Over the last few weeks we have seen some sensational headlines related to a low-carb diet, the ketogenic lifestyle and sugar substitutes. Here are just a few examples:
A quick google search will showcase a range of other articles on these topics that were picked-up by “news” agencies & bloggers alike, with a disappointing consistency of simply regurgitating a study without delving deeper into the facts and sorting through whether the research behind the information is actually credible. In other words, actually applying journalism. So, let’s review the latest barrage of salacious headlines, the questionable research and assess whether the news presented is credible.
Salacious Headline #1: Study Linking Erythritol to Heart Attack & Stroke
In case you haven’t seen one of the many articles, here’s a link to one, which to be fair to Time, does actually raise some questions about the research and linkage. The study we’re referring to was published in late February in the journal Nature Medicine, and is related to just over 1,100 patients undergoing a cardiac risk assessment. Circulating levels of sweeteners, especially erythritol, were associated with a higher risk of cardiovascular event. The study also referenced other research, on patients in both the U.S. and Europe, who were being evaluated for a range of heart related issues, and found a similar heightened presence of erythritol in the blood. Of particular concern was the potential of blood clotting related to platelet presence. Finally, in looking at a very small sample size (n=8) of “healthy” volunteers who ingested an erythritol drink, the sweetener was found at high levels in the blood stream, and a noticeable blood thickening was also observed, for at least 2 days. Based on this information, erythritol is now being associated with a higher risk of a cardiovascular event.
Background on Erythritol
Erythritol is a sugar alcohol, produced by plants and also produced in the human body at low levels through what is called the pentose phosphate pathway (PPP). Naturally found in some fruits and fermented foods, in the last decade it has seen a noticeable uptake in exogenous consumption through dietary, weight loss and low-sugar products due to the fact it is 30% less sweet than sucrose, has a negligible impact on blood glucose & insulin response, is almost fully absorbed and excreted in the urine, and generally does not have a bitter aftertaste. Today, erythritol is used extensively as a “healthier” sugar substitute, as it is not chemically created (like sucralose) and is found naturally in both plants and humans. It has also received a “safe” (GRAS) evaluation from both the USDA (2001) and European Food Safety Authority (EFSA) in 2003 for sweets and desserts (as a low-calorie sweetener replacement), and subsequently received broader use approval from EFSA in 2006, 2010 and 2015.
Unpacking the Study
There have been more studies related to erythritol and its impact on T2D, blood sugar, weight management & obesity given its potential to replace sugar with minimal metabolic impact. But, limited research has been done on erythritol related to cardiovascular health. However, a study in 2020 suggested high levels of erythritol in the blood stream could be a predictor of cardio-metabolic disfunction. It’s clear from the new study the patients were suffering from some collection of cardio-metabolic issues, so is it possible the erythritol levels in the blood were “warning signs” of the impending cardiovascular event? The folks at @Highintensityhealth have done a nice job in the below video talking through this exact issue, including some additional studies that support the premise erythritol is not the likely causation, but its presence in the blood is a result of poor metabolic health and is a warning sign for potential cardiovascular events.
The key point we need to understand on erythritol is whether exogenous consumption of the product has the potential to cause cardiovascular disease, OR, whether endogenous creation of erythritol is increased & found in the bloodstream of people with certain conditions (ie, metabolically unhealthy)? Importantly the latest study does not make that distinction, answer that question or prove any reliable science, so to infer or assume a causal distinction as represented in the headlines is simply inaccurate.
Parting Thoughts on Erythritol
The media coverage has painted the consumption of erythritol as causal of heart attacks & strokes. In reality, it could be elevated levels, produced as a part of a natural human pathway (PPP), that may be an indicator of an unhealthy metabolic state and a heightened risk of cardiovascular events if dietary & lifestyle changes are not made. The obvious next step would be to conduct a sound research study to better understand correlation vs. causation and the exogenous vs. endogenous erythritol question.
Finally, I do not have any personal allegiance to erythritol, nor do I consume it very often. I believe following the power of good nutrition is in eating natural foods, so consuming copious quantities of “keto-friendly” processed foods is a non-starter. It is absolutely possible someone eating a consistent, high volume of erythritol in various processed foods could see their blood levels elevated, but whether that increased consumption is responsible for higher blood levels, and whether there is a danger to those levels, are two questions still to be answered. However, given what we know today and the previous 20+ years of research, consuming a limited amount of erythritol as part of a healthy, smart lifestyle, assuming no other metabolic or physiological issues, should be of little concern.
Salacious Headline #2: Keto-like Diet linked to Heart Attack & Stroke
A “new” study, presented at the American College of Cardiology’s Annual Scientific Session, suggested a ketogenic or keto-like diet can elevate LDL cholesterol and directly raise the risk of heart attack & stroke. Let’s talk about the four things that are dangerously misleading about this headline.
- The research is epidemiology, one of the weakest forms of research that can be conducted. Epidemiology relies on patients recalling what they think they have eaten, and in this particular study, the patients completed a one-time, self reported, 24 hour questionnaire. Of the 70,000 people who answered the questionnaire, a whopping 305 claimed they followed a low-carbohydrate, high fat diet. So, 0.004% of the respondents claimed they followed a low-carb diet, which could not be verified or controlled, and that is the foundation from which this study is making its claims.
- The definition of the diet is completely inaccurate. The study clearly states the “keto-like” panel were people who were obtaining 25% of their daily calories from carbohydrates, which means, if the respondents were consuming 2,000 calories per day, 500 calories from carbohydrates equals consuming 125g in a day. To be ketogenic (in ketosis, using ketones as fuel), one needs to be consuming no more than 10% of calories from carbohydrates per day, and in some cases, as low as 5%. In grams, that might be a maximum of 50g/day. So, anyone consuming 125g of carbs per day is not ketogenic, is still running their body on glucose/sugar, and is not running on the power of ketones.
- LDL-cholesterol (LDL), without delving deeper into the specifics, does not tell the complete story. When measuring LDL, there are two types: LDL SD (small dense) and LDL LB (large buoyant). The difference is in the size of the LDL molecules moving through the bloodstream. The large, buoyant LDL molecules simply float through the bloodstream without penetrating the arterial walls and building up plaque, whereas the smaller, dense molecules can be the dangerous ones. While it is absolutely possible that someone following a true ketogenic lifestyle can see an increase in LDL, we have to dig deeper on other metabolic measures as well as understand the type of LDL in that patient and whether a heightened LDL is a concern. Are their HDL’s high/low? What about triglycerides? Blood pressure? It’s also being proven that some people following a ketogenic lifestyle are referred to as hyper-responders, meaning their LDL’s rise more than would be expected. The working hypothesis, which is still being further researched, is the LDL molecules act as the transport vehicle for fats through the bloodstream as the body has shifted fully into ketosis. So, more LDL LB, acting as a transport vehicle, and not increasing the risk of heart attack or stroke.
- Real Science. If you want to read real science on the risk/reward of an actual ketogenic lifestyle, start with a quality, controlled study which shows a material improvement in metabolic health and no risk to LDL. I also invite you to reference the following sites as sound, scientific research & reference points that offer quantifiable and well-researched examples of the power of the ketogenic lifestyle. Dr. Westman has been prescribing and counseling patients on the lifestyle benefits for over 20 years, and VirtaHeath is helping patients reverse their T2D, eliminate exogenous insulin, and achieve metabolic health and wellness through the counseling & application of the ketogenic lifestyle.
More than ever we have to filter the noise and falsehoods from reporting, and delve into the details when we see a salacious headline. Understand the quality of the research, who funded the work, has it been peer-reviewed, is it making broad generalizations based on limited input, and is it confusing correlation with causation? Most importantly, does it make logical sense and is there sufficient evidence to support the headline?
Secondarily, keep in mind we have been following a high-carbohydrate, largely “plant-based” diet as recommended by the US Dietary Guidelines for over 50 years, including a diet high in whole grains, wheat, potatoes, corn, rice, oats, vegetable/seed oils, fruits and vegetables, and we are sicker, fatter and have more metabolic disease than any time in recorded human history. Admitting that the advice we’ve been receiving for half a century has been wrong is going to cause a lot of people to have to answer for the appalling cost of sickness, disease and financial duress as a result. So, the playbook is simple. Blame our obesity & metabolic disorder epidemic on processed foods and a lack of exercise; disparage the lifestyles that recognize the need to change our dietary behavior through a significant reduction in carbohydrate intake; create doubt and angst through questionable (at best) “research”; and push a narrative that supports the current structure through even more consumption of carbohydrates now re-branded as ‘plant-based’ solutions. Ask yourself these two questions, and think about whether the answers are the same:
- If following this path for the last 5 decades has been a metabolic failure, who stands to benefit most if we stay the current course?
- If we were to dramatically change the course and reverse the metabolic disease through a revised approach to nutrition, who would stand to lose the most?
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