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Fructose & Cardiovascular Disease: A not so sweet connection Presented by: Cindy Brinn MPH, RD, CDE, BC-ADM PeaceHealth St. Joseph Medical Center Nutrition & Diabetes Clinic [email protected] SUGAR Empty calories . . . associated with dental carries. Obesity is really just an excess calorie problem . . source of calories doesn’t really matter. FDA, ADA, ADA . . . .Sugar is fine in “moderation” Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association Women: 100 calories a day of added sugar = 6tsp/day Men: 150 calories a day of added sugar = 9tsp/day Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; • Sugar associated with: – – – – Hypertension Altered lipids Inflammation Obesity Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; Sucrose, High Fructose Corn Syrup & Cardiovascular Disease •What’s the evidence that sugar and high fructose corn syrup is associated with CVD? •What exactly is high fructose corn syrup and what happens when we eat it? •How much sugar are we really eating? •What should I tell my patients? Who will win the Sweetener Race? • Artificial Sweeteners – – – – Saccharine Nutrasweet Acesulfame K Splenda Who will win the Sweetener Race? • Natural Sweeteners – – – – – – Sucrose High fructose corn syrup Agave syrup Honey & Maple syrup Sugar alcohols Stevia How Much Sugar do we really eat? 80 Sugar Intake UK & USA kg/person years 1700-2000 Johnson R. AJCN 2007;86:899-906 60 40 20 0 1700 1750 1800 1850 1900 1950 2000 Measurement of Sweetener Consumption: Added Sugar • Added Sugar Availability –Disappearance data – Over estimates • Up 19% between 1970-2005 • 148g/day to 176 g/day = 37t./day to 44t./day • Added Sugar intake ((NHANES) self reported consumption) – Under estimates • Up 25% between 1977-1999 • 64 g/day to 82 g/day = 16 t./day to 20 t./day • 256 calories/day to 328 calories/day Average added sugar: Increased about 4 tsp/day/past 25 years 80 60 Sugar Intake UK & USA kg/person years 1700-2000 Johnson R. AJCN 2007;86:899-906 40 20 0 1700 1750 1800 1850 1900 1950 2000 80 Sugar Intake UK & USA kg/person years 1700-2000 Johnson R. AJCN 2007;86:899-906 60 40 20 Problem: Chronic 50 year exposure to high and increasing intakes of sugar . . . 0 1700 1750 1800 1850 1900 1950 2000 ** How Much Sugar is OK to eat? WHO/FAO Expert Consultation: Diet, Nutrition and the Prevention of Chronic Diseases • “Free sugars” (added sugars) <10% of total caloric intake – 1600 calorie diet = 10 tsp sugar World Health Organization USDA Food Guide or DASH • 1600 calorie diet – 3 tsp. added sugar per day • 2000 calorie diet – 8 tsp added sugar per day Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; Institute of Medicine (IOM) U.S. Dietary Reference Intakes (DRIs) • <25% of energy from added sugar • Lack of clear and consistent relationship between total or added sugar intake and obesity • Insufficient evidence to recommend upper limit for dietary sugars http://books.nap.edu/openbook.php?isbn=0309085373 25%/day of calories from added SUGAR 25% calories for 2000 calorie diet = 500 sugar calories = 33tsp sugar = 2/3cup sugar per day How many people eat more than 25% of calories from added sugars? >25% of calories from SUGAR Males 13% 4-8 yrs 20% 9-18yrs 15% 19-50yrs Females 13% 4-8yrs 21% 9-13yrs 31% 14-18yrs 21% 19-50yrs National Academy of Sciences, IOM, Dietary Reference Intakes 2002 US Sources of Added Sugar Intake Soda 33% Sugar & Candy 16% Fruit Drinks 10% (fruitades & fruit punch) Dairy desserts & milk products 9% Other grains (honey nut waffles, cinnamon toast, etc.) 6% Are some eating < 10% of calories from added sugars? <10% of calories from SUGAR 25% 21% 30% 45% 4-8 yrs 9-18yrs 19-50yrs 50+yrs National Academy of Sciences, IOM, Dietary Reference Intakes 2002 • >50% of your patients eat more than 10tsp/sugar/day • >70% of your patients <50 years eat more than 10tsp/added sugar/day • Likely most of your patients consume more than 6tsp/added sugar/day Sugar Chemistry: Sucrose: The “Gold” Standard Natural Sugar Sources • Glucose* • Fructose* • Galactose* • Sucrose** (glucose-fructose) (Table Sugar) • Lactose** (glucose-galactose) (Milk Sugar) *Mono-saccharide **Di-saccharide Sugar Sources • Glucose*-– Sucrose (50%), High Fructose Corn Syrup (50%), Maple Syrup & Starches (100%) & Fruits, Juices & Milk (50%) • Fructose*-– Sucrose (50%), High-Fructose Corn Syrup (50%), Honey (40%), Maple Syrup, Fruits (520%) & Juices • Galactose*-– Milk/Dairy Sugar Sources Absorption/Metabolism Intestinal enzymes • • • • • Glucose* Fructose* Galactose* Sucrose** (glucose Lactose** (glucose fructose) galactose) Glucose & Fructose Metabolism • Galactose → – Liver quickly converts majority to glucose • Glucose → – Used as an immediate energy source by all cells – OR stored as glycogen by all cells – OR converted into TG by the liver and stored in cells • Fructose → – NO cells use fructose as an energy source! – Goes immediately to the liver where it is rapidly converted to fatty acids and transported as free fatty acids or triglycerides and ultimately stored Excellent article on Carbohydrate Chemistry & Metabolism http://www.medbio.info /Horn/PDF%20files/ carbohydrate_metabolism_Mar ch_2007b.pdf What’s the problem with added sugars? USDA Food Guide: Why “Moderate” intake of sugar? • Excess Energy & fewer nutrients • Adverse health effects of sugar – Dental carries Murphy S. AJCN 2003; 78(suppl):827s-33s American Diabetes Association & FDA • “No adverse health effects w/ increased sucrose consumption in individuals with diabetes or with normal glucose.” • Based mostly on acute blood glucose effects American Heart Association • Excess sugar linked to metabolic abnormalities & adverse health conditions • Reduces essential nutrient intake • Limited trial data . . Observational studies indicates soft drinks is associated with excess energy intake, higher body weight & lower intake of essential nutrients. Chronic Diseases & Sugar • Heart Disease – TG, LDL, HDL, insulin sensitivity • No conclusive studies • Cancer – lung cancer risk --Case-control study in Uruguay-- risk with sugar intake – Breast—inconsistent – colorectal cancer & polyps Mardes A. Fam Econ Nutr Rev 2001;13(1):87-91 Burly EurJCancerPrev 1997;6:422-34 Limitations of Nutrition Science Research • Nutrition Research isn’t easy to do! • Most study one nutrient at a time— (“deeply flawed”) Marion Nestle New York University Nutritionist Nutrition Research Challenges • Theory: Sugar causes heart disease • Study: Low Sugar diet – Diet is now higher in foods not containing sugar—what are these foods . . What is their impact on health? • Second variable introduced • Maybe it is not the reduced sugar that is working, but the increased mono fat or non-sugar containing food . . . . . . how do we know?? “Gold Standard” Clinical Investigation • Costly • Many variables to control— smoking, medications, stress, exercise and food 49,000 women followed for 8 years, 2 groups . . . “dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits and grains did not significantly reduce the risk of CHD, stroke or CVD . . . JAMA Feb. 8, 2006 •Women’s Health Initiative Trial •160,000 women •45 clinics •$625 million Low Sugar Diet Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; FRUCTOSE Fructose • Controversy & Confusion around high fructose corn syrup (HFCS) • Unique digestion, absorption & metabolism of fructose – Association with elevated lipids & insulin resistance Trends in obesity and Fructose Intake Bray G. AJCN 2004;79:537-43 Total Fructose HFCS Obesity Overweight HFCS Free Fructose Seattle Grocery Chain Stops Selling Foods Made With High Fructose Corn Syrup June 30, 2008 Seattle-area food cooperative PCC Natural Markets has removed all products containing highfructose corn syrup from its shelves, and has announced that it will no longer carry any product sweetened with the controversial ingredient. High Fructose Corn Syrup (HFCS) & Fructose ** AMA Press Release “ There is no scientific research that HFCS deserves the blame for obesity more than sugar or other caloric sweeteners.” Comparison of Caloric Sweetener Compositions HFCS-42 HFCS-55 Sucrose Honey Fructose 42% 55% 50% 45% Glucose 53% 42% 50% 43% Other Sugars 5% 3% 0 5% Sugar consumption (# per yr per person) 1970-2007 USDA Sugars& Sweeteners Yearbook. 2007 Powerpnt.lnk What is the difference between Sucrose & High Fructose Corn Syrup? • Sucrose = “Bound” fructose & glucose • HFCS = “Free” fructose & glucose Fructose = “Fruit Sugar” Fructose found in Sucrose & HFCS, Agave syrup & Honey & Fruit 50% fructose 5-20% fructose Honey: 40% fructose HFCS: 50% fructose ** Changes in Fructose Consumption Average added sugar: Increase of 4 tsp/day/past 25 years Average Fructose Consumption: 30g/day → 40g/day over 25 years 7 1/2 tsp/day → 10 tsp/day (increase of 2½ tsp/day) Bantle JP. AmJClinNutr 2000; 72:1128-34 ** Are some consuming a lot of added fructose? Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” . . . . . 50% fructose . . 3tsp/day fructose . . = Recommendation of 12g/day fructose Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; >25% of calories from SUGAR 20% Adults average more than Males Females 60grams/day added fructose 13% 4-8 yrs 13% 4-8 yrs 15tsp/day21% = 1/39-13yrs cup 20% =9-18yrs 15% 19-50yrs 31% 14-18yrs 21% 19-50yrs 25% Children averaging more than Males Females 75 grams/day added fructose 13% 4-8 yrs 13% 4-8 yrs 19tsp/day21% = 1/29-13yrs cup 20% =9-18yrs 15% 19-50yrs 31% 14-18yrs 21% 19-50yrs ** Fructose (grams) Fructose in Foods 12 oz. coke 20 grams ½ c. pudding 9 grams ¾ cup raisin bran 5 grams 1 apple 6 grams 1 banana 5 grams 1 c. apple juice 14 grams 1 peach 2 grams 1 apricot 1 gram Added Fructose Natural Fructose ** Fructose (grams) Fructose in Foods 12 oz. coke 20 grams ½ c. pudding 9 grams ¾ cup raisin bran 5 grams 1 apple 6 grams 1 banana 5 grams 1 c. apple juice 14 grams 1 peach 2 grams 1 apricot 1 gram Added Fructose Natural Fructose How is high fructose corn syrup made? • • • • Corn → Corn starch → Corn syrup (100% glucose) → Use enzymes to invert glucose to fructose → • Blend glucose and fructose to make HFCS-42 or HFCS-55 • HFCS-55 is used in most beverages What are researchers/organizations saying about fructose? American Diabetes Association & Fructose “In individuals with diabetes, fructose produces a lower postprandial glucose response when it replaces sucrose or starch in the diet; however, this benefit is tempered by concern that fructose may adversely affect plasma lipids. Therefore, the use of added fructose as a sweetening agent in the diabetic diet is not recommended. There is, however, no reason to recommend that people with American Diabetes Association & Sucrose “Substantial evidence from clinical studies demonstrates that dietary sucrose does not increase glycemia more than isocaloric amounts of starch. Thus, intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted because of concern about aggravating hyperglycemia. Sucrose can be substituted for other carbohydrate sources in the meal plan High Fructose Corn Syrup CUT BACK • • • • Not toxic, but large amounts may be unsafe or promote bad nutrition. HFCS not more harmful than sucrose Consume too much of both Large amounts increase TG’s-- increase risk of heart disease Large amounts may affect hormones insulin, “ leptin, ghrelin—hormones that regulate appetite, increasing risk of wt. gain & obesity Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association “100 calories a day of added sugar = 6tsp/day” Circulation 2009;120;1011-1020; originally published online Aug 24, 2009; What’s really the problem with fructose? (from sucrose or HFCS) Experimental Animal Studies w/Fructose • • • • • • • • • • • • Fructose induces Metabolic Syndrome Insulin Resistance Elevated TG’s Abdominal obesity Elevated BP Inflammation Oxidative stress Endothelial dysfunction Microvascular disease Hyperuricemia (Gout) Glomerular hypertension (Renal disease) Fatty liver Metabolic Changes NOT SEEN WITH GLUCOSE Sanchez-Lozada L. AmJClinNutr 2008;88:1189-90 Rat Study: High Fructose Diet (30% calories) • X 2 wks – Insulin resistance (esp. in muscle—related to accumulation of TG lipids in muscle) – IGT – Body fat – Blood pressure – Triglycerides—esp. VLDL TG – Non-alcoholic fatty liver disease Le KA. CurrOpClinNutr&MetabCare 2006;9:469-475 Experimental Animal Studies w/Fructose • • • • • • • • • • • • Fructose induces Metabolic Syndrome Insulin Resistance Elevated TG’s Abdominal obesity Elevated BP Inflammation Oxidative stress Endothelial dysfunction Microvascular disease Hyperuricemia (Gout) Glomerular hypertension (Renal disease) Fatty liver Human studies? Yes . . But not all. Absolutely with TG and Leptin Havel P. Nutr Rev 2005;63(5):133-157 Daly M. AJCN 2003; 78(4):865s-872s Bloomgarden Z. Diabetes Care 2004; 27(2):602-09 Insulin Grehlin Leptin Fructose Metabolism ** What is unique about fructose (vs. glucose)? • Does not stimulate insulin release. – Does not stimulate leptin release (a hormone that signals satiety). – Does not suppress grehlin release (an appetite-stimulating hormone). – Does not activate adipose tissue lipoprotein lipase What else is unique about fructose (vs. glucose)? These hormones are very involved with • Does not stimulate insulin release. carbohydrate & lipid metabolism and • Does not stimulate leptin release (a appetite regulation. hormone that signals satiety). • Does not suppress grehlin release (an appetite-stimulating hormone). ** Fructose Metabolism No controlled regulation of fatty acid synthesis from fructose— occurs rapidly & unchecked Adipose lipoprotein lipase . . So reduced clearance of TG’s Effects of Fructose or Sucrose Consumption on Circulating Lipids • 18 small studies reviewed (n=5-15) • Healthy or hyperinsulimic &/or obese ♀♂ • Fed fructose or sucrose or glucose—5-40% of energy x1-12 wks • Results: dose dependent rise in TG ** only w/fructose or sucrose diet Havel P. Nutr Rev 2005;63(5):133-157 2004 Teff Study: Fructose & Leptin Fructose • 12 normal weight women—30% kcals as fructose or glucose (45 AUC insulin leptin grehlin grams glycemiaat each meal)—followed hormone, etc. levels x 24hrs 55% 49% 24% 30% Teff K. JClinEndo&Metab 2004; 89(6):2963-72 TG 35% 2009 Teff Study Fructose & TG’s in Insulin Resistant Adults • 17 obese adults • 30% kcals added fructose or glucose leptin grehlin TG xAUC 24hrs glycemia a variety of hormones • Measured Fructose 50 % 30% No 200% difference Teff K. JClinEndoMetab 2009; doi:10.1210jc.2008-2192 Processing fructose exhausts liver ATP “A typical fructose meal can also reduce ATP levels in vascular endothelial cells . . . this actually acts like a type of ischemia and can cause transient arrest of protein synthesis and increase production of inflammatory proteins, endothelial dysfunction and Cirillo P. oxidative Nephrol Dial Transplant stress.”2009 24:1384-87 Fructose Stimulates Uric Acid Production Johnson, RJ etal 2009: Endocrine Rev 30(1):96-116 Elevated Uric Acid: Beyond Gout An independent predictor of: • Hypertension • Obesity • Hyperinsulinemia, Insulin resistance—(blocks the action of insulin), Type 2 diabetes • Renal disease • Metabolic Syndrome • Cardiovascular Disease (reduced endothelial nitric oxide) Johnson R. 2007 AmJClinNutr 86:899-906 Cirillo R. Nephrol Dial Transplant 2009: 24:1384-87 Association of Fructose to Metabolic Syndrome & Type 2 Diabetes Johnson RJ. Endocrine Rev 2009; 30(1):96-116 Sugar Intake UK & USA kg/person 80 years 1700-2000 Johnson R. AJCN 2007;86:899-906 60 40 20 0 1700 1750 1800 1850 1900 1950 2000 Sugar Intake UK & USA kg/person 80 years 1700-2000 Johnson R. AJCN 2007;86:899-906 Problem: Chronic 50 year exposure to high and increasing intakes of sugar . . . 60 40 20 0 1700 1750 1800 1850 1900 1950 2000 What could be the problem with “chronic” exposure to fructose? • Body adapts to chronic exposure – Increasing fructose transporters (GLUT 5) – Increasing fructokinase (enzyme responsible for converting to fatty acids) – As a result: even small amounts of fructose will cause metabolic abnormalities ( TG, Uric Acid, insulin resistance, etc.) Cindy’s thoughts: South Beach Diet . . . Atkins Diet ... When you eliminate the “enemy” . . the army of transporters and enzymes is no longer needed Long Term Intake of Fructose • Elevated fasting uric acid levels (after only 2 weeks of high fructose/sucrose intake) • Dose-dependent relationship Fructose up-regulates ins transporter (Glut 5) and fructokinase • Fructose up-regulates its transporter (Glut 5) and fructokinase • As a consequence . . .subjects administered a high fructose diet show an enhanced rise in uric acid in response to a standard fructose load • Subjects w/Met Sx &/or fatty liver ** NEW RESEARCH “Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans.” Stanhope KL. Etal. April 20, 2009. J. ** NEW RESEARCH: Study Design • Double blind parallel arm study with matched controls and 3 well controlled phases==10 weeks total • n=39, 40-72 yr old participants, BMI=25-35 • 8 week intervention period—25% daily energy from either glucose or fructose sweetened beverage, ** Results: % ChangesGlucose from Baseline Body Weight +1.8% Fructose +1.4% Total body fat (kg) +3.2% +2.8% Waist circumference +1.7% +1.9% Total abdominal fat +4.8% +8.6% Extraabdominal fat +4.6% +7.3% Intraabdominal fat +3.2% +14% ** Results: % ChangesGlucose from Baseline Body Weight +1.8% Fructose +1.4% Total body fat (kg) +3.2% +2.8% Waist circumference +1.7% +1.9% Total abdominal fat +4.8% +8.6% Extraabdominal fat +4.6% +7.3% Intraabdominal fat +3.2% +14% ** Results: % Changes from Baseline Glucose Fructos e Fasting TG +9.7% +3.9% TG area under curve -32% +99.2% % Glucose Results: TG Changes over 24 hrs ** Glucose Results: TG Changes over 24 hrs ** Fructose Results: TG Changes over 24 hrs ** ** Results: Lipid Changes from Baseline Fasting TG TG area under curve Fasting LDL Cholesterol Fasting sdLDL Cholesterol Fasting oxLDL Cholesterol Glucose Fructos e +9.7% -32% + 3.6% +13.3% +3.9% +99.2% +13.9% +44.0% +.7% +12.8% ** Changes from baseline: Glucose, insulin, insulin sensitivity Glucose Fructos e -1.4%% +2.9% +5.3% +10.2% Glucose 3-h AUC OGTT +31.4% % +60.2% Insulin Sensitivity index -17.3% Fasting Glucose Fasting Insulin +1.1% ** Study Conclusions: • In 10 weeks a 25% Fructose diet: • Abdominal visceral fat • small dense LDL & oxidized LDL Chol • Total postprandial TG • Insulin levels • Insulin sensitivity Stanhope KL. 2009. J. Clin. Invest. doi:10:1172JCI37385 More Fructose Thoughts “ . . . urgent need for public awareness of the risks associated with high fructose consumption and greater efforts should be made to curb the supplementation of packaged foods with high fructose additives (including sucrose!).” “ . . recent findings raise serious concern regarding the deleterious effects of fructose and its potential role in metabolic disorders .” Basciano H. Nutrition & Metabolism 2005; 2(5):1-14 Le KA. CurrOpinClinNutrMetabCare 2006 9:469-75 *** Fructose: Review Articles • Johnson, R. Hypothesis: Could Excessive Fructose Intake and Uric Acid Cause Type 2 Diabetes. Endocrine Rev 2009; 30(1):96-116 • Havel, Peter. Dietary Fructose: Implications for Dysregulation of Energy Homeostasis and Lipid/Carbohydrate Metabolism. Nutrition Reviews May 2005;63 (5):1331-57 • Basciano, H. etal. Fructose, insulin resistnace, and metabolic dyslipidemia. Nutrition & Metabolism Feb. 2005; 2(5):1-14 www.nutritionandmetabolism.com/content/2/1/5 • Elliott, S. etal. Fructose, weight gain and the insulin resistance syndrome. Am J Clin Nutr 2002;76:911-22 10% Added Sugar?? • • • • • 1600 calorie diet = 160 calories from added sugar ÷ 4kcals/gram = 40 grams sugar/day = 10 tsp./day Added Sugars • 12 oz. pepsi 40g CHO • ¼ c. pancake syrup 40g CHO • 2 oz. snicker bar CHO • 2” square cake 40g CHO • ¾ c. frosted cheerios 12g CHO 10 tsp 10 tsp 6 tsp 24g 10 tsp 3 tsp 5% added sugar from a “dessert” and 5% added sugar from other foods • 5 tsp from a dessert each day = 20 grams sugar . . . .maybe 150 calorie dessert—2 inch brownie, 2 cookies, ½ c. ice cream? • 5 tsp from other foods (crackers, cereal, jam, etc.) Translated for patients • 150 calorie sweet each day if desired (best to be limited) • Most other food choices should not have a sugar source listed on the label. ** What about artificial sweeteners? • 0-150 calorie sweet each day if desired (best to be limited—can be sweetened with an artificial or natural sweetener) • Most other food choices should be made without added natural or artificial sweeteners. “One small treat a day . . . . . sweetened with whatever you want!” “The Perfect Storm” → Diabesity • Modern Western Diet/Lifestyle—associated most chronic health diseases . . . – High in fructose—from sucrose or HFCS – High in damaged fats—trans fats & more – Low in healthy fats—omega 3’s & more – High in refined carbohydrates – Low in veges, fruits, whole grains, etc. – Low in body use/movement or exercise Combination of Captopril & Allopurinol Retards The Answer: Fructose-Induced Metabolic Syndrome “Combo therapy might provide a superior means to prevent diabetes and CVD.” Roncal C. Am J Nephrol 2009;30:399-404 A Reduced Fructose Diet Retards Fructose- Induced Metabolic Syndrome “Diet therapy might provide a superior means to prevent diabetes and CVD.” Brinn C. SJH CVD Grand Rounds 2009 Promote: “LifeStyle Medicine” ** Hippocrates: Father of Medicine “Let Food be thy Medicine . . . .and Medicine be thy Food.” 350 B.C. Promote: Profound healing benefits of healthy foods . . . Summary: 70% Reduction of Secondary Coronary Events: It’s all about the Fat! Cardiovascular Grand Rounds Feb. 2009 • “Eat fish often and/or take a fish oil supplement daily—1 tsp fish oil or 3 extra strength fish oil supplements. • Use extra virgin olive oil daily— simmer in main dishes or add to your salads. • Eat 10-20 nuts daily—not roasted— almonds or walnuts are the best Summary: Sucrose, High Fructose Corn Syrup & Cardiovascular Disease • Limit foods made with all sugars— especially high fructose corn syrup & sucrose • Sugars are not “just empty calories” • Sugars are becoming associated with as much disease as “cholesterol & saturated fats” • Our bodies were not designed to process so much fructose