Stephen Ponder, MD, FAAP, CDE, believes high-fructose corn syrup (HFCS) does play a significant part in the growth of the disease, but he also believes it is just one determinant with genetics and socioeconomics also involved in the equation. Dr. Ponder (pictured here) discusses the sugar substitute’s role along with what the latest medical literature says about genetics as a root cause for the disease.  
By: John Parkinson, Clinical Content Coordinator, 
Dr. Stephen Ponder is a pediatric endocrinologist who has his own practice, Lone Star Diabetes and Endocrinology in Odessa, Texas, and he believes the addition of HFCS into the food supply is partially to blame for the growing prevalence of type 2 diabetes.
Dr. Ponder gave a lecture titled “Children of the Corn Syrup” a few years ago where he made some specific points including how the sugar additive’s introduction into the mainstream American diet closely correlates to the rise of type 2 diabetes. (The video is available on YouTube under the title above.) 
He also points to lower socioeconomics and the emergence of the role genetic predisposition seems to be playing.

Specifically, Dr. Ponder points to one recent study which shows that the pancreas senses fructose and begins releasing excessive insulin which can then lead to hyperinsulinemia. Therefore, babies in utero, and within the first two years of life are being programmed to enjoy the taste of fructose, but with the potentially unhealthy consequences that come with it.

Extrapolating what the latest data and studies are reporting, Dr. Ponder believes setting up these genetic signals combined with the abundance of HFCS in the present food supply points to a need for a healthy diet very early in life; otherwise, a later intervention for a healthier diet might be more difficult to accomplish as individuals will likely be have a daily food intake that includes HFCS. talked with Dr. Ponder about this potentially disturbing link between genetic disposition and the vast amount of HFCS in the food supply, whether it is time to begin to seriously think about sugar regulation, and when the type 2 epidemic in children might begin to turnaround. Can you provide an estimation of the percentage of kids with type 2 diabetes in your practice and what you see as the main driver for obesity and the prevalence of the disease in them?
Dr. Ponder: We have approximately 25 to 35 percent of our patients with some form of obesity, prediabetes, or type 2 diabetes. One of the drivers of the problem is the toxic food environment, but there are certainly genetic underpinnings that set this up to occur.
Many of the eating behaviors such as soda and unhealthy food consumption--that we typically discuss with teens and young adults--are actually being programmed much earlier in life.

Possibly one of the more disturbing revelations is what happens prenatally to a baby, and in the first few years of its life. Specifically, genetics affect hypothalamic function and the epigenetic changes as a result of the fat and carbohydrate composition of meals in newborns and in the first year or two of life. This leads to physical and metabolic changes in the mediobasal hypothalamus, which acts to reset the baby’s weight set point towards greater caloric intake in predisposed individuals.
Ten years ago, I would have never thought epigenetics played such a role so early on. The more we learn about this, the more we realize pre- and peri-natal influences have a genetic impact on children. Is it your sense in reading the literature that it is more genetic influences than the food environment that is influencing the prevalence of type 2 diabetes?

Dr. Ponder: I think people inherit a risk for being programmed by the food environment. That may be a gross over simplication but that is what I walk away with the latest literature that is out there. A baby’s brain and pancreas are being programmed, much like a computer off an assembly that comes with a basic operating system and the owner puts their particular applications and software on it, which makes it more uniquely theirs.

One article of many that you want to read is a study in the Proceedings of the National Academy of Sciences. It is about how fructose affects pancreatic function and how that can contribute to the onset of type 2 diabetes.
In the report, it stated the pancreas has the ability to sense fructose and increases insulin output as a result. This can create problems with hyperinsulinemia, which is responsible in part for type 2 diabetes in both adults and children.

In fact, these changes become hardwired into the individual and can be passed onto subsequent generations.
We are losing the battle of childhood obesity within the first few years of life, and we are trying to administer palliative measures later on to offset the consequences. A therapy like bariatric surgery in teens to offset the effects of morbid obesity is one example.
On the other hand, there are people that are exposed to these factors, and they are not predisposed to have that problem--at least not early in life--and hence they don’t suffer the effects.
This is the problem we run into; advocates who do not want regulation would point to these individuals and say they don’t become overweight. In a way, we are picking out one particular population because they are genetically pre-disposed for type 2 diabetes.
Unfortunately, we cannot yet identify who is at risk and who isn’t. I do imagine a day where we have a newborn screening test where we can do a profile on babies to see what diseases they are at risk for simply because of their genetic makeup. This way, you could steer the baby away from the risks of type 2 diabetes by not exposing the baby to high calorie, high fat, processed foods or drinks in the first year or two of life. If part of the problem that has been identified is the abundance of HFCS in processed foods, do you think it is time for the federal government to step in and regulates sugar and corn syrup in the U.S.? 
Dr. Ponder: I don’t believe there will ever be any regulation, at least not any time in the near future. I would rather focus on educating the public about delaying introduction of sugar and corn syrup intake to young children. Caloric sweeteners are ubiquitous and enmeshed in the food supply. For your patients who are morbidly obese and have type 2 diabetes, what suggestions and strategies do you give to them for alternatives to foods with corn syrup?

Dr. Ponder: The biggest problem in medicine right now is the lack of access and comprehension to educational resources. The information is there, but it is getting it to the patients so that they see it in a way that makes sense to them. 

I have had many type 1 and type 2 patients in my practice who have not had access to a dietitian to sit down and discuss proper meal planning.

We do counsel them on medical nutrition—we don’t call it a diet--where we try to steer people away from higher caloric, processed foods and drinks in favor of prepared meals. We talk to them about eating more whole grains, staying away from refined sugars, and minimizing the amount of foods eaten.

Most of the time in these morbidly obese kids, there is massive consumption of processed foods and high calorie soft drinks. Sometimes going after these eating habits are like the low-hanging fruit, so to speak, so you can yield a significant benefit by cutting back on them.

We do make a concerted effort from a nutritional standpoint because lifestyle change is the cornerstone of type 1 or type 2 diabetes management. Patients need to have the knowledge of the proper amount and proper composition of meals.

Unfortunately, too many physicians break diabetes down to a pharmacologic approach only, and when you ask these patients if their doctors discussed a meal plan, many say they never did.

You also have situations where people may have gone to a diabetes education class years ago, and they were given this knowledge, but they didn’t understand how to use it. The system is broken in many ways, and part of it is the lack of ongoing, continuous diabetes education that patients can understand and use in their everyday lives. In addition, it is not reimbursed for very well; so many doctors’ offices cannot maintain or keep an educator. What is it going to take to reach that tipping point where Americans realize we need to change our ways in how we approach our diet?

Dr. Ponder: This may sound cynical but there was a state lawmaker who recently put up some legislation that was aimed at improving the quality of care that students with type 1 diabetes would be receiving in school in that state. The motivation for this legislator is that he had a child that recently developed type 1 diabetes.

If I was to look at Congress or the boardrooms of many major companies, if there are a growing number of lawmakers and business people getting type 2 diabetes or suffering health issues related to obesity like heart disease, there might be greater attention to doing something about this.

As type 2 diabetes continues to grow, we will all know somebody with diabetes. Once we start knowing people who are directly touched by this, we are more likely to be empathetic to the cause and will try to influence it for the better.

We treat diseases incrementally, just like when we buy computers or electronic gadgets. Companies keep creating the newer versions of the product. You see something very comparable in diabetes care. We also have to realize we are dealing with a “medical-industrial complex” so to speak that does not want to see it all go away anytime soon. You see new medicines coming out, new meters, and pumps. Yet all these medical devices and medicines are becoming increasingly more expensive.

We are fighting the battle on several different fronts. This is a problem that is going to consume most all of us if we don’t start acting soon.