Low-calorie sweeteners: Are they better or worse for you than sugar?

When EWG was developing Food Scores – our new food database that rates more than 80,000 products on nutrition, ingredient concerns and processing concerns – one of the many thorny questions that we had to confront was: How should low-calorie sweeteners score? This is far from a simple question, but it is an important one, given that these sweeteners are in products as varied as diet sodas, ice cream, yogurt, snack bars, salad dressings, instant oatmeal and bagels.

Notably, the Institute of Medicine does not encourage consumption of products with artificial sweeteners nor consider them appropriate to meet the nutritional recommendations of the federal Dietary Guidelines for Americans (IOM 2007). There is no scientific consensus on whether “diet” products with low-calorie sweeteners help with long-term weight loss. And there is ongoing debate over the safety of some sweeteners and on whether low-calorie sweeteners may condition the palate to make people crave more sweet foods or have other undesirable health effects.

Meanwhile, there is very clear data showing that eating a lot of sugar can be harmful, and the rising rates of diabetes and obesity are serious public health problems. Experts may disagree on exactly how much sugar is too much, but there is really no question that many Americans consume more of it than is good for them. Americans take in average of 22 teaspoons of added sugar a day, according to recent government estimates (NCI 2010; USDA and DHHS 2010).

So should consumers choose low-calorie sweeteners or should they opt for sugar? The answer is that it is probably best to avoid eating too much of either one. The downsides of eating sugar are clear, and there are too many questions about the long-term consequences of consuming low-calorie sweeteners for EWG to recommend them without reservation.

Consumers will notice that diet sodas tend to score better than full sugar sodas in EWG’s Food Scores database. This is because there is clear evidence showing that drinking a lot of sugary drinks is bad for your health, and the jury is still out when it comes to the potential benefits and drawbacks of low-calorie sweeteners.

Some low-calorie sweeteners raise more concerns than others, however, and these differences are reflected in those products’ scores.

Here is EWG’s summary of the state of the evidence on some key questions about sweeteners:

• Can low-calorie sweeteners help me lose weight?
  
  Probably not, but we can’t rule it out. Short-term studies of “diet” beverages and foods with artificial sweeteners support the notion that these products can help reduce calorie intake (Peters 2014; Tate 2012). But long-term studies generally find minimal or no positive effect on weight loss (Gardner 2014; Shankar 2013). Researchers have hypothesized that consuming diet beverages could induce compensatory eating, either because of the psychological reassurance that consuming fewer calories provides or as the result of appetite stimulation, which would negate the lower caloric content of diet beverages.
  
  If you are trying to wean yourself off a sugar-heavy diet and making the transition to eating healthier food and drinking more water for the long haul, low-calorie sweeteners might help. But don’t fool yourself into believing that they are the answer to your weight problems. Consider the cautionary tale of the San Antonio Heart Study. In this epidemiologic study, University of Texas researchers observed more than 2,000 volunteers for 7-8 years and found that the more diet sodas a person drank, the greater the odds that he or she would become overweight or obese (Fowler 2008).
  
  Overall, epidemiological studies of people who drink diet beverages are confounded by other dietary factors and prior weight and health issues. Regardless of the limitations in the existing data, however, the weight of evidence to date indicates that consuming diet beverages is not a reliable path to long-term weight loss.
• Are low-calorie sweeteners good for kids?
  
  They probably aren’t the best choice. Although artificially sweetened beverages might appear to be a “healthier” choice than sugar-sweetened drinks, many health experts are concerned that artificially sweetened beverages may contribute to developing a life-long habit of consuming sweet beverages and displace truly healthier options such as water or milk (Sylvetsky 2011; IOM 2007).
  
  The Institute of Medicine pointed out that foods and beverages that contain sweeteners with no nutritional value can displace nutrient-dense, healthful foods and reduce intake of essential nutrients. In a 2007 report titled “Nutrition Standards for Foods in Schools: Leading the Way toward Healthier Youth,” the Institute, a branch of the National Academies, classified diet beverages as secondary-tier products distinct from “foods to encourage” such as fruits, vegetables, whole grains, lower fat dairy products and water. It noted that “the use of non-nutritive sweeteners to provide lower calorie foods and beverages is not necessary to achieve weight control” (IOM 2007).
  
  It’s also worth noting that similar or higher rates of heart disease and hypertension have been reported in consumers of “diet” beverages than in those who drink sugar-sweetened alternatives (Gardener 2012). The risk of Type 2 diabetes is similar in both groups. (de Koning 2011). In all, the evidence suggests that low-calorie sweeteners don’t give you any benefit when it comes to your risk of heart disease and diabetes. 

• Could low-calorie sweeteners affect my metabolism in some fashion?
  
  It’s unclear. Artificially sweetened beverages have been linked to an elevated risk of metabolic syndrome, a disorder in the body’s energy usage and storage that is related to obesity and cardiovascular disease (Duffey 2012; Lutsey 2008). Concerns have also been raised that ingesting non-nutritive sweeteners that carry no calories can increase appetite, trigger compensatory appetite (Mattes 2009) and disturb normal glucose and energy metabolism in ways that promote, rather than fight, obesity (Swithers 2013a). A recent study has also raised the possibility that low-calorie sweeteners could actually elevate blood sugar (Suez 2014).
  
  A variety of expert publications agree that the currently available data are insufficient to settle the issue. However, the Institute of Medicine does not encourage consumption of products with artificial sweeteners nor consider them appropriate foods to meet the nutritional recommendations of the federal government’s Dietary Guidelines for Americans (IOM 2007).
• What about toxicity? Should I be concerned?
  
  A variety of low-calorie sweeteners are approved in the U.S. The three most common are sucralose (Splenda), acesulfame potassium and aspartame (Nutrasweet). Four less common ones are neotame, erythritol, sorbitol and saccharin, though saccharin used to be quite popular. One very new sweetener, approved by the Food and Drug Administration in May of this year, is advantame. Products with this compound may be hitting store shelves soon. In response to the negative public perception of artificial sweeteners’ safety, two plant-derived products have also been introduced: stevia and monk fruit (luo han guo fruit).
  
  In animal studies, low-calorie sweeteners generally exhibit low toxicity, and what little toxicity exists seems to be at least partially caused by the decreased food intake observed with high doses of artificial sweeteners, which can be unpalatable (Whitehouse 2008). There has been a long-standing debate over signs of carcinogenicity or other toxicity in animal studies of some sweeteners, including increased rates of bladder cancer in rats ingesting saccharin (Arnold 1983) and higher rates of lymphomas, leukemias and mammary tumors in rats ingesting aspartame (Soffritti 2007).
  
  Multiple epidemiological studies have examined the risk of brain cancers, blood cancers and digestive system cancers in people consuming aspartame. The focus on aspartame was primarily due to data availability, since aspartame was the most commonly used sweetener until 2008, when sucralose overtook it (BCC Research 2013). Most studies did not find a statistically significant risk of cancer (Marinovich 2013). One Harvard University Medical School study reported an elevated risk of non-Hodgkin lymphomas in men who consumed diet sodas, but it found a similar effect in those who consumed sugar-sweetened soda (Schernhammer 2012).
  
  Based on the current data, EWG classifies aspartame, neotame and sucralose as being of “lower concern” in food. Sugar alcohols such as erythritol and sorbitol that can cause gastrointestinal irritation in people who ingest large quantities are also of “lower concern.” Saccharin has a “moderate concern” rating since the level considered safe is lower than for other sweeteners that cause health effects in animals, mainly at very high doses. Acesulfame K, stevia and monk fruit show little to no toxicity and are rated accordingly in EWG’s Food Scores database.
  
  Some people may be more sensitive to the effects of low-calorie sweeteners than others, so EWG also recommends that you watch for any negative reactions you may experience. There are multiple case study reports of headaches and migraines associated with aspartame (Blumenthal and Vance 1997); acesulfame K and neotame have been also linked to headaches (Whitehouse 2008). These types of reactions have not been factored into EWG’s scoring system since, like food allergies, they seem to affect only a subset of the population and may not be relevant for all consumers.

References

Arnold DL. 1983. Two-generation saccharin bioassays. Environ. Health Perspect. 50: 27-36.

BCC Research. 2013. The Market For High-Intensity Sweeteners Is Expected To Reach Nearly $1.9 Billion In 2017 . Available: http://www.bccresearch.com/pressroom/fod/market-high-intensity-sweeteners-expected-reach-nearly-$1.9-billion-2017

Blumenthal HJ, Vance DA. 1997. Chewing gum headaches. Headache 37(10): 665-6

Browning L. 2008. New Salvo in Splenda Skirmish. New York Times September 22, 2008. Available: http://www.nytimes.com/2008/09/23/business/23splenda.html

de Koning L, Malik VS, Rimm EB, Willett WC, Hu FB. 2011. Sugar-sweetened and artificially sweetened beverage consumption and risk of type 2 diabetes in men. Am J Clin Nutr. 93(6): 1321-7

Duffey KJ, Steffen LM, Van Horn L, Jacobs DR Jr, Popkin BM. 2012. Dietary patterns matter: diet beverages and cardiometabolic risks in the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr. 95(4): 909-15

European Food Safety Authority. 2007. Neotame as a sweetener and flavour enhancer. Scientific Opinion of the Panel on Food Additives, Flavourings, Processing Aids and Materials in Contact with Food (Question No EFSA-Q-2003-137). Available: http://www.efsa.europa.eu/en/efsajournal/pub/581.htm

European Union Scientific Committee on Food. 2000. Re-evaluation of acesulfame K with reference to the previous SCF opinion of 1991 (opinion expressed on March 9, 2000). Available: http://ec.europa.eu/food/fs/sc/scf/out52_en.pdf

FDA. 2014. FDA Approves New High-Intensity Sweetener Advantame. Available: http://www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm397740.htm

Fitch C, Keim KS; Academy of Nutrition and Dietetics. 2012. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet. 112(5): 739-58

Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP. 2008. Fueling the obesity epidemic? Artificially sweetened beverage use and long-term weight gain. Obesity (Silver Spring) 16(8): 1894-900

Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D, Lichtenstein AH. 2012. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 35(8): 1798-808

Gardener H, Rundek T, Markert M, Wright CB, Elkind MS, Sacco RL. 2012. Diet soft drink consumption is associated with an increased risk of vascular events in the Northern Manhattan Study. J Gen Intern Med. 27(9): 1120-6

Gardner C. 2014. Non-nutritive sweeteners: evidence for benefit vs. risk. Curr Opin Lipidol. 25(1): 80-4

IOM (Institute of Medicine).  2007. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: The National Academies Press. Available: http://www.nap.edu/catalog.php?record_id=11899

Lutsey PL, Steffen LM, Stevens J. 2008. Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Circulation. 117(6): 754-61

Marinovich M, Galli CL, Bosetti C, Gallus S, La Vecchia C. 2013. Aspartame, low-calorie sweeteners and disease: regulatory safety and epidemiological issues. Food Chem Toxicol.  60: 109-15

Mattes RD, Popkin BM. 2009. Nonnutritive sweetener consumption in humans: effects on appetite and food intake and their putative mechanisms. Am J Clin Nutr. 89(1): 1-14

NCI (National Cancer Institute).  2010.  Usual intake of added sugars.  In: Usual Dietary Intakes: Food Intakes, US Population 2001–04.  November 2008.  Available: http://riskfactor.cancer.gov/diet/usualintakes/addedsugars.html

Pereira MA. 2013. Diet beverages and the risk of obesity, diabetes, and cardiovascular disease: a review of the evidence. Nutr. Reviews 71 (7): 433-40

Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC, Vander Veur SS, Herring SJ, Brill C, Hill JO. 2014. The effects of water and non-nutritive sweetened beverages on weight loss during a 12-week weight loss treatment program. Obesity (Silver Spring) 22(6): 1415-21

Schernhammer ES, Bertrand KA, Birmann BM, Sampson L, Willett WC, Feskanich D. 2012. Consumption of artificial sweetener- and sugar-containing soda and risk of lymphoma and leukemia in men and women. Am J Clin Nutr. 96(6): 1419-28

Shankar P, Ahuja S, Sriram K. Non-nutritive sweeteners: review and update. Nutrition 29(11-12): 1293-9

Soffritti M, Belpoggi F, Tibaldi E, Esposti DD, Lauriola M. 2007. Life-span exposure to low doses of aspartame beginning during prenatal life increases cancer effects in rats. Environ Health Perspect. 115(9): 1293-7

Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, Israeli D, Zmora N, Gilad S, Weinberger A, Kuperman Y, Harmelin A, Kolodkin-Gal I, Shapiro H, Halpern Z, Segal E, Elinav E.  2014.  Artificial sweeteners induce glucose intolerance by altering the gut microbiota.  Nature.  doi: 10.1038/nature13793. [Epub ahead of print]

Sugar Association. 2011. Artificial Sweeteners Encourage Eating. Available: http://www.sugar.org/sugars-and-sweeteners-research/may-2011/

Swithers SE, Sample CH, Davidson TL. 2013a. Adverse effects of high-intensity sweeteners on energy intake and weight control in male and obesity-prone female rats. Behav Neurosci. 127(2): 262-74

Swithers SE. 2013b. Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements. Trends Endocrinol Metab. 24(9): 431-41

Sylvetsky A, Rother KI, Brown R. 2011. Artificial sweetener use among children: epidemiology, recommendations, metabolic outcomes, and future directions. Pediatr Clin North Am. 58(6): 1467-80

Tate DF, Turner-McGrievy G, Lyons E, Stevens J, Erickson K, Polzien K, Diamond M, Wang X, Popkin B. 2012. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr. 95(3): 555-63

USDA and DHHS (U.S. Department of Agriculture and Department of Health and Human Services).  2010.  Dietary Guidelines for Americans, 2010.  Available: http://www.cnpp.usda.gov/dietaryguidelines.htm

Whitehouse CR, Boullata J, McCauley LA. 2008. The potential toxicity of artificial sweeteners. AAOHN J. 56(6): 251-9