Tag Archive for: sugar

Erythritol: Reserve Judgment for Now

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The study published in Nature Medicine on erythritol is complex to say the least. I gave you three quarters of the results. There was one more part that I want to cover and then give you my primary issues with the study. As I said in Tuesday’s Memo, I’ve posted a Straight Talk on Health podcast for Members and Insiders that gives my complete thoughts on sugar alcohols, especially erythritol (remember to log in first).

Erythritol and Clotting

The final part of the study was actually a preliminary report on a much larger study. They had eight subjects drink 30 grams of erythritol mixed with 300 ml of water. That corresponds to estimates of what a high intake would be. Then they tracked serum erythritol levels in the subjects for seven days. They also tested for indicators of blood clotting factors and found that some were increased for a few days after consuming the erythritol drink. The implication is that high intake of erythritol might contribute to blood clots forming. The question is: who is at risk?

Primary Issues

My primary concern is the lack of adequate controls. This was an observational study, not a clinical trial, so no cause and effect can be determined. Researchers took measurements on several cohorts of subjects with diagnosed coronary artery disease (CAD). Those subjects had a host of risk factors including high blood pressure, type 2 diabetes, high LDL- cholesterol, and on and on. The ages in each cohort ranged from a median of 65 in the Discover cohort up to 75 in the European cohort.

They did not have a comparable cohort of apparently healthy controls in the same age group. They could have chosen a group of subjects who had blood drawn at their annual physical but no apparent diagnosis of CAD. While still not getting to cause and effect, it would have strengthened the basic observations if major adverse cardiovascular events (MACE) was seen or not seen in the controls.

The same is true for the study on the erythritol drink. Why not get a group with diagnosed CAD and see if the same clotting effect happened? If not that, why not just do a simple test that measures clotting time? That’s done for anyone who takes a blood thinner such as warfarin.

The Bottom Line

The researchers called for more research on erythritol to examine the increased adverse events in the present study, and I agree. Because erythritol is part of many low-carbohydrate foods and drinks designed for diabetics and those on a ketogenic diet, we need to know more about the risks. This was a good research paper but incomplete. The best we can say as to whether we should use sugar alcohols is that we must reserve judgment until a lot more research is done.

If you’re concerned about artificial sweeteners, try to cut back and use a variety of them to reduce the risks associated with any particular one. But for your health’s sake, don’t switch to sugar; the risks of high sugar consumption are even greater than those associated with artificial sweeteners. For ideas of asking the right questions in those future trials and more on sugar alcohols, check out the Straight Talk on Health just posted by becoming a Member or Insider.

What are you prepared to do today?

        Dr. Chet

Reference: Nature Medicine. 2023. https://www.nature.com/articles/s41591-023-02223-9

Building a Healthy Microbiome

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After last week’s Memos on the importance of a healthy microbiome and immune health, let’s review how to have a healthy microbiome to protect your brain and boost your immune system.

First, eat a mostly plant-based diet: some raw, some cooked, some fermented. The raw will give you probiotics and fiber. The cooked, especially whole grains and beans, will give you fiber. The fermented such as sauerkraut and yogurt will give you even more probiotics.

Second, fast once in a while. I covered this in Memos from June, so you can re-read the Memos on fasting and microbiome health.

Third, reduce your refined carbohydrate and sugar intake. Simply put, they provide the bad microbes with the food they need to overtake the good bacteria. Good bacteria need fiber from foods or supplements, so make sure you’re getting 25–30 grams per day.

My knee replacement surgery is scheduled in six days, so I’ve been working on preparing my body to defend against staph infections. I’ll talk about that in Saturday’s Memo.

What are you prepared to do today?

        Dr. Chet

The Bottom Line on Sugary Drinks and Cancer

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The question is simple: do we avoid all sugary drinks, including fruit juices? The best I can come up with is to withhold judgment and don’t get excited about it for now. Let’s take a look at what the concerns of the researchers were and then my concerns.

Researchers’ Concerns

The first is that the NutriNet-Santé study was not a randomized sample. That means that only those people who were interested in participating for whatever reason did so. The sample was predominantly women at 78.7% of the cohort with a mean age of 42 years. The researchers accounted for age and gender in the statistical analyses, but that doesn’t account for the lack of randomization.

Researchers also stated that the rate of cancer was much lower: 620 of the 100,000 people in the study compared with 972 per 100,000 people in all of France. They adjusted the numbers to reflect the age and gender distribution in France, but I used the numbers actually given in the study. They also said the diagnosis of cancer was self-reported. I can’t believe anyone would say they have cancer if they don’t, but it would have been better if it were verified.

Related to that, some cancers were limited, thus affecting the statistics. If you don’t have enough of any type of cancer, it’s difficult and scientifically shaky to calculate a relationship.

Younger subjects consumed higher amounts of sugary drinks than older subjects. There were other factors as well, but these also were taken care of statistically. Further, they acknowledge what I alluded to: when people self-report, they can over- and under-estimate their intake. They also chose only the subjects that had at least two diet records completed in the first two years; the potential was 10 if all records were completed by all subjects. That seems low to me—there’s too much missing data.

Finally, this was an observational study and thus cause and effect can’t be attributed to the results. But it does raise questions.

My Questions

I think they could have gone a long way to answering the question about sugar intake if they had compared the fruit intake with the juice intake: take the fruit intake, calculate the sugar content, then match it with juice intake with the same sugar content. What was the rate of cancer in each group? Doing the direct comparison could go a long way to suggest whether it’s the sugar alone or if the effects were ameliorated with the fiber and phytonutrients of whole fruit with the same amount of sugar. That’s an obvious question; this is an ongoing study so maybe they’ll do that in the future.

I also think that running a comparison of total carbohydrate intake could also give us insight. If someone had a high carbohydrate intake, especially if it were high in refined carbohydrates, that might be meaningful as well.

The Bottom Line

The question I was left with was this: how could less than a half-cup per day of any type of added sugary drink that contained fewer than 50 sugar calories cause an increase in cancer? It just doesn’t make any kind of sense when you consider the total mean average calorie intake of the subjects was 1,850 calories. If the total sugar intake from solid foods of the individuals was high, or it was highly refined carbohydrates, that could make a difference. That analysis wasn’t done.

At this point, I wouldn’t stop drinking a glass of fruit juice or adding some juice to a smoothie. Don’t go out of your way to drink more fruit juice, but don’t avoid it either; certainly you should choose fruit juice from whole fruit over soda with sugar. If you have an artificial sweetener you like, use that instead of sugar. As for other drinks that contain sugar, they’re highly refined carbohydrates so you should be keeping those under control anyway. While this was an interesting and controversial report, nutrition is still about balance. Keep that in mind as you choose what you eat and drink every day.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Finding the Cancer Risk in Sugary Drinks

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In Tuesday’s Memo, I reviewed the methodology of the NutriNet-Santé study in France. As I suggested, it was solid. The sugary drink choices included fruit juices, sodas, sugar-sweetened hot and milk beverages, sports drinks, and energy drinks. In terms of the data collection, I can’t think of anything they could have done better.

Turning to the statistical analysis, it was complicated to say the least. The use of high-speed computers allows for many statistical analyses to be done in short order, even with over 100,000 subjects. My only concern is that, as they did the trend for hazard ratios, they adjusted for many variables including age, gender, energy intake, and family history. How many variables? About 24 in all by my count. That’s not necessarily wrong, but there are some that would seem obvious such as total carbohydrate intake from all foods, and percentage of calories from carbohydrates other than vegetables and fruit.

Another way of analyzing the data was something I’ve done before, and that’s compare the rate of cancer to the national cancer statistics in France. In this case, the rate of cancer in France is 0.95% while it was 0.87% in the unadjusted data from the study. That’s very close and a bit lower than the national average.

Must we avoid even a half-cup of fruit juice per day? Is the sugar in your coffee or sweet tea causing a significant increase in your risk of getting cancer? I’ll let you know on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Is There a Link Between Sugar and Cancer?

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Sugar has been in the news with the publishing of the latest results from the NutriNet-Santé study from France. The headlines of press releases suggest that drinking as little as four ounces of a sugary drink, including fruit juice, per day was related to an increased risk of getting cancer. Sugary drinks of all types except fruit juice were associated with an increased risk of getting breast cancer. These were all hazard ratio trend analyses; as the consumption increased, so did the risk of cancer.

If you read the Memos regularly, you know my approach is to always check how the data were collected. In this study, they used three 24-hour dietary records that included two weekdays and one weekend day. The diet records were done every six months throughout the duration of the follow-up, about five years. They subjects entered their data online; with over 100,000 subjects, that’s the only way this study could be done.

Of all the types of diet assessments, this is as close to the gold standard as I’ve seen. They had 97 different sugary drinks and 12 artificially sweetened drinks that were possible choices with very detailed descriptions and photos of drinks to help assess portion size. The only step they didn’t take was to have the records checked by a dietician before the subjects entered their data online. The methods in this study were solid compared to just about every other study I’ve talked about.

Should we avoid all sugary drinks at this point? More on Thursday. Tomorrow is the July Insider Conference call; this is your chance to learn more about nutrition and get your questions answers. You can still be included, so check out memberships right now.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

That Sugar Film: A Fantasy

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Let me clear up a few things right away. I’m not a fan of overeating sugar, whether pure cane sugar or high fructose corn syrup. But glucose is the perfect fuel because it burns completely with only carbon dioxide and water as the by-products. I think what everyone should do is respect glucose for what it can do and what overconsumption can do: make us fat—but no more than the other carbohydrates we over consume. With that in mind, let’s take a look at the filmmaker’s weight gain.

He claims to have eaten the equivalent of 40 teaspoons of sugar a day, keeping his calories the same as his regular diet, and gaining almost 20 pounds. My simple opinion is: bull. People in the movie spent some time suggesting that a calorie is not just a calorie, that somehow you can get more from sugar. I’ll address that in a moment. The real problem is that while he thinks he didn’t over eat, he absolutely must have to gain close to 20 pounds in two months. Period. I’m not suggesting he intentionally lied, but I watched him eat and he was not measuring much of anything. Unless you weigh or measure, you can’t say that you ate what you claimed you ate.

But let’s say that he was correct, that he ate 2,300 calories per day with 800 calories coming from sugar. What that would require was somehow more calories are extracted from sugar. My question is how? To go molecular for a second, the energy we get from food is the energy stored in the chemical bonds of the food; if we take in more fuel than we need, the body stores the extra energy as fat. If sugar has only so much energy stored in the chemical bonds, how can it release more? Glucose or fructose, doesn’t matter. That would require some form of unknown chemical reaction that could create energy. That doesn’t happen in any biochemistry of food I’ve ever studied. If it could, it would come at a cost, an energy cost somewhere.

The idea that a calorie is not a calorie has always been a foolish argument because there’s no chemistry to support it. We cannot make more energy than we begin with. The only way he gains 20 pounds is he overate. A lot.

He spends a lot of the movie talking about sugar spikes and falls that made him “addicted” to sugar. I’ve never seen anyone drink that much fruit juice, to the extent that it wasn’t reasonable. I asked on Facebook how sugar affects people who drink juice or any other form of sugar, but not sodas. The results were 1:3 against a sugar rush of any kind. I also included physicians and other healthcare professionals. Was it a formal study? No. And neither was what the author did to himself in this film.

To me, his film was a real work of fiction. Add it to your collection of fantasy films.

If you reduce the amount of sugar in your diet after watching this film, that’s great. You really can’t go wrong getting your calories from better nutritional choices. But don’t base your decision on this pretend research.

What are you prepared to do today?

        Dr. Chet

That Sugar Film: The Results

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I hope that this sunk in on Tuesday: Damon Gambeau, the filmmaker, was going to eat 40 teaspoons of sugar per day. The rest of the story was that he was not going to eat cakes and cookies or drink full-sugar soda. He was going to eat what might be considered health foods: low-fat yogurt, fruit juices, whole grain cereals with sugar added, and other things with Australian names I don’t recognize. By the end of each day, it had to equate to 40 teaspoons of sugar or about 168 grams, not counting all the other carbohydrates.

What happened after 60 days? One of his liver enzymes was off, up 20 points over the safety level, which was never really explained. His triglycerides were up significantly, from about 60 mg/dl to 132 mg/dl. While that’s up, it’s not really abnormal for a fasting triglyceride level.

The real change was in his weight. Based on weigh-ins, he gained 19.8 pounds in 60 days. He also gained 10 cm around his waist—that’s close to four inches. And here is the kicker: his estimated caloric intake before the self-study was around 2,300 calories per day. He claims that his caloric intake remained at 2,300 calories per day throughout the experiment. All the experts went nuts. Taubes said it’s got to be the sugar. Another said sugar has to be the problem.

Oh, really? I’ve got some comments on that on Saturday—and you won’t want to miss them.

What are you prepared to do today?

        Dr. Chet

Review: That Sugar Film

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Summer gives us a chance catch to up on reading or binge watch a television series, so I thought I’d watch some of the nutrition documentaries that I’ve been asked about. I’ve done some in the past such as Forks Over Knives. It gives me a chance to check the facts on what’s said and how true or relevant it is. That’s the case with the film titled That Sugar Film. It was written, directed, and starred in by an Australian filmmaker Damon Gambeau. Hugh Jackson even performed the opening scene.

The premise of the movie is that all sugar is bad. There was at least one anti-sugar and ketogenic diet proponent in Gary Taubes author of Good Calories, Bad Calories. The filmmaker also assembled a team of experts who were going to provide information and medical supervision during an experiment he wanted to conduct on himself. The experiment was to see how a high-sugar diet, one typical of the average Australian, would impact him. Based on what he claimed to eat, he was somewhere between the paleo diet and the ketogenic diet before that.

There was the requisite discussion of the cholesterol hypothesis and how fat was chosen as the demon to avoid instead of sugar as they relate to heart disease. The sugar industry conspiracy was also talked about in the same vein as the tobacco industry. But it’s what he did to himself that was by far the most interesting: switching to a diet that contained 40 teaspoons of sugar a day for 60 days. What happened to him? That’s coming on Thursday.

What are you prepared to do today?

        Dr. Chet

Sugar vs. Sweetener Research: Meaningless in the Real World

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I’m in a slight disadvantage in evaluating this study; I was able to read only the convention-session abstract and the press release. There were no recordings of the presentation that I could find, so there are details I don’t know. I have questions about the process, not the results, so here are my thoughts.

The In-Vitro Study

If you’re not familiar with the lingo, time to learn. In vitro is Latin, meaning literally “in glass.” An in-vitro study is conducted in a Petri dish, a test tube, or some location outside of an entire animal or human.

In this study, researchers exposed endothelial cells from the rats’ arteries to sugars and artificial sweeteners. We know there were changes in proteins; what we didn’t know is whether the change in protein genes that were activated in response to the artificial sweeteners mimicked a pattern we might see in a rat that’s diabetic. That’s an important question.

It would have been more meaningful if they examined a pattern of protein responses that occurred in the endothelial cells of rodents that already had diabetes. Just because something is activated in response to a stimulus, in this case sugars or artificial sweeteners, that doesn’t necessarily mean it’s a bad thing. It just means it happened.

The In-Vivo Study

In vivo is also Latin and means within a live animal or human. I have several issues with the rodent part of the study. First they gave high levels of sugar to the rats as well as high levels of artificial sweeteners. It would seem to me that it would be beneficial to get an estimate of what humans actually consume on a daily basis, dose it down to the appropriate amount for a rat, and start with that. Then you can compare your test results to a “normal” level. Next you can begin increasing the amount to see when the negative effects begin.

Second they used the DR/BB rat; DR stands for diabetes resistant and BB stands for biobreeding. This type of rodent is often used for research on type 1 diabetes because although it’s diabetes resistant, it has an underdeveloped immune system. It will respond to environmental insults differently than normal rats. Excess levels of sugar and artificial sweeteners may create an insult to the immune system to cause type 1 diabetes in this breed of rat.

The reason for doing the study was to see if artificial sweeteners may be contributing to the obesity and diabetes epidemic—type 2 diabetes, not type 1. Using this breed of rat seems like it would muddy the results. The changes they found in the blood of these rats fed excessive amounts sugar and artificial sweeteners would have been expected. The question is whether this is related directly to the research hypothesis or not. In my opinion, no.

To make this study pertinent to humans, we would need a similar pattern found in humans. Perhaps people under excessive stress and whose immune systems were compromised might show some relationship. But we’re not talking about susceptibility to type 1 diabetes. We’re talking about type 2 diabetes, and although they share a name, they’re vastly different diseases.

What we have is a study in test tubes on protein genes that are activated in response to artificial sweeteners and a second study on rodents with some dysfunction in over 200 different protein genes in response to sugar and artificial sweeteners. We may have people who use excessive amounts of artificial sweeteners everyday. We may have specific but as yet unknown gene patterns that may make people more susceptible to type 2 diabetes, but we haven’t identified what those genetic patterns are at this point or even if they exist at all.

The Bottom Line

So what does this study mean? This basic research shows that there may be a pattern to protein synthesis that’s different in high-sugar versus artificial-sweetener intake. But that does not resemble in any way what the authors of the study suggested in the press release. This study is relatively meaningless in the real world. Maybe we’ll know more about how all this impacts humans in another 5–10 maybe even 20 years. But as of today, it’s just provocative headlines. And we get far too many of those already.

Use artificial sweeteners or do not; that’s your choice. But don’t change based on this study. Use the old adage: everything in moderation including moderation.

What are you prepared to do today?

Dr. Chet

 

Reference: EB 2018. The Influence of Sugar and Artificial Sweeteners on Vascular Health during the Onset and Progression of Diabetes Board # / Pub #: A322 603.20.

 

What They Got Right in the Sugar and Artificial Sweetener Research

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Whether it’s a new form of treatment, a new medication, or even examining a phytonutrient for potential benefits, it all starts with basic research. That’s what the study I began talking about Tuesday is all about: basic research. I like it because this is the way all research has to begin. This is where test-tube studies are appropriate.

In this case they used epithelial cells from the vascular system of the rodents, exposed them to high amounts of sugars and artificial sweeteners, and then looked at specific changes in proteins that are involved in various types of cell action. In other words, they were looking for dysfunction in the way the genes for the proteins responded after exposure to the sugars and artificial sweeteners.

Were there differences? Yes. The important thing that they discovered was that the proteins inside these epithelial cells responded differently when exposed to sugar than when exposed to artificial sweeteners.

The question is this: was any of this meaningful in the real world? I’ll let you know what I think on Saturday.

What are you prepared to do today?

Dr. Chet

 

Reference: EB 2018. The Influence of Sugar and Artificial Sweeteners on Vascular Health during the Onset and Progression of Diabetes Board # / Pub #: A322 603.20.