Nutrition Essentials: Are You Risking Your Health Using Artificial Sweeteners? with Stanley Hazen, MD, PhD

Podcast Transcript

John Horton:

Hello, and welcome to another episode of Nutrition Essentials, an offshoot of our popular Health Essentials Podcast. I'm John Horton, your host.

So-called diet foods occupy a lot of shelf space at the grocery store. These products often promise the sweetness our taste buds crave without the sugar and pesky calories that come with it. How do they do it? The secret is often artificial sweeteners such as erythritol. This sugar replacement debuted in the food game more than two decades ago. Now, it's found in many items probably sitting in your pantry right now.

But there's growing evidence that erythritol and similar artificial sweeteners may come at a health cost far more concerning than a few extra calories. So today, we're going to take a closer look at research revealing how these sweeteners are closely associated with increased risk for heart attack, stroke and other concerns. As always, we have registered dietitian Julia Zumpano with us to cover the issue from the food and nutrition side. To learn more about the risk of artificial sweeteners, we're joined by a renowned physician-scientist at Cleveland Clinic who helped author several studies on the topic. Julia, can you introduce our guest?

Julia Zumpano:

Absolutely, John. We're joined today by Dr. Stanley Hazen, a researcher who has made pioneering discoveries in cardiovascular medicine. He's among the most cited researchers in the world and is listed as the inventor on more than a hundred patents. Dr. Hazen recently led a study that looked at the relationship between sugar alcohols, a type of artificial sweetener, and cardiac risk. The findings affect all of us, given how many foods contain erythritol and similar sweeteners. I'm looking forward to learning more about what he and his team discovered.

John Horton:

You and me both, Julia. So let's get this conversation started. Welcome to the Nutrition Essentials Podcast, Dr. Hazen. Thanks for joining us to chat about some of the eye-opening health risks connected to artificial sweeteners used in so many of the foods that we eat.

Dr. Stanley Hazen:

Oh, thank you for having me.

John Horton:

So we just have so much to cover here today, Dr. Hazen. But I'd like to start with something you mentioned when we spoke ahead of this podcast, namely that your ongoing research on heart disease risk factors didn't start with a focus on artificial sweeteners. Your findings just kind of led there.

Dr. Stanley Hazen:

That's correct. We've been interested in trying to identify what risk factors contribute to heart disease outside of the traditional risk factors like high cholesterol, diabetes, hypertension, obesity. And the way we've been doing that is by looking at plasma samples, blood samples collected from subjects who were followed over time, and then, trying to identify chemical signatures in the blood that predict the future of disease, like heart attack, stroke and death independent of the traditional risk factors. And it was during these types of analyses that we started to see that some of the compounds in the blood that were predicting future event risk, were the very same types of compounds that are used currently as sugar substitutes.

John Horton:

Wow. I guess you just never know what you're going to find when you start looking around.

Dr. Stanley Hazen:

That's correct. This is a kind of an unbiased approach to identifying new pathways, and it really led us into this discovery that many of the exact same compounds that are being used now commercially as sugar substitutes, they're actually natural compounds that our body makes, but in very small amounts, and they play a role in our energy metabolism.

But when used in large amounts, the taste bud on our tongue thinks they're sweet. And because they trick the taste bud into thinking it's a sweet compound, but they don't carry the calories … more recently, in the last decade or so, they've started to really be used in large amounts in the food industry as sugar substitutes or artificial sweeteners in the keto foods, the zero-calorie, many of the newer products that are coming out where the emphasis is on lowering the calorie count on the label with a sugar substitute.

John Horton:

Well, so let's dive into your research a little bit here and what exactly you found that really kind of raised the alarms.

Dr. Stanley Hazen:

So when our studies began, we were looking, as you said, for compounds that predict future development of disease. And compounds like erythritol or xylitol, which are also being used as artificial sweeteners, the circulating levels of these track with future risk of heart attack, stroke or death.

We began with studies with over a thousand subjects as a discovery cohort. Once we thought we knew what the compounds were that were tracking with risk, we developed improved assays that were very specific for them, and then replicated it in a very large U.S. cohort with thousands of subjects, and then a European cohort, and saw just the same associations kept replicating.

Now, association in a large clinical study doesn't equal causation. So to move beyond that, we started doing mechanistic studies with animal models of disease, studies with whole blood, studies with isolated platelets. That's a cell type in our body that helps form a clot. And what we found is that these compounds like erythritol or xylitol actually change how our platelets function, and makes them more prone to clot and more associated with heightened what we call thrombosis potential. And a heart attack and stroke is a clot, a thrombotic event.

John Horton:

That's just incredible, the way that you get these sweeteners in. And it just sounds like they do something in your blood and those clots get bigger and you have to worry about these things happening.

Dr. Stanley Hazen:

So what people have to realize is they don't make you spontaneously form a clot. What they do is increase your risk for clotting. They lower the threshold for clotting. So the way to think about it is that after ingest- …The other thing that we did is we gave healthy volunteers an artificially sweetened drink with either erythritol or glucose, for example, and saw that for the following several days after ingesting a typical portion size, the plasma levels, the blood levels stayed high enough to enhance clotting risk for that period of time.

John Horton:

Wow.

Dr. Stanley Hazen:

Now, it increases the risk by about a factor of two to four, somewhere in that range during that time.

John Horton:

Just from one drink, one can of a diet soda, and you're looking at a couple days of this increased risk.

Dr. Stanley Hazen:

That's true, except it's not a diet soda. You have to, unfortunately, read the labels. And so, most of diet soda like Pepsi, Coke products, those use a different artificial sweetener. They use something called Acesulfame K and aspartame. Those we have not really studied yet.

This is focusing on the sugar alcohols like erythritol, xylitol, anything that ends in an “itol” or is what we call a “polyol.” So on the label, it will say things like “polyols,” “sugar alcohols.” Sometimes, it'll even say something vague like “naturally sweetened” or “artificially sweetened.” And if they don't list the names, the regulations don't mandate that they do.

John Horton:

And that increased risk, I think you said it was a two-fold risk, how does that compare to some of these other things that we know are bad, like smoking or drinking alcohol or things like that?

Dr. Stanley Hazen:

So that's a good question. Something like smoking increases risk, but it's actually to a lesser extent, believe it or not. So that would be, typically, smoking would be a 25% increase in risk, not a doubling of the risk, which would be like a 200% risk. So what we found for erythritol, for example, is subjects whose levels were in the top quartile, meaning the top 25% of the population, they were at twice the risk for a heart attack, stroke or death in the ensuing follow-up period, which was three years compared to subjects whose level was in the bottom quartile. If you look at blood pressure for example, and say, "What about people whose blood pressure is in the top quartile versus the bottom quartile?" The risk is not a two-fold. It's less, like one-point-five-fold or one-point-three-fold, something like that.

John Horton:

Yeah. Well, that's enough where you look at these numbers and just like you said, how much higher that risk is. And it is the sort of thing that draws your attention. So we've been throwing out some names here of artificial sweeteners — erythritol, xylitol. I know there's a lot of other “itols” that folks might not really be familiar with. So Dr. Hazen and Julia, can you give us a quick rundown of kind of what these sugar alcohols are and how they're used?

Julia Zumpano:

Sugar alcohols — the name is quite misleading actually. There's actually no alcohol or no sugar, table sugar, in sugar alcohols. But they're a type of carbohydrate that have a chemical structure that's similar to sugar. They do naturally occur in foods and are made by the body, but levels that are present are very, very small. But most sugar alcohols are found in packaged foods and are man-made and manufactured. So that's really the issue, is that they're manufactured in such high volumes.

So these sugar alcohols obviously sweeten products while reducing calories, and they stimulate your tongue's sweet taste buds, which adds flavor without the extra calories or sugar. And then, food companies also can market them as being low-carb, sugar-free, diabetic-friendly without sacrificing the taste of the food product. So you'll find them, and the sugar alcohols end in “ol,” like Dr. Hazen mentioned, besides the isomalt, which is also a sugar alcohol. So these are the things you want to be mindful of when you're reading nutrition labels.

Dr. Stanley Hazen:

So one of the things I wanted to amplify on what Julia mentioned is how they're made. It is totally artificial. They're brewed or fermented in vats by bacteria or yeast. And it's actually cheaper to make some of these sugar alcohols than it is to grow sugar cane and isolate sugar. That's one of the driving factors that's bringing them and introducing them into the food chain because it's cheaper for the food manufacturers to use it. And plus, they get the potential added benefit of not having to raise the calorie count on the label.

And in all fairness, no one knew that these had this adverse potential side effect when used in these levels. But the levels that are being used by the food industry are literally just super, super physiologic, outside of the normal range by a thousand-fold at least. So you'd have to literally consume 500 to 1,000 watermelons to equal the amount that we're talking about in what might be in a serving size that uses it as a one-to-one replacement for sugar. And that's actually how erythritol is used as a supplement. It's purchased in a bag just like sugar, and it's recommended to be used as a one-to-one replacement when you're baking or to sweeten it like a drink, for example.

John Horton:

Dr. Hazen, the example you gave when we were talking earlier, which, it stuck with me, was comparing a shake of salt from a saltshaker to a salt lick and the giant thing you put out. And that really just struck home with me, just as kind of the volume and difference that you're talking at here with what might be safe or OK for consumption versus what's being thrown in a lot of these diet foods.

Dr. Stanley Hazen:

It is astonishing that it's allowed to happen, but once compounds get what they call “GRAS designation,” “generally recognized as safe,” they're grandfathered in and nothing has to be done to test them other than what's the maximum tolerated amount that doesn't cause side effects like GI bloating and problems. And basically, that's the only type of safety studies that have been done, is if you keep escalating the dose, at what point does the person say “uncle,” and then, that's the maximum amount.

John Horton:

Well, and that actually was leading right into my next question, which was, just how are these sweeteners just ever approved for consumption? From everything you've said, this just doesn't sound like stuff that we want to all be chowing down on regularly.

Dr. Stanley Hazen:

Well, because they're natural compounds, they automatically have a degree of ... it's a much lower bar to go through. And when the FDA was first established, basically, any organic compound that was considered natural already got listed as potentially GRAS status. And then, only a very bare minimum of safety studies have to be done by the food manufacturers before they can begin selling it. And that's just to demonstrate what the upper end of tolerability is.

John Horton:

What does GRAS mean again?

Dr. Stanley Hazen:

Generally recognized as safe.

John Horton:

Which is just a scary-sounding term. I've got to be honest. I want to know what I'm eating is just safe, not “generally recognized as.”

Dr. Stanley Hazen:

It's a term that the FDA uses for identifying things that get added to our foods.

Julia Zumpano:

The whole class of artificial sweeteners fall within that category as well. That generally recognizes safe status from the U.S. Food and Drug Administration. So it is kind of a sketchy gray area. Like Dr. Hazen said, a lot of them have been grandfathered in. And we've had ongoing studies regarding all the artificial sweeteners, and I don't know if there's enough data to support them to consider them to be unsafe. Would you agree, Dr. Hazen?

Dr. Stanley Hazen:

Well, I certainly do. And in fact, the World Health Organization recently reevaluated aspartame, saying that it was withdrawing its recognition of that. And they were concerned about not cardiovascular risk, but potential cancer risk associated with aspartame use. We've done nothing in terms of aspartame or with cancer analyses. In fact, as we mentioned in the beginning of this, we were looking for cardiovascular risk, new pathways, and that's how this whole cauldron of problems has boiled to the surface in terms of sugar alcohols and sugar substitutes showing up as compounds in our blood whose levels are predicting future risk for cardiac events.

John Horton:

Now, someone is listening to this and after hearing everything, they decide they want to just avoid artificial sweeteners like erythritol. I understand the problem is, they're not necessarily going to be able to do that just by reading food labels, right?

Dr. Stanley Hazen:

That's true. But I think there are some ways you can really be pretty safe in terms of avoiding them. I don't think it's something that is beyond what is possible. You can, first of all, just simply avoid any of the products which are labeled as “keto” and “zero-calorie,” and yet they're still sweet. They have to have some form of sweetener in them, and sugar, of course, calories, and you'd see “sugar” or “glucose” or “dextrose” on the label.

Julia Zumpano:

That's also my rule of thumb as well, Dr. Hazen. Anything that says “diabetes-safe,” “sugar-free,” “no sugar,” “low sugar,” “artificially sweetened,” even “naturally sweetened” can be very deceiving and confusing. “No-sugar-added,” “low calorie,” “calorie-free” — any of these terms indicate that they may be low sugar or no sugar at all. But if that item tastes sweet, it has some form of artificial sweetener in it.

Dr. Stanley Hazen:

The other thing is, is they often don't use them as a single compound, but as a blend. And so, even with artificial sweeteners that you think, "Oh, this one might be safe," like a sugar substitute that's a plant extract like stevia, it needs a carrier because it is so super sweet, like hundreds-fold sweeter than sugar, that if it's in a granular form, it needs a carrier. Now, it could be sugar, which is the carrier, like a very small amount of sugar spiked with the artificial sweetener.

But all of these artificial sweeteners, whether it's a blue packet or a pink packet or a yellow packet, the carrier is either sugar or often it's erythritol. And so, I would argue to avoid those types of artificial sweeteners that are granular and use the ones that are in a dropper because those tend to be the pure form and a very, very high amount. So a tiny little bit is then used if you have to use anything.

Alternatively, better to use, I think, honey or sugar or fruit, but in moderation, and just keep track of the calories. And if you're diabetic, monitor your glucose. Not a lot of sugar can add enough sweetness to satisfy a person's palate most of the time.

Julia Zumpano:

One comment on those droppers, too, that I want to add is when you buy stevia in a dropper, stevia on its own actually has a bitter flavor. So if you use it in excess, it will start to taste more bitter. It's naturally self-controlling. So a drop or two is just enough to add a little touch of sweetness if you're looking to avoid sugar sweeteners, sugar-containing, calorie-containing sweeteners. So those types of things are really helpful because again, anything that can self-regulate you will help you limit the consumption. But they add these artificial additives, the sugar alcohols to the packets, which then make them more palatable and then again, allow you to over-consume that, too. So I think that's really important to note to the benefit.

John Horton:

Yeah.

We always like to give our listeners some tips they can use in the kitchen. So what's the best way for them to build a diet that keeps you away from foods loaded up with these artificial sweeteners?

Julia Zumpano:

Well, we know we want to keep it to basics, right? So a whole-foods diet, getting your sugar cravings from things like natural fruit and even dried fruit can play a role depending on if you're diabetic or not. Again, you've got to read labels, check what's being added. Whole-foods-based diets can really help.

Commonly, I see that people who are over-consuming sugar or even artificially sweetened foods aren't eating enough whole foods, so their body's just kind of searching for nutrients. And if you're not getting enough protein or enough fiber and you're consuming too many carbohydrates or sugar-containing foods, those are consistently going to be addicting. You're going to be consistently driving toward those foods. So it does require a little bit of a taste bud change away from that sweetness and using natural whole foods as much as possible. So that's where some of that transition lies. And slowly decreasing these artificially sweetened foods, replacing them with real sugar, as Dr. Hazen mentioned, in the form of honey or maple syrup or actual table sugar or small moderate amounts of liquid stevia. But still, those are still not something we want to over-consume. So doing those foods in moderation.

John Horton:

Yeah. We had mentioned, as far as people who have diabetes and this kind of being an issue, because they will often kind of lean toward these sorts of foods to get that sweetness without having the sugar. What can they do in this sort of situation if they still want a little bit of that sweetness, but obviously, they need to stay away from too much sugar?

Julia Zumpano:

I think moderation is key here. As Dr. Hazen mentioned, these are large quantities of intake, so really, looking at what sort of sweetener is in the food you're consuming, how much you're consuming of it. So my goal is to try to wean those foods down slowly. So most of the time, I see them in drinks in the highest dosages, so really focusing in there and trying to transition the majority of their beverages being water.

Dr. Stanley Hazen:

Can I also add that diabetes is a coronary artery disease risk equivalent. So one of the things I want to reemphasize to any of the diabetes patients or subjects who are listening to this is that they should be working with their physician no matter what anyway about how do they lower their cardiac risk.

What I mean by a coronary artery disease risk equivalent is someone who has diabetes is at the same risk for their first heart attack as someone without diabetes who had one heart attack. And what's their risk for experiencing the second heart attack? And so, patients with diabetes in particular should be highly attuned to making sure their cholesterol levels are being monitored and treated to lower goals. Things like low-dose aspirin should be something to discuss with their physicians. And when it comes to these artificial sweeteners, they heighten clotting risk. And so, we don't know whether or not being on aspirin helps mitigate that risk, but there's every reason to expect that it should. And so, I still think if someone is diabetic, in addition to food, they should also be talking to their physician about what other medical problems they should take care of to lower their cardiac risk.

Julia Zumpano:

I have one more thing to add there, Dr. Hazen, great point. And then, also meeting with a dietitian, because that can really help. So sitting down with a dietitian, going through your diet, what you're consuming. And the dietitian can specifically provide recommendations that you and her or he or she can work together, and having realistic change and help you break down the label, break down what you're consuming, highlight the foods that may have those sweeteners, and really focus on healthy swaps to try to limit or avoid them.

Dr. Stanley Hazen:

Do you know, I'll just say one thing added to that — so many studies have shown in diabetes patients that seeing a nutritionist or seeing someone to review diet recommendations lowers their risk, that virtually all insurance companies cover meeting with a dietitian. And we have looked at and seen that the number of times per year that people meet with the dietitian, up to three, actually is dose-dependently linked to long-term survival. And other studies have shown that. So people who see the dietitian more frequently who have diabetes live longer, and that's why it's recommended.

John Horton:

Julia, you're saving people every time you come on here. That's what I'm hearing from this.

Julia Zumpano:

I love that. And I love that Dr. Hazen is supporting the data behind it.

John Horton:

Well, so much of the growth in the use of these artificial sweeteners seems to be rooted in a desire to just avoid sugar as part of healthier eating. Have we gone overboard in our vilification of sugar?

Dr. Stanley Hazen:

I think honestly, yes. The answer to that is “yes,” especially when we're replacing it with things that haven't even been tested or studied long term. I think something to also recognize is beyond the cardiovascular risks, there are many studies that argue that being on artificial sweeteners, for example, to try for weight loss or improve diabetes control doesn't necessarily work. There are some studies that show benefits, and even more studies that don't show benefits. And there are other mechanistic studies that show that being on artificial sweeteners can impact your gut microbiome and impact your susceptibility for developing diabetes and insulin resistance. And so, there are many possible reasons why ingesting these artificial sweeteners can not necessarily be the most healthful thing for you.

Julia Zumpano:

I want to add to that — Dr. Hazen, great points — but just in the practice of seeing patients, data aside, I noticed that patients who consume large amounts of artificial sweeteners really, really struggle losing weight. They struggle getting their intake of carbohydrates down, they struggle with a constant craving for sugar, a constant craving for carbohydrates. And it's very, very hard to work with them to get that craving controlled and under control. And in their head, they're thinking, "Well, there's no calories in this, so I can just consume it all day, right?” So we are providing these artificial sweeteners in such excess that they're really lighting up the brain, the pleasure centers of the brain. They're thinking, "Oh, this tastes wonderful." It's much higher in sweetness than sugar, as we've noted. And then, we're creating this addiction to these artificial sweeteners. So the consumption is excessive.

But if you think of going back to normal sugar, natural sweetness in the form of honey, maple syrup, sugar, whatever it might be, and controlling it in small amounts, that trigger won't happen as much because it's not so excessive. So as long as we teach and educate people on how to control their sugar intake and what is an appropriate amount of sugar, which again, we look at only 5% of total calories from the American Heart Association or the dietary guidelines, it's anywhere from 25 to 35 grams a day, which is really not that much. It's very little. But it still allows enough to give a little sugar in the diet but not get excess, and use real sugar and real sweeteners.

John Horton:

And in the end, it's really not that many calories if you just have a little bit of sugar in something, right?

Julia Zumpano:

Right, absolutely. So there's about 15, 15 calories for a teaspoon of sugar, which is 4 grams.

John Horton:

That's so little. And you think that you're taking in this artificial sweetener that's kind of manufactured to fool your brain and your taste buds and everything else. That doesn't sound healthy.

Julia Zumpano:

No. We really have so many great natural whole food alternatives, and we're really as a society providing so much artificial food as being normal and then, also labeled as healthy, which is so confusing to the consumer. And that's really the myths we want to debunk, is that these foods are not healthy. Diet and artificially sweetened foods and beverages are not healthy. Whole foods are healthy. Natural sugar, natural sweeteners are safe in moderation and advised.

Dr. Stanley Hazen:

And many of the protein extracts and protein bars and high energy drinks and bars are full of these artificial sweeteners also as the sweetened component to them. And so, someone thinks they're picking a quick fix for something they can eat on the run, and it's healthy and it's incredibly, highly, highly processed. And I would argue preparing a meal in advance and packing a lunch is the way to go.

John Horton:

And Dr. Hazen, I want to go back to something you mentioned right at the start, which is with that increased risk. And it's once you eat these products that have these artificial sweeteners in it, that risk kind of hangs in there for you for a few days, where all of a sudden, I say, the likelihood of maybe developing a clot is elevated.

Dr. Stanley Hazen:

So in the case of erythritol, we saw that. So after consuming 30 grams of erythritol, which is equivalent to the amount that you would expect in a keto-friendly ice cream or 12 ounces of an artificially sweetened drink with erythritol, we saw that it took between two to four days for the levels to come back down to baseline levels in healthy volunteers. The volunteers we looked at have all normal functional kidneys. People with diabetes don't always have normal kidney function. There's every reason to expect that in people who are at higher risk and have chronic kidney disease or diabetes, for example, it will be much, much longer even than four days after consuming that amount.

In the case of xylitol, it was faster. It was like four to six hours. It took that long for the levels to come back down in healthy volunteers after a typical portion size. Now the portion size we looked at for xylitol was when it's used as a sugar substitute, like in a baking product or in a diabetic confectionary. Many of the diabetes-safe candies are made with xylitol or erythritol, and the amount that's in that is much higher than the amount than in a stick of gum or a breath mint. So since our work has come out, people have asked us, "Well, what about a stick of gum or a breath mint? Is that a concern?" And while the amount is much, much less, if you're only sticking to one stick of gum or a breath mint, I think it's OK. But I would argue that most people don't just eat one stick of gum or one breath mint. They're continuously replacing it over the course of the day. And I think for people who are diabetic and at increased cardiovascular risk especially, or those with cardiovascular disease, they should just avoid them entirely.

John Horton:

Now, you mentioned just that serving size, which seems relatively mild, just a single serving size of that. A lot of people are eating far more than that over the course of the day. What happens if you put in even more of these artificial sweeteners?

Dr. Stanley Hazen:

Well, I don't think it will increase your risk above a certain amount because literally what happens is when we were studying the effect on platelets or looking at the effect of different levels versus cardiac event risk, it seems to plateau at the very high end. And so, what I think happens is it just prolongs the length of time if you ingest more, how long it would take for our body to get rid of it by excreting it, meaning elimination in the urine.

And so, there's something called “saturating effect.” Most biological processes … it's like turning on a light switch with a rheostat. You go to the high end and turn the rheostat up, but it doesn't continuously go brighter and brighter and brighter. At some point, you're on maximum. And I think that if subjects will ingest a larger amount, once you're in the fourth quartile, you're at two times increased risk. And then, how long you stay there will depend on how much you ingest. Because if the half-life of elimination is four hours, let's say every four hours, you can get rid of half of it. And if you're at a thousand-fold increase, you can count how many halves it would take before you get back down to baseline. That's where portion or the amount impacts I think more.

Julia Zumpano:

Something to note, too, is you're thinking about a one-time incident. Think about those who are drinking it all day long, right? So keep that in mind. If you're drinking it all day long, you're constantly in that red zone, constantly. You're never giving it a time to get down, or it's filtering out what it needs, but then just replenishing it. So just the frequency is also extremely important in addition to the volume.

John Horton:

So Dr. Hazen, as you've done this research and you've shared it with patients and people who come in who obviously are maybe concerned about their heart health and things like that, are they surprised to learn that foods that they think they're eating because they're healthy may be causing a potential problem?

Dr. Stanley Hazen:

I'll say just a little bit. More so they say, "You know what? It sounded too good to be true." Yeah. And if you think about it, it's like if we're taking something that's totally unnatural, and that's what this is at that level, at the level that we're ingesting it when it's thousands-fold higher than what's natural, it's totally artificial and it tricks the tongue. But we never anticipated that there would be these kinds of long-term risks. And as we said, we weren't looking for this, but this is what the data shows us. And so, I think people have been pretty accepting of it and saying, "OK." Then, people have to make a choice and decide how much, if any, that they will partake with.

Julia Zumpano:

One thing I wanted to add, too, Dr. Hazen, you mentioned in our initial discussion, was that these sugar alcohols are commonly found in toothpaste or mouthwash. But when you're just using it and spitting it out in small amounts, it's considered safe. Is that correct, Dr. Hazen?

Dr. Stanley Hazen:

Absolutely. I think anything where it's swish and spit, oral care products like that, it's completely fine. And in fact, xylitol is the No. 1 sweetener in these products. Why? Because data is suggesting that it blocks cavity formation and helps with fighting dental caries or cavities. And so, that is what has led to its use in many oral care products. And so, if you're gargling and spitting or brushing your teeth and spitting, you're not ingesting large amounts and you don't have to throw your toothpaste away. But on the other hand, if a breath mint is a gram and you're just taking one throughout the course of the day over and over, even though the amount is only 1 gram at a time, it's cumulative exposure, prolonged exposure. I think that that's something at least someone with diabetes, with cardiovascular disease, they should really recognize and then be able to make their own choices and see if they can find alternative products, for example, that don't have those in the labels.

Julia Zumpano:

There's tons out there for sure that don't have … that use natural sugar or yeah, small amounts. Mints don't really need that much sugar to begin with. So yeah, just look for the more natural alternatives for sure. They're out there.

John Horton:

I'm really struck. This entire discussion is exactly why we started this Nutrition Essentials Podcast, which is just to really show how what we eat can affect your body in so many different ways that you don't even think about. And I think, especially with these artificial sweeteners, you just would not necessarily think that this is going to be something where you have to worry about heart attack or a stroke risk being elevated because you're eating them. But as we've mentioned, these sweeteners are in a lot of foods that people probably have in their pantries and they might not even realize it.

If people are concerned about that or they're worried, what's something they can do or what's the main thing they should take out of this conversation as far as trying to maybe eat a little healthier or kind of avoid this potential problem?

Julia Zumpano:

I think it would just be being aware of those products that we listed, those so-called “acclaimed no sugar, sugar-free, diabetic-friendly, keto-friendly products,” and just screen the amount of those products you're consuming, in what volume, and taking it a step further if you can read the label, look at the ingredients. So just really, taking ownership of what you're consuming and what volume, and starting to really decrease the consumption as much as you possibly can.

Dr. Stanley Hazen:

I think, actually, in addition, I agree with that totally, but also, the artificial sweeteners themselves. A lot of times, people will take a few packets of this stuff and pour it in their morning coffee and think, "Oh, it's just an artificial sweetener." What I did not realize until I started reading about the topic was even if you go back 25 years, those were sugar packets that were spiked with the artificial sweetener. It was dextrose. It needs a carrier — I mentioned these super-sweet artificial sweeteners need a carrier — so saccharin, aspartame, sucralose, the packets of these, it's a granular packet. It used to be a little packet of sugar. I think that's a little bit … I would be surprised if most consumers realized when they reached for and bought an artificial sweetened packet that it was really a sugar packet that was spiked with the artificial sweetener.

Then, in the last 10 years, it turned into erythritol … often was the carrier that was used instead of dextrose, which is another word for sugar. Since the erythritol papers have come out, now a lot of places are advertising no erythritol. And you just have to read the labels. And so, I would say, I'd rather suggest someone use a packet of sugar, but in moderation, a small amount, not four packets or two packets. Try using one, and just watch your calories, watch your blood sugar if you're diabetic.

John Horton:

Dr. Hazen, I loved what you said about if something seems too good to be true, you should probably take a second look.

Dr. Stanley Hazen:

Yeah, I hate being cynical, but that is true, unfortunately.

John Horton:

Well, sometimes, eating natural, it sounds like, is always just your best option. And if you see anything labeled as “artificial,” it just maybe doesn't sound like something you should be putting into your mouth.

Julia Zumpano:

It's definitely the best way to go. Natural is the best way to go. If you have the ability to, or at least screening your diet for what artificial sweetened foods you have, in addition to the packets, what you're adding, and really minimizing it and replacing it with a natural food source is ideal.

John Horton:

So before we say our goodbyes from this just fascinating discussion, do you guys have any final thoughts or words of advice you'd like to pass along?

Dr. Stanley Hazen:

Well, putting my preventive cardiology hat on, I want to just end by saying the No. 1 killer is cardiovascular risk. And so, especially for people who might be reaching for what they hope is the healthier choice, and that's the artificial sweetener, don't.

Instead, reach for the whole-food product as Julia suggests.

But I also want to recommend, make sure you're monitoring your blood pressure, your cholesterol levels, you're doing all you can to lower your cardiovascular risk. I'll end it with that.

Julia Zumpano:

My takeaway would definitely be to utilize your healthcare professionals that can help you navigate through so much conflicting information, specifically register dietitians, but anyone that you have access to on a healthcare team that can really help you.

John Horton:

Well, thank you both for sharing so much just incredible information that should really help people make the best decisions for their health. So thank you both for being here.

Julia Zumpano:

Thanks for having us.

Dr. Stanley Hazen:

Thank you for having me.

John Horton:

Artificial sweeteners such as erythritol may satisfy your taste buds without adding many calories, but research shows that these manufactured food additives may come with a potential health cost. Your best bet, aim to eat foods that lean more natural instead of those classified as “artificial.” Your body will thank you.

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