Are Artificial Sweeteners Better for You Than Sugar?
Introduction
The global incidence of diabetes, obesity (childhood and adult), and metabolic syndromes has been on the rise primarily due to increased consumption of high-sugar foods. Growing evidence on the harmful effects of high sugar intake has raised awareness among people who are searching for better low-calorie sugar alternatives to remain healthy and fit.
Artificial sweeteners (ASs) are a popular choice and are chemically synthesised substitutes for real sugar to impart sweetness to foods and beverages. The level of sweetness is much higher than real sugar (300–13000 times); therefore, minimal amounts are required to achieve the same sweetness level. ASs are non-nutritive sweeteners (NNSs) as they possess negligible calories and lack nutrients, such as vitamins, minerals, antioxidants and fibre.
The US Food and Drug Administration has approved six NNSs for human consumption under the generally recognized as safe (GRAS) category, namely saccharine, sucralose, aspartame, acesulfame-K, stevia and neotame, and limits have been set on acceptable daily intake levels. It is widely used in foods and beverages and frequently consumed to reduce weight or sugar levels.
Types of sweeteners
Sweeteners are divided into two categories: caloric and non-caloric. Caloric sweeteners include sugar and polyols (sugar alcohols, e.g. sorbitol, mannitol, xylitol, etc.), and non-caloric sweeteners or NNSs are sugar substitutes with low caloric content but intense sweetness. NNSs are divided into ASs (saccharine, sucralose, aspartame, acesulfame-K, stevia and neotame), chemically synthesised in the laboratory, and natural sweeteners extracted from plants (stevia extracted from S. Rebaudiana). Natural sweeteners also include agavis, hoodia and Luo Han Guo Monk fruit extracts.
Sugar alcohols are also synthetically prepared like ASs but are not as sweet as ASs. They are used in processed foods and add taste and texture to chewing gum and hard candies. They are known to cause gas, bloating and diarrhoea in some people.
Benefits of Artificial sweeteners
Prevention of tooth decay
Aspartame, sucralose and saccharine in food, drinks and personal care products protect against tooth decay and caries development. In children with permanent teeth, toothpaste with fluoride and xylitol is more effective in preventing tooth decay than those with fluoride alone. ASs lack fermentable carbohydrates, reducing the chance of acid production by harmful bacteria and protecting the enamel.
Weight loss and obesity management
ASs have little to no calories; they are an attractive choice for weight management and limiting calorie intake. Studies have shown an association between ASs consumption and reduced body mass index (BMI) and body weight. Sugar drinks replaced with beverages with ASs were beneficial for adolescents with high BMI.
Metabolic disease prevention
The consumption of sugar drinks is one of the factors contributing to increased energy intake, obesity and its associated metabolic complications. Thus, the strategy to restrict energy intake is to replace sugars with ASs. Diabetic patients use ASs to prevent the glucose level spike observed after meals.
Side effects of Artificial sweeteners
It should be noted that research findings on the effects of ASs on health are conflicting and inconclusive. Most studies have been done in animals, with very few in humans. More rigorous studies are required to validate their benefits in large-scale clinical trials. The potential side effects of ASs are discussed below.
Gut microbiome
Gut bacteria influence glucose tolerance, fat storage, insulin sensitivity and hunger to maintain metabolic homeostasis. Studies in humans have shown ASs consumption is significantly associated with impaired glucose tolerance, elevated haemoglobin A1c and alanine aminotransferase levels and central obesity development. ASs consumption alters the intestinal microbial composition as shown by increased levels of Deltaproteobacteria, Actinobacteria phylum and Enterobacteriaceae.
Type 2 diabetes mellitus
A recent study has shown an association between ASs, such as aspartame, sucralose and acesulfame-K, and insulin resistance and increased risk of type 2 diabetes mellitus. These observations are against the common belief that ASs is a safe alternative to sugar for diabetic patients. Thus, diabetic patients should be warned against the extensive use of ASs. Studies have shown that compared with sucrose administration, aspartame administration in pre-school children and saccharine administration in school children increased post-prandial blood glucose levels.
Cancer risk
One study showed an association between ASs consumption and bladder cancer but was not corroborated by further studies. An increased risk of kidney cancer was observed in post-menopausal women who consumed more than one artificially sweetened drink per day. Aspartame was shown to be a chemical carcinogen in rodents but this has not been proven in humans. Some studies have shown alteration in the gut microbiota as an indirect cause of increased cancer risk. Further studies are required to understand the association between ASs and cancer risk.
Cardiovascular disease (CVD) and stroke risk
One study demonstrated that ASs consumption was associated with increased CVD risk. In particular, aspartame was associated with increased cerebrovascular disease (impaired blood flow to the brain) risk, and sucralose and acesulfame-K were associated with increased coronary heart disease (narrowing of coronary arteries due to plaque build-up) risk, suggesting that ASs may not confer any cardiovascular benefits. WHO reported an association between artificially sweetened soft drinks and CVD mortality, stroke and increased incidence of cardiovascular events.
Allergies
Aspartame is metabolised to formaldehyde and is responsible for contact dermatitis (a rash that develops when the skin comes in contact with an irritant) and skin rashes. Xylitol is associated with skin allergies and oral ulcers. Erythritol is linked to urticarial reactions (hives).
Changes in taste perception
ASs consumption is associated with altered taste perception and preferences. Fruits and vegetables do not appeal to the palate with an increased craving for sweet foods. There is a decreased consumption of nutrient-dense foods, negatively impacting health.
Headaches, migraines and neurological manifestations
Aspartame comprises 55% phenylalanine and 45% aspartic acid, and its consumption can increase phenylalanine and aspartic acid levels in the brain. This causes inhibition of dopamine, serotonin and norepinephrine synthesis and release. Reduced serotonin levels are associated with migraine pain. Aspartame behaves like a chemical stressor; it increases cortisol levels and produces excessive free radicals. The brain becomes susceptible to oxidative stress, affecting neuro behavioural health. Studies have demonstrated an increase in headache frequency due to aspartame consumption. Aspartame is also associated with depression, anxiety, seizures and insomnia.
Use of Artificial sweeteners in susceptible populations
Diabetics, pregnant women, lactating mothers, children and patients with epilepsy must exercise caution on the use of ASs. A correlation between AS-containing beverage intake and weight gain was found in children because the consumption of food and beverages per kilogram of body weight is much higher in children.
One study demonstrated increased pre-term delivery risk in pregnant women consuming artificially sweetened drinks. ASs must be avoided in patients with low seizure thresholds. The consumption of some ASs is known to trigger migraines and should be avoided in susceptible individuals. Diabetics routinely rely on ASs to reduce the number of calories; however, recently it was shown to have long-term harmful effects, such as glucose intolerance.
Guidelines to use ASs
Manufacturers market ASs as safe for consumption without scientific data backing the claims. Thus, physicians and dieticians should adopt an evidence-based approach while prescribing ASs to patients.
When ASs are consumed within the acceptable daily limits recommended by the regulatory authorities, they can limit carbohydrate intake and aid in managing weight and blood glucose levels. Dieticians should calculate the energy allowance separately for each patient based on their age, physical activity, nutritional status and sex.
ASs should be incorporated considering the overall diet plan that must include low-calorie foods with no added sugars, including fruits, green vegetables, fibre-rich foods and low or no fat dairy products. ASs are not beneficial when substituted for nutrient-dense foods such as fruits and milk. Physical activity should also be a part of the diet plan.
WHO released a new guideline that ASs must not be used to control body weight. This is based on evidence that ASs had no long-term benefits in body weight reduction in children and adults. In addition, long-term use may increase the risk of CVD and diabetes. This recommendation is for all individuals except those with pre-existing diabetes.
Diabetics should be advised to consume ASs in limited amounts. It must not be recommended for children below 2 years of age and patients suffering from migraine and epilepsy. It should be avoided or minimally consumed by pregnant women and lactating mothers.
Sugar or ASs – what should one choose?
Sugar is not bad for our body; it is the major fuel on which our body functions. Our body will be deprived of essential nutrients if sugar is removed from the diet. In the absence of sugar, our body is in starvation mode and uses ketone bodies (produced in the liver) as a source of energy. Brain fog, headache and fatigue are common symptoms when our diet lacks carbohydrates.
It is more important to determine the source of the sweetness. For example, the sugar in processed foods, such as donuts, candy, sweet tea and soda is added sugar. People consume an excess of added sugar that possesses no nutritional benefit and causes health problems, such as cavities, insulin resistance, elevated blood sugar levels and obesity. Honey, molasses, fruit juice and maple syrup have natural sugars with some nutritional benefits. For example, fruits have anti-oxidants, fibre and vitamins. Maple syrup and honey have anti-oxidants and minerals, such as calcium, zinc, iron and potassium.
The main aim of ASs is to add sweetness without adding calories. Ideally, they are supposed to be used in small quantities to experience their benefits; however, they have been used excessively, which can harm the body. ASs are much sweeter than real sugar, increasing the craving for foods with similar sweetness. This can predispose a healthy individual to diabetes. As research suggests that ASs alter the microbiome and increase the risk of cancer, we must avoid or use ASs in minimal amounts. For people with diabetes, ASs should be prescribed considering the benefits and risks, overall health and age to decide whether real sugar or ASs is suitable for them. Healthy adults and children should avoid ASs completely.
Thus, moderation is key whether you consume real sugar or ASs. Dieticians should advise their patients to cut back on foods with added sugar and ASs and encourage natural sources of sugar along with a balanced diet.
Conclusion
The incidence of diabetes, hypertension and obesity is increasing every year. Excessive consumption of processed foods and beverages is harming human health. Thus, ASs were introduced as a popular alternative to real sugar. ASs provide intense sweetness with few or no calories and have been popular among people who want to manage their weight or blood sugar levels.
Despite its benefits, increasing evidence indicates multiple side effects of ASs consumption. Further studies are required to assess their safety for human consumption. The use of ASs has been on the rise and healthcare professionals should educate themselves on their benefits and provide personalised advice to patients on ASs selection based on the benefits and the patient’s overall health.
For more insights on health and wellness, contact Kauvery Hospital, with branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy. Our experts are here to help!
Frequently Asked Questions
Are artificial sweeteners healthier than sugar?
Artificial sweeteners have fewer calories than sugar but may cause side effects and are not always the healthiest choice.
Can diabetics safely use artificial sweeteners?
In moderation, some sweeteners are safe for diabetics, but overuse may affect blood sugar and gut health.
What are the common side effects of artificial sweeteners?
Here are some common side effects associated with artificial sweeteners:
- Headaches
- Bloating and gas
- Diarrhea (especially from sugar alcohols)
- Altered taste perception
- Increased cravings for sweets
- Potential metabolic changes
- Possible mood or cognitive effects
- Rare allergic reactions
Are natural sweeteners better than artificial ones?
Natural sweeteners like stevia or monk fruit may offer some nutrients and are generally considered safer for long-term use.
Do artificial sweeteners help with weight loss?
They may help reduce calorie intake short-term, but studies show mixed results on long-term weight control.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
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