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

Session Title: Fructose, Sucrose & HFCS: Modern Scientific UnderstandingsDate: Monday, August 12, 2013

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.

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.

The Metabolic and Endocrine Response and Health Implications

of Consuming Sugar Sweetened Beverages:

Findings from Recent Randomized,

Controlled Trials

James M. Rippe, M.D.Professor, Biomedical SciencesUniversity of Central FloridaFounder and DirectorRippe Lifestyle Medicine

SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR ANNUAL CONFERENCE

AUGUST 12, 2013

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 SupportThe American Journal of Lifestyle Medicine and Encyclopedia of Lifestyle Medicine and Health

• CRC Press: Editorial Office SupportLifestyle Medicine (Second Edition)

• Springer Publishers: Editorial Office SupportPublisher of upcoming textbook on Sugars and Health

5

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.

6

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

7

IS THERE A UNIQUE LINK BETWEEN HFCS AND

OBESITY?

8

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.

9

10

Obesity Prevalence and Bottled Water Consumption

Teff et al (pure fructose versus pure glucose: some differences)

JCEM 8(6):2963-297211

0 240 480 720 96040

60

80

100

120

140HFCSSucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

GL

UC

OS

E (

mg

/dl)

Melanson et al HFCS versus sucrose: No differences

Nutrition 23(2007)103-112

0 250 500 750 1000 12500

10

20

30

40

50

60

70

80

90HFCSSucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

Ins

uli

n (U

/ml)

0 250 500 750 1000 12500

5

10

15

20

25HFCSSucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

Le

pti

n (

ng

/ml)

0 250 500 750 1000 1250600

700

800

900

1000

1100

1200HFCSSucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

Gh

reli

n (

pg

/ml)

12

Satisfaction Rating - AUC

Day 1 Day 20

10000

20000

30000

40000

50000

60000

Sucrose

HFCS

Note:Day 1 - 12.5 hoursDay 2 - 9 hours

†

Inte

gra

ted

Sat

isfa

ctio

n R

atin

gs-

AU

C

Desire to Eat Rating - AUC

Day 1 Day 20

10000

20000

30000

Sucrose

HFCS

Note:Day 1 - 12.5 hoursDay 2 - 9 hours† Different from HFCS, p<0.05

†

Inte

gra

ted

De

sir

e R

ati

ng

s-A

UC

Hunger Rating - AUC

Day 1 Day 20

10000

20000

30000

Sucrose

HFCS

Note:Day 1 - 12.5 hoursDay 2 - 9 hours

Inte

gra

ted

Hu

ng

er R

atin

gs-

AU

C

Thirst Rating - AUC

Day 1 Day 20

10000

20000

30000

Sucrose

HFCS

Note:Day 1 - 12.5 hoursDay 2 - 9 hours

Inte

gra

ted

Th

irst

Rat

ing

s-A

UC

Nutrition 23(2007)103-112

Appetite Ratings: Melanson et al

13

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 14

No Differences

Overweight and Obese Women (N=57; Ave BMI = 28.8kg/m2)

0 120 240 360 480 600 720 840 960 10800

10

20

30

40

50HFCSSucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

Le

pti

n (

ng

/ml)

0 120 240 360 480 600 720 840 960 10800

100200300400500600700800900

1000

HFCS

Sucrose

9:00 AMBreakfast

1:00 PMLunch

6:00 PMDinner

TIME (minutes)

Gh

reli

n (

pg

/ml)

15

No Differences

16

DOES DOSAGE MATTER?

6 GROUP RANDOMIZED, PROSPECTIVE DOUBLE BLIND STUDY COMPARING HFCS TO

SUCROSE AT 8%, 18% AND 30% OF CALORIES (N=136)

17

0

100

200

300

400

500

600

700

800

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Insu

lin (p

mol

/L)

Baseline8% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

Baseline

0

100

200

300

400

500

600

700

800

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Insu

lin (

pmol

/L)

Week 108% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

Week 10

0

5

10

15

20

25

30

35

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Lepti

n (µ

g/L)

Baseline8% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

0

5

10

15

20

25

30

35

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Lepti

n (µ

g/L)

Week 108% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

0

50

100

150

200

250

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Ghre

lin (p

g/m

l)

Baseline8% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

0

50

100

150

200

250

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Ghre

lin (p

g/m

l)

Week 108% Sucorse

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

0

0.5

1

1.5

2

2.5

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Trig

lyce

rides

(mm

ol/L

)

Baseline8% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

0

0.5

1

1.5

2

2.5

3

9:00 12:00 15:00 18:00 21:00 0:00 3:00 6:00

Trig

lyce

rides

(mm

ol/L

)

Week 108% Sucrose

8% HFCS

18% HFCS

18% Sucrose

30% HFCS

30% Sucrose

18

No difference at any dosage level or after 10 weeks of consumption

DO FRUCTOSE CONTAINING SUGARS INCREASE THE RISK OF HEART

DISEASE?

19

4 Group, Randomized Prospective, Double Blind Study Comparing HFCS to Sucrose at

10% and 20% of Calories

+10R

Fasting Blood work3 day Food Record

SF-36 Health SurveyWaist Circumference

DXA

Baseline

LipidsGlucoseInsulin

CRPPregnancy (HCG)R = Randomization

Baseline Testing

Fasting Blood work3 day Food Record

SF-36 Health SurveyWaist Circumference

DXA

WeeklyBody Weight

Compliance CheckMilk Product pickup

+6

Waist Circumference3 day Food Record

Blood Markers

Study Timeline

20

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)

21

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

22

Study TimelineWeekly

Body WeightCompliance Check

Milk Product pickupOther tests per

protocolR

Baseline

Baseline Testing

Fasting Blood with medical historyPhysical Exam

Weight, Height, BMIWaist Circumference

OGTT3 Day Food Record

REE

R = Randomization

Week 10

Repeat all baseline testing

Week 1

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)

23

Total GroupA

GroupB

GroupC

GroupD

0

50

100

150

200

250 CholesterolBaseline Wk10

Ch

ole

ste

rol (

mg

/dL

)

Total HFCS Fructose Glucose Sucrose0

20

40

60

80

100

120

140

160

180

200 Triglyceride Baseline Wk10

Tri

gly

ceri

de

(m

g/d

L)

Total HFCS Fructose Glucose Sucrose

0

10

20

30

40

50

60

70 HDL Baseline Wk10

HD

L (

mg

/dL

)

Total HFCS Fructose Glucose Sucrose0

20

40

60

80

100

120

140

160 LDL Baseline Wk10

LD

L (

mg

/dL

)

Total HFCS Fructose Glucose Su-crose

Blood Lipids

24

BOTTOM LINE: NO INCREASE IN RISK FACTORS FOR HEART

DISEASE

25

DO FRUCTOSE CONTAINING SUGARS INCREASE IN KEY

PERTINENT RISK FACTORS FOR DIABETES?

26

6 Group Randomized Prospective, Double Blind Study Comparing

HFCS to Sucrose at 8%, 18% and 30% of Calories

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

20

40

60

80

100

120Glucose Baseline Wk10

Glu

cose

(m

g/dL

)

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

2

4

6

8

10

12 InsulinBaseline Wk10

Insu

lin (

µU/m

l)

*

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

0.5

1

1.5

2

2.5

3 Insulin ResistanceBaseline Wk10

Insu

lin R

esis

tanc

e (H

OM

A)

27

Oral Glucose Tolerance Test

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc0

2

4

6

8

10

12

14

16 AUC GlucoseBaseline Wk10

AU

C g

luco

se (

min

*g/d

l)

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc0

1

2

3

4

5

6

AUC InsulinBaseline Wk10

AU

C I

nsu

lin

(m

in*µ

U/m

l)

28

0

20

40

60

80

100

120Glucose Baseline Wk10

Glu

cose

(m

g/d

L)

0

2

4

6

8

10

12Insulin Baseline Wk10

Insu

lin (

µU

/ml)

Total HFCS Fructose Glucose Su-crose

0

0.5

1

1.5

2

2.5

3 Insulin Resistance (HOMA)Baseline Wk10

Insu

lin R

esi

sta

nce

Total HFCS Fructose Glucose Sucrose

Total HFCS Fructose Glucose Sucrose

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)

29

Oral Glucose Tolerance Test

0

2

4

6

8

10

12

14

16AUC Glucose Baseline Wk10

AU

C G

luc

os

e (

min

*g/d

l)

Total HFCS Fructose Glucose Sucrose 0

0.5

1

1.5

2

2.5

3

3.5 AUC Insulin Baseline Wk10

AU

C In

su

lin (

min

*µU

/ml)

Total HFCS Fructose Glucose Sucrose

30

Study Timeline WeeklyBody Weight

Compliance CheckMilk Product pickup

Other tests per protocol

RBaseline

Baseline Testing

CT Scan of LiverMRI of Thigh

Other Tests per protocol

R = Randomization

Week 10

Repeat CT Scan of Liverand MRI of Thigh

Other tests per protocol

Week 1

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)

31

Skeletal muscle fat pre and post 10 week intervention of consuming either HFCS or

Sucrose at 8%, 18% or 30% of Calories (N=68)

32

BOTTOM LINE: NO INCREASE IN KEY PERTINENT RISK FACTORS

FOR DIABETES

33

DOES CONSUMPTION OF FRUCTOSE CONTAINING

SUGARS INCREASE BLOOD PRESSURE?

34

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)

35

0

20

40

60

80

100

120

140

160Systolic Blood Pressure

Baseline Wk10

Sys

tolic

Blo

od

Pre

ssu

re (

mm

Hg

)

***

Total HFCS Fructose Glucose Sucrose 0

10

20

30

40

50

60

70

80

90

100 Diastolic Blood PressureBaseline Wk10

Dia

sto

lic B

loo

d P

ress

ure

(m

mH

g)

*

Total HFCS Fructose Glucose Su-crose

Blood Pressure

*** p<0.001, * p<0.05

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)

36

Effects of consumption of low fat milk sweetened with either HFCS at

8%, 18% or 30% of calories on Uric Acid levels (N=98)

37

BOTTOM LINE: NO INCREASE IN KEY PERTINENT RISK FACTORS INCREASED BLOOD PRESSURE

38

DOES CONSUMPTION OF FRUCTOSE CONTAINING

SUGARS LEAD TO EXCESS ACCUMULATION OF ABDOMINAL FAT?

39

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.

Stanhope et al (N=32)

40

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

20

40

60

80

100

120

140

160

180

200 Body Mass Baseline Wk10

Bo

dy

Mas

s (l

bs)

***

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

5

10

15

20

25

30

35

Fat Mass Baseline Wk10

Fat

Mas

s (k

g)

***

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

10

20

30

40

50

60Fat Free Mass

Baseline Wk10

Fat

Fre

e M

ass

(kg

)

*

* p<0.05; *** p<0.001

Effects of HFCS or Sucrose at 8%, 18% or 30% of calories on body weight and abdominal fat.

(N=116)

41

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

5

10

15

20

25

30

35

40

45Body Fat %

Baseline Wk10

Bo

dy

Fat

(%

)

Total8% HFCS

8% Suc18% HFCS

18% Suc30% HFCS

30% Suc

0

10

20

30

40

50

60

Trunk Fat %Baseline Wk10

Tru

nk

Fat

(%

)

Percent and Trunk Fat

42

0

20

40

60

80

100

120

140

160

180 Body Mass

Baseline Wk10

Bo

dy

Ma

ss (

lbs)

***

Total HFCS Fructose Glucose Sucrose

22

22.5

23

23.5

24

24.5

25

25.5

26

26.5Fat Mass Baseline Wk10

Fa

t Ma

ss (

kg)

Total HFCS Fructose Glucose Sucrose0

10

20

30

40

50

60

Fat Free MassBaseline Wk10

Fa

t Fre

e M

ass

(kg

)

Total HFCS Fructose Glucose Sucrose

*** p<0.001

Effects of HFCS (18% of calories), Sucrose (18% of calories),

Fructose (9% of calories) and Glucose (9% of calories) on

abdominal fat (N=123)

43

Percent and Trunk Fat

0

10

20

30

40

50

60Trunk Fat %

Baseline Wk10

Tru

nk

Fa

t (%

)

**

Total HFCS Fructose Glucose Sucrose

*** p<0.001, ** p<0.01

0

10

20

30

40

50

60Body Fat %

Baseline Wk10

Bo

dy

Fa

t (%

)

***

Total HFCS Fructose Glucose Sucrose

44

BOTTOM LINE: NO INCREASE IN ABDOMINAL FAT OR IN KEY

PERTINENT RISK FACTORS FOR THE METABOLIC SYNDROME

45

DOES HFCS OR SUCROSE INCREASE THE RISK OF FATTY

INFILTRATION OF THE LIVER (NAFLD)

46

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

47

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

48

BOTTOM LINE: NO INCREASE IN LIVER FAT

49

DOES CONSUMPTION OF FRUCTOSE CONTAINING SUGARS

HAVE DIFFERENT EFFECTS ON NEURAL PATHWAYS THAN

GLUCOSE?

50

Page et al* (N=20)Mean Change in Hypothalamic Cerebral Blood Flow

Page KA, Chan O, Arora J, Belfort-DeAguiar R, Dzuira J, Roehmholdt B, Cline GW, Naik S, Sinha R, Constable RT, Sherwin RS. Effects of Fructose vs Glucose on Regional Cerebral Blood Flow in Brain Regions Involved with Appetite and Reward Pathways. JAMA:309:1;63-70

51

Pure Fructose Versus Pure Glucose: Increase in Hypothalamic Blood Flow

Purnell et al* (N=7)

Purnell JQ, Klopfenstein BA, Stevens AA, Havel PJ, Adams SH, Dunn TN, Krisky C, Rooney WD. Brain functional magnetic resonance imaging response to glucose and fructose infusions in humans. Diab, Obes, & Metab 13:229-234

Hypothalamic Signal Change

Brain Control Regions Signal Change

52

Intravenous Fructose Versus Intravenous Glucose: Differences in Brain Control Regions

Pilot StudyEffects of HFCS (18% of calories), Sucrose (18% of calories), Fructose (9% of

calories), Glucose (9% of calories), Unsweetened Milk (N=7)Each subject underwent 10 fMRI scans

Each scanning day can consist of:35’ pre-ingestion10’ ingestion45’ post-ingestion

Structural scan (T1)fMRI Food pictures

Resting-state fMRI

INGESTION

REST

Structural scan (T1)Resting-state fMRI

fMRI Food pictures

VAS questionnaire for satiety

VAS questionnaire for satiety and sweetness

VAS questionnaire for satiety

Divided into the following components:Pre-scanThree Factor Eating Questionnaire VAS (satiety and sweetness)35’ pre-ingestion:

-5’ Structural MRI (T1)-20’ Food fMRI (3 runs)-10’ Resting-state fMRI (2 runs)

10’ ingestion: -5’ Ingestion (outside scanner) -5’ Rest (outside scanner) (VAS administered)

45’ post-ingestion:-5’ Structural MRI (T1)-20’ Resting-state fMRI (4 runs)-20’ Food fMRI (3 runs)

Total scanning time: 90’ (1 hour and 30’ VAS) VAS administered

53

Percent Signal Change (PSC) over 7 subjects

- ROI (4mm, MNI 2,8,-4) of the hypothalamus obtained

from the PAGE study.

- Images were transformed to MNI standard space.

- Time series were extracted for each subject using this

ROI.

- PSC was computed using these time series. The baseline was

established as the first acquisition of under the fast

condition.

ROI on MNI standard space

fMRI data of an example subject transformed to MNI standard space. As well as ROI

54

Blue ROI from Page paper, used here

Different Time series extracted in different time bins in order to calculate the percent signal change

Percent Signal Change (PSC) over 7 subjects• There are NO significant

differences between each condition and baseline

• The baseline was established as the first acquisition under the fast condition.

• The comparisons of each condition were done with reference to this baseline.

• From time bin 2 to 3 there is the feeding condition.

7 40 47 54 61 min

55

Condition 1 Condition 5 Condition 3

-Functional Connectivity Maps of a single subject obtained after using the time series of a ROI in the Hypothalamus.

-Different experimental conditions (1,5,3). But all these maps were obtained after feeding condition.

-Same ROI (4mm, MNI 2,8,-4) in the hypothalamus

-Uncorrected Maps, No-threshold!!

-Similar patterns under different conditions.

Functional Connectivity Maps

56

• No difference in hypothalamic blood flow or blood flow to cerebral cortex between fructose containing sugars, glucose and unsweetened milk

• No differences between any of the fructose containing sugars and glucose

• No differences between HFCS or Sucrose and control (unsweetened milk)

• No differences in response to low calorie, high calorie or non food items

Results (Preliminary; Directional Only)

57

Real World Conditions: No Differences

CONCLUSIONS

58

No unique relationship between HFCS and Obesity.

No metabolic differences between HFCS and sucrose (both different from fructose vs. glucose).

No adverse effects on total cholesterol, LDL or HDL (10% increase in triglycerides) at dosages up to 90th percentile fructose consumption.

No increase in risk factors for diabetes.

No adverse effects on uric acid or blood pressure.

No increase in risk factors for metabolic syndrome.

Results from recent RCTs at levels of up to 90th percentile population consumption of fructose

59

No differences between fructose containing sugars and glucose at average population consumption levels of fructose.

No increase in fatty infiltration of the liver.

No differences in hypothalamic or cerebral blood flow between fructose containing sugars and glucose. (Pilot study data).

These findings suggest that we must be very cautious about attributing adverse health consequences to consumption of fructose containing sugars at normal population consumption levels.

More RCTs at normal levels and methods of consumption of added sugars are urgently needed.

60

REFERENCES1. 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.

2. Tappy L, Le KA. Metabolic Effects of Fructose and the Worldwide Increase in Obesity Physiol Rev 90: 23–46, 2010

3. Teff KL, Grudziak J, Townsend RR, Dunn TN, Grant RW, Adams SH, Keim NL, Cummings BP, Stanhope KL, Havel PJ: Endocrine and metabolic effects of consuming fructose- and glucose-sweetened beverages with meals in obese men and women: Influence of insulin resistance on plasma triglyceride responses. J. Clin. Endocrinol. Metab., Rapid Electronic Publication first published on Feb 10, 2009 as doi:doi:10.1210/jc.2008-2192

4. Melanson K, Zukley L, Lowndes J, Nguyen V, Angelopoulos TJ, Rippe J. Effects of High Fructose Corn Syrup and Sucrose Consumption on Circulating Glucose, Insulin, Leptin, and Ghrelin and on Appetite in Normal-Weight Women Nutrition. Nutrition, Vol.23:103-112-2007

5. Stanhope K, Griffen S, Bair B, Swarbrick M, Keim N, Havel P. Twenty-four-hour endocrine and metabolic profiles following consumption of high-fructose corn syrup-, fructose-, and glucose-sweetened beverages with meals. Am J Clin Nutr 2008;87:1194-203

6. Dolan LC, Potter SM, Burdock GA. Evidence-Based Review on the Effect of Normal Dietary Consumption of Fructose on Development of Hyperlipidemia and Obesity in Healthy, Normal Weight Individuals. Critical Reviews in Food Science and Nutrition, 50:53-84(2010)

7. Dolan LC, Potter SM, Burdock GA. Evidence-Based Review on the Effect of Normal Dietary Consumption of Fructose on Blood Lipids and Body Weight of Overweight and Obese Individuals. Critical Reviews in Food Science and Nutrition, 50:889-918 (210).

8. Hellerstein Mk, Schwarz JM, Neese RA. Regulation of Hepatic De Novo Lipogenesis in Humans. Ann Rev. Nutr 1996.16:523-557

9. Hellerstein MK. No common energy currency: de novo lipogenesis as the road lesstraveled. Am J Clin Nutr 2001;74:707–8.

10. Hudgins LC, Parker TS, Levine DM, Hellerstein MK. A Dual sugar challenge test for lipogenic sensitivity to dietary fructose. J Clin Endocrinol Metabl. 2011;96:861-868.

11. Stanhope KL, Schwarz JM, Keim NL, Griffen SC, Bremer AA, Graham JL, Hatcher B, Cox CL, Dyachenko A, Zhang W, Mcgahan JP, Seibert A, Krauss RM, Chiu S, Schaefer EJ, Ai M, Otokozawa S, Nakajima K, Nakano T, Beysen C, Hellerstein MD, Berglund L, Havel PJ. Consuming frructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. J of Clin Investigations. May 2009:119:1322-1334.

12. Hall KD, Heymsfield SB, Kemnitz JW, Klein S, Schoeller DA, Speakman JR. Energy balance and its components: implications for body weight regulation. Am J Clin Nutr 2012;95:989-94

13. Page KA, Chan O, Arora J, Belfort-DeAguiar R, Dzuira J, Roehmholdt B, Cline GW, Naik S, Sinha R, Constable RT, Sherwin RS. Effects of Fructose vs Glucose on Regional Cerebral Blood Flow in Brain Regions Involved with Appetite and Reward Pathways. JAMA:309:1;63-70

14. Purnell JQ, Klopfenstein BA, Stevens AA, Havel PJ, Adams SH, Dunn TN, Krisky C, Rooney WD. Brain functional magnetic resonance imaging response to glucose and fructose infusions in humans. Diab, Obes, & Metab 13:229-234

15. Lowndes J, Kawiecki D, Pardo S, Nguyen V, Melanson KJ, Yu Z, Rippe JM. The Effects of four hypocaloric diets containing different levels of sucrose or high fructose corn syrup on weight loss and related parameters. Nutr J. 2012,11:55.

16. Bravo S, Lowndes J, Sinnett S, Yu Z, Rippe J. The Effects of Various Levels of Sucrose and High Fructose Corn Syrup Consumption are Metabolically Equivalent and Do Not Increase Liver Fat or Ectopic Fat Deposition in Muscles. Applied Physiology, Nutrition and Metabolism, published online February 12, 2013

17. Klurfeld D, Foreyt J, Angelopoulos T, Rippe J. Lack of Evidence for High Fructose Corn Syrup as the Cause of the Obesity Epidemic. International J Obesity, advance online publication, doi:10.1038/ijo.2012.157, September 18, 2012

18. Rippe J, Angelopoulos T. Sucrose, High Fructose Corn Syrup and Fructose, and Their Potential Health Effects: What Do We Really Know? Advances in Nutrition, 4:236-245, 2013.

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19. Yu Z, Lowndes J, Rippe J. High Fructose Corn Syrup and Sucrose have Equivalent Effects on Energy Regulatory Hormones at Normal Human Consumption Level. Nutrition Research, (In Press)

20. Rippe JM. The Metabolic and Endocrine Response and Health Implications of Consuming Sugar Sweetened Beverages: Findings from Recent Randomized Controlled Trials. (Submitted to Adv in Nutr, In Review)

21. Sievenpiper JL, de Souza RJ. Are sugar-sweetened beverages the whole story? Am J Clin Nutr 2013;98:261-3

22. Rippe JM. Fructose, High Fructose Corn Syrup, Sucrose and Health. Springer Publishers (New York), In Press

Nutrition Guidance and Sweeteners:Working with Humans in the Real World

Kristine Clark, PhD, RD, FACSMDirector of Sports Nutrition

Pennsylvania State University

Annual MeetingAugust 12, 2013Portland, OR

Objectives

• Highlight the concept of diet quality

• Describe the position of the Academy of Nutrition and Dietetics on Sweeteners and their “fit” in the diet

• Determine if chocolate milk fits or is a misfit

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Diet Quality

• Ov

The overall quality of a dietbased on it’s nutrient profile

Nutrient Profile: based on recommended minimum or maximum levels of a variety of essential nutrients

65

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Energy Density vs. Nutrient Density

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The leading nutritional problem for Americans: Over consumption of calories

• 4 nutrients of concerno Calciumo Potassiumo Vitamin Do Fiber

• Milk is the leading source of 3 of the 4 nutrients of concern

Dietary Guidelines 2010: Diet Quality

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2010 Dietary Guideline: Recommendations and added sugars

Key Guidelines:

• Reduce calories from added fats and sugars

• Limit the consumption of foods containing refined grains, especially refined grain foods that contain solid fat, added sugars, and sodium

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Sources of Added Sugars

The major food and beverage sources of added sugars for Americans are:

• regular soft drinks, energy & sports drinks• candy• cakes• cookies• pies and cobblers• sweet rolls, pastries, and donuts• fruit drinks & fruit punch• dairy desserts (ice cream)

Source: 2010 Dietary Guidelines70

Functional Ingredients:• Water• Sugar

– Glucose, dextrose, maltodextrins, sucrose, high fructose corn syrup

• Electrolytes

Sports Drinks and Physical Activity

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Flavored milk contributes only 3% of the total added sugars* in children’s diets, and provides 9 essential nutrients, making it a better choice than many other beverages.

*Source: NHANES

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• Increase intake of fat free or low fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages

• Choose foods that provide more potassium, calcium, vitamin D, & dietary fiber which are nutrients of concern in the Am. Diet.

• These foods include fruits, vegetables, whole grains, milk & milk products.

2010 Dietary Guidelines:Foods & Nutrients to Increase

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Position of the Academy of Nutrition and Dietetics on Sweeteners

It is the position of the Academy of Nutrition and Dietetics that consumers can safely enjoy a range of nutritive sweeteners and nonnutritive sweeteners when consumed within an eating plan guided by current federal nutrition recommendations, such as the Dietary Guidelines for Americans.

Journal of the Am. Diet. Assn., April 25, 2012

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Institute of Medicine’s Recommendation on Added Sugars

• The intake of added sugars should not exceed 25% of energy to ensure adequate intake of essential micronutrients that are typically not present in foods high in added sugars.

• In a 2000 calorie diet, 25% of energy is 500 cal.

• In 8 oz of low fat chocolate milk there are 12 gr of added sugar or 48 calories.Institute of Medicine, Dietary Recommendations for Macronutrients, Oct. 15, 2009.

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Nutrition Counseling for Dietary Change and Weight Management

• Assess diet – look for balance & variety

• Find small ways to make improvements– Change cereal selection– Use small cereal bowls– Use juice glasses for juice vs tumblers– Use whole grain bread vs white or whole wheat– Reduce fat content of milk– Reduce high fat breakfast “meats”– Review snack habits– Talk to client about eating for hunger vs eating for emotional reasons or

boredom76

The Importance of Milk In Childhood Nutrition

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• 3 cups per day, fat free or low fat milk and milk products for adults and children and adolescents 9-18

• 2 ½ cups per day for children aged 4-8

• 2 cups per day for children ages 2-3

Recommendations for Milk Consumption

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Benefits of Milk Consumption

One serving of milk offers:• Calcium – 300 mg/8oz

• Vitamin D – 100 IU/8oz

• Potassium – 397 mg/8oz

• Vitamin A – 149 mcg (RAE)/500 IU

Moderate evidence: milk linked to bone health• Vitamin D and Calcium contributors

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• Only 1/3 to 1/2 of American children and adolescent boys meet DGA milk consumption guidelines

• Only 1/5 of adolescent girls meet DGA milk consumption guidelines

Consumption is Too Low

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• Flavored milk drinkers consume more milk than exclusively unflavored milk drinkers.

• Milk drinkers in general consume more Calcium, Phosphorus, Magnesium, Potassium and Vitamin A than non-milk drinkers.

• Flavored milk drinkers have lower intakes of soft drinks compared to those who do not drink flavored milk.

Source: MilkPEP.org

The Facts about Milk Consumption

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• Flavored milk drinkers do not have higher total fat or calorie intakes than non-milk drinkers.

• Children who drink flavored and unflavored milk don’t have higher body mass index (BMI) than those who do not drink milk.

• 66% of milk chosen by children in schools is flavored.

Source: MilkPEP.org

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What the Evidence Says

Children who drink flavored milk: (compared to children who do not drink milk)

• Have comparable or lower BMIs

• Consume more nutrients

• Do not consume more sugar

Journal of the American Dietetic Association, April 2008

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When flavored milk was removed, elementary school student milk consumption dropped 35%

Source: MilkPEP.org 84

Once milk drinkers leave, they don’t come back

Schools in Year 1 of Elimination

Schools in Year 2 of Elimination

Study Results(Consumption Change) -31%

-37%

Patterson J, Saidel M. The removal of flavored milk in schools results in a reduction in total milk purchases in all grades, K-12. J A D A, ’09; 109(9): A97.

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Nutritional consequences of removing flavored milk

Unit of Measure

Amount to be Replaced

Vitamin D mcg 3.6Vitamin D IU 130Calcium mg 363Potassium mg 653Magnesium mg 50Phosphorus mg 382Vitamin A RAE 197Vitamin A IU 668Protein g 10.6

Weekly Amounts per StudentEssential Nutrients to be Replaced

The impact on student milk consumption and nutrient intakes from eliminating flavored milk in schools. 2009. MilkPEP research, conducted by Prime Consulting Group. Presented at the School Nutrition Association Annual National Conference, 2010. 86

'06-'07 '09-'10 '10-'11

166.1154.0

142.8

Avg. Calories in 8 oz. of Flavored Milk

AVERAGE CALORIES PER 8 OZ OF MILK IN SCHOOLS by School Year

’06-’07 ‘07-’08 ‘08-’09 ’09-’10 ’10-’11 3 Yr Change

White 110.8 107.8 106.2 105.8 104.3 -6.7 calories -6.9%

Flavored 166.1 160.4 156.2 154.0 142.8 -23.3 calories -14.0%

TOTAL 150.0 144.1 141.2 140.0 131.0 -19.1 calories -12.7%

Flavored Milk Has 23 Fewer Calories Than 5 Years Ago

• 78% of flavored milk units are ≤ 150 calories.

• Now the average flavored milk is only 39 calories more than white milk.

Back-to-School Brings Changes to Flavored Milk; Now Lower in Calories and Sugar, Aug 25, 2011, MILKpep research 87

Added Sugar in Flavored Milk Has Declined 30%

Total sugar levels in chocolate milk have declined by 5 grams per serving over five years.

Added sugar has declined 30% (from 16.7g to 11.8g). Sugar from the cow has not changed (12g per serving).

4.012

12 11.8

16.7

2.8

Grams of Sugar per 8oz Serving Teaspoons

Back-to-School Brings Changes to Flavored Milk; Now Lower in Calories and Sugar, Aug 25, 2011, MILKpep research

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What the Science Says• Single ingredients or single foods do not cause a disease

• 30 yrs ago: Eating eggs will not cause heart attacks or strokes

• Drinking flavored milk does not cause obesity, diabetes, cancer, heart disease

• Excess calorie intake from a wide variety of sources + Inadequate calorie expenditure contributes significantly to weight gain

• Weight gain and obesity is a direct risk factor to disease processes

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New Study: Focus Nutrition Messages on Eating Health Balanced Diet

• Reviewed 53 scientific papers & found a strong and consistent inverse relationship between % energy coming from fats & sugars

• If sugars were low, fats were high

• “Sugar-Fat See-Saw”

Sadler, M.; Critical Reviews in Food Science and Nutrition, July 3, 2013

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Conclusions

• Legitimate concerns about childhood obesity

• Misplaced emphasis on low fat, lower sugar flavored milk

• Unintended consequences – loss of nutrients

• HFCS and Sucrose are metabolically equivalent

• Importance of science and facts driving policy

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