Are sugar substitutes safe?

Nutritive and nonnutritive sweeteners enhance the flavor and/or texture of food. Nutritive sweeteners provide the body with calories, while nonnutritive sweeteners are very low in calories or contain no calories at all. They can both be added to food and beverages.(7)

Nutritive Sweeteners

Nutritive sweeteners, also known as caloric sweeteners or sugars, provide energy in the form of carbohydrates.

Some sugars are found naturally in foods. For example, fructose is found in fresh fruits. By eating the whole fruit, you not only consume fructose, but you feed your body fiber, vitamins, minerals, and phytonutrients that you do not get from sugar alone.

Many of the sugars in our diet come from “added sugars” – sugars added to food prior to consumption or during preparation or processing. Added sugars are used to enhance the flavor and texture of foods and to increase shelf-life. Examples of added sugars include sucrose and high-fructose corn syrup (HFCS). (7)

Sugar Substitutes

Sugar substitutes are sweeteners that you use instead of regular table sugar (sucrose). They are natural or artificial. One problem is that the terminology is often open to interpretation.

Some manufacturers call their sweeteners “natural” even though they’re processed or refined. Stevia preparations are one example. (1)

Artificial sweeteners

Artificial sweeteners are synthetic sugar substitutes. But they may be derived from naturally occurring substances, such as herbs or sugar itself. Artificial sweeteners are also known as intense sweeteners because they are many times sweeter than sugar.

Artificial sweeteners can be attractive alternatives to sugar because they add virtually no calories to your diet. Also, you need only a fraction of artificial sweetener compared with the amount of sugar you would normally use for sweetness.

Uses for artificial sweeteners

Artificial sweeteners are widely used in processed foods, including:

Soft drinks, powdered drink mixes and other beverages
Baked goods
Candy
Puddings
Canned foods
Jams and jellies
Dairy products

Artificial sweeteners are also popular for home use. Some can even be used in baking or cooking.

Certain recipes may need modification because unlike sugar, artificial sweeteners provide no bulk or volume. Check the labels on artificial sweeteners for appropriate home use.

Some artificial sweeteners may leave an aftertaste. A different artificial sweetener or a combination may be more appealing.

Possible health benefits of artificial sweeteners

Artificial sweeteners don’t contribute to tooth decay and cavities. Artificial sweeteners may also help with:

Weight control. Artificial sweeteners have virtually no calories. In contrast, a teaspoon of sugar has about 16 calories — so a can of sweetened cola with 10 teaspoons of added sugar has about 160 calories. If you’re trying to lose weight or prevent weight gain, products sweetened with artificial sweeteners may be an attractive option, although their effectiveness for long-term weight loss isn’t clear.
Diabetes. Artificial sweeteners aren’t carbohydrates. So unlike sugar, artificial sweeteners generally don’t raise blood sugar levels. Ask your doctor or dietitian before using any sugar substitutes if you have diabetes.

Possible health concerns with artificial sweeteners

Artificial sweeteners have been scrutinized intensely for decades.

Critics of artificial sweeteners say that they cause a variety of health problems, including cancer. That’s largely because of studies dating to the 1970s that linked the artificial sweetener saccharin to bladder cancer in laboratory rats. Because of those studies, saccharin once carried a label warning that it may be hazardous to your health.

But according to the National Cancer Institute and other health agencies, there’s no sound scientific evidence that any of the artificial sweeteners approved for use in the United States cause cancer or other serious health problems. Numerous studies confirm that artificial sweeteners are generally safe in limited quantities, even for pregnant women. As a result, the warning label for saccharin was dropped.

Artificial sweeteners are regulated by the Food and Drug Administration (FDA) as food additives. They must be reviewed and approved by the FDA before being made available for sale.

Sometimes the FDA declares a substance “generally recognized as safe” (GRAS). Substances receive this designation if they meet either of these criteria:

Qualified professionals deem the substance safe for its intended use on the basis of scientific data. Stevia preparations are an example of this type of GRAS designation.
The substances have such a lengthy history of common use in food that they’re considered generally safe.

The FDA has established an acceptable daily intake (ADI) for each artificial sweetener. ADI is the maximum amount considered safe to consume each day over the course of a lifetime. ADIs are set at very conservative levels.

Novel sweeteners

Novel sweeteners are hard to fit into a particular category because of what they’re made from and how they’re made.

Stevia is an example. The FDA has approved highly refined stevia preparations as novel sweeteners but hasn’t approved whole-leaf stevia or crude stevia extracts for this use.

Tagatose is also considered a novel sweetener because of its chemical structure. Tagatose is a low-carbohydrate sweetener similar to fructose that occurs naturally but is manufactured from the lactose in dairy products. The FDA categorizes tagatose as a GRAS substance.

Sugar alcohols

Sugar alcohols (polyols) are carbohydrates that occur naturally in certain fruits and vegetables — although they can also be manufactured. Despite their name, sugar alcohols aren’t alcoholic because they don’t contain ethanol, which is found in alcoholic beverages.

Sugar alcohols aren’t considered intense sweeteners because they aren’t sweeter than sugar. In fact, some are less sweet than sugar. As with artificial sweeteners, the FDA regulates the use of sugar alcohols.

Sugar alcohols contain calories. But they’re lower in calories than sugar, making them an attractive alternative.

Uses for sugar alcohols

Sugar alcohols generally aren’t used when you prepare food at home. But they’re in many processed foods and other products, including chocolate, chewing gum and toothpaste. Sugar alcohols add sweetness, bulk and texture to food, as well as helping food to stay moist.

Sugar alcohols are often combined with artificial sweeteners to enhance sweetness. Food labels may use the general term “sugar alcohol” or list the specific name, such as sorbitol.

Possible health benefits of sugar alcohols

Like artificial sweeteners, sugar alcohols don’t contribute to tooth decay and cavities, and may also help with:

Weight control. Sugar alcohols contribute calories to your diet — but fewer calories than regular sugar. Sugar alcohols may help weight-control efforts.
Diabetes. Unlike artificial sweeteners, sugar alcohols are carbohydrates and can raise blood sugar levels. But your body doesn’t completely absorb sugar alcohols, so their effect on blood sugar is smaller than that of other sugars. Talk to your doctor or dietitian for guidance because sugar alcohols vary in their effects on blood sugar.

Possible health concerns with sugar alcohols

When eaten in large amounts, sugar alcohols can have a laxative effect, causing bloating, intestinal gas and diarrhea. Product labels may carry a warning about this potential laxative effect.

Natural sweeteners

Natural sweeteners are sugar substitutes that are often promoted as healthier options than sugar or other sugar substitutes. But even these “natural sweeteners” often undergo processing and refining.

Natural sweeteners that the FDA recognizes as generally safe include:

Fruit juices and nectars
Honey
Molasses
Maple syrup

Uses for natural sweeteners

Natural sweeteners have a variety of uses both at home and in processed foods. They’re sometimes known as “added sugars” because they’re added to foods during processing.

Possible health benefits of natural sweeteners

Natural sugar substitutes may seem healthier than sugar. But their vitamin and mineral content isn’t significantly different. For example, honey and sugar are nutritionally similar, and your body processes both into glucose and fructose.

It’s OK to choose a natural sweetener based on how it tastes rather than on its health claims. Just try to use any added sweetener sparingly.

Possible health concerns with natural sweeteners

Natural sweeteners are generally safe. But there’s no health advantage to consuming any particular type of added sugar.

Consuming too much added sugar, even natural sweeteners, can lead to health problems, such as tooth decay, weight gain, poor nutrition and increased triglycerides. Honey can contain small amounts of bacterial spores that can produce botulism toxin. Honey shouldn’t be given to children younger than than 1 year old.

Moderation is key

When choosing sugar substitutes, it pays to be a savvy consumer. Artificial sweeteners and sugar substitutes can help with weight management. But they aren’t a magic bullet and should be used only in moderation.

Food marketed as sugar-free isn’t calorie-free, so it can still cause weight gain. Keep in mind that processed foods, which often contain sugar substitutes, generally don’t offer the same health benefits as whole foods, such as fruits and vegetables. (1)

Role in the gastrointestinal tract

New data from both humans and animal models have provided convincing evidence that artificial sweeteners play an active role in the gastrointestinal tract, thus providing a mechanistic explanation for observed metabolic effects. Sweet-taste receptors, including the taste receptor T1R family and α-gustducin, respond not only to caloric sugars, such as sucrose and glucose, but also to artificial sweeteners, including sucralose and acesulfame-K. In both humans and animals, these receptors have been shown to be present not only in lingual taste buds, but also in glucagon-like peptide-1 (GLP-1) secreting L cells of the gut mucosa, where they serve as critical mediators of GLP-1 secretion. Mace et al. showed in rat studies that stimulation of intestinal taste receptors with sucralose led to more rapid absorption of sugars from the intestine into the bloodstream. We have demonstrated in young healthy volunteers that consumption of diet soda before an oral glucose challenge potentiates GLP-1 secretion, thus potentially altering both gastric emptying and insulin secretion. Translating these results into the clinical realm, consumption of an artificial sweetener in conjunction with a sugarcontaining food or drink could lead to more rapid sugar absorption, as well as increased GLP-1 and insulin secretion, potentially affecting weight, appetite, and glycemia. (2)

Nonnutritive sweeteners (NNS) have become an important part of everyday life and are increasingly used nowadays in a variety of dietary and medicinal products. They provide fewer calories and far more intense sweetness than sugar-containing products. Six of these agents (aspartame, saccharine, sucralose, neotame, acesulfame-K, and stevia) have previously received a generally recognized as safe status from the United States Food and Drug Administration, and two more (Swingle fruit extract and advantame) have been added in the recent years to this ever growing list. there is inconclusive evidence to support most of their uses and some recent studies even hint that these earlier established benefits regarding NNS use might not be true. There is a lack of properly designed randomized controlled studies to assess their efficacy in different populations, whereas observational studies often remain confounded due to reverse causality. (3)

Recent studies have suggested that NNS consumption can induce gut microbiota dysbiosis and promote glucose intolerance in healthy individuals that may result in the development of type 2 diabetes mellitus (T2DM). This sequence of events may result in changes in the gut microbiota composition through microRNA (miRNA)-mediated changes. NNS are not inert compounds as once thought. However, the specific mechanism(s) and details of the effects of NNS consumption on host metabolism and energy homeostasis remain to be elucidated. NNS consumption has been associated with increased risk factors for metabolic syndrome. metabolic syndrome refers to the collection of physiological, biochemical, clinical, and metabolic factors that contribute to the increased risk of cardiovascular disease and type 2 diabetes melitus (T2DM). Based on measurements and laboratory tests, metabolic syndrome can also contribute to hypertension, glucose intolerance, proinflammatory state, atherogenic dyslipidemia, prothrombic state, and kidney diseas.

Currently, the Food and Drug Administration (FDA) has approved the use of acesulfame-potassium (Ace-K), aspartame, neotame, saccharin, sucralose, and stevia (4)

Saccharin was discovered as early as 1876 and was the “original” artificial sweetener used in the food industry. Unfortunately, saccharin and many of its sweet alternatives have been considered to be health hazards, and as a result, are banned in many countries. Recently, other sweeteners have been developed and implemented within the food industry.

In general, there are three primary types of sweeteners used in the food industry today: high-intensity sweeteners (e.g., acesulfame potassium, advantame, aspartame, neotame, saccharin, and sucralose), sugar alcohols (e.g., erythritol, glycerol, mannitol, sorbitol, and xylitol), and natural sweeteners (e.g., honey, lucuma powder, maple syrup, monk fruit known as Siraitia grosvenorii swingle fruit extract, stevia, and yacon syrup) (5)

Any health problems with sweeteners

The consumption of sugar-free foods is growing because of their low-calorie content and the health concerns about products with high sugar content. Sweeteners that are frequently several hundred thousand times sweeter than sucrose are being consumed as sugar substitutes. Although nonnutritive sweeteners (NNSs) are considered safe and well tolerated, their effects on glucose intolerance, the activation of sweet taste receptors, and alterations to the composition of the intestinal microbiota are controversial. This review critically discusses the evidence supporting the effects of NNSs, both synthetic sweeteners (acesulfame K, aspartame, cyclamate, saccharin, neotame, advantame, and sucralose) and natural sweeteners (NSs; thaumatin, steviol glucosides, monellin, neohesperidin dihydrochalcone, and glycyrrhizin) and nutritive sweeteners (polyols or sugar alcohols) on the composition of microbiota in the human gut. So far, only saccharin and sucralose (NNSs) and stevia (NS) change the composition of the gut microbiota. By definition, a prebiotic is a nondigestible food ingredient, but some polyols can be absorbed, at least partially, in the small intestine by passive diffusion: however, a number of them, such as isomaltose, maltitol, lactitol, and xylitol, can reach the large bowel and increase the numbers of bifidobacteria in humans. Further research on the effects of sweeteners on the composition of the human gut microbiome is necessary. (6)

Increased incidence of obesity and diabetes make NNS and their low caloric value even more favorable diet supplements. It is generally accepted that high sugar diets contribute to metabolic disorders. The National Heart, Lung and Blood Institute (NHLBI) define metabolic syndrome as the group of risk factors that would increase heart disease and other health problems such as diabetes and stroke. The metabolic risk factors include abdominal obesity, high triglyceride level, low HDL cholesterol level, high blood pressure, and high fasting blood sugar. High sugar diets have been associated with the development of insulin resistance, T2DM, and additional cardiovascular diseases that fall within the realm of metabolic syndrome. Briefly, these conditions are a result of dietary sugar upregulating hepatic uptake and metabolism of fructose, which leads to liver lipid accumulation, dyslipidemia, decreased insulin sensitivity, and increased uric acid levels. The role of non-nutritive sweeteners in metabolic syndrome has been discussed in other reviews, with a focus on three potential mechanisms Non-nutritive sweeteners continue to be a staple in the Western diet. However, the health-related safety of NNS consumption remains to be a controversial topic. Recent reports on the role of NNS promoting shifts in gut microbiota composition and reports linking the gut microbiota to insulin signaling, confirm the importance of studying the physiological effects of NNS. The exact mechanisms of pathological changes induced by NAS are still under speculation. Thus, the recently discovered phenomenon of functional selectivity of GPCR-IR crosstalk, as well as miRNA modulation of gut microbiota function, may provide insight into the pathological effects of NNS.

Enhancing our knowledge through well-designed human trials should highlight the potential role of NNS in the alterations of microbial, neurological, and hormonal responses to consumed food. Energy intake compensation appears to be an area where additional studies need to test and compare different food as well as different NAS. Consumers must be aware that contrary to the existing belief, that substitution of natural sugar by NAS is beneficial for their health, there is growing evidence of NAS being implicated in the development of metabolic abnormalities. Continued research in this field will uncover the pathology of diet-induced metabolic changes as well as uncover new biomarkers and novel treatments using miRNAs. (5)

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