Patient EducationApr | 13 | 2023
Sugar Substitutes: What You Should Know
Too much sugar can negatively impact our health by contributing to tooth decay, diabetes, heart disease and unintentional weight gain. As a result, many people have switched to artificial sweeteners. Sugar substitutes, also called “artificial sweeteners” or “sugar alcohols,” have been used in diet sodas and sugar-free candies for decades, but now the number of food products containing them has expanded. Sugar substitutes have become more common in foods including protein bars, yogurts, cereals, ice creams, and salad dressings. The use of them allows food companies to market their products as “less sugar,” “reduced sugar” or “no added sugar.”
With an overwhelming number of colored packets to choose from and food and beverage companies sneakily replacing sugar with alternatives, what should you do? Here is a brief run-down of what you need to know.
How do non-nutritive sweeteners differ from sugar?
Normally, carbohydrate-containing foods are broken down into individual molecules of sugar called monosaccharides. Glucose, fructose, and galactose are examples of monosaccharides and are naturally found in various foods including fruits, vegetables, whole grains, and dairy. Table sugar, typically referred to as “refined sugar” or “added sugar” is sucrose, a disaccharide made up of glucose and fructose molecules. When any of these sugars are consumed, they contribute calories or units of energy to be used by the body. Our brain and red blood cells rely on glucose as their preferred energy source.
Non-nutritive sweeteners contain zero or very low amounts of carbohydrates and energy. Often, these are not absorbed into the blood stream from the digestive tract, as our bodies may not have the physiologic mechanisms to absorb and use them as energy. Non-nutritive sweeteners contribute less than 2% of the calories compared to an equivalent amount of sugar. Aspartame is the only artificial sweetener that is considered a nutritive sweetener, as it contains more than 2% of calories.
Sugar Substitutes by Category
- Sucralose (Splenda)
- Aspartame (Equal, NutraSweet, Sugar Twin)
- Saccharin (Sweet’N Low, Sweet Twin, Necta Sweet)
- Neotame (Newtame)
- Acesulfame potassium (Ace-K) (Sweet One, Sunett)
Artificial sweeteners do not enter the blood stream and do not raise blood sugar directly. Instead, they stay in the digestive tract until they pass in the stool. Additionally, some studies have found artificial sweeteners, particularly sucralose, aspartame, and saccharin, can alter the microbiome, the healthy bacteria that live in your gut. These microbiome changes can disrupt how cells recognize insulin, leading to elevated blood sugar levels when normal carbohydrate-containing foods are consumed.
Other studies have shown these artificial sweeteners may change our appetites and response to the taste of sweetness. Since artificial sweeteners can be 100 to 700 times sweeter than regular sugar, when our taste buds register that level of sweetness, a signal is sent to our brain that a large influx of calories is coming. But because artificial sweeteners contain few or no calories, our brain and taste receptors remain confused. This may cause stronger sugar cravings to develop.
Sugar alcohols can be found naturally in small amounts in fruits. They’re considered nutritive sweeteners as they provide some calories and may increase blood sugar levels, but not to the extent of table sugar. They don’t cause tooth decay, but consumed in large enough quantities, they can cause gastrointestinal discomfort such as bloating, cramps, gas, and diarrhea, as the bacteria in our gut ferment them. Xylitol, synthesized from corncobs and birch trees, can help remineralize tooth enamel. Often sugar alcohols can be found in commercial baked goods, sugar-free gums, toothpaste, and increasingly in protein bars, yogurts, and other packaged foods to reduce the added sugar content.
More research is needed on the long-term use of sugar alcohols. One recent study showed an association between erythritol and major adverse cardiovascular events such as heart attack and stroke. However, researchers only checked blood erythritol levels without considering dietary consumption, so it is unclear if these higher levels of erythritol in the blood were due to dietary intake or naturally occurring elevated levels.
Naturally Occurring Non-Nutritive Sweeteners
- Steviol Glycosides (Stevia, Truvia, PureVia, Enliten)
- Monk Fruit (Nectresse, Monk Fruit in the Raw, PureLo)
Foods that are labeled “no artificial sweeteners” may often be sweetened with stevia, monk fruit or other “natural” sugar substitutes. Steviol glycosides (stevia) and Luo Han Guo fruit extracts (monk fruit) are naturally occurring non-nutritive sweeteners. This means that they are harvested from plants, not produced in a lab, have a sweet flavor, but do not contribute calories or energy. The FDA’s acceptable daily intake of stevia is no more than 9 tabletop packets per day and there has not been an established limit for monk fruit.
- Maple syrup
A common myth is that natural sweeteners are “better” than refined sugar. The reality is these sweeteners are all broken down by the body into individual sugar molecules, contributing calories and raising blood sugar, the same way table sugar does. Agave and honey are primarily broken down into fructose and some glucose, while maple syrup is composed mostly of sucrose, some glucose and fructose.
Agave tends to have a lower glycemic index, meaning it does not raise blood sugar levels to the same extent as honey and maple syrup. This may be a great choice for those with diabetes.
Depending on the honey’s origin and how it is processed, it may contain nutrients, antioxidants, and prebiotic benefits. Similarly, the qualities of maple syrup can vary greatly depending on where it’s from, but the sugar content remains the same, regardless of the color, which can vary based on when in the season the sap was harvested.
So, what’s one to do?
It's clear that sugar is damaging to our health in large amounts. However, replacing all sugar with sugar substitutes may not be the answer either. It’s hard to fully understand all the health implications of sugar substitutes as research remains inconsistent and simply because there are so many of them! Rather than deeming sugar substitutes “bad” or “good,” it’s important to consider the consumption of sugar substitutes in the context of your whole diet and your unique dietary needs.