Case 3:16-cv-04958-WHO Document 273 Filed 10/12/20 Page 1 of 124
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`THE LAW OFFICE OF JACK FITZGERALD, PC
`JACK FITZGERALD (SBN 257370)
`jack@jackfitzgeraldlaw.com
`TREVOR M. FLYNN (SBN 253362)
`trevor@jackfitzgeraldlaw.com
`MELANIE PERSINGER (SBN 275423)
`melanie@jackfitzgeraldlaw.com
`Hillcrest Professional Building
`3636 Fourth Avenue, Suite 202
`San Diego, California 92103
`Phone: (619) 692-3840
`Fax: (619) 353-0404
`JACKSON & FOSTER, LLC
`SIDNEY W. JACKSON, III (pro hac vice)
`75 St. Michael Street
`Mobile, Alabama 36602
`Phone: (251) 433-6699
`Fax: (251) 433-6127
`Class Counsel
`
`
`UNITED STATES DISTRICT COURT
`NORTHERN DISTRICT OF CALIFORNIA
`
`
`DEBBIE KROMMENHOCK and
`STEPHEN HADLEY, on behalf of
`themselves, all others similarly situated, and
`the general public,
`
`
`
`
`
`POST FOODS LLC,
`
`
`
`v.
`
`Case No.: 3:16-cv-04958-WHO (JSC)
`
`CLASS ACTION
`
`THIRD AMENDED COMPLAINT FOR
`VIOLATIONS OF CALIFORNIA’S
`FALSE ADVERITSING LAW,
`CONSUMERS LEGAL REMEDIES ACT,
`& UNFAIR COMPETITION LAW; AND
`BREACH OF EXPRESS & IMPLIED
`WARRANTIES
`
`DEMAND FOR JURY TRIAL
`
`Plaintiffs,
`
`
`
`
`
`Defendant.
`
`
`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
`THIRD AMENDED CLASS ACTION COMPLAINT
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`Case 3:16-cv-04958-WHO Document 273 Filed 10/12/20 Page 2 of 124
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`TABLE OF CONTENTS
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`C.
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`D.
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`INTRODUCTION .................................................................................................................... 1
`THE PARTIES ......................................................................................................................... 1
`JURISDICTION AND VENUE .............................................................................................. 2
`FACTS ..................................................................................................................................... 2
`A.
`There Has Been a Recent Rise in Human Sugar Consumption .......................... 2
`B.
`The Body’s Physiological Response to Excess Sugar Consumption .................. 6
`1.
`The Body’s Response to Glucose ............................................................. 6
`2.
`The Body’s Response to Fructose ............................................................. 9
`3.
`The Addiction Response ......................................................................... 11
`There Has Been a Dramatic Rise in Obesity & Chronic Disease That
`Parallels the Rise in Human Sugar Consumption ............................................. 11
`There is Substantial Scientific Evidence That Excess Sugar
`Consumption Causes Metabolic Syndrome, Cardiovascular Disease,
`Type 2 Diabetes, and Other Morbidity .............................................................. 12
`1.
`Excess Sugar Consumption Causes Metabolic Syndrome ..................... 13
`2.
`Excess Sugar Consumption Causes Type 2 Diabetes ............................. 16
`3.
`Excess Sugar Consumption Causes Cardiovascular Disease ................. 20
`4.
`Excess Sugar Consumption Causes Liver Disease ................................. 22
`5.
`Excess Sugar Consumption Causes Obesity ........................................... 23
`6.
`Excess Sugar Consumption Causes Inflammation ................................. 27
`7.
`Excess Sugar Consumption Causes High Blood Triglycerides
`and Abnormal Cholesterol Levels ........................................................... 29
`Excess Sugar Consumption is Associated with Hypertension................ 32
`Excess Sugar Consumption is Associated with Alzheimer’s
`Disease, Dementia, and Cognitive Decline ............................................. 35
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
`THIRD AMENDED CLASS ACTION COMPLAINT
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`8.
`9.
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`E.
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`10. Excess Sugar Consumption is Linked to Some Cancers ........................ 36
`There is Substantial Evidence That Consuming Artificial Trans Fat—
`Found in Some Post Cereals—is Detrimental to Health ................................... 36
`POST’S MARKETING & SALE OF HIGH-SUGAR CEREALS ....................................... 39
`A.
`Post Great Grains Cereals .................................................................................. 43
`11. Cranberry Almond Crunch ..................................................................... 43
`12. Banana Nut Crunch ................................................................................. 45
`13. Raisins, Dates & Pecans ......................................................................... 47
`14. Crunchy Pecans ...................................................................................... 49
`15. Blueberry Pomegranate .......................................................................... 51
`16. Protein Blend: Honey, Oats & Seeds ...................................................... 52
`17. Protein Blend: Cinnamon Hazelnut ........................................................ 54
`Post Honey Bunches of Oats Cereal .................................................................. 57
`1.
`Honey Roasted ........................................................................................ 57
`2. With Almonds .......................................................................................... 60
`3.
`Raisin Medley .......................................................................................... 63
`4. With Pecan Bunches ................................................................................ 65
`5. With Cinnamon Bunches ......................................................................... 66
`6. With Vanilla Bunches .............................................................................. 68
`7. With Apples & Cinnamon Bunches ......................................................... 70
`8. With Real Strawberries ........................................................................... 71
`9.
`Fruit Blends – Banana Blueberry ........................................................... 73
`10. Fruit Blends – Peach Raspberry ............................................................. 74
`11.
`Tropical Blends – Mango Coconut ......................................................... 75
`
`B.
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`C.
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`12. Greek Honey Crunch ............................................................................... 76
`13. Greek Mixed Berry .................................................................................. 77
`Post Single Cereals ............................................................................................ 77
`1.
`Raisin Bran .............................................................................................. 77
`2.
`Honeycomb .............................................................................................. 80
`3. Waffle Crisp............................................................................................. 81
`POST’S UNLAWFUL ACTS AND PRACTICES ............................................................... 82
`A.
`Post Marketed and Continues to Market its Cereals with Health and
`Wellness Claims that are Deceptive in Light of the Cereals’ High
`Sugar Content .................................................................................................... 82
`1.
`Post Affirmatively Misrepresents that Some High-Sugar
`Cereals are “Healthy,” “Nutritious,” or “Wholesome” ........................... 82
`Post Affirmatively Misrepresents that Consuming Some of its
`High-Sugar Cereals Will Promote Bodily Health, Prevention of
`Disease, or Weight Loss .......................................................................... 84
`Even When Not Stating So Expressly, Post Strongly Suggests
`Its High-Sugar Cereals are Healthy ........................................................ 85
`
`2.
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`3.
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`a.
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`b.
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`c.
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`d.
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`Post Touts Its High-Sugar Cereals’ Whole Grain, Fiber,
`and “Real” Ingredient Content to Distract From Their
`High Added Sugar Content ........................................................... 85
`
`Post Leverages a Deceptive Industry “Certification”
`Program—the Whole Grains Council Stamp—to Make
`its High-Sugar Cereals Seem Healthy .......................................... 86
`
`In Representing that Many of Its High-Sugar Cereals
`Contain “No High Fructose Corn Syrup,” Post Leverages
`Consumer Confusion to Obscure the Dangers of the
`Added Sugar in it Cereals ............................................................. 87
`
`Post Falsely Markets Some of Its High-Sugar Cereals as
`“Simple,” “Whole Foods” that Are “Less Processed” ................. 88
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`Case 3:16-cv-04958-WHO Document 273 Filed 10/12/20 Page 5 of 124
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`e.
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`Post Deceptively Omits, Intentionally Distracts From,
`and Otherwise Downplays the Cereals’ High Added
`Sugar Content ............................................................................... 88
`
`4.
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`5.
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`6.
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`7.
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`Post Immorally Markets Some High-Sugar Cereals to Children,
`Who Are the Most Vulnerable to the Dangers of Excess Added
`Sugar Consumption ................................................................................. 89
`Post Egregiously Markets Some High-Sugar Cereals to
`Children Even Though They Contain Artificial Trans Fat ..................... 90
`Post Knows or Reasonably Should Know of the Strong
`Scientific Evidence Demonstrating Its High-Sugar Cereals are
`Unhealthy to Consume But Fails to Warn Consumers of the
`Known Dangers of Consuming Its High-Sugar Cereals ......................... 91
`Post Violates FDA and State Food Labeling Regulations ...................... 91
`
`a.
`
`In Violation of State and Federal Regulations, Post’s
`Health and Wellness Statements are False, Misleading,
`and Incomplete .............................................................................. 92
`
`B.
`
`Post Used its Website, as Referenced on Some Labels, and Other
`Online Fora, to Spread Misinformation about the Dangers of
`Consuming the Added Sugar in its Cereals ....................................................... 92
`Post Made Misleading Public Statements Concerning High-Sugar
`Cereals ............................................................................................................... 99
`The Foregoing Behaviors are Part of Post’s Longstanding Policy,
`Practice, and Strategy of Marketing its High-Sugar Cereals as Healthy
`in Order to Increase Sales and Profit ................................................................. 99
`Post’s Policy and Practice of Marketing High-Sugar Cereals as
`Healthy is Especially Harmful Because Consumers Generally Eat
`More than One Serving of Cereal at a Time, Which Post Knows or
`Reasonably Should Know ............................................................................... 100
`PLAINTIFFS’ PURCHASES, RELIANCE, AND INJURY .............................................. 101
`A.
`Plaintiff Debbie Krommenhock ...................................................................... 101
`B.
`Plaintiff Stephen Hadley.................................................................................. 103
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`C.
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`E.
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`CLASS ACTION ALLEGATIONS .................................................................................... 107
`CAUSES OF ACTION ........................................................................................................ 110
`PRAYER FOR RELIEF ....................................................................................................... 117
`JURY DEMAND ................................................................................................................. 117
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`Case 3:16-cv-04958-WHO Document 273 Filed 10/12/20 Page 7 of 124
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`Pursuant to the Court’s September 29, 2020 Order, Dkt. No. 264, Plaintiffs and Class
`Representatives Debbie Krommenhock and Stephen Hadley, on behalf of themselves, all
`others similarly situated, and the general public, by and through their undersigned counsel,
`hereby bring this action against Post Foods, LLC (“Post”), and for their Third Amended
`Complaint, allege the following upon their own knowledge, or where they lack personal
`knowledge, upon information and belief including the investigation of their counsel.
`INTRODUCTION
`The scientific evidence is compelling: Excessive consumption of added sugar is
`1.
`toxic to the human body. Experimentally sound, peer-reviewed studies and meta-analyses
`convincingly show that consuming excessive added sugar—any amount above approximately
`5% of daily caloric intake—greatly increases the risk of heart disease, diabetes, liver disease,
`and a wide variety of other chronic morbidity.
`Despite the compelling evidence that the fructose in sugar acts as a chronic liver
`2.
`toxin, detrimentally affecting health, to increase their price and sales, Post leverages a policy
`and practice of marketing high-sugar cereals with health and wellness claims. These claims,
`however, are deceptive because they are incompatible with the significant dangers of the
`excessive added sugar consumption to which these foods contribute.
`Plaintiffs bring this action against Post on behalf of themselves, other Post cereal
`3.
`consumers, and the general public, primarily to enjoin Post from continuing to engage in its
`practice of using deceptive health and wellness claims to market high-sugar cereals.
`THE PARTIES
`Plaintiff Debbie Krommenhock is a resident of Dublin, California.
`4.
`Plaintiff Stephen Hadley was a resident of Monterey, California when this case
`5.
`was filed in August of 2016. Currently, Mr. Hadley resides in San Antonio, Texas.
`Defendant Post Foods, LLC is a Delaware limited liability corporation with its
`6.
`principal place of business at 2503 S. Hanley Road, St. Louis, Missouri 63144.
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`JURISDICTION AND VENUE
`This Court has jurisdiction over this action pursuant to 28 U.S.C. §
`7.
`1332(d)(2)(A), the Class Action Fairness Act, because the matter in controversy exceeds the
`sum or value of $5,000,000 exclusive of interest and costs, and at least one member of the
`class of plaintiffs is a citizen of a state different from Post. In addition, more than two-thirds
`of the members of the class reside in states other than the state in which Post is a citizen and
`in which this case is filed, and therefore any exceptions to jurisdiction under 28 U.S.C. §
`1332(d) do not apply.
`The Court has personal jurisdiction over Post pursuant to Cal. Code Civ. P. §
`8.
`410.10, as a result of Post’s substantial, continuous and systematic contacts with the state,
`and because Post has purposely availed itself of the benefits and privileges of conducting
`business activities within the state.
`Venue is proper in the Northern District of California pursuant to 28 U.S.C. §
`9.
`1391(b) and (c), because Post resides (i.e., is subject to personal jurisdiction) in this district,
`and a substantial part of the events or omissions giving rise to the claims occurred in this
`district.
`
`FACTS
`A. There Has Been a Recent Rise in Human Sugar Consumption
`10. Sugars are sweet, short-chain, soluble carbohydrates. Simple sugars are called
`monosaccharides, while disaccharides are formed when two monosaccharides undergo a
`condensation reaction. The three most common sugars in our diets are fructose, glucose, and
`sucrose. Other sugars, like lactose, found in milk, and maltose, formed during the germination
`of grains like barley, are not generally consumed in large amounts. Glucose is a
`monosaccharide that occurs naturally in fruits and plant juices and is the primary product of
`photosynthesis. Most ingested carbohydrates (like bread and pasta) are converted into glucose
`during digestion, and glucose is the form of sugar transported around the body in the
`bloodstream, and used by the cells for energy. Fructose is a monosaccharide that occurs
`naturally in fruits and honey. It is the sweetest of the sugars. Sucrose is a disaccharide
`2
`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
`THIRD AMENDED CLASS ACTION COMPLAINT
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`comprised of one molecule of glucose chemically linked to one molecule of fructose. It is
`found in sugar cane and beets. Common table sugar is sucrose. During digestion and prior to
`blood absorption, enzymes called sucrases cleave a sucrose molecule into its constituent parts,
`glucose and fructose.
`11. Humans’ consumption of sugar has shifted dramatically over time. Cro-Magnon
`men during the Paleolithic age were hunters and gatherers, with a diet mainly comprised of
`meat, high in protein, moderate in fat, and low in carbohydrates. Fruits and berries were the
`major source of carbohydrates, and starch consumption was low.1 In 1200 B.C., a process
`was developed in India for extracting sugar in the form of cane juice called khanda, which is
`where the word “candy” comes from. For nearly 3,000 years, sugar was rare, reserved for
`nobility. The invention of the pot still in 1700 A.D., however, allowed mass production of
`refined sugar. But it was still extraordinarily expensive until the middle of the 18th century,
`when there was a worldwide growth in sugar production, including in America. Thus, humans
`have been consuming sugar in substantial amounts for less than 300 years.
`12. For most of that time, Americans’ sugar consumption was almost exclusively
`table sugar, with only small amounts of glucose and fructose ingested from fruit.2 And sugar
`was a condiment, added to coffee or tea, with control over the amount eaten.
`In the 1960s, the food industry developed technologies to extract starch from
`13.
`corn, then convert it to glucose, some of which could then be converted to fructose, leading
`to the development of corn-derived sweeteners, most notably high-fructose corn syrup
`(HFCS).3 Although HFCS is comprised of both fructose and glucose, unlike with sucrose, the
`fructose is not chemically bound to the glucose in a new molecule. Thus the fructose in HFCS
`
`
`1 Tappy, L., et al., “Metabolic Effects of Fructose in the Worldwide Increase in Obesity,”
`Physiology Review, Vol. 90, 23-46, at 24 (2010) [hereinafter “Tappy, Metabolic Effects of
`Fructose”].
`2 Id.
`3 Id. (citation omitted).
`
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`Case 3:16-cv-04958-WHO Document 273 Filed 10/12/20 Page 10 of 124
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`is referred to as “free” fructose. HFCS can be produced with different fructose-to-glucose
`ratios. The most common are HFCS-42 and HFCS-55, containing 42% and 55% fructose.
`Some HFCS, however, can be as much as 90% fructose, i.e., HFCS-90. Food manufacturers
`have recently begun referring to HFCS-90 on food label ingredients statements as simply
`“fructose.”
`14. Fructose is sweeter than either glucose or sucrose. In fruit, it serves as a marker
`for foods that are nutritionally rich. Before the development of the worldwide sugar industry,
`fructose in the human diet was limited to items like honey, dates, raisins, molasses, figs,
`grapes, raw apples, apple juice, persimmons, and blueberries (which contain approximately
`10-15% fructose). Food staples like milk, vegetables, and meat have essentially no fructose.
`Thus, until relatively recently, human beings have had little dietary exposure to fructose.4
`15. But the low cost and long shelf-life of HFCS has contributed to a rapid increase
`in its consumption over the last 45 years, and thus the consumption of fructose. Between 1970
`and 2000, the United States’ yearly per capita HFCS consumption went from 0.292 kg per
`person, to 33.4 kg per person, a greater than 100-fold increase.5
`16. Today, the majority of sugars in typical American diets are added to foods during
`processing, preparation, or at the table.6 The two primary sources of added sugar in processed
`food are HFCS and sucrose (i.e., granulated sugar used, for example, in baked goods). Added
`
`
`4 Bray, G., “How bad is fructose?,” American Journal of Clinical Nutrition, Vol. 86, 895-96
`(2007) [hereinafter, “Bray, How Bad is Fructose?”].
`5 Bray, G.A., et al., “Consumption of high-fructose corn syrup in beverages may play a role
`in the epidemic of obesity,” American Journal of Clinical Nutrition, Vol. 79, 537-43, at 537,
`540 (2004) [hereinafter “Bray, HFCS Role in Obesity Epidemic”].
`6 U.S. Dep’t of Agric. & U.S. Dep’t of Health & Human Servs., “Dietary Guidelines for
`Americans,
`2010,”
`at
`27
`(2010)
`available
`at
`http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
`4
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`sugar is in more than 74% of processed foods,7 under more than 60 different names.8
`Although the tendency is to associate sugar with sweets, added sugar is found in many savory
`processed foods, like bread, soup, and pasta sauce.
`17. There has been a rise over the past 45 years in Americans’ consumption of added
`sugars. From 1970 to 2000, there was a 25% increase in available added sugars in the U.S.9
`The American Heart Association found that between 1970 and 2005, sugars available for
`consumption increased by an average of 76 calories per day, from 25 teaspoons (400 calories)
`to 29.8 teaspoons (476 calories), a 19% increase.10 The Continuing Survey of Food Intake by
`
`
`7 Ng, S.W., et al., “Use of caloric and non-caloric sweeteners in US consumer packaged foods,
`2005-9, Journal of the Academy of Nutrition and Dietetics, Vol. 112, No. 11, 1828-34 (2012).
`8 Some examples: Agave nectar, Barbados sugar, Barley malt, Barley malt syrup, Beet sugar,
`Brown sugar, Buttered syrup, Cane juice, Cane juice crystals, Cane sugar, Caramel, Carob
`syrup, Castor sugar, coconut palm sugar, Coconut sugar, Confectioner’s sugar, Corn
`sweetener, Corn syrup, Corn syrup solids, Date sugar, Dehydrated case juice, Demerara
`sugar, Dextrin, Dextrose, Evaporated cane juice, Free-flowing brown sugars, Fructose, Fruit
`juice, Fruit juice concentrate, Glucose, Glucose solids, Golden sugar, Golden syrup, Grape
`sugar, High-Fructose Corn Syrup (HFCS), Honey, Icing sugar, Invert sugar, Malt syrup,
`Maltodextrin, Maltol, Maltose, Mannose, Maple syrup, Molasses, Muscovado, Palm sugar,
`Panocha, Powdered sugar, Raw sugar, Refiner’s syrup, Rice syrup, Saccharose, Sorghum
`Syrup, Sucrose, Sugar (granulated), Sweet Sorghum, Syrup, Treacle, Turbinado sugar, and
`Yellow sugar.
`9 Bray, How Bad is Fructose?, supra n.4, at 895 (citing Havel, P.J., “Dietary fructose:
`implications for dysregulation of energy homeostasis and lipid/carbohydrate metabolism,
`Nutrition Reviews, Vol. 63, 133-57 (2005) [hereinafter, “Havel, Dietary Fructose”]).
`10 Johnson, R.K., et al., on behalf of the American Heart Association Nutrition Committee of
`the Council on Nutrition, Physical Activity, and Metabolism and Council on Epidemiology
`and Prevention, “Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement
`From the American Heart Association,” Circulation, Vol. 120, 1011-20, at 1016-17 (2009)
`[hereinafter “AHA Scientific Statement”]. See also World Health Organization, Sugars intake
`for
`adult
`and
`children: Guideline”
`(March
`4,
`2014)
`at
`available
`http://www.who.int/nutrition/publications/guidelines/sugars_intake/en (Based on scientific
`evidence, recommending adults and children reduce daily intake of free sugars to less than
`10% of total energy intake and noting that “[a] further reduction to below 5% or roughly 25
`grams (6 teaspoons) per say would provide additional health benefits.”).
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
`THIRD AMENDED CLASS ACTION COMPLAINT
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`Individuals from 1994 to 1996 showed that the average person had a daily added sugars intake
`of 79 grams, equal to 316 calories and about 15% of energy intake. Those in the top one-third
`of fructose consumption ingested 137 grams of added sugars per day (548 calories, about
`26% of energy per day), and those in the top 10% of fructose consumption ingested 178 grams
`of fructose per day (712 calories, about 34% of energy).11
`In 2014, researchers analyzing data obtained from National Health and Nutrition
`18.
`Examination Survey (NHANES) showed that during the most recent period of 2005-2010,
`the mean percent of calories from added sugar in the American diet was 14.9%. Most adults,
`71.4%, consumed 10% or more of their calories from added sugar, while about 10% of adults
`consumed 25% or more of their calories from added sugar.12
`19. Today, “the vast majority of the U.S. population exceeds recommended intakes
`of . . . added sugars.”13 Despite some reduction in added sugar intake recently, “intakes of
`added sugars are still very high . . . and are well above recommended limits . . . .”14
`Approximately 90% of the population exceeds recommended daily limits.15
`The Body’s Physiological Response to Excess Sugar Consumption
`B.
`The Body’s Response to Glucose
`1.
`20. The body needs some glucose, largely to meet the brain’s metabolic demands,
`
`
`11 Bray, How Bad is Fructose?, supra n.4, at 895.
`12 Yang, Quanhe, et al., “Added Sugar Intake and Cardiovascular Diseases Mortality Among
`US Adults,” Journal of the American Medical Association, at E4-5 (published online Feb. 3,
`2014) [hereinafter, “Yang, NHANES Analysis”].
`13 U.S. Dep’t of Agric. & U.S. Dep’t of Health & Human Servs., “Scientific Report of the
`2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health
`and Human Services and the Secretary of Agriculture,” at 26 (February 2015), available at
`http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-
`the-2015-Dietary-Guidelines-Advisory-Committee.pdf.
`14 Id. at 38.
`15 Id. at 35.
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`but also because all living cells use glucose for energy. Blood glucose levels below 25mg/dL
`may result in coma, seizure, or death, while levels consistently exceeding 180 mg/dL can
`cause long-term damage, including renal failure and atherosclerosis.
`21. For these reasons, blood glucose concentration is tightly-regulated by
`homeostatic regulatory systems. When blood glucose rises after a meal, beta cells in the
`pancreas secrete insulin into the blood, which helps muscle, fat, and liver cells absorb the
`glucose for energy, lowering the blood sugar. Too little blood sugar stimulates the secretion
`of hormones that counteract the insulin and thus restore normal blood sugar.16
`22. During certain steps in processing glucose, the body forms fructose. However,
`unlike with glucose, there is no biological need for dietary fructose, i.e., fructose consumed
`from food, whether fruit, honey, HFCS, or some other form. Moreover, unlike glucose,
`fructose does not directly stimulate insulin secretion.
`23. The body processes glucose and fructose differently. With little processing,
`fructose passes through the small intestine, into blood bound for the liver, so that it is taken
`up nearly 100% for processing in the liver (a characteristic shared by substances commonly
`referred to as poisons). By contrast, glucose is both “burned up” by cells directly, and
`processed elsewhere outside the liver, so that the liver must process only 20% of glucose
`consumed.
`24. So much glucose is burned up prior to liver processing, because all the body’s
`cells contain a transporter that, when stimulated by insulin, takes in glucose from the blood.
`By contrast, fructose can only be absorbed by cells that contain a different transporter, which
`most cells lack.
`25. The liver is capable of processing relatively small amounts of sugar, meted out
`slowly. This is one of the reasons that eating the fructose in fruit is not problematic: the sugar
`in fruit is encased in the fruit’s fiber, which slows the sugar’s uptake, and some sugar encased
`
`16 Ludwig, David S., “The Glycemic Index: Physiological Mechanisms Relating to Obesity,
`Diabetes, and Cardiovascular Disease,” Journal of the American Medical Association, Vol.
`287, No. 18, 2414-23, at 2415 (May 8, 2002) (citation omitted).
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`Krommenhock et al. v. Post Foods LLC, Case No. 3:16-cv-04958-WHO (JSC)
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`in fruit fiber may not even be released. Thus fruit consumption does not overwhelm the liver.
`Notably, adding fiber to foods that are high in sugar does not replicate this effect, because the
`sugar and fiber remain separate, and the sugar is not encased in the fiber like it is in fruit.
`Fruit also comes packaged with nutrients, like vitamins, that are beneficial for health, and
`sends satiation signals to the brain, telling it that the body is full.
`26. Because the liver has some capacity to process sugar, there does appear to be a
`“safe” threshold of daily added sugar consumption, small enough not to overload the liver:
`approximately 5% of calories, or about 38 grams (9 teaspoons, 150 calories) per day for men,
`25 grams (6 teaspoons, 100 calories) per day for women,17 and 12-15 grams (3-6 teaspoons,
`50-60 calories) for children depending on age and caloric needs.18
`27. But the long-term consumption of excess sugar can have dire physiological
`consequences, acting as a chronic, dose-dependent liver toxin, overloading the liver and
`causing chronic metabolic disease, also sometimes called metabolic syndrome, a cluster of
`symptoms that, when present together, increase a person’s risk of chronic disease like
`cardiovascular disease and type 2 diabetes.
`28. When excess sugar consumption overloads the liver, the glucose increases
`insulin secretion, while the fructose gets turned into liver fat, causing insulin resistance. The
`combination over time results in rapid and dramatic increases in blood glucose and insulin
`concentrations.19 Over time, individuals with frequent insulin secretion may develop insulin
`
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`17 AHA Scientific Statement, supra n.10. Similarly, the World Health Organiz