Fat Chance: The bitter truth about sugar. Dr. Lustig Robert

fatty acids, or blood lipids, are cleared into fat cells for storage for a “rainy day,” where they get turned into greasy triglycerides (such as the fat surrounding your steak). There is no energy storage without insulin—it is the key that unlocks the door to the fat cell to let energy enter and subsequently be stored as fat. Insulin makes fat—the more insulin, the more fat. And there it sits…and sits…as long as there is insulin around. When the insulin levels drop, the process goes in reverse: the triglycerides get broken down, causing the fat cells to shrink—when it happens, that’s weight loss!—and the fatty acids reenter the bloodstream and travel back to the liver, where they are burned by the liver or other organs. In this way, by cycling our insulin up and down, we burn what we need, and store the rest.

       Introducing the Hypothalamus

      For the past sixty years we’ve known that the brain, especially the one cubic centimeter at the base of the brain called the hypothalamus, controls this process of energy balance. It’s about the size of a thumbnail, and it is “ground zero” for the control of almost all the hormonal systems in the body.

      Imagine the organization of a taxicab company. At the bottom are the taxicab drivers, getting their orders from a central dispatcher by radio and shuttling passengers all over town. The target organs—the thyroid, the adrenal, the testicles, the ovaries—are like the cabbies. They receive their orders from the central dispatcher, or, in this case, the pituitary or “master gland,” which acts as the main control system. The hormones released are similar to the taxi’s computerized system, signaling to the pituitary to tell it how things are going out in the field. Like the central dispatcher who directs the cabs based on their location, the pituitary will then adjust its message.

      However, there is another layer of control: the chief executive officer, or CEO, who decides on hiring and firing, contracts, upgrades, and mergers and acquisitions. The company can’t turn a profit without the cabbies, be efficient without the dispatcher, or be sustainable long term without a CEO. Furthermore, the CEO can alter the direction of the company based on the profitability of its cabdrivers. The CEO is akin to the hypothalamus. It sends blood-borne hormonal signals to tell the pituitary what to do. It then makes large-scale decisions based on the function of the peripheral glands, which send it information via the bloodstream. And it integrates information from other areas of the brain to alter the long-term hormonal milieu. Marie’s hypothalamus was damaged beyond repair, which caused it to be ineffective in controlling her hormones and, therefore, her behavior.

       The Ventromedial Hypothalamus (VMH) and Energy Balance

      The hierarchy of energy balance is even more complicated. A subarea of this thumbnail is called the ventromedial hypothalamus (VMH), which serves the executive function of controlling energy storage versus expenditure. Because energy balance is so important to survival, there are redundant systems in case one goes amiss to ensure that the organism doesn’t die. It’s clear that energy balance is the most complex function we humans perform. It’s likewise apparent that energy storage, or the creation of fat cells, is the default strategy. Bottom line, we humans won’t give up our hard-earned energy without a fight.

      There are afferent (incoming) and efferent (outgoing) systems that control energy balance¹ (see figure 4.1). The VMH receives acute meal-to-meal information from the GI (gastro-intestinal) tract on both hunger and satiety (not shown in the figure). Either one can turn the feeling of hunger on or off by itself. But that’s not all. In addition, the VMH receives more long-term information on one’s fat stores and nutrient metabolism: in other words, whether your body needs to consume more calories for longer-term survival. This information is conveyed via the hormones leptin and insulin to the hypothalamus, where it is decoded and either stimulates or suppresses appetite, and adjusts energy expenditure accordingly.

      Fig. 4.1. How the Brain and Hormones Work Together (or Don’t) to Regulate Energy Balance. The hypothalamus receives hormonal information from the fat cells (leptin). This information is processed into one of two signals: (a) anorexigenesis (I’m not hungry and I can burn energy) or (b) orexigenesis (I’m hungry and I want to store energy). Anorexigenesis turns on the sympathetic nervous system (responsible for muscle activity and fat loss), and turns off the vagus nerve (responsible for appetite and fat gain); while orexigenesis does the opposite. However, high insulin blocks the leptin signal, mimicking “brain starvation” and driving orexigenesis, so that we feel hungry even when we have eaten.

      From there, the hypothalamus sends signals from the brain to the body via two components of the autonomic nervous system. The autonomic nervous system is that portion of your body that controls your heart rate, blood pressure, and energy metabolism without your conscious effort. It is composed of two parts: the sympathetic nervous system (responsible for the fight-or-flight response) and the parasympathetic nervous system (responsible for “vegetative” functions such as food absorption and energy storage). The vagus nerve is one of the key components of the parasympathetic nervous system. There is a delicate balance and feedback loop between the sympathetic and parasympathetic systems. When that balance changes, that’s when problems ensue.

      The vagus nerve is fascinating. It connects the brain to all the digestive organs in the abdomen: the liver, the intestine, the pancreas, and also to the fat cells. It performs many different functions but with one ultimate goal: to store energy. The vagus is your energy storage nerve. The vagus has two parts: the afferent part (organs to brain), and the efferent part (brain to organs). The afferent vagus communicates the sensation of hunger between the stomach and brain, and also communicates information on energy processing during a meal between the liver and brain. The VMH interprets all these afferent signals, which leads to one of two physiologic states: anorexigenesis (I don’t need any more food, I can burn energy as needed, and I feel good) or orexigenesis (I don’t have enough food, I don’t want to burn any energy, and I will feel lousy until I get some more).

      The anorexigenesis signal turns on the sympathetic nervous system (SNS), which promotes energy expenditure by telling the adipose (fat) tissue and the muscles to burn energy, thereby resulting in weight loss and a sense of well-being. Anorexigenesis also turns off the vagus nerve and, in so doing, reduces appetite. Conversely, orexigenesis stimulates the vagus nerve to promote energy storage by increasing appetite. It accomplishes this by sending multiple signals through the vagus nerve: to the gastrointestinal tract to digest and absorb the food; to the adipose tissue to store more energy (make more fat); and to the pancreas to increase the amount of insulin released (promoting more energy storage into adipose tissue).

       Leptin and the Elusive “Holy Grail” of Obesity

      When the hormone leptin (from the Greek Leptos, for “thin”) was discovered in 1994, for the first time, scientists thought that obesity might have a biochemical basis. Leptin has been a veritable godsend to scientists who study obesity. It provided the starting point to understanding the biochemistry of the brain pathways that control food intake and the impetus for scientists and the National Institutes of Health (NIH) to believe that there was a simple way out of this mess, one that could be easily treated with medicine and science. The U.S. government began, and continues today, to shovel money at obesity research, hoping for a treatment that works. Conversely, leptin has been the biggest disappointment to those who suffer from obesity. And woe to the pharmaceutical industry, which hoped to harness its potential for a cure and generate megabucks in the process. The pharmaceutical company Amgen was so enamored of leptin’s blockbuster marketing potential that it offered $30 million for the exclusive marketing rights to the hormone, even before a human experiment had been performed. Amgen has since become so disillusioned that it has farmed leptin out to another company, Amylin Pharmaceuticals, to see if it will have better luck.

      Leptin is a protein made and released by fat cells. It circulates in the bloodstream, goes to the hypothalamus, and signals the hypothalamus that you’ve got enough energy stored up in your fat.² The discovery of leptin closed the loop, providing a servomechanism (like your home’s thermostat) in which