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Tuesday, November 9, 2010

Finding a Middle Ground on Artificial Sweeteners

One of the hottest topics I’ve ever seen in the WebMD Diabetes Community is the highly polarized debate over artificial sweeteners. Below I share my views on this controversial, interesting, and scientifically challenging topic.

I believe the debate is entirely legitimate. There are strong arguments to be made both in favor and against using artificial sweeteners in my opinion. One thing that is easy to agree upon is that there we could benefit from stronger scientific data on the long-term effects of artificial sweeteners on the body. The lack of strong data helps fuel the debate in my view.

The argument in favor of artificial sweeteners goes something like this:

Excess sugar is unhealthy. When added to foods and beverages it encourages overeating and has negative health effects that help fuel diabetes, heart disease, and associated risk factors, even in the absence of obesity. For example, drinking 1 can per day of regular soda is associated with nearly a doubling of the risk of type 2 diabetes. In principle it would be great to simply avoid foods and beverages with added sugar, but in practice we recognize that living life to the fullest generally includes eating sweetened foods, including desserts. Furthermore we are genetically designed to love sweet foods because this was a survival advantage during the vast majority of human history, therefore it is very hard to overcome cravings for sweet foods.

Since we are going to be eating sweet foods, it makes sense to find healthier ways to sweeten food, if possible. Saccharin (Sweet-n-Low, Sugar Twin), aspartame (Nutrasweet, Equal), acesulfame K (Sweet One, Sunett, Swiss Sweet), neotame, and sucralose (Splenda) are currently approved by the FDA for this use. Extensive testing has demonstrated no evidence of toxicity or negative short-term health effects. Years of experience with these products has not demonstrated any clear signs of trouble.

Moreover, the availability of the “diet” version of sodas and other artificially sweetened foods helps people avoid the higher sugar alternatives, and to maintain caloric reductions and weight loss. In patients with diabetes, the availability of artificial sweeteners can help control blood sugar when used to reduce sugar intake. For example, a person switching from two regular sodas to two diet sodas per day could reasonably expect to lose about 25 pounds over time, and maintain that weight loss on a long-term basis. If this occurred in someone with type 2 diabetes, this change alone could potentially result in less medication or even a remission. Major medical organizations such as the American Diabetes Association and American Heart Association endorse the use of artificial sweeteners for the various reasons cited above, and these organizations review the evidence and make a determination on a yearly basis.

Artificial sweeteners have been blamed by various individuals for many types of medical symptoms (such as headaches) but scientific studies attempting to find an association with any symptom typically fail to confirm any relationship with artificial sweeteners. Even if a small minority of individuals are truly sensitive to certain artificial sweeteners, that would not necessarily be a good reason to discourage others from using them. Furthermore, some would argue that even if artificial sweeteners have minor health risks, that would not necessarily offset their potential benefits.

The argument against artificial sweeteners goes something like this:

As a general principle, humans and other animal species are genetically designed to eat foods that occur in nature, and artificial sweeteners do not fit this criterion. Obviously not everything that is natural is healthy, but one should assume that chemicals that do not occur naturally are not fit for human consumption. Anyone who argues otherwise should be required to prove that a specific artificial chemical is safe for long-term consumption, and the scientific methods available at this time are not sufficient to be confident that such artificial substances are truly safe.

If a compound such as aspartame, which has a relatively simple chemical structure, was fit for consumption it would be found in nature. Its absence in nature is suspicious, as it would certainly occur in nature unless there was some important reason (evolutionary disadvantage) for its absence. Along the same vein, the chemical structure of sucralose, with its atypical presence of a chlorine atom (as opposed to chloride ion), seems suspicious as well, and nobody would be terribly shocked to learn 20 years from now that such a compound caused subtle, yet significant increases in risk of serious health problems (such as diabetes, metabolic syndrome, cancer, etc.) that became clear only in retrospect. Such diseases are clearly linked to changes in the human diet, particularly as a result of food industry processes, and artificial ingredients are a clear marker of this trend.

A small but growing body of scientific evidence supports the hypothesis that non-caloric sweeteners stimulate food intake, obesity, diabetes, and related diseases. As summarized on the Harvard School of Public Health website, the concern is that sweetness in the absence of calories is unnatural and may stimulate hormonal changes that encourage overeating. Non-conclusive studies suggest that people who drink diet soft drinks are at increased future risk of obesity, and are more likely to have type 2 diabetes, than people who avoid diet (and sugar-sweetened) beverages.

For these reasons, and others, some specialty grocery chains, such as Whole Foods, do not carry any foods with artificial sweeteners or other artificial ingredients. Their position may reflect a popular philosophy that that sugar derived from natural sources is the lesser evil compared to artificial sweeteners. Natural sweeteners such as stevia and erythritol and other sugar alcohols, are typically welcomed by those who are concerned about both sugar and artificial sweeteners. However they do not provide a perfect solution either due to taste limitations, and they may raise the same concerns about sweetness in the absence of calories discussed above.

Finding an Elusive Middle Ground:

So what is the most prudent approach to sweeten foods and beverages? It is impossible to build a consensus around this topic. All approaches have limitations and concerns. Sugar tastes the best, but is clearly unhealthy when used to excess. Stevia and sugar alcohols seem the least risky, but have taste limitations. Artificial sweeteners may represent a middle ground, depending on the degree to which one believes they are safe versus risky, and data are inconclusive and sparse.

I have had the opportunity to work with food industry experts on new food development. Although water can be flavored sufficiently with stevia extract and erythritol (eg. Vitamin Water), in my experience, a complex beverage like a protein shake cannot be “sugar-free” unless artificial sweeteners are used. There is no way to make it taste good enough with just stevia and erythritol unless some form of sugar is present. The amount of sugar necessary to provide the minimum acceptable taste appears to be about 1.2 grams of sugar (5 calories) per ounce of beverage. This is about 30% to 50% of the amount of sugar typically found in other complex beverages.

So the question becomes “how much sugar should one be willing to accept in order to avoid artificial sweeteners?” I wish I could answer this question more definitively, but it is open for debate. I think it is hard not to have mixed feelings based on the current evidence.

I look forward to hearing thoughts from readers on this complex and provocative topic. Come to the Diabetes Community to share your thoughts.

- Michael Dansinger, MD

Posted by: Michael Dansinger, MD at 10:10 am

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