Sugar substitutes are nonnutritive substances used to sweeten foods and drinks that provide little if any energy in the form of calories. Sugar substitutes do not affect blood sugar levels. They are intended to serve as an alternative to sucrose (table sugar).

The U.S. Food and Drug Administration (FDA) approves all sugar substitutes for use once they have been shown to be safe and effective. Examples of approved sugar substitutes include:

• Acesulfame-K
• Aspartame
• Neotame
• Saccharin
• Sucralose

Two other sugar substitutes are awaiting FDA review. They are called alitame and cyclamate.

Concerns have been raised about the potential safety of some sugar substitutes. However, the FDA has found that nearly all of these substances are safe when used as recommended. The only exception is Aspartame, which contains the amino acid phenylalanine, and therefore should not be used by people who have the inherited disease phenylketonuria (PKU).

Most experts agree that a diet containing modest levels of sugar substitutes, in addition to regular exercise, can help people maintain their weight level or lose excess pounds. Sugar substitutes may also benefit people with certain health conditions. For example, people with diabetes can use sugar substitutes without having to worry about it affecting insulin or blood sugar levels. Use of these sweeteners also can help manage calorie intake.

For people with diabetes, artificial sweeteners are extremely beneficial because they provide sweetness with few or no calories and do not affect glucose (blood sugar) levels. Obesity is strongly linked to insulin resistance, prediabetes and type 2 diabetes, and treatment plans for these individuals usually include weight loss.  Artificial sweeteners can help people with diabetes lose weight and control glucose.

Sugar substitutes are substances used to sweeten foods and drinks and serve as an alternative to sucrose (table sugar). Also known as artificial sweeteners, they are usually many times sweeter than table sugar and thus can be used in smaller amounts to sweeten foods.

For example, just 20 milligrams of the sugar substitute saccharin provides the same sweetness as 4,000 milligrams (about 1 tablespoon) of table sugar. Because sugar substitutes are effective in relatively small quantities, they provide far fewer calories in a person’s diet than table sugar.

The rising rates of obesity and associated health concerns such as heart disease, diabetes and some types of cancer have led many Americans to look for alternatives to sugar to help manage their weight and intake of calories. In response to consumer demand, many companies have developed a variety of sugar substitutes.

Sugar substitutes are often known as nonnutritive sweeteners, because they provide little if any energy in the form of calories. Nonnutritive sweeteners also do not affect blood sugar levels.

The U.S. Food and Drug Administration (FDA) approves sugar substitutes for use once they have been demonstrated to be safe and effective. FDA-approved sugar substitutes include:

• Acesulfame-K. Also known as acesulfame potassium (the “K” represents potassium), it was approved by the FDA in 1988. It is a white, odorless, crystalline sweetener that is 200 times sweeter than table sugar, with a slight, bitter aftertaste that is countered by combining it with other sweeteners. Acesulfame-K is not digested by the body, but is instead eliminated through urine, therefore, does not provide any calories.  This sweetener has an excellent shelf life and is suitable for cooking.  This sugar substitute is used in candies, baked goods, frozen desserts, soft drinks and tabletop sweeteners. It is marketed under the name Sunette or Sweet One.
  
  
• Aspartame. Made up of a simple chemical compound (including the amino acids phenylalanine and aspartic acid, plus chemicals known as a methyl group), it has a taste that is 200 times sweeter than table sugar. Once aspartame enters the digestive tract, it is split into its component parts, with the body absorbing the amino acids as though they were protein and the methyl group eventually being broken down into carbon dioxide.
  
  Aspartame is found in soft drinks, puddings, gelatin, frozen desserts, breakfast cereals, hot cocoa mix, yogurt, teas, breath mints, chewing gum and tabletop sweeteners. It generally is not used in foods that require cooking because it is not considered heat stable, meaning that its properties change (e.g., a loss of sweetness) when heated. It is commonly marketed under the names NutraSweet, Equal, NatraTaste, and SugarTwin.
  
  
• Neotame. The FDA approved this newest sugar substitute in 2002. It is intensely sweet, about 8,000 times sweeter than table sugar. Neotame, unlike many other sugar substitutes, is heat stable and may be used in cooking and baking.  Neotame has been approved in several foods, including baked goods, non-alcoholic beverages, chewing gum, frozen desserts, gelatin, puddings, jams and jellies , processed fruits and fruit juices, and toppings and syrups..
  
  
• Saccharin. Used for more than 100 years in the United States, it is produced from a substance that naturally occurs in grapes and is between 300 and 500 times sweeter than table sugar. It has a bitter aftertaste, and therefore is often blended with other sweeteners. Saccharin is excreted in urine and does not accumulate in the body, therefore, does not provide energy (calories). Saccharin is used primarily in soft drinks and as a tabletop sweetener. It is commonly marketed under the name Sweet ’N Low or SugarTwin,
   
• Sucralose. Made from sucrose, although its chemical makeup includes chlorine atoms instead of three hydroxyl groups. This makes sucralose 600 times sweeter than table sugar. Sucralose does not provide calories because, unlike sucrose, it is not broken down and passes through the body virtually unchanged. The FDA approved sucralose for use in 1998.  Sucralose is found in products such as baked goods, nonalcoholic beverages, chewing gum, frozen dairy desserts, fruit juices, and gelatins.  Sucralose has a good shelf life, is heat stable, and may be used in cooking. It is marketed under the brand name Splenda.

Two other sugar substitutes are awaiting FDA approval. They are called alitame and cyclamate. While alitame does not appear to pose any safety risks, questions have surrounded cyclamate for more than 50 years. Studies indicate that while cyclamate does not cause cancer, it may promote cancer development after cancer has already appeared. For this reason, FDA approval is considered unlikely, although many other countries (including Canada) have approved the substance.

The U.S. Food and Drug Administration (FDA) approves a sugar substitute for use only after it has been shown to be safe and effective. The amount of a sweetener that is deemed safe for daily use is referred to as its acceptable daily intake. This represents a level of daily consumption considered to be safe by a wide margin.

Concerns have been raised about the potential safety of some sugar substitutes. However, the FDA has found that nearly all of these substances are safe when used as recommended. The health concerns raised about individual sugar substitutes include the following:

• Acesulfame-K. There is some controversy about this substitute, as skeptics claim it produces tumors in rats. The FDA has countered that such tumors are typical of those found in rats during studies and were not the result of acesulfame-K. More than 90 studies have shown acesulfame-K to be safe in humans, according to the FDA.
  
  
• Aspartame. Numerous studies have documented the safety of aspartame, and the FDA approved it for use in 1981. However, this sugar substitute contains the amino acid phenylalanine, and, therefore, should not be used by people who have the inherited disease phenylketonuria (PKU).  According to the FDA, a small segment of the population is sensitive to one of the sweeteners byproducts and therefore,  intake should be restricted.  In limited amounts, phenylalanine is necessary for normal growth and development. Too much phenylalanine is toxic to the nervous system and can result in irreversible brain damage.
  
  People with PKU cannot properly dispose of excessive levels of phenylalanine and thus should limit their exposure to it. People with advanced liver disease, women with certain genetic traits (i.e., phenylketonuria), and pregnant women with high levels of phenylalanine in the blood also may have difficulty metabolizing phenylalanine.  The FDA requires all products containing aspartame to be labeled to alert consumers to the presence of phenylalanine.
  
  Aspartame also contains aspartic acid, which has been associated with brain damage and other neurotoxic effects. However, the FDA has found aspartic acid poses no threat to people who consume this substance at normal levels. The average person who uses aspartame only consumes about 4 to 7 percent of the acceptable daily intake, according to the FDA.
  
  In 2005, a European study reported that aspartame caused leukemia and lymphoma in laboratory rats. The study’s authors suggested reevaluating the use of aspartame in humans. FDA officials say they are standing by research showing that aspartame is safe in humans. However, the agency is also reviewing the findings of the European study and will announce its conclusions at a future date.  
  
  
• Neotame. Like aspartame, it contains the amino acids phenylalanine and aspartic acid and a methyl group. However, neotame has additional molecules that prevent digestive enzymes from separating phenylalanine. As a result, this amino acid is not absorbed, which allows people with PKU to safely use neotame.
  
  
• Saccharin. In the late 1970s, concern arose after experiments found that saccharin caused bladder cancer in laboratory rats. For a brief time, saccharin was banned from the U.S. market. However, this order was later rescinded pending further investigation. Although experts have not been able to prove that saccharin is safe when used by humans, large studies have failed to reveal a significant link between saccharin use and cancer in humans. It is believed that saccharin does not pose a threat to humans when consumed at normal levels. In 2001, federal legislation removed the requirement that saccharin contain a health-warning label.
  
  
• Sucralose. The body does not recognize sucralose as a carbohydrate, so it passes through the digestive tract without being broken down or absorbed. It does not affect blood sugar levels or insulin production, and therefore may be safely used by people with diabetes.

Questions remain about the impact of sugar substitutes on a person’s weight. Most studies have found that these substitutes help people to lose weight or maintain their present weight level. However, other studies have indicated that some sugar substitutes may stimulate appetite, potentially causing increased weight gain. Most experts maintain that a diet containing modest levels of sugar substitutes, in addition to regular exercise, is likely to affect weight loss or maintenance.

Sugar substitutes may benefit people with certain health conditions. For example, patients with diabetes may use sugar substitutes without having to worry about its effect on insulin or blood sugar levels. This allows people with diabetes to satisfy their taste for sweets without having to worry about hyperglycemia. However, as with any carbohydrate-containing food, sugar substitutes must be worked into a patient’s meal plan. Use of these sweeteners can also help manage calorie intake.

Pregnant and breastfeeding women can safely consume foods with certain types of sugar substitutes. This allows pregnant or breastfeeding women to enjoy the occasional sweet treat without excess calories. However, these women should be careful with the use of saccharin during pregnancy because saccharin can cross the placenta and may remain in fetal tissues. Pregnant women with high levels of phenylalanine in the blood also may have difficulty metabolizing the phenylalanine found in aspartame.

Consuming large amounts of sucrose or fructose can result in elevated levels of triglycerides. Some people with high triglyceride levels (hypertriglyceridemia) may be advised to cut back on sugary foods, especially if they are diagnosed with insulin resistance. Such people may benefit from using sugar substitutes. To lower triglycerides, it is also important to achieve and maintain a healthy body weight, which is best accomplished through a healthy diet and regular exercise.

Children should only occasionally use sugar substitutes. Children require ample amounts of calories and nutrients to provide adequate levels of energy and help them grow.

The FDA has established acceptable daily intakes (ADI) for artificial sweeteners.  They are as follows:

In addition to nonnutritive sugar substitutes, polyols (referred to as sugar replacers or nutritive sweeteners) are often used as alternative sweeteners. Nutritive sweeteners do not contain sucrose, but do contain sugar alcohols that sweeten and add bulk to various products. Unlike nonnutritive sugar substitutes, these sweeteners provide calories, although in lesser amounts than table sugar.

Sugar alcohols do not promote tooth decay or cause a sudden increase in blood glucose.  They may, however, have a laxative effect if consumed in excess.  Therefore, products containing large amounts of sugar alcohols must be labeled with the warning, “Excess consumption may have a laxative effect.”  

Sugar alcohols are classified as carbohydrates and appear naturally in fruits and vegetables. They may also come from substances such as glucose, starch and sucrose. Examples of polyols and the products in which they may be found include:

• Isomalt. Used in candies, chewing gum, ice cream, jams and jellies, frostings, beverages and baked goods.
  
  
• Lactitol. Used in candies, chewing gum, frozen dairy desserts, jams and jellies, frostings, baked goods.
  
  
• Maltitol. Used in candy coatings.
  
  
• Mannitol. Used as a bulking agent and found in chewing gum.
  
  
• Sorbitol. Used in special dietary foods, candies and gums.
  
  
• Xylitol. Used in chewing gum, candies, pharmaceutical and oral health products.

It should be noted that sorbitol also is made in the human body, and hyperglycemia encourages its formation. Sorbitol has trouble passing through cell membranes and can injure the cells. This damage has been linked to eyes diseases (diabetic retinopathy and cataracts), nerve disease (diabetic neuropathy) and kidney disease (diabetic nephropathy). However, dietary sorbitol is poorly absorbed and is not believed to cause diabetic complications. People with diabetes may safely consume polyols and artificial sweeteners in moderation, according to the American Diabetes Association.  

Tagatose is another type of nutritive sweetener. It is similar to fructose and derived from lactose. About 80 percent of tagatose is not absorbed until it reaches the large intestine, where bacteria chemically break it down and release gas and fatty acids that are absorbed by the body. It may be used in carbonated beverages, yogurts, chewing gum, mints and frostings.

Other products that use nutritive sweeteners include toothpaste and mouthwash.

The sweetness of nutritive sweeteners varies. They may be anywhere from 25 percent to 100 percent as sweet as table sugar. They often are combined with nonnutritive sweeteners to provide certain products an even sweeter flavor.

Nutritive sweeteners do not contribute to dental caries because bacteria do not convert them to acids. As a result, they are valuable in chewing gums, breath mints and other products that remain in the mouth for extended periods of time. They can affect blood sugar levels, but are absorbed slowly and incompletely and do not require much insulin to be metabolized. This makes them good alternatives to table sugar for people with diabetes.

Preparing questions in advance can help patients to have more meaningful discussions with health professionals regarding their conditions. Patients may wish to ask their doctor or registered dietitian the following questions related to sugar substitutes:

1. Who can help me plan a diet that includes sugar substitutes in appropriate amounts?
   
   
2. Are there cookbooks available that will tell me which sugar substitutes I should use when preparing various dishes?
   
   
3. Is one type of sugar substitute especially appropriate for me, or should I use a variety of substitutes?
   
   
4. How will I know if I’m using too much of a certain type of sugar substitute?
   
   
5. I have diabetes – which types of sugar substitutes are most appropriate for me?
   
   
6. I have PKU – how can I be sure that I’m not consuming aspartame in various products? Can I safely consume a little aspartame?
   
   
7. As someone with PKU, can I safely use neotame?
   
   
8. I’m pregnant – which types of sugar substitutes can I safely use? Which should I avoid?
   
   
9. If a sugar substitute has been approved in another country, is it safe for me to use when I visit that country?
   
   
10. Who can help me start an exercise program that will help me lose weight?