On April Fools’ Day 1998, the FDA announced its approval of the artificial sweetener sucralose,1611 sold as Splenda, a.k.a. 1,6-dichloro-1,6-dideoxy-β-D-fructofuranosyl-4-chloro-4-deoxy-α-D-galactopyranoside. Despite its scary-sounding chemical name, the worst thing about it seemed to be that it was a rare migraine trigger in susceptible individuals, to which the manufacturer of sucralose responded that you have to weigh whatever risk there may be against the “broader benefits,” such as “helping to mitigate the health risks associated with the national epidemic of obesity.”

How’s that going?

Large-scale population studies have found that the consumption of artificial sweeteners, particularly in diet sodas, is associated with increased weight gain and abdominal fat over time. Now, the obvious explanation for this finding would be reverse causation: Instead of drinking more diet soda leading to obesity, it would make more sense that obesity leads to drinking more diet soda. But even when researchers controlled for preexisting differences in body fat, they still found evidence of increased obesity risk. 

However, not all reviews of the science concluded there was a link between artificial sweeteners and weight gain. Can you guess which ones? An analysis of industry bias found that reviews funded by the food industry were 17 times less likely to suggest unfavorable effects, and in nearly half of the sponsored reviews, the authors failed to even disclose their conflicts of interest. That’s even worse than the sugar industry, whose studies were “only” five times as likely to question the link between sugar-sweetened beverages and obesity. You don’t really know, though, until you put them to the test.

Ironically, many of the interventional studies on artificial sweeteners and weight gain were executed by animal agribusiness, feeding them to farm animals to fatten them faster. (Is there anything they won’t feed to chickens?) Animal agriculture has been feeding artificial sweeteners to farm animals since the 1950s, boasting that their addition “increases … body weight gain and … optimizes return on investment.” What about in people?

If you give obese individuals the amount of sucralose found in a can of diet soda, for example, they get significantly higher blood sugar and insulin spikes in response to a sugar challenge, suggesting sucralose is not just an inert substance. The Splenda company emphasizes that sucralose is hardly even absorbed into the body and ends up in the colon to be eliminated. Therein may lie the problem. The adverse metabolic effects of artificial sweeteners correlate with “pronounced” changes in the microbiome that occur within a week of daily consumption. 

The good news is that after stopping artificial sweeteners, your original balance of gut bacteria can be restored within a matter of weeks. The problem is that we may be exposed without even knowing it. Nearly half of study participants randomized to avoid sucralose, for example, still turned up positive, thought to be due to exposure from nondietary sources, such as toothpaste and mouthwash.

Another way artificial sweeteners can lead to metabolic disturbance is via the disconnect that develops between the amount of sweetness the brain tastes on the tongue and how much blood sugar actually ends up reaching the brain. Your brain may end up feeling cheated by the artificial sweeteners, figuring you have to consume more and more sweetness in order to get enough calories. For example, researchers slipped people either Sprite, Sprite Zero (a no-calorie, artificially sweetened Sprite), or unsweetened, carbonated lemon-lime water, and then, later on, offered them a choice: They could have M&M’s, spring water, or sugar-free gum. Guess who picked the M&M’s? Those who drank the artificially sweetened soda were nearly three times more likely to take the candy than either those who had consumed the sugar-sweetened soda or the unsweetened drink. So it wasn’t a matter of sweet versus nonsweet or even calories versus no calories. There appeared to be something about noncaloric sweeteners that tricks the brain into wanting more junk.

The same researchers performed another study in which every subject was given Oreos and then asked how satisfied the cookies made them feel. Again, those who had drunk the artificially sweetened Sprite Zero reported feeling less satisfied after eating the Oreos than either the subjects who had had normal Sprite or sparkling water. These results are consistent with brain imaging studies demonstrating that regular consumption of artificial sweeteners can alter the reward pathways responsible for the pleasurable response to food. 

What about the natural, plant-based sweeteners derived from stevia and monk fruit? Researchers randomized people to drink a beverage sweetened with sugar, aspartame, monk fruit, or stevia. Blood sugars were measured over 24 hours, and surprisingly, there was no significant difference found among any of the four groups. 

Wait a second. The sugar group was given sixteen spoonfuls of sugar, the amount in a 20-ounce bottle of Coke, so the other three groups consumed 16 fewer spoonfuls of sugar—yet all four groups still had the same average blood sugars? How is that possible? Table sugar causes a big blood sugar spike. Drink that bottle of sugar water with its 20 sugar cubes’ worth of sugar, and your blood sugars jump 40 points over the next hour. In contrast, after drinking a beverage sweetened with aspartame, monk fruit, or stevia, nothing immediately happens to blood sugars, which is what we would expect. These are noncaloric sweeteners. Since they have no calories, isn’t it just like drinking water? How could our daily blood sugar values average out the same? The only way that could happen is if the noncalorie sweeteners somehow made our blood sugar spikes worse later in the day—and that’s exactly what happened. In the group who drank the aspartame-sweetened beverage, even though their blood sugars didn’t rise at the time, they shot up higher an hour later in response to lunch, as if they had just consumed a bottle of soda.

That was for an artificial sweetener, though. What about the natural sweeteners, stevia and monk fruit? The same thing happened. The same exaggerated blood sugar spike to a regular meal occurred an hour later. So that’s how it all equals out in terms of average blood sugars even though, in these three noncaloric sweetener groups, the subjects took in 16 fewer spoonfuls of sugar. This is at least partly because they ate more. After drinking a Diet Coke, you’re more likely to eat more at your next meal than you would if you had drunk a regular Coke. In fact, you’d eat so much more that the energy “saved” from replacing sugar with noncaloric sweeteners would be fully compensated at subsequent meals, resulting in no difference in total daily caloric intake. It’s like the zero-calorie sweetener groups—whether artificial or natural—had chugged a bottle of soda. So, when it comes to caloric intake, blood sugars, or insulin spikes, all the other sweeteners appeared just as bad as straight sugar.

Do we have direct evidence that diet beverages can adversely impact body weight? Yes. If you swap out diet beverages for water, there theoretically should be no difference in weight control since they both provide zero calories, right? Well, when researchers put it to the test, overweight and obese individuals on a diet randomized to replace diet beverages with water lost significantly more weight, about 15 percent more over six months.

The researchers who demonstrated artificial sweeteners can disrupt our microbiomes and metabolisms recognized the irony of their findings. Though these food additives were introduced to reduce caloric intake and counter the obesity epidemic, they noted their findings suggest artificial sweeteners may have instead “directly contributed to enhancing the exact epidemic that they themselves were intended to fight.”

Excerpted  from HOW NOT TO DIET: The Groundbreaking Science of Healthy, Permanent Weight Loss by Michael Greger. Copyright © 2019. Reprinted with permission from Flatiron Books. All rights reserved.

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Research showing that coronary heart disease can be reversed with a plant-based diet—with or without other healthy lifestyle changes—has been published for decades in some of the most prestigious medical journals in the world. Why hasn’t this news translated into public policy yet?

In 1977, the U.S. Senate Committee on Nutrition and Human Needs tried to do just that. Known as the McGovern Committee, they released Dietary Goals for the United States, a report advising Americans to cut down on animal-based foods and increase their consumption of plant- based foods. As a founding member of Harvard University’s nutrition department recalls, “The meat, milk and egg producers were very upset.”¹ That’s an understatement. Under industry pressure, not only was the goal to “decrease meat consumption” removed from the report but the entire Senate nutrition committee was disbanded. Several prominent senators reputedly lost their election bids as a result of supporting the report.²

In more recent years, it was uncovered that many members of the U.S. Dietary Guidelines Advisory Committee had financial ties to everything from candy bar companies to entities like McDonald’s Council on Healthy Lifestyles and Coca-Cola’s Beverage Institute for Health and Wellness. One committee member even served as “brand girl” for cake-mix maker Duncan Hines and then as the official Crisco “brand girl” before going on to help write the official Dietary Guidelines for Americans.³

As one commentator noted in the Food and Drug Law Journal, historically, the Dietary Guidelines Advisory Committee reports contained:

“No discussion at all of the scientific research on the health consequences of eating meat. If the Committee actually discussed this research, it would be unable to justify its recommendation to eat meat, as the research would show that meat increases the risks of chronic diseases, contrary to the purposes of the Guidelines. Thus, by simply ignoring that research, the Committee is able to reach a conclusion that would otherwise look improper.”⁴

What about the medical profession, though?

Why haven’t my colleagues fully embraced this research demonstrating the power of good nutrition? Sadly, the history of medicine holds many examples of the medical establishment rejecting sound science when it goes against the prevailing conventional wisdom. There’s even a name for it: the “Tomato Effect.” The term was coined in the Journal of the American Medical Association in reference to the fact that tomatoes were once considered poisonous and were shunned for centuries in North America, despite overwhelming evidence to the contrary.⁵

It’s bad enough that most medical schools don’t even require a single course on nutrition⁶, but it’s even worse when mainstream medical organizations actively lobby against increased nutrition education for physicians.⁷ When the American Academy of Family Physicians (AAFP) was called out on their proud new corporate relationship with Coca-Cola to support patient education on healthy eating, an executive vice president of the academy tried to quell protests by explaining that this alliance was not without precedent. After all, they’d had relationships with PepsiCo and McDonald’s for some time.⁸ Even before that, they had financial ties to cigarette maker Philip Morris.⁹

This argument didn’t seem to placate the critics, so the AAFP executive quoted them the American Dietetic Association’s policy statement that “[t]here are no good or bad foods, just good or bad diets.” No bad foods? Really? The tobacco industry used to broadcast a similar theme: Smoking per se wasn’t bad, only “excess” smoking. Sound familiar? Everything in moderation.

The American Dietetic Association (ADA), which produces a series of nutrition fact sheets with guidelines on maintaining a healthy diet, also has its own corporate ties. Who writes these fact sheets? Food industry sources pay the ADA $20,000 per fact sheet to explicitly take part in the drafting process. So we can learn about eggs from the American Egg Board and about the benefits of chewing gum from the Wrigley Science Institute.¹⁰

In 2012, the American Dietetic Association changed its name to the Academy of Nutrition and Dietetics but didn’t appear to change its policies. It continues to take millions of dollars every year from processed junk food, meat, dairy, soda, and candy bar companies. In return, the academy lets them offer official educational seminars to teach dietitians what to say to their clients.¹¹ When you hear the title “registered dietitian,” this is the group they are registered through. Thankfully, a movement within the dietitian community, exemplified by the formation of the organization Dietitians for Professional Integrity, has started to buck this trend.

What about individual doctors, though?

Why aren’t all my colleagues telling their patients to lay off the Chick-fil-A? Insufficient time during office visits is a common excuse physicians cite, but the top reason doctors give for not counseling patients with high cholesterol to eat healthier is that they think patients may “fear privations related to dietary advice.”¹² In other words, doctors perceive that patients would feel deprived of all the junk they’re eating. Can you imagine a doctor saying, “Yeah, I’d like to tell my patients to stop smoking, but I know how much they love it”?

Neal Barnard, M.D., president of the Physicians Committee for Responsible Medicine, recently wrote a compelling editorial in the American Medical Association’s journal of ethics, describing how doctors went from being bystanders—or even enablers—of smoking to leading the fight against tobacco. Doctors realized they were more effective at counseling patients to quit smoking if they no longer had tobacco stains on their own fingers.

Today, Dr. Barnard says, “Plant-based diets are the nutritional equivalent of quitting smoking.”¹³

References
<sup>1. [Hegsted, M. “Dietary Guidelines.” Food Politics.]
2. [Campbell, TC. The Low-Carb Fraud. Dallas, TX: BenBella Books, Inc.; 2014.]
3. [Herman J. Saving U.S. dietary advice from conflicts of interest. Food and Drug Law Journal 2010.]
4. [Herman J. Saving U.S. dietary advice from conflicts of interest. Food and Drug Law Journal 2010.]
5. [Goodwin, JS and JM. “The tomato effect.” Rejection of highly efficacious therapies. JAMA. 1984; 251 (18):2387-90.]
6. [Adams KM, Kohlmeier M, Zeisel SH. “Nutrition education in U.S. medical schools: latest update of a national survey.” Acad Med. 2010;85(9):1537-42,]
7. [Hearing of California Senate Bill 380. Vimeo.]
8. [Murray, JL. Coke and the AAFP—the real thing of a dangerous liaison? Fam Med. 2010; 42(1):57-8.]
9. [Blum, A. AAFP-Coke editorial was music to (our) ears. J Fam Pract. 2010;59(2):74.]
10. [Brownell, KD, Warner, KE. The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? Millbank Q. 2009;87(1):259-94.]
11. [Simon, M. AND now a word from our sponsors. Eat Drinks Politics.]
12. [Bruckert, E., Pouchain, D., Auboiron, S., Mulet, C.. Cross-analysis of dietary prescriptions and adherence in 356 hypercholesterolaemic patients. Arch Cardiovasc Disc. 2012;105(11):557-65.]
13. [Barnard, ND. “The physician’s role in nutrition-related disorders: from bystander to leader. Virtual Mentor. 2013;15(4):367-72.]</sup>

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Thanks in part to the American Heart Association’s recommendation that individuals at high risk for heart disease should ask their physicians about omega-3 fish oil supplementation, fish oil pills have grown into a multibillion dollar industry. We now consume more than one hundred thousand tons of fish oil every year.

But what does the science say? Are the purported benefits of fish oil supplementation for the prevention and treatment of heart disease just a fish tale? A systematic review and meta-analysis published in the Journal of the American Medical Association looked at all the best randomized clinical trials evaluating the effects of omega-3 fats on life span, cardiac death, sudden death, heart attack, and stroke. These included studies not only on fish oil supplements but also studies on the effects of advising people to eat more oily fish. What did they find? Overall, the researchers found no protective benefit for overall mortality, heart disease mortality, sudden cardiac death, heart attack, or stroke.

What about for someone who had already had a heart attack and is trying to prevent another? Still no benefit was found.

Where did we even get this idea that the omega-3 fats in fish and fish oil supplements are good for you? There was a notion that Eskimos were protected from heart disease, but that appears to be a complete myth. Some early studies, however, looked promising. For example, the famous DART trial from the 1980s involving two thousand men found that those advised to eat fatty fish had a 29 percent reduction in mortality. That’s impressive, so it’s no wonder the study got a lot of attention. But people seem to have forgotten about the sequel, the DART-2 trial, which found the exact opposite. Run by the same group of researchers, the DART-2 trial was an even bigger study— three thousand men— but this time, participants advised to eat oily fish and particularly those who were supplied with fish oil capsules had a higher risk of cardiac death.

After putting all the studies together, researchers concluded that there was no longer justification for the use of omega-3s in everyday clinical practice. What should doctors do when their patients follow the American Heart Association’s advice and inquire about fish oil supplements? As the director of Lipids and Metabolism at Mount Sinai’s cardiovascular institute put it: “Given this and other negative meta- analyses, our job [as doctors] should be to stop highly marketed fish oil supplementation to all our patients . . .”

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Do you think I’m being dramatic? Let’s take a look at three commonly prescribed treatments for diet-related illnesses: stents, statins, and stomach stapling. Then let’s examine their cost, effectiveness and safety compared to a food-based approach.

Stents are tubular devices inserted into cholesterol-clogged arteries in an attempt to keep blood flowing. For more than a decade, stenting has been the mainstay of interventional cardiology, with up to 500,000 performed every year in the United States at a cost of $10,000 to $50,000 per procedure. Recently, however, a study published in the American Medical Association’s Archives of Internal Medicine sent shockwaves through the medical industry when the chief editor declared that stenting for stable heart disease has “no known benefit and … definite harms.”

Next on the list: statins, the most popular drugs in the world. Prescribed for life, and costing up to $200 per month, in many instances these drugs “might do more harm than good,” according to a comprehensive study published in 2011. Adding insult to injury, earlier this year the FDA announced new side-effect warnings for statins, including increased risk of confusion, memory loss, new-onset diabetes and muscle injury.

Stomach stapling, once reserved for only the most severe cases of morbid obesity, is another highly invasive procedure that seeks to bypass, literally, the root cause of the problem. The most commonly performed stomach stapling surgery has now been labeled “severely dangerous” by the AMA, but even the new and improved methods continue to cost $20,000 to $25,000. These procedures are served with a laundry list of potential complications including infection, hernias, ulcers, blood clots, staple leakage, respiratory failure, heart attacks, stroke, and death. Despite these risks and the fact that many patients eventually regain much of their lost weight, stomach stapling is now being recommended to combat diabetes and for overweight children as young as 12.

The high cost, questionable effectiveness, and inherent dangers associated with these band-aid solutions would be tolerable if there were simply no other options. But there is a safe, cheap and highly effective solution: stop hurting yourself! Our body wants to heal and be healthy – if only we’ll let it.

In the case of diet-related diseases like high blood pressure, heart disease, type 2 diabetes, obesity, and potentially certain cancers, an overwhelming convergence of evidence suggests that preventing and even reversing these diseases may be as simple as eating whole plants instead of animals and their byproducts. If you want to treat the symptoms of eating poorly all you really need to do is start eating well.

But what’s eating well? In the case of preventing and reversing heart disease, our nation’s number one killer of both men and women, eating well means avoiding the three main ingredients that increase bad (LDL) cholesterol: trans fats, which come mostly from junk food and animal products; saturated fat, mostly from dairy products and chicken; and dietary cholesterol, which comes exclusively from animal products.

What’s the safest, cheapest, and most effective way to combat heart disease? A whole-food, plant-based diet. The same applies to type 2 diabetes, which can not only be prevented, but even reversed, by eating this way.

As a physician specializing in clinical nutrition, it’s a relief when a patient walks into my office suffering from a disease caused by poor eating choices, because the power to get better is still in their hands — or mouth, so to speak. Once fully informed of the options, the choice to stop banging their head against the wall is remarkably easy.

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