Nov. 8, 2019 -- Marquita Adams, 46 of Alexandria, VA, whips out her little bottle of Splenda Zero from her pocket and squirts it twice into her coffee. She also squirts Crystal Light into her water a few times a week for “a little pizazz.”
Consumers turn to them for weight loss and/or to control their blood sugar. Type 2 diabetes runs in Adams’ family. “When I learned 2 years ago that I was prediabetic, I switched from using natural sweeteners like agave and Sugar in the Raw to artificial ones.”
Chris Brown, 64, of Aurora, OH, made the switch to artificial sweeteners when she was diagnosed with Type 2 diabetes 6 years ago. “I was drinking at least two cans daily of regular Coke [with high-fructose corn syrup] and then switched to Diet Coke with aspartame before discovering Coke Zero. I now drink about two cans daily of Coke Zero, which tastes more like regular Coke than Diet Coke.”
Adams and Brown are not alone in their use of these low-calorie sweeteners (LCS). A quarter of children and 41.4 % of adults reported using them in the 2009-2012 National Health and Nutrition Examination Survey (NHANES). This represents a 200% jump in their use for children from 1999 and a 54% increase in use among adults. The majority of children and adults said they ate or drank one or more sweeteners daily, according to a 2017 study.
Drinks accounted for the most common source of low-calories sweeteners, followed by food, and then sweetener packets, according to the study. Besides beverages, the faux sugars appear in breads, cereals, snacks, yogurt, no-sugar ice cream, reduced-sugar cookies, and condiments. They may not always be easy to spot.
Many parents do not want their children eating or drinking low-calorie sweeteners, but often they do not recognize them when the shop for groceries. “They may buy items that say no sugar added, sugar-free, or light, thinking they are healthier options,” says Allison Sylvetsky, PhD, lead investigator of the study and assistant professor of exercise and nutrition sciences at the George Washington University Milken Institute School of Public Health.
The highest users of low-calorie sweeteners were obese college-educated women with type 2 diabetes who had higher family income. “People are now more educated and aware of the negative health effects of sugar and seek out products labeled sugar-free or no sugar added,” Sylvetsky says.
She attributed the increasing use to several recent things, including obesity prevention campaigns focused on cutting added sugars and calories from diets; how the sweeteners are used more in foods, including a trend toward blending them to improve the taste of some products; combining the sweeteners with sugars that have calories; and falling costs.
The Research Is Contradictory
The FDA has approved eight “high-intensity sweeteners.” Six are approved as food additives: saccharin, aspartame, sucralose, acesulfame potassium, neotame, and advantame. Stevia extracted from chemical compounds in the plant’s leaves was the first natural sweetener the FDA approved as “generally recognized as safe,” followed by monk fruit (luo han guo) found in China, with compounds extracted from the plant’s fruit.
The FDA also has approved sugar alcohols as sugar substitutes because they are low-calorie carbohydrates with a sweetness of 25% to 100% of regular sugar. Examples include sorbitol, xylitol, lactitol, mannitol, erythritol, and maltitol.
But there is evidence to suggest that frequent use of the sweeteners, especially in diet sodas, raises the risk of several chronic diseases, including obesity, metabolic syndrome, type 2 diabetes, and heart disease.
A large long-term study published in October found that drinking at least an additional half-serving daily of artificially sweetened beverages was associated with a 16% higher risk of diabetes. Interestingly, when people replaced one daily serving of a sugary beverage with water, coffee, or tea, but not an artificially sweetened beverage, it was associated with a 2% to 10% lower diabetes risk.
Other studies have linked artificially sweetened beverages with stroke and heart disease. For example, after controlling for lifestyle factors, a February study found that women who drank two or more artificially sweetened beverages each day were 31% more likely to have a clot-based stroke, 29% more likely to have heart disease, and 16% more likely to die from any cause than women who drank diet beverages less than once a week or not at all.
Yet another study from 2017 tied drinking diet soft drinks to a higher risk of ischemic stroke.
But low-calorie and no-calorie sweeteners have been considered healthy sugar substitutes because they provide sweet taste without calories or glycemic effects on blood sugar that have contributed to obesity and diabetes.
Some older studies have shown that these sweeteners can aid weight loss. One concluded that “overall, the balance of evidence indicates that use of low-calorie sweeteners in place of sugar, in children and adults, leads to reduced caloric intake and body weight, and possibly also when compared with water.”
Another study found that when 318 overweight and obese adults replaced caloric beverages with no-calorie ones during a 6-month period, they lost an average of 2% to 2.5% of their weight.
Where Do Nutritionists Stand?
The position of the Academy of Nutrition and Dietetics since 2012 is that people can safely enjoy a range of sweeteners, including non-nutritive sweeteners with few or no calories, as part of an eating plan that takes into account federal nutrition guidelines, personal health goals, and preferences.
“I think these low-calorie sweetener products are great. Consumers can have the sweetness they want and drink it too,” says Debbie Petitpain, a media spokesperson for the academy and a wellness director in the Office of Health Promotion at the Medical University of South Carolina.
She also thinks they are safe, based on the numerous studies the FDA reviews as part of its approval process of these food additives. The FDA website says human studies, along with animal studies, were done for saccharin, advantame, and neotame. Advantame is 20,000 times sweeter than table sugar, and neotame is 7,000 to 13,000 times sweeter.
“It makes sense to cut back on calories, given that there is mounting evidence that sugar contributes to chronic disease such as obesity, type 2 diabetes, and heart disease,” Petitpain says.
She referred to the recommendation in the 2015-2020 Dietary Guidelines for Americans that people take in less than 10% of calories per day from added sugars. But a 2017 report indicated that only 42% of adults from 2013-2014 were able to meet that recommendation.
The American Heart Association and American Diabetes Association took the position in 2012 that non-nutritive sweeteners can be part of a diet that aims to cut added sugars. But they also said it would be premature, based on the research, to conclude that they definitely reduced added sugars, body weight, metabolic syndrome, and diabetes -- all things that can lead to heart disease. One concern researchers expressed was whether people make up for the calories they save in other ways.
Petitpain advises clients to look for the low-hanging fruit to cut back on added sugars. Most added sugars are in what people drink. “For clients who rather not drink plain water and still want something sweet-tasting, using LCS [low-calorie sweeteners] is a good choice.”
Although Petitpain doesn’t steer clients toward any specific sweetener, she does take into account their health history, goals, and personal preferences, which may be to avoid low-calorie sweeteners altogether. If people have phenylketonuria (PKU), a rare genetic disorder, the FDA recommends that they avoid or restrict their use of aspartame because they have a difficult time metabolizing phenylalanine, which is in aspartame.
Petitpain also says some clients may be put off by saccharin because they recall a warning label of bladder cancer after studies in rats in the 1970s linked the sweetener to this cancer. After several studies done in humans showed that saccharin is safe for humans, the warning label was no longer required.
The Academy of Nutrition and Dietetics also says the sweeteners are safe for kids and are not linked to cancer, birth defects, or behavior problems. But it cautioned that kids shouldn’t overdo eating foods or drinking beverages with them as they often contain “empty calories.” The American Academy of Pediatrics agrees there is no scientific evidence linking them to those health concerns. But the organization calls for more research, saying it is not clear whether the sweeteners have long-term health effects. Without other diet and lifestyle changes, using them is not likely to lead to significant weight loss, it says.
Petitpain is also cautious about recommending low-calorie sweeteners to women during pregnancy, because there is no safety data to know for sure.
Another consideration is how the sweeteners will be used -- some perform better at high temperatures than others. Sucralose, acesulfame potassium, neotame, and advantame are considered “heat stable,” meaning they stay sweet at high temperatures. Aspartame, on the other hand, “loses its sweetness when heated, so it typically isn’t used in baked goods,” according to the FDA.
Sandra Arevalo, a media spokesperson for the Academy of Nutrition and Dietetics and director of community and patient education at Montefiore Nyack Hospital in Nyack, NY, prefers natural sweeteners to artificial ones, which may be easier to digest for people with sensitive stomachs.
Stevia and monk fruit extract shouldn't aggravate sensitive bowels, she says, but Truvia might, because it blends Stevia with the less digestion-friendly erythritol.
Sugar alcohols can also cause digestion problems, says Arevalo. “It’s based on the digestion process and chemical reaction of the sugar alcohols. These aren’t fully absorbed and get fermented, causing bloating and gas and, in some instances, diarrhea.”
Too Much of a Good Thing
A large long-term study published in April found that only the highest intake of artificial sweeteners was associated with a higher risk of heart disease and death among women.
In general, Petitpain recommends that clients use a variety of sweeteners to avoid consuming too much of one. “For example, if your favorite diet soda is sweetened with aspartame, consider using sucralose in your iced tea.”
To know whether foods or drinks have low-calorie sweeteners, look for phrases like “sugar-free,” “no sugar added,” or “light.” But to be sure, look at the names of the ingredients on the back of the package.
Sugar alcohols are in some products like Truvia. To find out, look at the Nutrition Facts label under carbohydrates. Food makers may voluntarily list the amount in grams (g) per serving. Specific names of sugar alcohols may also be listed under Ingredients.
Brown thinks switching to artificial sweeteners in her daily Coke has helped her cut back on sugar, although she still has diabetes. “I really loved regular Coke and would drink it even in the middle of the night.”
Adams was surprised that her blood sugar didn’t fall after she switched to artificial sugars in her drinks. When her doctor suggested she just use one Splenda packet in her coffee and tea, which has a few carbs and calories due to other ingredients, she started using the little bottle of Splenda Zero, which has no carbs or calories.
Adams hopes to see a decrease in her blood sugar when she goes for her next annual physical. In the meantime, she plans to continue using artificial sweeteners, which she views as the “lesser of the two evils,” compared to diabetes.