“Seriously people, just use a teaspoon of sugar and throw out the garbage additives! The stuff tastes horrible anyway!”

That was the first text I sent to a friend when I saw the recent study on the artificial sweetener erythritol. The study reported an increased risk of heart attacks and strokes in people who had higher blood levels of the substance. The sugar-substitute, called erythritol, is a type of sugar alcohol, known as a polyol that has long been associated with short-term gastrointestinal side-effects. People who suffer with irritable bowel syndrome (IBS) have been told to avoid the polyols for years due to their causing flatulence, abdominal pain, and diarrhea. Erythritol was thought to be the best of the bunch in terms of these unwanted effects. Current evidence, however, suggests that it might be far more dangerous than having to spend the day in the bathroom.

The study researchers did not expect to find erythritol in high amounts in the blood of heart attack and stroke victims and weren’t particularly looking for it when they started analyzing the study participants’ blood. Because they were so surprised by these findings, they then tried to figure out why the erythritol was leading to strokes and heart attacks by investigating whether it increased the ability of the blood to clot. It did.

The study reported an increased risk of heart attacks and strokes in people who had higher blood levels of the substance.

Looking at what additives do in the real world, on a variety of different human bodies, is leading to a plethora of disheartening findings, with diseases such as diabetes, colitis, and cancer, having been recently associated with some. Nutrition studies are far from perfect and the association with various disease states isn’t settled science. But from the perspective of scientific rigor, the erythritol study is superior to the small scale, short-term, mostly animal studies that get additives approved in the first place.

No one could have predicted that erythritol would increase the risk of blood clotting and cardiac events because no one had ever looked for anything like this before. Additives are not generally studied for their long-term effects on our bodies. They are also not studied in very large groups of people and usually not in combination with other things that we might be ingesting.

A wise person once said, “You don’t know what you don’t know.”

But here’s what we do know. A teaspoon of sugar has about five grams of carbohydrates. How many grams a day of carbohydrates someone consumes is important to people struggling with their blood sugar. In general, I ask patients with diabetes to try to keep their carbohydrate count for the day to less than 150 grams and to try to get those carbohydrates in the form of whole foods like fruits and vegetables with small amounts of minimally processed whole grain products. And if they want a spoon of sugar in their coffee or a cookie? I tell them it is absolutely fine. Because it turns out that what’s most important is what their entire day looks like, or better yet, what their week looks like. Eating whole foods, consistently, while avoiding the highly processed, additive-laden stuff, is the key to a healthy diet. Unfortunately, for many of us, we’ve forgotten how to do this.

This study is a bitter pill for us all to swallow. We’ve become accustomed to artificial sweeteners like erythritol. Even though I don’t personally use them and haven’t for years due to my own struggles with IBS, I keep some packets in my house for guests who prefer them. It won’t be as difficult for me to toss them out as it might be for everyday users who may not have had a teaspoon of real sugar in years.

And that’s okay. This study isn’t cause for panic, but it is a good reason to reflect on what we are eating. While this is only one study pointing to one additive, the evidence for eliminating highly processed foods in favor of real, whole foods, has been building for years.  If you’ve been thinking about ditching your highly processed and maybe artificially sweetened breakfast cereal and instead going for a bowl of oatmeal, sweetened with just a little sugar and lots of natural fruit, tomorrow would be a great day to try it.

To learn more about how avoiding key additives can help you feel better:

weight loss drugs versus eating real whole food

In 2005, I started writing a medical mystery called Not Quite Dead, where a diabetes researcher discovers a drug that helps people to lose a remarkable amount of weight. Only there might be significant side effects. My idea was that if people knew about these side effects, the drug might flop.

…After three months on the experimental drug, the mice were losing about fifteen percent of their body weight. Of equal importance, no significant side effects could be noted. So none were.

—Not Quite Dead (page 7)

If you think this sounds a little like semaglutide, a medication initially developed to control blood sugar (also called Ozempic or Wegovy), but which turned out to be a jaw-droppingly effective medication for weight loss, you’d be wrong. Because despite a link to thyroid cancer, the drug is an absolute blockbuster. These side effects might turn out to be much ado about nothing. Or, they might not.

What happens when there is a new medication that gets widely used by millions of people, possibly for decades, is that we learn more about the drug—both good and bad. Using a newly approved medication is a little bit of an experiment, but if the benefits outweigh the potential costs for a given individual, it is not unreasonable to try it. I have prescribed semaglutide (and others in this medication class) for patients who are able to get a hold of it (read: afford it, because in the US, it is almost $1,000 a month without insurance) and who medically qualify for it. It’s hard not to get excited about this medication, especially for people who struggle with their weight and diabetes.

For years, the medications to control diabetes led to further weight gain, precipitating a vicious cycle in which people with diabetes would need more and more medication to control their blood sugar as their weight increased. Drugs that help people with diabetes to lose weight and break this cycle were long sought after. These drugs got additional approval for people with a medical problem that wasn’t diabetes, like high blood pressure or sleep apnea, and obesity. It makes sense that people with stubborn medical problems would want to take a newly approved drug that might help them lose weight and better control their medical issues. But now, it seems that everyone wants semaglutide. Articles are being written about healthy people who want to lose 10 or 20 pounds and find a provider to prescribe the medication. Instead of being afraid of side effects, which I thought would doom the fictional medication in my book, people are more concerned with weight loss, even in the absence of medical problems.

Vanity often gets the blame for the incredible off-label demand for these new medications. But, I don’t agree with this. Besides marketing and societal pressures to be thin, we are actually hungry—hungrier than we think we should be—and we are looking for something, anything to help control our cravings.

Besides marketing and societal pressures to be thin, we are actually hungry—hungrier than we think we should be—and we are looking for something, anything to help control our cravings.

A piece of the puzzle that I write about in Eat Everything: How to Ditch Additives and Emulsifiers, Heal Your Body, and Reclaim the Joy of Food, is the idea that when our digestive systems are presented with certain food additives, they encourage us to eat more.

In Eat Everything, I tell the story of a patient named Thomas (not his real name), who reports that he feels like he can’t control himself around store-bought ultra-processed cookies and cakes. But, Thomas has a lot more control over his intake of sweets when he is eating homemade desserts made with whole ingredients—even if they are cookies and cakes. Those treats have lots of sugar and flour in them too, but they don’t generally have a substance, ubiquitous in ultra-processed food, called maltodextrin.

Maltodextrin imparts a sweetness to foods and can allow producers to use less “sugar.” So, it can make an ultra-processed food appear lower in sugar than it otherwise would be. It helps the product to last longer on the shelf too. As a result, you can now find it on ingredient lists on everything from breakfast cereals to pricey chocolates. But, it has been noted to raise blood sugar faster than real sugar does, causes mice to consume more calories when they are given the substance in their water, and is even taken by bodybuilders who are trying to bulk up on purpose. There have also been studies linking it to changes in our gut microbiomes that may contribute to colitis. The International Organization for Inflammatory Bowel Diseases asks patients suffering from colitis to avoid maltodextrin in their 2020 guidelines. While maltodextrin might be the biggest offender, there are plenty of other reasons to avoid ultra-processed foods.

Most of my patients can’t afford expensive weight loss drugs, even if they have diabetes or other conditions for which they’ve been approved. Sometimes we turn to less expensive medications to help with weight loss (after discussions about benefits and possible side effects), but sometimes we are only left with dietary modification and that can work, too.

In one of the best-done studies on ultra-processed versus whole foods, participants lost two pounds in just two weeks of being on a whole foods diet, while they gained two pounds when on the ultra-processed one. Large population-based studies have also shown a strong association between the consumption of ultra-processed foods and weight gain. Importantly, ultra-processed foods aren’t just what we think of as “junk” foods like fast food and candy. Many whole-grain breads and yogurts marketed as health foods are classified as ultra-processed.

Whether or not you are in the market for one of the new weight loss drugs, if you want to cut cravings and increase your ability to be sated by your food, skip the ultra-processed stuff (especially foods with maltodextrin) and try to eat as whole food-based a diet as possible. Sure, eggs are expensive these days, but not as expensive as semaglutide.

To learn more about how avoiding key additives can help you manage your weight more easily:

best diet for losing weight

“Which diet is best for losing weight?”

That’s a question I’m asked a lot.

Few seem to have a straight answer for that one, except for people who have deeply held religious-like, ideological beliefs around food. Keto adherents are quite sure that avoiding carbs is the way to go. For vegans, eliminating animal products provides a clear path to health. If you’d like to experience the passion of an old school religious war without the bloodshed, head over to your favorite social media battlefield and read a few keto responses to a vegan post or vegan responses to keto posts. While they may not actually be killing each other, each is convinced that the other’s dietary habits will do it for them.

Low-carb, High-fat vs. High-carb, Low-fat

That brings us to Dr. Kevin Hall of the National Institutes of Health (NIH), who has entered the arena as a peacemaker of sorts by providing combatants with a healthy dose of science. Dr. Hall designed a study where participants would be fed either a high-fat, low-carb diet or a low-fat, high-carb diet. The participants had two weeks in each arm of the trial, so that they could be compared to themselves. Like a previous study he had done at the NIH looking at an ultra-processed diet vs. a whole foods diet, all the food was provided to the participants and their activity was carefully tracked. Also like the former study, participants could eat as much as they wanted and the food was rated by them as pretty good in both arms of the trial.

The folks on the low-fat diet ate about 500-700 fewer calories a day, but had higher insulin and blood sugar levels (suspected drivers of some diet-related diseases). The people doing the high-fat diet ate more calories, but had lower insulin and blood sugar levels. There were possibly advantages to both diets.

So, back to the original question, which one produced more weight loss?

Examples of dinners given to study participants: low-carb, animal-based diet (top) and low-fat, plant-based diet (bottom). Amber Courville and Paule Joseph, NIH

Here’s where we need to go back to Dr. Hall’s previous work on ultra-processed vs. whole foods diets.

Participants in this study lost about 2 pounds on the whole foods diet and gained 2 pounds on the ultra-processed one. When he designed the low-fat vs. low-carb study, he pretty much avoided giving the participants ultra-processed foods.

The short answer is that they both resulted in weight loss, but the low-fat diet resulted in more body fat loss in the participants. Case closed? The vegans win, right? But wait! These weren’t restrictive diets. I told you earlier that the people in the study could eat as much as they wanted. Neither the low-fat nor the low-carb participants were hungry and they both lost weight, though the low-fat participants lost a little bit more. How?

OK, but the vegans still win? Sort of. Plant-based diets are probably better for you, both in the short term, like in this study and in the long term, as Dean Ornish and others have shown with improved cardiovascular outcomes. So, if you can avoid eating animals, that might be best for you and for the environment. But even if you can’t or don’t want to (and I don’t want to either, so don’t feel bad), if you can avoid ultra-processed foods (think stuff that has ingredients on the list that you wouldn’t have in your own pantry or in anyone’s pantry for that matter), you’ll be a lot healthier and quite possibly weigh a bit less too.

So, how do I answer the question, “Which diet is best?”

It turns out that it’s not so complicated after all: Any style of eating that avoids ultra-processed foods that you can stick with and enjoy.


How should you talk to your doctor? Short answer: Like you would talk to any other human. It’s your doctor’s job to listen.

Here goes the longer answer.

This week, I gave a lecture to first-year medical students on how to take a medical history from a patient. I’ve delivered this lecture for the past seven years. The central message I impart to the students is one that reaches back to the beginning of modern medicine, but is no less relevant today.

Sir William Osler, a physician from the 1800s, stated it most clearly when he said, “Listen to your patient. (They are) giving you the diagnosis.”

I put this quote up on a slide for the students, who are new to medical school, but who have nevertheless heard this quote already from several faculty before hearing it from me. I tell them, “We repeat it a lot, but then we ignore it.”

I ask the students, “If it is so important to listen to our patients, why don’t we?”

“There’s not enough time.”

“We’re too busy.”

“We have biases.”

“We forget how important it is.”

The students call out all the right answers. What used to a be a 30-minute office visit has been cut down to 15 minutes, if that. Computer work and paperwork have increased at an astronomical rate, further cutting into patient care time. We rush to judgement, abandoning the idea that we should be thinking about all possible diagnoses before narrowing our focus. And, in an era where blood tests and imaging studies abound and require only a click of the computer mouse to order, minutes can be saved by just doing that, at the expense of giving our attention to the person in front of us.

Over the next three hours, through practice patient interviews and other small group exercises, I try to convince the students that no matter what the external forces pressing on them are, when they have a patient in front of them over the course of their careers, they should try to block out the rest of the world and just listen. They will have many more practice and empathy-building sessions over the next several years of their medical education, but eventually, they will enter the real world. And the real world does not pay doctors to listen to their patients. It pays them to go quickly and “efficiently” through their day.

So, what’s a patient to do?

I have a friend who is dealing with a very serious health issue. She tells me how she brings copies of her tests and CDs of her scans along with her so the results are always on hand in case the doctor doesn’t have them. She tries to be as brief as possible and show little emotion to her obviously harried physician, who she fears will dismiss her if she is too “difficult.” Instead of being able to focus on what she needs from her visit, she tries to bond with the doctor over shared interests and manage the doctor’s needs. And my heart breaks for her every time I hear about her latest visit. In addition to dealing with a miserable diagnosis, she has to expend mental energy to try to figure out how to make the most of the time with her physician.

It shouldn’t be this way, but for so many patients, it is. As medical professionals, we have to do better. Someone who comes to us for care and compassion deserves just that. There are some medical facilities that give their physicians the resources to be able to spend more time with their patients. There are physicians in private practice who have, through a combination of good luck and good business sense, figured out how to keep a practice afloat and give their patients the time they need. In some areas, these practices can be hard to find, or even if they exist, they are not necessarily on your insurance plan.

I can ask you to find a doctor who will give you the time to listen, but I imagine that you’ve tried this already. So, as much as it pains me to say it, my friend is doing what she needs to do to be heard and treated appropriately. Bring your important records with you (never assume the doctor has them). Be ready to summarize your story as “efficiently” (yes, I hate this word in medicine) as possible. For some people, bringing a typed-out version of their story can help. Tell your doctor all the issues you would like for them to address at the beginning of the visit so you can be sure that something you may need isn’t left until the end when time may have run out. And importantly, be your own advocate. If something isn’t right, say so. If something isn’t working, say so. Ultimately, your doctor wants you to get better. They want to help, but the system we all find ourselves in isn’t conducive to forming a strong patient-doctor relationship. There are some who are working to change this, but as always, change can never come fast enough.


What makes something trashy?

Urban Dictionary tells us that “trashy people contribute little or nothing to society.” They are flashy, but don’t have much substance. No one wants to be called “trashy.” And we shouldn’t call people “trashy”—everyone deserves respect. Some food, on the other hand, deserves no respect. There is definitely some trashy food out there.

 Similar to a celebrity who hires a publicist to make sure he is photographed at a soup kitchen, so that no one is paying attention to his sexual harassment charges[AG2] , trashy foods cover themselves in clever packaging that hails them as “organic” or “high in fiber.”

Dr. Carlos Monteiro, M.D., Ph.D., professor and chair of the Center for Epidemiological Studies in Health and Nutrition at the University of São Paulo in Brazil, calls this trashy food, “ultra-processed” because he’s classier than I am.

Dr. Monteiro developed the NOVA food classification system, defining the ultra-processed stuff as, “made mostly or entirely from substances derived from foods and additives, with little if any intact (whole) foods.” This makes a lot of sense to me. However, when nutrition professionals were asked to place food into one of his four NOVA categories (ultra-processed being the 4th one), there wasn’t much consistency in where ultra-processed stuff should go.1[AG3]  

Which begs the question—why can’t we agree on what an ultra-processed (trashy) food is?


I’m not big into conspiracy theories, but in this case, I’m going to have to go with the possibility that the ultra-processed food industry has been working for decades on muddying the waters of what an ultra-processed food vs. a processed food vs. even what a whole food is. [AG4] If the celebrity has a publicist, trashy foods have an army of them.