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Caloric Sweeteners and Health: What is the Truth? G. Harvey Anderson Professor Departments of Nutritional Sciences and Physiology Faculty of Medicine, University of Toronto. November 2 , 2016 Conflicts o of Interest Consultant to many

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Caloric Sweeteners and Health: What is the Truth?

  • G. Harvey Anderson

Professor Departments of Nutritional Sciences and Physiology Faculty of Medicine, University of Toronto. November 2 , 2016

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Conflicts o

  • f

Interest

  • Consultant to many food and drug companies and

associations.

  • Kelloggs, CocaCola, Mead Johnson, Nestle, Baxter-

Travenol, EliLily, PepsiCo, Kraft, Alliance for Potato Research and Education, American Beverage Association,Winston Strawn LLP

  • Served on many industry science advisory committees
  • McCain Foods, Maple Leaf Foods, General Mills,

McDonalds, Hillshire Brands, Unilever, Heinz, ADM, Healthy Grains Institute, Canadian Sugar Institute.

  • Own a farm in Ontario
  • Direct the UofT Program in Food Safety, Nutrition and

Regulatory Affairs (15 Food Industry Members)

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Caloric Sugars Under Siege

  • Institute of Medicine (2002)
  • Insufficient evidence to set a UL for either total or added sugars
  • Suggested that added sugars should not exceed 25% of total calories

based on preventing the displacement of foods that are major sources of essential micronutrients

  • 2015 Dietary Guidelines Advisory Committee (DGAC)
  • Added sugars should be limited to less than 10% of calories
  • Based on analysis of USDA food patterns and a review of the evidence

that added sugars negatively impacts the health risks for obesity, type II diabetes, cardiovascular disease and dental carries

  • World Health Organization (2015)
  • In both adults and children, intake of free sugars not to exceed 10% of total

energy (strong recommendation) Based on moderate quality evidence from

  • bservational studies of dental caries
  • Further reduction to less than 5% of total energy (conditional recommendation)

Based on very low quality evidence from ecological studies

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Results from a failure to achieve energy balance Unclear whether obesity develops in susceptible individuals because physiological mechanisms of food intake control are compromised first

  • r if these are simply overridden by

the environment and become compromised

(Ebbeling et al, JAMA 2004)

Obesity

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The Environment

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The WHO's nutrition director, Dr Francesco Branca, said "nutritionally, people don't need any sugar in their diet". October 2016

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Food Policy? Environment vs. Physiology

  • Epidemiology-We have the evidence! Associations

enough.

  • Regulate the environment (food policies)
  • Tax SSB
  • Experimental-We don’t have the evidence?
  • Fat causes obesity?
  • High GI foods cause obesity
  • French fries cause obesity
  • SSB cause obesity
  • Sweetness causes obesity
  • Energy intake adjusts for exercise
  • Food TV ads increase food intake
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The Sweet Environment

  • Exposure of sweet taste occurs from in utero to death
  • Frequency of exposure to sweetness has increased
  • Quantity of caloric sweetener consumption has

declined in 20 years

  • Sweet foods and beverages are:
  • Safe
  • easily stored and transported,
  • need no preparation
  • inexpensive
  • Policy makers and government see no harm in reducing

caloric sweetener consumption and see public support in taking action.

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Dietary Sugars and Health: What does the evidence say?

John L Sievenpiper, MD, PhD, FRCPC1,2,3,4

1Associate Professor, Department of Nutritional Sciences, University of Toronto 2Consultant Physician, Division of Endocrinology & Metabolism, St. Michael’s Hospital 3Scientist, Li Ka Shing Knowledge Institute, St. Michael’s Hospital 4Knowledge Synthesis Lead, Toronto 3D Knowledge Synthesis Unit, St. Michael’s Hospital

October 21, 2016

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http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight38.pdf http://www.nice.org.uk/niceMedia/pdf/GDM_Chapter7_0305.pdf

Hierarchy of evidence in evidence based medicine

Systematic Reviews & meta-analyses RCTs Non-randomized controlled trials (NRCT) Cohorts studies Case-control studies Cross-sectional studies Case series/time series Expert opinion

Decreasing bias

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Lack of relation of total sugars with diabetes:

13 cohort comparisons, n=108,170 (14,752 cases)

Relative Risk: 0.88 [0.74, 1.06] p = 0.17

Tsilas et al., CMAJ, under review

Benefit harm

Risk ratio IV random, 95% CI

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Lack of relation of fructose with diabetes:

6 cohort comparisons, n=107,972 (3,833 cases)

Relative Risk: 1.04 (0.84, 1.29) p = 0.72

Tsilas et al., CMAJ, under review

Benefit harm

Risk ratio IV random, 95% CI

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Lack of relation of sucrose with diabetes:

8 cohort comparisons, n=192,332 (4,535 cases)

High BMI = Body Mass Index ≥ 29 kg/m2 Low BMI = Body Mass Index < 29 kg/m2

Relative Risk: 0.89 (0.80, 0.98) p = 0.02

Tsilas et al., CMAJ, under review

Benefit harm

Risk ratio IV random, 95% CI

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SSBs and incident diabetes:

Meta-analysis of 17 cohorts, N=464,937 (38,253 cases), FU=12y (3-21y)

Unadjusted for adiposity Adjusted for adiposity Adjusted for adiposity & within person variation Imamura et al. BMJ. 2015 Jul 21;351:h3576. RR= 1.28 (1.12-1.46) RR=1.27 (1.10-1.46)* RR= 1.18 (1.09-1.28) RR= 1.13 (1.06-1.21) *Calibrated for publication bias

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How do SSBs compare with other risk factors?

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Mozaffarian et al. NEJM 2011;364:2392-2404

+3.35lb +1.69lb +0.57lb +1.00lb +0.95 lb +0.28 to 0.36lb +0.65lb

Increased servings of different foods contribute to weight change over 4 year intervals:

NHS I (1986-2006), NHS II (1991-2003) and HPFS (1986-2006), N=120 877

+0.93 lb

**Multivariate adjustment for age, BMI, sleep, physical activity, alcohol, television watching, smoking, and all dietary factors**

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Mozaffarian et al. NEJM 2011;364:2392-2404

  • 0.22lb
  • 0.49lb
  • 0.57lb
  • 0.82lb
  • 0.37lb
  • 0.11lb

Increased servings of different foods contribute to weight change over 4 year intervals:

NHS I (1986-2006), NHS II (1991-2003) and HPFS (1986-2006), N=120 877

**Multivariate adjustment for age, BMI, sleep, physical activity, alcohol, television watching, smoking, and all dietary factors**

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Relation of different dietary factors and incident type 2 diabetes in adults:

Summary of 5 systematic reviews and meta-analyses or individual prospective cohort studies

Sievenpiper et al. Can J Diabetes. 2016 Aug;40(4):287-95

Benefit Harm Food source of sugars Cohort comparisons Participants Cases Median Follow-up Risk ratios (95% CIs) I2 Fried foods [104] Processed meat [105] SSBs [14] French fries [106] High GI diet [107] Red meat [105] Potatoes [106] High GL diet [107] 2 9 17 1 20 10 1 30 111,631 371,492 464,937 84,555 394,039 442,101 84,555 710,314 10,323 26,256 38,253 4,496 35,715 28,228 4,496 46,115 25y 14y 12y 20y 11y 14y 20y 11y 1.55 (1.32 to 1.83) 1.51 (1.25 to 1.83) 1.28 (1.12 to 1.46) 1.21 (1.09 to 1.33) 1.19 (1.14 to 1.24) 1.19 (1.04 to 1.37) 1.16 (1.05 to 1.29) 1.13 (1.08 to 1.17)

  • 94%*

73%*

  • 69%*

93%*

  • 26%

0.5 1 1.5 2

  • 14. Imamura Fet al. BMJ. 2015 Jul 21;351:h3576.
  • 104. Cahill LE, et al. Am J Clin Nutr 2014;100(2):667-675
  • 105. Pan A, et al. Am J Clin Nutr. 2011 Oct;94(4):1088-96.
  • 106. Halton Tlet al. Am J Clin Nutr. 2006 Feb;83(2):284-90.
  • 107. Bhupathiraju SN et al. Am J Clin Nutr. 2014 Jul;100(1):218-32.
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So why do SSBs appear to be the special case?

  • 1. Is it because liquid calories are

poorly compensated?

  • 2. Is it because they are easier to

measure?

  • 3. Is it because SSBs are a marker of an

unhealthy lifestyle?

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“Substitution trials”= Energy from sugars substituted for

  • ther sources of energy in the diet

“Addition trials”= Energy from sugars “added” to the diet “Subtraction trials” = Energy from sugars “subtracted” from the diet Ad libitum trials = Energy from sugars is freely replaced with other macronutrients

4 trial designs: To interpret results, follow the energy…

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Sugars mediate weight change through excess calories

Te Morenga et al. BMJ. 2012;345:e7492 Kaiser et al. Obes Rev. 2013 Aug;14(8):620-33. Malik et al. AJCN. 2013 Oct;98(4):1084-102.

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Take away messages

1. It is difficult to separate the contribution of fructose-containing sugars from that

  • f other factors in the epidemics of obesity, diabetes, and their complications,
  • wing to the interaction with excess energy.

2. Any threshold for the effect of sugars on body weight and cardiometabolic risk is highly dependent on energy balance, nutrient adequacy (food sources). 3. There are many pathways to overconsumption leading to weight gain and

  • diabetes. Dietary patterns that bring these pathways together have the greatest

influence on weight gain and cardiometabolic risk and represent the best

  • pportunity for successful interventions.

4. Targeting sugars as a source of excess calories remains a prudent strategy, as sugary foods and beverages can be a proximate pathway to overconsumption. 5. One cannot choose a healthy diet by sugars alone! A little sugar helps the wholegrains, fibre, fruits, and dairy/non-dairy alternatives to go down.

Is the evidence enough for setting policy and regulations?

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Recommendation: Not enough evidence to make policy Need to know more about sugars intakes from solid foods.

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The Role of Physiology?

  • Taste determines food preference
  • Thirst determines fluid intake
  • Hunger drives food intake
  • Regulation of energy intake is precise but errs

slightly high (1%)

  • Why do we drink SSB? To satisfy thirst, hunger or

both?

  • Is sweetness an energy detector?
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Garcia-Bailo et al., OMICS, 13:69-80, 2009

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Visit 1

Thr/Thr Thr/Ile + Ile/Ile 50 75 100 125

86 g 112 g

Genotype Sugars (g/d)

P= 0.01

Visit 2

Thr/Thr Thr/Ile + Ile/Ile 50 75 100 125

82 g 111 g

Genotype Sugars (g/d)

P= 0.003

Eny et al., Physiol. Genomics, 33:355-60, 2008

Sugar

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Thr/Thr Thr/Ile + Ile/Ile 100 125 150

115 g 131 g

Genotype Sugars (g/d)

P= 0.007

Eny et al., Physiol. Genomics, 33:355-60, 2008

Sugar

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Caloric Beverages Satisfy Thirst but Not Appetite in healthy young adults: Bypass Intake Regulation?

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Food intake: No Effect of Beverage on Meal Intake.

Values are means ± SEM; n=29.

600 650 700 750 800 850 900 950 1000 1050 Water 1% Milk Orange Juice Regular Cola Diet Cola Food Intake (kcal)

Panahi et al. (2013) Appetite 65: 75-82.

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Values are means ± SEM; n=29. Means with a different superscript letters are significantly different, P<0.05 (treatment effect using proc mixed, Tukey’s post hoc).

Adults: All caloric beverages with meals add calories, but milk results in the lowest post-prandial glucose

50 100 150 200 250 300 Water 1% Milk Fruit Drink Regular Cola Diet Cola

Blood Glucose AUC (mmol/L * min)

c a ab bc ab

200 400 600 800 1000 1200 1400 Water 1% Milk Orange Juice Regular Cola Diet Cola

Total Caloric Intake (Kcal)

b a b b a Panahi et al. (2013) Appetite 65: 75-82.

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Children: Cumulative energy intake higher after all caloric beverages compared to water

Values are means ± SEM; n=32. Means with different supers script letters are significantly different. One-way ANOVA (Drink; P < 0.001) S Vein (MSc Thesis) n Presss APNM 2016

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Conclusion

All caloric beverages consumed ad libitum during a meal add to total meal-time energy intake, but 1% milk favours a lower post- meal blood glucose and subjective appetite score and adds to nutrient intake.

Calorie free beverages alone or with milk should be available at meal-time. Sweetness not the issue?

Panahi et al. (2013) Appetite 65: 75-82.

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Caloric Sugars Under Seige

  • Institute of Medicine (2002)
  • Insufficient evidence to set a UL for either total or added sugars
  • Suggested that added sugars should not exceed 25% of total calories

based on preventing the displacement of foods that are major sources of essential micronutrients

  • 2015 Dietary Guidelines Advisory Committee (DGAC)
  • Added sugars should be limited to less than 10% of calories
  • Based on analysis of USDA food patterns and a review of the evidence

that added sugars negatively impacts the health risks for obesity, type II diabetes, cardiovascular disease and dental carries

  • World Health Organization (2015)
  • In both adults and children, intake of free sugars not to exceed 10% of total

energy (strong recommendation) Based on moderate quality evidence from

  • bservational studies of dental caries
  • Further reduction to less than 5% of total energy (conditional recommendation)

Based on very low quality evidence from ecological studies

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NUTRITION LABEL CHANGES IN THE U.S.

US Label

Added Sugars Mandatory

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Canadian Food Label

Current Proposed

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Grouping Sugar Based Ingredients

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Beverage Consumption in Canada

SYMPOSIUM: Is it time for guidance on beverages? Canadian Nutrition Society Gatineau QC, May 6, 2016

Mary R. L’Abbé, PhD

Earle W. McHenry Professor and Chair, Department of Nutritional Sciences

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Caloric Sweeteners and Health: What is the Truth?

  • G. Harvey Anderson

Professor Departments of Nutritional Sciences and Physiology Faculty of Medicine, University of Toronto. November 2 , 2016