#361 - AMA #74: Sugar and sugar substitutes: weight control, metabolic effects, and health trade-offs

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Welcome to ask me anything AMA episode 74. In today's AMA, we're taking a closer look at one of the most common and misunderstood questions we receive how to evaluate sugar and its substitutes in the context of health. To help answer these questions, we'll walk through a three part framework that reflects the most popular scenarios where sugar substitutes come into play. 1 beverages, things like regular soda vs diet soda 2 protein supplements, powders and bars which often rely on sweeteners to make them even remotely palatable and three Sweet treats, everything from candy to low calorie desserts, where the goal is simply to satisfy a sweet craving or while minimizing the consumption of sugar and calories. We'll discuss why humans are hardwired to crave sweetness and how that evolutionary advantage now collides with today's food environment. Whether or not sugar is uniquely fattening, the evidence on isocaloric comparisons and sugar's rapid effects on hunger hormones, fructose versus glucose, drinks versus solids and natural versus refined sugars why the timing of your sugar intake matters what the big three sweeteners saccharin, aspartame and sucralose do and don't deliver for weight loss, glycemic control and the microbiome what makes allulose a standout sweetener and why it is challenging to use in all products sugar, alcohols, erythritol, xylitol and sorbitol their calorie savings, common GI pitfalls and xylitol's unique dental benefits and the long term safety of common sweeteners. Do they raise cancer or heart disease risk? If you're a subscriber and you want to watch the full video of this podcast, you can find it on the Show Notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy AMA number 74.

Peter, welcome to another ama. How you doing?

Good. Thank you for having me.

Yes, thank you for showing up. Anything interesting going on today? Anything recent going on?

Well, I was playing What I thought was the game of my life this morning in chess. And then I made a very tactical blunder and found myself on the receiving end of checkmate inside of two moves at the hands of my seven year old, which is becoming a constant theme these days. He's probably beating me six out of 10 games, which is simultaneously enjoyable to watch and infuriating to experience.

Yeah, I was gonna say, for people who have listened a while, read the book, the assumption would be you might not take losing to a seven year old in a mental game. Overtly positive. So what's the reaction? Like when you have a 7 year old, not only you have his friends lecturing you on diet sodas, which fits to this conversation today, and then they're beating you in chest.

Yeah, I hope that kid is listening. So I am actually not a competitive person. I think people are always surprised to hear that because they assume I am. I'm really not. I'm internally competitive. I'm not at all externally competitive. But chess is different. Chess is the only thing I do because you have to play against another person where I get insanely upset when I lose. And so I'm trying to teach the boys sportsmanship. So every time I lose, I put my hand across the table and I say, good game and we shake hands. And I have mostly done a good job of that. But a week ago, when Arie beat me, I took my king. Well, he was going to beat me, so I was resigning. So I was, I wanted to just tip my king over, which is to say I resign. Or maybe he had checkmated me and I put my king down. But anyway, I was so pissed I smacked my king across the room and my wife happened to be sitting there and see this and she is like amazing modeling there, Peter. Like, what a great job of a 52 year old modeling for his two boys. How to be a sore loser. Good for you. Good for you. Just, just. So now you have your pissed that you lost the shame of the realization that your wife is right. Plus you're pissed at her for calling you out. I mean, it was not a fun couple of hours after that.

I just love the concept of you and your wife dual parenting. Except when you play chess and at that point your wife now has four children that she's looking after to make sure they don't do anything rash.

My guess is people who are listening right now who don't play chess are like, what are you idiots talking about? I hope that somebody listening also plays chess and can go, yeah, I get it, man, I get it sometimes. Look, I've seen videos of Magnus Carlsen taking a sledgehammer to a computer screen when he lost to a bot, so I get it.

So there's something to look forward to for you. You still have areas you can move up the ladder in reaction. And it's even better because most people haven't met your 7 year old. But for anyone who has the joy that he would get when you did, that is going to be great because I feel like he loves a little trash talk himself.

He does. His nickname is Little Bag Smoker and he just walks around going, I'm going to smoke your bags. Like I am going to smoke your bags.

I just love it.

So good.

It's all right. Well that tangent out the way, what we're talking about today is something we hinted at earlier, which you got lectured on at elementary school the other day, which was diet soda.

Yeah.

So today's topic is one that I think is interesting, not only because we get so many questions on it, but I think the reason we get so many questions on it is it's a topic people think about and are faced with decisions day to day. And that's everything around sugar and sugar substitutes. So we'll start looking at sugar, why we're wired to crave it, how it affects appetite, how it affects weight, how it affects metabolic health, natural sugar versus refined sugar, timing of sugar and how much that matters compared to how much you consume. And then we'll look at sugar substitutes, everything from aspartame to sucralose, stevia, monk fruit allulose, what their effects on weight, insulin, microbiome are, what we know about sugar, alcohols like xylitol, erythritol, what we know about the risk of cancer, cardiovascular disease, long term safety, and then hopefully be able to wrap it up with what your philosophy foundation is for, how you apply this knowledge for yourself and patients. So all that said, a lot of good stuff to get to. Anything else you want to add before we get rolling?

Two things. One is this is a topic we covered two years ago, maybe three years ago, and in working with the research team who did an awesome job in the preparation of this, what we saw was there had been so much additional literature on various topics, especially on the non nutritive sweetener side. So not so much on sugar per se, which we'll start by talking about, but on the sugar substitute side that I think this is a very important podcast. Even if you think you were fully up to speed on our point of view on this based on where we.

Were two years ago.

So again, science makes progress and I think a lot of progress has been made. That's kind of the first comment I would make. Second comment I would make is despite the fact that we're going to go down a bunch of rabbit holes, I want to make sure everybody listening is anchoring to a framework. This is where we're going to land this plane. Okay. Where I want to be able to land this plane is in a practical recommendation around the following scenarios, which is, if I'm currently eating a ton of sugar, is that okay? If not, am I better off switching to sugar substitutes, but at the same quantities of the food that I was eating before? The example I would give here is if I'm sitting here drinking six Mountain Dews a day, would I be better off doing everything the same, but moving to six diet Mountain Dews a day? So I want to be able to land that plane and talk about those trade offs. The second thing I want to be able to get at is really explore the nuance around what are the. What I think of as the three cases for artificial sweeteners. So let's just put the sugar question aside. And I really think it boils down to three cases. One of them is beverages. So I gave that example a second ago. Diet Mountain Dew versus Mountain Dew, Diet Coke versus Coke, et cetera. I want to make sure we understand that the second is in protein products. So this is either protein powders or protein bars. Why this matters comes down to something I don't think I fully understood until I got heavily involved with a company that makes protein bars.

David.

The David bar. What you don't realize until you get into the world of protein is protein is a brutal macronutrient to work with. The reason I will always maintain that if your goal is to get X number of grams of protein, do your best to get it in real food. Is that is hands down the best way to do it? If you're trying to hit 150 grams of protein per day, I would like you, and I would encourage you to get every gram of that through actual food. The problem is most people can't, myself included. Okay, so we are typically relying on at least one form of processed food in the form of protein. Well, largely processed foods in the form of protein fall into two categories. Anhydrous salty protein, meaning protein sources where the water has been stripped out and a preservative or two has been added, and that's usually in the form of jerky. Or a stick or something like that, or you're on a totally different path where you're going with a sweetened protein product, namely in the form of a powder to make a shake or a bar. Why? Why does that latter one have to be sweetened? This is the thing that, again, I didn't fully understand until I kind of got into the chemistry of this stuff. Basically, the short and long answer is protein is impossible to work with and it tastes horrible. That's what it comes down to. I think most people would be surprised at how difficult it is to to work with protein compared to carbohydrates and fat, and how abhorrent it tastes. So if you can't get all your protein in real food, which we want you to, and you're stuck supporting your protein needs with something that is processed, and you don't want to go down the dry, salty route, you're gonna have to ingest something sweet. And the reason is if you don't, you won't be able to consume it unless you have no taste buds. And even then you probably won't be able to tolerate the texture of it. So this becomes the second very important use case around artificial sweeteners is are you better off with an artificial sweetener or a real sugar in a protein product? The third use case comes down to treats. Do you like sweet treats? I love sweet treats. I love me some licorice. I mean, I just love anything sweet. I'm not particularly unique in that regard, but I do. And so that becomes the third meta case that I want to make sure people are thinking through, which is if I want something sweet and it's not fruit, am I better off eating something sweet that is sweetened with sucrose or.

High fructose corn syrup, or pick your.

Favorite thing or something that is sweetened.

With one of these artificial sweeteners?

Okay, I say all of that, Nick, to just make sure that the listener understands where we're going.

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