Sweeteners: Issues and Uncertainties (1975)

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THE BIOLOGICAL AND CULTURAL ROLE OF SWEETENERS Lloyd M. Beidler I would like to present the thesis that our desire for sweets is the result of a basic biological drive and that cultural factors upset this proper balance. In pursuing this thesis, I wish to introduce two ques- tions: Can this drive be effectively limited? Should the government take a more positive stance toward the search for new methods of limit- ing sugar intake? The problems we will be discussing over the next two days center on the taste receptors of the tongue. These receptors are found in clus- ters over the surface of the tongue, as shown in Figure l. The tongue can respond to tens of thousands of different chemical stimuli. Many of these stimuli are not of biological origin but are synthetic chemicals. If a chemical stimulates a taste cell, there is a reasonable chance that it may interact with other body cells, since cell membranes are often similar. For example, it is well known that alloxan and tolbutamide interact with the 3-cells of the pancreas and that they also affect the response of taste cells (l). Note the similarity be- tween the molecular structures of saccharin and tolbutamide in Figure 2. Thus, there is always the possibility that synthetic sweeteners may in- teract with human tissues other than those of taste. It is very important to obtain objective and quantitative information concerning the response of human taste cells to chemical stimuli. This is possible by intercepting the electrical messages of the taste nerves as they leave the tongue and pass through the middle ear on the way to the brain. Figure 3 illustrates the response of the human tongue to a number of different sweet stimuli (2). The same method of recording can be used with other mammals and insects (3,4,5). Such studies re- veal that a very wide variety of animals respond to sugars, and behav- ioral experiments indicate that they prefer these sweet substances. ll

l2 FIGURE l Tongue of young child showing fungiform papillae where taste buds are clustered. c — c 0 H 0 H u \ 11 H3C-C c- -S N C--N — (CH.,) CH3 1l L ' c=c 0 DE TOLBt M JTAM 0 ' II 0 » f K 1 — S- 1 •OH MI r m <{ >^ s=o 1 1 1 H SACCHAR1N 0 ^e N AM t CYCL 1C AC1 D FIGURE 2 Structural formula of tolbutamide, saccharin, and cycla- mic acid. For example, the housefly has its taste receptors in its feet. If it walks into a drop of sugar solution, its taste is stimulated and its mouth parts are lowered into the solution, which is then consumed (6). Sweet preference is such a general response of animals that one may conclude that it is a result of a biological drive. In fact, an adult

l3 ARAB1NOSE FIGURE 3 Summated electrical re- sponse of human taste nerve as various sugars are applied to the tongue (2). male fly may live entirely on sugar solution. Such a drive, coupled with an aversion for bitters, allows a wild animal, including primitive man, to select those foods, such as fruits, that contain an energy source as well as vitamins, proteins, et cetera, and to avoid those toxic substances, such as alkaloids, that are bitter. Is there more direct evidence that man possesses an innate desire for sweets rather than a learned preference dictated by culture? It has long been observed that babies, either aborted or delivered at nor- mal term, grimace in response to sugar, which indicates to some ob- servers that the baby enjoys the sugar (7,8,9). Similarly, the baby has an aversion for bitters. To be sure, such observations are neither very objective nor quantitative, but they are quite dramatic when care- fully chosen grimaces are presented. Another dramatic observation is that a five-month human fetus will increase its swallowing rate when saccharin is injected into the amniotic fluid of the mother (l0) . This suggests that man prefers sweets long before birth! In fact, the hu- man fetus has taste buds five months before birth (ll). More scien- tific and quantitative data is currently being gathered by Dr. Robert Bradley at the University of Michigan through recording the electrical responses of taste nerves of fetal sheep (l2). Although the taste response to sugars is widespread through the ani- mal kingdom, the response to synthetic sweeteners is more limited and species specific. For example, Figure 4 shows that rats prefer saccha- rin solutions but not cyclamate. Aspartame, the new dipeptide sweetener, produces neither a preference nor aversion in rats, hamsters, and gerbils.

l4 100 o 5 80 u fa (T O. ,_ 60 o: p °-40 d 20 u o A-HAMSTER (N-8) D- RAT (N-8) -3 -2 -I 0 FIGURE 4 Hamster preference and LOG PERCENT CONCENTRATION rat aversion to cyclamate. The biological drive for sweets has performed well for man until recently. Sugars, particularly sucrose, have become widely available and at a price that most consumers can afford. Sucrose is as rich in energy as proteins and half as rich as fats. No body "pollution" is involved, because sucrose is broken down to CO2 and H2O, both easily eliminated. If sucrose has all these excellent features, what is the problem? Unfortunately, man is not always temperate, and his craving for sweets may be so great that his increased sucrose consumption both increases his total caloric intake and decreases his protein consump- tion. Cultural patterns have overridden man's ability to balance his diet in a way most beneficial for his health and longevity. A child three or four years old tends to emulate the eating habits of adults around him. In particular, television bombards the child with the con- cept that sweetness is equated with goodness. Only in unusual circum- stances, such as adrenal cortex deficiency, does man again regain his ability to regulate his diet for self-betterment (l3). Most primitive societies did not have easy access to a large number of sweets. They obtained, for example, fructose in many of their fruits or honey. Those societies where sugarcane was prevalent ate quite a bit of sugar. On the other hand, sugars were not prevalent in the Japa- nese diet. However, as the per capita income of Japan increases, so does sugar consumption; it now has one of the highest rates of increase in sugar consumption of all nations. This again emphasizes the fact that most people, if given a choice, will eat sweets; this is why we are here at this conference today. If this is the result of a very basic biological drive, the possibility of limiting sweet intake is small and difficult.

l5 Sweetness is an old problem, and it is useful to search the litera- ture to learn how other societies solved that problem. When Moses guided his people across the Red Sea, they would not drink the bitter water that was available. When Moses asked God what he should do, he was told to put a certain shrub into the water, which then would turn sweet. No one has ever learned the identity of that shrub. A former student of mine, Dr. M. Nejad, sent to me a copy of a page from an old Arabic book indicating a certain tree leaf that was used to change taste. While traveling in Iran I found that particular type of tree growing along the Caspian Sea. Leaves, taken back to Tallahassee, were chemically investigated and taste-tested. They were found to inhibit all sweetness for a period up to an hour or two without affecting other taste qualities; sucrose in the mouth resembled sand, gritty but taste- less. After a year's work, we found the molecular structure of the active leaf ingredient to be similar to that of another plant found in India, namely, Gymnema sylvestre. The structure of the above ingredient resembles in some ways that of the licorice sweetener, glycyrrhizin (l4). Figure 5 shows the similar- ity of the two. Perhaps the Iranian plant substance is a competitive inhibitor of sweet-containing molecules and thus eliminates sweet sensation. Inhibition can be studied by recording from the human taste nerve. Figure 6 shows the taste-nerve response to stimuli of diverse qualities before and after application of gymnemic acid to the tongue surface (l5). Note the specificity of inhibition of sweet tastes. In our laboratory we make a lollipop, using a tea made from Gymnema sylvestre leaves, to demonstrate this remarkable effect. After licking it for a short time, Coca Cola tastes horrible, a Hershey bar is milky, and granulated su- crose is tasteless but gritty. This could be used to decrease intake of of sweet foods. When the urge to eat something sweet begins, the per- son could take a lozenge we make with the inhibitor. It is initially sweet and slowly turns into a taste similar to that of hoarhounds. For the next hour or two, the sweet taste of all candies or foods taken into the mouth are completely depressed and the individual avoids them. The chance of marketing this specific item is small, since it has a structure similar to glycyrrhizin, which has unusual physiological activity (l6). HjC. COOK CHj CH, Clycyuhetic Hcid HOCH, CH] G>inn(ina|tnin FIGURE 5 Structural simi- larities of aglycones from glycyrrhizin and gymnemic acid (l4).

l6 PRE POST FIGURE 6 0.2 m NaCl, 0.5 m sucrose, 0.02 m citric acid, 0.002 m quinine hydrochloride and 0.004 m sodium saccharin were flowed over the human tongue before and 90 s after l percent Gymnema extract was applied. The chorda tympani taste nerve response was re- corded. Note inhibition of "sweet" responses (l5). Taste modification, another method of satisfying the desire for sweetness without the use of sugars or artificial sweeteners, refers to a change in taste sensation and not a change in taste bud function. It is accomplished by tightly binding a specially selected stimulus mole- cule close to the sweet receptor site and allowing it to react only when the pH is lowered. Thus, sweetness can be turned on and off by merely taking sour substances into the mouth. The most common taste modifier is found in a Nigerian berry (Synsepalum dulcificum') called miracle fruit. Since Nigerians had no refrigeration at the turn of the century, their stale bread and wine turned sour. If, however, they ate but one miracle fruit the size of an olive, their taste was modified for an hour or two and all sour things tasted sweet. My laboratory raised hundreds of these plants and isolated their active ingredient, which was found to be a glycoprotein of molecular weight about 44,000 (l7). The glycoprotein, or miracle fruit extract, can be freeze-dried to maintain its activity for several years, although it cannot be heated or stored in liquid form. It can be added to chewing gum to extend the flavor or used to coat unsweetened popsicles or candies. One can also utilize the extract in drop form so that it can be chewed before a meal, causing all sour foods to taste sweet: unsugared iced tea will be sweet if lemon is added; suitable puddings, gelatins, and dressings can be formulated; and lemon chiffon pie can be eaten although no sugar is used in its baking. Thus, a diabetic or calorie watcher would enjoy a meal with great satisfaction, although it was low in calories and sugars (l8).

l7 It is customary to think of artificial sweeteners when considering the problem of excessive sucrose intake. In the past, sweeteners such as cyclamate, saccharin, and aspartame have been the result of acciden- tal discoveries. Basic information concerning the physiology and psy- chology of taste is seldom utilized to develop new methods to combat increased sugar consumption. I have given examples of a taste modifier and a taste inhibitor, emphasizing the need for new knowledge concern- ing the origin of the biological drive related to the craving for sweet foods. The plight of overweights and diabetics is serious. If it is of concern to the national health community, some federal agency also should become aware of the seriousness of the problem and search for answers. In addition to responding to the need for relevant research, the Food and Drug Administration (FDA) should encourage the development of new sweeteners, inhibitors, and taste modifiers by taking a more positive approach. Research without development is useless in the present con- text. This is particularly true if inhibitors, modifiers, or protein sweeteners are to be encouraged. A suitable product is the goal. The FDA recently banned the use of miracle fruit; maybe it should have or maybe not. But the result is that the ban will stop all re- search and all development in this field. It also serves as a warning to anyone else interested in innovative ideas concerning sweeteners. DISCUSSION KASHA: Would the audience like to ask Dr. Beidler any questions? MICHAEL SVEDA, Research and Management Consultant: I am fascinated by your statement, Dr. Beidler, that even in the embryo we have a taste for sweets. Why is this so? KASHA: May I interrupt and point out to the audience that Dr. Sveda is the discoverer of cyclamate, one of the well-known sweeteners. BEIDLER: I was trying to make the point that if man or animals would, on the average, take in sweet things, they would live a lot longer. If they avoid the bitter things, they avoid most of the poisons. I am thinking of man out in the open, not civilized man, where he had to search for his food. I think this ingestion of sweet things is very basic with many, many animals. SVEDA: I have another suggestion as to why we have a sweet taste. Nature, I think, tries to keep the race going, and it makes the two things that are fundamental to that continuation rather pleasant: one is sex and the other is eating. The first food that we have is lactose either in mother's milk or yak's milk or reindeer's milk or

l8 cow's milk, whatever it is. Also, there is a nice pleasant feeling, I suppose, in nestling up to a mother's breast. On the other hand, lactose is sweet. So I am wondering whether nature is building into us a means for survival by putting in a sweet taste that we can't legislate out. My own feeling is that as we were being developed a couple of hundred thousand, perhaps a couple of million years ago, I don't think nature ever "realized" that we would ever get to the point of having enormous amounts of sucrose available. I think we are pandering a taste that is available for survival. BEIDLER: I have no argument whatsoever. Your argument that nutrition and sex are the two most important aspects of life for the survival of a species, I think is correct in the chemical sense. Taste plays a very big part in finding food and in finding mates, except possi- bly for modern man. MARSHA COHEN, Consumers Union: Dr. Beidler suggested that FDA had banned miracle fruit. It was my understanding that FDA said that the purveyors of miracle fruit had to prove it safe as a food addi- tive and comply with the law. It had been marketed as a GRAS sub- stance. FDA decided that it was not generally recognized as safe and that its purveyors would have to make a positive showing. So I wouldn't say that it had been banned, simply that FDA had said, "You haven't come to us with what we need to see." BEIDLER: No matter how you look at it, if miracle fruit was on the market and is not allowed there now, it has been banned.

PATTERNS OF USE Sidney M. Cantor It is my job to talk about patterns of use of sweeteners and in so doing to describe to the extent possible the many factors that determine the pattern of sugars that we consume at the present time. I say this de- spite the fact that sucrose is the subject at issue, as was described by Dr. Handler, and despite the fact that because of its familiarity most of our attention will be directed at sucrose. As has already been pointed out, there is no question about other sugars being involved in our diet, many other sugars, and what has been happening over the years, as we will see, is that the amounts of these sugars are increasing. If we go back historically to about 5000 B.C. and to the first men- tion of a concentrated sweetener, which was honey, the consumption at that time was relatively small. Honey was synonymous with the good life. In the absence of any other sweeteners and aside from those that were consumed in natural foods, the principal sugars in the diet were fructose and glucose from the honey. As we know now, there are a host of other sugars in honey, too numerous to mention. They have all sorts of esoteric names, and they all end in ose, because that is the chemi- cal suffix for sugars. Even though many of you may identify sugar only as sucrose, the chemists in the audience know that the suffix ose helps to define hundreds of compounds. These include the simple sugars, the kind that we are talking about, and also very complex carbohydrates, polymeric carbohydrates. One of the most interesting aspects of our diet, the carbohydrate portion of the diet in particular, is that we seem to have moved over the past 50 years from a preponderance of polymeric carbohydrates to a preponderance of simple sugars. Two of the factors that have influenced this in the past, going rapidly through the centuries, were the discov- ery and the transportation of sugarcane as a tropical source of sucrose l9

20 from India around the world, and the development of the sugar beet at the time of the Napoleonic Wars -- a major historical event in the his- tory of sugar technology -- as the technological answer to the British blockade of continental ports. Sugar, which Europeans had already learned to like, could not be brought in from the colonies because of the blockade. That broke down after the Battle of Waterloo, but sugar beets as a temperate zone source of sugar were here to stay, even though they required subsidization. Sugar and sweeteners have always been associated with major events in history, and this continues to be the case. At the present time, we are experiencing what might be called another technological revolution. This, in some ways, relates to the honey story, as we shall see. To understand the patterns of sweetener use properly, it seems to me that we have to examine them in the context of general patterns of food usage and in terms of food elements. At the present time, there are available to Americans each day -- that is, what apparently disappears in our distribution system -- about 3,200 calories on the average per capita, of which about 375 grams is carbohydrate, about l50 fat, and somewhere between 96 and l00 protein. Sugars in the carbohydrate por- tion make up about 200 grams. In l9l0-l9l3, which is the base period for U.S. sugar statistics, the figure for carbohydrates was approximately 500 grams total per day, of which l55 grams were sugars. This is the point. We have gone from the polymeric to the simple sugars in a major way. We have reduced our carbohydrate intake, and we have substituted for the starch portion, which represents the main difference, the protein and fat from the ani- mals of which we eat large amounts and to whom we feed the starch- bearing grain that we formerly took directly. Figure l is a Department of Agriculture illustration that I have up- dated, showing how the amounts of total carbohydrate, sucrose, total sugars, and starch in our diet have changed. This change is noted in terms of percentage and is indicative of the situation that prevailed at the beginning of the statistical collection, which is the l9l0-l9l3 period. The points represent five-year moving averages, and I think that they show quite clearly what has happened. Starch has gone down, sucrose has come up, total sugars have come up, and total carbohydrates have gone down. In Table l are shown some of the data from Figure l, along with others in a slightly different context. These numbers are estimates. They are calculated from disappearance statistics, and because of this they don't always add up. The reason that I picked these particular dates is because of the development of corn sweeteners. The corn sweet- ener figure for the l9l0-l9l3 period is about 8 g; that for l974 is 33 g. So from l9l0 to l974, in about 65 years, we have multiplied our corn sweeteners consumption four times. Corn sweeteners is the general name given to those materials that are produced by the hydrolysis of starch. In this term we include principally two products: corn syrups, which contain maltose and other maltose type oligo or intermediate

2l 1900 1910 1970 FIGURE l Per capita consumption of total sugars, refined sugar, starch, and total carbohydrate. Agricultural Research Service, U.S. Department of Agriculture, l972. TABLE l Calculated Daily Average Consumption of Various Carbohydrates (g/day) Year l9l0-l9l3 l960 l974 Starch 342 l88 l79 Sugars Sucrose l0l l2l l23 Corn sweeteners 8 l9 33 Lactose 2l 25 23 Glucose 6 ll l2 Fructose 6 4 3 Maltose 2 4 4 Others l2 5 3 TOTAL SUGARS l56 l89 200 TOTAL CARBOHYDRATE 498 377 379 PERCENT OF SUGARS 3l.5 50.0 52.6 ^Compiled from USDA/ARS l972 data and sugar statistics (USDA).

22 saccharides, as well as dextrins and some dextrose, and crystalline dextrose itself. While I want to dwell on the technological revolution in sweeteners later, let me identify it in advance. One of the events that has hap- pened very recently and that came to a climax in l974 was that the corn- refining industry, that is, the manufacturers of corn sweeteners, com- completed a research project that had been in process a long time. What they learned how to do commercially was to isomerize or transform the sugar glucose into the sugar fructose. This was a major event, be- cause fructose is sweeter than glucose. One of the disadvantages that corn sweeteners had been suffering from over years of development was lack of sweetness, which in direct relationship to sucrose in the mar- ketplace put corn sweeteners on the defensive as "substitute" sweeteners. Now, as a result of a major technological development over the past five years involving immobilized enzymes -- a revolutionary development on its own, and the sweeteners development is really the first major application of immobilized enzymes -- we have the commercial production of fructose-containing corn syrups, i.e., sirups containing up to nearly a 50-50 glucose-fructose ratio. This is, of course, the ratio of glu- cose to fructose in sucrose. This is equivalent to another commercial product produced by the sugar industry called invert syrup, which is a mixture of glucose and fructose produced by the hydrolysis of sucrose, or sugar. So in a sense, cane and beet now come together with corn as sources of equivalent sweetness -- a major breakthrough. Going back to Table l, I would like to explain that the reason I en- closed the 3 is that if you use Department of Agriculture percentages to measure approximately the amount of fructose derived from the foods we eat daily -- fruit sugar, et cetera -- it is about 3 g a day. But if we now begin to think in terms of the amount of fructose that is being distributed as a result of this technological development -- last year more than l billion pounds of this material was produced and put into commercial use -- and if we also think in terms of how sucrose is used in processed food and how it breaks down into glucose and fructose during processing, what we have in the diet is about ten times as much fructose, namely, about 33 g/day. This represents a sizeable amount of free fructose and a significantly different representation in the pat- tern of sugars that we consume than the USDA statistics provide. In Table 2 the previous data are expressed another way, using again l9l0-l9l3, l960, and l974 dates. Note that the corn sweetener usage figure is about 5 percent in the base period, that it has doubled in terms of percentage of total sweeteners by l960, and risen to over l6 percent by l974. Data for l974 are preliminary figures, and it is be- coming apparent that the anticipation of l03 pounds projected by USDA statistics was high for sucrose in l974, which was a climactic year. On a total sugars basis, sucrose was about 60 percent for l974, but corn sweeteners is now over l6 percent. Total consumption, including all categories, is l6l pounds instead of the l26 pounds experienced in the l9l0-l9l3 base period. The point, of course, is that the pattern of sugar consumption is changing.

23 TABLE 2 Shares of Various Sweetener Sources (Calculated from Averaged Distribution Data)a Item l9l0-l9l3 (Ib/cap. %) l960 (Ib/cap. %) l974 (Ib/cap. %) Sucrose 8l.3 64.3 97.6 63.2 96.5 59.9 Corn sweeteners 6.4 5.l l5.5 l0.0 26.4 l6.4 Dietary (Intrinsic) 38.6 30.6 38.9 25.2 32.l l9.9 Noncaloric (Sugar equivalent) — — 2.5 l.6 6.0 3.7 TOTAL l26.3 l54.5 l6l.0 aData from USDA/ARS; Sweetener Statistics (USDA) Figure 2 is another indication of a changing pattern. This is the way our cooking activities or our food preparations have moved from the home kitchen to the factory. The consumption of sugars generally is an indicator of this kind of social change; indeed, it is an excellent one. You will note that household use of sugar is going down from l9l0 on to a point where, in l970, the figure is only about one-third of the base period. Meanwhile, beverages, one of the major uses of sweeteners, is going up, bakery goods usage is going up, and, in short, total processed foods use of sugars is going up. Also shown is the sucrose curve, and above that total sucrose and corn sweeteners. Table 3 gives you an idea of what has happened to corn sweeteners over the years, and you can also see corn, cane, and beet as a kind of three-commodity basis for sweeteners. Since l950 the beet sugar por- tion has not changed very much. What has happened, of course, is that the percentage of sucrose from cane has dropped significantly, while corn has risen with equal significance. Of course, both cane and beet sugar are sucrose, while corn sweeteners are the combination of corn syrup and dextrose. The jump between l973 and l974 is a very interesting one. The rise in corn sweeteners per capita is an indication of something happening -- that something being the climactic character of l974, which involved a quadrupling in the price of sucrose. It resulted in an even further penetration of the market by corn sweeteners and, perhaps, is an indi- cation of things to come. Let me say that most of the statistics on these charts were gathered from the USDA Agricultural Research Service and Sugar Branch series, and they are based on the disappearance of sugar into the diet or into the garbage can. In other words, they are based on disappearance, but we call them consumption. We have no continuing, true measure of actual consumption in the United States. We have some spot data.

24 120 100 I- o 60 CC UJ Q. 53 40 20 1900 1920 1940 YEAR 1960 Sucrose and Corn Sweeteners Sucrose Total Processed Foods and Beverages Beverages (soft drinks) Bakery Goods 1980 FIGURE 2 Use of sugar in selected products, processed foods, and households. TABLE 3 Annual Per Capita Consumption of Sucrose and Corn Sweeteners Pounds Per Capita Annual Percent of Total Total Year Cane Beet Sucrose Corn Sugars Cane Beet Corn l950 75.7 24.7 l00.4 l5.l ll5.5 65.5 2l.4 l3.l l960 67.9 29.7 97.6 l5.5 ll3.l 60.0 26.3 l3.7 l970 72.7 29.8 l02.5 l8.5 l2l.0 60.l 24.6 l5.3 l97l 70.8 3l.6 l02.4 l9.3 l2l.7 58.2 26.0 l5.8 l972 7l.l 3l.9 l03.0 2l.0 l24.0 57.3 25.7 l7.0 l973 73.9 29.3 l03.2 23.6 l26.8 58.3 23.l l8.6 l974 68.6 27.9 96.5 26.4 l22.9 55.8 22.7 2l.5

25 The curve in Figure 3 is a profile from data produced by the USDA's Economic Research Service in its l965 consumer survey, which was called "One Day in Spring l965." On that particular day a survey was taken that revealed this pattern of consumption of sugars and sweets by age and sex. Note that females consume somewhat less of these than males. Also note where the concentration is, or where the peak curve is -- namely, in the l0- to 20-year group. Figure 4 is a profile of soft-drinks consumption on that same day in Spring l965. Again female consumption is lower than male, and the peak is in the teens near the twentieth year. I emphasize that we have very little true consumption information, and that because there are begin- ning to be calls for true consumer surveillance data, this information situation may change drastically. As further illustration of shifts in sweetener delivery, which should be obvious to you by this time, let me summarize some l973 data. First of all, to establish a base, in l9l0 25 percent of sugar was delivered for industrial use and the rest for household use. In l97l the sucrose fraction that was delivered as industrial sugar was 69 percent. If you add the corn sweeteners to that, the total for industrial use was about 72 percent. The point here is that the discretionary use of sugars by the consumer at the present time is very limited. In other words, the bulk of the sugar consumed is presented in foods. For example, between l955 and l965, the use of sugar in frozen des- serts went up 3l percent; in baked goods, 50 percent; in soft drinks, 78 percent. Now on this base, the l973 delivery situation provides an 80 r 20 40 AGE 60 80 FIGURE 3 Average individual consumption of sugar and sweets by age and sex -- one day in spring l965. Agricultural Research Service, U.S. Department of Agriculture, l972.

26 400 r 300 w < 200 tc o 100 20 40 YEARS 60 80 FIGURE 4 Average individual consumption of soft drinks according to sex and age - - one day in spring l965. Agricultural Research Service, U.S. Department of Agriculture, l972. interesting set of statistics: two-thirds of all sugar went to proces- sors again. If you add the corn sweeteners, almost all of which go to processors, that brings the total to more than 70 percent. Of all that industrial sweetener, 23 percent went to bottlers, l3.5 percent to bakery and cereal manufacturers, 9.6 percent to confections, and 5.5 percent to canning and preserving. The data in Figure 5, at least as a starter, give you some idea of the pattern of distribution of total sweeteners, of total sucrose, of industrial sucrose moving up and of nonindustrial sucrose moving down -- in other words, the discretionary portion becomes smaller. You also will see that corn sweeteners are going up. When the high-fructose corn syrup appeared there was a sudden utilization rate increase. Please note the line for corn syrup growth. The dots represent the quick rate of change from the lower curve to the curve above it. In other words, an increasing commercial demand for high-fructose corn syrup occurred in part, we are sure, because of the high price of sugar, and also because the food manufacturer knows how to mix sugars to both function and cost requirements. But this rapid increase is a most in- teresting phenomenon. Referring now to Figure 6, this set of curves is largely speculative. Above the regular corn syrup projection is the line showing the dis- placement due to high-fructose corn syrup, then the point denoting announced plans for growth to l979. This is followed by a point showing a sugar industry estimate for l985 on the penetration this new product will make into sucrose use. Remember, this is no longer sucrose, but a

27 30 20 10 ._.__ Total Sweetener Total Sucrose 1ndustrial Sucrose High Fructose Corn Syrup Corn Syrup __, —— Dextrose 1950 1960 1970 YEAR 1980 1990 FIGURE 5 Trends in sweetener use basis: Disap- pearance from stocks. mixture of fructose and glucose. These projections are highly specula- tive; but the possibility of substituting a major part of the sugar imported into the United States is being discussed, just as foreign sugar producers are discussing a worldwide organization that would con- trol the price of raw sugar. The last point on the curve then repre- sents about 50 percent of sugar usage being displaced by the new product (import equivalent). All of these speculations are based on a per capita consumption of l30 pounds of total sweeteners, with industrial sugar dropping, as shown in Figure 6. Table 4 presents the previous data, that is, what may happen in the period l979-l985 in terms of shares of market among the sources of nutri- tive sweeteners. Since there is a basis for assuming that total sugar consumption may go either up or down, Table 4 presents percentages of market at near l30 and l20 pounds per capita consumption. In any instance, what happens clearly is that corn, cane, and beet come closer

28 20 10 o X I 0 1ndustrial Sucrose Total Sugars at 130-per c,,p 1mport Equivalent MFCS, Sugar 1ndustry Estimate 1985 Current and Planned Rate 1979 1 ' 30% Penetration f Regular Corn Syrup l 1950 1960 1970 1980 YEAR 1990 2000 2010 FIGURE 6 Corn syrup projections. Possible effects of HFSC. TABLE 4 Shares of Market Cane, Beet, Corn (l974-l985) l979 l974 Projected0 Actual (%) High (%) Low (%) l985 Sweetener Source Projected High (%) Low (%) Q Beeta Cane 22.7 55.8 23 53 24 50 23 49 25 44 Corn 2l.5 24 26 28 3l TOTAL SUGARS POUNDS l22.9 l28 l2l l30 ll8 Beet assumed annual per cap. Ib. l979: 29; l985: 30. For further projection assume domestic cane-beet. j 'Projection based on continuing high and low sweetener consumption.

29 and closer together as sources and the total amount of sucrose in distribution declines sharply. What I have described here is a most dynamic situation in the domes- tic sweetener picture, one in which patterns of usage are changing constantly. We are truly in a technological revolution with respect to sweeteners. The discretion of the consumer is limited, because most of our foods that contain sweeteners are convenience foods and sweeteners are chosen on the basis of both function and cost. The manufacturing consumer obviously knows more about this combination than the household consumer. Such a dynamic change in the patterns of use would not be possible without a highly industrialized food system. So the clear evidence is that the role of sucrose in the diet is receding. If one considers the fact that about 50 percent of the sucrose that is dis- tributed probably arrives in the consumer's hands (or mouth, if you will) already hydrolized -- the sugar in bottled beverages, the sugar in canned fruits -- what seems to be happening is that the percentage of fructose in the diet is showing the most rapid rate of increase of any of the nutritive sweeteners. In closing, let me emphasize again our great need for more true con- sumption data if we are to have a clearer understanding of the patterns of sweetener use. DISCUSSION KASHA: Before I ask for audience questions, there is a clarification I would like to ask of the speaker. In your Table 2, citing various sweetener sources, there is an item labeled "Dietary." What is a dietary sugar? CANTOR: It is the sugar that is in the food naturally. I included that amount of sugar already taken in in the food we eat. Those calcu- lations are made regularly by the Department of Agriculture in an effort to see exactly what is happening in our diet. For example, what is the changing percentage of lactose in the diet as a result of the consumption of dairy products? RICHARD AHRENS, University of Maryland: I consider this report very interesting, because from the earliest, when there were evidences that there are biochemical differences between the way sucrose and starches are handled, one of the culprits that has been investigated has been fructose. I think there is good evidence in most bio- chemistry books that fructose is metabolized differently than glu- cose, and that you get an increase in activity of a number of different enzymes when fructose is given in place of glucose. The conclusion of Dr. Cantor's report -- that fructose consumption is going up -- is important because one of the reasons people have

30 been concerned about sucrose is that it is a major source of fruc- tose in the diet once it is digested. KASHA: So, we may be unwitting victims of technology in terms of bio- chemical nutritional changes. Is there response to this? CANTOR: No. I think we are going to hear some more about different metabolic patterns of various sugars from other people in the Forum. MIA TALERMAN, Georgetown University: I think, though, that we should try to consider the investment for the return. We should consider the nutritional value of the calories consumed, and, also, the possi- bility of the interference on a molecular level. It is no sense taking sweeteners that will just fool ourselves and make us believe that, in fact, we are very well taken care of on a nutritional level. We find today that sweeteners in additives are doing just that. This is basically because people do not have a fundamental knowledge of what nutrition is all about or the body mechanism, which I think we should take into consideration if we are going to proceed with any type of sweeteners. CANTOR: I am sure that that is going to be discussed over and over again. I have no comment. SVEDA: I don't understand your figure, Dr. Cantor, about sucrose con- sumption. I get the sugar reports, and last year the quota was 25 billion pounds divided by, roughly, 200 million people. That is about l20-l25 pounds a year, which equates to about l/3 pound a day. You have l23 grams, which is about l/4 pound a day. CANTOR: The sucrose figures for quite some time have been about l00 pounds per capita annually. The figure reached its peak in l973. But we have an expert on the subject of sucrose consumption right here in the front row. SAUL KOLODNY, Director of Economic Research, Amstar Corporation: Dr. Sveda referred to a quota figure. It is true that with respect to calendar year l974 the Department of Agriculture set a quota fig- ure of l2.5 million short tons, raw value, but actual distribution was just a bit above ll million short tons. We do make some adjust- ment for possible stocks that were carried over into l975. Dr. Cantor's per capita figure equates to the ll.2 million tons reported disappearance. His figure is correct. JAMES WARREN, Ohio State University: Just a point about the matter of disappearance rates. I think they make us all a little uneasy, and, of course, the question that makes us uneasy is how much goes into the garbage can. I wonder if a cultural change, from a "clean-up- your-plate" philosophy to today's philosophy about eating,

3l accompanied by the change from cooking in the kitchen to cooking in the factory, have altered the percentage that has gone into the garbage can. CANTOR: As you probably know, there have been numerous garbage surveys looking for answers of this kind. It is very difficult to get answers on real consumption unless 24-hour recall patterns or simi- lar means are used. We have such small amounts of information of that kind in this country that the need is coming to national at- tention and perhaps to a head. But the figures that we do have are anywhere from 5 percent to about l5 percent. From a discussion I recently had at Bryn Mawr College with some young people who are very much concerned about the world food problem, I think that one of the best ways to generate a greater surplus here is to get rid of that 5 to l5 percent waste. If we knew more about ourselves in terms of consumption we might be able to generate help for someone else. ROBERT CHOATE, Council on Children, Media and Advertising: I have known you a long time, Dr. Cantor, and I never knew you were an expert on garbage. I just wonder what the change towards the corn-based sweeteners will mean in dental concerns, particularly among children in the years to come. I think we will try to bring that out in the next two days, particularly among the dental experts in the audience. KASHA: Is Dr. Navia able to respond? JUAN NAVIA, University of Alabama: I think that foods containing corn sweeteners or fructose, when consumed improperly -- in large quanti- ties, frequently, and taken not with a meal but as a snack between meals -- can be as dangerous as those foods containing sucrose. So, I don't think that such substitutions would improve anything in terms of the threat of sugar-containing foods to dental health. KASHA: You could say there would be veritably no change, no improvement or no reason to think it is particularly worse for one. SAMUEL STUMPF, Vanderbilt University: The kinds of questions that are going on in my mind have not yet been provoked. In other words, it would not be easy for me, at this point, to be able to answer the question, why are we here? That is to say, no issue, really, has crystallized yet. For example, apart from these quantitative reports and the physiological characteristics of our inborn natural propen- sity to want to eat sweets, I would want to know what problem has been created for our society by the increased use of sweeteners of whatever kind, of whatever form? Is there some pressing issue that we now face? Is there some health problem that is emerging as a result of these factual developments? Once it can be established

32 that there are some genuine problems, then I think we get into poten- tially all kinds of rather serious questions of methodology as to how we are making decisions either to approve or disapprove of the use of things. I think we might even get into ethical questions that relate to the defensibility of making available to our popula- tion the kinds of things that injure them. KASHA: There are topics coming up this afternoon that point out an unwitting drift toward a diet substitution, and the theme is a total bulk and satiety diet that can be accepted by the individual, and that, by having a trend in one direction of carbohydrate usage, re- places other macronutrients with consequences that are unknown but are important to bring out. Then the question becomes, what information is there to the con- sumer, what is known about what that consumer is eating? It is complex, because sucrose added is not sucrose consumed. The sucrose itself is converted in the food before it is consumed, and so the consumer is in a very tricky position of not even knowing precisely the sugar composition nor its consequences. CANTOR: One of the points that may very well be an issue - - I am not prepared to actually say so at this time --is the shift from poly- meric carbohydrates, mainly starch, to simple sugars. This is some- thing about which there has been a great deal of discussion. Nutritionists are beginning to encourage us to move back toward more polymeric carbohydrates, and also, in the same context, to move us toward more fiber for reasons that are clear. There also is as much suggestion, as I noted, from the statistics at least, that the total carbohydrate in the diet is going up as there is that it is going down. We don't know. We do know it is changing. JOAN GUSSOW, Columbia University: Something was said yesterday pri- vately about there being a topping out effect on the amount of sugar that a culture would consume given the opportunity to consume a maximum amount. That was based, I think, on some charts that show sucrose consumption remaining at about l02 pounds a year for a num- ber of years. If I read your charts right that is not true if one looks at total sugars. Your figure of 200 pounds included food sugars, as I under- stand it. CANTOR: Two hundred grams per day incorporates the figures from the Department of Agriculture on all sugars included in the diet - - intrinsic and added. GUSSOW: Is it your reading of the figures between, say, l960 and l974, that there has been an increase in the total use of caloric sweeteners?

CANTOR: Exactly. GUSSOW: To what extent? CANTOR: The increase has come substantially from other sources rather than from sucrose. Sucrose has been relatively constant. GUSSOW: Could you give me those two figures, that is, what is the total for l960 versus the total for l974? Do you recall? CANTOR: As I recall, l960 for sucrose was 97.6 and the total was ll3. In l974 sucrose was down, according to Mr. Kolodny, to 96.5 after correcting for stocks left over, whereas the figure for corn sweet- eners was 26.4, and the total thus about l23. Now, there is another interesting effect here. Since the price of sugar quadrupled in that period, we are beginning to understand a little more about the price elasticity of demand for sucrose in the American food culture. It is not as elastic as we might think from available data. You have to raise the price fairly high before the sweetener consumption goes down substantially. In the 25 per- cent or thereabouts that is in the discretion of the consumer to purchase, it looks as though there may have been an actual three- to four-pound per capita drop in sucrose disappearance. GUSSOW: But the fructose isomerization actually enhances the sweetness of the corn syrup. CANTOR: Exactly. It makes it competitive on a sweetness basis with sucrose, so it begins to penetrate the sucrose market, and it is cheaper. GUSSOW: And the total sweetness that is represented by those figures goes up? CANTOR: Is equivalent. GORDON NEWELL, Stanford Research Center: I think of your presentation as another reflection of the total changes in our way of life and economy. As you pointed out, in l9l0 there was a very high consump- tion of sucrose in the home, and now it is relatively small. This in a way reflects today's high proportion of our foods being prepared outside the home and the large numbers of people eating in restaurants. In view of some of these changes -- our starting to consume larger proportions of fructose, the increasing push on maltose -- what effects might they be having on the total nutritional state of man in our country? These are changes that the individual now has little chance to control in terms of his intake of sugars as opposed to when we did more of our cooking at home.

34 CANTOR: So far as the discretion of the consumer is reduced, you are quite right. There is a good deal of work going on in a number of areas relating to the exact metabolic effects of the kinds that you are talking about. At the present time, I don't know that anybody is terribly alarmed about this. It is a matter, really, of quantity rather than identity at this particular time and not a widespread concern about toxic effects. I am concerned about this matter of choice -- what needs to be done about it, and what can be done about it. We seem to be moving away from standardized foods, that is, standards of identity. Pre- sumably, the nature of a sweetener in those foods can be established by such standards. But we are moving in the opposite direction. This may very well be a desirable direction that offers more free- dom of choice on the part of the manufacturing consumer to choose a sweetener according to function and cost. I think one of the func- tions of this Forum is to discuss exactly the point that you raised. KASHA: In your reference to standardized foods, did you mean that the diversity of sugars is changed and concealed, so to speak, from the consumer? CANTOR: I wouldn't put it as a matter of concealment. The standards hearings as carried out are public. Whether the consumer is inter- ested in or understands what is going on is another matter; but there is nothing concealed. For example, for a long time there was a standard that no more than 25 or 30 percent of corn syrup could be used in the sugar mixture used for canning fruit. There is no longer such a standard. KASHA: I didn't mean that the concealment was malicious. It might be just accidental. VIRGIL O. WODICKA, Consultant: I would like to comment on that. There was originally a limitation imposed on the use of corn sweeteners in a number of standardized foods arising out of a long and emotional series of hearings, the primary motivation being, shall I say, to limit economic fraud. The idea was that corn sweeteners were cheaper than sucrose; in the interest of maintaining sensory quality, because they did react differently at that time, a limitation was imposed. In other words, there would be strong economic motivation on the part of the processor to substitute corn sweeteners for cane and beet sugar, whereas the product became less desirable in terms of the resulting taste. The kinds of technological developments that Dr. Cantor has pointed out have made this ceiling on the use of corn sweeteners irrelevant, because the products are no longer inferior in a sensory context, and also, as he has pointed out, in acid fruits, which is the main context here, the chemical result is identical and renders equivalent sweetness. In other words, the sucrose that goes in is very largely hydrolized in the course of processing and storage

35 and winds up as an equal molecular mixture of glucose and fructose, and that is exactly what the corn sweetener now is doing. So there appears to be no longer any point in imposing this kind of limita- tion on the use of corn sweeteners in standardized foods. ROSS HALL, McMaster University: I would just like to make a comment in terms of some of the figures that Dr. Cantor produced. Seventy-five percent of the total sweetness is now in the form of manufactured foods. Some of the questions to which we will address ourselves here in this Forum are the health effects, the safety effects, of this quantity of sweetness in the North American diet. We just heard a comment to the effect that fructose is metabolized differently than other sugars, and this is, indeed, something that has to be taken into account. I also would like to raise an additional factor. If we have this vast technological capability for introducing sweetness into the North American diet, what kinds of foods does it invite? So it seems to me that in discussing these safety and health factors of sweetness or sugar, whatever you wish to call it, we have to take into consideration the kinds of foods that are produced, in other words, what kinds of foods are invited. I am afraid that our present methods, present systems of evalua- tion of the quality of these foods, the safety factors, are quite inadequate. I hope that we will have a chance to look at this in a little more depth and that we will not only center on sugar, but also on the kinds of foods in which sugar is incorporated.

MEDICAL AND TOXICOLOGICAL ISSUES James V. Warren My role, as I see it, is to act like what I am -- a physidian, an internist, really a cardiologist -- and to lay out for you what I see as the major medical problems that are before us in these two days. In doing my homework for this Forum, I looked through the various retriev- al systems for all the literature on this subject. It is vast. You must remember, then, that I have fifteen minutes to summarize a great amount of information. In trying to do this briefly, I also will try to do it as honestly as I know how. I am going to tell you what my opinions are, for what they are worth, and try to set the stage for our further discussions. Sugars are interesting in that they have been around for a long period of time, and we have always considered sugar as part of the car- bohydrade component of our diet. In recent years there has been some tendency to reduce the fat component in our diet; this means that if we are to keep caloric intake level the same we are probably going to in- crease protein or carbohydrates, which may or may not mean sugar. There has not been a drastic change, as you can see, in terms of percentages. But I find some of our discussion a little like \he story about the man who drowned in water, the mean depth of which was six inches: he happened to be in a place where it was ten feet deep. It has not yet been stated that the youth of the U.S.A. are participating in a great spree of eating refined sugars and some of the new products that you heard about this morning. Therefore, I would say that the mean data may not be totally illuminating about some of the potential medical problems. I would like to consider what I see as the potential areas of problems about sugars, and I will only say a bit about the noncaloric sweeteners. 36

37 First of all, I would point out a fact well known to nutritionists: sugar is not an essential in our diet. In the dietitian's terminology, there is no required daily allowance. We can get along without sugar, and in some cultures do. But, as you know, most people in our society consume quite a bit of it. It tastes good in itself, and it makes other foods taste better. We have this sort of inborn tendency to use sugars that you have heard about. The real questions from a medical standpoint in dealing with a non- essential dietary substance are: How much risk should we accept in eating it? How much should this lead us to be conservative in its consumption? Are there any specific types -- fructose has been men- tioned -- that we should avoid as particularly hazardous? As I look over the field, four major areas of concern are obvious to me. The first problem is the one of simple obesity. Calories do count. Sugar is caloric and constitutes, as we have already said, a large com- ponent of dietary intake. So it is a part of the large mosaic that makes up an important medical problem of our country -- obesity. We know the life insurance figures as well as a lot of others that point out that obesity is not a good thing in terms of life expectancy. We know it is a very complicated matter, and I think it has been oversim- plified in the press. It is commonly brought out that obesity leads to heart disease and to hypertension. When one studies these facts by modern medical methods and modern statistical methods, they fall apart to some extent, and the relationships are much less clear than people have thought. Such large organizations as that of Dr. Ancel Keys and his colleagues at the University of Minnesota have pointed out that -- although obesity rides along with some of the noxious factors they can recognize, as a factor in the generation of heart disease, an etiologic factor if you will -- obesity is probably not as important as we once thought. Nevertheless, the facts still stand that obesity is bad cosmetically and in terms of life expectancy. There are a lot of reasons why we want to avoid obesity, and the amount of sugar in the diet is a factor. It has been suggested that simple substitution of some other sweetener for sugar is not really the best way to reduce weight. Dr. Sebrell, who is here, can tell you much more about that from his experience. But I would just point out that sugar is a factor in obesity, and that obesity is still medically thought to be undesirable. On the other side of the coin, doing away with simple sugars in the diet may not be the best way to control obesity. The second medical or health problem is dental caries. Here, again, one finds differences of opinion in the vast literature that exists. To me, the simple story about this is as follows: When one eats sugars, they accumulate around the base of the teeth; in that environ- ment they are subject to bacterial action which, on a brief time course, creates an acid state that is detrimental to the enamel of the teeth and is related to plaque formation, leading to dental disease, caries, and periodontal disease.

38 There is some evidence that the matrix, the sugar it is in, is im- portant. If it is a very sticky, gooey material like a candy bar, and you eat it just before you go to bed without brushing your teeth, the situation may be worse than drinking a fluid that has sugar in it and flows by your teeth. There are numerous debates in this general field, but I would point out that this is one of the important medical prob- lems we will be looking at. It is a special one in that it relates more to the matrix than it does to amount of sugar. The third problem is diabetes mellitus. Diabetes in popular parlance is thought to be a disease of sugar. It was thought by many to be a simple deficiency of the hormone insulin that controls in part the glucose levels in our blood and in our body tissues. Unfortunately, I must bring you the message that I know the physicians here share -- it is not at all that simple, and, indeed, diabetes today remains essentially an unexplained disease. There are some very interesting recent theories about an imbalance of other substances in the blood, such as one called glucogon that is also related to sugar levels. But I would have to say that the under- standing of the metabolic nature of diabetes is unclarified and compli- cated at this point. It is not merely an over-amount of sugar being introduced into the body. It clearly involves sugar, and in the pre- insulin days, control of sugar was the major way of controlling the disease. When people died of diabetes at that time, they often died of so-called diabetic coma, which was an extreme chemical imbalance related to disturbances in sugar metabolism. Today that is far less common, and diabetes is an important medical disease because of its effects on the blood vessels and other tissues of the body that lead to heart attack and other problems. There is some debate, although it is not very active today, that the careful control of glucose in the blood is not a major determinant of how long you live with diabetes. Now, if you just do not do anything about it, do not take any insulin, then you may get into trouble like in the pre-insulin era. But with good medical control there are X factors that we have not identified that control longevity in the dia- betic. There is a particularly interesting study of the Yemenites in the Middle East that tends to show, especially if you have latent diabetes or the potential for the development of the disease, that a change in sugar intake from low to high may precipitate the clinical incidence or evidences of the disease. I do not think this is a debated point. The general interpretation of it may be debated, and my big worry about this is that it may be overly used to serve the belief that sugar causes diabetes. I think it is just a matter of the increased intake bringing out this unobserved tendency in that individual, but it may be more complicated than that. One other analogy for your thinking. Those of you with medical backgrounds know that in congestive heart failure the major therapeutic problem for the physician deals with the retention of sodium chloride in the body. Although sodium chloride is an important consideration in

39 congestive heart failure, none of us say that it is the cause of that disease. Equally so, then, my position would be that sugar is deeply involved in diabetes but is not causative. Finally, we come to the fourth general area, and a rather intriguing one brought out by the loud clarion voice from London of Professor Yudkin. On the basis of epidemiologic studies of a modern sort, look- ing at vascular disease rather than typhoid fever or something like that, Professor Yudkin came up with a strong statement that the current epidemic, if you will, of ischemic heart disease, coronary heart dis- ease, heart attacks, is related to our increased consumption of refined sugars. There is no question that by modifying the sugar intake of an indi- vidual in an experimental situation, you can alter to some degree, usually a modest one, the cholesterol triglycerides and other lipids in his blood. We have all recognized that there is something there that relates to coronary artery disease. A number of distinguished cardio- vascular epidemiologists in this country have commented on Professor Yudkin's theories, frequently with emotion. Dr. Ancel Keys and Dr. Henry Blackburn, to name two, have written articles pointing out the frailties of Yudkin's argument. This is one of those ongoing arguments that we will not resolve over the next day and a half. I am on the side of Keys and Blackburn. The evidence is not really convincing that the amount of sugar in the diet is related to coronary artery disease. You can make this argument for almost anything, including gasoline, that leads to a refined, western- ized way of living. I do not want to sell Professor Yudkin too short, and I would say that it is an issue. But if you take a vote, I would think, among people who are students in the field, there would be higher numbers against his theories than for them. So, it seems to me those are the four major areas of consideration about the large intake of sugar in our style of diet. These are: simple obesity problems, problems of dental caries, the problems of diabetes, and the potential problem of coronary artery disease. There are some other, less-frequent involvements. I would be remiss if I did not point that Dr. Donald Fredrickson has been a pioneer in studying the lipid substances of the blood. In certain of the less- common types -- "Fredrickson types," as we call them -- there is apparently a relationship to sugar intake, but I do not think it is a large health hazard. So what is my conclusion about sugar? I would just say that I think it does merit our attention. There is some apprehension that the amounts consumed are getting larger. They are getting, if not forced on us, involuntarily pushed before us in these prepared foods that we have heard about. It is worthwhile for us to look into these problems. They all are involved with some controversy. My worry about this Forum and about the understanding of the public at large in this area is that there will be a tendency to overinterpret the facts. If you just pick up one paper, say Yudkin's paper, and do not look at Blackburn's paper, then you can get a very one-sided view of these problems. I would

40 suggest you not fall into that trap. That is really all I have to say about sugars. I want to say a few things about the compounds we are going to talk about tomorrow that are essentially but not totally noncaloric. They are not involved in the obesity problem. They are not really involved in these medical hazards that I have talked about. On the other hand, there is no guarantee that taking away sucrose and putting in these other substances will relieve us of all these problems. This is true to some degree in the obesity area and in the others. The medical problems switch over here. Rather than a problem as direct as a food substance, the problem now becomes one of hazard. The first question, of course, is are they carcinogenic? The important thing to remember here, as I see it, is that there are levels of carcinogenicity and that literally the purest substance you know, if painted vigorously enough on the back of a rat or handled in some other way may eventually become a carcinogen. We have to make some assessment of the vigor of the potential carcinogenic action, and in many of these areas we do not have that information at hand. Finally, a point has been made that we should not get so worked up about the carcinogenicity and hazards of food additives that we forget about a lot of other problems, those of bacterial contamination in our food, and so forth. We should maintain a rational balance of what we are going to attack. I feel that sometimes the question of carcinogen- icity has become so prominent, so emotional, that it has led us away from other more important and rational medical points. That is a judg- ment, and I am not sure it is totally right; but I would put it before you to watch as we go through this conference. I would just summarize by saying, from the standpoint of a physician, that there are interesting questions being raised here today. The problem of the apparent increase in sugar composition of our diet as it relates to obesity, dental caries, diabetes mellitus in susceptible in- dividuals, and coronary artery disease does merit our consideration. DISCUSSION RICHARD AHRENS: Dr. Warren, would you elucidate a bit on the point that obesity now is not considered to be as important as it once was. Dr. Keys is saying that hypertension is the major risk factor and that, if you are overweight but luckily not hypertensive, then your risk of getting heart disease or a number of other things is not increased. WARREN: We refer to risk factors very loosely these days. The term is just an epidemiologic association, and there is no real implication that taking away the item found to be a risk factor will relieve us of the health problem involved.

4l Obesity is associated with a number of diseases, including diabetes mellitus, hypertension, and heart disease. The point, as I understand Dr. Keys and others, is that obesity per se, if you could isolate it in pure culture, is not a specific etiologic factor in heart disease. It may make heart disease worse, and it is so often associated with diabetes that it appears to be a risk factor, but it really is not. Don't let me mislead. Obesity is not good; there is no question about it. But its role needs to be clarified, and that is what I have tried to do. AHRENS: There was a very interesting paper in the Transactions of the New York Academy of Sciences last April by Sidney Pell from DuPont. In making a computer analysis of the medical records of some ll0,000 employees at DuPont, he found that for the person who is overweight but not hypertensive, the chance of getting diabetes or heart dis- ease is not greatly elevated; but, if he is hypertensive, all bets are off and the risk is greatly increased. WARREN: It is not a simple matter, and these studies are only achieved by the most sophisticated of epidemiologic statistical analyses. HERMAN KRAYBILL, National Cancer Institute: I would like to agree with one of your statements on carcinogenicity indicating that we may devote too much of our attention exclusively to such events. I am always requesting that we look at noncarcinogenic events. But you made another statement about painting a substance on the back many, many times, implying that high amounts of materials will necessarily bring on a neoplastic process. Many of us may have believed that years ago, but we could cite numerous instances where that is not the case at all. Indeed, by overloading and by high dosing, you produce lethality and do so much stress and damage to the organ that you actually never see the neoplastic process at all. In many in- stances that process is evoked by very low levels of insult over a long period of time. I am sure you would agree with that. WARREN: Yes, I would. I was thinking of some of the data on drugs in which the control group develops l0 carcinomas out of l00, while the group on drug X develops l3. Is that drug really a carcinogen? The line is hard to define. SHELDON REISER, Carbohydrate Nutrition Laboratory, USDA: You mentioned something about a small component of the population being somewhat more susceptible to carbohydrates than the majority of the popula- tion. Do you have any idea of what figure that represents in per- cent? WARREN: I have to say that I can't give you one.

42 REISER: I was wondering about an article by Woods, estimating that l3 percent of the male volunteers that he examined in California were classified as type 4, or carbohydrate sensitive. When you talked about a negligible percentage, did you have that or some other in mind? WARREN: I don't know the exact percent, and I would have thought it was somewhat smaller than that. It is not generally considered that this is the reservoir from which important clinical diabetes comes. These studies on the various lipid groups have been very enlighten- ing; we have learned a lot about prognosis in the different groups. Dr. Leaf, who is here in the audience, is more of an expert in this area than I am. Maybe he would comment on that. ALEXANDER LEAF, Massachusetts General Hospital and Harvard Medical School: In response to your question of what percentage of the population is at risk for diabetes, I don't think we have a very good figure. The estimates are somewhere between 2 and 4 million. But again, as Dr. Warren emphasized, the level of ingestion of sugars is probably not the thing that puts one at risk for diabetes. I would like to ask another question. Dr. Warren has given such a clear summary of the medical perspectives of refined sugars that I would encourage him to make a statement, since he snared me just now, as to the importance of highly refined sugars versus the poly- meric sugars in changing the diet of our Western culture from an in- crease in the purified, refined sugars and a decrease in the polymeric carbohydrates and fiber. This is, of course, a very hot medical topic at the present time. WARREN: Well, my comment would have to be that it is so much of a matter of debate that the picture isn't clear to me. It may be that some of these sugars that we heard about that are now coming up in our diet may be more problem producing than good old sucrose. I really do not think on the basis of my personal knowledge that I could make any more definitive comment. CHOATE: Dr. Warren, could you cast any light on how the four major health problems possibly connected with sugar are revealed in the population under fifteen? WARREN: I would suspect that first in terms of frequency would be dental caries. I can't give you a figure, but there are some people in the audience who can; it is an extraordinarily high percentage. There is a childhood obesity that is not statistically high but a serious problem. Diabetes of a childhood type, which is a common medical subdivision and may be different from so-called adult onset diabetes in its mechanism, is a severe problem. Although it is not common, those people who have it experience a tremendously severe problem.

43 The coronary artery disease problem, I think, in terms of mani- festations, is essentially no problem in childhood. But there are a lot of us who believe that the beginnings of coronary disease are started at that time. The evidence that everybody quotes in this context are the autopsies done on our soldiers both in Korea and Vietnam, young men age 20 plus or minus. A substantial percentage of them already had coronary arteries that showed evidence of begin- ning arteriosclerosis. I worry that we haven't paid enough atten- tion to prevention in those of college age and early adult life. That is the hunting ground that I would search. KASHA: I would like to direct Dr. Leaf's question in a different sense to Sidney Cantor. Do you have figures for the Soviet Union on diet- ary carbohydrate ratio of sugar to starch? CANTOR: No. But just qualitatively we know that the consumption of grain products is higher in the Soviet Union than it is in the United States. KASHA: Dr. Warren, is there a difference in the incidence of the dis- eases you mentioned in the two societies? WARREN: Our methods of studying are different. The Russian society includes a wider span, it seems to me, of living styles. I am doing this just from impressions, but I would think that between the Westernized Russian and the usual American citizen there is no sub- stantial difference. The Oriental is different. But as their sugar consumption increases, the incidence of coronary artery disease is going up. Whether that is cause and effect, I have no idea. LLOYD BEIDLER, Florida State University: Did I understand you correctly that you think that diet foods have little to do with obesity? WARREN: Let us define diet foods. BEIDLER: You made a comment that nonnutritive sweeteners have little impact on the problem of obesity. WARREN: When I sit down to the lunch table and see my friend put saccharin in his coffee, I do not believe that such a moderate change in his dietary habits, if that is all there is to it, is go- ing to be a successful way of combatting his obesity. Dr. Sebrell will point out the usefulness of sugar substitutes, but that is more related to psychologic factors, satiety factors, than it is to caloric factors. W. HENRY SEBRELL, Weight Watchers' International: I don't want to initiate now what I will discuss more fully tomorrow. But what has been said here is correct. There is little or no evidence that

44 people using artificial sweeteners succeed in losing weight as a result of the sweeteners. If one is trying to combat obesity by using artificial sweeteners, the caloric substitution is immaterial. It makes no important difference in the total caloric intake. Nevertheless, artificial sweeteners are essential in the practical control of obesity, as I will explain tomorrow. SALLY McLAUGHLIN, nutritionist: Dr. Warren, I am a little bit con- cerned about your dismissing the epidemiological evidence of Dr. Cohen. Are you saying that the Yemenite is an incipient diabet- ic, and that is why his data really cannot be considered? Would you say the same thing about Dr. Otto Schaeffer's conclusions concerning the Eskimo when they changed their diet, or about the conclusions with the Zulu Indians? In both cases, obesity and diabetes did in- crease when refined flour and sugar was consumed. WARREN: The last statement you made is also my impression of what has happened. The debate -- and I think it is a moot area -- relates to why. Is there something about adding the sugar to the diet of the Yemenite, we will say, that de novo creates the disease state of diabetes mellitus? I do not think so, although I cannot say that it is a proven fact. As I said originally, it is a moot question. However, there is evidence that this particular population group has a high incidence of the tendency toward diabetes. Diabetes as a clinical disease is like the traditional iceberg. There are a number of people who frankly and openly have the disease; but there are many others who have abnormal glucose tolerance tests, and so forth, who have disturbance in sugar metabolism so that it really becomes, in part, a semantic question of whether they have diabetes or not. It is especially difficult when I say that I can't draw on a lantern slide with finality what the mechanisms of dia- betes really are. I think we have ideas, and one could draw a ten- tative chart, but these are changing. Just in the last few years there have been substantial new thoughts in this area.

REGULATORY ISSUES Richard J. Ronk I have been contemplating the ceiling of this auditorium and find it appropriate to the National Academy of Sciences. It reminds me of a grove. If we could paint palm fronds up there, perhaps we would be in an Arab grove, eating grapes and contemplating problems before our society. This too would be appropriate, because some of the issues before this Forum are rather Greek in origin; since Greek philosophy passed through the Arabs to us, I think the grove is a suitable place to discuss these issues: the good, the true, the beautiful, and the safe. Dr. Warren mentioned disease states, and we are concerned with whether there are any disease states that come from sugar consumption or changing sugar consumption patterns. But we are also concerned with that unattainable goal of seeking the good, the true, the beautiful, and the safe. So our relative attainment of that will be, in a large measure, responsible for what our response will be both to the question of sweeteners in the diet and also to the question of the use of arti- ficial sweeteners in the diet of American consumers. Samuel Stumpf has stated his concern about the directions and focus of this Forum. Since the Food and Drug Administration put up the money for it, I think it might be of interest to you to have some idea of where we think we are going in this meeting. We are here to listen, and we are here to learn. We could have called for papers, and we could have impressed you with a gigantic stack of papers on these subjects. We could have our own people review the literature and come to our own conclusions. But one of the things that we are trying to do in a forum such as this is to listen and to hear what other people's views are on societal issues facing our country, that is, the use of sweets, the use of traditional sweeteners, and the changing dietary patterns within this area. 45

46 Some of the considerations and discussions heard in the Bureau of Foods these days are embodied in the following list of fifteen issues: l. Is there competent and reliable evidence that sugar is a cause of, or associated with, any disease(s)? Which disease(s)? 2. Is the evidence of association with disease sufficient to render some form of disclosure of the presence of sugar necessary or reason- able to prevent deception or unfairness to consumers? If so, what facts should be disclosed? Specifically, is a disclosure of the per- centage of sugar necessary or reasonable? 3. Is there competent and reliable evidence associating dental caries with sugar-containing foods that are eaten between meals? Does any such evidence relate only to foods containing added sugar or also to ones with natural sugar or a combination of added and natural sugars? 4. Is there a percentage of natural or added sugar content below which there is no significant correlation with disease production, in- cluding caries? If so, what is that percentage for solids? For liquids? 5. What is the basis for determining the sugar content in liquid and nonliquid foods (e.g., weight/weight for nonliquid foods, weight/ volume for liquid foods)? 6. Does the relationship between the ingestion of sugar (added or natural) and the production of caries warrant, in lieu of or in addi- tion to a disclosure of sugar content, a disclosure to the effect that eating frequently between meals may cause tooth decay? For what types of foods should such a disclosure be required? 7. Are there any additional or alternative disclosures concerning sugar or tooth decay that should be required? Why? 8. Should any disclosure of sugar content be limited to added sugar, or should it also include natural sugar? 9. Should any disclosure of sugar content be limited to any partic- ular type of sugar (added or natural)? Should it include sorbitol, mannitol, or other hexitols? l0. Does a higher consumption of sugar in the diet result in a de- crease in the intake of other foods that provide essential nutrients, thereby reducing the recommended or desirable level of nutrients in the daily diet? ll. To what extent are the food consumption patterns of people formed by the foods they eat during childhood? What other factors affect childhood food consumption patterns? l2. What are the consumption patterns of children in relation to foods containing added sugar? Which foods containing added sugar are usually eaten as snack items between meals as opposed to being eaten at meals with other foods? Which such foods are eaten between meals more than occasionally by many children, and which ones are consumed slowly, e.g., by slow sipping or sucking, rather than quickly? From the stand- point of caries, what will be the difference between the consumption of a food containing added sugar eaten as the only item at mealtime and the same food eaten between meals?

47 l3. Are there any foods with added sugar that are eaten by many children as the only item at breakfast, lunch, or dinner? Do any such foods contain added and/or natural sugars? l4. What competent and reliable evidence, if any, is there associ- ating tooth decay with between-meal consumption of foods that do not contain any added or natural sugar? l5. With respect to the production of caries: What weight and minimum values should be assigned to the following variables in identi- fying foods that should be subject to some form of regulatory action: frequency, time, and duration of likely consumption; the effect of other ingredients in the food on inhibiting dental decay; the form of food, including its adhesiveness; and the amount of sugar or other sweeteners in the food? What other criteria should be applied? These are the issues that we see with sweeteners. The first one we share in common with the Federal Trade Commission. Whether we are talking about advertising or about food in relation to sweetness and to sweeteners, it is concerned with what Dr. Warren posed. Is there com- petent and reliable evidence that sugar is a cause of, or associated with, any disease or diseases; if so, which diseases? That is our focus on the meeting today. We are here to listen and to see if any new thoughts are developed along these lines. Is there any evidence that the component of traditional sweeteners in the American diet is having a detrimental health effect on the American consumer? If this is the case with the traditional sweeteners, can this effect be quantified in terms of levels? If adverse health effects can be attributed to traditional sweeteners, are these effects expressed in forms other than obesity and cariogenesis? Should cario- genesis and obesity that might result from the use of traditional sweeteners be controlled by regulation or education? Should sweetened foods be offered in such a way as to dilute important nutritional com- ponents of the diet? Should FDA designate a category of fun foods, saving from super-sweetening the basic nutrient components of the diet? Those are the kinds of questions that we are thinking about, and those are the kinds of things we will be listening for today to find out what ultimately might be our solutions to some of these problems. We don't expect decisions from this meeting; we don't expect clear so- lutions from it. But with the transcript of this meeting plus the other information that is before us, we hope to come to some decisions about what the role of sweeteners will be in the American diet, and what FDA's role should be. In terms of artificial sweeteners, there are other questions: Can saccharin continue to be safely used while the additional studies sug- gested by the Academy are commissioned? Should FDA scrap the term artificial sweetener in favor of nutritive/nonnutritive sweetener designations? Is there any rational reason for mixing nutritive and nonnutritive sweeteners? Should nonnutritive sweeteners be limited to special dietary foods? Would there be any added real rather than potential risks to the consumer if nonnutritive sweeteners or

48 nontraditional sweeteners totally replaced traditional sweeteners? Considering the potential for abuse with any food additive not incor- porated in a food product, can FDA approve any type of free-flowing tabletop sweetener? Those are the kinds of things that we will be listening for in the rest of the meeting. We are here to interact. We are here to listen and to learn, but we are not here to direct the discussion. We are here to listen to the real views and opinions of the experts and the public component at this meeting. DISCUSSION CHOATE: I would like to ask Dr. Beidler if he can briefly explain the change in taste bud patterns that occur in the youngest children? BEIDLER: There is a loss of taste buds in the middle of the tongue. However, when we looked at the same individuals over a period of fifteen years, we find that there is no net loss, for as the tongue grows, the taste buds in the center of the tongue are merely going out to the sides. CHOATE: Are there sweetness taste buds in the side of an infant's cheek? BEIDLER: There are taste buds distributed quite widely throughout the oral cavity in an infant, and many of these get lost. CHOATE: At what age, roughly, do they disappear? BEIDLER: Well, I think during their first two or three years most of them disappear. For some of them, such as those on the palate and the pharynx, it may be a little later than that. When you call them sweet taste buds, keep in mind that actually they respond to many things. CHOATE: Thank you. Sidney Cantor, in some of the curves on sweetener consumption, you showed a peaking that occurred between, I guess it was, the tenth and the twentieth year. That was a l965 analysis, I believe. Do we know that that peaking has occurred over, say, the last century in that particular age group, or is that a new phenom- enon? CANTOR: I don't think that we know whether or not it is a new phenom- enon. First of all, you must recognize that human consumption data are rare, although Dr. Stare was talking about some limited samples in the work session yesterday. What the Agricultural Research

49 Service did in this particular case was to pick one day in the spring of l965 and go out and collect a lot of information on food recall, taking enough of a sample to be able to estimate these fig- ures on an age basis. They used bar charts. What I did was to draw a profile curve through the bar charts, because I thought that the message would get across better that way. There is a very interesting point about this information. While it was collected on one day in the spring of l965, the evidence, the analysis, the analytical data didn't come out until l972. The reason was not that they were withholding it, but that it turned out to be so difficult to analyze. In effect what they did was to de- velop a whole new method of analysis of information of this kind, and initiate a data bank that could be used as a research tool. That is just beginning. I think we are starting to learn about the methodology that will enable us to answer the kinds of questions you are asking. CHOATE: Would it then be safe to say that since World War II -- using that as the dividing line --we don't have accurate data as to the amount of sweetness consumed by the young post-World War II versus pre-World War II? CANTOR: I don't know that we do. CHOATE: Which gets me to Mr. Ronk. I recently have had an opportunity to read some of the Weight Watchers' literature, and I am fascinated by the regimen and the recommendations of that group, which seem to be almost totally the reverse of what television tells children about food. You were talking, Mr. Ronk, about the questions that came to FDA's mind in the regulations that they might consider about sweeteners. I would point out to you the messy interagency area of whether FDA should not so label foods heavily touted to the young that the FTC and the FCC then would have justification for putting special warning messages on such foods, particularly when they are sold to a moderate TV-watching child l4,000 times a year. RONK: As soon as FDA decides that it has a role in nutritional educa- tion, which you know to be of rather recent vintage if you are an FDA watcher, whatever it does will have to be nutritionally sound and make good nutritional sense. To say that there is some signifi- cant health disability to the eating of sweeteners is completely different from just saying that prudence and good common sense will tell us that we should limit the amount of sweeteners in our diet. So from the standpoint of warning labeling, you can see it is a completely different situation than if FDA would say that the con- sumer has a right to know what the percentage of sugar in the prod- uct is. If we did that, of course, then the Federal Trade Commis- sion would say, "Is there some compelling reason that the consumer is being deceived by this advertising or are they being conditioned,

50 let us say, to select a food for some nonfactual reason?" So their approach to advertising would be a little bit different than our approach to labeling, but they have made the point that we would have to define for them in some quantifiable terms what we mean by the disabilities of sweeteners. CHOATE: What I am trying to raise before this audience and will try to reemphasize this afternoon as we distribute a brief paper on the point (see Appendix) is that, since World War II, the adult corpo- rate executive has been able to sell directly to the eight-year-old child without the parent having any opportunity to mitigate or change the message. I think this brings a new and as yet unrecog- nized responsibility to the Food and Drug Administration, the Feder- al Trade Commission, and the Federal Communications Commission, as well as to private sponsors and advertisers: namely, since adults are selling to an eight-year-old child, they have a particular re- sponsibility to include in the label and in the advertisement of a product such information as will improve that young recipient's knowledge of how properly to use that product. As yet, and I say this with great regret, the FDA, the FTC, and the FCC are unaware that they have special responsibilities to the young child in this era when adults can sell directly to the child. RONK: We are not unaware of our responsibilities. Part of the reason we are supporting this Forum is to try to get other people's points of view about public policy matters. This gets down to questions of free will and free choice. Cer- tainly, my children don't have independent sources of income so that they go out and buy the groceries in my house. I am sure that they influence me as to whether or not they have a candy bar or buy some sugared cereal foods. There is no question but that there is a com- ponent of that influence. But it is a further question of how much and how vigorous should the federal government, using the powers that it has, regulate the lives of consumers and choices that they make in the marketplace. That is an undercurrent of this particular meeting, and it is certainly one of the things that has to be fully exposed. CANTOR: Without seeking to counter your remarks about television ad- vertising directed at children, Mr. Choate, there is a point that needs to be emphasized. This is what we might call the television equivalent of introducing sweetness to infants. We heard Dr. Beidler talk about the fetus in the uterus and its sensitivity to sweetness. A child's first taste is apparently a sweet taste, and that is accompanied by all sorts of pleasant sensations -- warmth and loving care, being held -- all associated with sweetness. This is rein- forced probably three or four times a day for the first few years of that child's life. When children finally arrive at being able to understand and watch television, they are rather thoroughly condi- tioned to sweetness and sweeteners.

5l In addition to that, if you want further evidence, examine the whole range of language and associations of words and ideas with the words sweet, honey, sweetheart, dear, sugar, and so on. There isn't a bad association with these words in any language that I have found, and that goes back to the land of milk and honey or manna from heaven. Maybe that is old-fashioned television. CHOATE: I think you started to prove that the reason men like women's breasts is because of the sugar. CANTOR: I am reminded of Dr. Sveda's earlier remark about food and sex. A few years ago an English lady wrote a book entitled Consuming Passions. It was really a detailed description of the development of the English food system in terms of its relationship to sexual practices, among other passions, but the title, I thought, was very revealing. STUMPF: I have two questions, and your comment about the land of milk and honey and manna from heaven reminds me that I once heard of a religious man who said that life would not be worth living if he couldn't believe in Hell. I never knew, really, what he had in mind except that, when it is translated to meetings of this kind, there are those who are not very happy unless they can see some terrible problems. I also was reminded of that particular fact the other day when NBC, finding that there was no real news and no additional new prob- lems in our society, did something that I, as a surviving college president from those anarchic days, was not too happy about -- they reran several of those pictures of students storming buildings just to see what it was like. Some of us would just as soon forget those times. There are those who, when they come to nutrition, it seems to me, also want to discover the most horrendous kinds of complications for the health of our society. Having that in mind, I would like to ask this as my first question. What is there about sugars and sweeteners that is really good for man, forgetting pathology for the moment? What are the positive aspects to the presence in our diet of sweet- eners and sugars? RONK: That is why I asked in one of my categories if FDA should desig- nate a category for fun foods. Sugar is fun. You know, it is strictly pleasure. STUMPF: Well, I would have thought that there might have been another kind of answer as, for example, that sugar may be a very good source of energy. CHOATE: I think one of the pluses in sugar -- and I am quoting Fred Stare for the first time in five years - - is that sugar beets

52 and sugarcane produce more calories per acre than almost any other crop in the world. So when we are in a situation where calories are desperately needed, that is a justification for growing sugar. STUMPF: The motive behind my first question is to try to provide some of the material for a calculus that we are going to have to achieve later on. The calculus, of course, is the central concern here, namely, the one of risk versus benefit. We ought to have some idea of what the benefit is before we go over into the risk. But I would like to go now to the question of risk and ask my second question. In order to make the question a meaningful one, I want to dis- tinguish three different levels of treatment of the information about nutrition, sugar, or sweeteners as we try to come to the point of an appreciation or evaluation of the risk, if there is any in- volved here. There is, of course, the public's level of knowledge, based upon whatever source of information we have as laymen with respect to any food, but now particularly with respect to sugar and the various substitutes for sugar, the so-called sweeteners. But how accurate is the public's perception of what is involved in the consumption of these things? Is it accurate, and what has formed the public's ideas about this? There is a second level of discourse that is different from the public's, but the public is affected by it to some extent. That is the discussion that goes on within the scientific community. As I have been listening to and reading the scientific discourse on the question of sugar and sweeteners, I cannot help but feel that at two points there is considerable disagreement and debate. There is disagreement about the pathological consequences of the use of sugars. We have heard this morning from Dr. Warren the notion that, if you are to list the diseases that are assumed to be the consequences of the consumption of sugar, you would have to list obesity, dental caries, diabetes, and heart disease. But what came out, and what seems to be clear in the literature, is that in every point there is considerable debate as to whether or not there is a causal relationship between the consumption of sugar and these par- ticular medical consequences. It seems to be not that decisive. Dr. Warren almost went out of his way to make it clear to us that there is a debate at each one of these particular points. So, there are two levels now. There is the public's perception, and then there is the area of highly skilled specialized physicians, among whom there is rather serious disagreement as to whether sugar causes these four diseases. The implication is that because there is this possible correlation or possible causal relation, then that helps to explain the reason for the shift from sugars to the substitutes or the so-called non- caloric sweeteners. There the problem was that you created a new risk, which is to say that these are suspected of being carcinogenic. Here also, Dr. Warren said and the literature confirms, there isn't

53 that kind of clear evidence that these are carcinogenic, and cer- tainly it opens up that whole question of the amounts and ways of ingestion by human beings compared to animals. At any rate, these two levels are controversial. They are not at all clear cut, namely, that sugar causes diseases or, for that matter, that its substitutes, the sweeteners, are carcinogenic. There is now, then, a third possible level of knowledge that finally leads me to my question. Beyond the public's perception, beyond that area of controversial debate, is there a body of clear, confirmed data or information about certain uses of either sugar or its substitutes that clearly constitutes a risk for man? To put it even more sharply, is there for the use of sugar and sweeteners any analogy with respect to hard data comparable to what we think we know about cigarettes and the consequences of the smoking of ciga- rettes? That is my question on the risk side. Is there a clear, unambiguous problem, apart from these other two levels? CHOATE: I think there is. We have said it several times this morning, and I am interested to hear it somewhat dissipated or diluted as we summarize what we have talked about. I hope this afternoon we can really bring out what is the predominance of evidence that sugar does cause cavities in children. I think that this is an absolute proven fact under certain conditions, and that it should not now be dismissed as being one of the unproven. There is another area of lack of knowledge that I would offer for the cavity argument. Do you realize that there is nobody in the United States who can tell you how much sugar you are consuming per day? We can say how much sugar is produced, and how much 2l0 million people consume of that pile, but we really cannot say how much sugar you yourself consume. Why can't we? This is particularly relevant for children with their lower weight. It is a fact that neither the Food and Drug Administration, nor any other body of government, has been able to persuade the manufac- turers of prepared foods to give us the sugar content of their foods. We have constantly sought this data in behalf of various child groups in the United States, and we cannot find any manufacturer of foods who will instantly reveal the amount of sugar in their prod- ucts. I would point out that back in l972, in response to direct questioning, the Quaker Oats Company and General Mills did acknowl- edge the percentage of sugars in certain of their cereals. General Mills, Ralston Purina, Kellogg, and a number of other manufacturers of food products for children would not reveal it, and I believe that is still the same state today. RONK: I would like to ask Mr. Stumpf a question in terms of risk. You seem to have a certain priority of risk. While you were talking the word lethal kept coming into my mind, accompanied by the thought that you wanted to see a body count before you would say there was a problem. Is that a fair statement?

54 STUMPF: No. I was building on the following kinds of information that had emerged from the discussion. There was the possibility that if you eat sugars, you would become obese; if you become obese, you are a candidate for heart disease. Medical literature is not going in that direction; authorities on the subject are arguing that there is no necessary causal relationship between obesity and heart disease. Even more specifically, a relevant five-year study has just been concluded -- and I get this information by word of mouth from Dr. George Mann of the Vanderbilt Medical School, who is very much involved in this. As I understand it, the whole point of this par- ticular five-year program was to try, by the use of certain drugs, to reduce the cholesterol level in man with the notion that thereby you would have the effect of preventing heart disease and heart attacks. At a recent meeting, the announcement was made of the re- sults of that experiment with the rather sad conclusion that the drugs did, indeed, reduce the cholesterol levels, but in no way had any effect upon the incidence of heart disease. What the whole upshot of that is to say that you don't have here -- and certainly Dr. Warren made that point very clear -- a causal relationship between the use of sugar and that particular disease. I certainly don't want to have a body count in the grue- some sense in which you mention it, but I do think it would be nice to have some slides on it. RONK: I think you make a good point, but I guess we were hearing dif- ferent data this morning. I thought that I heard Dr. Warren say that in his opinion a causal relationship with cavities was a real possibility. STUMPF: You have shifted now from obesity to cavities. RONK: You were saying that there is no need for concern. You have a little difficulty here in finding out why anybody is concerned at all about either artificial sweeteners or the traditional sweeteners. STUMPF: I don't think I put it that way. I think it is a fair ques- tion. It is fair to require that you give us a bill of particulars of what is wrong. W. H. BOWEN, National Caries Program, NIH: I think it would be remiss of me if I were to let the idea go that dental caries and the asso- ciation with sugar was still in the realm of controversy. There is now an overwhelming abundance of evidence from experiments carried out in animals (both rodents and primates), epidemiological studies in humans, and kindred other bodies of evidence that proves quite conclusively, and is no longer a matter for discussion, that the development of caries and ingestion of sugar are closely associated. I don't want to elaborate any more at this stage other than to tell Mr. Choate that the information on levels of sugar in cereals is now

55 readily available and appeared in the Journal of Dentistry for Children in an article by Dr. Shannon some months ago. CHOATE: Children don't read that publication. WARREN: I would like to agree. I think the dental caries case is really well based, even though there are debates about mechanism and things like this, but the basic fact stands. There is no question that if you eat enough sugar, you can get fat. I don't think that is a debatable issue. Its relative position as a causative factor among the fat people of the United States is a little more question- able. The other two items --on the role of sugar in diabetes, the studies that you heard about that I think are significant, and the role in coronary heart disease -- are so controversial that I am in- clined to put them on the negative side at the moment. I am trying to figure out, Mr. Choate, what kind of a labeling you would feel would be effective and useful. Every morning I read "Peanuts," and when I look at these nondairy coffee whiteners, I have the same reaction as Charlie Brown -- it is just filled with ingredients. I suspect that a detailed list of ingredients on a label would bring some reaction like that. On the other hand, would you propose putting something, like on a cigarette package, that "This candy bar may be hazardous to your health" or "damaging to your teeth"? Just what directions do you think should be the ones in which we could go? CHOATE: I doubt that we can regulate the content of sugars or sweet- eners in the food supply. I do think, however, that there is suffi- cient concern over children's teeth so that, if the American parent knows the magnitude of sugar in a product on the market, he or she then may start to exercise certain judgments right in the home about what that child shall have on the breakfast table. Mr. Ronk suggested that children don't buy. But as the Cereal Institute can tell you, children do buy. In fact, something in excess of 70 percent of the dry breakfast cereals are chosen by children. Isn't that true, Mr. Hayden? EUGENE HAYDEN, Cereal Institute: I don't think I can respond factually to that comment. The statement that the Institute makes, which is a factual one, is that about 30 percent of the total volume of ready- to-eat cereals sold in the United States are presweetened products; the other 70 percent of the products that are consumed are not pre- sweetened.

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