Why choosing sweeteners may be better than sugar
Sweeteners sometimes get a bad rep, but you might want to consider some swaps.
What this article includes:
The contention around this topic
Sugary beverages and weight gain
What sweeteners are and commonly used artificial sweeteners
Naturally occurring alternatives to sugar
Health risks & concerns of sweeteners
Sweeteners and the perception of ‘sweetness’
This topic has conflicting information online
This topic went front of mind when I saw social media kick off on diet coke. One doctor essentially endorsed the safety profile of diet-coke for her viewers.
This seems sensible, but it also sat uncomfortably with me.
It appears logical that diet-coke may be ‘better’ than original coca-cola from the perspective of metabolic health, diabetes and weight loss.
However I also felt that this drink, that provides no real meaningful nutritional value still may not be the right alternative.
It’s a reputational and status war online when it comes to nutrition, and one that I, as many of my colleagues are hesitant to enter, especially is conflicting and can be interpreted in different ways.
Do sugary drinks increase weight gain?
Yes.
Sugar contains calories and so as we consume sugary drinks, we are essentially drinking our calories. Physiologically this does not send the same signals to tell us that we’re full, compared to eating a meal with the same number of calories.
Studies back this up. One study which analysed participants from the Nurse Healthy Study looked at weight gain and development of type 2 diabetes based on sugary drink intake. It was an observational study, analysing self-reported data on over 90,000 women over 20 years.
There was an 83 percent increased risk of developing diabetes for women drinking a sugary drink once a day, compared to women drinking less than one per month.
There was a significant increase in risk of diabetes. The study did adjust for other lifestyle factors, weight and total calorie intake, and still found a slight increased risk.
There are some issues with this study, as this doesn’t take into account whole eating patterns; rather one specific aspect of a person’s diet. The study doesn’t directly link to causation, but it does give us strong suspicion, and recognises the correlation.
This study has been backed up with a large systematic review and meta analysis analysing over 38,000 new type 2 diabetes cases and nutritional intake.
There was an 18% increase risk of type 2 diabetes if people had associated excess weight, and a 13% increased risk without excess weight.
Artificial sweeteners were also found to potentially increase the chance of type 2 diabetes in a larger study.
However the the quality of these studies was considered to be low, and when adjusting for publication bias, the impact was seen to be non-significant.
It may be due to overall eating patterns rather than sweetened beverages
The difficulty here is that the 25% increased risk does not mean it was the artificially sweetened beverage. It could simply be due to overall eating patterns rather than the specific drink.
The study also found there was no clear convincing evidence that fruit juice increased the risk of developing type 2 diabetes.
We’ve established that sweeteners are likely better than sugar sweetened artificial beverages. So let’s go look at these sweeteners in more detail.
What are sweeteners?
Sweeteners are typically naturally found substances, or synthetically made. They are designed to provide a ‘sweet’ taste, and that typically mimic the taste of sugar.
They are often found in plants or fruits in very small quantities.
They are usually not easily metabolised (broken down by the body) and some are not well absorbed by the body. This is where some may be seen to have their benefits.
This is because they don’t lead higher glucose levels and most will not have a high caloric content, with many having zero calories.
Commonly used sweeteners (synthetically made)
Aspartame - 180-200x sweeter than sugar (sucrose)
Acesulfame-K - 200x sweeter than sucrose - slightly bitter aftertaste - zero calories
Sucralose - 600x sweeter than sucrose - zero calories
Saccharin - 300x sweeter than sucrose - metallic aftertaste - zero calories
Cyclamate - 30x sweeter than sucrose - Banned in the USA, but available in other countries
Neotame - 7,000-13,000x sweeter than sucrose - Not recommended to have more than 18mg/day (USA)
Alitame - 200x sweeter than sucrose - higher cost of production so less widely used.
Commonly used alternative sugars
These alternative sugars are naturally found, but tend to be artificially and industrially produced. These typically are rare, but due to this processing they can be produced in large quantities.
Typically they tend not to be matabolised by the body, or by a limited amount so a very low or have zero calories.
D-psicose - 70% sweetness of sucrose and does not raised blood glucose
Xylitol
Tagatose
D-allose / Allulose
Health Risks of sweeteners
The World Health Organisation Position
My thoughts on the WHO paper
There is conflicting evidence. And the evidence depends on the types of studies that are used.
Randomised Controlled Trials (RCTs) tend to take a specific snapshot in time.
Cohort studies tend to look at people over longer periods of time, but typically look for correlations in the data, rather than specific comparisons.
Weight outcomes
The RCTs found that there was a small reduction in weight using sweeteners of 0.71 kg (BMI - 0.14) but no significant changes with waist circumference or body fat percentage.
The cohort studies suggest an increased BMI of 0.14, with a higher chance of being significantly overweight.
The differences are likely due to differences in study design.
The take-home from this, is that changing from sugar to sweetened foods doesn’t make much difference and at this stage we can’t accurately predict what will happen.
We also don’t know why this happens.
E.g. One of the reasons a cohort study might show differing results is that over time, the sweeteners could potentially drive more consumption of other foods.
HbA1c & Diabetes
RCTs did not show any difference between sugar and non-sugar sweeteners.
But cohort studies found an increased risk of developing diabetes by roughly 23% in drinks, and 34% for tabletop sweeteners.
This suggests a potential long-term risk from the cohorts, which may not be picked up in shorter trials.
Liver Disease
There is limited data, but there does not appear to be an increased risk of non-alcoholic fatty liver disease (NAFLD).
Blood Pressure & Cardiovascular Disease
There were no significant findings suggesting an increase or decrease in risk.
Cancer
There is a potential increased risk of Bladder Cancer & one type of sweetener - Saccharin use.
This is less frequently used, but older studies showed a 31% increased risk.
Brain & Cognition
There is no obvious risk in mood or cognitive function in adults.
One study suggested a potential increased risk of dementia and another study indicated lower cognition scores in offspring of pregnant mothers consuming more NSS.
Comparison of safety between different non-sugar sweeteners
Sucralose might impair insulin sensitivity when eaten with other carbohydrates.
What products have sweeteners in them?
Ultra-processed foods are the most common products with sweeteners in them.
This is because they are only found in small quantities in the natural world. So to be in high amounts, we need to create this industrially, and then these will be added to foods.
Does this mean they’re unhealthy?
No, in short, but it does raise potential concerns about them.
However they’ve also been marketed as an alternative to sugar, to help reduce calorie intake and avoid glucose spikes.
What’s the problem?
There are concerns that they could lead to the over-consumption of other unhealthy foods, increase consumption of ultra-processed foods, lead to weight gain and conversely impact diabetic control.
We get questions on sweeteners and supplements and it is a difficult one to answer easily and quickly.
The effect on blood glucose
One study looked at 452 participants and found a very slight reduction in glucose levels in those using sweeteners, and was considered to be non-significant in non-diabetic patients.
There was a small reduction in insulin levels too. But again the reduction was not seen to be significant.
Type 2 Diabetes
There was a 0.3mmol/L reduction in glucose levels after eating (based on data from 86 individuals).
However this is temporary, so the actual change on A1c is likely to be far less on average, which is in keeping with WHO data that there is unlikely a statistical significance on average blood glucose.
A deeper dive into 2 natural sugar sweeteners
Allulose
It’s a sweetener, found naturally in certain foods, in very small quantities.
One commonly cited source are figs.
What is it and does it work?
It’s a type of sugar that is absorbed by the body, but is not metabolised. This means we cannot derive energy from allulose, therefore it doesn’t add to extra calories eaten.
Sounds promising so far.
It’s not metabolised by the liver, which means it doesn’t cause other extra pressure on the body and is removed by the kidneys without any known harm to the kidneys.
It has been reported to have a 70% sweetness level compared to sugar (if sugar is 100% sweet) and it has been shown to impact on GLP-1 levels too.
GLP-1 is a hormone that regulates our hunger and appetite.
This means it might help us to eat less.
So what’s the problem?
It may not support re-setting perception of sweetness in the brain, so we will continue to crave more sweet foods.
We don’t have long term data on heavy use in the body, because it hasn’t had the extensive testing.
It still does not treat the root cause, and seems to perpetuate the message that we can supplement our way out of type 2 diabetes.
Should you take it then?
This is a decision for you to take, but if you want a general opinion; it could be used for occasional treats or as a direct substitute to adding in sugar, should you not feel able to avoid a sweet taste altogether.
We only get small amounts of this in nature. Eating in a way that nature intended is not a scientific concept, but is a sensible route to consider when reducing processed food.
Erythritol
What is it?
Erythritol is another form of sugar, with an approximate 70% level of sweetness compared to sugar. It’s part of a family of carbohydrates called polyols.
They’re hard for the body to break down, and have a small amount of calories per gram (approximately 0.4 calories per gram) compared to glucose which has 4 calories per gram.
Allulose has a nearly 0 glycaemic index rating and Erythritol has a 0 on glycaemic index.
Naturally it is found in very small quantities.
Should you have it then?
I have the same concerns as with allulose, as it’s only been around in higher quantities for around 40 years through factory processing of foods. This depends your opinion on safety with foods. This is likely to mean that it is safe but..
3 reasons why you need to be careful:
Continuous exposure to the taste of sweet food, may alter your perception of sweetness, and it might be better to try and avoid sweet tastes altogether.
Long term knowledge of side effects isn’t clearly known.
It’s not treating the root cause. But it may help.
It’s not a high quality nutrient that you’re adding to your diet.
It’s certainly a better alternative to sugar when looking purely from a diabetic perspective.
Do the sweeteners change our taste perception
Does this affect our drive to consume sweet things?
One narrative review studied this question.
Artificial sweeteners trigger the same sweet taste receptors as sugar, so they taste sweet without adding calories, but it appears they do not usually make people crave more sweetness, or eat more during the day.
Should you go artificial?
This is not an endorsement of artifically sweetened drinks, as they don’t constitute a health benefit or promote health gains. But based on the studies I have looked at, they do appear to be safer than I previously thought.
From a purely diabetes and weight management perspective non-sugar sweetened beverages are a better alternative to sugar-sweetened beverages.
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