Sweet Talk About Sugar Alternatives by Christina Badaracco, MPH, RD
Updated: May 5, 2021
Americans have long been interested in alternative sweeteners (also known as nonnutritive sweeteners) as a means to reduce their sugar intake while continuing to eat sweets. These sweeteners appeal to our inherent desire for sweetness, yet they don’t cause the same rise in blood glucose as sugar because they are metabolized differently.
The fact that many people are reading food labels more closely and seeking greater transparency in their food supply indicates a desire to better understand both the variety of alternative sweeteners on the market and the conflicting information from clinicians and public health experts about whether they are healthy. As a dietitian who is regularly confronted with questions about sweeteners, I know it is important to help raise awareness of how ubiquitous they are and what is known (and unknown) about their health implications.
Where are alternative sweeteners found in the diet?
Americans have a strong sweet tooth. Adults currently consume an average of 77 grams (or about 19 teaspoons) of added sugar per day—more than three times the amount recommended by the American Heart Association. As the prevalence of obesity and diet-related disease has risen over the past century, health professionals and policymakers have begun investigating the most effective methods to reduce our consumption of added sugar (as one of the multiple culprits causing our chronic disease burden).
Increasingly, consumers are turning to alternative sweeteners. Indeed, in the US, consumption of all caloric sweeteners has declined over at least the past two decades, while the consumption of alternative sweeteners—including those in products that also contain caloric sweeteners—continues to rise. Alternative sweeteners can be purchased in isolated form for use in home cooking and baking. They are also routinely included as ingredients in purchased foods and beverages (most commonly in the items listed in the table below).
*These may be either caloric or noncaloric, depending on whether they include caloric sweeteners and other ingredients. Data Source: Dunford et al. 2020
Labels such as “light,” “reduced calorie,” “reduced sugar” or “diet”—particularly when found on snack and dessert foods—will often indicate the presence of these sweeteners. While Americans have consumed alternative sweeteners for years, their preferred varieties are changing; for example, stevia has grown in popularity while saccharin has decreased.
How do the different types of alternative sweeteners compare?
Alternative sweeteners generally fall into three categories:
Low- and no-calorie sweeteners, such as aspartame and sucralose
Sugar alcohols, such as erythritol and xylitol
Carbohydrate sweeteners, such as allulose and fructose
A brief summary of the widely available sweeteners is found below.
*Note that each gram of sucrose provides 4 kcal/g.
These various sweeteners are found in soft drinks, baked goods, chewing gum, protein bars and even vitamins and pharmaceuticals. Note that they are typically used in much smaller amounts than sugar because they have a different chemical structure and can be hundreds of times sweeter (yet still have no or very few calories). Also, some liquid sweeteners, such as honey and maple syrup, may be considered alternative sweeteners. These liquid sweeteners are entirely natural and actually have some beneficial phytonutrients; however, they do contain sugar (in the form of glucose and fructose) and are metabolized more similarly to white sugar.
Are alternative sweeteners healthier than regular sugar?
While the adverse health effects of caloric sweeteners are widely and consistently known to impair health (such as an increased risk of type 2 diabetes, fatty liver disease and cardiovascular disease), conflicting evidence makes the effects of nonnutritive sweeteners less certain. Some studies have shown that they are linked to increased risk of similar chronic diseases, but randomized control trials have failed to show a causal link between their consumption and increased total calorie or sugar consumption. Despite early concerns that they may cause cancer, the American Cancer Society claims that there is no concern about eating these sweeteners in their typically consumed amounts.
The most recent Dietary Guidelines for Americans state that “replacing added sugars with low- and no-calorie sweeteners may reduce calorie intake in the short-term and aid in weight management, yet questions remain about their effectiveness as a long-term weight management strategy.” Further, the most recent meta-analysis on the glycemic response (the rise in blood glucose after consumption) to these sweeteners suggested that consumption doesn’t elevate blood glucose, but that future research should assess the health implications of frequent and chronic consumption of alternative sweeteners and also investigate the underlying biological mechanisms.
More recent studies complicate the picture further. One showed that our metabolic responses to each alternative sweetener differs, with saccharin actually contributing to increased weight gain. Another showed that sucralose consumed together with caloric sweeteners impairs glucose metabolism and reduces the brain’s sensitivity to sweetness.
An emerging area of research is the effect of alternative sweeteners on the gut microbiome. A 2019 review found that saccharin, sucralose, stevia and sugar alcohols can change the composition of the microbiota—and they have mixed effects on the diversity and health of the microbiome, as only some varieties are fermentable. The finding that this alteration of the microbiome led to impaired glucose responses even suggested that the composition of an individual’s gut microbiota could indicate the personalized response to these sweeteners. Finally, findings from a study earlier in 2021 showed that exposure to some alternative sweeteners actually enhances gene transfer in bacteria, leading to concern about the possibility of spreading antibiotic resistance genes following human consumption. However, all of this research is complicated by the fact that manufacturers aren’t required to list the amounts used in products, making it difficult to estimate how much people are actually consuming from purchased foods (and it is already difficult to track how much they might be adding to their own beverages at coffee counters).
How do alternative sweeteners fit into my diet?
Because the evidence about negative health impacts is still inconclusive, it’s best to avoid having too many alternative sweeteners in your diet. If you choose to use them, try to consume them sparingly and only on occasion. Choose sources of sweetness that contain other nutritional benefits, such as fresh or dried fruit that has fiber, micronutrients and antioxidants—as well as other sources of flavor and texture to make your food satiating. Be especially careful about sticking to very small servings of sugar alcohols to avoid GI distress.
To learn more about using these substitutes in baking, view this post from Epicurious.
If you are otherwise healthy and can eat a small amount of natural sweetener, try to limit your added sugar consumption to:
150 calories per day (36 grams or 9 teaspoons) for men
100 calories per day (24 grams or 6 teaspoons) for women
If you’d like to reduce the amount of added sugar in your diet, try gradually reducing the amount you put in coffee or tea, baked treats, etc., rather than cutting it out completely. You can also start buying plain yogurt and oatmeal—instead flavoring them yourself—and choosing dark chocolate instead of milk chocolate.
Learn more by visiting the USDA’s National Agricultural Library, Food and Drug Administration or the Academy of Nutrition and Dietetics’ Position Paper.
American Heart Association. How much sugar is too much? Accessed January 28, 2021. www.heart.org/en/healthy-living/healthy-eating/eat-smart/sugar/how-much-sugar-is-too-much
Anderson GH, Foreyt J, Sigman-Grant M, Allison DB. The use of low-calorie sweeteners by adults: Impact on weight management. J Nutr. 2012; 142: 1163S–1169S. academic.oup.com/jn/article/142/6/1163s/4689074
Dunford EK, Miles DR, Ng SW, Popkin B. Types and Amounts of Nonnutritive Sweeteners Purchased by US Households: A Comparison of 2002 and 2018 Nielsen Homescan Purchases. J Acad Nutr Diet. 2020;120(10):1662–1671.e10. jandonline.org/article/S2212-2672(20)30442-1/abstract
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Higgins KA, Mattes RD. A randomized controlled trial contrasting the effects of 4 low-calorie sweeteners and sucrose on body weight in adults with overweight or obesity. Am J Clin Nutr. 2019; 109: 1288–1301. academic.oup.com/ajcn/article/109/5/1288/5475055
IHS Markit. Chemical economics handbook. High-intensity sweeteners. (Published 2017. Accessed January 18, 2020.) ihsmarkit.com/products/high-intensity-sweeteners-chemical-economics-handbook.html
Nichol AD, Holle MJ, An R. Glycemic impact of nonnutritive sweeteners: a systematic review and meta-analysis of randomized controlled trials. Eur J Clin Nutr 72, 796–804 (2018). doi.org/10.1038/s41430-018-0170-6
Rock CL et al. American Cancer Society Guideline for Diet and Physical Activity for Cancer Prevention. CA: A Cancer Journal for Clinicians, 9 June 2020. acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21591
Suez J et al. Non-caloric artificial sweeteners and the microbiome: findings and challenges. Gut Microbes. 2015;6(2):149–55. pubmed.ncbi.nlm.nih.gov/25831243/
Tate DF et al. 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. 2012; 95: 555–563. academic.oup.com/ajcn/article/95/3/555/4578292
US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov
Yu Z et al. Nonnutritive sweeteners can promote the dissemination of antibiotic resistance through conjugative gene transfer. ISME J. (2021). www.nature.com/articles/s41396-021-00909-x
Christina Badaracco, MPH, RD
Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook.
Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency’s Office of Water. She has also enjoyed contributing to children’s gardens, farmers’ markets and a number of organic farms.