MS. DIANE REHMAnd thanks for joining us. I'm Diane Rehm. This week, big soda makers pledge to cut beverage calories in the American diet by 20 percent over the next decade. That news comes as the Centers For Disease Control announced the rate of diabetes in the U.S. appears to be leveling off. At the same time, some researchers have new concerns that artificial sweeteners may interfere with the way our bodies metabolize sugar.

MS. DIANE REHMJoining me in the studio to talk about the latest development in the fight against obesity, Maya Rockeymoore of The Center For Global Policy Solutions and Kristina Rother of the National Institutes of Health. Joining us by phone, Robert Lustig of the University of California and Marion Nestle of New York University. Do join us, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or send us a tweet. And welcome to all of you.

MS. MAYA ROCKEYMOOREIt's wonderful to being here.

DR. KRISTINA ROTHERThank you for having us.

DR. ROBERT LUSTIGThank you.

MS. MARION NESTLEGlad to be here.

REHMGood to have you all. Maya Rockeymoore, give us a picture of what's happening with obesity in this country.

ROCKEYMOOREWell, all of the statistics seem to show that obesity rates seem to be plateauing for the general population, that we have seen some signs of progress in communities across the country where we see childhood obesity rates significantly slowing down and then, of course, the overall numbers for adults. However, we have a significant challenge when it comes to people of color and low income populations.

ROCKEYMOORESo, for example, we see disparities and the rates not slowing for African-American and Latino populations and that is a significant problem, primarily because these are the very populations that are experiencing the fastest population growth. According to the U.S. Census Bureau, by the year 2019, African-Americas, Latino, Asian-Pacific Americans and other people of color will be the majority of the under-18 population.

ROCKEYMOOREAnd by the year 2043, they'll be the majority of the nation. So we need to take stock and the fact that we're actually not closing health disparities will have a significant implications for where we go with this trend in the future.

REHMAnd Dr. Rother, as chief of the pediatric diabetes and metabolism section at the NIH, how does that news relate to the latest news on diabetes rates here in the U.S.?

ROTHERAs Maya just said, it is the minority populations who are very much affected by diabetes and we're mostly now talking about Type 2 diabetes, the diabetes that is associated with overweight and obesity. And we have seen an incredible rise of this type of diabetes over the past 20 years so that now, childhood diabetes is not the juvenile diabetes, Type 1 diabetes, often anymore, but it is the adult type or Type 2 diabetes.

ROTHERSo this diabetes is related to obesity and since you just said you're very concerned about the rise of -- or the persistence of obesity, especially in the minority populations, it is these kids who are affected with Type 2 diabetes.

REHMSo what do you think? Do you think the awareness campaign is paying off?

ROTHERI absolutely think this is true, yes. Now, pediatricians tell parents that their child is not only chubby, but actually that that child is overweight or obese because they're presenting the growth curves and they're explaining that early chubbiness, as it was called before, may not actually be a contributor to good health, but, in fact, you should watch out for maintaining normal weight throughout childhood and adulthood.

REHMAnd turning to you, Dr. Lustig, what is your thinking? Is this guarded good news on diabetes credited more to awareness about obesity?

LUSTIGWell, it's possible that there has been a plateauing in diabetes rates and if that's true, it's certainly good news. It comes a few years after the change in soft drink started going down. And our data suggest that whenever sugar changes, diabetes changes three years later. So that's a reasonably good correlation to have and a good precedence in terms of proximate cause. However, I want to make one point.

LUSTIGWe have countries that are obese without being diabetic, such as Iceland and Mongolia. We also have countries that are diabetic without being obese, such as India and China. While diabetes and obesity correlate with each other, they are not concordant. They are not the same. And there are certain things that can make obesity, for instance potato chips and french fries are the numbers one and two items in terms of weight gain, but sugar is very specifically and inexorably linked to the development of diabetes through completely separate biochemical mechanisms.

LUSTIGThat fact that sugar's gone done a little bit and we are now seeing a plateauing in diabetes three years later, I think, really does two things. It says, number one, we're on the right track, which is great, and number two, it was the sugar all along and we have to be not just more vigilant personally, but more vigilant societally and governmentally.

REHMBut when you talk about french fries and potato chips, what you're saying is carbohydrate intake of that kind, fried, may indeed be a partial contributor here.

LUSTIGOh, certainly, refined carbohydrate drives insulin up and insulin drives energy into fat and that will drive weight gain. No question. And carbohydrate -- and potato chips and french fries are not just carbohydrate. They're carbohydrate plus fat, making doubly worse. So there are many things that contribute to weight gain and, you know, trying to pin the weight gain issue on one item in our diet is problematic.

LUSTIGBut when it comes to the chronic metabolic disease aspects like diabetes, you know, we have the best data, without question, very robust for sugar being the proximate cause.

REHMAll right. And turning to you, Marion Nestle, what is your understanding about obesity? Is it more about sugar or more about calorie intake?

NESTLEWell, I think it's both. I mean, what we're seeing in countries like India and China is a very rapid rise in levels of obesity. And often in some of these populations, a rise in Type 2 diabetes at levels of weight that in the United States would be considered quite low. And we have a lot to learn about what's going on in these international populations.

NESTLEBut what we do know is that the marketers of junk foods and sugary drinks, because the consumption of these products is going down in the United States, are moving all of their marketing efforts overseas with great effect. And these countries are experiencing great rises in Type 2 diabetes for which their healthcare systems are even less well prepared than ours.

REHMSo Dr. Rother, while we're talking about what's happening here in this country, what we seem to be doing is sending not-so-good messages abroad.

ROTHERYes, that's actually true. But I would like to very briefly come back to -- put a little bit of skepticism into praising the progress we have made and that is that the latest data are for adults. The data on the leveling of diabetes have been shown for people above the age of 20. We don't have data on what is happening to diabetes rates in kids. Actually, we do have some, but we do not have this amount of data. So I would like to very much caution that we have made so much progress and now all diabetes is leveling off.

ROTHERIn fact, I don't think this is true for kids with Type 2 diabetes and especially, again, for the kids who are -- come from minority backgrounds.

REHMAnd Maya Rockeymoore, for global policy solutions, I presume you're looking at both children and adults.

ROCKEYMOOREAbsolutely. We actually work in an initiative called Leadership For Healthy Communities. It's a national program office of the Robert Wood Johnson Foundation and we work in collaboration with advocates across the country who have been really working on this for the last decade. And so, I mean, I credit a lot of work, grass roots work, going on on the ground, public health work, to educate the public about the dangers of both sugars and high caloric and fat intake.

ROCKEYMOOREAnd then, the environmental policy and psychosocial factors are all an important part of this. But what she just said is absolutely important. Childhood obesity rates are significantly -- we're seeing the same kinds of disparities that we're seeing for adults for children. So, for example, African-American children, 20.2 percent, their childhood obesity rate is 20.2 percent compared to 14.3 percent for white children.

ROCKEYMOORELatino children, 22.4 percent compared to 14.3 percent for white children. So this -- back to what we were saying about the nation's changing demographics, that even though we're seeing this plateauing, that means that what we're likely seeing is a reduction in these rates among whites. More education and more affinity for change amongst whites and not seeing that amongst Latino, African-American, both children and adults and this has significant implications for our future.

REHMSo as with most other problems, some progress in some areas, but lots more work to go. Maya Rockeymoore is director of Leadership For Healthy Communities, president of the Center For Global Policy Solutions. When we come back, we'll talk with the CEO of the American Beverage Association. Short break, right back.

REHMAnd welcome back as we talk about obesity. And joining us now from her office here in Washington, Susan Neely. She's president and CEO of the American Beverage Association. Thanks for joining us.

MS. SUSAN NEELYThank you, Diane. Good morning.

REHMGood morning. Tell us about the latest agreement between the three largest U.S. soda makers to cut beverage calories 20 percent in the next decade.

NEELYWell, this is an agreement that we have made with the Alliance for a Healthier Generation and the Clinton Global Initiative. And we're very excited about it. It's the single largest voluntary effort of an industry to fight obesity. And we've set a big goal and have a lot of steps we're going to take to reach that goal.

REHMTell me about some.

NEELYWell, first and overall, we're going to do what we do well which is to use our marketing and innovation and distribution systems to create more interest in and access to lower calorie or smaller portion choices. We're going to have a national calorie awareness program.

NEELYSo within the next two years we'll be putting calorie labels on self-serve fountains, vending machines and coolers along with what we call a little nudge, some kind of sticker or sign to say, you know, look at the calories before you make your selection. And that point of purchase engagement is really important because, you know, we feel like we're providing a lot of different choices but -- and there's more to come in terms of the R & D efforts of the companies. But at point of purchase you've got to be thinking about the calories as you make your selection.

NEELYAnd then I think importantly, we're going to work in eight to ten cities and go into neighborhood where there historically just is not a lot of interest in the smaller portions or lower calorie options and see if we can turn that around. So we'll be going to Los Angeles first as well as Little Rock and working to try to, you know, change the interest and access to smaller portions.

REHMAll right. And -- but aren't you already seeing a decline in the consumption of sugary drinks, and therefore couldn't you actually reach that 20 percent cut in 10 years or even less?

NEELYNo. There has been in the first part of the century, 2000 to 2011, '12 a decline in calories that's come from the surge of bottled water, more lower-calorie choices. But that -- those trends are impossible to sustain with what's happening right now. We don't expect the bottled water growth bubble to continue at the same pace. There's been less interest in some of the lower calorie choices. So we've got a lot to do to propel this forward.

REHMTell me how much of your plan involves drinks with artificial sweeteners?

NEELYWell, we've got a lot of no- and low-calorie beverages out there that have various sweeteners in them. And I hear in your voice a question about that. I would say that, you know, there is decades of scientific research that talks about the benefit and safety of those ingredients. You know, everyone from FDA in our country to the European FDA, the British FDA have all said that these ingredients are safe. And obviously they're beneficial for somebody who wants to manage their weight.

REHMNow on -- at some level, however, there have been questions raised about the health effects of these artificial sweeteners. I wonder if the beverage industry is at all concerned about those.

NEELYWell, because the science has been so clear on the safety of the sweeteners, we feel a lot of it -- of the questions are just based on this information. So that's something that we'll be working with the Alliance for a Healthier Generation to address out there. And make sure that from health professionals and other, you know, sources that we all go to, to give us reassurance about what we're eating and drinking and doing, that people get the facts on the safety of these ingredients.

REHMTell me how much of a role you think the soda industry actually plays in the obesity problem.

NEELYWell, this is the single largest effort of an industry to fight obesity and -- but we see this doing our part. We make a product that has calories in it. And if you over consume any source of calories and don't get enough exercise, you're going to have problems with weight. So we had a great partnership with the Alliance and the Clinton Foundation in 2006 to 2009 around our initiative in schools where we reduced calories from our beverages shipped to schools by 90 percent. We supported the first lady's Let's Move effort with our calorie labels that we put on the front of our cans and bottles. And we're all in on the Drink-Up Initiative.

NEELYSo to us as a continuation of trying to advance solutions that support our consumers and people in enjoying our products but doing so in a way that is healthy and good for their overall wellbeing.

REHMI know that the soda industry has been under increased political pressure on questions about taxing sugary drinks. So do you see this voluntary agreement as a way of trying to, at least in part, head off some of the arguments for taxes on sugary drinks?

NEELYWe see this agreement as a way to be on the front foot advancing serious solutions that are going to support people in their goals around weight management. It's another significant leadership initiative on top of what we've already done. And, yes, I do think that the public wants support not mandates. And of course as a consumer product company, we want to be on the side of the consumer and supporting them, not dictating to them.

REHMBut you do have efforts in New York to reduce drink size portions and a tax on sugary drinks that both San Francisco and Berkeley residents are going to vote on. What is your thought about that?

NEELYWell, the industry and our consumers are not supportive of what we think are mandates on people's personal choices. So, yes, we oppose the ban as, I think according to the New York Times, most of New York City opposed the ban on portion sizes and the courts ruled on that. And, yes, we're going to oppose the ballot measures in San Francisco and Berkeley. And we'll see what the people decide.

NEELYI gather that the American Beverage Association has put in a good bit of money, like half a million dollars or so, to fight that proposed tax in Berkeley.

NEELYWe are definitely supporting the campaign there to oppose the tax and there's no question about it. And we -- you know, we've got a consistent position staked out that we don't think the taxes that restrict consumer choice as the way to go. I can assure you we're going to be putting a lot more money into these positive constructive initiatives than we are in to fighting taxes. And that's how we want it to be.

REHMSusan Neely. She's president of the American Beverage Association. Thanks for joining us.

NEELYThank you.

REHMAnd to you Maya, your reaction to Susan Neely of the American Beverage Association. Do you think they're on the right track with trying to, as she said, reduce the amount of sugar and the portion size in the next decade?

ROCKEYMOORESo far as -- I should say yes, that I think that everyone has a role to play, from government to school leaders to businesses. And so I applaud, of course, the beverage companies for seeking to play their part to reduce the consumption of -- or actually the number of calories sold. But let's make the distinction. They're only making a commitment to reduce the number of calories sold. They -- it's also very important to make sure that we measure the amount of calories consumed.

ROCKEYMOOREAnd so, you know, these companies actually do a lot of marketing of these sugar-sweetened beverages, you know, if you go to a ballpark, if you go to watch television. And the evidence shows that they're actually heavily marketing to low-income communities of color especially. So while it's important to make sure that our public has choice, we need to work harder to make sure that the healthy choice is the easy, affordable and accessible choice primarily for low-income and communities of color that are finding it so hard to actually reduce their overweight and obesity numbers.

REHMDr. Rother, do we have any idea what percentage these sweetened sodas play in the U.S. sugar intake?

ROTHERYes, we do. And we have pretty good data and they're about one-third of the added sugar...

REHMOne-third.

ROTHERThat's right, of the...

REHMSo in addition to cookies and candies and everything else we've gotten into such a habit of drinking these sweetened drinks that it's totaling one-third.

ROTHER...of added sugar. That is absolutely correct. Yes. So...

REHMThat seems like a lot to me.

ROTHERThat's correct. That's correct. But may I make a point with regard to what the new policy of the beverage industry will let to? It will probably lead to the increase of intake of artificially sweetened beverages. And there I need to disagree with Ms. Neely in that the fact's also clear that the artificial sweeteners are completely safe.

ROTHERAnd here I want to make very clear that I'm not saying safe with regard to not causing cancer. I actually agree, we don't have data that any of the artificial sweeteners cause to immediate cancer development. But I want to point out that we have, in fact, good evidence that the artificial sweeteners may contribute to the development of obesity, the exact topic that they actually try to...

REHMHow do these artificial sweeteners do that?

ROTHERDoesn't it sound like a paradox? And actually some of my...

REHMIt certainly does. It certainly does.

ROTHERSome of my colleagues have written about it with this word in the title, paradox. There are many fold reasons. In fact, last week, we had a publication in nature -- and when I say, we it's the scientific community, not my group -- that came from the Weizmann Institute in Israel that showed that artificial sweeteners changed the microbiome mostly in mice. That's what their data are about.

ROTHERHowever, we have reasons to believe, according to results that my colleague Susan Schiffman has published already in 2008 that there are -- there's a possibility this also happens in humans.

REHMNow, what you're saying is that there are changes in the way that the stomach processes artificial sweetener that does what?

ROTHERYeah, so the -- I just want to very briefly explain the microbiome. This is a big word. But we have a lot of bacteria and fungi living inside ourselves, for example in the gut. We also have them on the skin and in many places. And the artificial sweeteners seem to change the composition and the function of these bacteria. Many of them are helpful, help us with digestion, help us with maintaining good health and immune system.

REHMAnd you're listening to "The Diane Rehm Show." Marion Nestle, what's your reaction to that?

NESTLEI was just awestruck. I don't know what to say. And it's hard to know where to begin but I'm particularly astonished by the business about going into low-income minority communities in Los Angeles and other places and trying to promote smaller portions, lower-calorie products in those communities when the soda industry has a 50-year history of deliberately targeting minorities in low-income communities for the highest sugar product.

NESTLEThe relationship of the soda companies to minority communities is a very complicated one because initially starting in the 1950s, minority communities demanded that soda companies advertise in minority publications. And there have been boycotts and all kinds of political activity to try to get soda companies to do more marketing to these communities. And so this long history needs to be reversed. And it's very difficult for me to imagine how the soda industry is going to do it.

NESTLEIf you look at the sales of sodas in the United States, particularly of full-sugar, but also of diet sodas, they are going down at a very steady trajectory. And if you extrapolate that line to 2025, they will be able to meet that 20 percent target doing absolutely nothing except sitting back in their offices and figuring out how they can market more sodas overseas.

REHMSo what you're saying is they could have a far more ambitious goal for reduction if indeed they really wanted to?

NESTLEBut why would they want to? Their companies -- these companies are based on sales of these products. If sales go down their stockholders will be extremely upset and they won't stay in business. So they have to sell more product. The question is, can they sell more low-calorie drinks and waters to make up for the loss in sales of the full-sugar products. So far, no.

REHMAll right. Dr. Lustig, I'd like to get briefly your thoughts on the article in Nature that Dr. Rother was talking about regarding artificial sweeteners.

LUSTIGRight. Well, let me start by saying Dr. -- Ms. Neely told us about three things they're going to do, marketing, distribution and packaging. Nowhere in there did you hear anything about reformulation. And that's very specific. They're not changing the product itself. And the reduction that they're talking about, a 20 percent reduction, is going to take us from 3.5 times the World Health Organization's limit on added sugar to 3.3 times the limit. In other words, almost nothing at all. And that, as Dr. Nestle said, is already happening.

LUSTIGNow with respect to the article in Nature, it's a very early and very preliminary article. It does bear importance to repeat it. The fact that artificial sweeteners might change what goes on inside our intestines...

REHMAll right. We'll have to come back to that after a very short break. Stay with us.

REHMAnd welcome back as we talk about soft drinks, sweetened drinks and the number of calories, the effects even artificially sweetened drinks have on the body. Here's our first email to Dr. Lustig. "Should companies not reduce the level of sweetness in drinks and process foods so that taste buds are reeducated and thereby fewer sweet calories will be craved?"

LUSTIGAbsolutely. That's exactly what needs to happen. And it is very doable. In fact, the United Kingdom did this. There's a group, a political action group, made up of academicians called Action On Salt. And over the past five years they have reduced their consumption of salt across the board, in all industries, because the government actually did the regulating and did the referring by 30 percent. And most recently the British Medical Journal showed a 40 percent reduction in hypertension and stroke in the UK population over that time. And the populace didn't even notice it.

REHMInteresting.

LUSTIGThis all went on under the wire and it was brilliant. And we could do the exact same thing for sugar here if our government took it on.

REHMAll right.

LUSTIGUnfortunately, our government won't.

REHMLet's go to Sam, in Houston, Texas. You're on the air.

SAMHello?

REHMYes. Go right ahead, sir.

SAMGood morning. Wonderful show.

REHMThank you.

SAMMy comment relates to what role does the individual consumer have to play in all of this? I certainly respect the notion that the companies have to play a role, that they have to appropriately label their offerings. And I would say the same thing for others, such as the fast food companies.

REHMAll right. What do you think, Marion Nestle?

NESTLEWell, it's always a question. Obviously both are important. But people don't make food choices in a vacuum. They make food choices in the context of a food environment in which food companies spend billions of dollars -- excuse me -- to encourage people to buy their products.

NESTLEAnd as Maya said, the objective of public health campaigns is to make the healthy choice the easy choice, to create an environment of food choice in which healthy foods are cheaper, easier, more readily available and more supported by the population, by peers so that healthy eating is what's normal to do and junk food is junk food and saved for special occasions.

REHMAll right. We've had a number of questions, Dr. Rother, about stevia, an artificial or so-called natural sweetener. Can you tell us about that?

ROTHERYes. The history of stevia is that it came from South America and was originally a natural product. But in the meantime, some of the components of stevia, of the original root have been isolated and are being used in isolation as a sweetener. So therefore, it's not really a very natural product any more.

REHMNot natural?

ROTHERWell, I want to warn that everything that's natural is good and everything that's artificial is bad. I don't think this is true. So we have a lot more information and studies about the other artificial sweeteners, saccharin, sucralose, acesulfame potassium. We don't have the same amount of information about stevia and stevia products.

REHMAll right. And Dr. Lustig, here's a question from Greg, in Helsinki, Finland. He says he moved to Finland a few years ago. He say, "It's very rare to see someone order a soft drink, especially at lunch. Restaurants leave a pitcher of water with glasses on the table. Instead of taxing or limiting sugary drinks, perhaps we could push America's restaurants to similarly make water the obvious choice and curb these endless refills of sugar."

LUSTIGWell, I've been to Helsinki and he is absolutely right.

REHMAnd I have as well.

LUSTIGHowever, in fact many restaurants in the United States now don't even put water on the table…

REHMI know.

LUSTIG…because they have to then clean the glasses. And, of course, they're asking for you to order something. So there's an inherent bias there. Let me give you an example. When I moved to San Francisco every restaurant had brown rice. When I moved back 17 years later, no restaurants had brown rice because they found out they made money on the white rice. And so there's, you know, an inherent push by restaurants to do, you know, to make people consume what they want them to consume. And in this case that would be sugary drinks.

REHMAll right.

LUSTIGWe're not going to see that in America.

REHMMarion Nestle?

NESTLEOh, I just wanted to say that restaurants have an enormous disincentive to do that because the profit on restaurant -- on drinks -- on sodas that are poured are absolutely staggering. The cost of soda in a restaurant to the restaurant is about two cents per ounce. And you can do the math on that.

REHMMarion, I want to go back to this question of artificial sweeteners and whether you believe it actually aggravates the obesity epidemic.

NESTLEWell, I don't think we know that it aggravates it. Certainly doesn't help. The research that's been done so far shows very little correlation between consumption of diet sodas and a decrease in obesity. In fact, they went up in parallel. The production of artificial sweeteners rose exactly in parallel with rising rates of obesity. That doesn't mean that there's causality involved, but it does mean that people can compensate for artificial sweeteners by eating other kinds of foods that make up for the calories. I just don't think that artificial sweeteners taste good.

REHMThat's another question. But Dr. Rother, what about effects on the brain? What do we know about artificial sweeteners and their effects on the brain?

ROTHERI very much agree with what Marion said, namely that it seems difficult to understand how artificial sweeteners drive the obesity, but it seems like they still -- they definitely haven't helped with obesity development. And with regard to the brain, the amazing thing is that our brains can distinguish between receiving something sweet that is -- comes from sugar or something sweet that comes from artificial sweetener.

ROTHERAnd it seems like real sugar makes us happier. And therefore it was questioned was whether if you ingest a lot of artificial sweeteners, you still crave for that bit of sugar that makes you happy.

REHMMaya?

ROCKEYMOOREI just want caution that, I mean, because the jury is still out and the science is still be examined and new information is being learned every day, that the very products that are being marketed as a solution to obesity, could possibly be causing complications that lead to further increases in obesity. And so we have to be cautious about turning to artificially sweetened products, as the solution, I think, at this stage in our knowledge.

REHMDr. Lustig?

LUSTIGYes. Let me just mention a study that was done last year out of Wash. U., St. Louis, where they took 17 morbidly obese adults without diabetes and did glucose tolerance testing on them twice, once with a diet soda pre-treatment, once without. And what they saw was an increase in the insulin released -- the insulin area under the curve -- of 20 percent, even though there were no calories.

LUSTIGIn other words, when you consume a diet soda, you're pancreas is primed to release more insulin. And so even though those calories didn't come in from the soft drink, your pancreas is putting out all that extra insulin and that means you're going to go find more calories to go work on. So the concept that sugar is the only problem is probably not true. It's probably the concept of sweet that actually contributes to the problem. We need to de-sweeten our lives.

REHMAll right. Let's go to Janet, in Indianapolis. You're on the air.

JANETThank you for taking my call.

REHMSurely.

JANETI just wanted to make a comment on the fact that I feel like in our society right now we spend so much time trying to avoid consequences, that this really shows up in the way we eat, in the way we choose to exercise or not exercise. Obviously we can eat anything we want, but there are consequences. And I think we look all the time for ways to avoid those consequences. And so to me, when we're blaming the food industry for our obesity, we're blaming someone else when it's our choices that are causing these problems.

REHMMarion Nestle, do you agree with that?

NESTLEWell, I do think it's, you know, it comes down to an individual choice, but one of the things about marketing is that you're not supposed to notice it. I don't know anybody who thinks that marketing affects their food choices. They think they have complete independence and can go into a store and pick what they want, and that the food environment has no influence. But food marketers know otherwise.

NESTLEAnd that's why they put $17 billion a year into promoting foods, restaurants and alcohol, because they know that that marketing is going to encourage people to buy the products. So if we were working in a vacuum, yes. Personal responsibility and personal choice would be all that mattered. But that's not the way the world operates.

REHMDr. Lustig?

LUSTIGFirst of all, where did personal responsibility come from? Everybody thinks it's part of the Union. It was there when we first, you know, created the Constitution. Garbage. Personal responsibility was created by the tobacco industry to fend off the complaints about its being toxic back in 1962. There are four caveats to personal responsibility that have to be met before you can say that's what it is. The first is knowledge. While we are kept from the knowledge of what we are eating -- for instance, there are 56 different names for sugar and there's no upper limit on the sugar package label, on the nutrition facts label.

LUSTIGNumber two, access. You have to be able to access different choices. And lower socioeconomic status groups can't because there isn't even grocery stores. There are only convenience stores, all of which have high sugar because that's what keeps the food stable, because it acts as a preservative. Number three, affordability. You have to be able to afford your choice and society has to be able to afford your choice.

LUSTIGWell, today, employers have to pay $2,750 per employee for obesity-related services, whether you're obese or not. And number four, your choice can't hurt anyone else. And when that reduces medical access, when it reduces the ability for the medical system to be able to do something to help everyone, you have actually hurt others. So personal responsibility does not work in the context of addictive substances.

REHMDr. Robert Lustig is at the University of California's San Francisco's Weight Assessment for Teen and Child Health Program. He's also the author of "Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity and Disease." And you're listening to "The Diane Rehm Show." We have an email from John, in Cincinnati. "Do you think that eventually we'll see a future where sugary drinks carry a surgeon general's warning concerning diabetes, much the same as the warning labels printed on tobacco sold today?" Marion Nestle?

NESTLEWell, I -- they've been tried in a couple of places. I don't know whether they'll be necessary. Food isn't tobacco. It's the marketing of food that's very similar to the way tobacco works. But tobacco is one product, one message, don't smoke. Put those companies out of business. Food is much more complicated. We have to eat to live. In that sense, I suppose we're addicted to food in the same way as tobacco, but it's not the same.

REHMDo you think that there is an addictive process to the sugary drinks?

NESTLEWell, some people do. Certainly sugar affects the pleasure centers in the same way that more addictive -- that addictive drugs do or cigarettes do, but not to the same extent. I don't like thinking about food as being addictive. I think food I one of life's greatest pleasures. And I wish that everybody would just eat healthfully and enjoy it.

REHMI think we all do that. And let's go to Rick, in Falls Church, Va. Quick question, please, Rick.

RICKHi. If I could make a couple of comments. I'd just like to say that people eat between 100 and 150 pounds of sugar per year. And it's ludicrous to think that replacing that sugar with a few envelopes of Equal or a squirt of sucralose or a couple of diet sodas is going to have the same metabolic effect. If it changes the microbiome, drink some kefir or eat some cultured yogurt and change it back.

RICKIf it increases insulin production, that's not necessarily a bad thing. Insulin resistance is the problem. And that's caused by chronic low-grade inflammation, which is caused by a Western diet. Secondly, the fact that we're worried about artificial sweeteners tells me that we're going wrong with the obesity issue because we're looking at the micro issue. The macro issue is where the problem is. We eat too few fruits and vegetables.

RICKWe eat hardly any whole grain. These are foods that go through us quickly, fill us up and help us maintain our weight. And we're obsessed with foods that stick with us, like high-fat animal proteins, which are totally unnecessary.

REHMAll right, sir. I appreciate that information, which I think is certainly helpful for everyone. Where are we going with this issue, Maya Rockeymoore? Do you think consciousness is being raised?

ROCKEYMOOREI do. I do. I think that we've seen in the span of a decade, we've seen a significant amount of attention to this, both in the general public, but also among policy leaders and the first lady. And so when you have a bully pulpit like that, and when you're talking about this issue or the public health message is constantly being reinforced from a variety of sources, I think that where we're going is we're building a culture of health in this nation.

REHMI hope you're right. Maya Rockeymoore, Kristina Rother, Dr. Robert Lustig, Marion Nestle. Thank you all so much.

ROCKEYMOOREThank you.

ROTHERThank you, Diane.

LUSTIGThank you.

NESTLEThank you.

REHMAnd thanks for listening. I'm Diane Rehm.