4.7: Sugar Substitutes

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Learning Objectives

Discuss the pros and cons of consuming foods and beverages that contain sugar substitutes.

Sugar substitutes have replaced added sugars in many foods and beverages due to the potential health consequences of consuming too many added sugars. Sugar substitutes include artificial sweeteners and sugar alcohols.

Artificial sweeteners are non-nutrients that provide little or no energy/calories (see Table \(\PageIndex{1}\)). They are much more intense in sweetness when compared to sucrose (see Table \(\PageIndex{1}\)), so they are added in very small amounts to foods and beverages. Artificial sweeteners must be approved by the U.S. Food and Drug Administration (FDA) for use in foods and beverages; those approved by the FDA include saccharin, aspartame, acesulfame potassium, advantame, neotame, and sucralose.¹

Sugar alcohols, such as xylitol, sorbitol, erythritol, and mannitol, are carbohydrates that occur naturally in some fruits and vegetables. However, they are industrially synthesized with yeast and other microbes for use as food additives. The FDA requires that foods disclose the fact that they contain sugar alcohols, but does not require scientific testing of it. (Though many of them have undergone studies anyway.) Sugar alcohols are typically less sweet than sucrose. Sugar alcohols are somewhat digested and absorbed and contribute fewer calories per gram compared to sucrose (see Table \(\PageIndex{1}\)).

Benefits

Consuming foods and beverages containing sugar substitutes may benefit health by reducing the consumption of simple sugars, which are higher in calories, potentially linked to chronic disease, and cause tooth decay. There is limited scientific evidence that consuming products with artificial sweeteners decreases weight or improves blood glucose control.²

Artificial sweeteners and sugar alcohols are not “fermentable sugars” and therefore do not cause tooth decay. Chewing gum with artificial sweeteners is the only proven way that artificial sweeteners promote oral health. The American Dental Association (ADA) allows manufacturers of chewing gum to label packages with an ADA seal if they have convincing scientific evidence demonstrating their product either reduces plaque acids, cavities, or gum disease, or promotes tooth remineralization.

Health Concerns

The most common side effect of consuming products containing sugar substitutes is gastrointestinal upset, a result of their incomplete digestion. Since the introduction of sugar substitutes to the food and beverage markets, the public has expressed concern about their safety. The health concerns of sugar substitutes originally stemmed from scientific studies, which were misinterpreted by both scientists and the public.

In the early 1970s, scientific studies were published that demonstrated that high doses of saccharin caused bladder tumors in rats. This information fueled the still-ongoing debate of the health consequences of all artificial sweeteners. In actuality, the results from the early studies were completely irrelevant to humans. The large doses (2.5 percent of diet) of saccharin caused a pellet to form in the rat’s bladder. That pellet chronically irritated the bladder wall, eventually resulting in tumor development. Since this study, scientific investigation in rats, monkeys, and humans have not found any relationship between saccharine consumption and bladder cancer. In 2000, saccharin was removed from the US National Toxicology Program’s list of potential carcinogens.³

Aspartame is made by joining two amino acids (aspartic acid and phenylalanine) together. When digested, it is broken down to aspartic acid, phenylalanine, and methanol. People who have the rare genetic disorder phenylketonuria (PKU) have to avoid products containing aspartame. Individuals who have PKU do not have a functional enzyme that converts phenylalanine to the amino acid tyrosine. This causes a build-up of phenylalanine and its metabolic products in the body. If PKU is not treated, the build-up of phenylalanine causes progressive brain damage and seizures. The FDA requires products that contain aspartame to state on the product label, “Phenylketonurics: Contains Phenylalanine.”

The International Agency for Research on Cancer (IARC) has classified aspartame as possibly carginogenic to humans while also noting limitations in the available evidence for cancer and the need for more research.⁴ The FDA disagrees with the IARC's conclusion stating that FDA scientists do not have safety concerns when aspartame is used under approved conditions and that the sweetener is approved in many countries.⁵ Navigating different information from different health organizations can be challenging, so, ultimately, individuals can decide whether or not to include sugar substitutes in their diet based on their individual level of concern.

Regulation

Prior to introducing any new artificial sweetener into foods, the artificial sweetener is rigorously tested and must be legally approved by the FDA. The FDA regulates artificial sweeteners along with other food additives, which number in the thousands. The FDA is responsible for determining whether a food additive presents “a reasonable certainty of no harm” to consumers when used as proposed and, if safe, is designated Generally Recognized As Safe (GRAS) for public use.. As part of the approval process, the FDA establishes Acceptable Daily Intake (ADI) levels for artificial sweeteners. The ADIs are the maximum amount in milligrams per kilogram of body weight considered safe to consume daily (mg/kg bw/day) and incorporates a large safety factor. For more details on sugar substitutes including each sweetener's ADI please refer to Table \(\PageIndex{1}\).

Table \(\PageIndex{1}\): Sugar Substitutes
Sweeteners with Trade Name	Calories	Source/Origin	Consumer Recommendations	Controversial Issues
Aspartame NutraSweet Equal	4 kcal/g	Composed of two amino acids (phenylalanine + aspartic acid) + methanol. 200 times sweeter than sucrose.	ADI: 50 mg/kg body weight = 16 12 oz. diet soft drinks for adults. Cannot be used in products requiring cooking. People with PKU should not consume aspartame.	Children have potential to reach ADI if consuming many beverages, desserts, frozen desserts, and gums containing aspartame routinely.
Saccharin Sweet ‘n’ Low	0 kcal/g	Discovered in 1878. The basic substance is benzoic sulfinide. 300 times sweeter than sucrose.	ADI: 5 mg/kg body weight. Can be used in cooking.	In the 1970s, high doses of saccharin were associated with bladder cancer in laboratory animals. In 1977, FDA proposed banning saccharin from use in food protest launched by consumer & interest groups warning label listed on products about saccharin and cancer risk in animals until 2001 when studies concluded that it did not cause cancer in humans
Acesulfame K Sunnett Sweet One	0 kcal/g	Discovered in 1967. Composed of an organic salt, potassium (K). Structure is very similar to saccharin. Acesulfame K is not solely sold in stores; it is often blended with another sweetener when sold under a brand name (e.g., Sweet One). It passes through the body unchanged which means it does not provide energy. 200 times sweeter than sucrose.	ADI: 15 mg/kg body weight. Body cannot digest it. Can be used in cooking.
Sucralose Splenda	3.31 kcal/g	First discovered in 1976. Approved for use in 1998 in the United States and in 1991 in Canada. Derived from sucrose in which three of its hydroxyl (OH) groups are replaced by chlorine (Cl−). 600 times sweeter than sucrose.	ADI: 5 mg/kg body weight. Can be used in cooking.
Stevioside Stevia Sweet Leaf	N/A	Derived from stevia plant found in South America. 200-400 times sweeter than sucrose.¹	Considered to be a dietary supplement and approved not as an additive, but as a dietary supplement.	Used sparingly, stevia may do little harm, but FDA could not approve extensive use of this sweetener due to concerns regarding its effect on reproduction, gastrointestinal microbial imbalance, and energy metabolism.
Siraitia grosvenorii Monk fruit	N/A	Siraitia grosvenorii comes from a small green melon native to southern China. 100-250 times sweeter than sucrose.¹	ADI: not specified¹
Sugar Alcohols Sorbitol Xylitol Mannitol	1.6–2.6 kcal/g	Sorbitol is derived from glucose.	Less likely to cause tooth decay than sucrose.	May cause diarrhea and gastrointestinal distress if consumed in large amounts.

Key Takeaways

Sugar substitutes have replaced added sugars in many foods and beverages due to the potential health consequences of consuming too many added sugars.
Chewing gum with artificial sweeteners is the only proven way that artificial sweeteners promote oral health.
The most common side effect of consuming products containing sugar substitutes is gastrointestinal upset, a result of their incomplete digestion.
Prior to introducing any new artificial sweetener into foods it is rigorously tested and must be legally approved by the FDA.

References

United States Food and Drug Administration. fda.gov. Additional Information about High-Intensity Sweeteners Permitted for Use in Food in the United States. https://www.fda.gov/food/food-additives-petitions/additional-information-about-high-intensity-sweeteners-permitted-use-food-united-states. Accessed November 23, 2021.
Toews I, Lohner S, Küllenberg de Gaudry D, Sommer H, Meerpohl JJ. Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies. BMJ. 2019;364:k4718. doi:10.1136/bmj.k4718.
National Cancer Institute. cancer.gov. Artificial Sweeteners and Cancer. http://www.cancer.gov/cancertopics/factsheet/Risk/artificial-sweeteners. Accessed June 15, 2020.
World Health Organization. Aspartame hazard and risk assessment results released. https://www.who.int/news/item/14-07-2023-aspartame-hazard-and-risk-assessment-results-released#:~:text=IARC%20classified%20aspartame%20as%20possibly%20carcinogenic%20to%20humans%20(Group%202B,a%20type%20of%20liver%20cancer). Accessed March 26, 2024.
U.S. Food & Drug Administration. Aspartame and Other Sweeteners in Food. https://www.fda.gov/food/food-additives-petitions/aspartame-and-other-sweeteners-food#:~:text=Aspartame%20being%20labeled%20by%20IARC,a%20possible%20carcinogen%20to%20humans. Accessed March 26, 2024.

Contributors

Metropolitan State University of Denver Nutrition Department: Gabriel J. Duran de Casaus and Dr. Jerald Foote