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April 19, 2017

Infrequently Asked Questions: What's the difference between the sugar substitutes?

Splenda, Sweet'N Low, Equal, Truvia -- truly, can anyone really explain the difference between those sugar imposters that stock morning coffees everywhere? 

Curious to understand the distinguishing factors between the popular "artificial" sugars out there (and a rundown on the trendiest of the bunch, sugar alcohol), we reached out to Jefferson Health dietician Cheryl Marco for some explanation. 

Getting to the nitty gritty, what are the main "artificial" sugars and what's the difference between them?

I think, in terms of terminology, we probably want to use the terminology of 'nutritive' versus 'nonnutritive' sweeteners. For example, stevia, there's nothing artificial about it, but it doesn't have any nutritional value like sugar. Even sugar, there's nothing unnatural about it, but in its nutritive meaning it provides calories. So, I think we're looking more at nonnutritive sweeteners, ones that don't provide any calories. The major classification would be saccharin, aspartame, sucralose and stevia. There are others, less well-known, but those would be the major ones.

What are the distinguishing factors between them? Is it just a branding thing?

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Saccharin (Sweet'N Low) is the oldest nonnutritive sweetener approved for use. It's not metabolized in the body; it's heat-stable, it's approved as an additive as well as for tabletop use. Saccharin is what you'll see in Sweet'N Low. Originally, I think, you saw a lot of diet sodas have saccharin in them; now, very few. It is -- there was that loose association with bladder cancer in laboratory animals, and it was found that it, in normal use, would have almost zero risks. It's 300 times sweeter than sugar and the packets per day that would be equivalent to what the FDA says is safe would be 250, or 56 cans of Coke. The acceptable daily intake of saccharin is set by the FDA and that is per kilogram of body weight; that's 15 milligrams per kilo of body weight. Just to give you a sense of what the acceptable amount would be.

Aspartame (Equal) is 200 times sweeter than sugar. It's what's called, chemically, it's a methyl ester of aspartic acid dialamine dipeptide. It was approved by the FDA in 1981 and in 1983 for soft drinks, and in 1986 as a general-use sweetener. So, it does have calories. It provides -- just like sugar -- four calories per gram, but it's just so much sweeter, so with that intensity you'd need small amounts, so it has virtually no caloric effect. In the U.S., our biggest use of it is diet sodas, but you still find it in other products. Ice creams, that sort of thing. When it's broken down it turns into an amino acid called phenylalanine ... You can't cook with aspartame since it degrades during heating. The acceptable daily intake is 50 mg per kilo of body weight. It would take 165 packets of aspartame, or 37.6 cans of Diet Coke, to reach that intake. 

The next one would be sucralose, or what we know as Splenda. That's 600 times sweeter than sugar. The acceptable daily intake is 5 mg of kilo body weight; 165 packets would equal the acceptable daily intake, or 36 cans of Diet Coke. It was approved by the FDA in 1998, as a tabletop sweetener and for use in beverages, and as a general use sweetener in 1999. Eighty-five percent of sucralose goes through our body unabsorbed and is excreted unchanged. And what is absorbed is actually excreted unchanged in urine. It's heat-stable for cooking and baking. 

And then the last really commonly used nonnutritive sweetener is stevia from the stevia plant. It was approved for use as a sweetener in a purified form in 2008, and its' been sold since 1994 as a supplement. So, the whole stevia leaf has lots of other components. Some people will grow stevia and sweeten with a stevia leaf, but there are some bitter components. What they do is extract the sweet part from the leaf in order to make Stevia or Truvia -- whatever your brand name is. It's shelf-stable, and you can cook with it. It is 300 times sweeter than sugar and has an acceptable daily intake of 4 mg per kilo of body weight, which would equal 29 packets or six cans of soda.

My concern with non-nutritive sweeteners has nothing to do with cancer -- it has to do with the perpetuation of desire for sweetness. That we constantly want something sweet and never begin to change.

Is one of these better than the other for your health?

This is where it gets murky. I'd have to say no, that it's a personal preference. Most people prefer Splenda; it has less of an after taste. And I think the way we have to look at this -- I'm a diabetes educator, so most people I work with have diabetes, and from a safety standpoint, drinking sugar or regular soda would be pretty dangerous in terms of making blood sugar go up. Using a sweetener or a can of soda that has a nonnutritive sweetener in it isn't going to have any effect on their blood sugar. Perfect world, we wouldn't be using these products -- we'd be drinking water. But how can I tell a patient in my office, "You can't have diet soda," when someone was drinking -- not an exaggeration, I see it every day -- five-plus sodas a day.  Sometimes I can get them to switch to a diet soda; I'm certainly not going to get them to change to water overnight. 

I think we have to look at the grade of safety and who we're talking about. In general, we don't want people using large amounts of sugar either. But using the nonnutritive sweeteners for a certain segment of the population -- particularly those people who have diabetes -- is much safer. You're not going to die from the overuse of, say, Splenda or aspartame; you are going to die from chronically high blood sugar, using lots of sugar. It's not uncommon for me to see people putting several packets of sugar into their coffee. If I can get them to use Splenda or Equal, I'm thrilled. I know there's so much bad press on nonnutritive sweeteners and I'm not necessarily saying we should be using them -- perfect world, we don't use sugar or nonnutritive sweeteners, but it's a very small segment of the population that lives in that world.

What's the deal with sugar alcohol?

First of all, it's not alcohol. Nothing to do with alcohol. The technical name for them are polyols and it just has to do with the chemical configuration. They are not completely non-nutritive because they do provide some calories. Bottom line is, polyols are a larger carbohydrate molecule, and they provide greater sweetness than sugar would, but you can get away with using less of them. One standard polyol is sorbitol -- it's much sweeter than sugar. Sorbitol is 50 to 70 percent as sweet as sucrose, so not quite as sweet as sugar but it is still sweet. But the problem is this -- which you've probably heard. people talk about, if you consume a fairly large amount of sugar alcohol, it has a laxative effect. Becuase it's such a large molecule, when you consume it, liquid from other parts of your body move to the stomach to help with digestion of sugar alcohols, and then that causes sort of a rush through your G.I. system, causing somewhat of a laxative effect. Most people are able to tolerate a certain amount of sugar alcohol; I would say, it's said people can tolerate 10 to 15 mg a day. I find that I have patients who have a couple sticks of sugar-free gum and they have diarrhea. I think it's just something people need to be aware of. Sugar-free mints, gum -- they contain polyols.

It's also in ice cream. That's a popular ingredient these days.

And they're not small amounts! Ice cream is a good example. Serving size is listed as half a cup, but if you're eating a normal size portion of ice cream, you're getting a whole lot more sugar alcohol than you might be realizing is listed on the label. Or the other place you see a lot of sugar alcohol is some of those so-called nutrition bars; so they take sugar out, and on the surface, it does seem healthier. But there are those negative consequences. Sugar provides 4 calories per gram and sugar alcohol is 2. They aren't completely nonnutritive like the other four I mentioned. They're like the in-between for sugar and nonnutritive sugars. You just have to be careful.

Is there a natural sweetener you'd recommend?

If someone is going to use a nonnutritive sweetener, the one I'd probably recommend is stevia. The problem is there are few diet sodas with stevia. And that's our biggest consumption of nonnutritive sweeteners. You can go to Wawa or Starbucks and get sweetener for coffee, but very few -- maybe Whole Foods makes a diet soda with stevia in it, buy you pay a fortune for it. And that's not where the average diet soda consumer is shopping, at Whole Foods for a couple dollars a can. That would be it, but it's not something most people can do. I don't know that those diet sodas have been perfected to be appealing to people at this point.

Diet soda causing cancer: Is that a myth or is there some truth to it?

The research has been pretty strenuous. I don't want to say it's a myth but it's very unlikely that it's going to cause cancer. That being said, if that's something someone is worried about -- I think someone has to look at 'What am I at risk for?' My patients with diabetes are at much greater risk for [consequences of high blood sugar] than some seemingly obscure risk of developing cancer from these sweeteners. I think it's a very small risk. And as far as I know there are no reportable cases. You can always find someone to say something and how do you ever separate that out – that someone develops cancer from drinking diet soda?

But, if I'm sitting process from a patient who's drinking five cans of diet soda per day, I'm going to encourage him or her to decrease that. And my concern with nonnutritive sweeteners has nothing to do with cancer -- it has to do with the perpetuation of desire for sweetness – that we constantly want something sweet and never begin to change. It is an innate taste craving we have; babies, if you introduce sweetness to a baby, they love that. We have that innate desire, but if we're constantly feeding into that, we can't begin to alter it. And we do, as a nation, consume way too much sweet foods. We need to be looking at decreasing sugar intake. That doesn't necessarily mean changing to nonnutritive sweeteners.