In recent decades, sugar has been positioned as the dietary enemy, claimed by many to be the cause of growing rates of chronic disease, and the so-called (albeit controversial) ‘obesity epidemic’. As a result, many of us choose to use ‘sugar alternatives’ in an attempt to avoid the claimed negative health effects of sugar, reduce our calorie intake and manage weight. With so many alternatives to sugar available, and more and more diet products popping up on the market, there has been growing controversy about their safety concerns and potential health benefits.
In today’s article, my colleague Leigh (who is someone many of you will be familiar with by now) will be taking us on an extensive journey into the world of sugar alternatives. Aside from some minor feedback from yours truly, Leigh wrote the article in it’s entirety and it’s a damn good one if I do say so myself.
Any questions you may have had about sugar alternatives will be answered.
Are Sugar Substitutes Good For Your Health?
Let’s get the ball rolling by defining what sugar alternatives are. Sugar substitutes are a loose term for any product that gives something a sweet taste as an alternative to sucrose (or pure table sugar). Some of them have calories and still contain naturally occurring sugars, while others are calorie free or much lower in calories but still provide a sweet flavour when added to foods like baked goods and drinks.
They are commonly grouped as such:
Caloric Natural Sweeteners (contain calories, minimally processed)
Honey, maple syrup, date sugar, molasses, coconut sugar, agave syrup, thaumatin
Non-caloric natural sweeteners (do not contain calories, considered “less processed” than artificial sweeteners)
Sugar alcohols (contain less calories and less carbs than sugar)
Erythritol, sorbitol, isomalt, maltitol, mannitol, xylitol
Artificial sweeteners (no calories, high intensity sweeteners)
Acesulfame-K, aspartame, neotame, saccharin, cyclamate, sucralose
As you can see, there is quite a variety of products that are used to substitute sugar, with a large range in calorie content and sweetness. Of these sugar alternatives, artificial sweeteners and sugar alcohols are considered the least “natural” and therefore subjected to the most controversial health claims. Let’s define these two types of sugar substitutes a bit more.
Artificial sweeteners provide sweetness to foods, but are absent in calories and have no impact on blood sugar. They are synthetic substances, created with the purpose of allowing individuals to reduce their caloric intake, but still enjoy sweet foods and drinks.
Although they may be derived from natural sources (eg. sucralose is made from sugar), they have been chemically modified to produce a sweetness much more intense than sugar without any calories. Sucralose (Splenda ®) is the most widely used artificial sweetener due to its close resemblance in taste to natural sugar, and is 400-700 times sweeter than table sugar (sucrose).
Sugar alcohols also provide sweetness to foods, but in a lesser intensity. Despite their name, they do not contain any alcohol or sugars. Most sugar alcohols are produced industrially from other sources such as sucrose, glucose and starch, and are found as a white powder as a table sweetener or additive to foods.
Sugar alcohols are not well absorbed by the body (they have a small laxative effect), and therefore have a minimal effect on blood sugars. The only exception to this is maltitol, which is fairly well-absorbed by the body so it does have some effect on blood sugars (caution if you have diabetes or on a low-carb diet).
They vary in sweetness, calorie content, and taste when compared to pure sugar. Erythritol has 70% of the sweetness of sugar, but only 5% of the calories. Maltitol is about 90% sweet as sugar, but has half the calories. Xylitol is considered equally sweet as sucrose but with 33% less calories.
Unlike artificial sweeteners, sugar alcohols may even have some beneficial health effects, such as preventing tooth decay and dental cavities when consumed regularly . They may also act like as a prebiotic, supporting the growth of healthy bacteria in the gut( 1,2,3 )
Where do I find artificial sweeteners and sugar alcohols?
You’ll know when a product contains artificial sweeteners and sugar alcohols as it will likely be marketed as a “sugar free” or “diet” product. These sweeteners are found in a variety of foods and beverages like diet pop, sugar free chocolates and candies, and even packaged yogurts, cereals and cookies. The popular quest-bar (a low carb, high protein snack bar) contains a blend of erythritol and sucralose to provide sweetness without any actual added sugars.
You can also purchase them as table sweeteners, in small packets to add to your coffee and tea, or in bulk to use in baking or other recipes. Splenda ® in particular is often marketed as an ideal sugar replacement for baked goods because it is ‘heat stable’ (retains its sweetness under high heat).
Are artificial sweeteners and sugar alcohols safe?
Before Health Canada can permit these products to be sold and used as a food additive in Canada, sugar substitutes must undergo substantial testing to prove they are safe for human consumption. There are several sugar substitutes approved for use as additives in Canada, including:
aspartame (Equal ®, Nutrasweet ®)
neotame (Newtame ®)
sucralose (Splenda ®)
sugar alcohols (polyols) including erythritol, sorbitol, isolmalt, lactitol, maltitol, mannitol and xylitol
*The artificial sweeteners Cyclamate (Sugar Twin ®, Sweet n Low ®) and Saccharin (Hermestas ®) are available as table sweeteners, but are not yet permitted to be added to packaged foods and beverages.
The approved sugar substitutes are considered safe when consumed in the recommended Acceptable Daily Intake (ADI) level set out by Health Canada. Reaching the ADI would be pretty tough for most of these table top sweeteners.
75 packs of Nutrasweet or Sugar Twin
45 packs of Sweet and Low
23 packs of Splenda or Sweet one
4920 packs of advantame
A common fear people have about artificial sweeteners are that they may be carcinogenic (or cancer-causing). Although limited research has been conducted in humans, a systematic review published in 2015 showed that current research data are inconclusive as to any association between artificial sweeteners and cancer risk.
Another common concern are sensitivity reactions such as headaches, anxiety or depression with use. A double-blind control trial in the UK looked at individuals who self-reported sensitivity to aspartame and compared them to age and gender matched aspartame non-sensitive individuals. The trial demonstrated no evidence of any acute adverse responses to aspartame after ingestion in the subjects.
Sugar alcohols are also considered safe, however, the main concern with their consumption are digestive issues (bloating, gas, diarrhea) if eaten in excess, (>10 g of sugar alcohols per day). For those with Irritable Bowel Syndrome (IBS), they may trigger problems even in small amounts and need to be avoided entirely.
If you are familiar with the popular Halo Top ice cream, it contains about 20 g of sugar alcohols (erythritol) per pint. Erythritol is the most well-tolerated sugar alcohol because it is least absorbed by the body, so you may be able to tolerate larger amounts of this particular sugar alcohol (estimated at twice that of other sugar alcohols, so 20 g per day).
Although you might be able to tolerate eating the whole container of Halo Top (and justify that decision as it is only 280 calories), we wouldn’t exactly recommend it. One container contains approximately double the amount of recommended sugar alcohols for one day, so your ice cream excursion could potentially lead you having to run to use the bathroom shortly after, and cancel your plans for the remainder of the day.
Despite no concrete evidence linking these products with cancer or any other direct safety concerns, there is still question about their ability to achieve what they were created to do. Artificial sweeteners and sugar alcohols were developed to satisfy sweet cravings without contributing to weight gain and diet-related disease such as diabetes, but have they really accomplished their goal?
Do they harm or help with weight loss/ maintenance?
Although evidence is limited, recent studies do not support the use of artificial sweeteners for weight management, and (shockingly) they may actually be associated with an increase in BMI rather than helping the population maintain a lower weight.
The San Antonio Heart Study, one of the largest observational studies to date, found a positive connection between consumption of artificial sweeteners and prevalence of long-term weight gain.
The American Cancer Society study of 78,694 women ages 50-69 years found that at one-year follow-up, artificial sweetener users were significantly more likely than non-users to gain weight, regardless of initial BMI or differences in food consumption patterns.
A systematic review & meta-analysis from 2017 showed that evidence from RCTs and observational data do not clearly support nonnutritive sweeteners for weight management, and routine intake of nonnutritive sweeteners may be associated with increased BMI and cardio-metabolic risk.
Scientists are still not exactly sure why artificial sweeteners are not achieving their purpose of weight loss/maintenance, but multiple mechanisms are being explored.
The main ones include:
Artificial sweeteners may not elicit the same satiety response as consuming actual sugar (or glucose) does. When we consume natural sugars, the brain responds in a way that supports that cravings have been met and so it reduces production of hunger hormones. However, several studies done in both humans and animals show that a different response occurs with consumption of artificial sweeteners; there is a lack of appetite suppression and satiety response. This lack of appetite suppression may lead to overconsumption and cravings for other high fat and high calorie foods.
Artificial sweeteners are 200-13,000 times sweeter than sugar. There is potential that those who routinely consume them may have altered taste buds, leading to an increased appetite for intensely sweet, highly calorie foods.
In recent years, we have learned that the health of our microbiome (the bacterial culture in our gut), plays a huge role in how our food is absorbed and metabolised. In turn, the health of our microbiota can play a role in obesity and diseases such as diabetes. Although evidence is limited and human studies are lacking, routine consumption of artificial sweeteners may cause an altered gut microbiome leading to glucose intolerance and reduced insulin sensitivity, potentially contributing to weight gain.
Since they do contain some calories, the theory is that sugar alcohols may not exhibit the same body response when compared with artificial sweeteners. We may be safe to say that they are recommended over artificial sweeteners due to known health benefits such as improved dental health, and gut bacteria. The major downside with sugar alcohols being that they can cause digestive upset when consumed above 10 g per day, or in certain individuals with irritable bowel syndrome (IBS). However, the research surrounding their effect on weight-management is even more limited and so we really aren’t sure if they too have a negative or at best neutral effect on weight management.
What about “natural” calorie-free sweeteners like stevia?
Stevia is often seen as a “healthy” alternative to artificial sweeteners, as it is considered natural and is not implicated with controversial health claims. It has zero calories per gram, no effect on blood sugar, and it is 100-300 times sweeter than pure sugar by weight.
The stevia products found on your grocery store shelf today contain an extract of the leaves of the stevia plant, a perennial shrub. To make the extract that is used as a sweetener, a process of refining must be done to obtain what are called ‘steviol glycosides’. These include stevioside, rebaudioside (A to F), steviolbioside, and isosteviol which are responsible for the plant’s sweet taste. However, products hardly ever contain these pure, unprocessed extracts of stevia leaf as they actually have quite a bitter aftertaste. So then, other artificial sweeteners and chemicals are often added to stevia extract to make a variety of different stevia products.
Stevia in the Raw – a blend of stevia and dextrose, a corn-derived sweetener that is chemically identical to glucose
Sweet Leaf – natural stevia extract with inulin (a root fibre to add bulk)
Truvia – contains stevia leaf extract, natural flavours and erythritol
Purevia – contains dextrose, natural flavours and Rebaudioside A
As you can see, although stevia is marketed as a natural alternative, most stevia products available contain both the refined version of the original plant, along with other additives such as sugars or sugar alcohols to improve the flavor. So it may not be so natural after all.
In terms of safety, stevia extract is considered safe when consumed in the recommended amount. The ADI is set out at 4 mg/kg/day, which would be approximately 9 table top packets of TruVia.
Although many think stevia is the new sweetener on the block, stevia leaf and its extracts have actually been used around the world as both a medicine and a sweetener for centuries. Despite its history, this nonnutritive sweetener has not been extensively studied. Studies have shown that steviol glycosides are generally safe, and non-carcinogenic (4,5)However, current studies are mostly done on animals, involving only short-term observations, and so we lack information on its long-term health effects. In regards to weight-management, a recent systematic review looked at both artificial sweeteners and stevia, which concluded that evidence does not clearly support the weight-management benefits of non-nutritive sweeteners. However, the review included only two studies which looked at stevioside usage.
Given that stevia offers an intensely sweet taste without any calories or actual sugar, it might make sense to assume that it has a similar effect as artificial sweeteners, in terms of a lack of appetite suppression and altered taste receptors when consumed. However, research must be developed before we can make similar claims. Based on lack of evidence, it is better to err on the side of caution and not be too quick to promote stevia as the next miracle product in terms of weight management and health benefits.
Although considered safe and approved for consumption in Canada, the long-term benefits of low-calorie and non-nutritive sweeteners are not very promising in terms of weight management. It is an emerging area of study that has given us some insight into their effectiveness, but we certainly have more to learn about their long-term effects on metabolism.
Like we say, all things in moderation and sugar substitutes fall under this prescription as well. If used in a balanced diet and within recommended amounts, then there is no strong evidence that you should stop consuming them. However, it is good to keep in mind that they are likely not a benefit to your health or your weight loss goals in the long run.
I have to thank and applaud my colleague Leigh who has developed her critical writing, thinking and analysis skills IMMENSELY since she first started writing for me as an undergraduate student.
She really knocked it out of the park with this article.
Until next time,
Andy De Santis RD MPH