Substituting Sugar Part 2

In the U.S., children and adults frequently take in artificial sweeteners. According to the American Academy of Pediatrics (AAP), one in four children eat or drink an artificial sweetener. It is especially important to understand how these products affect children so the AAP calls for more research in their policy statement. Exposure may begin before birth and in breast milk given that artificial sweeteners are found in many products so we need to understand how long-term use can affect our bodies.  
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Numerous research studies were done to make sure that these sweeteners are safe to eat and drink. In part one of this blog on artificial sweeteners, we explored the safety and characteristics of the six artificial sweeteners approved by the FDA as food additives - acesulfame-potassium, aspartame, advantame, neotame, saccharin, and sucralose.

Research into “safety” focused on whether it was poisonous or caused cancer. With these initial concerns lifted, the focus is now on how artificial sweeteners affect our weight, taste preferences, gut health, and risk for diabetes and stroke. We discuss these concerns in part two of this month’s blog on artificial sweeteners.

​Do artificial sweeteners lead to obesity or chronic diseases like diabetes?
Short answer: We do not know.  

Tell me more: Epidemiological studies (studies that look at how often diseases occur in groups of people and why) show an association between artificial sweetener intake and chronic disease. Association does not equal causation. Did using sweeteners lead to weight gain or did earlier weight gain lead to the use of artificial sweeteners to lower calories? A similar question could be asked for the association with diabetes. Did artificial sweetener intake lead to diabetes or did a diabetes diagnosis change intake and lead individuals to choose artificial sweeteners over sugar? Further research is needed, in particular, randomized controlled trials (the gold standard) to explore if there is a relationship here.

Will artificial sweeteners give me diarrhea? 
Artificial sweeteners aspartame, saccharin and acesulfame potassium seem to be well-tolerated by the general population but there is not enough research that looks at if and how often symptoms like diarrhea occur. Pay attention to how your body responds to sweeteners and in what amounts you can tolerate.
   
Sugar alcohols are another story. Sugar alcohols like sorbitol and xylitol are not fully broken down by our gut. You may get explosive diarrhea if you eat large amounts of them - like when one or two pieces of sugar-free gummy bears becomes the entire package. It happens. Erythritol behaves differently than other sugar alcohols so it may be better tolerated than other sugar alcohols. Check the ingredients. Many brand name sweeteners like Swerve and Truvia are blends of natural and artificial sweeteners with sugar alcohols.  

Let’s talk a bit more about your gut…
Your dentist may like your switch from sugar to artificial sweeteners. Artificial sweeteners stop the growth of bacteria that wreak havoc on teeth and gums. The helpful bacteria in your gut? Probably not a fan. So far, studies show changes to the bacteria within the gut of rodents with sucralose, saccharin, and aspartame. We need human studies to see if this happens in the human gut too. The bacteria within our gut play a role in digestion, sure, but they may do more. Our helpful bacteria may help us produce neurotransmitters like serotonin, a key player in mood. The more scientists discover about our gut, the more we will want to take note of substances, like artificial sweeteners, that could switch up the bacteria living there.

Will an artificial sweetener make me hungry?
Short answer: There is very limited research but the evidence does not show an increase in hunger.

Tell me more: Two small trials (12 and 24 participants) looked at how an artificially-sweetened (aspartame) beverage affected ghrelin, the “hunger hormone”. Amounts of this hormone rise between meals, our appetite increases, we eat, and ghrelin lowers. It is thought that the way we experience sweet tastes may play a role in how this hormone works. If an artificial sweetener tastes sweet, would our body behave the way it does when we take in calories and our hunger go down? The answer was “no” with these two studies. These are small trials and there are more ways to study how artificial sweeteners may or may not influence hunger. If you are hungry after drinking a diet soda, it may be that you are hungry, just not because of the diet soda.

This is how we want it to work, by the way. Ghrelin is just one of the gut hormones that tells us if we are hungry or full. The system works when food is available and we can eat based on our needs. For those who choose to bypass the system to lose weight, these results may be disappointing but artificial sweeteners are not a source of energy. Our survival is tied to our body knowing the difference.      

​Will artificial sweeteners lead to a stroke?
Short answer: We do not know. More research is needed.

Tell me more: Earlier this year, a study published in the journal Stroke showed an association between artificially-sweetened beverages (ASB) and the risk of stroke in a large group of women. They used data from the Women’s Health Initiative - a big study tracking the health of women over time. Women who drank an average of two or more ASB per day (24 ounces/day or more) had an increased risk of all stroke (all stroke types overall), in particular ischemic stroke, coronary heart disease, and all-cause mortality (death from any cause) compared with those who had less than one ASB per week. The results were the same as previous studies but not all of them. We need more evidence to draw conclusions, especially when studies show different outcomes.  ​

The information gathered from this type of study can be used to plan future research. Important questions such as “which ASBs are people using?” and “how long have they used them?” may be asked in future studies. Weight changes and history of dieting are important to know too. In the Stroke study, they grouped together results by body mass index (BMI) and found that women with higher ASB intake were only at a higher risk for stroke if they were also “obese” based on BMI. High intakes of ASBs in “normal” or “overweight” women did not match up with a higher risk of stroke so maybe it isn’t to do with the ASBs at all. Could women classified as “obese” have something else in common? Yes! Weight stigma, experienced by those in larger bodies, may do more harm for health. 

How do artificial sweeteners affect my taste preferences?
Short answer: High-intensity or artificial sweeteners are much sweeter than table sugar and may affect how your taste buds pick up on sweet flavors.  

Tell me more: Using large amounts of artificial sweeteners could skew your taste preferences more toward overly sweet foods and beverages. There is no harm in this. If you find that a preference for sweet makes it difficult to eat a variety of foods, then it may be worth lowering your intake.  

Bottom Line: Artificial sweeteners are safe well beyond the Adequate Daily Intake (ADI) for the individual sweetener. Numerous studies were done to ensure that they are safe to eat and drink and do not cause cancer. Early research suggests changes in the bacteria in our gut but we don’t know yet if and how these changes influence health. More research is needed to understand the impact of long-term artificial sweetener use, especially in children and individuals with specific health conditions, like diabetes. As research continues, it will be important to explore how characteristics like body size, age, etc. influence the effect of artificial sweeteners within our bodies.

For those managing diabetes: Check your blood sugar so you know how a food or drink affects you. Write down blood sugar readings to share with your doctor, dietitian, and/or diabetes educator.
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We’ve covered the top questions we hear.  What did we miss? Reach out to us on social media or send in the Ask a Dietitian form with your questions.