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Wednesday, October 15, 2014

Seeking the sweet spot, from mouth to microbiome

A study out last week in the top-tier journal Nature told us that non-caloric artificial sweeteners (NAS) may contribute to glucose intolerance by mucking up our microbiomes. That’s a serious indictment, since these products are intended to help defend against glucose intolerance, and other ills related to diabetes risk and weight gain. After all, they are replacements for sugars that have already been comparably indicted.

The study, which received considerable media attention and may already have caught yours, was both elegant, and complicated. It was actually one paper, but a series of studies in both mice and people. Most of the work was in mice, where the introduction of NAS, specifically saccharin, aspartame, or sucralose, induced glucose intolerance. The underlying cause of this metabolic effect was traced to a marked change in the bacterial populations colonizing the GI tracts of the mice. The adverse effect was reversible with antibiotics that killed off the newly favored bacterial colonies.

Studies in humans suggested much the same, but these were less controlled, and conducted in very few people, with less consistent results. The translation of these findings from mice to people was generally supported.

While the human research was far from decisive, the takeaway from the constellation of studies was clear enough. Replacing sugar with artificial sweeteners may fail to facilitate the intended benefits. By compromising the ecology of the microbiome, of both mouse and man, the effect may be just the opposite.

The epidemiology is, for the most part, rather consistent with such unintended consequences. Diet soda has been linked to obesity, although questions are routinely raised about the direction of causality (i.e., maybe drinking diet soda makes people fat; maybe overweight people turn to diet soda to help control their weight). Associations have been established with serious chronic diseases as well, although again, both specific proof of causality and mechanism are lacking.

From my perspective, this new research, provocative though it may be, merely puts the icing on a well-baked cake. I think we had good reason to avoid artificial sweeteners before now.

In brief, we are right when in the vernacular we refer to a “sweet” tooth, rather than a “sugar” tooth. The taste preference we are referencing is, indeed, generic to all substances that trigger the recognition of “sweet” in the brain.

What we mean, of course, when we say “sweet tooth” is a preference for all things sweet. When the issue of food addiction is debated, the sensation that tops the list of likely candidates is sweet. If any response to food hardwired into our nervous systems rises to the level of addiction, it would be the response to sweet.

This means several things. First, a sweet tooth may be exploited to propagate our eating and profit from it. Put sweeteners into foods, even foods not customarily thought of as sweet, and the amount of eating we are apt to do before stopping increases. This is done, and the results are as predicted, entirely by profitable and exploitative design.

It also means that the more we get, the more we want, and need, to feel satisfied. In addiction, this is called tolerance. In the case of a sweet tooth, it means graduation to a sweet fang that pretty much takes over your kitchen, and your life.

There is every reason, residing in sense as well as science, to suspect that NAS contribute just as readily to this phenomenon as caloric sugars. The commonly used artificial sweeteners are intensely sweet, all much more so than sugar. The net result, then, is that while NAS might remove sugars and the associated calories at any given time, they would cultivate the sweet tooth that would favor their readmission at some other time. That’s easily done, since there are popular brands of bread, crackers, chips, pretzels, salad dressings and pasta sauces with added sugar. One might favor such products due to a sweet tooth, and never even be aware of it.

What, then, is the answer? Neither the current excess of sugars, nor the sugar substitutes that foster a sweet tooth and disrupt the microbiome. There may be better options in the pipeline, namely non-caloric sweeteners that don’t exert unintended harms. Both stevia and monk fruit extract look promising at this point, but we need more data.

In my opinion, the best answer is a method I call “taste-bud rehab,” that allows for titrating down one’s standard daily exposure to sweeteners quite painlessly, then acclimating to that ever lower level. Taste-bud rehab is one example of skillpower, willpower’s oft-neglected cousin. Titrate down exposure to total sweeteners, come to prefer foods less sweet, and then use actual sugar, but much less of it.

The nutritional sweet spot will never be reached courtesy of the prevailing excess of added sugars, whatever their formulations. We now have more cause than ever to think that it will not be facilitated by substituting non-caloric artificial sweeteners, either.

Science and sense have long suggested that the way to go was reducing the total amount of “sweet” in our diets, and rehabilitating our taste buds in the process. The result is not only a diet much lower in sugars and free of NAS, but a diet that you genuinely prefer that way. Add the relevant skillpower to science and sense, and you can get to the much-less-sweet sweet spot from here. When you do, you will find yourself loving food that loves you back, from your mouth, to your microbiome.

And, I suppose, to your mice, too, if you happen to have any of those.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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