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Health Information | 06/16/2022

The Bittersweet Truth about Artificial Sweeteners

By  Dr. Wei Yang
If you’ve ever tried to lose weight or cut calories, you’re probably familiar with alternative sweeteners.

Nonnutritive sweeteners (NNS), also known as artificial sweeteners, are natural or man-made (synthetic) compounds that usually taste sweeter than table sugar (sucrose). NNS became widely used as sugar substitutes starting in the early 1900s. They gained popularity because they make food and beverages taste as good as their sugary counterparts and, at most, only add a few calories.

Many people are not aware of the prevalence of NNS in the food and beverages they consume every day. Foods and drinks marketed as "sugar-free,” "diet," or “low calorie,” including baked goods, soft drinks, powdered drink mixes, candy, puddings, canned foods, jams, jellies, and dairy products, include NNS.

You may be curious, can NNS help reduce my risk of obesity, diabetes, or cardiovascular disease by replacing the consumption of added sugars like high-fructose corn syrup? Can they help me lose weight? Are they safe to use? I’ll try to answer these questions in this article.

Categories of Nonnutritive Sweeteners

There are two categories of NNS:

Safety Regulations in the United States

Synthetic Sweeteners

In the United States, synthetic sweeteners including saccharin, aspartame, Ace-K, and sucralose have been approved by the U.S. Food and Drug Administration (FDA) as food additives. Based on the available scientific evidence, the FDA concluded that these sweeteners are safe for the general population if consumed within the acceptable daily intake (ADI).

Saccharin (Sweet'N Low®, Sweet Twin®, and Necta Sweet®) was first discovered and used in 1879. It is 200 to 700 times sweeter than table sugar, and it does not contain any calories. In the early 1970s, saccharin was linked with the development of bladder cancer in laboratory rats. Since then, more than 30 human studies demonstrated that the results found in rats were not relevant to humans and that saccharin is safe for human consumption. Products containing saccharin no longer have to carry a warning label about the risk of developing cancer.

Aspartame (Equal® and Sugar Twin®) does contain calories but is about 200 times sweeter than table sugar, so people are likely to use much less of it than table sugar. It is not heat stable and loses its sweetness when heated, so it typically isn’t used in baked goods. Aspartame is one of the most exhaustively studied substances in the human food supply, with more than 100 studies supporting its safety. The only exception is people with a rare hereditary disease known as phenylketonuria (PKU). They have difficulty metabolizing phenylalanine, a component of aspartame, and should limit their intake of aspartame.

Sucralose (Splenda®) is about 600 times sweeter than table sugar and is heat stable. Sucralose has been extensively studied, with more than 110 studies supporting its safety.

Acesulfame Potassium (Ace-K) (Sunett® and Sweet One®) is about 200 times sweeter than table sugar. It is heat stable, making it suitable as a sugar substitute in baked goods. More than 90 studies support its safety.

Natural Sweeteners

Stevia (Truvia®, NutraSweetM™, and Stevia in the Raw®) is a natural sweetener made from the leaves of the stevia plant. It is classified as zero-calorie because the calories per serving are so low. Stevia is about 200 – 300 times sweeter than table sugar. The FDA approved the purified form of stevia, called stevioside, as GRAS (generally recognized as safe). GRAS is a regulatory review process category used by the FDA. Whole stevia leaves or crude stevia extracts have not been approved by the FDA and should be avoided.

Monk Fruit (luo han guo) is a plant native to Southern China. Monk fruit sweetener is made from an extract derived from dried fruit and is 150 to 250 times sweeter than table sugar. It has been deemed GRAS by the FDA.

Sugar Alcohols

Sugar alcohols (polyols) are another class of sweeteners that includes sorbitol, xylitol, lactitol, mannitol, erythritol, and maltitol. The FDA does not consider sugar alcohols as a food additive. The sweetness of sugar alcohol varies from 25 to 100% as sweet as table sugar. Sugar alcohols are slightly lower in calories than sugar and do not promote tooth decay or cause a sudden increase in blood glucose. They are primarily used to sweeten sugar-free candies, cookies, and chewing gum.

Health Impacts of Nonnutritive Sweeteners

Effects on Weight. Randomized controlled trials have found mixed results regarding NNS on weight loss. It sounds counterintuitive that something with zero calories could make you gain weight. However, some research indicates that the sweetness of artificial sweeteners actually enhances appetite, causing you to eat more and possibly counteracting the caloric benefit of consuming a low/no-calorie food or drink containing an NNS.

Concern of Cancer. 
In the 1970s, animal studies using rodents raised concerns that saccharin caused bladder cancer. However, further evaluation demonstrated no relationship between saccharin consumption and the development of malignancies in humans. Although limited observational data suggest a possible weak association between the consumption of NNS with cancer, there is no high-quality evidence that any of the available NNS increase the risk of cancer in humans.

Cardiovascular Effects. 
The Framingham Heart Study Offspring cohort study found that consuming one or more artificially sweetened soft drinks per day was associated with an increased incidence of ischemic stroke. A retrospective cohort study in the Women's Health Initiative found that consumption of two or more diet drinks per day was associated with a higher risk of major cardiovascular events, cardiovascular (CVD) mortality, and overall mortality.

Glycemic Effects. Clinical trials found no direct association between artificial sweetener consumption and an increased risk of developing type 2 diabetes. However, a later study found a correlation, the conclusion being that NNS may alter the taste of foods so that you start to find naturally sweet foods, such as fruit, less appealing, and you crave more sugary food.

Neurological Effects. There was no association between the consumption of NNS with dementia. Researchers have found that the consumption of NNS can disrupt the quality of sleep and can trigger migraine headaches in some individuals.

Bowel Effects. Many NNS, particularly the sugar alcohols, may disrupt the normal gut microbiota and aggravate symptoms in individuals with various types of bowel disorders, including malabsorption syndromes, inflammatory bowel diseases (Crohn’s disease and ulcerative colitis), irritable bowel syndrome, celiac disease, gluten sensitivity, small intestinal bacterial overgrowth, and dumping syndrome. Additionally, evidence suggests that NNS cause changes to the gut’s normal digestive responses and processes, which may contribute to the onset of inflammatory bowel disease. Even among individuals with no known bowel disorders, sugar alcohols and other NNS may cause flatulence, bloating, and osmotic diarrhea.

Dental Health. Evidence has shown that replacing sugar-sweetened products (e.g., carbonated beverages, chewing gum, candies, and lozenges) with NNS-sweetened ones may reduce the risk of dental cavities. Sugar alcohols such as erythritol and xylitol disrupt the colonization of bacteria that cause cavities. However, carbonated beverages themselves are acidic and may weaken tooth enamel. Therefore, regular consumption of artificially sweetened soft drinks is discouraged.

In Summary

Non-nutritive sweeteners, including artificial and natural sweeteners, are generally safe to use as long as they are FDA approved and are consumed within the FDA’s ADI. Although there is no definitive evidence that they cause cancer, some studies have shown an increased risk of stroke and heart disease.

What’s most important to understand is that there is no consistent evidence NNS help with weight loss, blood sugar management, or the prevention of cardiovascular disease. In fact, studies generally conclude that there are no improved health outcomes from using NNS over sugar-sweetened foods and beverages. The best way to maintain or improve your overall health is to adopt a healthy lifestyle, including reducing stress, getting enough quality sleep, exercising regularly, and eating a well-balanced diet.

If you have any chronic health conditions, it’s best to talk with your primary care provider for guidance before adding any artificial or natural sweeteners to your diet.

About The Author

Dr. Wei Yang

Dr. Yang joined Atrius Health in 2013 and is a board-certified internist at our Burlington practice. She received her medical degree from West China University of Medical Sciences, Chengdu. Dr. Yang completed both her internship and residency at St. Elizabeth’s Medical Center in Boston. She has a strong interest in preventative medicine. Dr. Yang is a fellow of the American College of Physicians.

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