HealthHints

Sugar Substitutes –
Weight loss, diabetes, safety, nutrition?

April/May 2010 – Vol. 14, No. 4 & 5

Editors: Janet M. Pollard, MPH; and Mary K. Bielamowicz, Phd, RD, LD, CFCS

Sugar substitutes (sometimes referred to as artificial sweeteners, low-calorie sweeteners, non-caloric sweeteners, or non-nutritive sweeteners) are ingredients added to foods and beverages to add sweetness without adding a significant amount of calories.1 “Some sugar substitutes are low in calories, while others have no calories.”2 Because sugar substitutes are many times sweeter than sugar (also called sucrose or table sugar), it takes less to provide the same level of sweetness, resulting in fewer or no calories added.2

More than one-half of American adults are overweight or obese, a condition that substantially increases the chances of high blood pressure, diabetes, heart disease, and some cancers.3 “According to the American Dietetic Association (ADA) ‘Position of the American Dietetic Association: Use of Nutritive and Nonnutritive Sweeteners,’ low-calorie sweeteners can assist in weight management and control of blood glucose [also called blood sugar] – an essential element to the health of people with diabetes. They add only minute amounts of energy [calories or kilocalories (kcals)] and elicit less of a glycemic response (PDF).”4

Unfortunately, “a magic formula for managing weight does not exist. The basic equation ‘calories in equal calories out’ still stands as the foundation for successful weight management. If weight loss is desirable, the balance needs to tip in favor of the elimination of calories (e.g., through the ingestion of fewer calories or through more physical activity). For diabetes sufferers, “total carbohydrates are what counts.”6 Reading food and ingredient labels to see what else is in the product you’re eating is essential. Just because something is made with a sugar substitute does not mean it is low in calories or carbohydrates. “Many products made with artificial sweetener, such as baked goods and artificially sweetened yogurt or pudding, still contain calories and carbohydrates that can affect your blood sugar level”6 and your weight.

Controversy exists over the safety and consumption of sugar substitutes, which may pose questions for the consumer. The circulation of misinformation and urban legends abound (see http://snopes.com to investigate potential urband legends). Let’s take a look at these sweeteners, old and new, and see if we can clarify some of the facts at present.

Approved Sugar Substitutes: Old and new

Sugar substitutes must be approved by the U. S. Food and Drug Administration (FDA). Sugar substitutes have been approved for use in the U.S. since the 1950s, and manufacturers are constantly trying to find new ones that taste more like table sugar, while not adding calories, not increasing blood sugar, and not having health risks. There are currently six sugar substitutes approved by the FDA (PDF) for use in the U.S.:

  • Saccharin (approved for use prior to 1958),
  • Aspartame (approved for use in 1981),
  • Acesulfame potassium (ace-K) (approved for use in 1988),
  • Sucralose (approved for use in 1998),
  • Neotame (approved for use in 2002), and
  • Rebaudioside A (Reb-A), a highly purified form of stevia (approved for use in 2008).

Characteristics of the Six FDA-Approved Sugar Substitutes: Sweet flavor without the calories

So, how do you decide whether or not you should use sugar substitutes and, if so, which ones and how much? Use of sugar substitutes is a personal decision. Because they vary in flavor and uses, this information may help you decide.

Saccharin

Saccharin (Sweet’N Low®, Sugar Twin®, Sucaryl®, Adolph’s®, and Sweet 10®) ranges from 200 to 700 times sweeter than table sugar. Saccharin does not convert to glucose. It is readily absorbed and is excreted unchanged by the kidneys. Therefore, saccharin contains zero calories per gram.7 The acceptable daily intake (ADI) [PDF] for saccharin is 5 mg per kg (2.2 lbs) body weight. The ADI is the maximum amount considered safe (by the FDA) to consume on a daily basis over a person’s lifetime without adverse effects.13 Saccharin does not affect glucose or triglyceride levels8 and can be used in a diabetes meal plan.

Saccharin remains stable in heat and, therefore, can be used in cooking. “The Sweet’N Low® brand sells packets as well as a bulk version for baking, a liquid formula, and a brown sugar blend. When baking, replace 1 cup of sugar with 24 packets, 2 tablespoons of saccharin liquid, or 1 cup of brown sugar saccharin.”9 Some people report a bitter aftertaste that may be eliminated in prepared foods by combining it with another sweetener.8 “Saccharin is found in many foods and drinks, including chewing gum, canned fruit, baked goods, soft drinks, and as a tabletop sweetener. It is also used in some medicines and vitamins.”8

So, is saccharin safe for all? Those watching their sodium intake should be sure to read the ingredients list on food labels since most common brands of saccharin are “sodium saccharin,” which may increase the sodium content in your diet. Also, women who are pregnant should be aware that saccharin does cross the placenta. There is no evidence, however, to support that it is harmful to the developing baby. Both the American Dietetic Association and the American Diabetes Association state that saccharin can be consumed in moderation during pregnancy.11 “It has been suggested that caregivers may want to limit the intake of saccharin in children because of the limited amount of data available for use in children.”12 Because pregnant women and children especially need important nutrients and minerals for healthy growth and weight, it is a good idea to see a physician or registered dietician to discuss your nutritional needs during pregnancy, as well as the needs of children.

Aspartame

Aspartame (Equal®, NutraSweet®, and Natra Taste®) is 200 times sweeter than table sugar. Aspartame is made from protein (unlike the other approved sugar substitutes), and each gram of aspartame contains 4 calories (like table sugar); however, because the amount needed to sweeten foods is so tiny, the amount of calories you get is insignificant.14,15 The ADI (PDF) for aspartame is 50 mg per kg body weight.13 Aspartame does not affect blood glucose and can be used in a diabetes meal plan.

Aspartame is not heat stable. “High temperatures can diminish aspartame’s sweetness, so even though some brands (like Equal®) sell bulk versions, most chefs avoid baking with them.”9 Storing foods containing aspartame can also diminish their sweetness. For example, if you store drinks that contain aspartame in the heat, they will eventually lose their sweetness. If you desire the sweetness of aspartame, you can try combining it with other sugar substitutes or simply adding aspartame after the baking process. One reason that people like aspartame-sweetened foods is that “there’s no aftertaste associated with aspartame, though some say it has an unnatural flavor.”9 Another is that “aspartame can extend the sweet taste of some fruit flavors, such as orange or cherry. When it is added to food with these flavors, it makes the taste last longer. For example, chewing gum made with aspartame maintains its sweet flavor longer than those made with sugar.”17 “Aspartame can be found in thousands of foods and drinks, as well as a tabletop sweetener. Some foods and drinks with aspartame include yogurt, frozen desserts, pudding, dry dessert mixes, chewing gum, and soft drinks. Aspartame can also be found in some medicines, such as cough drops and vitamins.”17

So, is aspartame safe for all? Aspartame is not safe for people with phenylketonuria (PKU). People with PKU cannot metabolize the amino acid phenylalanine, which is found in aspartame, and should avoid it.9 A warning label is required on products containing aspartame to help these individuals avoid it. Newborns have been screened for PKU in the U.S. and other industrialized countries for the past 50 years. Therefore, there is no need for undue concern in regards to the safety labeling on aspartame. If you or a loved one has PKU, you would likely know it.7 If you “search the Web for aspartame’s side effects…you’ll find stories about its purported link to cancer, dementia, headaches, and depression. Most scientists (as well as the American Diabetes Association) maintain that the powder is a safe alternative to sugar for people with diabetes.”9 Some people say that aspartame causes a wide variety of symptoms. Research has been unable to prove this sensitivity or to describe how these symptoms could be triggered by the body. “Prior to its approval, aspartame underwent one of the most thorough scientific reviews ever conducted, and regulators consider it one of the most widely tested ingredients in the food supply. The safety of aspartame has been affirmed by the FDA and leading independent health groups, such as the American Medical Association, the American Dietetic Association, and the American Diabetes Association”16 for use in the general population.

Acesulfame Potassium (Ace-K)

Acesulfame Potassium, also called Ace-K (Sweet One®, Sunett e®, and DiabetiSweet®) is 200 times sweeter than table sugar. Ace-K is not used by the body and remains unchanged in body waste. Thus, it is a non-caloric sweetener, meaning it contains zero calories per gram.14 The ADI (PDF) for Ace-K is 15 mg per kilogram (kg) of body weight.13 Ace-K does not affect glucose or triglycerides18 and can be used in a diabetes meal plan.

Ace-K remains stable when heated and can be used to cook or bake. Ace-K does not lose its sweet taste when it is baked at high temperatures and is said to have little aftertaste, if any.18 “Acesulfame K can be found in a variety of foods and drinks, including baked goods, candy, dairy products, and soft drinks, and can be used as a tabletop sweetener. It is also used in some medicines, such as cough drops, and in oral hygiene products like toothpaste and mouthwash.”18

So, is Ace-K safe for all? It seems to be. “More than 90 studies on the safety of acesulfame K conducted have shown it to be safe for people to consume in moderation. Acesulfame K has been approved for use in the United States since 1988.”18 Remember, ace-K, like all sugar substitutes, should be used in moderation and used as a substitute for other sweet foods – not in addition to them.

Sucralose

Sucralose (Splenda®) is 600 times sweeter than table sugar. “Most of the sucralose people consume is not absorbed and passes through the body. The little that is absorbed is excreted in the urine and doesn’t accumulate in the body.”19 Because sucralose is not metabolized by the body for energy, it contains zero calories.19 The ADI (PDF) for sucralose is 5 mg per kg of body weight.13 Sucralose does not affect glucose or triglycerides21 and can be used in a diabetes meal plan.

Sucralose is the “most heat stable of all the sugar substitutes.”21 “Splenda® sells various baking products, including a granular version that measures cup for cup with sugar. If you use the half sugar blend or half brown sugar blend, replace a cup of sugar with a half cup of the blend.”9 Sucralose, reportedly, does not have an aftertaste.21 “Sucralose is used in thousands of different kinds of foods and drinks. Some examples include soft drinks, juices, sauces, syrups, candy, desserts, baked goods, and canned fruits. It is used in medicines, nutritional supplements, and vitamins. It is also available as a tabletop sweetener.”21

So, is sucralose safe for all? “Sucralose is approved for use by everyone including pregnant women and children.”20 “Sucralose has been used safely as an artificial sweetener for over 20 years…. The FDA approved sucralose in 1998 after reviewing 110 scientific studies.”20 “Since Splenda® is [one of] the newest artificial sweeteners to hit the market, there are fewer long-term studies of it than of saccharin and aspartame. That said, the FDA says that Splenda is safe.”9

Neotame

The FDA has approved the NutriSweet® Company to market neotame. Neotame is used in commercially cooked and baked foods; however, it is not currently marketed to consumers in packet or bulk form. Neotame is 7,000 to 13,000 times sweeter than table sugar. It is rapidly metabolized and completely eliminated in the body wastes; therefore, it does not accumulate in the body and has zero calories. The ADI (PDF) for neotame is 18 mg per person per day.7 Neotame does not affect blood glucose levels and can be used in a diabetes meal plan.

Neotame is heat stable (unlike the NutriSweet Company’s other sugar substitute, aspartame), but because neotame is not currently marketed to consumers in packet or bulk form there are no current instructions for cooking with it. Neotame is described as a clean, sweet taste without a bitter metallic after-taste. It is used “in a range of products including carbonated and non-carbonated soft drinks, as well as beverage mixes, dairy beverages, non-dairy desserts, ice creams and sorbets, yogurts, confectionery, chewing gum, fruit preparations, and salad dressings.”30

So, is neotame safe for all? Although researchers have looked at possible links to cancer as well as reproductive and developmental toxicity, they have found no concerns on the basis of the available studies.31 Researchers consider neotame to be a substance of low toxicity in a range of species, including humans. Appropriate studies indicated that neotame is not carcinogenic (cancer-causing) or associated with any reproductive/developmental toxicity (such as birth defects).31

Stevia (Rebaudioside A or Reb-A)

Stevia (Truvia®, PureVia®, and SweetLeaf®) is only approved as a sugar substitute by the FDA in its highly purified form, rebaudioside A (Reb-A). Stevia rebaudiana is a South American plant in the Chrysanthemum family of plants.25 “Only certain parts of the plant are sweet. The sweet components extracted from the leaves of the plant are called steviol glycosides.”25 Though the term “stevia” can refer to the whole plant, for this article “stevia” will refer to the sugar substitute made from the plant, since that’s how the term is commonly used.25 It is very important to make this distinction: only the highly purified form of stevia – Reb-A – is approved as safe. For many years, stevia has been sold as a dietary supplement. Dietary supplements do not have to go through the FDA approval process and, despite what ingredient labels say, may not be pure forms of the stevia plant or the highly purified Reb-A.

Stevia is 250 to 300 times sweeter than table sugar. Based on the most recent studies, it is believed that “stevia sweeteners are metabolized by a common pathway, beginning in the gut where the steviol glycosides are broken down to steviol. Steviol is excreted in the urine as steviol glucuronide. The metabolized components of steviol glycosides essentially leave the body with no accumulation.”22 Thus, they contribute no calories to the diet. The ADI (PDF) for the Reb-A form of stevia is 0–4 mg per kg body weight.24 Stevia that is not in the highly purified (Reb-A) form has not been FDA approved and does not have a recommended ADI.

The Reb-A form of stevia is heat stable and can be substituted for sugar in baking. “Each stevia brand recommends its own sugar-tostevia ratio (so check your brand’s website), and some brands sell the sweetener in liquid or bulk form. A good start is to replace a cup of sugar with 24 packets of [Reb-A] stevia.”9 “Some people say the sweetener derived from the whole leaf of the stevia plant leaves behind a licorice taste.”9 The approved, highly purified portion of the leaf, Reb-A, however, is said to have less of an aftertaste.9 “Stevia can be found in many foods and drinks, such as desserts, chewing gum, baked goods, candy, yogurt, and as a tabletop sweetener.”25

So, is the Reb-A form of stevia safe for all? “Studies have demonstrated, and FDA concurs, Reb-A-based sweeteners are considered safe for consumption as tabletop sweeteners or ingredients in foods and beverages. However, the studies supporting the highly purified compound Reb-A should not be attributed to other stevia-derived sweeteners until approved by the FDA.”24 Although stevia does not affect blood pressure22 or blood glucose levels,25 people with diabetes or high blood pressure should be cautious because of the risk that it might cause hypoglycemia or hypotension when combined with diabetes or blood pressure drugs.23 Additionally, until we have more research, it is recommended that women who are pregnant or breast-feeding avoid using stevia sweeteners of any kind.23 “At this time, no data exist that Reb-A-based sweeteners offer a clinical advantage over any other nonnutritive sweeteners, although studies are ongoing to test whether there are natural plant compounds that offer some additional health benefits. While the sweeteners are marketed as ‘natural,’ no official FDA definition of ‘natural’ exists.”24 The highly purified Reb-A form of stevia may be an appropriate choice for the general, healthy population; however, it should presently be used with caution in some groups. If you are pregnant, nursing, have diabetes, high blood pressure, or another chronic illness, consult with your doctor or a registered dietician.

Weight Loss, Diabetes Management & Nutrition: Are sugar substitutes effective?

“Low-calorie sweeteners can play a role in a weight loss program by providing sweet options that do not contribute extra calories. They also offer a way for people with diabetes to decrease their carbohydrate intake”26 and control their blood glucose levels.

Weight Management.

“Individuals who wish to lose weight may choose to use nonnutritive sweeteners but should do so within the context of a sensible weight management program including a balanced diet and exercise.”12 If you take calories in, to lose weight you must use up (burn) more calories than you eat. This means you must either eat less or exercise more – or both. Sugar substitutes can help some individuals by giving them the sweet taste they crave without the calories. The most important issue here is to make sure you are “substituting” low-calorie foods containing sugar substitutes for high-calorie sweets. The temptation is to have a food or beverage sweetened with a sugar substitute and then give yourself “permission” to eat calorie-laden foods or beverages because you were “good” earlier in the day. Rather, a sugar-sweetened food should be replaced with a reduced- or no-calorie food sweetened with a sugar substitute to eliminate the calories, appease the sweet tooth, and achieve weight loss.

Recent controversy exists over whether sugar substitutes actually heighten appetite. “Most of the purported mechanisms by which this occurs are not supported by the available evidence, although some warrant further consideration.”27 Still, if sugar substitutes are used truly as “substitutes” for high-calorie sweeteners, they have the potential to aid in weight management.27

Diabetes Management.

According to the American Dietetic Association ‘Position of the American Dietetic Association: Use of Nutritive and Nonnutritive Sweeteners,’ “low-calorie sweeteners can assist in …the control of blood glucose – an essential element to the health of people with diabetes. They add only negligible amounts of energy (calories) and elicit no glycemic response (PDF). Since sugar substitutes do not affect the glycemic response (PDF), they can be safely used by those with diabetes.”12 (Note that Reb-A stevia was not approved at the time of this position statement, and caution should be used by those with diabetes [see Stevia (Rebaudioside A or Reb-A) above]. See the Characteristics of Common Nonnutritive Sweeteners (PDF) that are safe for people with diabetes.

“The primary goal for those with diabetes should be to maintain near-normal blood glucose levels. The American Diabetes Association suggests that attention be given to the total amount of carbohydrates in meals and snacks rather than to glycemic responses (PDF) resulting from their consumption. Sugar substitutes need not necessarily be restricted, but if consumed, they should be substituted for other carbohydrate sources rather than added. Sugar substitutes are appropriate in medical nutrition therapy for people with diabetes and may help control energy [calorie] intake. Dietetic professionals can help persons with diabetes incorporate sugars and sugar substitutes into their individual meal plans.12

“Sugar-Free” and “Reduced-Calorie” Foods.

For people trying to lose weight and people with diabetes, it is important to recognize that “‘sugar-free’ does not mean to use freely. ‘Sugar-free’ means that no white sugar, brown sugar, or any other sugar-based sweetener, such as honey, high-fructose corn syrup, dextrose, fructose, maltose, and other sweeteners have been added to a food or drink. A food may have the words ‘sugar-free’ on the front label, but that does not mean the food is carbohydrate-free or calorie-free.”28 For example, some sugar-free gums may have few calories, while sugar-free cookies often contribute calories and carbohydrates and need to be worked into your meal plan and carb budget.28 Read both the ingredients list and the Nutrition Facts label to decide how to include a sugar-free food or drink within your meal plan,28 not in addition to it.

Nutrition.

Whether you’re trying to lose weight, follow a diabetes meal plan, or just trying to eat a healthy, balanced diet, it is important to get appropriate nutrients and minerals. Though sugar substitutes can play a part in a healthy meal plan, they should not play a major role.29 When it comes to sugar substitutes, your mother was right when she said “everything in moderation.” “Like sugar, sugar substitutes and many of the foods that contain them contribute little or nothing in the way of nutrients, and also take the place of more nutritious foods in the diet.”29 Ensure that you are getting good nutrition and not simply empty calories. Empty calories (those that provide little or no nutrients or minerals) can lead to ill health if substituted for more nutrient-rich foods. Many of the foods that contain sugar substitutes may contribute less nutrients, so use them in moderation. For help in learning what you should eat for a healthy, balanced meal plan, follow the USDA Food Guide Pyramid. For people with diabetes, see your doctor or a registered dietitian to provide you with appropriate meal plans.


This document is meant for educational purposes only and is not intended to replace the advice of your doctor or other health care provider.


References:

  1. International Food Information Council Foundation (2009). Facts about low-calorie sweeteners [online]. Retrieved March 11, 2010. From http://www.foodinsight.org/Content/6/LCS%20Fact%20Sheet_11_09.pdf.
  2. American Academy of Family Physicians (2010). Sugar substitutes: What you need to know [online]. Retrieved March 11, 2010. From http://familydoctor.org/online/famdocen/home/healthy/food/general-nutrition/1006.html.
  3. International Food Information Council Foundation (2009). Low-calorie sweeteners and health [online]. Retrieved March 11, 2010. From http://foodinsight.staging.r2integrated.com/Content/76/Low-Calorie-Sweeteners-and-Health.pdf.
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  12. American Dietetic Association. Position of the American Dietetic Association: Use of nutritive and nonnutritive sweeteners. Journal of the American Dietetic Association 2004; 104:255-275.
  13. Mayo Clinic (2008). Artificial sweeteners: A safe alternative to sugar? Retrieved March 11, 2010. From http://www.mayoclinic.com/health/artificial-sweeteners/MY00073.
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Last updated: 27 November, 2013

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