This is the text from the Eating Liberty podcast, Episode 234

Listen to the podcast here.

This past February 27th, 2023 a report in “Nature Medicine” about erythritol was published. On February 28th, 2023, CNN had panic-inducing headlines about how this sugar substitute causes heart attacks. A cardiovascular event they called it. An event. like it’s a thing to look forward to. Ah, medical doublespeak, but that’s another show.

If you read the CNN article and are or are thinking of going Keto, this would have given you pause. It’s not a bad thing to consider and reconsider a decision that has a large impact on your life. It is another matter when fear porn from the best there is paints only part of the picture.

I saw a post about the study on social media. There were some Keto type shows that responded to it and that seemed a good start. I wanted to read it myself, if I could, to see what they saw.  

I got the report. I’ll admit it was a struggle with the words. I don’t read scientific reports and don’t speak doctor so I was looking up a lot of words. This is probably a good example of these kinds of reports. I’m sure there’s a good reason they are incomprehensible to lay folk, but I don’t know what that reason is. 

One thought that came to me was maybe I was too eager for the report responses to be what I wanted them to be, finding some errors and debunking them. Maybe, just maybe, I was looking for confirmation that this was hooey. More than a few people have made video and podcast responses to this report. Most of the responses I watched or listened to were from Keto-type folks. Nearly everyone had similar objections to some aspects of how the study was conducted.  

Consensus is a funny thing. It’s useful at times and useless at other times. If the consensus is 99% of people asked say driving into traffic is a bad idea, I agree with that. If the consensus is 97% of dieticians agree that sugar is a healthy food, I want to learn more about that seemingly impossible claim. The articles about this erythritol study I read and the podcasts I listened to all cited some of the same issues from the report. So at least there’s a place to start.

Keto folks and diabetics and dieters may be more familiar with non-sugar sweeteners like erythritol. It isn’t a sugar but it is a sugar alcohol. Now, that sounds impressive and confusing. A confounding phrase except it isn’t a sugar and it isn’t an alcohol so what the heck is it?

A quick bit about sugar alcohol and a disclaimer, in reverse order, in case my FBI guy is listening. I am not a doctor and I am not providing medical advice. No part of this podcast should be heard to be medical advice or diet or health advice. I make no claims to specialized knowledge. My opinion is just that, my opinion.  

Sugar alcohols are carbohydrates with no or few calories which is the appeal for dieters. They aren’t sugar with is an appeal to people looking to avoid sugar. Sugar alcohols taste sweet on the tastebuds which is the appeal.  

The downside is some sugar alcohols are not found in nature. Some, maybe most, are not fully digested. I spoke with Jess Reid about some of those replacements for sugar and how some of them can cause inflammation and bloating and some can even disrupt bowel movements, causing a laxative effect.

So, sugar alcohols are carbohydrates, but not sugar, and don’t increase insulin too much–and this is interesting but not for this show. Eating erythritol does stimulate insulin. Seems that eating anything at all stimulates insulin.

The paper called erythritol an artificial sweetener even though it is found in pears and watermelon and mushrooms and some fermented products like soy sauce. They call it artificial because in the quantities it is used commercially, it is processed. That aside, the authors identify artificial sweeteners as safe but also write, correctly, that little is known about the long-term effects of them. That’s a valid point. The long-term effects of table sugar seem well known (or are they? that’s another show) and that knowledge seems to be rejected. Mostly it’s rejected by big sugar. I can steer you toward anecdotal evidence the next time you go shopping. Look at the people and look in their carts. What they are buying has a direct impact on what they look like. If you think there isn’t an effect of eating pop tarts and sugar bomb cereal and sodas and energy drinks and chips and dip, go people-watching at your local food mart.

Getting into prep for this, I watched a few videos and these same points were brought up. Here are some concerns.

Correlation is not causation. At no point in the study do the researchers identify a cause for the issues they found which were the subjects had high levels of erythritol. It seems almost like they were looking at various human subjects susceptible to major adverse cardiovascular events for something and found erythritol.

They didn’t measure the dietary consumption of erythritol, only the erythritol in the bloodstream. This part gets interesting. Humans make erythritol through the metabolism of glucose. Most of the subjects in the study were overweight and in poor heart health. The authors even write as much. “Both cohorts were enrolled at quaternary referral centers with large catchment areas with high prevalence of CVD and risk factor burden, including type 2 diabetes and obesity.”

The study does reveal their weaknesses. “This study has several limitations. Measurement of erythritol in clinical cohort studies was only performed once as an overnight fasting level at the time of enrollment. Whether serial measures would provide enhanced prognostic value for incident CVD risks remains unknown. Because patients in our observational cohorts were recruited at quaternary referral centers and show a high prevalence of CVD and traditional risk factors, the translatability of our findings to the general population needs to be determined.” They follow that comment with this. “Another limitation of our clinical observational studies is that by design, these studies can only show association and not causation.”

The GreenbertTraurig website posted an article about the study as well. Part of their post is a discussion about potential legal action by the study participants and how manufacturers of erythritol and products which use erythritol might move forward. That’s not the focus of this show. That same article did rewrite some of those limitations cited by the authors which read.

• An overnight fasting level of erythritol was measured only once at enrollment, and the value of successive measurements for determining incident cardiovascular risks is unknown.

• The individuals followed in both cohorts had high prevalence of cardiovascular risk factors, such that it is unclear how the Study’s findings would translate to the general population.

• The cohort studies, by design, show only association, not a causal link, between erythritol and adverse cardiovascular events.

• Unmodelled confounding factors, such as diet, may have affected the Study’s results.

I set out to blast this report. It seemed easy enough. But, it wasn’t. What was impressive wasn’t the report but the response by the media to the report. This report came out on February 27th, 2023 and on February 28th CNN had their article online. On January 1, 2023, the National Library of Medicine published the article “Erythritol: An In-Depth Discussion of Its Potential to Be a Beneficial Dietary Component“. Their conclusion, in part, is that “Erythritol is a naturally occurring, safe, and non-nutritive sugar alcohol. Compared to other sugar alcohols, evidence from human studies indicate that it is mostly absorbed and excreted in urine unmetabolized. Minimal amounts reach the colon; therefore, it is better tolerated, with less undesirable gastrointestinal effects.” Anecdotally, I can offer that erythritol can have undesirable gastrointestinal effects. That’s an interesting report and from a quick search I found zero hits about the news and that article. That’s also interesting I think.

Erythritol is made by the body when it metabolizes glucose through a process called the pentose phosphate pathway and it’s there that erythritol is produced. What seems to be so is that more erythritol is produced in the body when the body has inflammation. That’s a tricky word. An infection, red and oozing with puss, is obviously an inflammation. But cells not functioning normally, whatever that is, can also be inflamed. Also, stress on the system causes oxidative stress. Obesity, diabetes, metabolic disorder, and cardiovascular disease are stresses on the system and inflammation on the system. So the system responds by making more erythritol. In the in-depth discussion report, they write that there are few clinical dietary studies on erythritol and cardiovascular health. They follow that with this, “An exception is a promising pilot study conducted in 24 patients with type II diabetes who consumed 26 gm/day of erythritol for 4 weeks. These patients exhibited reduced arterial stiffness and improved endothelial function. Endothelial dysfunction contributes to the pathogenesis of cardiovascular disease in type II diabetes and predicts cardiovascular events.”

I had to look up endothelial. The Cedars-Sinai website writes “endothelial cells release substances that control vascular relaxation and contraction as well as enzymes that control blood clotting, immune function and platelet adhesion.” Platelets are a colorless substance in the blood. Pathogenesis is the origin of disease.

If I read this right, and I’ll accept that’s a big if, in the body, erythritol production has a positive effect on our arteries. Erythritol production might be a response to a highly stressed body to cope with the stress and make more if there is more stress. Since the report that started all this shows they did not test dietary erythritol, except for four hours in 8 people, too many questions exist with no answers.

I learned more than a little bit by prepping for this show. What seems to be the real horror isn’t news at all. The horror is CNN, but all media really, showed us smoke and desperately–I’m projecting–wanted us to see fire. Fear and panic that food is going to kill you seems to be the message and clicks and shares are the goal. To that end, it worked.

I looked for a video in support of this report. It might be out there but I didn’t find it. Loads of folks are beating this up and you can see some of then here, here, here, here, but it really seems to be a nothing burger of a report. The authors have a few minutes ticked off of their allotted 15 and the talking heads who bashed this report got loads of Youtube plays and pitched their wares.  

The report and response is like a rugby scrum. Everyone is kicking at the wee story looking to gain control. What does all of this mean? I’m not certain, but I have some ideas. One thing it means is the news is not your friend. A massive news push of a story is for clicks. Someone is selling soap and making mad stacks.

It means go find responses to the story. That ain’t easy, let me tell you. I found plenty of content against that report but not all of it on the up and up. One doctor did a bait and switch. He started talking about the report and then switched to a conclusion seeming to claim it was the conclusion from the report he was discussing. It wasn’t. He mumbled something but he could have been very plain and he was not. The conclusion was from this article written two years ago. Certainly, that was not a response to the article from this year.  In fairness to that doctor, he did at least put this link on the Youtube page.

Exercise. Move your body.  Even a brisk walk. Don’t eat too much. Sugar probably isn’t the Voldemort we’ve been told it is but I’m pretty sure it’s no Dumbledore either. That sugar problem is massively compounded by the partners it has in the foods it is in. Packaged goods contain ingredients that used to be food but are processed to the point of being unidentifiable, wheat mostly, and seed oils, and chemical preservatives, and artificial colors are mixed together to create products that are no damned good. Sugar is empty calories and that’s not good. But, most of the crap that is sold as food containing sugar is also empty calories with pretty colors and fortified with the very things that were stripped out. If you want cookies, make them.  

The point is granny was right. Eat real food.  

I mentioned that maybe sugar isn’t the supervillain we’re expected to think it is. Being misheard on this will be easy. I am not suggesting sugar is a healthy food. Far from it. What I am saying is that given the near-religious fervor attached to vilifying sugar, maybe there’s something about it we’re not being told. I know secrets are kept about sugar and lobbying and saturated fats and seed oils and salt. I am saying that there seem to be a lot of moving parts in the discussions about what makes us fat and unwell. To exclude all the other ingredients and be certain it is only sugar is something I don’t know. I thought I did know. The massive, uniform response to this unimpressive article makes me wonder if those people selling sugar as the sin of the ages might be doing so while laughing all the way to the bitcoin. That’s a banking joke.