SNEB Panel Session Summaries Dr. James Rippe & Dr. Kristine Clark

1. SNEB Panel Session SummariesDr. James Rippe &Dr. Kristine Clark Session Title: Fructose, Sucrose & HFCS: Modern Scientific Understandings Date: Monday, August 12, 2013

2. Dr. James Rippe Presentation SummarySNEB 2013 • Presentation Title: The Metabolic and Endocrine Response and Health Implications of Consuming Sugar Sweetened Beverages: Findings from Recent Randomized, Controlled Trials • Objectives: • Compare the metabolism of sucrose, high fructose corn syrup (HFCS) and fructose. • Review the strengths and weaknesses of the available scientific literature on sugars and health. • Share recent data from methodologically-strong research on sugars consumption. • Key Messages: • There is no unique link between HFCS and obesity compared to other sugars. • There are no differences in effect on appetite, blood pressure, hormone regulation, diabetes and heart disease risk factors between fructose-containing sugars and other sugars. • Existing research suggesting that fructose-containing sugars increase diabetes risk is weak. • At real-world consumption levels (and consumption levels recommended by the IOM, AHA and Dietary Guidelines), fructose-containing sugars have no uniquely harmful effects on health. • It is important to evaluate research with a critical eye, understanding that temporal associations do not prove cause-and-effect, and much of the available data is subject to methodological limitations. • Decades of experience reveal that blaming one particular food or ingredient for increasing obesity rates has never worked.

3. Dr. Kristine Clark Presentation SummarySNEB 2013 • Presentation Title: Nutrition Guidance and Sweeteners: Working with Humans in the Real World • Objectives: • Reinforce that diet quality, encompassing total caloric intake and the nutrient profile of foods and beverages, is the most important consideration in achieving a healthy diet. • Help nutrition educators translate scientific information on sugars and caloric sweeteners into relevant, actionable messages for clients, students and consumers. • Key Messages: • Singling out one particular food or nutrient/ingredient is not a successful strategy to solve obesity and other health problems. • While flavored milk contributes a small amount of extra energy to the diet, the nutritional benefits of milk consumption should outweigh this concern. • Reducing total calorie intake by eating fewer energy-dense foods will help lower added sugars intakes in America. • Sugar itself isn’t leading to disease; it’s the overconsumption of energy-dense foods, including those high in sugar, that are leading to increased risk. • Strong scientific evidence and facts should be driving U.S. food and nutrition policy.

4. The Metabolic and Endocrine Response and Health Implications of Consuming Sugar Sweetened Beverages: Findings from Recent Randomized, Controlled Trials Society for Nutrition Education and Behavior Annual Conference August 12, 2013 • James M. Rippe, M.D. • Professor, Biomedical Sciences • University of Central Florida • Founder and Director • Rippe Lifestyle Medicine

5. Disclosure of Relationships • ConAgra Foods: Research Grants and Consulting Fees • (uses Sucrose and High Fructose Corn Syrup products) • Kraft Foods: Research Grants • (uses Sucrose, High Fructose Corn Syrup and Fructose in products) • PepsiCo: Research Grants and Consulting Fees • (uses Sucrose, High Fructose Corn Syrup; owns Tropicana) • Corn Refiners Association: Research Grants and Consulting Fees • (members make High Fructose Corn Syrup and Fructose) • Weight Watchers International: Research Grants and Consulting Fees • (makes weight loss and nutritional recommendations) • International Life Sciences Institute • (writing fees related to Fructose, Sucrose and High Fructose Corn Syrup) • Coca Cola • (uses sucrose, High Fructose Corn Syrup; owns Minute Maid) • Sage Publishers: Editorial Office Support • The American Journal of Lifestyle Medicine and Encyclopedia of • Lifestyle Medicine and Health • CRC Press: Editorial Office Support • Lifestyle Medicine (Second Edition) • Springer Publishers: Editorial Office Support • Publisher of upcoming textbook on Sugars and Health

6. Objectives • Understand if there are differences in metabolism among sucrose, high fructose corn syrup and fructose. • Understand the strengths and weaknesses of the evidence supporting putative links between the consumption of these sugars and health consequences. • Present results from recent randomized controlled trials using various levels of HFCS, sucrose, fructose and glucose consumption ranging from the 25th – 90th percentile population consumption level of fructose.

7. HFCS, Sucrose and Fructose: The “Perfect Storm” For Mistaken Identity • Failure to distinguish between association and cause and effect • In retrospect, unfortunate choice of name • (“high fructose” corn syrup) • Research on pure fructose vs. pure glucose • Emotional issue • Low hanging fruit

8. Is There a Unique Link Between HFCS and Obesity?

9. Source: Bray GA, Popkin BM, Nielson SJ. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr 2004;79:537– 43.

10. Obesity Prevalence and Bottled Water Consumption

11. Teff et al (pure fructose versus pure glucose: some differences) JCEM 8(6):2963-2972

12. Melanson et al HFCS versus sucrose: No differences Nutrition 23(2007)103-112

13. Appetite Ratings: Melanson et al Nutrition 23(2007)103-112

14. No Differences • Plasma glucose (A), insulin (B), triacylglycerol (E) and free fatty acid (F) concentrations during a 24-h period (0800-0800) in 34 women and men consuming HFCS- or sucrose-sweetened beverage with each meal. Change (∆) in plasma leptin (C) over the morning nadir and ghrelin concentrations (D) from mean baseline levels (0800-0900) during a 24-h period (0800-0800) in 34 women and men consuming HFCS- or sucrose-sweetened beverages with each meal. Data shown as mean ± SEM. Am J Clin Nutr 2008;1194-203

15. No Differences Overweight and Obese Women (N=57; Ave BMI = 28.8kg/m2)

17. does dosage matter? 6 Group Randomized, Prospective Double Blind Study Comparing HFCS to Sucrose at 8%, 18% and 30% of Calories (n=136)

18. No difference at any dosage level or after 10 weeks of consumption Baseline Week 10

19. Do Fructose Containing Sugars Increase the Risk of Heart Disease?

20. 4 Group, Randomized Prospective, Double Blind Study Comparing HFCS to Sucrose at 10% and 20% of Calories Weekly Body Weight Compliance Check Milk Product pickup Study Timeline Fasting Blood work 3 day Food Record SF-36 Health Survey Waist Circumference DXA Waist Circumference 3 day Food Record Baseline +6 +10 R Baseline Testing Blood Markers Fasting Blood work 3 day Food Record SF-36 Health Survey Waist Circumference DXA Lipids Glucose Insulin CRP Pregnancy (HCG) R = Randomization

21. The effect of consuming low fat milk sweetened with HFCS or sucrose at 10% or 20% of recommended calorie intake for ten weeks. (N=64)

22. Lipid Response to consuming low fat milk sweetened with HFCS or sucrose at 8%, 18% or 30% of calories (N=342)

23. 4 Group Randomized Prospective, Double Blind Study Comparing HFCS (18% of calories), Sucrose (18% of calories), Fructose (9% of calories) and Glucose (9% of calories) Weekly Body Weight Compliance Check Milk Product pickup Other tests per protocol Study Timeline R Baseline Week 1 Week 10 Baseline Testing Repeat all baseline testing Fasting Blood with medical history Physical Exam Weight, Height, BMI Waist Circumference OGTT 3 Day Food Record REE = Randomization R

24. Blood Lipids

25. Bottom line: no increase in risk factors for heart disease

26. Do Fructose Containing Sugars Increase in Key Pertinent Risk Factors for Diabetes?

27. 6 Group Randomized Prospective, Double Blind Study Comparing HFCS to Sucrose at 8%, 18% and 30% of Calories

28. Oral Glucose Tolerance Test

29. Effects of consumption of low fat milk sweetened with either HFCS 18% or calories, Sucrose 18% of calories, Fructose 9% of calories or Glucose 9% of calories on risk factors for diabetes (N=123) • Total HFCS Fructose Glucose Sucrose

30. Oral Glucose Tolerance Test • Total HFCS Fructose Glucose Sucrose

31. Changes in skeletal muscle fat pre and post 10 week intervention of consuming either HFCS or Sucrose at 8%, 18% or 30% of calories (N=68) • Study Timeline • Weekly • Body Weight • Compliance Check • Milk Product pickup • Other tests per protocol R • Baseline • Week 1 • Week 10 • Baseline Testing • Repeat CT Scan of Liver • and MRI of Thigh • Other tests per protocol • CT Scan of Liver • MRI of Thigh • Other Tests per protocol R • = Randomization

32. Skeletal muscle fat pre and post 10 week intervention of consuming either HFCS or Sucrose at 8%, 18% or 30% of Calories (N=68)

33. Bottom line: no increase in key pertinent risk factors for diabetes

34. Does Consumption of Fructose Containing Sugars Increase Blood Pressure?

35. Effects of low fat milk sweetened with either HFCS or sucrose over 10 weeks at 8%, 18% or 30% of calories on Blood Pressure (N=352)

36. Blood Pressure Effects of low-fat milk sweetened with either HFCS at 18% of calories, Sucrose at 18% of calories, Fructose at 9% of calories or glucose at 9% of calories on Blood Pressure (N=123) • *** p<0.001, * p<0.05

37. Effects of consumption of low fat milk sweetened with either HFCS at 8%, 18% or 30% of calories on Uric Acid levels (N=98)

38. Bottom line: no increase in key pertinent risk factors increased blood pressure

39. Does Consumption of Fructose Containing Sugars Lead to Excess Accumulation of Abdominal Fat?

40. Stanhope et al (N=32) Changes of BW and abdominal fat. (A) Changes of BW during the 2-week inpatient baseline, 8-week outpatient intervention, and 2-week inpatient intervention periods. **P < 0.01; ****P < 0.0001, day 56 outpatient: intervention vs. day 1 outpatient: intervention; paired Student’s t test. Glucose, n = 15; fructose, n = 17. (B) Changes of total abdominal adipose tissue, SAT, and VAT volume in subjects after consuming glucose- or fructose-sweetened beverages for 10 weeks. *P < 0.05; **P < 0.01, 10 weeks vs. 0 weeks; paired Student’s t test. Glucose, n = 14; fructose, n = 17. Data represent mean ± SEM.

41. Effects of HFCS or Sucrose at 8%, 18% or 30% of calories on body weight and abdominal fat. (N=116) • * p<0.05; *** p<0.001

42. Percent and Trunk Fat

43. Effects of HFCS (18% of calories), Sucrose (18% of calories), Fructose (9% of calories) and Glucose (9% of calories) on abdominal fat (N=123) • *** p<0.001

44. Percent and Trunk Fat • *** p<0.001, ** p<0.01

45. Bottom line: no increase in abdominal fat or in key pertinent risk factors for the metabolic syndrome

46. Does HFCS or Sucrose Increase the Risk of Fatty Infiltration of the Liver (NAFLD)

47. Metabolism of Fructose and Glucose in the Liver • Source: Tappy L, Le KA. Metabolic Effects of Fructose and the Worldwide Increase in Obesity Physiol Rev 90: 23–46, 2010

48. Percent Liver Fat Pre and Post 10 week Intervention of consuming either HFCS or sucrose at 8%, 18% or 30% of calories (N=68)

49. Bottom line: no increase in liver fat

50. Does Consumption of Fructose Containing Sugars Have Different Effects on Neural Pathways Than Glucose?