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SUMMARIES BY THE CO-CHAIRMEN MICHAEL KASHA In thinking back over these two days, the large number of participants, the battery of data and ideas put before the Forum, certain salient issues remain with me, some of which are in contrast to the expression given. In the issue of the psychology of taste, in contrast to the nones- sentiality of sugars in nutrition, everyone seemed to stress that the quality of taste is improved by sweetness. But I think that is only a fashion. That sweetness improves taste is not necessarily true. How often we are served glazed carrots, sugared tomato sauce over stuffed cabbage, and sugar-frosted apple pie, none of which tastes like carrots, stuffed cabbage, and apple pie. They taste like sugar. And I really think the quality of taste, as broadly described by Morley Kare, does not necessarily involve sweetness. I don't think anyone has proved that quality is improved by sweetness. So that was an issue that I thought was brought up, but left somewhat open. We are unwitting victims of industrial changes, and it was stressed that there is a revolution in the production and use of sugar: a shift from carbohydrates generally to sugar; a shift from sucrose to other sugars; and the shift from home use to industrial use of sugars. And against this great change in our habits, which is being put upon us, I think a response might be that there be labeling as to total sugar content accompanied by some informational or educational program to allow the public to decide what kind of food they would like to use. There was a mention made of the revolution in nutrition and a change in emphasis from minimum dietary essentials as a quantitative matter to the qualitative nature of food: the quality, the taste, the texture, 233
234 and so forth. There were suggestions made about how that shift might take place. It sounds like going to an old-fashioned diet (grains, fruits, and fibrous vegetables). It was rather disappointing to learn that there is a contrast between the data for caloric sweeteners and that alleged to be avail- able for noncaloric sweeteners. The remarkably good kind of epidemio- logical evidence available for saccharin, we were told, is impossible to find for sugars as influencing Western diets, because so many other influences are in the Western diet and in the Western environment. So we were told that perhaps we will never know decisively what is optimum and what is hazardous regarding sugar intake unless there is found a causal effect. The multifactorial nature of the metabolic ab- errations mentioned were so complex that it seems as if the medical ad- vice might be very restricted. We were told very general things about what optimum limits there might be on the use of sugars. We also were told early in these talks that the use of sugars has gone from nearly zero to a large fraction of the total carbohydrate diet. This was an issue that was rather unsatisfactory from the scientific point of view because it was not sharply defined. In the issue of the specific Academy report on saccharin, one of the possible requirements for a definitive statement was an epidemiological study that has been completed only recently. So there is a different status of that subject today as compared with the date of issuance of the report. But it may well turn out that scientists asked to interpret labora- tory experiments will always ask for more, and there has to be then a point of decision. Perhaps some second panel will have to come in and say, "We are able or willing to make the public affairs decision that this material, at least on the level of safety, is now comparable with other risks in society." Those are some of the issues that were brought out. In answer to a voiced criticism, I feel that we are not talking to ourselves -- we are talking to each other. In the sense that this was one of the most heterogeneous groups that we could possibly have assembled, I was quite pleased to see the fresh conflicts and the interactions between people, and I hope we learned something about our own limitations from this kind of Forum. CARL PFAFFMANN The second day of this Forum was a success in identifying the nature of the clash of ideas, methodologies, and motivations between various sec- tors of the scientific community, governmental regulatory agents, the general public as consumers and their advocates. One question, as a broad carry-over from the first day, was: Why should sweeteners, natu- ral or synthetic, be applied to food products at all? Sugars and other carbohydrates are sources of calories, and man and other organisms have, through evolution, acquired a sensory apparatus
235 for their detection in relation to food-seeking and appetite. We can assume that at one time in the "wild state" such biological mechanisms ensured adequate finding, selection, and ingestion of nutritious mate- rials, including those both sweet and not sweet. Current problems in part derive from the fact that processing of food, selection of various ingredients, and their combination in a variety of ways occur in a more or less free market situation where what is attractive sells better. Thus, there is the possibility that overuse of a natural "sign stimulus" to excite eating might be exaggerated and made use in a way that would prove deleterious to general well-being. Ethological studies of animal behavior are replete with examples of man-made "super" releasing stimuli or signs. An artificial egg four times normal size is preferred by the ringed plover to its own natural egg when both are presented. Indeed, the bird will continue attempts to roll the super egg into the nest even though it is unable to sit on it and incubate it properly. Are sweeteners super stimuli? I will not discuss sugar but will focus on the second day and the use of synthetic agents as sweeteners, most of which have no or less caloric value than sugar. In our affluent society sweeteners tend to be regarded as sugar substitutes and less damaging to the waistline. It was noted, however, that the way synthetic sweeteners are used in coffee or tea in place of sugar probably aids very little in the reduc- tion of caloric intake. More important and of more concern is the widespread use of synthetic sweeteners in processed foods and beverages, such as soda and other drinks, that may be consumed in large quantities. Statistics on the vastly increased saccharin production in wartime as an alternative in sugar-scarce nations was cited as historical valida- tion of man's desire for sweet. As the Forum approached these questions in terms of risk-benefit ratios, risk was much clearer of definition as toxicological or other untoward physiological effects; the benefit side of the picture was less clear. Accepting the fact that people like sweet things for their own sake or as a masking agent, for example, of the bitterness of coffee, three rather special cases were cited, probably of lesser quantitative signif- icance in proportion to the total public welfare. One was the use of synthetic sweeteners in medical and nutritional management of diabetes. There seems little doubt of this particular benefit. Another is the relationship between dental caries and sugar ingestion. Good oral hy- giene could or might counteract the caries-producing tendencies of sugar-containing candies, drinks, and delicacies; but as a practical matter, the corresponding hygienic measures are rarely carried out. Synthetic sweeteners in a sense avoid the issue. A third and final case is that of the obese patient in his/her effort to control weight, as in "weight watcher" programs. Practical management of diet in such cases is said to be facilitated and remarkably eased by availability of good synthetic sweeteners. Toxicity was the central concern of the Academy report on the safety of saccharin. It became quite clear in the presentations of the scien- tists that the weight of evidence did not permit the committee to
236 condemn saccharin for widespread use. But the report was sufficiently conditional on technical matters, e.g., with regard to toxicological tests on animals, that the Academy committee could not conclude there was absolutely no cause for concern. The qualification that toxicology on animals did not necessarily solve the human case was countered at the Forum by reports of widespread epidemiological studies in Canada and the United Kingdom with a negative outcome. The fact that some of the toxicological studies showed bladder calculi, especially in cases where doses were administered through two generations including one pregnancy, was disturbing. The final proviso that further research on this problem was warranted seemed to register uncertainty on this issue. Usually accustomed to treating data in statistical terms, coupled with the concept that one cannot prove the null hypothesis, most scientists in the audience appeared satisfied with the committee's conclusions. But it was apparent in the response from attorneys and consumer advo- cates that all this was not satisfactory. In considering the report the nonscientist seemed to take the view that all data were to be weighed equally in reaching a conclusion. Scientists wanted to evalu- ate the methodology of the different studies and downgrade some. To the nonscientist, any evidence of presumed risk seemed to justify ban- ning the potentially offending agent. Consumers and consumer advocates were looking for proof positive of no deleterious effect of saccharin. They were not satisfied with a conclusion of high probability of safety. On this particular issue the Forum ended in a confrontation, not a res- olution. As one consumer advocate asked, "How can we go on ingesting this material until we have proof of safety?" In reviewing other sweeteners, questions of the validity of banning of cyclamate were raised with new evidence relative to a hearing soon to be held. Another new product, the dipeptide aspartame, it was em- phasized, is composed of substances occurring naturally in foods. But one of these is phenylalanine, which requires specific safeguards in the case of children (l in l0,000) who suffered from the genetic meta- bolic defect phenylketonuria. Test trials at l00 to 200 times estimated level of normal consumption were reported without deleterious effect, yet one scientist participant objected that such tests did not take in- to account other amino acids being ingested at the same time with possible effects on brain function. Dosage level appeared to be cru- cial here and would undoubtedly feature in forthcoming hearings on this material. From the scientists' points of view, the diversity of other potential synthetic or natural sweeteners provided a vast array of pos- sibilities yet to be tapped. All agreed that adequate and satisfactory tests must be part of the development and evaluation in each case. However, further debate and litigation focusing on the criteria of safety and the nature of the toxicological and other tests can be antic- ipated. One shortcoming of the Forum may have been too great an emphasis on detail of scientific presentation (an information overload) by the par- ticipant experts, with inadequate preparation for cross-examination in the sense of true debate rather than confrontation. Could more of a
237 working panel format with a critic for each presenter have better elucidated problems and public issues and brought the factions closer to discourse? Yet this, of course, was the aim of the Forum. The long process of mutual exchange and education takes time. In the present scene, it could be anticipated that the legal process of scientific public interest litigation would be an increasingly im- portant vehicle in resolving such issues. In this litigation, scien- tists were warned of their disadvantage in communication with the public and with lawmakers. They were urged to learn how to present their findings in language understandable to informed laymen so that what science had to offer could be understood and appreciated. The Forum additionally was admonished of the broader philosophical terms behind the issues it had been considering. John Stuart Mill was quoted to the effect that it is never appropriate for the government to try to make an individual a better person. The only justification for intrusion of government into our lives is if a mode of action on the part of someone jeopardizes someone else, i.e., the collective welfare is at stake. Did the meeting establish a clear and present danger to the welfare of the people, at least in the case of the specific Academy report under consideration? Here the consensus was negative. But also into the balance must be placed the cost of answering with greater pre- cision some of the questions raised in the Academy report as against devoting limited resources to other recognized and more demanding health problems. Dr. Handler noted in his final remarks that some of what the Forum had been concerned with was the reflection of a growing "chemophobia," a distrust of the introduction of chemicals into our society. There is good cause for such distrust, he noted, and it behooved scientists, as individuals and as members of the scientific community, and the govern- ment to assure themselves and everyone that each time a new chemical is introduced, it is both desirable and acceptable. Proving either is just extraordinarily difficult, he concluded. Perhaps more than any other participants, the scientists came away with more of an appreciation of what they must do and the kind of scru- tiny to which the public and their advocates would subject their pro- cedures and conclusions. It is not clear that nonscientists came away assured nor with much change in attitude.
APPENDlXES
