1. Overview
As American society grapples with increasing concerns related to obesity, diabetes, and other diet-related health issues, the role of sweetening agents in our daily lives has come under heavy scrutiny. Is sugar bad for you? Are artificial sweeteners the answer, or are they potentially more harmful? In this guide, we will explore the most common sweeteners, how they taste, how they work, and their benefits and health impacts.
2. Sugars
What are sugars?
Sugars, categorized as carbohydrates along with starches and fibers, play a crucial role in providing energy for the body. Sugars come in various types, with the simplest and fundamental form being glucose, serving as the body's primary source of energy. Due to their uncomplicated structure, sugars are easily and rapidly digested, efficiently converting into energy within the body.
There are two subtypes of sugar: monosaccharides, or "simple sugars," and disaccharides. Monosaccharides, such as glucose and fructose consist of one molecule. Disaccharides, like sucrose (glucose + fructose), lactose (glucose + galactose), and maltose (two glucose molecules), consist of two molecules. Both subtypes of sugar naturally occur in foods like fruits, vegetables, and dairy products. [1]
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Glucose: Often referred to as blood sugar, glucose is a primary energy source found naturally in many foods and is a key component in the body's energy metabolism.
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Fructose: Naturally occurring in fruits and some vegetables, fructose is a sweet-tasting sugar widely used in the food industry, including in high-fructose corn syrup (HFCS).
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Sucrose: Known as white or table sugar, it is commonly extracted from sugarcane or sugar beets and is frequently used in cooking and baking.
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Lactose: Found in milk and dairy, lactose is a primary source of energy in the diet. Its digestion requires the enzyme lactase, which breaks it down into its component sugars for absorption in the small intestine.
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Maltose: Formed during the breakdown of starches, maltose is present in certain grains and malted foods.
Added Sugars:
In comparison, the colloquial term "sugar" transcends its technical classification as a carbohydrate, taking on a different meaning in everyday language. This informal usage often centers around added sugar. Added sugar is sugar that is deliberately introduced into processed and prepared foods to enhance flavor. [4]
Other study findings include:
- A meta-analysis of data from 310,819 people found that those with a high consumption of sugary drinks had a 20% higher risk of metabolic syndrome and a 26% higher risk of type 2 diabetes than those with a low consumption. The study defined “high consumption” as between one and two sugary drinks per day and “low consumption” as most often none or 1 serving per month. [6]
- Over the course of the 15-year study, people who got 17% to 21% of their calories from added sugar had a 38% higher risk of dying from cardiovascular disease compared with those who consumed 8% of their calories as added sugar. [7]
- A prospective cohort study of 118,363 people followed for 34 years in the US, during which time 36,436 deaths were documented. After adjustment for diet and lifestyle confounders, the consumption of two or more servings of sugar sweetened beverages a day was linked with a 21% higher risk of total mortality, a 31% higher risk of cardiovascular disease mortality, and a 16% higher risk of cancer mortality. [8]
- One study found that for each additional 12-ounce soda children consumed each day, the odds of having obesity increased by 60% during 1½ years of follow-up. [9]
The aforementioned umbrella review, in conjunction with the World Health Organization, American Institute for Cancer Research, and World Cancer Research Fund, recommended reducing the consumption of added sugars to below 25 g/day (approximately 6 teaspoons/day) and limiting the intake of sugar-sweetened beverages to less than one serving per week (approximately 200-355 mL/week) to mitigate the adverse effects of sugars on health. For reference, the recommended consumption of added sugar is approximately one-third of the average daily intake of added sugars in the US for both adults and children (17 teaspoons). [5],[10]
3. Sugar Alternatives
Given the risk factors associated with added sugar, it is not surprising that many individuals and companies have actively sought alternatives deemed to be 'safer.' This quest for safer options has led to the surge in the popularity of various sugar substitutes. Many of these substitutes are promoted for their low caloric and blood glucose impact, avoiding two of the significant pitfalls of added sugar. However, a growing body of research points out that they may not be the magical solution we had dearly hoped for.
Sugar substitutes, also known as sweeteners, are not all the same and can be broadly categorized into several groups based on their origin, composition, and sweetness profile.
Sugar Alcohols:
Sugar alcohols, or polyols, constitute a class of sweeteners derived from sugars through a chemical process called hydrogenation. Despite their name, they are neither sugar nor alcohol, but actually, a carbohydrate with a chemical structure similar to both sugar and alcohol. While some sugar alcohols occur naturally in certain fruits and vegetables, most are produced from other sugars. [11]
Sugar alcohols are slowly and incompletely absorbed from the small intestine into the blood, primarily due to their unique chemical structure. This incomplete absorption results in a reduced caloric impact (1.5-3 calories per gram compared to 4 calories per gram from sugar) and a smaller change in blood glucose and insulin levels than sugar. These properties make them suitable for diabetics and individuals seeking alternatives with fewer calories and a lower glycemic impact. [12]
Common sugar alcohols include erythritol, xylitol, sorbitol, maltitol, isomalt, mannitol, and lactitol. They are often used individually or combined to create specific taste profiles in sugar-free and reduced-calorie products like gum, candies, and beverages. Below is a rough comparison of sugar alcohols. [13]
Sugar Alcohol Side Effects and Safety:
While generally considered safe, excessive consumption of sugar alcohols can lead to gastrointestinal side effects, including bloating, gas, and diarrhea. Since sugar alcohols are only partially broken down in the small intestine, the unabsorbed portion (50-70%) moves to the large intestine. There, it feeds gut bacteria, producing gases and fatty acids that cause water retention and a laxative effect. Consuming large amounts of sugar alcohols, especially for individuals with underlying gastrointestinal conditions like irritable bowel syndrome or inflammatory bowel disease, may result in flatulence, bloating, abdominal pain, and diarrhea. Studies indicate that specific amounts of sorbitol (20-30 g), xylitol (100 g), and mannitol (20 g) can cause abdominal pain, diarrhea, and a laxative effect, respectively. Individual tolerance varies, and it's essential to be mindful to avoid discomfort. [14]
Additionally, a 2023 study found that individuals with higher levels of erythritol in their blood had a significantly higher risk of cardiovascular problems. 'The top 25% had twice the risk of heart attack, stroke, and death compared to the bottom 25%,' says Stanley Hazen, a cardiologist at Cleveland Clinic, Ohio, who led the research. 'This places it on par with the strongest cardiovascular risk factors, such as diabetes.' Erythritol stood out as the best predictor of heart problems, even above high cholesterol levels. [15]
Artificial Sweeteners:
Artificial sweeteners, commonly known as non-nutritive sweeteners (NNS), are synthetic or chemically altered sugar substitutes that impart sweetness to foods and beverages without the calories or blood sugar response associated with traditional sugars. These sweeteners work by binding to the same taste receptors on the tongue as sucrose. However, they form stronger bonds than sucrose due to differing molecular structures, resulting in a sweetness that is 100 times stronger than sucrose. Like sugar alcohols, they are often calorie-free because the body does not metabolize them. Despite their lack of calories, artificial sweeteners also lack any beneficial nutrients, such as vitamins, fiber, minerals, or antioxidants. The FDA has approved several artificial sweeteners: [16], [17]
Artificial Sweeteners Side Effects and Safety:
Artificial sweeteners might seem like a safe way to enjoy sweet food without gaining weight. However, recent studies indicate the opposite and suggest links to other major health issues.
- A 2017 analysis of 37 studies on artificial sweeteners' effectiveness for weight management, spanning approximately 10 years with over 400,000 participants, including seven randomized controlled trials, indicated a potential link between regular consumption of these sweeteners—especially in the form of one or more artificially-sweetened beverages per day—and an increased risk of health issues such as weight gain, obesity, diabetes, and heart disease. [18]
- In a large study involving 103,388 people, artificial sweeteners were linked to a 9% higher risk of any type of cardiovascular problem (including heart attacks) and an 18% greater risk of stroke. The study identified three artificial sweeteners that appear to be the most problematic. Aspartame (NutraSweet, Equal) was linked to a higher risk of stroke (+17% compared to non-consumers). Additionally, acesulfame potassium (Sunnett, Sweet One) and sucralose (Splenda) were associated with higher risks of coronary artery disease, 40% and 31%, respectively, compared to non-consumers. [19]
- In August 2022, a randomized-controlled trial involving 120 healthy adults assessed the impact of non-nutritive sweeteners (NNS), including saccharin, sucralose, aspartame, and stevia, over a 2-week period. The study found that NNS administration led to distinct changes in both stool and oral microbiome, as well as alterations in the plasma metabolome. Notably, saccharin and sucralose were associated with significant impairments in glycemic responses. [20]
- In May 2023, the World Health Organization advised people not to consume non-sugar sweeteners, including sucralose, for weight loss. The recommendation is based on a systematic review of the most current scientific evidence linking non-sugar sweeteners to type 2 diabetes, cardiovascular diseases, all-cause mortality, as well as increased body weight. [21]
While none of these studies can prove a direct cause and effect, they are worth noting and keeping in mind when consuming artificial sweeteners, especially in large quantities.
Novel Sweeteners:
Novel sweeteners, often referred to as "plant-derived non-caloric sweeteners," represent a relatively new type of sugar substitute derived from natural sources. Combining the advantages of both artificial and natural sweeteners, they offer sweetness without being a significant source of calories or sugar. This characteristic makes them suitable for those seeking alternatives that do not contribute to weight gain or blood sugar spikes. Additionally, novel sweeteners are typically less processed and maintain a closer resemblance to their natural sources compared to artificial sweeteners. [22], [23], [24], [25], [26]
Novel Sweeteners Side Effects and Safety:
Allulose, monk fruit, stevia, and tagatose are generally recognized as safe (GRAS) by the U.S. Food and Drug Administration (FDA), indicating that these sweeteners have been shown to be safe for their intended use in food. Similar to other sugar substitutes, consuming large quantities of some novel sweeteners may cause stomach discomfort, including gas and bloating. However, novel sweeteners also show some promising benefits.
- In a prospective, randomized, single-blind, crossover study involving 24 patients with type 2 diabetes, it was found that a diabetic diet containing D-allulose significantly improved post-meal blood sugar levels in comparison to a standard diabetic diet. Moreover, the inclusion of D-allulose appeared to reduce the need for insulin, suggesting a positive impact on pancreatic insulin secretion. [27]
- A 2011 study utilizing cells and a mouse model found that mogrosides, the active components of monk fruit, helped reduce inflammation by suppressing the activity of certain genes responsible for inflammation and enhancing genes that protect against inflammation.[28]
While some novel sweeteners show promising benefits, more rigorous testing will be required for greater validation.
4. Next Steps
So, what is the right course of action given all this information?
- Be mindful of your total sugar consumption and its sources. You don't need to eliminate all sugar from your diet. Natural sugars from fruits, vegetables, dairy, and grains contain essential nutrients. However, try to avoid large quantities of added sugar. Take the time to read the nutrition or supplement facts on products, as you might be surprised at the number of items containing added sugar, including sauces, salad dressings, oat milks, and other unexpected sources.
- Remember, "sugar-free" doesn't necessarily mean healthier. Be cautious of the sugar substitutes in sugar-free products, as they aren't the magical solution touted for weight loss and have been linked to other health issues.
- While novel sweeteners look promising, it's probably best to use them in lower quantities.
