“How do your take your coffee?”

Black with 3 Splendas.

With all this talk about the dangers of sugar consumption, there is a lot of discussion about sugar substitutions.  People often think that replacing sugar with a sugar substitute is a get out of jail free card, an easy healthy solution with no consequences.  I tend to cringe when people tell me they drink diet soda or sweeten their coffee with 3 packets of Splenda, but is that truly cringe-worthy?  Diagnosed with type 1 diabetes in 1992, I grew up drinking diet soda on occasion, assured by the fact that it wouldn’t affect my blood sugar.  When did it all change?  How safe are these sugar substitutes, and do they even have the desired effect?

Sweeteners are broken down into two categories, nutritive and nonnutritive, categorized by whether they provide calories or not.

Nutritive Sweeteners

Nutritive sweeteners provide calories when consumed.

1. Sugar Alcohols (Polyols)

Polyols are nutritive sweeteners often used in candy and confections and often labeled as sugar free.

You may have heard of these because of  recent studies on gluten intolerance and IBS that indicated a potential connection between polyol ingestion and digestive issues.  They represent the P in FODMAP (You can read more in my post on gluten intolerance).

Sugar alcohols are carbohydrates which provide fewer kcal/gram than sugar does.  They on average provide 2 kcal/g.  This is because sugar alcohols are not completely absorbed by the body.  Foods that use these sweeteners can be labeled as sugar-free, because this type of sweetener packs fewer calories than sugar.

Be warned that although these are recognized as safe in limited amounts, high intake of sugar alcohols can cause gas, bloating, and diarrhea.  The American Dietetic Association suggests intakes of less than 50 g per day of sorbitol and less than 20 g per day of mannitol.

Sugar Alcohols	Where you’ll find them
Sorbitol	Sugar free candy, Chewing gum, flavored jam, frozen foods, baked goods
Mannitol	Chewing gum, hard and soft candy, frosting, confection
Xylitol	Chewing gum and hard candy
Erythritol	Baked products, some beverages, chewing gum
Isomalt	Hard and soft candy, lollipops, wafers, fudge, toffee, chewing gum
Lactitol	Chocolate, cookies, cakes, frozen dairy desserts
HSH	Low calorie foods
Malitol	Sugar-free chocolate, hard candy, baked goods, ice cream

Although sugar alcohols are generally regarded as safe and approved for use in limited amounts, I would advise limiting intake.  Although higher in calories, honey, maple syrup, and agave are still considered safer nutritive substitutions for sugar.

Nonnutritive Sweeteners

Given what we know about nutritive sweeteners, it would follow that nonnutritive sweeteners do not provide calories upon intake.  Although all of the following nonnutritive sweeteners are generally recognized as safe and approved for consumption in limited amounts in the United States, studies have highlighted potential health concerns and side effect associated with consumption.

Nonnutritive Sugars	Also known As	Safety Concerns
Saccharin	Sweet’N Low Acceptable Daily Intake ADI: 5 mg/kg of body weight	–       1977 research showed ingestion caused bladder tumors in male rats –       Results were not replicated in human studies –       Saccharin removed from the national list of carcinogens in 2000 –       Conclusion: normal consumption in humans determined safe
Aspartame	Nutasweet, Equal   ADI: 50 mg/kg of body weight	–       Cannot be consumed by those with PKU –       Studies on safety controversial due to conflicts of interest –       H.J. Roberts MD described possible side affects of ingestion in 1998: dizziness, headaches, mood alteration, nausea, abdominal pain, diarrhea, seizures, memory loss, fatigue –       In studies, migraine frequency was increased with ingestion in those prone to migraines. –       Individuals with mood disorders were found to be particularly sensitive
Highly Purified Steviol Glycosides	Stevia, Truvia, PureVia	–       Newer popular sweetener on the market –       Whole leaf stevia not yet proven safe –       Generally recognized as safe (GRAS) –       No long term studies on safety have been conducted
Sucralose	Splenda ADI : 5 mg/kg body weight	–       No long term studies have been conducted –       Possible side affects: bloating, gas, diarrhea, nausea, wheezing, cough, runny, nose, anxiety, chest pain, skin irritation –       Recent study found that Splenda affected medication absorption in rats. It also was found to reduce good gut bacteria by 50%

If you are desperate for a zero calorie sweetener, current research seems to point towards stevia as the safest.  I wouldn’t go wild with stevia, however, because we still lack research on the long term effects stevia may have.  I personally eschew polyols and nonnutritive sweeteners due to the potential health concerns.

Artificial Sweeteners, Weight Gain, and Diabetes

For years artificial sweeteners were lauded for their role in weight loss; however, recent research on artificial sweeteners, weight-loss, and weight maintenance does not favor artificial sweeteners.  The research is still somewhat inconclusive and does not establish a clear relationship.

A study published in 2013 linked both consumption of sweetened and artificially sweetened beverages with increased risk for type 2 diabetes.*  The nature of this link is not clear.  More research needs to be done to establish whether this is a causal relationship.  Another study following a diverse group of 6,814 Americans found that those who consumed diet soda at least once a day were at 67% greater risk of developing type 2 diabetes than those who did not consume diet beverages.

Another study of 3,682 individuals studied the long-term relationship between artificially sweetened beverages and weight.  The study found a 47% increase in BMI in those that drank the artificially sweetened beverages compared to those that did not.**

One potential explanation is that artificial sweeteners may not trigger the same brain response as sugar.  They may cause us to crave more sweets, increasing caloric intake.  The American Diabetes Association and the American Heart Association; however, still conclude that nonnutritive sweeteners may help with weight loss and weight control.

How do I take my coffee?

Without sweetener.

Sometimes with a touch of milk.

If sweetener is necessary, than a tsp of honey.

*Fagherazzi G, Vilier A, Saes Sartorelli D, Lajous M, Balkau B, Clavel-Chapelon F. Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes in the Etude Epidemiologique aupres des femmes de la Mutuelle Generale de l’Education Nationale-European Prospective Investigation into Cancer and Nutrition cohort. Am J Clin Nutr. 2013;97(3):517-23.

**Sharon P. Fowler, Ken Williams, Roy G. Resendez, Kelly J. Hunt, Helen P. Hazuda, Michael P. Stern.  Fueling the obesity epidemic? Artificially sweetened beverage use and long-term weight gain.  Obesity (Silver Spring) 2008 August; 16(8): 1894–1900. Published online 2008 June 5. doi: 10.1038/oby.2008.284