February 8, 2012

Nutritional Biochemistry

What are the side effects of aspartame, stevia, and other sugar substitutes?

Read Time 10 minutes

Once you realize how harmful sugar is (by sugar, of course, I mean sucrose and high fructose corn syrup or HFCS, primarily, but also the whole cast of characters out there like cane sugar, beet sugar, dextrose, corn syrup solids, and others that masquerade as sugar), you inevitably want to understand the impact of substituting non-sugar sweeteners for sugar, should you still desire a sweet taste.

Want more content like this? Check out my article on replacing sugar with allulose and my Ask Me Anything (AMA) podcast on sugar and sugar substitutes.

If you’re not yet convinced sugar is a toxin, it’s probably worth checking out my post, Sugar 101, and the accompanying lecture by Dr. Lustig. Sugar is, tragically, more prevalent in our diets today than we realize – our intake of sugar today is about 400% of what it was in 1970.  And it’s not just in the “obvious” places, like candy bars and soda drinks, where sugar is showing up, either.  It’s in salad dressings, pasta sauces, cereals, “healthy” sports bars and drinks, low-fat “healthy” yogurt, and most lunch meats, just to name a few places sugar sneaks into our diet.

I know some people have an aversion to aspartame (i.e., Nutrasweet, Equal) over sucrose (i.e., table sugar, sucrose, or HFCS).  In other words they think Coke is “better” that Diet Coke because it uses “real” sugar instead of “fake” sugar.   If you find yourself in this camp, but you’re now realizing “real” sugar is a toxin, this poses a bit of a dilemma.

There are two things I think about when considering the switch from sugar to non-sugar substitute sweeteners:

  1. Are non-sugar sweeteners more or less chronically harmful than sugar?
  2. What are the immediate metabolic impacts of consuming these products, relative to sugar?

Let’s address these questions in order.

Question 1: Are artificial (i.e., non-sugar or substitute) sweeteners more chronically harmful than sucrose/HFCS?

There’s no shortage of fear out there that consuming aspartame, sucralose, or other non-sugar substitute sweeteners will lead to chronic diseases like cancer or heart disease.  However, there is no credible evidence of this in humans.  One can actually make a convincing case that no substance ingested by humans has been more thoroughly tested by the FDA than aspartame.  The former Commissioner of the FDA noted, “Few compounds have withstood such detailed testing and repeated, close scrutiny, and the process through which aspartame has gone should provide the public with additional confidence of its safety.”  While it might be the case that you can harm a rat with aspartame, it seems you need to force the rat to eat its bodyweight in aspartame every day for a year to do so (I’m being a bit facetious, but you get the idea).   In fact, even water would be harmful to us in the quantities required to render aspartame harmful if we extrapolate from rat studies.

Since its invention/discovery in 1965, there is not a single well-documented case of chronic harm to a human from ingesting aspartame, and prior to its approval for human consumption in the early 1980’s it had been studied in approximately 100 independent studies.  A possible exception to this might be in the rare person with phenylketonuria (PKU).  Such folks lack an enzyme required to metabolize a breakdown product of aspartame.

So, aside from the rare person with PKU, does this mean aspartame is 100% harmless?  Not necessarily. 100% harmless is a pretty high bar.  “Harmless,” using air travel as an analogy, is not getting on an airplane at all.  Consuming aspartame is more like getting on a commercial airplane – statistically speaking you are very safe, but something bad could happen that we’re not aware of yet.  Consuming sugar in the amounts we typically do, by contrast, is downright harmful.  “Harmful,” by the air travel analogy, is not only getting on an airplane but skydiving with a poorly-packed parachute – you might make it, but you’re really taking a chance.

As far as other non-sugar substitute sweeteners go (e.g., sucralose, saccharin, stevia, xylitol), the same logic holds except that we don’t have quite as much data on them because most of them (see figure, below, for the most popular ones) haven’t been on our tables quite as long as aspartame.  However, to date there are no data linking these substances to the diseases people tend to erroneously link them to in casual conversation.


Sugar substitutes with molecular structures

Question 2: What are the metabolic differences between sugar and non-sugar substitute sweeteners?

The metabolic effects of table sugar (sucrose) and high fructose corn syrup (HFCS) are well understood, so I won’t review them again.  If you want a quick review of sugar and why it’s probably as chronically harmful as tobacco, see my previous post on the topic.  Also, Dr. Lustig and his colleagues last week published a paper in the journal Nature titled, The toxic truth about sugar, which you may want to check out if you have a subscription to Nature.  The press picked this up in spades, also, and here is one such story.

So how do non-sugar substitute sweeteners compare to sucrose/HFCS in the acute or immediate metabolic phase?  Most non-sugar sweeteners (e.g., aspartame, saccharin, sucralose, stevia) are much more potent in their sweetness relative to sucrose, and therefore require a fraction of the amount to give the same “sweetness” as sucrose.  So for these sweeteners, only a fraction of the substance is required for equal sweetness.  That’s why when you look at a can of Diet Coke it has no calories in it.  The amount of aspartame that’s used is so small (given its sweetness), it doesn’t even add a calorie worth of energy.  Hence, we consume a fraction of them, relative to “real” sugar to get the same sweetness.

Other non-sugar substitute sweeteners, such as alcohol sugars (e.g., xylitol, sorbitol), are not actually sweeter than sucrose, but they have very different metabolic and digestive properties.  Furthermore, one actually uses similar amounts of these sweeteners, relative to sucrose (e.g., substituting an alcohol sugar in the place of sucrose occurs at about a one-to-one ratio).  In other words, when consuming alcohol sugars you actually ingest non-zero calories of them.  This is why you’ll note non-zero amounts of them when you look at the ingredient labels of foods containing them.  Even a piece of gum sweetened with alcohol sugars contains 1 to 2 grams per piece.  While an excess of alcohol sugars can cause gastrointestinal distress (e.g., if you overdo it on these you can get diarrhea), in most people they do not cause secretion of insulin from the pancreas due to their distinct chemical structure (see figure of their structures, above).

The same is true for the first group of non-sugar substitute sweeteners I mentioned (e.g., aspartame, saccharin, sucralose), with respect to the lack of insulin response.  In addition to studies confirming this, I’ve also documented this in myself for xylitol (my personal favorite), aspartame (Equal), and sucralose (Splenda).  I cannot speak to the other substitute non-sugar sweeteners in myself, but these three compounds seem to pass through my digestive tract without ever alerting my pancreas (i.e., without stimulating insulin).  When I consume these non-sugar sweeteners neither my blood glucose nor insulin levels rise.

I should point out that some people have noted/suggested a cephalic insulin response to non-sugar substitute sweeteners.  A cephalic insulin response occurs when the pancreas begins to secrete insulin before the “meal” actually gets into the bloodstream – the usual step required for the pancreas to secrete insulin.  In other words, the anticipation of the meal leads to the release of insulin.  This has been documented in humans, and a few studies have attempted to elucidate the mechanism indirectly by using various drugs to attempt to block this response.  Furthermore, some have suggested that you can still experience the harmful effects of regular soda while consuming an equal amount of diet soda.  It’s not clear to me this is true.  First, this hypothesis has never been studied rigorously (i.e., prospectively and with random assignment in a controlled setting).   Second, if there is some cephalic insulin response to non-sugar sweeteners, it is probably significantly less than that of sugar in both magnitude and duration, based on the studies I’ve read.  To reiterate a common theme – this phenomenon is probably minimal in most people but significant in others.  When I work with people who seem to be doing everything “right” but can’t seem to make improvements (e.g., fat loss), I will usually suggest removing all non-sugar substitute sweeteners to test this hypothesis.

Lastly, there has been some recent discussion about how diet soda may cause even more harm than regular soda.  A few observational studies have commented on this, including a study released last week in the Journal of General Internal Medicine.  Due to time and space, I’m not going to comment broadly on this paper in this post (though I will write a great deal more about this sort of study in the future).  I do want to make one very important point that is true of virtually every study of this nature: it is impossible to make a correct inference without doing a prospective, random-assignment, controlled trial.

While the authors of this study acknowledge that “further study is warranted,” the lay press picks up the title of this paper: Diet soft drink consumption is associated with an increased risk of vascular events in the Northern Manhattan study, and fails to ask any questions.  While I am not trying to be overly critical of the study authors (whom I do not know, either personally or by reputation), I am actually quite critical of the press that like to report on bumper-sticker messages without reading the fine print.  Most people (including many policy makers, who are bombarded with this sort of bumper-sticker information) tend to form their opinions based on this sort of information.

A table from this study (Table 2) is shown below.  It’s a bit hard to read unless you click on it, which I’d suggest you do to see what I’m talking about.  The group of 163 people who consumed diet soft drinks daily had worse clinical outcomes than the group of 1,948 people who consumed no more than 1 diet soft drink per month (all self-reported).  That is, the people who drank more diet soda were more likely to have a vascular “event” (on a per person basis).  Seems pretty bad, right?  Is drinking diet soda actually causing this?

Well, let’s double-click on this question.  Note that the people who were consuming daily diet soda (relative to those not) also had a few other factors not working in their favor including higher blood pressure, higher circulating triglycerides, a higher rate of diabetes, higher BMI, lower HDL-C, higher pre-existing vascular disease, a higher rate of metabolic syndrome, and a higher rate of previous cardiac surgery just to name a few.  And in many of these factors the difference between the groups was very large (e.g., diabetes, history of peripheral vascular disease).  You will also note that both groups of diet soft drink consumers reported between 1,500 and 1,700 calories per day, below the national average, suggesting yet another problem with this sort of study — self-reporting.

The authors try to correct for this obvious shortcoming by employing a statistical technique called “adjustment.”  This means you try to “strip out” the differences between groups and see if the effect still holds.  I do not want to turn this into a detailed post on elaborate statistics (a topic I greatly enjoy), but it’s REALLY important that you understand why this is a dangerous way to conduct science.  The reason this is “dangerous” is that it only proves an association exists, not that there is any causal link between drinking diet soda and getting cardiovascular disease.

If anyone is really interested in the details of this, I actually reached out to my thesis adviser who did his Ph.D. in applied statistics at Berkeley at the age of 20 (and is one of the smartest people I’ve ever met).  Just to make sure I hadn’t gone too far off the reservation, I asked him his view.  Here was his response:

Do I buy the analysis? The unadjusted data (Table 2) is pretty hard to disagree with. The adjusted results are open to debate, because the conclusions depend on the form of the model that the authors proposed.  A Cox proportional hazards model assumes that the predictors enter linearly into the model. This form is chosen for computational and mathematical convenience, not because anybody has a convincing argument for why the model is correct. But it’s the most popular model out there for survival analysis.

Remember also that the study is observational, not a controlled experiment. The authors can’t conclude that the diet soda is the cause of the greater disposition toward a vascular event, only that there is an association.

My translation: Taken as-is (i.e., unadjusted) there is no way to draw any conclusion from this.  After statistical adjustment, you might be able to make the case that it’s worth looking into things further, but as it stands there is only an association between consuming diet soda and having a vascular event.

Want another way to think about? Think of a simple (and silly) example:  I once read (I’m not making this up) that people with red cars are more likely to get into car accidents.  Let’s assume this is true (though I can’t confirm it).  Does it mean owning a red car causes you to have a higher chance of getting into a car accident? Or is it more likely that someone who buys a red car may drive in such way that they are more likely to have an accident?  My guess is, even if this correlation between car color and accident frequency were true, there is no causal information contained within it.


Table 2 JGIM paper

Yes, it is possible the reporting of all behavior (e.g., intake) was accurate, and yes it is possible that, even when adjusting for these pre-existing differences between the groups, the outcome would have been the same.  But is it likely? It is very hard for me to believe this.

There is a reason I refer (only half-jokingly) to observational epidemiology studies as “scientific weapons of mass destruction.”  If you remember nothing else I write or say, please remember this: Never confuse association with causation.  If we want to definitively know the answer to this question, we need to design a prospective, well-controlled, random-assignment experiment.

So what is the upshot of all of this?

I would argue (along with a legion of others) that once you eliminate sugar from your diet, your cravings for sugar actually vanish.  So the question, rather than, Is it ok to consume sugar substitutes?, may actually be: Why do we need things to be sweet in the first place?

I think this is a personal choice, and something worthy of self-experimentation.  I know many people who have eliminated everything sweet (both sugar and non-sugar sweeteners) from their diet, and within weeks they completely lose the desire or craving for sweet foods.  Others (like me) still like the occasional taste of sweet things. One of my favorite snacks is home-made whip cream (heavy cream whipped with a touch of xylitol). But the point is this: despite occasionally consuming sugar substitutes I’ve really shed my pathologic need for sweet things.   There was a day when I needed something sweet with every meal.  That’s no longer true.  I go days without ingesting anything sweet and don’t miss it.  Other days, I feel like having some xylitol-enriched whip cream, or drinking a Diet Dr. Pepper, and I do so.  Would I be better off without them?  Maybe.  But now we’re well past first-, second-, and third-order terms.  (For a refresher on the concept of “ordered terms,” check out my post on irisin).

In summary, if you must drink a sweet beverage (or add sweetener to your coffee or tea) you are better off using a substitute for sugar than you are using sugar.  But if you want to be really sure, and you want to kick the habit of needing a sweet taste, you’re probably better off avoiding substitute sweeteners altogether.  If you want to be 100% safe, drink water.  Just don’t make it bottled water (though that’s a whole other story).  And don’t fly in airplanes or drive in cars, either.


Photo by Brooke Lark on Unsplash

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  1. Great writing, Peter. I just wanted to chine in that I got over my diet pop “addiction” by switching to club soda. The ice cold fizz was more than half of what I was missing. After about a year, I quit buying even that and didn’t miss it anymore.

  2. I find that aspartame and sucralose seem to fire up hunger pangs similar to what sugar used to do. Stevia does not seem to be nearly as bad for me, so I try to use it in moderation instead of the others. There are even some decent stevia-flavored soda flavors out there now.

    • Matt, another example of why EVERYONE needs to figure this out for themselves. Glad to hear you’ve been patiently experimenting with it. Keep it up.

  3. Sort of related question. I do have those Quest protein bars – which use artificial sweeteners (both with or without sugar alcohols).

    My question is – what is the real deal with “net carbs.”

    One bar has 21g of carbs, but 17g of fiber. They claim “net 4g carbs.”

    How is fiber counted as a carb, but then netted out? Does it or does it not affect insulin?

    That’s my magic question. 🙂

    • The calculation attempts to strip out the carbs that don’t really stimulate insulin, such as insoluble fiber or sugar alcohols. It seems to vary a bit across people, so to be “conservative” I just keep total carbs below 40-50 per day which, in reality for me, probably means my “net carbs” are around 20-30 gm/day.

      • Gotcha – so to be on the safe side, I ought to factor in that top number and not automatically assume the “net” is as trustworthy as it may seem. Better safe (and lower carb) than sorry!

        Thanks again for your extra-active involvement in the comment sections!

  4. Hi Peter! I’ve been reading your blog for awhile, but this is my first time commenting. I always enjoy your posts, and thanks for another great post about this topic — I know there’s a lot of debate ranging about sugars versus sweeteners, and I always like to hear new takes on it. 🙂

    I thought I’d drop in a bit of personal observation here as it might be interesting to some. I switched to a LCHF diet about a year ago, after eating a rather unhealthy diet for almost all my life. (My parents basically weaned me on Coke (normal, not diet) and I had a heck of a sweet tooth and ate junk all the time most of my life. I’m in my mid thirties now, and it’s honestly a wonder I didn’t end up fatter than I was on such an awful diet.)

    About 7 years ago, I randomly developed pulsatile tinnitus in my right ear. It’s tinnitus that sounds in time with your pulse, so it’s a constant dull thudding in your ear. Nobody knew why, so I was told to just put up with it. (Which sucked, for what it’s worth.) When it got worse about 3 years ago, so that it started interfering with my ability to hear normal conversations, a doctor did a CT scan and told me that there was a blood vessel on that side of my head closer to my ear than normal, and that I had probably come to “hear my pulse” through that. (And again, I was told to just put up with it.)

    Just one week after I went LCHF, my tinnitus started to go away. At first it was for about five minutes here or there, but it was the first time I had heard silence AT ALL for six years, so I really noticed it. It was blissful. Over the course of the following week, the silent periods grew longer, until it vanished almost completely. (And that was just one of the many, many health benefits I got from going low carb.)

    What I found interesting, though, was that it would come back at any time that I consumed anything with sugar in it. Only for a few hours, but obviously I noticed it.

    I also found over time that whenever I eat fruit on a regular basis (such as a half an apple a day) or high-carb veggies with a meal (pumpkin, sweet potato, etc) that it will set my tinnitus off as well.

    So I came to the conclusion that my tinnitus is related to how much carb I consume, particularly refined sugar, which is the biggest direct trigger.

    However, the other thing I noticed was that if I consumed things with sweetener in them, the tinnitus also came back, though not as strong, and only from higher doses than sugar. It was quite specific though, and I tested it plenty. Diet sodas with any sort of sweetener would cause it — they are generally designed to be very sweet, just like regular sodas — but putting a very small amount of sweetener in my tea would not.

    I was living in Japan at the time, which uses a wider range of sweeteners in drinks and foods and has a wider range of sweeteners on the shelf, so I tested it with stevia, aspartame, acesulfame-K, sucralose, luo han, erythritol, xylitol, maltitol, and goodness knows what else. Pretty much all of them set off my tinnitus, but again, it needs to be at a higher concentration than sugar — any dose of real sugar will set me off.

    Interestingly for me, erythritol really turned out to be the best of the lot, and I find it pretty hard to set off my tinnitus with it. So I tend to prefer it as my sweetener of choice, when I do choose to use sweetener. (They had an awesome sweetener in Japan that was 99% erythritol with a dash of luo han, it was perfect. Can’t find it anywhere else, which makes me so sad!)

    I don’t really know what any of this means in regards to sugar versus sweeteners, as it’s all a hypothesis for me — supposing that it was the sugar in my diet boosting my blood sugar? insulin? so that I constantly had the tinnitus, then fixing that problem theoretically fixed my tinnitus, but what does that say about sweeteners that aren’t supposed to affect blood sugar or insulin?

    Who really knows, but whatever it may mean, I’m able to use my tinnitus to gauge how well I’m eating. 😉 One thing’s for sure — the tinnitus was so debilitating in my everyday life that I will never, ever go back to a diet with any sugar in it. I can’t tell other people what to do with their lives, but I know firsthand now just how much sugar was ruining my life.

    Cutting sugar out really cut back on cravings for me, too, and has readjusting my “sweet tooth” so that fruit really does taste sweet now, and “normal” junk food tastes sickly sweet and ucky. So I really don’t feel the need to have much sweetness in my diet, beyond some blueberries here and there, and a few salad recipes that have apples or grapes to enhance the overall taste. Even tea is nice with no sweetener! I do like an occasional really sweet cup of chai, though. Thank goodness for erythritol on those days. 😉

    • Cassiel, thank you so much for sharing your experience with me and others. I have not heard of this before. Obviously it’s hard to draw a conclusion we can extrapolate to everyone, it’s pretty clear that you’ve figured out a way to mitigate this condition. What I like most about your story is the journey. Sometimes folks are too reluctant to try experiments on themselves and they are too willing to accept “feeling bad” as way of life. Thanks, again, for sharing.

      • Thanks for taking the time to reply, Peter! 🙂 I like to share my experiences — I always figure if what I write helps even one person reading it, then I’ve done some good!

        I first started low-carbing via Atkins, for weight loss… but once I realised all the health benefits, I just had to go out there and research as much as I could about it. That’s when I first found Gary Taubes’ books, and low-carb websites and forums, and Paleo communities, and realised how much info there was. And one thing it really taught me was to read, to consider, and then to experiment on myself.

        All the theories and information give you somewhere to start — but your body is the best guide to what’s best for you. So I’ve had a lot of fun testing things over the last year.

        Going low-carb — in particularly, cutting out sugar and gluten — not only cleared up my tinnitus, it completely got rid of severe eczema I’d suffered for 20 years, resolved my constant ongoing gastro problems, got rid of spider veins on my legs, gave me more energy, and allowed me to lose a ton of unwanted weight. And it’s allowed me to finally be able to better manage my lifelong battle with severe depression.

        Once I realised what a difference diet makes, there was absolutely no going back, and I am not sorry in the slightest. The hardest part now is to NOT be too preachy with other people. 😉

        Thanks again for helping to fight the good fight, and keep it up. Know that there’s lots of us out here supporting what you’re doing!

    • Cassiel, thanks for this comment. You have me thinking. I have a similar pulsitile tinnitus in my right ear that I developed over a year ago. My experience went like this. Started low carb around six years ago as a last ditch attempt to help with migraines and chronic daily headaches, after having tried every “natural” and pharmaceutical approach to no avail. Low carb resulted in a dramatic improvement, but did not eliminate headaches. I kept trying to improve upon this approach, eventually trending more paleo, more high saturated fat etc, but no further improvements were seen. I then stumbled upon the Perfect Health Diet about a year and a half ago. I was impressed with their discussion of disease processes including Migraines, and decided to try the version of their diet recommended for migraines. For me this meant adding 200 calories of the recommended starches (white rice, taro, sweet potatoes and some others) adding a lot of coconut oil, and taking all the recommended supplements. Very dramatic improvement, indeed near elimination of headaches. A few other pesky problems, like joint pain, went away as well. The only downside was that I developed the aforementioned tinnitus. MIne is not so bad as to affect my hearing, but is annoying none the less. I always assumed it was one or more of the supplements, or the coconut oil, although trial periods of no supplements and or no coconut oil, didn’t seem to make a difference. I don’t do any sugar or sugar substitutes–I guess I am one of the lucky few whose sweet tooth totally atrophied upon going low carb. You do have me wondering, however, if one or more of the “safe starches” I eat might be the offender! I’ll have to experiment.

    • Cassiel, I am so glad I came upon your post. I too started suffering from pulsatile tinnitus in my right ear randomly about a year ago. I was inspired by your story and started to eliminate foods and sweetners to find a possible culprit. It turns out that sucralose was the main factor. I hadn’t realized how much of it I was consuming. I am so happy to say that after cutting it out of my diet my pulsatile tinnitus has eased up, and for the first time in months and months I can enjoy silence. It has taken about two months for my body to recover from sucralose, and I am sure it will always be an issue. When I start to hear a whoosh in my ear now I know something had sucralose snuck into it and I don’t touch it again. Anyways, I hope you one day see this because I just wanted to say heartfelt thank you.

    • Cassiel, thank you so much for your post! I cut out diet sodas (I easily drank 5 diet cokes a day for years and years) and switched to water and my tinnitus of two years nearly disappeared after just a week. I thought surely that must be a fluke, drank several diet cokes one day and by about 4 that afternoon it came back full force. :/ I tried splenda drinks as well thinking it was the aspartame, but no luck, sucralose triggers it too. I came across this blog googling if Stevia caused tinnitus, I was going to try that next. 🙂 As much as I hate to give up diet cokes, you understand what a relief it is to have a moment of silence. I’m just going to have to find something else to satisfy my sweet tooth!

  5. Hi,

    When I was at the supermarket I was reading the labels of sugar substitutes and it amazed me that the carboydrates per 100g are the same as for sugar. Which I believe is 100 per 100g?

    So being on a low carb diet, wouldn’t the artificial sweetners have the same effect from a carbohydrate intake perspective?

    • This is where the “net carb” argument comes in, since most do not stimulate an insulin response, so they don’t “act” like carbs in our body. That said, I don’t count net carbs, and aspire to keep all carbs below about 40 gm/day.

      • Peter how many gms of carb do you calculate heavy cream as? The carton says <1 gm per TBS. So do you calculate a cup of cream (your fat shake) 16gms or 8gms?

      • Why not use net carbs? Dr. Slavin, the world’s expert on fiber, says we should. Insoluble fiber is indigestible, it can’t have any effect on blood sugar – she’s stated that position for the record. Or do you have other strong evidence-based information? Would love to see the URL for that study! Ty.

        • I don’t bother with net carbs because it’s easier for me to keep track of total carbs and it’s a “higher bar” so to speak. In other words, if I keep total carbs below 40-50, I know I’ve kept net carbs far below that.

        • Ty for that Peter! So you use total carbs simply for ease of accounting and would rather have a little less subtraction than optimal fiber. I hear ya.

  6. Thank you for yet another great article, Peter.
    Do you have any thoughts or data on sweeteners used elsewhere that aren’t available in the United States? Sodium cyclamate is approved as a sweetener in over 55 countries, including Canada, though it is banned in the US. I prefer its taste (and lack of an aftertaste) to that of either aspartame or saccharine. In Switzerland we use cyclamate under the brand name Assugrin.

    • James, I am not familiar with these, sorry. It would not surprise me if the same logic held, though. Of course, I can’t speak to the regulatory process outside of the U.S.

    • I remember when they banned Cyclamates in the US in 1970. I used one drop in my bowl of cereal and from what I could calculate, I would have to drink 567 sodas daily to be at risk from cancer from Cyclamates. The US continued to allow the sale of Saccharin which became banned in Canada in 1977. Most bans on Saccharin and some on Cyclamates have either been lifted or are under appeal.

  7. I just wanted to say this is a great post, very informative. Thank you for the time you spent writing and researching. I’ve shared this post with several people already! Looking forward to the next one 🙂

  8. Peter,
    You mention sugar and HFCS and various other sugars, but didn’t mention honey (50% fructose and 50% glucose) and Agave Nectar (in some cases as high as 92% fructose). I mention this because many people are under the impression that natural products are fine for some reason and are even healthy.

    According to Dr. Robert Johnson glucose does not seem to have the same ill effects as fructose. Yes it raises insulin (obviously) but because it doesn’t follow the same metabolic pathway as fructose and so it doesn’t do the kind of damage that fructose has been shown to do. Is my understanding correct?

    On the topic of sugar substitutes, I’ve been using Stevia based products. Of these I like Truvia and NuStevia (The zero carb, version) in terms of taste. Other Stevia products I’ve tried such as SweetLeaf are quite distasteful. The NuStevia is so potent that I need just a sprinkling of it in my tea/coffee. It’s probably about 1/8 tsp if that.

    Coming to the point, I believe stevia has stalled my fat loss progress. I’ve never been a soda drinker but I do prefer my tea/coffee sweetened. I’m been on a low carb diet for the last 6-7 months and introduced Stevia about 2 months into it and have been pretty much the same weight since.

    In order to kick my fat loss into higher gear (I hope) I’ve been on a strict ketogenic diet since the 1st of the month and if I haven’t lost any fat by the 15th then I plan on removing stevia from my diet. My diet (each meal) is about 85% calories from fat with about 100g of protein divided across 3 meals and carbs not exceeding net 20g per day. I feel great physically and mentally but no fat loss yet.

    Just to be clear I count 1gm of carb for each cup of tea/coffee in my daily total carb count. I’d like to lose 35-40 pounds (currently at 20% body fat) bringing my BMI to 23. So it’s not like I’m trying to lose the last 3-5 pounds.

    My blood glucose (starving or 2 hours after a meal doesn’t matter) hovers between 79-83. I haven’t checked insulin and intend to buy the meter and sticks to test blood ketone levels.

    If I were to test my insulin after ingesting stevia, how would I go about it? I mean I realize I need to get my blood test done but what exactly do I tell my doctor and what protocol should I/we follow?

    • Yes, this is a GREAT point about honey and agave. THANK YOU for mentioning it. See my Sugar 101 post for my comments on glucose versus fructose. To quote Lustig, “it’s a numbers game.” Currently, insulin levels can only be tested at a lab. Not possible to check it with a home device, the way glucose or beta-hydroxybutyrate can be checked.

      • Peter, I get that I need to go to a lab to get my insulin test done. But if I wanted to see if me having Stevia stimulates my insulin, how should I go about it? You seem to have done this and so I ask.

        • You’ll need your doctor to order the test (and you’ll need to pay for it). Lab draws a fasting level. You drink/eat what you’re testing. Wait 2 hours, re-check insulin.

  9. I’ve been enjoying your blog lately. One thing I might mention, for any dog lovers out there, is how *deadly* Xylitol is for dogs, I mean totally toxic. I won’t even have xylitol in my house, but accidentally wound up with some pudding that contained xylitol that sort of fell into my shopping cart. I didn’t want it, but since I found it when I was home I just decided to keep it and try it out. I had one, but it was awful tasting, but I ended up finishing it anyway. Put down the carton and went into the other room, but heard a sound from the kitchen, and there was my dog licking out the carton!

    Knowing its deadly properties I rushed her to the vet for a stomach pump. She turned out to be okay. They said that just licking the carton was probably not going to hurt her. But they did say it was good I’d eaten the whole pudding! Those snack sized puddings are not very big, but as little as 1/2 a small snack-sized pudding would have been enough xylitol to kill a dog the size of mine (45 pounds).

    Needless to say I put the rest of the puddings in the trash when I got home and will be even more stringent about what goes into my shopping cart, either accidentally or on purpose. 😀

  10. Dr. Attia,

    Is there a protein level that you recommend for a ketogenic state? Is there an amount that would be “too little”? Where you may lose muscle mass?

      • Does 1-2 gm/kg/day hold for larger individuals as well? Or should you just try to be closer to 1 gm/kg/day as 2 gm/kg/day could be well over the 150 gm/day you discussed elsewhere.

        • I’m about 77-78 kg, and I do about 1.5 gm/kg/day. One thing to keep in mind, when you are ketotic, you actually require fewer amino acids, as the ketones help preserve them, especially the BCAA.

  11. I rarely eat anything that needs sweetener except for the occasional treat. And I’ve found I dislike all sweeteners. Sucralose has an ammonia aftertaste to me and I’ve learned they use ammonia in processing it. Stevia tastes bitter even the pure stevia that seemed ok to me at first. I don’t like aspartame. Xylitol is ok but I have a dog and it’s highly toxic to dogs.

    I’m thinking about trying small amounts of prune purée (actually baby food) as a sweetener. It would come out to 1 gram of carb per serving with the amount I want to use in a particular recipe. I know the fructose argument, but it’s a VERY small amount. Would this be harmful in small quantities? I sometimes eat a few blueberries or strawberries, very small amounts (5 small strawberries, 20 blueberries) and I don’t see that using the prune purée would have any more impact than that.

    • Janknitz, a limited amount of fructose is ok, depending on how you define “limited.” My preference for fructose-containing foods: raspberries, blackberries, strawberries, in that order. Because I’m in ketosis, I limit myself on days I eat fruit to no more than about 5 or 6 gm. As for baby food, you’ll need to do the math on what’s actually in it.

      • Thanks, the baby food prune puree I’m looking at is Earth’s Best organic–it contains ONLY prune puree and water. And the entire jar is about 11 net grams of carbs, I would divide that into 10 servings, so it’s pretty negligible.

        Not sure how it’s going to taste, but I’ll give it a try ;o)

      • Rice syrup contains only glucose, not fructose, and is supposed to be less sweet than sugar. I like the taste. I also use it in my homemade ice cream because it gives a better texture and isn’t as sickeningly sweet as ice cream made with table sugar. It’s a pretty good use for heavy cream!

  12. Peter, count me among your avid fans. Your blog is terrific all by itself, but I’m blown away by your generous responses to comments.

    I’ve been doing low carb/high fat for a year, reached my goal weight in about five months (I lost 23 pounds), and have easily maintained ever since. I have avoided all sweeteners, and usually use no more than one packet of Sweetleaf Stevia per day. One tip I’d like to share that might help someone else – I do eat some 85% dark chocolate nearly every day. When I find that I’m developing a craving for that chocolate, wanting more and more, it is usually a signal that I have slipped into old habits and am not eating enough fat. Adding more fat has, so far, always made those chocolate cravings go away, and it returns to being a nice treat of a couple of squares.

    The question that has been troubling me is whether it is possible to make myself more insulin sensitive by eating fewer carbs than I need to eat. I have found that I can eat between 45 – 60 carbs per day without causing any problems, as long as I don’t eat more than about 20 carbs at one sitting – and even then, it had better be in combination with a hearty dose of fat.

    However, although I can eat those 60 carbs per day, there are many days where I might not eat more than 10. If I do that (eat VLC) for too many days in a row, is it possible that my body will then decide that 45 – 60 carbs a day is now too much, and I won’t be able to do that any more?

    I am so glad to have been led to your site via Gary Taube’s blog. With my unusually slim shape for my age (52), I am now a walking advertisement for low carb, which is causing my friends and family to jump on board. It’s nice to be able send people here to get clear, concise information about this way of life. Thank you for that, and for all you’re doing to get the message out there!


    • Conni, thanks for your kind comments. In general, the more you consistently restrict carbohydrates, the more insulin sensitive your cells become. This implies that subsequent carbohydrate load will actually stimulate less insulin (than prior to carb restriction). I don’t actually know the answer to your real question (which I think is: if I fluctuate between 10 and 60 gm/day, does my body do worse with the 60 than it would have previously?). Two ways to think about this: the 60 gm/day in isolation (relative to a 60 gm/day from your previous eating ways, which would have been a low day), and in “totality.” You are certainly better off in “total” doing 10, 10, 10, 60, than you are doing 100, 100, 100, 60 — so that’s part 2. As for part I, I suspect you’re still better off, but I do not know for sure.

      • I think this point is very important, because the greater the variety of vegetables and fruits we can eat and not cause our insulin too soar too high, the better. In fact, it’s an argument that anti-low-carbers use: that we’re setting ourselves up for future problems by actively causing our bodies to be overly insulin resistant.

        If you’re saying that’s true, then it seems it would be rather critical for each of us to find the highest level of carbs we can eat and still lose or maintain our weight, and then keep eating at that level so as not to lose the ability to eat the widest variety of foods possible. I’m concerned about how to guide my family and friends so as not to cause them preventable future harm.

        Thank you so much for your response.


        • Well, I’m saying that’s the case, only that I don’t know the answer. The far bigger issue is the aggregate one — it’s clearly better being in the lower insulin-secreting space.

  13. Doc,
    Please help! What can one do to control the bad breath that comes with ketosis. My wife can’t take it anymore.

    • Mike, in my experience this goes away after sufficient time in ketosis when you body gets more and more efficient at utilizing the ketones. Timing is variable.

  14. I’ve been strictly low-carb for two years now after reading Taubes et al. and finding the argument very persuasive. I’ve also recently discovered this blog and thoroughly enjoy it. I’m grateful to you for making the obviously considerable effort to keep up both your original writing as well as maintaining a dialogue with your readers.

    I’d like to present some objective data about my personal experience with an artificial sweetener and ask a few questions about how you might interpret them.

    BACKGROUND: After an initial weight loss of 30 lbs. during the first few months of low-carb, I’ve been more or less stuck with 120 lbs. left to go. Not surprisingly, this is really frustrating and my eating plan has lost all credibility with my wife and others who say “If low-carb is the key, why isn’t it working for you?” Anyway…my doctor, who is generally positive about low-carb, keeps latching on to one thing and another to try to explain my stalled state. The latest suggested culprit was Diet Coke (by implication, all artificial sweeteners) and the alleged insulin response to the Sucralose etc. I had actually stopped regular consumption of Diet Coke months before, but I still had the occasional large dose 3-5 times per month. So, I was pretty skeptical that this had anything to do with anything and, as a data junkie, I wasn’t all that interested in the bewildering array of merely anecdotal “evidence” out there on the topic. So, I managed to arrange a “glucose” tolerance/insulin level test, but without the glucose. The results surprised and confused me in equal proportions.

    DATA: I was fasted for 8 hours, and my fasting BG was 115 (yes, I’m borderline Type-2) and my insulin level was 32.6! Immediately after the first draw, I slammed down my drink of choice–a 52 oz. QT cup of iced Caffeine-free Diet Coke. It took me 6 minutes to get it down–quite a feat, I have to say. Here are the remaining insulin results: 30 minutes – 41.7; 60 minutes – 32.2; 120 minutes – 23.1.

    Since I obviously couldn’t run the experiment with glucose simultaneously, I have to wonder what those data would have shown. It would have been interesting to compare. Maybe glucose would have caused a 300% rise in insulin–who knows? That would at least have given some sense of proportion to the rise caused by the Diet Coke. Guess I’ll have to wait on that one.

    While my doctor found the test results interesting, she interpreted them straightforwardly as support for her Diet Coke theory but had little else to offer and, naturally, had no time to really thoroughly discuss the implications of the results.


    1) First, after 2+ years of seeing several doctors including endocrinologists, who all obsessed about making sure my BG didn’t get too high (it’s under pretty tight control with A1C at 5.3), no one ever suggested testing my insulin levels. I was pretty dismayed when I saw the 32.6. From what I have read, 2-10 is a normal healthy fasting insulin level. If insulin is so short-lived in the system, what might explain such an elevated FASTING level? Could this piece in and of itself hold a key to understanding long term non-weight loss?

    2) Given the high starting point and the transience of the effect (gone at the 60-minute mark), is it likely that the 9.1 point increase (+28%) after consuming the Diet Coke would have any significant effect on fat retention, assuming, of course, that one wasn’t consuming this quantity of Diet Coke every hour or two?

    3) I understand the notion of cephalic response–really no more mystifying than one’s mouth watering when thinking about or seeing tasty food. But, if the analogy holds, one’s mouth doesn’t go on watering long-term (Homer Simpson being an exceptional case, I suppose). In this instance, I was certainly not excitedly anticipating the taste of the Diet Coke and forcing that amount down in six minutes was anything but an enjoyable taste experience. So, has anyone actually measured the magnitude of cephalic response, which I’m sure varies widely? Are there any data out there indicating how much this seemingly transient effect might actually matter in terms of overall body fat regulation?

    Note: In support of the anti-artificial sweetener position, my doctor cited a study that found that the small intestine has taste receptor cells similar to the tongue’s that are sensitive to sweetness. The implication was that artificial sweeteners could trigger these and contribute to the cephalic response. (If it’s true, I guess we can be grateful that it functions unconsciously as the idea of tasting the contents…well, you get the idea). I read the study and didn’t find it all that compelling, but what do I know? Are you familiar with this study or with this theory?

    I apologize for the long posting. I hope that the objective test results showing that Sucralose did, indeed, seem to cause an increase in insulin level will be of general interest and I would definitely appreciate any insight you can share regarding the issues in the questions I’ve raised. Thanks.

    • Hi Mitt, thanks for your questions and appreciation for the blog. Unfortunately, I can’t respond completely to questions of this nature on a blog for several reasons, perhaps the most important being the legal one (I’m not permitted to practice medicine via a blog). Hopefully the information in the blog and in other references can help answer your personal questions. It is clear, by calculating your HOMA-IR, that you are insulin resistant. It’s great that you were able to gather such data and I sure wish more doctors were willing to do this sort of work to really get at the individual level of what’s going on. Your doctor was wise to do this test. There are folks (like me) who do not appear to have much of an acute insulin response to sugar substitutes. What I don’t know is if there is a more long-term impact on insulin sensitivity from these substances.

      As for your question about the cephalic insulin response, it’s not actually clear (to me, at least) what is mediating the trigger or the duration. I’ve seen papers suggesting parasympathetic mediators (i.e., the same transmitters involved in saliva secretion). In fact, I just read a paper from PNAS suggesting that other (non-glucose) circulating nutrients can stimulate the beta-cell and potentiate the glucose-triggered response of insulin. Clearly “we” don’t know enough to provide definitive guidance. When in doubt, though, cut it out.

    • Its worth noting that distension of the gut also causes secretion of insulin. So drinking such a large amount of Diet Coke might have been sufficient to prompt an insulin response through this mechanism, despite aspartame’s (probably) negligible affect on insulin levels.

      This should also be applied more broadly when considering your diet. If you consume large meals, even of seemingly innocuous foods, the quantity might spike a disproportionate insulin response. I seem to recall Dr. Bernstein stating that you can feed a diabetic rocks and still get an insulin response.

      • Scott, I’m not sure this is true in general. Obviously, anything can be true for some folks. Gastric distention may cause some component of satiety, though not insulin secretion in most.

  15. Peter,

    Is it wheat or sugar that is killing us? I would love a commentary on this subject from you or Gary Taubes. I read “Wheat Belly” by Dr. Davis and then listened to dr. Lustwig’s lecture on sugar. Seems there is some contradictory messages out in the low carb world. Perhaps you could help enlighten?

    Although dr davis’s “wheat belly” lacked the scientific rigor that dr lustwig applied it appears to be very popular in the mainstream.

  16. Hi Peter, Thank you for taking the time to make this wonderful website! It’s very informative and easy to read. Just wondering, what advice do you have on organic vs non organic meat? grass fed vs. grain fed beef? I would like to eat more organic but the cost is prohibitive. Is it worth it? Also, do you believe that consumption of animal products contributes to global warming? I’ve heard both sides on this issue and am wondering where you stand on this. Thanks again for your work!

    • Aaron, all things equal, I would prefer grass fed meat over grain fed meat because of the increased omega-3 over omega-6, but there is an economic difference. If it’s “worth it” is a personal decision that depends on other competing priorities. It’s probably not worth it if paying rent is tough. I don’t know enough about the last issue you’ve asked about to have a credible opinion (yet, at least).

  17. I’m not Peter, but I can’t resist. Are all these meat animals contributing to global warming?

    The January 1, 2010 inventory of cattle and calves [was] at 93.7 million


    In the early 1800s, there were 30-60 million buffalo roaming around (to say nothing of untold numbers of deer and antelope).


    If the effects of all those critters in the early 1800s didn’t bring the ecosystem crashing down, I doubt there’s going to be a problem today. 🙂

    P.S. I’m old enough to remember Global Cooling, which was blamed on many of the same things Global Warming is now. TMTCTMTSTS

    • Interesting links, thanks Marilyn. As I understand it, the problem it has more to do with the nature of industrialized agriculture than the number of animals being raised. How our eating choices impact the environment is an important topic worth exploring. (Though not completely related to Peter’s work).

  18. On 2/8/12 James P wrote:

    I am concerned about my own mother. She is 61 years old and has metabolic syndrome. She is overweight & has been diagnosed as borderline Type-2 diabetic. She has also read “Why We Get Fat” and for the past 2 months, she has begun following carb-restriction ideas and no longer eats traditional sources of carbs. Her observation is that she has not seen any amount of on-the-scale body weight change either up or down. Her clothing is not any tighter or looser.
    James, that’s because your mother probably doesn’t have Metabolic Syndrome. She probably has Metabolic Syndrome XX (MSXX). From my comments on Chris Masterjohn’s blog —
    It was after reviewing their blood tests over and over again that I realized I was seeing a pattern, and one that had left them undiagnosed for insulin resistance/Metabolic Syndrome for years, despite the fat gain and complaints. We who have MSXX do not fit the MS category — at all. We have high HDL and low TG. We have normal blood pressure. We have normal TSH, and rising but still normal A1c and fasting insulin (most of the time; hyperinsulinemia is seen in 100% of women who took HCG injections). Yet we are fat. We are tired. We are cold and we often offered tranquilizers for our clearly deluded minds.

    In MSXX however, the symptoms are quite different from those in MS. With MSXX, the particular flavor of IR is PCOS, regardless of age, regardless of menstrual regularity or ability to get pregnant. Unschooled doctors often insist that PCOS isn’t there when it is. Insulin levels are usually normal, but insulin in MSXX is bone-ass lazy. It just can’t do the job. Thus, 1-hr PP’s are often lower than 2-hr PP’s – a major MSXX symptom.

    Gluconeogenesis is out of control. We are exquisitely sensitive to Cortisol. As a result, when *we* do “Body By Science” workouts, we may put on muscle — but we *always* put on fat around the middle. Impossible, but true. The slightest amount of excess protein sends sugars way up, despite eating no carbs but veggies. Reverse T3 is enormous. Free T3 and Free T4 are in the basement. Temps are incredibly low, and energy is negligible. It’s very difficult for women with MSXX to achieve lipolysis, despite very low calories and carbs. One symptom of untreated MSXX is water loss and gain of the same 2 – 5 pounds, over and over and over again.

    The Protocol treats and reverses all that. All of it. Although for the most resistant cases, Metformin is necessary. In fact, in helping so many women with it, I finally had to ask myself if female obesity and male obesity are somehow different. My answer now is: Yes. This helps explain why so many women follow Taubes, Groves, Lutz, and Attia to no avail. What those men, who I greatly respect, know most about is male obesity, and their advice seems to work wonderfully for men. For women, it’s hit or miss. For women with MSXX, it’s always miss. Especially if they go VLC for an extended period, which invariably shuts down their metabolisms with massive thyroid hormone problems.
    James, I hope you and your mom read the full comments, and then go to the blog to read the Protocol Participants journals to see if they fit your mom’s parameters. I bet they do. If so, the Protocol can help her.

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