblethekindofevidencethatwouldstandupinacourt

oflawandallowgovernmentstoregulatesugar,astheyalreadydotobaccoandalcohol, remains to be seen. But whether we have enough evidence andreasonable assumptions to convince ourselves to avoid sugar, to minimize itsconsumption,andtoconvinceourchildrentodothesameisadifferentquestion.That’sthequestionthisbookwilltrytoanswer.Second,Ineedtoclarifywhatexactlywe’retalkingaboutwhenwetalkabout

sugarorsugars.Thismayseemobvious,butitcertainlyhasn’tbeeninthepast.The controversy over the health effects of sugar—proceeding, as it has, forhundreds of years—is littered with erroneous statements and conclusions thathavedriven thinking to the currentday.Often, if not largely, it is because theindividualsconsideredauthoritiesonthesubjectoftenhadnotrueunderstanding

of what they were talking about, and thus no understanding of how differenttypesofsugars—allcarbohydrates—mighthaveprofoundlydifferenteffectsonhuman health. This confusion still exists and still haunts some of the mostinfluentialreportingondietandhealth,despitethemultitudesofarticleswrittenonsugarandhealthinthepastdecade.Biochemically, theterm“sugar”refers toagroupofcarbohydratemolecules

consisting, as the word “carbohydrate” implies, of atoms of carbon andhydrogen. The names of these carbohydrates all end in “-ose”—glucose,galactose, dextrose, fructose, lactose, sucrose, etc. All of these sugars willdissolve inwater,andtheyall tastesweet tous,althoughtoagreateror lesserextent.When physicians or researchers refer to “blood sugar,” they’re talkingaboutglucose,becauseitconstitutesvirtuallyallofthesugarcirculatinginourblood.Themore common usage of “sugar” refers to sucrose, thewhite crystalline

variety that we put in our coffee or tea or sprinkle on our morning cereal.Sucroseinturniscomposedofequalpartsglucoseandfructose,thetwosmallersugars (monosaccharides, in the chemical lingo) bonded together tomake thelargerone(adisaccharide).Fructose,foundnaturallyinfruitsandhoney,isthesweetestofallthesesugars,andit’sthefructosethatmakessucroseparticularlysweet.Lately, researchers havebeen askingwhether fructose is toxic, becauseit’s the significant amount of fructose in sugar (sucrose) that differentiates itfrom other carbohydrate-rich foods, such as bread or potatoes, which breakdownupondigestion tomostly glucose alone.Becausewenever consume thefructose without the glucose, though, the appropriate question is whethersucrose, the combinationof roughlyequalparts fructoseand glucose, is toxic,notonealone.This would be confusing enough without the introduction in the 1970s of

high-fructosecornsyrup(HFCS),whichreplacedasignificantpartoftherefinedsugar (i.e., sucrose) consumed in the United States over the decade thatfollowed. High-fructose corn syrup comes in different formulations; the mostcommon one is known as HFCS-55, because it’s 55 percent fructose and 45percentglucose.*3Insucrose,theratiois50-50.Itwascreated,infact,toreplacesucrose inexpensivelywhen used as the sweetener in soft drinks—specificallyCoca-Cola—withoutanynoticeabledifferenceintasteorsweetness.TheU.S.DepartmentofAgriculture includesboth sucroseandHFCS in the

category of “caloric” or “nutritive” sweeteners, along with honey and maple

syrup—bothglucose-fructosecombinations—differentiatingthemfromartificialsweeteners such as saccharin, aspartame, and sucralose, which are effectivelycalorie-free.Public-healthauthoritiesoftenrefertosucroseandHFCSas“addedsugars” to differentiate them from the component sugars that can be foundnaturally(inrelativelysmallproportions)infruitsandvegetables.BecausetheintroductionofHFCS-55roughlycoincidedwiththebeginningof

the obesity epidemic in the United States, researchers and journalists latersuggestedthatHFCSwasthecause,implyingthatitwassomehowdistinctfromsugar itself.HFCSwaspromptlydemonizedasaparticularlyperniciousaspectofthediet—“theflashpointforeverybody’sdistrustofprocessedfoods,”astheNew York University nutritionist Marion Nestle has described it—and that’soften still considered to be the case. This iswhy cans of Pepsi sweetened bysucroseratherthanhigh-fructosecornsyrupproudlyproclaimthattheycontain“natural sugar.” Newman’s Own lemonade, sweetened with sucrose (“canesugar,” as the label says),proclaimsprominentlyon the carton that it contains“nohighfructosecornsyrup.”In2010,theCornRefinersAssociationpetitionedtheFoodandDrugAdministrationtoallowittorefertohigh-fructosecornsyrupas“cornsugar”on food labels, thus trying toavoid thisdemonizationprocess.Thesugar industrypromptlysued themtoprevent it fromhappening,atwhichpoint the Corn Refiners countersued. In 2012, the FDA denied the CornRefiners’ petition—sugar, the FDA said, “is a solid, dried, and crystallizedsweetener”andHFCSisnot—andsothelatterisstillclearlyidentifiableasbothsyrupyandderivedfromcorn.All of this controversy, however, though itmay benefit the sugar (sucrose)

industryinparticular,servesonlytoobfuscatethekeypoint:high-fructosecornsyrupisnotfructose,anymorethansucroseis.(Thereasonfor theappellation“highfructose”isthatHFCShasagreaterproportionoffructosetoglucosethanpreviouscornsyrups,whichdatebacktothenineteenthcenturyandwereneversweetenoughtochallengetheprimacyofsucroseinfoodsandbeverages.)Ourbodies appear to respond the sameway to both sucrose andHFCS. In a 2010review of the relevant science, Luc Tappy, a researcher at the University ofLausanneinSwitzerland,whoisconsideredbybiochemistswhostudyfructosetobeamongtheworld’sforemostauthoritiesonthesubject,saidtherewas“notthesinglehint”thatHFCSwasmoredeleteriousthanothersourcesofsugar.ThequestionI’llbeaddressinginthisbookiswhethertheyarebothbenign,orbothharmful—notwhetheroneisworsethantheother.Myusageofthewords“sugar”or“sugars”throughoutthetextwilldependon

context.IfI’mspeakingaboutthepresent,whensucroseandhigh-fructosecornsyrupareusedtoanequalextent,I’lluse“sugar”torefertoboth.Ifthecontextis prior to the introduction of high-fructose corn syrup in the late 1970s, then“sugar”willonlymeansucrose,andI’lloftenqualifyitbydescribingitaseitherbeetsugarorcanesugar.IfI’mreferringtospecific(monosaccharide)sugars—fructose,glucose,lactose,etc.—thenthat,too,willbeclearfromthecontext.The last issue that requires clarification before we continue is that of how

muchofthesesugars(i.e.,caloricsweeteners)weactuallyconsumeor,forthatmatter,everdid.Throughthe1970s, thepercapitaconsumptionnumberscitedby government organizations, historians, and journalists—the numbers Itypically use in this book— would have been for sugar “deliveries,” as theDepartmentofAgriculturenowreferstothem.Thisistheamountthatindustrymakesavailableforconsumeruse.Theformula issimple:domesticproductionplusimportsminusexports,alldividedbythecurrentpopulation.Governmentsacquire these numbers for tax, tariff, and other purposes, and they do itreasonably well. Hence, these numbers are (relatively) reliable, as are trendsbased on these numbers.We can assume, for instance, that when the USDAreportsthat114poundsofsugarandHFCSweredeliveredtoretailersin2014,that number can bemeaningfully comparedwith the 153 pounds delivered in1999,whendeliveries (and,soweassume,consumption)peaked in theUnitedStates, and both can be compared with the few tens of pounds delivered percapitatwohundredyearsago.Beginninginthe1980s,however,withaFoodandDrugAdministrationreport

thatwewill discuss in chapter 8, authorities have often tried to estimate howmuchof thisavailablesugarisactuallyconsumed.Afterall,muchgets thrownout with stale bakery products, for instance, or flat soda or the juice at thebottomofacuporcan.Theauthoritiesbasetheseestimatesprimarilyonsurveysinwhich individuals are asked to recallwhat they ate and drank. This surveydata is known to be exceedingly unreliable, which the USDA readily admits.(“Limitations on accuratelymeasuring food loss,” it says, “suggest that actuallossratesmaydifferfromtheassumptionsused.”)Still, theUSDAnow reports that in 2014 (the latest numbers available as I

write this) theaverageAmericanconsumedonly67poundsof thesucroseandHFCSoutofthe114poundstheindustrymadeavailable—slightlylessthan60percent.Bydoingso,areasonablyreliablenumber(114poundsdelivered)hasbeen transformed intoanunreliablenumber (67poundsconsumed).Anumberthatcanbeusedforhistoricaltrendsandcomparisonshasbeenconvertedintoa

numberthatcannot.Thesugarindustryprefersthelatter,smallernumber—“Weperceiveit tobe

in our interest to see as low a per-capita sweetener consumption estimate aspossible,”asonesugar industryexecutivewrote ina2011e-mail.Thesmallernumbersuggeststhatwedon’teatordrinkallthatmuchsugar(orHFCS),afterall.But it hasno comparison.Wehavenomeaningfulwayof adjusting sugardeliveries for loss decades or centuries ago. Nor can we use it to drawmeaningfulcomparisons to theamountofother foodswesupposedlyconsumetoday,becausethoseadjustednumbersarealsobasedonunreliablesurveysandunsubstantiatedassumptions.For the sakeof simplicity, Iwill typically refer in the text to theamountof

sugar consumed per year (100 pounds per capita in the U.S. in 1920, forinstance) because that’s how it was referred to in the documents I cite, eventhough this number was technically the amount of sugar made available byindustry, i.e., deliveries.When I refer tonumbers thatpurport tobe legitimateestimatesofconsumption,Iwillbeexplicit.It’saconfusingbusiness,butI’lldomybesttokeepitclearaswecontinue.

*1AtMassachusettsGeneralHospital, theverysamehandwrittenmedical records thatJoslinwould lateranalyzerevealthatfortwentyoftheforty-fiveyearsbetween1824and1869therewasnotasinglecaseofdiabetes.Innoneoftheseyearsweretheremorethanthreecases.*2 Because type 2 diabetes is so much more common, when I refer to diabetes in this book I will bereferringtothetype2formorbothtype2andtype1together,unlessspecifiedotherwise.*3This ratiowas called into question in a 2010 analysis claiming that fructose content in somepopularsugarybeverageswasthenashighas65percent.

CHAPTER1

DRUGORFOOD?

ThesweetshopinLlandaffintheyearof1923wastheverycenterofourlives.Tous,itwaswhatabaristoadrunk,orachurchistoaBishop.Withoutit,therewouldhavebeenlittletolivefor….Sweetswereourlife-blood.

ROALDDAHL,Boy:TalesofChildhood,1984

Imagine a moment when the sensation of honey or sugar on the tongue was anastonishment,akindofintoxication.TheclosestI’veevercometorecoveringsuchasenseof sweetnesswas secondhand, though it left a powerful impression onme even so. I’mthinkingofmyson’sfirstexperienceofsugar:theicingonthecakeathisfirstbirthday.Ihave only the testimony of Isaac’s face to go by (that, and his fierceness to repeat theexperience),butitwasplainthathisfirstencounterwithsugarhadintoxicatedhim—wasinfactanecstasy,intheliteralsenseofthatword.Thatis,hewasbesidehimselfwiththepleasureofit,nolongerherewithmeinspaceandtimeinquitethesamewayhehadbeenjustamomentbefore.BetweenbitesIsaacgazedupatmeinamazement(hewasonmylap, and I was delivering the ambrosial forkfuls to his gapingmouth) as if to exclaim,“Yourworldcontainsthis?FromthisdayforwardIshalldedicatemylifetoit.”

MICHAELPOLLAN,BotanyofDesire,2001

WhatifRoaldDahlandMichaelPollanareright,thatthetasteofsugaronthetonguecanbeakindofintoxication?Doesn’titsuggestthepossibilitythatsugaritselfisanintoxicant,adrug?Imagineadrugthatcanintoxicateus,caninfuseus with energy, and can do so when taken by mouth. It doesn’t have to beinjected, smoked, or snorted for us to experience its sublime and soothingeffects. Imagine that it mixes well with virtually every food and particularlyliquids, and that when given to infants it provokes a feeling of pleasure soprofound and intense that its pursuit becomes a driving force throughout theirlives.

Overconsumptionofthisdrugmayhavelong-termsideeffects,buttherearenone in the short term—no staggering or dizziness, no slurring of speech, nopassingoutordriftingaway,noheartpalpitationsorrespiratorydistress.Whenitis given to children, its effects may be only more extreme variations on theapparently natural emotional roller coaster of childhood, from the initialintoxicationtothetantrumsandwhiningofwhatmayormaynotbewithdrawala few hours later. More than anything, our imaginary drug makes childrenhappy,at leastfor theperiodduringwhichthey’reconsumingit. Itcalmstheirdistress, eases their pain, focuses their attention, and then leaves them excitedandfullofjoyuntilthedosewearsoff.Theonlydownsideisthatchildrenwillcometoexpectanotherdose,perhapstodemandit,onaregularbasis.Howlongwoulditbebeforeparentstooktousingourimaginarydrugtocalm

their children when necessary, to alleviate pain, to prevent outbursts ofunhappiness,ortodistractattention?Andoncethedrugbecameidentifiedwithpleasure, how long before it was used to celebrate birthdays, a soccer game,goodgradesatschool?Howlongbeforeitbecameawaytocommunicateloveand celebrate happiness?How long before no gathering of family and friendswascompletewithoutit,beforemajorholidaysandcelebrationsweredefinedinpartbytheuseofthisdrugtoassurepleasure?Howlongwoulditbebeforetheunderprivilegedoftheworldwouldhappilyspendwhatlittlemoneytheyhadonthisdrugratherthanonnutritiousmealsfortheirfamilies?Howlongwoulditbebeforethisdrug,astheanthropologistSidneyW.Mintz

saidabout sugar,demonstrated“anear invulnerability tomoral attack,”beforeevenwritingabooksuchasthisonewasperceivedasthenutritionalequivalentofstealingChristmas?

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What is it about the experience of consuming sugar and sweets, particularlyduring childhood, that invokes so readily the comparison to a drug? I havechildren,stillrelativelyyoung,andIbelieveraisingthemwouldbeafareasierjobifsugarandsweetswerenotanoption,ifmanagingtheirsugarconsumptiondidnotseemtobeaconstantthemeinourparentalresponsibilities.Eventhosewho vigorously defend the place of sugar and sweets in modern diets—“aninnocent moment of pleasure, a balm amid the stress of life,” as the BritishjournalistTimRichardsonhaswritten—acknowledgethat thisdoesnot includeallowing children “to eat asmany sweets as theywant, at any time,” and that

“mostparentswillwanttorationtheirchildren’ssweets.”Butwhy is it necessary?Childrencravemany things—Pokémoncards,Star

Warsparaphernalia,DoratheExplorerbackpacks—andmanyfoodstastegoodto them. What is it about sweets that makes them so uniquely in need ofrationing,which is anotherwayof askingwhether the comparison todrugsofabuseisavalidone?This is of more than academic interest, because the response of entire

populations to sugar has been effectively identical to that of children: oncepopulationsareexposed,theyconsumeasmuchsugarastheycaneasilyprocure,although theremaybenatural limits set by culture and current attitudes aboutfood. The primary barrier to more consumption—up to the point wherepopulationsbecomeobeseanddiabeticand then,perhaps,beyond—has tendedto be availability and price. (This includes, in one study, sugar-intolerantCanadian Inuit, who lacked the enzyme necessary to digest the fructosecomponentofsugarandyetcontinuedtoconsumesugarybeveragesandcandydespite the “abdominal distress” it brought them.)As the price of a pound ofsugar has dropped over the centuries—from the equivalent of 360 eggs in thethirteenthcentury to two in the earlydecadesof the twentieth—theamountofsugarconsumedhassteadily,inexorably,climbed.In1934,whilesalesofcandycontinued to increase during the Great Depression, The New York Timescommented,“Thedepressionprovedthatpeoplewantedcandy,andthataslongastheyhadanymoneyatall,theywouldbuyit.”Duringthosebriefperiodsoftime during which sugar production surpassed our ability to consume it, thesugar industry andpurveyors of sugar-rich products haveworked diligently toincreasedemandand,atleastuntilrecently,havesucceeded.The critical question, what scientists debate, as the journalist and historian

CharlesC.Mannhaselegantlyputit,“iswhether[sugar]isactuallyanaddictivesubstance,or ifpeople just act like it is.”Thisquestion isnot easy to answer.Certainly, people andpopulationshave acted as though sugar is addictive, butscience provides no definitive evidence. Until recently, nutritionists studyingsugar did so from the natural perspective of viewing sugar as a nutrient—acarbohydrate—and nothing more. They occasionally argued about whether ornot itmight play a role in diabetes or heart disease, but not aboutwhether ittriggered a response in the brain or body thatmade uswant to consume it inexcess.Thatwasnottheirareaofinterest.Thefewneurologistsandpsychologistsinterestedinprobingthesweet-tooth

phenomenon,orwhywemightneedtorationoursugarconsumptionsoasnottoeat it to excess, did so typically from the perspective of how these sugarscomparedwith other drugs of abuse, in which themechanism of addiction isnow relatively well understood. Lately, this comparison has received moreattention as the public-health community has looked to ration our sugarconsumption as a population, and has thus considered the possibility that oneway to regulate these sugars—aswith cigarettes—is to establish that they are,indeed, addictive. These sugars are very likely unique in that they are both anutrientandapsychoactivesubstancewithsomeaddictivecharacteristics.Historians have often considered the sugar-as-a-drugmetaphor to be an apt

one. “That sugars, particularly highly refined sucrose, produce peculiarphysiologicaleffects iswellknown,”wrotethelateSidneyMintz,whose1985bookSweetnessandPowerisoneoftwoseminalEnglish-languagehistoriesofsugar on which other, more recent writers on the subject (including myself)heavilyrely.*Buttheseeffectsareneitherasvisiblenoraslong-lastingasthoseof alcohol, or caffeinated beverages, “the first use of which can trigger rapidchangesinrespiration,heartbeat,skincolorandsoon.”Mintzhasarguedthataprimary reason that through the centuries sugar has escaped religious-basedcriticisms, of the kind pronounced on tea, coffee, rum, and even chocolate, isthat,whateverconspicuousbehavioralchangesmayoccurwheninfantsconsumesugar, it did not cause the kind of “flushing, staggering, dizziness, euphoria,changesinthepitchofthevoice,slurringofspeech,visiblyintensifiedphysicalactivity, or any of the other cues associatedwith the ingestion” of these otherdrugs. As this book will argue, sugar appears to be a substance that causespleasurewithapricethatisdifficulttodiscernimmediatelyandpaidinfullonlyyears or decades later. With no visible, directly noticeable consequences, asMintz says, questions of “long-term nutritive or medical consequences wentunaskedandunanswered.”Mostofustodaywillneverknowifwesufferevensubtlewithdrawal symptoms from sugar, becausewe’ll never go long enoughwithoutsugartofindout.Mintzandothersugarhistoriansconsiderthedrugcomparisontobesofitting

inpartbecausesugarisoneofahandfulof“drugfoods,”touseMintz’sterm,thatcameoutofthetropics,andonwhichEuropeanempireswerebuiltfromthesixteenth century onward, the others being, tea, coffee, chocolate, rum, andtobacco. Its history is intimately linked to that of these other drugs. Rum isdistilled,ofcourse,fromsugarcane,whereastea,coffee,andchocolatewerenotconsumedwithsweetenersintheirregionsoforigin.Intheseventeenthcentury,

however, once sugar was added as a sweetener and prices allowed it, theconsumptionofthesesubstancesinEuropeexploded.Sugarwasusedtosweetenliquors and wine in Europe as early as the fourteenth century; even cannabispreparations in India and opium-based wines and syrups included sugar as amajoringredient.Kola nuts, containing both caffeine and traces of a milder stimulant called

theobromine,becameaproductofuniversalconsumptioninthelatenineteenthcentury, first as a coca-infusedwine in France (VinMariani) and then as theoriginalmixtureofcocaineandcaffeineofCoca-Cola,withsugaraddedtomaskthebitternessoftheothertwosubstances.Theremovalofthecocaineinthefirstyears of the twentieth century seemed to have little influence onCoca-Cola’sabilitytobecome,asonejournalistdescribeditin1938,the“sublimatedessenceofallthatAmericastandsfor,”thesinglemostwidelydistributedproductontheplanetandthesecond-most-recognizablewordonEarth,“okay”beingthefirst.It’s not a coincidence that John Pemberton, the inventor of Coca-Cola, had amorphine addiction that he’d acquired after being wounded in the CivilWar.Coca-Colawasoneofseveralpatentmedicinesheinventedtohelpweanhimofftheharderdrug.“LikeCoca,Kolaenablesitspartakerstoundergolongfastandfatigue,” read one article in 1884. “Two drugs, so closely related in theirphysiologicalproperties,cannotfailtocommandearlyuniversalattention.”As for tobacco, sugarwas, and still is, a critical ingredient in theAmerican

blended-tobacco cigarette, the first of which was Camel, introduced by R. J.Reynoldsin1913.It’sthis“marriageoftobaccoandsugar,”asasugar-industryreport described it in 1950, that makes for the “mild” experience of smokingcigarettes as compared with cigars and, perhaps more important, makes itpossibleformostofustoinhalecigarettesmokeanddrawitdeepintoourlungs.It’s the “inhalability” of American blended cigarettes that made them sopowerfully addictive—aswell as sopotently carcinogenic—and that drove theexplosionincigarettesmokingintheUnitedStatesandEuropeinthefirsthalfofthetwentiethcentury,andtherestoftheworldshortlythereafter,and,ofcourse,thelung-cancerepidemicsthathaveaccompaniedit.Unlike alcohol, which was the only commonly available psychoactive

substance in the OldWorld until sugar, nicotine, and caffeine arrived on thescene,thelatterthreehadatleastsomestimulatingproperties,andsoofferedaverydifferentexperience,onethatwasmoreconducivetothelaborofeverydaylife. These were the “eighteenth-century equivalent of uppers,” writes theScottishhistorianNiallFerguson.“Takentogether,thenewdrugsgaveEnglish

societyanalmightyhit;theEmpire,itmightbesaid,wasbuiltonahugesugar,caffeineandnicotinerush—arushnearlyeveryonecouldexperience.”Sugar,more than anything, seems to havemade lifeworth living (as it still

does) for so many, particularly those whose lives were absent the kind ofpleasuresthatrelativewealthanddailyhoursofleisuremightotherwiseprovide.As early as the twelfth century, one contemporary chronicler of theCrusades,Albert ofAachen,was describingmerely the opportunity to sample the sugarfrom the cane that theCrusaders foundgrowing in the fieldsofwhat arenowIsrael and Lebanon as in and of itself “some compensation for the sufferingsthey had endured.” “The pilgrims,” he wrote, “could not get enough of itssweetness.”Assugar,tea,andcoffeeinstigatedthetransformationofdailylifeinEurope

and theAmericas in theseventeenthandeighteenthcenturies, theybecametheindulgencesthatthelaboringclassescouldafford;bythe1870s,theyhadcometobeconsiderednecessitiesoflife.Duringperiodsofeconomichardship,astheBritishphysicianandresearcherEdwardSmithobservedatthetime,theBritishpoorwouldsacrificethenutritiousitemsoftheirdietbeforethey’dcutbackonthe sugar they consumed. “In nutritional terms,” suggested three Britishresearchers in 1970 in an analysis of the results of Smith’s survey, “it wouldhavebeenbetterifsomeofthemoneyspentonsugarhadbeendivertedtobuybreadandpotatoes,sincethiswouldhavegiventhemverymanymorecaloriesforthesamemoney,aswellasprovidingsomeprotein,vitaminsandminerals,whichsugarlacksentirely.Infacthoweverwefindthatatasteforthesweetnessofsugartendstobecomefixed.Thechoicetoeatalmostasmuchsugarastheyusedtodo,whilesubstantiallyreducingtheamountofmeat,reinforcesourbeliefthat people develop a liking for sugar that becomes difficult to resist orovercome.”Sugarwas “an ideal substance,” saysMintz. “It served tomake a busy life

seemlessso;inthepausethatrefreshes,iteased,orseemedtoeasethechangesback and forth fromwork to rest; it provided swifter sensations of fullness orsatisfactionthancomplexcarbohydratesdid;itcombinedeasilywithmanyotherfoods, in some of which it was also used (tea and biscuit, coffee and bun,chocolateandjam-smearedbread)….Nowondertherichandpowerfullikeditsomuch, and no wonder the poor learned to love it.”What OscarWilde wroteabout a cigarette in 1891, when that indulgence was about to explode inpopularity and availability, might also be said about sugar: It is “the perfectpleasure.Itisexquisite,anditleavesoneunsatisfied.Whatmorecanonewant?”

Sugar craving does seem to be hard-wired in our brains. Children certainlyrespond to it instantaneously, from birth (if not in the womb) onward. Givebabies a choice of sugarwater or plain,wrote theBritish physician FrederickSlare threehundredyearsago,and“theywillgreedilysuckdowntheone,andmakeFacesattheother:Norwilltheybepleas’dwithCowsMilk,unlessthatbebless’d with a little Sugar, to bring it up to the Sweetness of Breast-Milk.”Slare’s observationwas confirmed experimentally in the early1970sby JacobSteiner, a professor of oral biology at the Hebrew University of Jerusalem.Steiner studied and photographed the expressions of newborn infants given ataste of sugar water even before they had received breast milk or any othernourishment. The result, he wrote, was “a marked relaxation of the face,resembling an expression of ‘satisfaction,’ often accompanied ‘by a slightsmile,’ ”whichwas almost always followed“by an eager lickingof theupperlip, and sucking movements.” When Steiner repeated the experiment with abittersolution,thenewbornsspititout.This raises the question of why humans evolved a sweet tooth, requiring

intricate receptorson the tongueand the roofof themouth,anddown into theesophagus, thatwill detect the presence of evenminute amounts of sugar andthen signal this taste via nerves extending up into the brain’s limbic system.Nutritionistsusuallyanswerbysayingthatinnatureasweettastesignaledeithercaloricallyrichfruitsormother’smilk(becauseofthelactose,arelativelysweetcarbohydrate, which can constitute up to 40 percent of the calories in breastmilk), so that a highly sensitive system for distinguishing such foods anddifferentiating them from the tastes of poisons, which we recognize as bitter,wouldbeadistinctevolutionaryadvantage.Butifcaloricornutrientdensityistheanswer,thenutritionistsandevolutionarybiologistshavetoexplainwhyfatsdo not also taste sweet to us. They have twice asmany calories per gram assugarsdo(andmorethanhalfthecaloriesinmother’smilkcomefromfat).One proposition commonly invoked to explain why the English would

become theworld’s greatest sugar consumers and remain so through the earlytwentieth century, alongside the fact that the English had the world’s mostproductive network of sugar-producing colonies, is that they had lacked anysucculent native fruit, and so had little previous opportunity to accustomthemselvestosweets,asMediterraneanpopulationsdid.Assuch,thesweettastewasmoreofanovelty to theEnglish,and their firstexposure tosugar,as thisthinkinggoes, occasionedmore of a population-wide astonishment.Accordingto this argument, Americans then followed the British so closely as sugar

consumers because the original thirteen colonies were settled by the English,who brought their sweet cravings with them. The same explanation holds forAustralians,whohadcaughtup to theBritishas sugarconsumersby theearlydecadesofthetwentiethcentury.All of this is speculation, however, as is the notion that it was the

psychoactive aspects of sugar consumption that provided the evolutionaryadvantage. The taste of sugar will soothe distress, and thus “distressvocalizations” in infants; consuming sugar will allow adults to work throughpain and exhaustion and to assuage hunger pains. That sugar works as apainkiller or at least a powerful distraction to infants is evidenced by its useduring circumcision ceremonies—even in hospitals on the day after birth—tosootheandquietthenewborn.Ifsugar,though,isonlyadistractiontotheinfantand not actively a pain reliever or a psychoactive inducer of pleasure thatovercomesanypain,asthisviewposits,wehavetoexplainwhyinclinicaltrialsit ismore effective in soothing thedistress of infants than themother’s breastandbreastmilkitself.Manyanimalsdorespondpositivelytosugar—theyhaveasweettooth—but

notall.Catsdon’t,for instance,but they’reobligatecarnivores(innature, theyeat only other animals). Chickens don’t, nor do armadillos, whales, sea lions,some fish, and cowbirds.Despite theubiquitoususeof rats in the researchonsugaraddiction,somestrainsoflaboratoryratsprefermaltose—thecarbohydrateinbeer—to sugar.Cattle, on theotherhand,will happily fatten themselvesonsugar, an observation that was made in the late nineteenth century, when thepriceofsugarfellsufficientlythatfarmerscouldaffordtouseitforfeed.Inonestudypublished in1952, agronomists reported that theycouldget cattle to eatplants they otherwise disdained by spraying the plantswith sugar ormolasses(the cattle preferred the latter)—in other words, by sugar-coating them. “Inseveralinstances,”theresearchersreported,“thecattlequicklybecameawareofwhat was going on and followed the spraying can around expectantly.” Thecattlehadthesameresponsetoartificialsweeteners,suggestingthat“thecattleliked anything sweet whether it had food value or not.” By sweetening withsugar,asanessayinTheNewYorkTimesobservedin1884,“wecangiveafalsepalatablenesstoeventhemostindigestiblerubbish.”Theactualresearchliteratureonthequestionofwhethersugarisaddictiveand

thus anutritional variationon adrugof abuse is surprisingly sparse.Until the1970s and for the most part since then, mainstream authorities have notconsidered this question to be particularly relevant to human health. The very

limited research allows us to describe what happens when rats and monkeysconsumesugar,butwe’renotthemandthey’renotus.Thecriticalexperimentsare rarely if ever done in humans, and certainly not children, for the obviousethical reasons: we can’t compare how they respond to sugar, cocaine, andheroin,forinstance,todeterminewhichismoreaddictive.Sugardoesinducethesameresponsesintheregionofthebrainknownasthe

“rewardcenter”—technically, thenucleusaccumbens—asdonicotine,cocaine,heroin,andalcohol.Addictionresearchershavecometobelieve thatbehaviorsrequired for the survival of a species—specifically, eating and sex—areexperiencedaspleasurableinthispartofthebrain,andsowedothemagainandagain.Sugarstimulatesthereleaseofthesameneurotransmitters—dopamineinparticular—throughwhichthepotenteffectsof theseotherdrugsaremediated.Because the drugs work this way, humans have learned how to refine theiressenceintoconcentratedformsthatheightentherush.Cocaleaves,forinstance,aremildlystimulatingwhenchewed,butpowerfullyaddictivewhenrefinedintococaine; even more so taken directly into the lungs when smoked as crackcocaine.Sugar,too,hasbeenrefinedfromitsoriginalformtoheightenitsrushandconcentrateitseffects,albeitasanutrientthatprovidesenergyaswellasachemicalthatstimulatespleasureinthebrain.Themoreweusethesesubstances,thelessdopamineweproducenaturallyin

thebrain,andthemorehabituatedourbraincellsbecometothedopaminethatisproduced—the number of “dopamine receptors” declines. The result is aphenomenonknownasdopaminedown-regulation:weneedmoreofthedrugtoget the same pleasurable response, while natural pleasures, such as sex andeating, please us less and less. The question, though, is what differentiates asubstance that works in the reward center to trigger an intense experience ofpleasure and yet isn’t addictive, and one that happens to be both.Does sugarcross that line?Wecanlovesex,for instance,andfindit intenselypleasurablewithoutbeingsexaddicts.Buyinganewpairofshoes,formanyofus,willalsostimulateadopamineresponseintherewardcenterof thebrainandyetnotbeaddictive.Rats given sweetened water in experiments find it significantly more

pleasurablethancocaine,evenwhenthey’readdictedtothelatter,andmorethanheroinaswell(althoughtheratsfindthischoicemoredifficulttomake).Addictaratoverthecourseofmonthstointravenousbolusesofcocaine,astheFrenchresearcher SergeAhmed has reported, and then offer it the choice of a sweetsolutionoritsdailycocainefix,andtheratwillswitchovertothesweetswithin

two days. The choice of sweet taste over cocaine, Ahmed reports,may comeaboutbecauseneuronsinthebrain’srewardcircuitrythatrespondspecificallytosweettasteoutnumberthosethatrespondtococainefourteentoone;thisgeneralfindinghasbeenreplicatedinmonkeys.This animal research validates the anecdotal experience of drug addicts and

alcoholics,andtheobservationsofthosewhobothstudyandtreataddiction,thatsweets and sugary beverages are valuable tools—“sober pleasures”—to weanaddicts off the harder stuff, perhaps transferring from one addiction, or onedopamine-stimulatingsubstance,toanother,albeitarelativelymorebenignone.“Thereislittledoubtthatsugarcanallaythephysicalcravingforalcohol,”astheneurologist JamesLeonardCorning observed over a century ago. The twelve-step bible of Alcoholics Anonymous—called the Big Book—recommends theconsumption of candy and sweets in lieu of alcohol when the cravings foralcoholarise.Indeed, thepercapitaconsumptionofcandyintheUnitedStatesdoubled with the beginning of Prohibition in 1919, as Americans apparentlyturned en masse from alcohol to sweets. Ice-cream consumption showed a“tremendousincrease”coincidentwithProhibition.By1920,sugarconsumptionintheUnitedStateshitrecordhighs,whilebrewerieswerebeingconvertedintocandy factories. “Thewreckage of the liquor business,”The New York Timesreported,“isbeingsalvagedfortheproductionofcandy,icecreamandsyrups.”Five years later, British authorities suggested that this tremendous increase inice-cream consumption “due to prohibition was injurious to health,” but anAmericancollegepresidentcounteredthatthetrade-offwasapparentlyworthit,ashehad“neverheardofamanwhoateexcessivequantitiesoftheconfectiongoinghometobeathiswife.”All of this is worth keeping inmindwhenwe think about how inexorably

sugarandsweetscametosaturateourdietsanddominateourlives,astheannualglobalproductionofsugarincreasedexponentiallyfromthe1600sonward.TheyearlyamountofsugarconsumedpercapitamorethanquadrupledinEnglandinthe eighteenth century, from four pounds to eighteen, and then more thanquadrupled again in the nineteenth. In the United States, yearly sugarconsumptionincreasedsixteen-foldoverthatsamecentury.Bytheearlytwentiethcentury,sugarhadassimilateditselfintoallaspectsof

our eating experience—consumed during breakfast, lunch, dinner, and snacks.Nutritionalauthoritieswerealreadysuggestingwhatappearedtobeobvious,thatthis increasedconsumptionwasaproductofat leastakindofaddiction—“thedevelopmentofthesugarappetite,which,likeanyotherappetite—forinstance,

theliquorappetite—growsbygratification.”Acenturylaterstill,sugarhasbecomeaningredientavoidableinpreparedand

packagedfoodsonlybyconcertedanddeterminedeffort,effectivelyubiquitous:notjustintheobvioussweetfoods—candybars,cookies,icecreams,chocolates,sodas, juices, sports and energy drinks, sweetened iced tea, jams, jellies, andbreakfastcereals(bothcoldandhot)—butalsoinpeanutbutter,saladdressing,ketchup,barbecuesauces,cannedsoups,coldcuts, luncheonmeats,bacon,hotdogs, pretzels, chips, roasted peanuts, spaghetti sauces, canned tomatoes, andbreads. From the 1980s onward, manufacturers of products advertised asuniquelyhealthybecausetheywerelowinfatorspecificallyinsaturatedfat(nottomention“glutenfree,noMSG&0gtransfatperserving”)tooktoreplacingthose fatcalorieswith sugar tomake themequally, ifnotmore,palatable,andoftendisguising thesugarunderoneormoreof the fifty-plusnamesbywhichthefructose-glucosecombinationofsugarandhigh-fructosecornsyrupmightbefound.Fatwas removed fromcandybars, sugaraddedorat leastkept, so thattheybecamehealth-foodbars.Fatwasremovedfromyogurtsandsugarsadded,andthesebecameheart-healthysnacks,breakfasts,andlunches.Itwasasthoughthefoodindustryhaddecidedenmasse,oritsnumerousfocusgroupshadsentthe message, that if a product wasn’t sweetened at least a little, our modernpalates would reject it as inadequate and we would purchase instead acompetitor’sversionthatwas.Alongtheway,sugarandsweetsbecamesynonymouswithloveandaffection

and the language with which we communicate them—“sweets,” “sweetie,”“sweetheart,” “sweetie pie,” “honey,” “honeybun,” “sugar,” and allmanner ofcombinationsandvariations.Sugarandsweetsbecameaprimarycontributiontoour celebrations of holidays and accomplishments, bothmajor andminor. Forthoseofuswhodon’trewardourexistencewithadrink(andformanyofuswhodo), it’s a candy bar, a dessert, an ice-cream cone, or a Coke (or Pepsi) thatmakesourday.Forthoseofuswhoareparents,sugarandsweetshavebecomethetoolswewieldtorewardourchildren’saccomplishments,todemonstrateourlove and our pride in them, to motivate them, to entice them. Sweets havebecomethecurrencyofchildhoodandofparenting.Thecommontendencyis,again, to thinkof this transformationasdrivenby

themere fact that sugarsandsweets tastegood.Wecancall it the“pause thatrefreshes”hypothesisofsugarhistory.Thealternativewaytothinkaboutthisisthatsugartookoverourdietsbecausethefirsttaste,whetherforaninfanttodayor for an adult centuries ago, is literally, as Michael Pollan put it, an

astonishment,akindof intoxication; it’s thekindlingofa lifelongcraving,notidenticalbutanalogoustothatofotherdrugsofabuse.Becauseitisanutrient,andbecause theconspicuous sequelaeof its consumptionare relativelybenigncomparedwiththoseofnicotine,caffeine,andalcohol—atleastintheshorttermand in small doses—it remained, asSidneyMintz says, nearly invulnerable tomoral,ethical,orreligiousattacks.Itremainedinvulnerabletohealthattacksaswell.Nutritionistshavefounditinthemselvestoblameourchronicillsonvirtually

anyelementofthedietorenvironment—onfatsandcholesterol,onproteinandmeat, on gluten and glycoproteins, growth hormones and estrogens andantibiotics, on the absence of fiber, vitamins, andminerals, and surely on thepresence of salt, on processed foods in general, on overconsumption andsedentarybehavior—beforethey’llconcedethatit’sevenpossiblethatsugarhasplayed a unique role in any way other than merely getting us all to eat (asHarvard’sFredStareputitfortyyearsago)toodamnmuch.Andso,whenafewinformed authorities over the years did, indeed, risk their credibility bysuggestingsugarwastoblame,theirwordshadlittleeffectonthebeliefsoftheircolleaguesorontheeatinghabitsofapopulationthathadcometorelyonsugarandsweetsastherewardsforthesufferingsofdailylife.

*Theother isTheHistoryofSugar,published in twoencyclopedicvolumes in1949and1950,byNoëlDeerr,asugar-industryexecutiveturnedsugarhistorian.

CHAPTER2

THEFIRSTTENTHOUSANDYEARS

M.Delacroix,awriterascharmingasheisprolific,complainedoncetomeatVersaillesaboutthepriceofsugar,whichatthattimecostmorethanfivefrancsapound.“Ah,”hesaidinawistful, tendervoice,“if itcaneveragainbeboughtforthirtycents,I’llnevermoretouchwaterunlessit’ssweetened!”Hiswishwasgranted.

JEANANTHELMEBRILLAT-SAVARINThePhysiologyofTaste,1825

Sugar isa fuel forplantsandcanbe found inallof them—insome,however,morethaninothers.It’sasafebetthathumanshavetriedtoextractsugar,atonetimeoranother,fromprettymucheverysubstanceorplantthatwasnoticeablysweet and held the promise of offering its sugar up in quantity. Honey wasconsumed throughout Europe and Asia before sugar displaced it, and whenEuropean colonists arrived in the New World and found no honey, theyintroduced honeybees, which Native Americans took to calling the “EnglishMan’sFly.”NativeAmericanswereusingmaplesyrupasasweetenerbeforetheEuropeans arrived, and they introduced the colonists to the taste. (ThomasJefferson was a proponent of maple syrup because it rendered slave laborunnecessary.Thesugarmaple,hewrote,“yieldsasugarequaltothebestfromthecane,yieldsitingreatquantity,withnootherlaborthanwhatthewomenandgirlscanbestow….Whatablessing.”)Butneithermaplesyrupnorhoneycanbeused to sweeten cold beverages, and neither mixes well with coffee. Neithercould be produced in the quantities necessary to competewith sugar.We stillconsumethem,butinlimitedquantitiesandforlimiteduses.Evensorghum,anOldWorldgrassusedascattlefeedinAfricaandchewed

byvillagersthereforitssweetness,hadaruninthelatenineteenthcenturyasa

potential source of sugar, a competitor to cane and beet sugar. The U.S.DepartmentofAgriculturetookitupand“kindledanenthusiasmthatamountedtoacraze,”butdroughtsandinsectvisitationsdiditin.Caneandthenbeetsugarand now high-fructose corn syrup simply won out, in that they were thesweetenersthatcouldbemass-producedeconomicallyandprovidedinquantitiesnecessarytosatisfywhatappearstohavebeenanalmostlimitlessdemand.Anthropologists believe that sugarcane itselfwas first domesticated inNew

Guineaabouttenthousandyearsago.Asevidencethatitwasreveredeventhen,creationmyths inNewGuineahave thehuman raceemerging from thesexualcongress of the firstman and a stalk of sugarcane. The plant is technically agrass,growingtoheightsoftwelvetofifteenfeet,withjuicystalksthatcanbesix inches around. In tropical soils, sugarcane will grow from cuttings of thestem,andwill ripenormature inayear toayearandahalf.The juiceor sapfrom thecane, at least themodernvariety, ismostlywater andasmuchas17percent sugar. This makes the cane sweet to chew but not intensely so.Anthropologists assume that early farmers domesticated the cane for thesweetness to be derived from chewing the stalks and the energy it provided.Wellbeforetheartofrefiningcamealong,sugarcanedomesticationhadalreadyspreadtoIndia,China,thePhilippines,andIndonesia.Withoutrefining,thejuiceofsugarcaneisforlocalconsumptiononly.Within

adayofcutting,thesugarcanestalkswillbegintofermentandthenrot.Butthejuicecanbesqueezedorcrushedorpoundedoutofthecane,andthat,inturn,asfarmersinnorthernIndiadiscoveredbyaround500B.C.,canbetransformedintoa raw sugar by cycles of heating and cooling—a “series of liquid-solidoperations.”Thesugarcrystallizesastheliquidevaporates.Oneendproductismolasses, a thickbrownviscous liquid;another, requiringgreaterexpendituresoftimeandeffort,isdrycrystallinesugarofcolorsrangingfrombrowntowhite.Thegreatertherefiningeffort,thewhiterandmorepureistheendproduct.When cultivatedwith the instruments ofmodern technology, sugarcane can

produce (as the sugar industry and nutritionists would state in its defenserepeatedlyinthetwentiethcentury)morecaloriesperacretofeedapopulationthananyotheranimalorplant.Itcansurviveyearsofstorage;ittravelswell;itcanbeconsumedonarrivalunheatedanduncooked.And,unlikehoneyormaplesyrup, it has no distinctive taste or aftertaste. Refined sugar is colorless andodorless. It is nothingmore than the crystallized essence of sweet.Other thansalt, it is the only pure chemical substance that humans consume. And itprovidesfourcaloriesofenergypergram.

Sugar is extraordinarily useful in food preparation, evenwhen sweetness isnot necessarily the desired result, and this is one reason why sugar in all itsvariousnamesand forms isnowubiquitous inmodernprocessed foods.Sugarallows for the preservation of fruits and berries by inhibiting the growth ofmicro-organisms that would otherwise cause spoiling. As such, inexpensivesugarmade possible the revolution in jams and jellies that began in themid-nineteenthcentury(oneofmanyrevolutionsinsugar-richfoodsthatbeganatthesametime,aswe’lldiscussshortly).It inhibitsmoldandbacteriaincondensedmilk andother liquids by increasingwhat’s called the osmotic pressure of theliquid.Itreducestheharshnessofthesaltthat’susedforcuringandpreservingmeat(andthesaltincreasesthesweetnessofthesugar).Sugarisanidealfuelforyeast, and thus the rising and leaveningof bread.The caramelizationof sugarprovidesthelight-browncolorsinthecrustofbread.Dissolvesugarinwateranditaddsnotonlysweetnessbutviscosity,andthuscreatesthebodyandwhatfoodscientistscall the“mouthfeel”ofasodaor juice.Asaseasoningoraspice, itenhancesflavorsalreadypresentinthefood,decreasesbitterness,andimprovestexture.All of this was assuredly secondary to sweetness and nourishment, and

perhaps any perceived medicinal use, when sugar began its dispersionthroughouttheworldtwothousandyearsago.FromIndia,BuddhistmissionariescarriedittoChinaandJapan.MuslimexplorersthendiscoveredsugarinChinaandcarrieditbacktoArabiaviaPersiashortlybeforetheMuslimexpansionthatbegan in theseventhcenturyafter thedeathofMuhammad.As thestorygoes,ChosroesI,EmperorofPersia,askedforadrinkofwaterfromayounggirlinagarden,andshegavehimacupofsugarcanejuicechilledwithsnow.Chosroespromptlyaskedforarefillandthencontemplatedstealingthegardenwhileshewas gone. “I must remove these people elsewhere and take this garden formyself,” he said to himself.Whether he did or not, Chosroes is creditedwithtaking the sugarcane back to Persia, and the Muslim Empire then spreadsugarcane-growing around the Mediterranean—to Malta, Sicily, Cyprus,southernSpain,andNorthandEastAfrica.Bythetenthcentury,thetwogreatsugar-producingareasoutsideofIndiaand

ChinawereattheheadofthePersianGulfintheTigris-Euphratesdelta,andintheNile RiverValley in Egypt. It was the Egyptianswho first developed therefiningtechniquesthathavebeenusedmoreorlesseversince.Recordsexistofthe use of sugar at that time in the royal households of Egyptian viziers andcaliphs to the tune of a thousand pounds per day, and of Ramadan feasts in

whichseventy-fivetonsofsugarwereusedatasinglecelebration,muchofittosculpt table decorations that were either consumed outright or given to theneighborhoodbeggarsafterthefeasts.SugarbegantoseepintoNorthernEuropewith theCrusades in theeleventh

century.WhenthefirstCrusadersmadeitbackhome,theytoldstoriesaboutthefieldsofsugarcanetheyhadseenandthelocals,asAlbertofAachenrecorded,“sucking enthusiastically on these reeds, delighting themselves with theirbeneficialjuices,andseem[ing]unabletosatethemselveswiththepleasure.”Bythen the Crusaders were overseeing sugar production in the areas they hadconquered.Sugarwas“amostpreciousproduct,verynecessaryfortheuseandhealthofmankind,”wroteonecontemporarychronicler.WhenCrusaderswithataste for sugar returned home, Italian city-states began shipping sugar by landand sea routes toNorthern Europe and theBritish Isles. Sugar appears in thekitchenexpendituresofHenryIIatthetailendofthetwelfthcentury,listedasaspice; thiswasamong the firstmentionseverof sugaruse inBritain. In1288,EdwardI’shouseholdusedoversixty-twohundredpoundsofsugar.As sugar diffused through Europe, it did so primarily as a medicine—as

wouldtea,coffee,tobacco,andchocolatecenturieslater—adecorative,aspice,and a preservative. (Edward I’s delicate son, who suffered perpetually fromcolds,wasgivensugarandsugarsticksaspartofhistreatment—“tonoavail,ashe died early.”) In the thirt