Understanding Fructose, HFCS, and Sugars.”
1 From Science to Communication: UnderstandingUnderstanding Fructose,Fructose, HFCS,HFCS, andand SugarsSugars
A Web cast for dietitians by:
International Food Information Council Foundation International Life Sciences Institute (ILSI), North America
September 10, 2009 2:00 - 3:30 pm EDT ILSI North America
On September 10, 2009 the International Food Information Council Foundation and the International Life Sciences Institute (ILSI), North America held a Webinar for registered dietitians on dietary sweeteners containing fructose, "From Science to Communication: Understanding Fructose, HFCS, and Sugars.”
This Webinar has been converted into an online, learning level two, self‐study module that is worth one credit hour. In addition to the content on the slides, speaker comments are summarized in the notes section below each slide.
The International Food Information Council Foundation is a Commission on Dietetic Registration (CDR)‐accredited provider of Continuing Professional Education (CPE) for Registered Dietitians (RD) and Dietetic Technicians, Registered (DTR). Welcome to the Fructose Webinar 2 Goals for this Webinar: • To disseminate the findings of the USDA ILSI workshop “Dietary sweeteners containing fructose: The state of the science” • Published as a supplement J Nutr. 2009 Jun;139(6):Suppl
• To share new data on fructose intake in the USA • Compare normal and extreme fructose intakes with study levels indicating fructose consumption is problematic
• To address common misunderstandings associated with this sweetener
• To describe fructose absorption and the problem of fructose intolerance • To share insights on how to communicate about sugars in a consumer- friendly manner
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
This Webinar was created to disseminate findings from the 2008 workshop on the "State of the Science on Dietary Sweeteners Containing Fructose," sponsored by the ILSI North America Technical Committee on Carbohydrates and the U.S. Department of Agriculture. The workshop proceedings were published as a supplement to the June 2009 issue of the Journal of Nutrition.
The goals for this learning module are listed on the slide. TodayToday’’ss SpeakersSpeakers 3
• Fructose: An Overview • Julie Miller Jones, PhD, CNS, LN (Moderator) • Distinguished Scholar and Professor Emeritus, St. Catherine University
• Dietary Sweeteners Containing Fructose: Summary of Physiological Effects and Tested vs. Usual Fructose Intakes • Fran Seligson, PhD, RD • Nutrition Consultant, Hershey, PA
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The original live Web cast featured: •Julie Jones, PhD, CNS, LN, Distinguished Scholar & Professor Emeritus at St. Catherine University •Fran Seligson, PhD, RD, Nutrition Consultant •Suzanne Skoog, MD, Gastroenterologist at Digestive Health Specialists, Arizona •Sarah Alligood, MPH, RD, Program Manager, Nutrients at the International Food Information Council Foundation
The slides in this online module were created by these four experts. TodayToday’’ss SpeakersSpeakers (cont.)(cont.) 4
• Fructose, High Fructose Corn Syrup, and Fructose Intolerance • Suzanne Skoog, MD • Gastroenterologist, Digestive Health Specialists, Scottsdale, AZ
• Fructose, Carbohydrates and the Consumer: The Communicator Role of the RD • Sarah Alligood, MPH, RD • Program Manager, Nutrients, International Food Information Council
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009 5
Fructose: An Overview
Julie Miller Jones, PhD, CNS, LN Distinguished Scholar and Professor Emeritus St. Catherine University
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The Web cast began with an overview of fructose by Julie Jones, PhD, CNS, LN, Distinguished Scholar & Professor Emeritus at St. Catherine University. 6 Why A Fructose Webinar?
Fructose-Sweetened Drinks Associated Adverse Effects of with Adverse Health Effects Dietary Fructose Results of a recently completed study have confirmed that Alan R. Gaby, MD drinks sweetened with fructose increases levels of bad Alternative Medicine Review cholesterol, or LDL cholesterol, and triglycerides, both of which are known risk factors for cardiovascular disease.
Liquid Fructose Gives Ratty A Fatty Liver Fructose-Sweetened Linda von Wartburg Beverages Linked to Heart May 18, 2007 Risks April 22, 2009
Fructose Linked to More Metabolic Problems than Glucose April 21, 2009 Reviewed by Robert Jasmer, MD; Associate Clinical Prof. of Medicine, University of California, San Francisco.
Fructose and fructose‐containing sweeteners are a hot topic in the nutrition world, with interest from the media, scientists, dietitians and consumers alike. The sample of headlines on the slide exemplify some of the recent headlines involving fructose in both popular and professional press.
6 7 Fructose Overview
• Fructose Chemistry and Role in the Diet • Fructose Forms in the Diet • Comparable to sucrose but not identical • Changes in fructose consumption over time • Changes in body weight and increased consumption of all food types • Fructose and health – an intro
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The following slides address the topics on the screen.
7 8 Chemistry of the Sugars
Glucose - aldose Fructose - ketose
Sucrose (table sugar)
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
You may remember these molecular structure diagrams from your life in organic chemistry. You may remember that fructose is a ketone, a six carbon ketose sugar.
Glucose is also a six carbon aldose sugar. When you combine these two molecules you form a sucrose sugar. Glucose and fructose individually are both reducing sugars; however, together sucrose is a non‐reducing sugar. Fructose Occurs in Nature 9 Fructose Fruit, vegetables, nuts, dairy (% total sugars) ≥66 Apples, pears 56-65 Asparagus, raspberries, spinach, watermelon Almonds, apricots, bananas, blackberries, blueberries, broccoli, Brussels sprouts, cabbage, cantaloupe, carrots, cashews, cherries, Clementines, sweet corn, cucumbers, currants, dates, figs, filberts, grapefruit, grapes, hazelnuts, honeydew, melon, kiwi fruit, lentils, 42-55 lettuce, lime juice, macadamias, nectarines, sweet onions, navel oranges, peaches, peanuts, peas pecans, sweet peppers, persimmons, pineapple, pistachios, raisins, summer squash, strawberries, sweet potatoes, tomatoes, walnuts, cooked wild rice
31-41 Artichokes, celery, okra, plums, radishes, turnip greens
21-30 Avocados, tangerines 11-20 Cranberries, egg yolks 1-10 Milk (2% fat)
Source: NutritionData.com. Conde Nast. 2008.
Fructose occurs in nature. In fact, the word “fructose” itself means “fruit.” You can see that in nature it occurs in varying percentages of the total amount of sugar in a product. As shown in the chart, the majority of naturally occurring products are made up of 42-55% fructose.
9 SourcesSources ofof AddedAdded FructoseFructose 10
• Crystalline fructose • 89% pure fructose • 2% water and trace minerals • ~20% sweeter than glucose • Used seldom • Liquid fructose sweetener • Used seldom
• Agave, honey, concentrated fruit juice
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
This slide discusses sources of added fructose.
Crystalline fructose is available at health food and other grocery stores. •It consists of 89% pure fructose, with a little water and trace elements. •It is about 20% sweeter than glucose but this is dependent upon the pH, so it is not always sweeter. •Crystalline fructose is used seldom as well as its counterpart, liquid fructose.
In addition, added fructose can come in agave syrup, honey, or concentrated fruit juices such as concentrated pear juice. SourcesSources ofof AddedAdded FructoseFructose 11 • Corn syrup - corn starch (a glucose polymer) that is treated with acid • Yields a syrup that is not very sweet
• High Fructose Corn Syrup - corn syrup with enzymes to convert a portion of the glucose into fructose, hence the name HFCS. • Commercial HFCS contains from 42% to 55% fructose
• No Hg is used in its manufacture
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Added fructose can also come in the form of high fructose corn syrup (HFCS). Corn syrup is made from corn starch which is a glucose polymer. It is treated with a acid or sometimes with an enzyme to yield a syrup that is not very sweet (the kind your grandmother might have used to make pumpkin pie). Since the corn syrup is made entirely from a glucose polymer, in the 1970s some scientists used an enzyme to change the glucose residues in the corn syrup to fructose. This then began known as high fructose corn syrup. “High” is really a misnomer because the corn syrup didn’t contain any fructose before, and now any new syrup with fructose is claimed as “high fructose” corn syrup. Commercial high fructose corn syrup is between 42‐55% fructose, just like the concentrations of the natural fruits in the chart displayed on slide 9. Despite the various messages on the Web, mercury is not used in the manufacturing of high fructose corn syrup. 12 Fructose and Glucose Together in Nature
% Total sugars* Total Total Sweetener Fructose:Glucose fructose glucose Crystalline 99.5+ 0.1 max — fructose Honey 48 52 0.9 Sugar (sucrose) 50 50 1.0
Grape juice conc. 53 47 1.1
Apple juice conc. 65+ 35 1.9
Pear juice conc. 74+ 26 2.8 Agave nectar 74+ 24 3.1
+ Higher fructose than HFCS * Total sugars = ∑(sucrose + glucose + fructose + lactose + maltose + galactose) Used with permission White Technical Res.
Another important point is that fructose and glucose occur together in nature but at different ratios.
12 SucroseSucrose andand HFCSHFCS 13 Table Sugar/Sucrose HFCS-55
• 50% Fructose, 50% • 55% Fructose, 45% Glucose Glucose (Sweetness equivalent to sucrose) • Must dissolve; can crystallize in foods • Already dissolved; less likely to crystallize • Less product browning • Promotes browning • Some moisture retention • Great moisture retention
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In general, sucrose and high fructose corn syrup are very similar in that they contain almost the same percent compositions of glucose and fructose. They are equivalent in terms of sweetness.
Due to the reducing sugars in high fructose corn syrup, browning is more likely to occur.
Both help retain moisture, but high fructose corn syrup will do that to a greater extent.
13 HFCS Substituted for Sucrose 14 80.0
70.0
60.0
Sucrose 50.0
40.0
30.0
HFCS
Per capita availability (pounds/yr) availability capita Per 20.0
10.0
0.0 1970 1975 1980 1985 1990 1995 2000 2005 Year
Source: USDA-ERS 2007 Per capita caloric sweeteners data set, loss-adjusted availability
Here you can see that since it’s introduction in 1970, high fructose corn syrup has replaced sucrose.
14 15
“Childhood“Childhood obesityobesity isis atat epidemicepidemic levelslevels inin thethe UnitedUnited States.”States.” -David-David SatcherSatcher USUS SurgeonSurgeon GeneralGeneral
Some people say that as we have increased high fructose corn syrup, we have become fatter and that is linked to obesity.
15 HFCS, Free and Total Fructose Consumption 16 And Prevalence for Obesity and Overweight
30 100 Total Fructose
75 20 Obesity 50
10 (g/capita/d) Free Fructose 25
Percentage Obese HFCS
0 0 HFCS, Free & Totalfructose Intake 1961 1970 1975 1980 1985 1990 1995 2000 Year
Bray, Nielsen & Popkin, AJCN 2004;79: 537-544
People who claim that HFCS is linked to obesity have used these types of graphs to demonstrate their point.
You can see in the light blue line that obesity rates have been increasing over the past three decase along with intake of high fructose corn syrup in the yellow line.
Therefore, proponents of this theory charge HFCS as the cause for obesity. Calorie intake is up 24% since ‘70 17
Year 1970 1975 1980 1985 1990 1995 2000 2005 2,800 +24%
2,700
2,600
2,500
2,400
2,300 USDA-ERS Nutrient food category Nutrient food USDA-ERS Total per capita calories (kcal/day)
2,200
2,100 -4 -3 -2 -1 0 1 2 3 4 5 6 Change in percent of total daily per capita calories by category: 1970 to 2005
Source: USDA-ERS 2007 Caloric nutrients data set
However, what is not on that graph but is very important is the fact that the average caloric intake has increased by 24% since 1970. We all know that an increase in calories is associated with obesity.
17 More Calories from All Foods 18 Year 1970 1975 1980 1985 1990 1995 2000 2005 2,800
Added sugars (∆ = -1%) +24% 2,700 Added fats
2,600 Flour, cereal products
2,500 Vegetables
2,400 Fruit
Dairy 2,300 USDA-ERS Nutrient food category Total per capita calories (kcal/day) calories capita per Total
2,200 Meat, eggs, nuts
2,100 -4 -3 -2 -1 0 1 2 3 4 5 6 Change in percent of total daily per capita calories by category: 1970 to 2005 Source: USDA-ERS 2007 Caloric nutrients data set, loss adjusted
Here you can see that the increase of calories is mainly from added fats, added flour, and added cereal products. It is the added calories from all foods that really become responsible for obesity.
18 Concerns about Too Much Fructose 19 and Data on Intake Will Be Addressed
• Body weight • Insulin resistance • Elevated blood lipids • Elevated blood pressure • Fructose intolerance
• Studies with pure fructose fed at high levels will be compared with dietary levels of fructose
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The issues on the screen will be addressed in the following slides.
19 20
Dietary Sweeteners Containing Fructose - Summary of Physiological Effects - Tested vs. Usual Fructose Intakes
Fran Seligson, PhD, RD Nutrition Consultant
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The next section of the Web cast was delivered by Fran Seligson, PhD, RD, Nutrition Consultant. In this segment she: •Summarized discussions from the ILSI/USDA fructose workshop about the metabolism and physiological effects that have been associated with fructose. •Compared fructose intakes that have been tested in studies to new data on what people actually consume. 21 Summary of Physiological Effects
• A calorie is a calorie whether from glucose, fructose, or a combination of both
• Data not compelling for a significant difference in satiating effects • Fructose vs. glucose • HFCS vs. sucrose
• HFCS and sucrose have similar metabolic effects
• Fructose and glucose can have different metabolic effects
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
There were four major areas of agreement from the fructose workshop: •A calorie is a calorie whether from glucose, fructose, or a combination of both •Data are not compelling for a significant difference in satiating effects of •Fructose compared to glucose and of •HFCS compared to sucrose •HFCS and sucrose have similar metabolic effects •Fructose and glucose can have different metabolic effects 22 Glucose and Fructose Compared
Glucose Fructose • Active Transport • Passive diffusion • Insulin required • Insulin not required • High glycemic • Low glycemic • Feedback control • No feedback control • Metabolized to • Can be metabolized fructose-6-P in the first the same as glucose reaction depending on dietary conditions
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Fructose and glucose can have different effects because they are absorbed and metabolized differently.
Glucose: •Is absorbed by active transport •Requires insulin for uptake by most cells •Produces a glycemic response •Has a feedback control mechanism on its metabolism, and •Is actually converted to a form of fructose (F‐6‐P) early in its metabolism
Fructose, on the other hand: •Is absorbed generally by passive diffusion •Does not require insulin for cellular uptake •Produces a low glycemic response •Does not have a feedback control on its metabolism, but •Can be metabolized the same as glucose depending on overall dietary conditions.
It is the absence of a feedback control in fructose metabolism that can lead to adverse physiological effects under certain conditions.
22 Hepatic Fructose and Glucose Utilization 23
1 4 2 3
6
7 5
Copyright ©2002 The American Society for Nutrition Elliott, S. S et al. Am J Clin Nutr 2002;76:911-922
I am not a fan of metabolic pathways, but there are times when it is important to review some bas This slide shows a schematic of how fructose and glucose are metabolized in the liver.
1. Glucose metabolism follows along this pathway to the Krebs or TCA cycle (tricarboxylic 2. Along the way glucose is converted to Fructose‐6‐phosphate and then to fructose 1,6‐d 3. It is at this point that there is a negative feedback control as citrate and ATP accumulat 4. Fructose conversion to fructose‐1‐phosphate, on the other hand, is not under negative 5. Excess fructose and/or excess calories will drive fructose metabolism to triglyceride syn 6. Otherwise fructose can be metabolized into the TCA cycle or …. 7. Be converted to glucose and stored as glycogen. Adverse Effects of Pure Fructose 24 Reported and/or Hypothesized
• Triglyceride synthesis • Nonalcoholic liver • Triglycerides (fasting disease and postprandial) • Visceral fat • HDL cholesterol • Fasting glucose • LDL cholesterol • Insulin sensitivity • ApoB • Glucosylated proteins • Small dense LDL • High blood pressure cholesterol • Uricemia • Oxidized cholesterol • Kidney disease
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Results from studies in which humans or rodents were fed very large amounts of pure fructose compared to glucose or other available carbohydrates have generated a long list of adverse effects—some of which are listed in this slide. The root cause of these adverse effects is usually traced back to fructose metabolism itself and increased triglyceride synthesis. Factors that May Influence the 25 Physiological Effects of Fructose • Amount consumed • g/d and % kcal • How consumed • Pure fructose vs. HFCS/sucrose • Liquids vs. solids • Length of consumption • Acute vs. chronic • Subject characteristics • Sex, age, genetics • BMI • Energy balance
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Whether fructose has beneficial, neutral, or adverse physiological effect depends on the experimental conditions under which the effects are evaluated. Some of these conditions are •Amount consumed •g/dand % kcal •How consumed •Pure fructose vs. HFCS/sucrose •Liquids vs. solids •Length of consumption •Acute meal or over 1 day as compared to chronic feeding up to 2 weeks or longer •Subject characteristics, such as •Sex, age, genetics, • BMI, and •Energy balance also influence the effects of high fructose diets
In the next several slides I will suggest how some factors may confound interpretation of study results. Fructose Effects 26
Fructose
TG synthesis Serum fasting and pc levels Nonalcoholic liver disease Body fat distribution HDL Insulin sensitivity Uric acid Blood pressure Kidney disease
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
First we start with effects that are likely specific to fructose metabolism itself. These can be identified in studies in which pure fructose is fed at very high amounts and includes things such as effects on triglyceride synthesis, HDL levels, insulin sensitivity, uric acid, blood pressure, and kidney disease.
26 Added Sugars Effects 27
Fructose Added Sugars
TG synthesis HFCS & sucrose Serum fasting and pc levels Fructose effects Nonalcoholic liver disease Glucose effects Body fat distribution Calorie effects HDL Diet quality Insulin sensitivity Uric acid Blood pressure Kidney disease
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
However, when fructose is consumed in the form usually present in the diet, that is as sucrose or HFCS, other factors need to be considered when evaluating cause‐effect relations: •There obviously are the effects associated specifically with fructose, however •The simultaneous consumption of glucose can mitigate some of the effects of fructose on hormones such as insulin, leptin, ghrelin, and so on. •Depending on how much added sugars are consumed, sucrose and HFCS can exert a general excess calorie effect and can also influence •Diet quality through increased energy density and reduced nutrient density.
27 Excess Calorie Effects 28
Fructose Added Sugars Excess Calories
TG synthesis HFCS & sucrose Nondiscretionary Serum fasting and pc levels Fructose effects Discretionary Nonalcoholic liver disease Glucose effects Added sugars Body fat distribution Calorie effects Solid fats HDL Diet quality Alcohol Insulin sensitivity Diet quality Uric acid Body composition Blood pressure Kidney disease
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
But the physiological effects of added sugars also need to be considered within the context of overall energy balance. Excess calories can come from nondiscretionary sources (such as meats, grains, and oils) as well as discretionary sources such as added sugars, solid fats, and alcohol. Where the excess calories come from—both in terms of amount and relative proportions—may influence how fructose is metabolized. Also, if long term consumption of excess calories has caused overweight or obesity, metabolic abnormalities associated with those conditions may influence how fructose is metabolized.
28 29 29 Diet and Health
Fructose Added Sugars Excess Calories
Genetics Lifestyle (physical activity, sleep) Socioeconomic factors
TG synthesis HFCS & sucrose Nondiscretionary Serum fasting and pc levels Fructose effects Discretionary Nonalcoholic liver disease Glucose effects Added sugars Body fat distribution Calorie effects Solid fats HDL Diet quality Alcohol Insulin sensitivity Diet quality Uric acid Body composition Blood pressure Kidney disease
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Similarly the dietary effects of fructose alone, added sugars alone, and the interaction of fructose and added sugars in the presence of excess calorie intake will be influenced by many other factors such as a person’s genetic predisposition, lifestyle factors including physical activity and sleep habits, and socioeconomic factors.
29 30
What’s Been Tested
• Sugars • Pure Fructose • Sucrose • HFCS • Amounts
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
So, given the fact that the metabolic effects of fructose will be influenced by the conditions under which it has been consumed, how has it actually been tested in terms of amounts and sources?
30 What’s Been Tested – 2000 kcal 31 Example ± Excess Calories Fructose
% kcal g Fructose 17 85 20 100 25 125 30 150
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Early studies evaluated pure fructose as a possible sucrose replacement for people with diabetes. These studies typically tested pure fructose at 17 to 20% of kcal to match the estimated usual intake of sucrose. More recent studies have tested pure fructose at 25 to 30% or more of kcal. These are very, very high intakes. The purpose for feeding such high amounts has been to increase the probability of showing metabolic differences between pure fructose and pure glucose. The gram amount of fructose tested depends on total energy intake: for a 2000 kcal diet the amount would be anywhere from 85 to 150 g of fructose. The gram amounts would be less with lower energy intakes and greater with higher energy intakes.
31 What’s Been Tested – 2000 kcal 32 Example ± Excess Calories Fructose Added Sugars (HFCS, Sucrose)
% kcal g Fructose % kcal g Fructose 17 85 25 62−69 20 100 30 75−82 25 125 30 150
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
While studies that test high amounts of pure fructose are interesting, they have been criticized for not being realistic. Consequently a few recent studies have tested diets containing 25 to 30% or more kcal from either HFCS, sucrose, or both. For a 2000 kcal diet, the amount of fructose in such diets would range from 62 to 82 grams.
32 Health Effects of Pure Fructose vs. 33 Other Available Carbohydrates
Probable benefit Equivocal Probable risk 0 to 50 g/d 50 to 100 g/d >100 g/d
Livesey meta-analysis
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
One of the experts who participated in the fructose workshop (Geoffrey Livesey) shared this summary of a meta‐analysis he conducted on studies involving pure fructose.
•Fructose intake in g/day is listed across the top •Parameters that were evaluated include glycosylated hemoglobin, insulin sensitivity, fasting triglycerides, postprandial triglycerides, serum uric acid, and body weight. •The physiological effect of the parameter affected by fructose intake is color coded as to being beneficial (green), neutral or equivocal (yellow), or probably adverse (red). •The strength of the evidence associating the measured parameters with a particular intake range of fructose is listed the outermost columns as weak, moderate, or strong. •The results of the meta‐analysis suggest • Probable benefits with fructose at intakes of 50 g or less •Equivocal or neutral benefits with intakes from 50 to 100 g, and • Probably risk of adverse effects at intakes >100 g (amounts which I have already shown as typically being tested)
33 34
What People Consume
• NHANES 1999−2004 • Fructose Usual Intakes • Amounts • Food Sources
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
So now it’s time to put into perspective what has been tested with what people actually consume. I will review new estimates of usual fructose intakes and food sources as determined from NHANES 1999−2004 data that were literally hot off the press at the time of the workshop.
34 35 Fructose Intake (% kcal by percentile ± SEM)
Sex/Age Added fructose* Total fructose** Group (percentile) 50th 90th 95th 50th 90th 95th Total 8 ± 0.2 11 ± 0.2 13 ± 0.5 9 ± 0.1 12 ± 0.2 15 ± 0.4 Both Sexes 1-3 y 6 ± 0.2 10 ± 0.3 11 ± 0.4 9 ± 0.2 13 ± 0.3 14 ± 0.4 4-6 y 8 ± 0.3 11 ± 0.3 12 ± 0.4 10 ± 0.2 13 ± 0.3 14 ± 0.4 7-10 y 8 ± 0.2 11 ± 0.3 12 ± 0.3 10 ± 0.2 12 ± 0.3 13 ± 0.3 Males 11-14 y 9 ± 0.5 13 ± 0.5 14 ± 0.5 10 ± 0.3 14 ± 0.4 15 ± 0.5 15-18 y 10 ± 0.4 14 ± 0.7 15 ± 0.9 11 ± 0.4 15 ± 0.6 16 ± 0.7 19-22 y 10 ± 0.6 14 ± 0.9 16 ± 1.0 11 ± 0.6 16 ± 0.8 18 ± 1.0 23-50 y 8 ± 0.2 12 ± 0.4 14 ± 0.5 9 ± 0.2 14 ± 0.3 15 ± 0.4 51+ y 6 ± 0.2 10 ± 0.3 11 ± 0.3 7 ± 0.2 11 ± 0.3 13 ± 0.3 Females 11-14 y 9 ± 0.4 12 ± 0.4 13 ± 0.4 10 ± 0.4 13 ± 0.4 14 ± 0.4 15-18 y 10 ± 0.4 14 ± 0.6 15 ± 0.7 11 ± 0.4 15 ± 0.6 17 ± 0.7 19-22 y 10 ± 0.5 15 ± 0.8 16 ± 0.9 12 ± 0.5 16 ± 0.7 18 ± 0.8 23-50 y 8 ± 0.3 13 ± 0.5 16 ± 0.6 9 ± 0.3 14 ± 0.4 16 ± 0.5 51+ y 6 ± 0.2 10 ± 0.3 11 ± 0.4 8 ± 0.2 12 ± 0.3 13 ± 0.3 * Fructose from HFCS and sucrose ** Added + naturally occurring fructose Marriott et al. 2009
First, let’s look at fructose intakes as a % of total energy intake. This slide lists the intake of fructose as a % of calorie intake •At the 50th, 90th, and 95th percentiles; •by age/sex group; and •whether the fructose is from added fructose or from added plus naturally‐occurring sources; in this analysis • Added fructose is that provided by sucrose and HFCS. •Total fructose is added fructose plus that from naturally‐ occurring sources, such as fruits
A few points to make: •First, the vast majority of fructose in the diet comes from added sources. For example, for the total population, added fructose represents 8% of calories at the 50th percentile compared to 9% of calories from total fructose. This relation holds for all age/sex groups and at the 90th and 95th percentiles. •Second, only when fructose intakes are at or above the 95th percentile do people consume 16% or more of their calories from added fructose or 18% or more of their calories from total fructose. •Such intakes are seen only in young adult males and females ages 19‐22 and females ages 23‐50, cells in the table that are shaded •These intakes contrasts with recent human feeding studies that tested 25% or more of calories from pure fructose 35 36 Fructose Intake (g/day by percentile ± SEM)
Sex/Age Added fructose* Total fructose** Group (percentile) 50th 90th 95th 50th 90th 95th Total 41 ± 1 68 ± 1 78 ± 4 49 ± 1 75 ± 2 87 ± 4 Both Sexes 1-3 y 20 ± 1 40 ± 2 47 ± 2 32 ± 1 54 ± 2 62 ± 2 4-6 y 33 ± 1 50 ± 2 56 ± 2 41 ± 1 61 ± 2 68 ± 2 7-10 y 42 ± 2 66 ± 4 74 ± 4 50 ± 2 71 ± 3 79 ± 4 Males 11-14 y 51 ± 2 78 ± 4 87 ± 5 58 ± 3 87 ± 4 97 ± 9 15-18 y 64 ± 3 102 ± 4 116 ± 5 72 ± 3 109 ± 5 121 ± 5 19-22 y 63 ± 5 107 ± 9 122 ± 13 70 ± 4 117 ± 9 134 ± 12 23-50 y 50 ± 2 93 ± 3 108 ± 3 59 ± 2 103 ± 3 118 ± 4 51+ y 28 ± 1 57 ± 3 69 ± 4 38 ± 1 67 ± 3 79 ± 4 Females 11-14 y 41 ± 2 63 ± 3 71 ± 3 48 ± 2 69 ± 3 76 ± 3 15-18 y 46 ± 2 71 ± 4 80 ± 5 53 ± 2 80 ± 4 89 ± 4 19-22 y 50 ± 3 90 ± 6 105 ± 8 57 ± 3 100 ± 6 116 ± 7 23-50 y 34 ± 1 70 ± 3 84 ± 5 41 ± 1 76 ± 2 90 ± 3 51+ y 21 ± 1 42 ± 2 50 ± 2 30 ± 1 52 ± 1 60 ± 2 * Fructose from HFCS and sucrose ** Added + naturally occurring fructose Marriott et al. 2009
This slide shows the same data but presented as grams/day. Key points to observe: •Several age groups of males have fructose intakes above 100 g/day at or above the 90th percentile—the intake level with possible adverse effects. •Females 19‐22 y exceed 100 g of added fructose at the 95th percentile and total fructose at the 95th percentile. •Several sex/age groups have fructose intakes in the 50 to 100 g intake range—the intake level with neutral to equivocal effects.
Now to switch to food sources…
36 37 Food Sources of Added Fructose* (% of intake)
Food Group All Children Males Females 23-50 15-18 11-14 15-18 19-22 11-14 19-22 23-50 7-10 51+ 51+ 1-3 4-6 1+ Age (y)
Milk & milk 9 14 16 12 9 6 4 6 12 8 6 8 9 11 products Grain 20 26 23 24 20 16 11 17 26 20 16 14 20 32 products
Sugars and 12 16 15 16 12 8 8 10 14 14 11 13 13 15 sweets
Sugar- sweetened 54 39 43 46 56 68 73 63 41 56 65 63 54 36 beverages
* Fructose from sucrose and HFCS Marriott et al. 2009
This slide shows the top 4 food sources of added fructose, i.e., fructose from sucrose and HFCS. Some key points from this slide: •Overall, half of the fructose is from sweetened beverages, but the actual amountt varies by age and sex group. •The contribution is above 50% for males and females ages 11‐50 and below 50% for children ages 1‐10 and males and females ages 51+ .
37 38 Food Sources of Added Fructose* (% of intake)
Food Group All Children Males Females 11-14 15-18 19-22 23-50 11-14 15-18 19-22 23-50 7-10 51+ 51+ 1-3 4-6 1+ Age (y)
Milk & milk 9 14 16 12 9 6 4 6 12 8 6 8 9 11 products Grain 20 26 23 24 20 16 11 17 26 20 16 14 20 32 products
Sugars and 12 16 15 16 12 8 8 10 14 14 11 13 13 15 sweets
Sugar- sweetened 54 39 43 46 56 68 73 63 41 56 65 63 54 36 beverages
* Fructose from sucrose and HFCS Marriott et al. 2009
It is important to note that for children and older adults, the combined contribution of fructose from added sugars in grain products and sugars & sweets is almost as much as, and sometimes more than, the amount from sweetened beverages.
This is an important point because the recent studies on fructose have been conducted with subjects in the older adult age range and with test sugars provided exclusively as beverages. These studies also provide the test sugars in amounts far in excess of what is consumed by this age group (25% kcal vs. 11‐13% kcal).
38 Summary of Fructose Intakes: 39 Feeding Trials vs. Usual Intakes
• High intakes of pure fructose are not real world • Studies typically feed 17–30% kcal pure fructose Calories Fructose, g/d 1600 68–120 2000 85–150 2400 102–180 2800 119–210 • Fructose in nature rarely occurs without glucose • ≈ 41−71% of energy as added sugars • Studies may reflect acute metabolic overload , NOT chronic physiologic effects of usual intakes
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Now to summarize what we know about fructose intakes used in feeding trials compared to estimates of usual fructose intake. •While research studies that test high amounts of pure fructose provide interesting insight into fructose metabolism and physiological effects under such conditions, they are not real world situations! •Human feeding trials typically feed anywhere from 17 to 30% or more of total energy intake from pure fructose. Rodent studies feed even high amounts, up to 60 to 70% of the diet. For the human studies, the actual amount of fructose consumed by subjects can range anywhere from 68 g/day to 210 g/d depending on the total energy intake of the subjects and the % of calories provided by fructose. •Fructose in nature rarely occurs without glucose. Thus in order for a person under real‐ world conditions to ingest 17 to 30% of their calories from fructose, that person would need to consume a diet that contains 41 to 71% of total calories from added sugars. Admittedly not a healthful diet. •The last point about most feeding trials is that they often assess the effects of high amounts of pure fructose from a single meal or over the course of 1 or 2 days. The results from such studies may be reflecting a situation of acute metabolic overload rather than what occurs with chronic ingestion of fructose in amounts and from sources commonly consumed. 40 Total Fructose Intake Comparisons
Source % kcal g/d NHANES 1999–2004 Population mean* 9 49 Subpopulation means 7–12 32–75 Subpopulation 90th percentiles 11–16 52–117 Subpopulation 95th percentiles 13–18 60–134
* 2148 kcal
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
According to the most recent estimate of usual fructose intakes, people overall on average consume 9% of their calories, or 49 g/day, from all sources. Across the spectrum of age and sex groups, average fructose intakes range from 7 to 12% of calories or 32 to 75 g/day. The vast majority of people consume <18% kcal and <100 g/d. Intakes greater than 18% of calories are observed only at or above the 95th percentile and only for 19‐22 year‐old males and females. Intakes at 100 g/day or more are observed only at or above the 90th percentile and only in males ages 15‐50, a function of their total calorie intake, and in females ages 19‐22 with an estimated total energy intake of 2500 kcal. 41 Total Fructose Intake Comparisons
Source % kcal g/d NHANES 1999–2004 Population mean* 9 49 Subpopulation means 7–12 32–75 Subpopulation 90th percentiles 11–16 52–117 USDA Food Guide (2000 kcal**) 0% disc kcal from added sugars 5 23 50% disc kcal from added sugars 8 40 100% disc kcal from added sugars 11 57
*2148 kcal **267 discretionary kcal
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
According to the recommendations of the USDA Food Guide, a 2000‐calorie diet containing only naturally‐occurring sources of fructose (i.e., fruits and vegetables) would provide 5% of total calories if there are no discretionary calories from added sugars. If it provided 50% of discretionary calories from added sugars, the diet would contain 8% of total calories from fructose. So, current usual fructose intakes on average are consistent with getting half of discretionary calories from added sugars and 50 gram or less fructose per day—the amount with which beneficial effects have been observed. About half of the population is consuming above the recommendation of the Dietary Guidelines for added sugars, but only 5 to 10% of certain age/sex groups are consuming 100 grams or more of fructose. 42 Conclusion: More Research Needed
• Controlled feeding trials that use levels and sources of fructose as commonly consumed • Dose response • g/d vs. % kcal • Mixture of sucrose and HFCS • Solid & liquid food forms • Chronic feeding, rather than acute dosing • Subjects in energy balance vs. positive energy balance • A variety of subject groups and characteristics
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Here I am at my final, concluding slide. My conclusion as a dietitian trained in human nutrition research is—naturally—more research is needed! Research studies have shown that very high intakes of pure fructose, provided solely as beverages, are associated with adverse effects. These studies are interesting but… what has been tested does not reflect what people actually consume and thus do not provide a good basis for making dietary recommendations specific to fructose intake. What we need are: •Controlled feeding trials that use levels and sources of fructose as commonly consumed •We need to establish a dose response relation. •We need to determine which metric for evaluating intake is the most relevant, g/d or % kcal. •We need to evaluate diets that contain mixtures of sucrose and HFCS, and •These mixtures need to be fed in solid and liquid food forms commonly consumed by the age/sex group under study. •We need more chronic feeding studies that go beyond 4 or 8 weeks or more, rather than acute dosing. •We need to study subjects who are in energy balance and compare their responses to when they are in positive energy balance (that is gaining weight) and •We also need to study a variety of subject groups with different characteristics.
Results from such studies would provide a more realistic scientific basis for making dietary recommendations about fructose intakes that go beyond the current Dietary Guidelines for discretionary calories from added sugars. 43
Fructose, HFCS, and Fructose Intolerance
Suzanne Skoog, MD Digestive Health Specialists, Scottsdale, Arizona
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
During this section of the Web cast, Suzanne Skoog, MD, Gastroenterologist at Digestive Health Specialists, Arizona discussed fructose, high fructose corn syrup, and fructose intolerance. MyMy BackgroundBackground 44
• B.S. Nutrition, University of MN, 1985 • One year dietetic internship, Baylor University Medical Center, Dallas, TX 1985-86 • Public Health Dietitian, WIC Program, Davenport, IA 1987 • CNSD, VAMC, St. Cloud, MN 1988 – 1993 • Medical School, University of MN 1993 - 1997 • Internal Medicine Residency, Abbott NW Hospital, Minneapolis, MN 1997-2000 • Chief Resident, ANW 2000-2001 • Internal Medicine Hospitalist, ANW 2001-2002 • GI Fellowship, Mayo Clinic, Rochester, MN, 2002-2005 • Gastroenterologist, Digestive Health Specialists, Scottsdale, AZ, 2005 - present
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Dr. Suzanne Skoog is a former registered dietitian with a nutrition degree from the University of Minnesota in 1985. She worked as a public health dietitian and continued to gain experience until she went to medical school in Minnesota. She continues to work in both private practices as well as public hospitals and is currently a gastroenterologist in Scottsdale, AZ. 45 OutlineOutline
• Breath testing • Fructose absorptive capacity • Fructose intolerance • Diet influences fructose absorption • High Fructose Corn Syrups • Our study
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Here is an outline of my fifteen minute talk in which I am going to look at: •Breath testing, which is important to have a basic understanding if we’re going to talk about fructose •Fructose absorptive capacity •Fructose intolerance •Diet influences fructose absorption •High fructose corn syrups •Our study using the breath test to compare fructose and high fructose corn syrups in health and IBS 46
“Fructose Intolerance: An Under- Recognized Problem”
Choi YK et al., Am J of Gastroenterol, 2003
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
If you survey the medical literature for articles on fructose intolerance, you will find articles such as this one published in 2003. 47
If you survey the newspaper and magazine articles on fructose intolerance, you will find articles such as this one, published in a local pape. Hydrogen Breath Test 48
• Bacteria in the colon ferment carbohydrates that are not absorbed.
• Fermentation yields gases that can be detected in breath.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
To better understand fructose intolerance, you need a basic understanding of the test used in making the diagnosis. Any carbohydrate that is not absorbed or digested reaches the colon and is fermented by bacteria. Hydrogen is a byproduct of this fermentation process, that when detected in breath, indicates bacterial fermentation. Fructose Intolerance 49
• A rise in breath hydrogen of greater than 20 ppm peaking 2-3 hours following fructose ingestion
• Plus symptoms
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The diagnosis of fructose intolerance requires two things: a positive breath test and symptoms. A positive breath test without symptoms signifies incomplete fructose absorption. Fructose Absorptive Capacity in Health 50 (when consumed alone) • Based on breath testing results, fructose absorption ranges from <5 to >50 grams and is both dose and concentration dependent
• Increasing from 25 grams to 50 grams (10% solution), the prevalence of incomplete absorption increased:
• 0 to 37.5% Rumessen and Gudman-Hoyer Gut 1986
• 11 to 58% Ravich WJ, et al. Gastroenterology 1983
• 50 to 80% Truswell AS, Am J Clin Nutr 1988
• Doubling the fructose concentration from 10 to 20%, the prevalence of incomplete absorption increased
• From 37.5 to 71.4% Ravich WJ, et al. Gastroenterology 1983
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The absorptive capacity for fructose in healthy individuals ranges from less than 5 grams to greater than 50 grams. Fructose absorption is both dose and concentration dependent. Fructose Absorptive Capacity 51 (when consumed with and without glucose)
Fructose 10 • 50 g (8/10) 8 6 • 37.5 g (7/10) 4 Number of • 25 g (5/10) Participants 2 • 0 20 g (4/10) 15 20 25 37.5 50 • 15 g (1/10) Amount of Fructose (g)
Fructose + Glucose 10 • 50 g/50 g (0/10) 8 6 • 50 g/25 g (3/10) 4 Number of • 50 g/12.5 g (7/10) Participants 2 0 50/12.5 50/25 50/50 Amount of Fructose/Glucose (g) Rumessen and Gudman-Hoyer, Gut 1986
In this study published in 1986, 8 of 10 healthy subjects incompletely absorbed 50 grams of pure fructose (above the line). When these 10 subjects were fed 50 grams of fructose accompanied by 50 grams of glucose, not one incompletely absorbed fructose (below the line). Glucose Facilitates Fructose 52 Absorption • An equal amount of glucose prevented incomplete fructose absorption in healthy subjects Ramessen JJ, et al. Gut 1986 Kneepkens CM, et al. Arch Dis Child 1984
• Glucose at one-half the fructose dose decreased the prevalence of incomplete fructose absorption by over 50% Ramessen JJ, et al. Gut 1986
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Glucose facilitates fructose absorption and when given in an equal amount, glucose prevents incomplete fructose absorption. 53 HighHigh FructoseFructose CornCorn SyrupsSyrups
• HFCS-42 • HFCS-55 • 42% fructose • 55% fructose • 53% glucose • 42% glucose • 5% oligo • 3% oligo
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Published studies on fructose intolerance have taken results obtained from studies using pure fructose and applied these results to the ingestion of HFCS. But you can see, HFCS and pure fructose are not the same thing: high fructose corn syrups contain fructose AND glucose. HFCS‐42 contains a small excess of glucose and should be well absorbed; HFCS‐55 contains a small excess of fructose which may be incompletely absorbed by a few individuals. 54
Comparison of breath testing with fructose and high fructose corn syrups in health and IBS
Skoog, Bharucha, Neurogastroenterol Motil 2007 Supported by a $10,000 Clinical Research Award from the American College of Gastroenterology
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
These findings led us to complete this study which was published in 2007 comparing breath testing with pure fructose to breath testing with HFCS in health and IBS The Study 55
• Hypothesis: that fructose intolerance would occur more frequently with pure fructose compared to fructose provided as HFCS in healthy subjects and in IBS.
• Subjects: • 20 healthy subjects • 30 patients with a functional bowel disorder
• This was a double-blind, randomized, crossover study comparing fructose alone to HFCS.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In this study, we hypothesized that fructose intolerance would occur more frequently with pure fructose compared to fructose provided as HFCS in healthy subjects and those with irritable bowel syndrome.
This double‐blind, randomized, cross over study, included 20 healthy subjects and 30 patients with a functional bowel disorder. 56 Subjects were randomized in a double blind fashion to one of two sugar solutions:
• 40 grams of fructose in tap water to total 330 mL (12%) • 40 grams of fructose as 95 gram HFCS-55 (77% dry weight) in tap water to total 600 mL (12%)* • Second day followed the first by 2-7 days
* provides an excess of 9.5 g fructose and mimics the ingestion of two cans of cola sweetened with HFCS-55 consumed in isolation
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Since fructose absorption is both dose and concentration dependent, it was critical to keep these factors constant. In order to achieve this, the volume of the solutions had to be different. We chose this dose of fructose to mimic the ingestion of 2 cans of cola sweetened with HFCS‐55 Study Design 57
• Solutions were provided in identical, covered, opaque containers with a straw
• Subjects were not informed of the volumes of these solutions
• Neither the subjects nor study personnel administering the test were allowed to hold the container
• Subjects were required to consume the solutions within 10 min and to remain sedentary
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In order to keep this double blinded, the differences in volume were disguised by this design. StudyStudy DesignDesign 58
• Breath samples were obtained at baseline and every 30 minutes after the test meal for 3 hours after administration and analyzed for hydrogen content
• Symptoms were recorded for bloating, flatulence, nausea, and abdominal pain at baseline and every 30 minutes after the test meal for 3 hours after administration
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Breath samples were taken beforehand and every 30 minutes after the test meal for 3 hours. At these points, hydrogen content was analyzed as well as a any symptoms including bloating, flatulence, nausea, and abdominal pain were recorded. BreathBreath TestTest ResultsResults 59
Patients Healthy subjects
• 21/30 after fructose • 13/20 after fructose (70%) (65%) • 9/30 after HFCS • 4/20 after HFCS (30%) (20%) • 9/21 after both • 4/13 after both
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Seventy percent of patients and 65 percent of healthy subjects demonstrated incomplete fructose absorption by having a positive breath test; no subject had a positive breath test with HFCS but not with fructose. SymptomSymptom ResultsResults 60
Patients Healthy Subjects
• 15/30 after fructose • 7/20 after fructose (50%) (35%) • 14/30 after HFCS • 2/20 after HFCS (47%) (10%)
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Half of patients reported symptoms regardless of the solution while 35 percent of healthy subjects had symptoms after fructose and 10 percent after HFCS. We believe some symptoms after HFCS may have been volume related. FructoseFructose IntoleranceIntolerance 61
Patients Healthy Subjects
• 12/30 after fructose • 5/20 after fructose (40%) (25%) • 2/30 after HFCS • 0/20 after HFCS (7%)
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Putting this information together, 40 percent of patients met the diagnosis for fructose intolerance after fructose and 7 percent after HFCS, while 25 percent of healthy subjects had fructose intolerance after fructose and none after HFCS. Conclusion 62
• Our results demonstrate that fructose intolerance is more prevalent after fructose alone than after HFCS in healthy subjects and patients with IBS.
• The prevalence of fructose intolerance is not significantly different between healthy subjects and patients with IBS.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
We concluded after our results that fructose intolerance is more prevalent after fructose alone rather than after high fructose corn syrup.
The prevalence of fructose intolerance is not significantly different between healthy subjects and those with irritable bowel syndrome. Furthermore,Furthermore, 63
• HFCS-42 should be well tolerated
• Unless consumed in isolation, absorption of the “excess” fructose in HFCS-55 may be facilitated by nutrients contributed by other foods
• Breath testing using pure fructose in isolation overestimates the true frequency of incomplete fructose absorption
• Breath testing uses doses and concentrations of fructose not normally encountered
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
As well, it is important to note that high fructose corn syrup‐42 should be well tolerated by everyone.
HFCS‐55 also may be facilitated by the nutrients in other foods (specifically glucose and amino acids) if not consumed in isolation. 64
Fructose, Carbs & the Consumer: The Communicator Role of the RD
Sarah Alligood, MPH, RD International Food Information Council Foundation
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The final segment of the Web cast was delivered by Sarah Alligood, MPH, RD, Program Manger, Nutrients at the International Food Information Council Foundation, who discussed “Fructose, Carbs & the Consumer: The Communicator Role of the RD.”
So far we have heard some great information about the science related to dietary sweeteners, and now we are going to talk about applying that science when communicating with consumers.
It is important to know where consumers currently are when it comes to knowledge and attitudes toward nutrition and health to understand what to tell them to encourage more healthful diets.
Today I will be sharing some consumer research that has been compiled by the International Food Information Council Foundation. International Food Information Council 65 Foundation Mission: To effectively communicate science-based information on health, nutrition, and food safety for the public good.
Primarily supported by the broad-based food, beverage and agricultural industries.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The Foundation is a non‐profit nutrition and food safety communications organization located in Washington, D.C.
65 The Foundation Food & Health Survey 66 http://www.ific.org
2006
2007
2009 2008
The data I will be sharing today regarding consumer attitudes, knowledge, and perceptions of carbs, sugars, and health information in general comes from the IFIC Foundation Food and Health Survey.
This is a trended consumer survey with four years of data providing insights into consumers’ attitudes toward food, nutrition, and health.
Today, I will be sharing some of our most recent findings from the 2009 survey. MethodologyMethodology 67
Methodology Web Survey
Population Representative Sample of Americans Aged 18+
Data Collection Period February 19-March 11, 2009
n=1,064 Sample Size (Error) (+ 3.0 for 2009) (+ 4.4 among 2009, 2008, 2007, 2006) Data Weighted on Age, Gender, Income, Data Weighting* Education and Race
*Weighting is a widely accepted statistical technique that is used to ensure that the distribution of the sample reflects that of the population on key demographics. With any data collection method, even when the outgoing sample is balanced to the Census, some populations are more likely than others to respond.
Research conducted by Cogent Research, LLC
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
The Food & Health Survey is a web‐based survey with a sample size of just over 1,000 American adults ages 18 and older.
This is a representative sample that has been weighted against the U.S. census.
67 Perception of Food & Health Info 68 Reading or hearing about the Food and health info relationship between food and is confusing and health is of interest to me conflicting
42% 67% Agree
29% Neither
24% Disagree 29% 10% (n=1064) 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
We are going to start out here with some general information about how consumers perceive food and health information.
About two thirds of Americans agree that reading or hearing about the relationship between food and health is of interest to them.
But at the same time, 42% also agree that food and health information is confusing and conflicting.
68 ConfusingConfusing andand Conflicting?Conflicting? 69
Fructose-Sweetened Beverages High-fructose tax The Salt Lake Tribune, April 1, 2009 Linked to Heart Risks The New York Times, April 23, 2009
Sugar-sweetened soda is back in mainstream Corn Syrup - A Fort Worth Star-Telegram, Natural Sweetener April 22, 2009 Intelligencer Journal, May 1, 2009
'There Is Indeed Little Difference Between High Fructose Corn Syrup and Table Sugar' NBC Nightly News, MSNBC.com, April 23, 2009
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
This is certainly applicable to the area of fructose where there has been a lot of information from the media, the internet, health professionals and other sources that can appear to be contradictory.
A lot of this may stem from a lack of distinction between pure fructose and high fructose corn syrup as mentioned by previous speakers.
So, it is important for nutrition communicators to claim the role as expert and be clear, simple, and deliberate in how we talk about sweeteners so as to not confuse our audiences. 70 DesiredDesired FoodFood && HealthHealth InfoInfo
I am more interested in hearing about what TO eat, rather than what NOT to eat
Disagree Neither Agree
13% 31% 56%
(n=1064) 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Also, in terms of food and health information, consumers tell us that they are more interested in hearing about what to eat, rather than what not to eat.
56% of the survey respondents agreed with this statement.
We’ve heard from consumers that they feel unmotivated to make changes when they are simply told all of the food and beverages that they are not supposed to eat.
On the flip side, they do feel motivated when they receive positive information about what they should be including in their diets and how to include foods they enjoy.
With this in mind, consumers may find it more helpful if we talk about how to include sweeteners in an overall healthful diet, emphasizing moderation and appropriate portions rather than avoidance. In other words, we should be talking about management, not banishment.
70 Taste: The #1 Factor Influencing 71 Purchase Decisions
Some Impact Great Impact Taste 34% 53% 87%
Price 31% 43% 74%
Healthfulness 35% 26% 61%
Convenience 26% 26% 52%
Question: How much of an impact do the following have on your decision to buy foods and beverages? (n=1064) 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Along those same lines, it’s important to remember that humans are hardwired to enjoy the sweet taste. No matter what we say about health, taste is the primary factor driving food and beverage purchase decisions.
When asked about the impact of convenience, healthfulness, price, and taste on their decisions to buy goods and beverages, taste ranks highest every year, with 87% in 2009 saying it has some or great impact.
So again, since sugars do enhance the taste of foods and beverages and consuming them is enjoyable, complete avoidance messaging is not likely going to be the most effective way to communicate with consumers about sugars.
71 72
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In effect, that can be a quick way to alienate the audience we are trying to engage. Awareness: Carbs and Sugars 73
Percent Heard of Whole grains 83% Fiber 87% Carbs Complex carbohydrates 52% Refined carbohydrates 33%
Sugar 90% Fructose 80% Glucose 78% High fructose corn syrup 76% Lactose
Sugars 72% Sucrose 64% Added sugars 59% Question: Which of the following have you heard of? (n=1064) 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Now we are looking at awareness data specific to carbs and sugars.
This slide shows the percentage of Americans who say they have heard of various types of carbohydrates and sugars.
In general, awareness is high, with more consumers being familiar with individual types of carbs and sugars than some grouping terms like complex carbs, refined carbs, and added sugars.
Of significance to this Web cast, • 80% said they have heard of fructose specifically • 76% said they have heard of high fructose corn syrup
73 74 Fructose & HFCS Consumption
Less Neither More
Fructose (n=853) 52% 43% 5%
HFCS (n=805) 68% 30% 2%
Question: (IF AWARE) Please indicate whether you are trying to consume more or less of the following. 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Looking at survey respondents who were aware of these two sugars specifically, we asked them whether they were trying to consume more or less.
The majority said they were trying to consume less, more so for HFCS than fructose.
This is not surprising given the amount of negative information about these two sweeteners in the media.
We know from IFIC’s research that the media is considered by consumers to be one of the top sources of food and health information.
74 PerceptionsPerceptions aboutabout SugarsSugars 75
Percent Agree With
Moderate amounts of sugar can be part 66% of an overall healthful diet
It is not necessary to eliminate sugar 45% from your diet in order to lose weight
People with diabetes can include some 39% foods with sugar as part of their total diet
All types of sugars affect 17% health in the same way
None of the above 13% Question: As far as you know, which of the following statements, if any, are true? Select all that apply. (n=1064) 2009 Food & Health Survey
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
This slide shows some of the common perceptions, and in some cases misperceptions, about sugars.
Especially relevant to this Web cast is that only 17% of survey respondents agreed that all types of sugars affect health in the same way.
Also important is that 66% of Americans believe that moderate amounts of sugar can be part of an overall healthful diet.
This re‐emphasizes the need to help consumers understand how to include sugars in moderation as part of a well‐balanced, healthful diet in accordance with the Dietary Guidelines for Americans.
75 What are Consumers Striving For? 76
Where they ARE
Unhealthy Healthy
Where they WANT to be
International Food Information Council, 2004
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
When it comes to achieving a healthful diet and lifestyle, consumers remind us that they are not striving for perfection.
Back in 2005, IFIC conducted focus groups with consumers when they were asked to place themselves on a scale from unhealthy to healthy and then to mark where they wanted to be in the future.
While they definitely hoped to improve, they told us that getting too close to the perfect 10 meant having to give up on too many pleasures, for example never enjoying a slice of cake on a birthday.
When communicating with consumers, it is important to include them in goal‐ setting, allowing them to set goals that are realistic and attainable for them personally. HowHow toto CreateCreate NutritionNutrition andand 77 HealthHealth MessagesMessages withwith IMPACTIMPACT Insightful Motivating Positive Action-oriented Context and Choices Tailored and Tested by Science
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
We can help them achieve their goals by creating messages about health and nutrition that have an impact. •They should be insightful, simple, clear, and specific. Dietitians are the experts on nutrition science and it is up to us to translate this science into easily understandable guidance for consumers. •Our messages should also be motivating, providing the payoff, considering the individual’s specific values and goals. •Consumers want us to offer positive advice, focusing on what they can do rather than what they shouldn’t do to take control of their diets and health. •They also want us to share action‐oriented information, providing the how‐to. Personalized tips are what make nutrition advice realistic and doable for consumers. •We can empower them to make behavior changes by offering context and choices. •Lastly, our advice should always be science‐based and tailored appropriately to the specific audience we are working with. 78
ConclusionsConclusions
Julie Miller Jones, PhD, CNS, LN Distinguished Scholar and Professor Emeritus St. Catherine University
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
Julie Jones, PhD, CNS, LN wrapped up the Web cast with conclusions. 79 FructoseFructose WebinarWebinar ConclusionsConclusions
• Fructose is a naturally occurring sugar. In nature it occurs with glucose, not fructose alone.
• High-fructose corn syrup (HFCS) and sucrose have similar compositions and metabolic effects in humans.
• Pure fructose is metabolically different from HFCS.
• Large amounts of fructose should be avoided due to negative effects on triglyceride and blood lipid levels.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In conclusion, •Fructose is a naturally occurring sugar. In nature it occurs with glucose; it does not occur alone. •High‐fructose corn syrup and sucrose have similar compositions and metabolic effects in humans. •Pure fructose is metabolically different from HFCS, and trying to help consumers sort out the differences is very important. •Large amounts of fructose should be avoided due to negative effects it could have on triglyceride and blood lipid levels.
79 80 Fructose Webinar Conclusions
• Diabetics • Small amounts of fructose may be advantageous due to a blunted glycemic response, but intake must be controlled.
• The average fructose intake is 9% of calories.
• Consumers at the 95th percentile of intake ingest 14.6% of calories from fructose on average.
• Fructose intolerance is much less common than it is perceived to be.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
•Diabetics can eat a small amount of fructose, and this in fact may be advantageous because fructose has a blunted glycemic response, but overall intake must be controlled, in terms of effects on lipids and after a certain amount it will go back to the liver and become glucose again.
•The average fructose intake in the United States is 9% of calories.
•Consumers at the 95th percentile of intake ingest 14.6% of calories from fructose on average. It is these consumers about whom we are concerned.
•Fructose intolerance is much less common than it is perceived to be by popular press and even in some medical literature. 81 Fructose Webinar Conclusions
• Consumer messages
• ‘Added sugars’ includes all sweeteners – sucrose, concentrated juices, HFCS, honey, agave, etc.
• Extra calories from foods sweetened with any of these sweeteners need to be managed.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
In terms of consumer messages, we want to take Sarah’s advice and have “IMPACT.” Impact and understanding. We want to tell consumers what they CAN consume and help them plan for at. As part of that, we want to help them remember that they need to control all added sugars including, sucrose, concentrated juices, HFCS, honey, agave, etc. All of these must be managed.
Extra calories from foods sweetened with any of these sweeteners need to be managed and planned for.
81 82 FructoseFructose WebinarWebinar ConclusionsConclusions
• Food is to be enjoyed and the judicious selection of sweeteners should be part of an overall diet plan.
• Consumers need simple consistent messages about all sweeteners and sweetener sources.
• Sugars including fructose need ‘Management Not Banishment.’
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009
What we really want to encourage is management not banishment. We want to help consumers plan and learn how they can enjoy foods and make judicious selection of sweeteners that can be part of an overall diet plan, one they can live with for a lifetime. Consumers need simple consistent messages about all sweeteners and sweetener sources, and we as dietitians are there to give it to them. ReferencesReferences 83
• Bray, Nielsen & Popkin. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr 2004;79: 537-544. • Choi YK et al. Fructose intolerance: an under-recognized problem. Am J of Gastroenterol. 2003; 98:6:1348-53. • Elliott, S. S et al. Fructose, weight gain, and the insulin resistance syndrome. Am J Clin Nutr 2002;76:911-922. • International Food Information Council Foundation. 2009 Food & Health Survey. 2009. Available at: http://www.ific.org/research/foodandhealthsurvey.cfm (accessed October 8, 2009). • International Food Information Council Foundation. Food Label & Calorie Research: Qualitative Research Findings. 2004. Available at: http://www.ific.org/research/calorielabelres.cfm (accessed October 8, 2009). • Jones, Julie M. Dietary sweeteners containing fructose: overview of a workshop on the state of the science. J. Nutr. 2009; 139(6). Available at http://jn.nutrition.org/cgi/content/abstract/139/6/1210S (accessed October 8, 2009). • Kneepkens CM, Vonk RJ, Fernandes J. Incomplete intestinal absorption of fructose. Arch Dis Child. 1984 Aug;59(8):735-8. • Livesey. Fructose ingestion: dose-dependent responses in health research J. Nutr.2009; 139: 1246S- 1252S. Available at http://jn.nutrition.org/cgi/reprint/139/6/1246S.pdf (accessed October 8, 2009). • Marriott et al. National estimates of dietary fructose intake increased from 1977 to 2004 in the United States. J. Nutr.2009; 139: 1228S-1235S. Available at http://jn.nutrition.org/cgi/content/abstract/139/6/1228S (accessed October 8, 2009).
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009 References,References, continuedcontinued 84
• NutritionData.com. Chart on percentage of fructose in different foods. Available at http://www.nutritiondata.com/ (accessed October 8, 2009). • Ravich WJ, Bayless TM, Thomas M. Fructose: incomplete intestinal absorption in humans. Gastroenterology. 1983;84(1):26-9. • Rumessen JJ, Gudmand-Høyer E. Absorption capacity of fructose in healthy adults. Comparison with sucrose and its constituent monosaccharides. Gut. 1986 Oct;27(10):1161–1168. • Skoog SM, Bharucha AE, Zinsmeister AR. Comparison of breath testing with fructose and high fructose corn syrups in health and IBS. Neurogastroenterol Motil. 2008;20(5):505- 11. Epub 2008 Jan 22. • Truswell AS, Seach JM, Thorburn AW. Incomplete absorption of pure fructose in healthy subjects and the facilitating effect of glucose. Am J Clin Nutr. 1988;48(6):1424-30. • USDA-ERS. Per capita caloric sweeteners data set, loss-adjusted availability. 2007. Available at http://www.ers.usda.gov/Data/FoodConsumption/Spreadsheets/sweets.xls (accessed October 8, 2009). • White Technical Research. “Fructose and Glucose Together in Nature” Chart. Used with permission White Technical Res.
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009 AdditionalAdditional ResourcesResources 85
• Journal of Nutrition Supplement: “The State of the Science on Dietary Sweeteners Containing Fructose” http://jn.nutrition.org/content/vol139/issue6/#SUPPLEMENT__THE_STATE_OF_THE_ SCIENCE_ON_DIETARY_SWEETENERS_CONTAINING_FRUCTOSE
• IFIC Fact Sheet: “Fast Facts about High-Fructose Corn Syrup” http://www.ific.org/publications/factsheets/hfcsfs.cfm
• IFIC Review: The Science of Sugars http://www.ific.org/publications/reviews/sugarsir.cfm
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009 86 ThankThank you!you!
A Web cast for dietitians From Science to Communication: Understanding Fructose, HFCS & Sugars 9.10.2009