Photo Credits: "Valentine's Day" by L.A. Foodie is licensed under CC BY 2.0. "Halloween Candy Target" by Phillip Pessar is licensed under CC BY 2.0. "Christmas Candy Bar // Sweet Table" by niner bakes is licensed under CC BY 2.0
By Dale Mayo, October 24, 2023
Sweets, treats, and sodas are a part of the American diet. Holidays are defined by specific candies and desserts. Foods you don’t even think of as sweet may contain sugar or a sugar substitute (breads, breakfast cereals, flavored yogurts, condiments like ketchup). For the past several decades, people have been trying to reduce their sugar intake. Too much added sugar has been blamed for many illnesses, including high blood sugar, insulin resistance, metabolic syndrome, dental issues such as cavities, increased triglycerides, obesity, and type 2 diabetes.
Table sugar is a type of carbohydrate commonly used in sweet desserts and baked goods. Sugars are found in fruit (e.g., fructose in agave, fruit juices, honey), vegetables (e.g., sucrose in sugar beet and sugar cane plants; glucose in corn syrup), grains (e.g., glucose in wheat; glucose, maltose, maltotriose in brown rice syrup), and dairy products (lactose). Table sugar (sucrose) is a disaccharide made up of glucose and fructose.
What are sugar substitutes?
Sugar substitutes include natural and artificial sweeteners that can be added at the table (e.g., to iced tea) or incorporated into processed foods and drinks. Most sugar substitutes are far sweeter than sugar, so it takes less to sweeten food or drink and many have few or no calories. Sugar substitutes are regulated by the Federal Drug Administration (FDA). The following sugar substitutes are FDA approved as food additives in the United States.
|Low-Calorie Sweetener||Brand Names†||Sweetness as compared with sugar||Acceptable Daily Intake* (max number of tabletop sweetener packets per day)|
|Aspartame||Equal®, NutraSweet®, Sugar Twin®||200 times sweeter||75**|
|Acesulfame-K||Sunett®, Sweet One®||200 times sweeter||23|
|Saccharin||Sweet’N Low®, Sweet Twin®, Necta Sweet®||200-700 times sweeter||45|
|Sucralose||Splenda®||600 times sweeter||23|
|Neotame||Newtame®||7,000-13,000 times sweeter||23|
|Advantame||No brand names||20,000 times sweeter||4,920|
Sugar alcohols (polyols) are sometimes used in toothpaste, skin creams, and medicines like cough syrups. They occur naturally in small amounts in fruits and vegetables, including berries, apples, and plums, but for large-scale commercial use they are manufactured from common sugars. Common sugar alcohols are mannitol, sorbitol, xylitol, lactitol, isomalt, maltitol, and hydrogenated starch hydrolysates. Studies have shown that it is safe to consume 10 to 15 grams of sugar alcohols per day (see longevity section, below for further information).
The FDA’s Generally Recognized as Safe (GRAS) notification program permits two further sweeteners in the food supply:
- Certain Steviol Glycosides, from the South American Stevia plant, Stevia rebaudiana (Rebaudioside A, Stevioside, Rebaudioside D, or steviol glycoside mixtures), are found in Truvia® and PureVia® (of which the acceptable daily intake is 9 packets). Steviol glycosides are 200 to 400 times sweeter than sugar. Stevia leaf and unrefined stevia extracts are not considered GRAS and are not allowed in the U.S. for use as sweeteners.
- Monk Fruit (luo han guo or Siraitia grosvenorii Swingle fruit extract) comes from a plant native to Southern China. One to two hundred times sweeter than sugar, an acceptable daily intake has not yet been determined.
Sugar vs. artificial sweeteners
The Centers for Disease Control and Prevention (CDC), in its Dietary Guidelines for Americans 2020–2025 recommends that Americans 2 years and older keep their intake of added sugars to less than 10% of their total daily calories. For example, in a 2,000 calorie diet, no more than 200 calories should come from added sugars (about 12 teaspoons). Children younger than 2 years should not be fed foods and beverages with added sugars at all.
The FDA regulates health and nutrient content claims on food and drink packaging and revised the Nutrition Facts label to list both “Total Sugars” and “Added Sugars” in 2016. This assists consumers to make more informed and healthier choices. Products listing low levels of sugar often contain a sugar substitute or low-calorie sweetener. Replacing sugary foods and drinks with sugar-free options containing non-nutritive sweeteners (NNSs) is one way to limit calories and achieve or maintain a healthy weight, to help people with diabetes manage blood glucose levels, and to help prevent tooth decay.
Do artificial sweeteners affect health and longevity?
There is enough evidence of potential associations between the use of artificial sweeteners and an increased risk for metabolic disease, cardiovascular disease, and cancer that the World Health Organization has issued guidelines about limiting their consumption. This recommendation to limit use does not apply to individuals with pre-existing diabetes, nor does the recommendation address sugar alcohols. Current thinking about sugar alcohols is also changing, however, as a recent study shows that one sugar alcohol, erythritol, is closely associated with an increased risk for “major adverse cardiovascular events,” including heart attack and stroke.
Polyols (e.g., sorbitol, xylitol, and erythritol) can have a laxative effect if consumed in large amounts. Some foods contain polyols naturally, such as certain fruits and vegetables. The American Heart Association reports that heavy use of artificial sweeteners may increase blood sugar by altering natural gut bacteria. In addition, it appears that some individuals with irritable bowel syndrome may experience digestive distress after eating fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP). Non-nutritive sweeteners are not an energy for humans, but they can be broken down by some bacteria in the gut microbiome. The composition of the breakdown products (metabolites) depends on the sweetener and the individual’s gut bacteria, and some metabolites can potentially impact brain function.
The research examining the association between artificial sweeteners and various health problems does not appear to be conclusive. Meta-analyses of clinical trials examining non-nutritive sweeteners and metabolic health have found little significant effect on weight, blood lipids, and blood glucose levels while epidemiologic studies show an increased risk of insulin resistance, cardiovascular disease, stroke, and dementia. The difference in the findings may come from differences in the study populations and level of consumption.
Is there a connection between artificial sweeteners and dementia?
In 2017, a study published in Stroke showed an association between diet soda and both stroke and dementia, with people drinking diet soda daily being almost three times as likely to develop stroke and dementia as those who consumed it weekly or less. The study comes with a caution: an editorial that accompanies the study describes the potential for selection bias which could affect the association. For example, someone with a preexisting risk (e.g., overweight or obesity) may switch to diet soft drinks to control weight and insulin resistance. The cause of stroke or dementia may have more to do with the individual’s risk factors and nothing to do with the intake of artificially sweetened soft drinks.
Other studies examining the relationship between artificial sweeteners and dementia have also been inconclusive. One animal study showed an increase in anxiety with the ingestion of aspartame – and the effects extended up to two generations from the males exposed to the sweeteners. Future research will identify the molecular mechanisms that influence the transmission of aspartame’s effect across generations.
Further clinical research is needed to determine whether there is a biological mechanism that links low-calorie sweeteners and the circulatory issues that lead to strokes, dementia, or other health problems.
There is a clear link between obesity and health problems attributed to the consumption of sugar and possibly artificial sweeteners. Other lifestyle factors are not always taken into account in studies focusing on one product – people who eat a western diet high in processed meats, french fries, cookies, and cakes may drink only diet sodas to offset their otherwise high caloric intake. As the WHO director for nutrition and food safety says, “People need to consider other ways to reduce free sugars intake, such as consuming food with naturally occurring sugars, like fruit, or unsweetened food and beverages.” Non-sugar sweeteners “are not essential dietary factors and have no nutritional value. People should reduce the sweetness of the diet altogether, starting early in life, to improve their health.” Because we don’t know whether they are bad for you, it is best to limit the use of artificial sweeteners when possible, just as with sugar.
Following a healthy, well-balanced diet like the Mediterranean diet is good for heart health and overall well-being and may help reduce sugar intake. Such a diet means eating primarily fruits, vegetables, legumes, nuts and seeds, whole grains, olive oil, and seafood - and occasionally, red meat and desserts. You get a higher level of nutritional value from these foods than from highly processed foods and juices or soft drinks containing lots of sugar OR artificial sweeteners.
Please Note: Any information published on this website is not intended as a substitute for medical advice and you should not take any action before consulting with a healthcare professional.