Artificial Sweeteners: To Use or Not To Use?

What's the deal with artificial sweeteners?

There has been a lot of negative publicity going around about diet sodas and artificial sweeteners recently. A controlled, clinical trial from the Washington University School of Medicine and a series of epidemiological studies are seeking to change the public’s and health care community’s take on the safety and efficacy of these calorie-free additives.

The Washington study looked at one sweetener in particular, sucralose. In this small study of 17 obese, healthy participants, subjects were given either 60 mL of 2mmol/L sucralose or water and then asked to consume a 75 g glucose meal. The amount of sucralose provided mimicked the amount in a can of diet soda. Blood glucose levels were collected prior to beginning the study and for 5 hours after consuming the glucose. The researchers measured glucose, insulin, c-peptide, glucagon and a variety of incretin-based hormones.

Peak glucose concentration, insulin and C-peptide (a byproduct of insulin production) concentration were higher after sucralose than after water. In addition, insulin clearance rates were lower after sucralose. The concentration of the incretins was not significantly different with sucralose than water.

The findings indicate that sucralose may have a negative effect on insulin sensitivity in people who have never used artificial sweeteners before. Whether this effect is clinically (real-world) significant is unknown as is whether the results translate to other populations. It is also unknown whether the findings for sucralose can be applied to other artificial sweeteners.

The study from Washington University School of Medicine, mentioned above, that was published in Diabetes Care used a research model to test if and how sucralose might change the body’s hormonal responses compared to a known inert substance, water. Population-based studies (these studies do not test interventions), on the other hand, compare weight outcomes of people who drink diet sodas to those who do not. Several studies have found a correlation between the increasing intake of diet sodas and weight gain, a seemingly paradoxical outcome.

Even people who believe the rumors that artificial sweeteners cause cancer, generally agree with the supposition that they are metabolically inert and that products made with them provide fewer calories than their high sugar cousins. Artificial sweeteners are often touted as a weight loss aid, but there are rumblings in the scientific literature that this might not be the case.

You might start to shake your head and ask how this could possibly be true. After all we know that the non-nutritive sweeteners are just that –non-nutritive -meaning they don’t contain any appreciable calories. Even sucralose, which has about 1 calorie per packet, would require the use of massive quantities per day to truly contribute to excessive calorie intake.

Scientists have postulated a number of possibilities to explain this possible incongruity including a change in hormonal homeostasis as demonstrated by the study above. Others include that the sweet taste of artificial sweeteners may stimulate people to eat more calorie-containing foods.

Given the limitations of population-based studies, the size of the Washington study, its confinement to one population and the question of its relevance to the real world, much more research needs to be done before health authorities issue a proclamation to reduce or eliminate artificial sweeteners in the diet.

Still it is difficult to know what to believe since a new study comes out almost every day. When you have diabetes, foods with artificial sweeteners can make the diet more palatable. And some sweeteners such as saccharine have been around since the 1880s (although it didn’t gain widespread appeal until after World War I) without being linked to any serious health outbreaks.

Each person needs to weight the impact artificial sweeteners have on making his diet and glucose control manageable against the possible long-term negative consequences of their continued use. Sometimes this is a difficult decision to make on your. Discussing your options with your diabetes educator and/or heath care provider may help you decide what course of action is best for you.

–UPDATE: The following sweeteners, aspartame, saccharin, acesulfame-K, sucralose, rebiana and monk fruit extract have been found safe to use for the general public, including people with diabetes and pregnant women.  The American Diabetes Association concurs with this assessment.–

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11 Responses to Artificial Sweeteners: To Use or Not To Use?

  1. As a Diabetic child I grew up with Cyclamates and then later on ,Saccharin…
    This year I turned 50 and celebrated 50 years of Diabetes also. As I’ve gotten older..I rarely use any sweetener in coffee or tea…I just dont care for it anymore. However I do drink Diet Sodas pretty often.. Probably 5 or 6 x a week. … I guess Ive been though them all…and continue to plow ahead….LOL

  2. JKH says:

    I have been a Type 2 diabetic for the past 10 years. I try to monitor my carb intake, as most all of us probably do. And, I do not add sugar to food and drinks. Sugary drinks were a problem and likely led to my diagnosis, but I did not want to go to artificially sweetened drinks either. So, I gave up soft drinks of all kinds. I use xylitol instead of sugar, but in moderation. Would like to hear more about ways to satisfy my needs for sweetness; like at the holidays, birthdays, and other celebrations. Thanks!

  3. Rainbow says:

    This study talks about sweeteners’ effect on insulin production. How does this relate to people with Type 1 diabetes who have no insulin production?

  4. For me, the answer to this question is pretty straightforward. If I can use the real thing, then I am going to pass on the artificial sweetener. It’s funny, I recently went to San Francisco for the first time, and all of the coffee shops that I went to did not offer any artificial sweeteners, which is pretty cool. However, I also have to think that many of us end up consuming these artificial sweeteners in many of the foods we eat anyways. Frankly, the can be a difficult thing to completely avoid.

  5. On Aug. 19 we posted this piece about Artificial Sweeteners. Hope Warshaw, M.MSc., R.D., C.D.E., B.C.-A.D.M. from Hope Warshaw Associates, LLC and consultant to McNeil Nutritionals, LLC asked for an opportunity to respond. Here is what she wrote:

    I’m responding to your blog, Artificial Sweeteners: To Use or Not to Use? as a registered dietitian and certified diabetes educator, as well as on behalf of McNeil Nutritionals, the manufacturer of the sucralose-based Splenda® Brand Sweetener.

    Unfortunately there continues to be long-standing myths and misconceptions about the safety and effective use of low calorie sweeteners including the beneficial role that low calorie sweeteners can play in weight control and diabetes management. Many of these myths and misconceptions have been and continue to be perpetuated by studies that have limitations forced by their design and/or confounding factors, yet the media picks these studies up and turns them into headlines.

    In this spirit, I want to particularly respond to the discussion of the study by Pepino et al. (2013) in the above noted blog (posted 8/19/2013) and to put the results of this study into context with the large body of existing research that shows sucralose does not affect blood glucose control or A1c levels. In addition, I want to clarify the research to date on the effective use of low calorie sweeteners in weight management.

    The Pepino study, published online in Diabetes Care (4/30/13), was a small study in 17 not insulin resistant very obese African Americans, which, though randomized, was not a blinded study. Participants were aware of the study group they were in, which, in and of itself, can have effects on study results. Subjects came to the research facility to undergo two Oral Glucose Tolerance Tests (OGTTs), one, following consumption of 60 ml of water, and a second following consumption of 60 ml of water with sucralose. While the Joslin blog correctly states that “the amount of sucralose provided mimicked the amount in a can of diet soda”, this amount of sucralose was dissolved in only 60 ml of water, so, compared to a can of diet soda, the drink was about 5 times sweeter than a can of diet soda – i.e., pretty darn sweet. Hence, the study was not a blinded study. The subjects that participated in the OGTTs were also not housed there for the entirety of the study, which means that they were not fully observed and overnight fasting was self-reported.

    The Joslin blog states: “Peak glucose concentration, insulin and C-peptide…were higher after sucralose than after water…In addition, insulin clearance rates were lower after sucralose.” This is an overstatement. There was a statistically significant difference reported in the difference between OGTT results in the change from baseline to peak plasma glucose levels. What is not made clear is that the peak glucose levels were actually well within the normal range for response to an OGTT. Thus, the change does not reflect a clinically meaningful impact on blood glucose levels. With no significant effect on blood glucose levels found in the study it’s also hard to interpret changes in insulin measures reported in the study. This is particularly true, when the study was so small and in subjects who were very obese. Both of these latter conditions can have impacted the study findings.

    It is important to consider the Pepino study in the context of many studies done over the years to determine the effect of sucralose, the sweetening ingredient in Splenda® Brand Sweetener, on blood glucose and insulin levels or A1c. For example, a study by Metzitis et al. looked at the effect of one large amount of sucralose on short term glucose control in people with type 1 or 2 diabetes and showed no effects. A 3-month study by Grotz et al., in people with type 2 diabetes, showed that consuming large volumes of sucralose than most people would ever consume each day had no effect on glucose, insulin or A1c. A study by Baird was done with sucralose in people who didn’t have diabetes and showed no effect on blood glucose control. Data from these studies were submitted to the FDA in support of the approval of sucralose back in 1998. (References for these studies are below.)

    It’s worth noting that the American Diabetes Association, in their current nutrition recommendations (2008), state: “Before being allowed on the market, all [low calorie sweeteners] underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy.”

    Regarding the effectiveness of low calorie sweeteners on weight control the Joslin blog states, “Several studies have found a correlation between the increasing intake of diet sodas and weight gain, a seemingly paradoxical outcome.” The blog also states: “much more research needs to be done before health authorities issue a proclamation to reduce or eliminate artificial sweeteners in the diet.” In reality, over the last few decades and beyond numerous research studies, review papers and position statements from healthcare organizations have been published on this topic. In addition, sucralose and several other low calorie sweeteners have been approved by FDA and numerous regulatory agencies around the world. Research published over the years has shown that low calorie sweeteners can help people achieve or maintain a healthy weight – an important goal in the prevention of type 2 diabetes or in type 2 management. Recently, additional studies continue to show the benefits of judicious use of low calorie sweeteners in weight management.

    This research, as well as the many position statements from health associations, points out that achieving and/or maintaining a healthy weight results when people make quality food choices, consume an overall healthy food intake and otherwise practice a healthy lifestyle.

    Thanks for the opportunity to provide this response.

    Hope Warshaw, MMSc, RD, CDE, BC-ADM
    Owner, Hope Warshaw Associates, LLC and consultant to McNeil Nutritionals, LLC

    References:
    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;19(9):1004-1005.

    Grotz VL, Henry RR, McGill JB, Prince MJ, Shamoon H, Trout JR, Pi-Sunyer FX. Lack of effect of sucralose on glucose homeostasis in subjects with type 2 diabetes. J Am Diet Assoc. 2003;103(12):1607-1612.
    Baird IM, Shephard NW, Merritt RJ, Hildick-Smith G. Repeated dose study of sucralose tolerance in human subjects. Food Chem Toxicol. 2000; 38 Suppl 2:S123-9.

  6. Tammy says:

    I am not a doctor, nor do I play one on the internet, that being said, this is my regular person theory.!
    Our bodies recognize sugar, the body knows what to do with it and does it’s job.
    When we give it artificial sweeteners, at first, our body say yay, sugar, and starts to react to sugar. Then, wait minute, breaks on, that’s not sugar, stop what we are doing and store up that sugar we got before!
    I think this process breaks down the pancreas, turns more stored sugar into fat, creates our big belly’s, and starts a mean cycle.

  7. Yashar says:

    I never really liked the taste of artificial sweeteners, I stick with the natural stuff :)

  8. Mark Chen says:

    Joslin, do you think that the artificial sweetener campaigners in the US are trying to suppress research showing how it’s negative? Is this country profit motivated? I’m tired of my kids growing up in this kind of country and afraid it could have detrimental effects for my kids. It’s good the Washington University School of Medicine did investigation into this matter, because I always felt aspartame and other sweeteners increase weight gains. It’s not surprising the conclusion they discovered.

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