Introduction:
There are so many different artificial sweeteners present in food products, it sometimes seems impossible for consumers to avoid them. This information is designed to educate the patient so that informed decisions can be made regarding all of these different sweeteners. Many artificial sweeteners may be used by food companies in combination with other sweeteners.
Concerns about artificial sweeteners:
A study by Andreatta et al entitled, “Artificial sweetener consumption and urinary tract tumors in Cordoba, Argentina,” compared artificial sweetener use with occurrence of urinary tract tumors. Individuals reported on a questionaire how long they have been consuming the artificial sweeteners saccharin, aspartame, and acesulfame. According to the study, a 118% increase in risk of developing urinary tract tumors was seen after subjects reported consuming artificial sweeteners for a period of greater than or equal to 10 years and a 10% increase in risk of urinary tract tumors with short term consumption of artificial sweeteners. (1)
Aspartame, also known as “Nutrasweet” and “Equal”: Aspartame is made from a combination of the 2 amino acids phenylalanine and aspartic acid. It is 220 times sweeter than sugar. Patients with phenylketonuria (PKU) should not use aspartame as they cannot break down amino acids present in the sweetener. An acceptable intake in the United States for aspartame is set at 50 mg per kilogram by the FDA. Asparatme contains no calories or nutrition and does not increase blood sugar. Therefore, it often promoted for use by diabetics instead of sugar.
Danger of aspartame intake:
The FDA has stated as of 2006 after a review of over 100 clinical and toxicology studies on aspartame, that there was “no scientific information that would support a change in our conclusions about the safety of aspartame.” Patients with a genetic disorder named phenylketonuria (PKU) are required to avoid aspartame which can increase phenylalanine amino acid levels which may result in mental retardation and other neurologic disorders.
Aspartame and cancer:
Mead et al reviewed research studies in laboratory rats that showed a link between high intakes of aspartame and lymphomas, leukemias and mammary tumors. Rats were treated from 12 days of fetal life until death. There was a nonsignificant increase in malignancies found in rats treated with 400 ppm (parts per million) of aspartame, but concentrations of 2000 ppm of aspartame increased the risk of these cancers to 31.4%. A prior study by the same team was done using aspartame postnatally only and leukemias and lymphomas were increased by 18.7%. This 2,000 ppm level of consumption corresponds to about 100 mg per kilogram of bodyweight per day, 5 cans of diet soda for a 45-pound child or 14 packets of sweetener per day consumed by an adult weighing about 150 pounds. The author expressed concern because of an increase in malignancies resulting from prenatal exposure to aspartame over those exposed to aspartame postnatally. (2)
Aspartame may cause DNA damage:
A study by Bandyopadhyay A et al found that aspartame at high doses caused damage to DNA in bone marrow cells of mice, but not as severe as that caused by saccharin and acesulfame K. (8)
Sucralose:
This sweetener is also known as “Splenda”: Sucralose is currently the most widely used artificial sweetener and is 600 times sweeter than sugar without calories or nutrition.
Sucralose and diabetes:
Sucralose does not increase blood sugar or affect diabetes control (3).
Adverse effects of sucralose:
Case reports have been published with concern for sucralose as a migraine trigger. (4)
Safety of sucralose:
Grotz VL and Munro IC performed an overview of sucralose and stated that collective evidence supports that it is safe (5), and no gastrointestinal side effects were seen in studies.
Saccharin:
Saccharin is also known as “Sweet N Low,” and is on average, 450 times sweeter than sugar.
Saccharin and cancer:
Saccharin may cause urinary tract tumors (bladder cancer) in humans but this is unclear because the study grouped the 3 artificial sweeteners; saccharin, aspartame, and acesulfame together when subjects were asked to report consumption of all artificial sweeteners. (1)
Saccharin in animal studies:
Studies have shown that rats developed urinary tract tumors but this was not demonstrated in mice, hamsters, or monkeys. As of 1990, there was no clear evidence of saccharin causing cancer in humans. (7)
Saccharin and DNA damage:
DNA damage is the precursor to the cause of many cancers. Evidence of a study by Bandyopadhyay A et al, found that saccharin at high doses caused damage to DNA in bone marrow cells of mice. (8)
Acesulfame K:
Acesulfame K is also known as “Sweet One.”
Acesulfame K and cancer:
Acesulfame K increase risk of urinary tract tumors (bladder cancer) in humans but these results have been determined inconclusive by skeptics because the study grouped the 3 artificial sweeteners; saccharin, aspartame, and acesulfame together when subjects were asked to report consumption of all artificial sweeteners. (1)
Acesulfame K and DNA damage:
A study by Bandyopadhyay A et al found that acesulfame K at high doses caused damage to DNA in bone marrow cells of mice. (8)
Acesulfame K and cancers:
The National Toxicology Program did not find an increase in incidence of cancers in mice at high doses (9)
Neotame and Advantame:
Neotame and Avantame is derived from aspartame. It is a chemically changed derivative of aspartame to enhance sweetness so that less may be needed at a lesser cost to sweeten foods.
Regarding the safety of Neotame and Avantame, an overview of animal and human trials showed it to be generally safe. (10)
Stevia:
Stevia is a natural sweetener 250-300 times sweeter than sugar derived from the Stevia plant. Stevia does not provide significant calories or nutrition.
Stevia and diabetes:
Stevia has low calories and do not affect glucose levels in diabetics.
Stevia adverse effects:
A review of stevia research explained that a study showed DNA damage in a strain of bacteria and another showed DNA damage in rat tissues, but the majority of studies did not show gene toxicity and they concluded stevia does not have a risk of genotoxicity in humans by the weight of evidence (11). More human studies need to be done in order to determine potential adverse events.
Erythritol and Xylitol:
Erythritol and Xylitol are natural sugars. Erythritol occurs naturally in fruit or can be made by yeast fermentation of glucose. Xylitol is made from the extraction of fruit or corncobs
Erythritol and xylitol sweetness:
Erythritol is about 2/3 as sweet as sugar and xylitol about equivalent sweetness to sugar
Erythritol and xylitol in diabetes:
Both have low calories and do not affect glucose in those with diabetes.
Erythritol compared to other sugar alcohols:
Erythritol is the only sugar alcohol without a laxative effect since most is absorbed in the small intestines
Xylitol compared to other sugar alcohols:
Xylitol does have a laxative effect, but much less than sorbitol and maltitol.
Erythritol, xylitol and bacteria:
Erythritol and xylitol may prevent bacterial adherence to mucous membranes of the mouth and gastrointestinal tract. (12)
Erythritol, xylitol, dental caries (cavities), and otitis media:
Both erythritol and xylitol may prevent dental caries (cavities). Mäkinen KK et al found a statistically significant reduction in dental plaque and mutans streptococci after taking 7 gram chewable tablets of either xylitol or erythritol twice per day. (13)
Xylitol has promising potential application in the prevention of otitis media in young children. These ear infections were reduced by 25% in children that took 2 pieces of chewing gum containing 8.4 grams of xylitol and chewed the gum for 5 minutes twice per day. (14)
Sorbitol and Maltitol:
Sorbitol and maltitol are sugar alcohols commonly used in sugar free foods
Sorbitol and maltitol calorie content:
Sorbitol and maltitol have about ½ the calories of sugar with 2-3 calories per gram as opposed to 4 in sugar and may increase blood glucose.
How sorbitol and maltitol are made:
These sugar alcohols are found in fruits or can be produced from glucose
Sorbitol and maltitol adverse effects:
These sugar alcohols may result in excess gas production and diarrhea. They may also cause a laxative effect by pulling water into the intestines and predispose patients to dehydration.
Assessment and Plan: Natural and Artificial Sweeteners
- Artificial sweeteners are present in thousands of modern food products and may be associated with some adverse effects.
- The FDA has stated as of 2006 after a review of over 100 clinical and toxicology studies on aspartame, that there was “no scientific information that would support a change in our conclusions about the safety of aspartame.”
- Patients with a genetic disorder named phenylketonuria (PKU) are required to avoid aspartame which can increase phenylalanine amino acid levels which may result in mental retardation and other neurologic disorders.
- In patients with diabetes, aspartame, sucralose, saccharin, acesulfame, neotame, advantame, stevia, erythritol and xylitol will not raise blood sugar.
- Sucralose may trigger migraines (4).
- Alcohol sugars sorbitol and maltitol may cause flatulence, diarrhea and dehydration.
- Consider use of xylitol or erythritol mouthwash, gum, or tablets to help prevent dental caries (13).
- Xylitol may be considered in the form of gum to help prevent ear infections in children (14), but more research is needed.
- As a sugar substitute, the best options appear to be erythritol, xylitol, stevia, or non-refined naturally derived sugars such as whole date powder, agave nectar, brown rice syrup, or molasses.
References:
1.Andreatta MM, Muñoz SE, Lantieri MJ, Eynard AR, Navarro A., Prev Med 2008 Jul;47(1):136-9. Epub 2008 Apr 8. http://www.ncbi.nlm.nih.gov/pubmed/18495230
2.Mead, M. Aspartame cancer risks revisited: prenatal exposure may be greatest concern. Environ Health Perspect. 2007 September; 115(9): A460. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964912/
3.Mezitis NH, Maggio CA, Koch P, Quddoos A, Allison DB, Pi-Sunyer FX. Glycemic effect of a single high oral dose of the novel sweetener sucralose in patients with diabetes. Diabetes Care. 1996 Sep;19(9):1004-5. http://www.ncbi.nlm.nih.gov/pubmed/8875098
4.Grotz VL. Sucralose and migraine. Headache. 2008 Jan;48(1):164-5. http://www.ncbi.nlm.nih.gov/pubmed/18184301
5.Grotz VL, Munro IC. An overview of the safety of sucralose. Regul Toxicol Pharmacol. 2009 Oct;55(1):1-5.Epub 2009 May 21. http://www.ncbi.nlm.nih.gov/pubmed/19464334
6.Roberts A, Renwick AG, Sims J, Snodin DJ. Sucralose metabolism and pharmacokinetics in man. Food Chem Toxicol. 2000;38 Suppl 2:S31-41.Saccharin
7.Ellwein LB, Cohen SM. The health risks of saccharin revisited.Crit Rev Toxicol. 1990;20(5):311-26. http://www.ncbi.nlm.nih.gov/pubmed/2202324
8.Bandyopadhyay A, Ghoshal S, Mukherjee A. Genotoxicity testing of low-calorie sweeteners: aspartame, acesulfame-K, and saccharin. Drug Chem Toxicol. 2008;31(4):447-57. http://www.ncbi.nlm.nih.gov/pubmed/18850355
9.National Toxicology Program. NTP toxicology studies of acesulfame potassium (CAS No. 55589-62-3) in genetically modified (FVB Tg.AC Hemizygous) mice and carcinogenicity studies of acesulfame potassium in genetically modified [B6.129-Trp53(tm1Brd) (N5) Haploinsufficient] mice (feed studies)mice. Natl Toxicol Program Genet Modif Model Rep. 2005 Oct;(2):1-113. http://www.ncbi.nlm.nih.gov/pubmed/18784762
10.Otabe A, Fujieda T, Masuyama T, Ubukata K, Lee C. Advantame–an overview of the toxicity data. Food Chem Toxicol. 2011 Nov;49 Suppl 1:S2-7. http://www.ncbi.nlm.nih.gov/pubmed/22036024
11.Food Chem Toxicol. 2008 Jul;46 Suppl 7:S83-91. doi: 10.1016/j.fct.2008.05.002. Epub 2008 May 16. A critical review of the genetic toxicity of steviol and steviol glycosides. Brusick DJ. http://www.ncbi.nlm.nih.gov/pubmed/18556105
12.Söderling EM, Hietala-Lenkkeri AM. Xylitol and erythritol decrease adherence of polysaccharide-producing oral streptococci. Curr Microbiol. 2010 Jan;60(1):25-9. http://www.ncbi.nlm.nih.gov/pubmed/19777305
13.Mäkinen KK, Saag M, Isotupa KP, Olak J, Nõmmela R, Söderling E, Mäkinen PL. Similarity of the effects of erythritol and xylitol on some risk factors of dental caries. Caries Res. 2005 May-Jun;39(3):207-15. http://www.ncbi.nlm.nih.gov/pubmed/15914983
14.Azarpazhooh A, Limeback H, Lawrence HP, Shah PS. Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age. Cochrane review, Published Online: November 9, 2011. Accessed March 30, 2013. http://summaries.cochrane.org/CD007095/xylitol-sugar-supplement-for-preventing-middle-ear-infection-in-children-up-to-12-years-of-age_
15.Cleveland Clinic Newswire Team. Are Artificial Sweeteners Safe? A Look at the Evidence. May 6, 2013. Accessed August 25, 2014.
16.FDA Statement on European Aspartame Study. May 8, 2006. U.S. Food and Drug Administration 10903 New Hampshire Avenue, Silver Spring, MD 20993, Ph. 1-888-INFO-FDA (1-888-463-6332). Accessed August 25, 2014. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm108650.htm