#361 - AMA #74: Sugar and sugar substitutes: weight control, metabolic effects, and health trade-offs

View the Show Notes Page for This Episode https://peterattiamd.com/ama74/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250818-pod-ama74&utm_content=250818-pod-ama74-podfeed Become a Member to Receive Exclusive Content https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250818-pod-ama74&utm_content=250818-pod-ama74-podfeed Sign Up to Receive Peter's Weekly Newsletter https://peterattiamd.com/newsletter/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250818-pod-ama74&utm_content=250818-pod-ama74-podfeed In this "Ask Me Anything" (AMA) episode, Peter explains how to evaluate sugar and its substitutes in the context of health. Peter explores the role of sweeteners in three common use-cases – beverages, protein supplements, and sweet treats – and breaks down how our evolutionary craving for sweetness now clashes with today's food environment. He examines whether sugar is uniquely fattening, the hormonal effects of sugar consumption, and the significance of timing in sugar intake. The episode compares natural versus refined sugars, sugar in beverages versus in solid foods, and the pros and cons of popular sweeteners including saccharin, aspartame, sucralose, allulose, and sugar alcohols like erythritol and xylitol. With a focus on weight management, glycemic impact, gut health, and long-term safety, this episode offers a comprehensive guide to navigating the sweetener landscape with clarity and nuance. If you're not a subscriber and are listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed https://peterattiamd.com/members/private-podcast-feed/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250818-pod-ama74&utm_content=250818-pod-ama74-podfeedor our website at the AMA #74 show notes page http://peterattiamd.com/ama74/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250818-pod-ama73&utm_content=250818-pod-ama74-podfeed. If you are not a subscriber, you can learn more about the subscriber benefits here https://peterattiamd.com/subscribe/?utm_source=podcast-feed&utm_medium=referral&utm_campaign=250714-pod-ama73&utm_content=250818-pod-ama74-podfeed. We discuss: A quick tangent on chess and parenting [2:30]; Overview of key scenarios for evaluating sugar and sweeteners [6:15]; Why humans are hardwired to crave sweetness [13:30]; Evaluating whether sugar is uniquely fattening or more harmful than other macronutrients under isocaloric conditions [15:15]; Why sugar drives appetite: low satiety, insulin response, and reward system activation [18:45]; How sugar type, liquid vs. solid form, and processing level influence appetite and metabolic impact [20:15]; Addressing the common belief that natural sugars are healthier than refined sugars [26:00]; How the timing of sugar consumption alters the body's metabolic response [29:15]; How Peter advises patients on sugar intake, factoring in metabolic health, insulin sensitivity, and activity level [34:45]; The most common sugar substitutes, their sweetness relative to sugar, and their caloric content [36:30]; Evaluating the role of sugar substitutes in weight control: efficacy vs. effectiveness and limitations in study design [40:15]; Assessing the real-world impact of sugar substitutes on weight, and the role of sweetness without calories [44:00]; The impact of sugar substitutes on glycemic control [47:30]; Are microbiome changes from artificial sweeteners substantial enough to cause obesity and diabetes? [50:30]; How Peter advises patients on the use of sugar substitutes across different contexts [52:30]; Allulose—a sweetener with unique satiety and glycemic benefits and potential for weight control [57:15]; Emerging evidence that stevia, monk fruit, and sugar alcohols may provide modest metabolic benefits compared to sugar [1:03:00]; Sugar alcohols explained [1:04:15]; Sugar alcohols and GI issues [1:05:00]; Xylitol's dental health benefits and considerations for use [1:06:30]; Artificial sweeteners and cancer risk: evaluating evidence, the aspartame controversy, and the role of dose in toxicology [1:07:15]; Sugar substitutes and cardiovascular disease: assessing flawed studies and the absence of direct risk evidence [1:11:00]; Why artificial sweeteners seem to attract so many negative headlines [1:12:45]; Balancing benefits and risks of sugar substitutes: guidance for desserts, beverages, and protein products [1:14:15]; and More. Connect With Peter on Twitter https://twitter.com/PeterAttiaMD, Instagram https://www.instagram.com/peterattiamd/, Facebook https://www.facebook.com/peterattiamd/ and YouTube https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:10Dr. Peter Attia?

  Hey everyone, welcome to a sneak peek Ask Me Anything, or AMA, episode of the Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com/subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything, AMA, episode 74. In today's AMA, we're taking a closer look at one of the most common and misunderstood questions we receive: how to evaluate sugar

• 0:52Dr. Peter Attia?

  and its substitutes in the context of health. To help answer these questions, we'll walk through a three-part framework that reflects the most popular scenarios where sugar substitutes come into play. One, beverages, things like regular soda versus diet soda. Two, protein supplements, powders and bars which often rely on sweeteners to make them even remotely palatable. And three, sweet treats, everything from candy to low-calorie desserts where the goal is simply to satisfy a sweet craving while minimizing the consumption of sugar and calories. We'll discuss why humans are hardwired to crave sweetness and how that

• 1:35Dr. Peter Attia?

  evolutionary advantage now collides with today's food environment. Whether or not sugar is uniquely fattening, the evidence on isocaloric comparisons and sugar's rapid effects on hunger hormones, fructose versus glucose, drinks versus solids, and "natural" versus "refined" sugars. Why the timing of your sugar intake matters.

• 1:59Dr. Peter Attia?

  What the big three sweeteners, saccharin, aspartame, and sucralose do and don't deliver for weight loss, glycemic control, and the microbiome? What makes allulose a standout sweetener and why it is challenging to use in all products? Sugar alcohols, erythritol, xylitol, and sorbitol? Their calorie savings, common GI pitfalls, and xylitol's unique dental benefits? And the long-term safety of common sweeteners? Do they raise cancer or heart disease risk? If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page.

• 2:42Dr. Peter Attia?

  So without further delay, I hope you enjoy AMA number 74.

• 2:51Dr. Peter Attia?

  Peter. Welcome to another AMA. How you doing? Good. Thank you for having me. Ah, yes. Thank you for showing up. Anything interesting going on today? Anything recent going on? Well, I was playing what I thought was the game of my life this morning in chess, and then I made a very tactical blunder and found myself on the receiving end of checkmate inside of two moves at the hands of my seven-year-old, which is becoming a constant theme these days. He's probably beating me six out of 10 games, which is simultaneously enjoyable to watch and infuriating to experience.

• 3:31Dr. Peter Attia?

  Yeah, I was gonna say, for people who have listened a while, read the book, the assumption would be you might not take losing to a seven-year-old in a mental game overtly positive. So what's the reaction like when you have a seven-year-old, not only he has friends lecturing you on diet sodas, which fits to this conversation today?

• 3:56Speaker 01

  And then they're beating you in chess.

• 3:58Dr. Peter Attia?

  Yeah, I hope that kid is listening. So I am actually not a competitive person. I think people are always surprised to hear that because they assume I am. I'm really not. I'm internally competitive. I'm not at all externally competitive. But chess is different. Chess is the only thing I do. Because you have to play against another person where I get insanely upset when I lose. And so I'm trying to teach the boys sportsmanship. So every time I lose, I put my hand across the table and I say, good game. And we shake hands. And I have mostly done a good job of that. But a week ago, when Ari beat me, I took my king. Well, he was going to beat me, so I was resigning.

• 4:43Dr. Peter Attia?

  So I was, I wanted to just tip my king over, which is to say I resign. Or maybe he had checkmated me and I put my king down. But anyway, I was so pissed, I smacked my king across the room. And my wife happened to be sitting there and see this. And she is like, amazing modeling there, Peter. Like what a great job of a 52 year old modeling for his two boys, how to be a sore loser. Good for you. Good for you. Just, just, so now you have, you're pissed that you lost. The shame of the realization that your wife is right. Plus, you're pissed at her for calling you out. I mean, it was not a fun couple of hours after that.

• 5:26Speaker 01

  I just love the concept of you and your wife dual parenting, except when you play chess. And at that point, your wife now has four children that she's looking after to make sure they don't do anything rash.

• 5:40Dr. Peter Attia?

  My guess is people who are listening right now, who don't play chess are like, what are you idiots talking about? I hope that somebody listening also plays chess and can go, yeah, I get it, man. I get it sometimes. Look, I've seen videos of Magnus Carlsen taking a sledgehammer to a computer screen when he lost to a bot. So I get it.

• 6:00Speaker 01

  So there's something to look forward to for you. You still have areas you can move up the ladder in reaction. And it's even better because most people haven't met your seven year old, but for anyone who has, the joy that he would get when you did that is going to be great because I feel like he loves a little trash talk himself.

• 6:19Dr. Peter Attia?

  He does. His nickname is Little Bag Smoker and he just walks around going, I'm gonna smoke your bags. Like, I am gonna smoke your bags.

• 6:29Speaker 01

  I just love it.

• 6:30Dr. Peter Attia?

  So good.

• 6:32Speaker 01

  It's all right. Well, that tangent out the way, what we're talking about today is something we hinted at earlier, which you got lectured on at elementary school the other day, which was diet soda.

• 6:43Dr. Peter Attia?

  Yeah.

• 6:44Speaker 01

  So today's topic is one that I think is interesting, not only because we get so many questions on it, but I think the reason we get so many questions on it is it's a topic people think about and are faced with decisions day to day. And that's everything around sugar and sugar substitutes. So we'll start looking at sugar, why we're wired to crave it, how it affects appetite, how it affects weight, how it affects metabolic health, natural sugar versus refined sugar, timing of sugar and how much that matters compared to how much you consume. And then we'll look at sugar substitutes, everything from aspartame to sucralose, stevia, monk fruit, allulose, what their effects on weight, insulin microbiome are,

• 7:27Speaker 01

  what we know about sugar alcohols like xylitol, erythritol, what we know about the risk of cancer, cardiovascular disease, long-term safety. And then hopefully be able to wrap it up with what your philosophy foundation is for how you apply this knowledge for yourself and patients. So all that said, a lot of good stuff to get to. Anything else you want to add before we get rolling?

• 7:51Dr. Peter Attia?

  Two things. One is, this is a topic we covered two years ago, maybe three years ago. And in working with the research team who did an awesome job in the preparation of this, what we saw was there had been so much additional literature on various topics, especially on the non-nutritive sweetener side. So not so much on sugar per se, which we'll start by talking about, but on the Sugar substitute side that I think this is a very important podcast, even if you think you were fully up to speed on our point of view on this, based on where we were two years ago. So again, science makes progress and I think a lot of progress has been made. That's kind of the first comment I would make. Second comment I would make is despite the fact that we're going to go down a bunch of rabbit holes,

• 8:37Dr. Peter Attia?

  I want to make sure everybody listening is anchoring to a framework. This is where we're going to land this plane. Okay, where I want to be able to land this plane is in a practical recommendation around the following scenarios, which is if I'm currently eating a ton of sugar, is that okay? If not, am I better off switching to sugar substitutes, but at the same quantities of the food that I was eating before? The example I would give here is if I'm sitting here drinking six Mountain Dews a day, would I be better off doing everything the same, but moving to six diet Mountain Dews a day? So I want to be able to land that plane and talk about those trade offs.

• 9:20Dr. Peter Attia?

  The second thing I want to be able to get at is really explore the nuance around, what are the, what I think of as the three cases for artificial sweeteners? So let's just put the sugar question aside, and I really think it boils down to three cases. One of them is beverages. So you gave that example a second ago. Diet Mountain Dew versus Mountain Dew, Diet Coke versus Coke, et cetera. I want to make sure we understand that. The second is in protein products. So this is either protein powders or protein bars. Why this matters comes down to something I don't think I fully understood until I got heavily involved with a company that makes protein bars. David, the David Bar.

• 10:04Dr. Peter Attia?

  What you don't realize until you get into the world of protein is protein is a brutal macronutrient to work with.

• 10:13Dr. Peter Attia?

  The reason I will always maintain that if your goal is to get X number of grams of protein, do your best to get it in real food, is that is hands down the best way to do it. If you're trying to hit 150 grams of protein per day, I would like you and I would encourage you to get every gram of that through actual food. The problem is, most people can't, myself included, okay? So we are typically relying on at least one form of processed food in the form of protein. Well, largely processed foods in the form of protein fall into two categories. Anhydrous salty protein, meaning protein sources where the water has been stripped out

• 10:54Dr. Peter Attia?

  and a preservative or two has been added, and that's usually in the form of jerky or a stick or something like that. Or you're on a totally different path where you're going with a sweetened protein product, namely in the form of a powder to make a shake or a bar. Why? Why does that latter one have to be sweetened? This is the thing that, again, I didn't fully understand until I kind of got into the chemistry of this stuff. Basically, the short and long answer is, protein is impossible to work with and it tastes horrible. That's what it comes down to. I think most people would be surprised at how difficult it is to work with protein compared to carbohydrates and fat, and how abhorrent it tastes.

• 11:35Dr. Peter Attia?

  So if you can't get all your protein in real food, which we want you to, and you're stuck supporting your protein needs with something that is processed, and you don't want to go down the dry salty route, you're gonna have to ingest something sweet. And the reason is, if you don't, you won't be able to consume it unless you have no taste buds. And even then, you probably won't be able to tolerate the texture of it. So this becomes the second very important use case around artificial sweeteners, is are you better off with an artificial sweetener or a real sugar in a protein product? The third use case comes down to treats. Do you like sweet treats? I love sweet treats.

• 12:19Dr. Peter Attia?

  I love me some licorice. I mean, I just love anything sweet. I'm not particularly unique in that regard, but I do. And so that becomes the third meta case that I want to make sure people are thinking through, which is if I want something sweet and it's not fruit, am I better off eating something sweet that is sweetened with sucrose or high fructose corn syrup, or pick your favorite thing, or something that is sweetened with one of these artificial sweeteners? Okay, I say all of that, Nick, to just make sure that the listener understands where we're going. Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member.

• 13:01Dr. Peter Attia?

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• 13:43Dr. Peter Attia?

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• 14:25Dr. Peter Attia?

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• 15:07Dr. Peter Attia?

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• 15:50Dr. Peter Attia?

  where I keep an up-to-date and active list of all disclosures.