Q&A: How Sweeteners Differ: Sugar, Artificial Sweeteners and Sugar Alcohols?

Take-Home Messages on Sweeteners

Introduction 📚🍇

Understanding the role of sugar and its alternatives in our diet is essential for making informed and healthier dietary choices. From natural sugars in fruits and vegetables to added sugars in processed foods, and from artificial sweeteners to sugar alcohols, each form impacts our health differently. Here I explore the differences between these sweeteners.

Carbohydrates and Natural Sugars: The Basics 🥦🍎🥛

Sugar is a fundamental component of our diets, but its definition and implications vary depending on its source and form. In dietary terms, natural sugar or simple carbohydrates consisting of carbon, hydrogen and oxygen atoms (CHO) are naturally present in foods i.e. fruits, milk and vegetables or added during food processing. Naturally occurring sugars, such as fructose in fruits and lactose in milk, are accompanied by fibre and/or vitamins and minerals, making them nutritionally beneficial.

Guidelines for Carbohydrate Intake 📊🍞

The RDA for carbohydrates, based on the minimum amount of glucose required by the brain daily, is 130 g for adults. This requirement can be easily achieved through a balanced diet that includes fruits, vegetables and grains. The acceptable macronutrient distribution range (AMDR) for carbohydrates is 45–65% of total energy intake (1). Research indicates that an optimal carbohydrate intake for minimal mortality risk lies between 50–55% of total energy (2). However, both low- and high-carbohydrate diets have been linked to increased mortality risk, particularly when low-carb diets prioritise animal-based proteins and fats rather than plant-based alternatives, which are associated with lower mortality (2, 3). Although the sugar in fruit juices is natural, it is not considered healthy to consume more than half of your daily fruit servings as juice. It is strongly recommended to consume whole fruits instead.

Table: Carbohydrate Exchanges for Meal Planning🥕

Footnote: *An exchange standardises food portions with equal amounts of carbohydrates, proteins, or fats, allowing flexible meal planning by substituting foods within the same category while maintaining consistent macronutrient intake. ^#The actual weight of sugar in a teaspoon can vary depending on factors such as how the sugar is packed or its granule size.

Added Sugars: Hidden Kilojoules in Everyday Foods 🧃🍬

Added sugars i.e. table sugar (sucrose), high-fructose corn syrup and syrups contribute to excess energy intake in products such as soft drinks and candy without providing additional nutrients and are called empty calories/energy. These sugars exist in forms such as monosaccharides (a single sugar molecule i.e. glucose, fructose, galactose) or disaccharides (two monosaccharides bonded together i.e. sucrose, lactose, maltose). Not all sugar substitutes have the same health effects. E.g, replacing refined sugars with maple syrup has been shown to improve health markers such as reducing glucose area under the curve, systolic blood pressure and android fat mass in individuals with mild metabolic alterations, compared to sucrose syrup (4). Additionally, maple syrup consumption has been linked to beneficial changes in gut microbiota, suggesting a potential role in promoting cardiometabolic health (4).

Some people consider honey, molasses (US), treacle (UK), or less refined sugars such as, raw sugar (turbinado) and dark brown sugars (demerara, muscovado, or jaggery) to be healthier alternatives to refined white sugar. However, these options offer limited nutritional value, with minimally processed versions containing only trace amounts of vitamins and minerals beyond the energy they provide. Honey, in particular, has notable antibacterial and antimicrobial properties, but its consumption should still be moderated due to its high energy content (5). Raw honey retains more nutrients and bioactive compounds than processed honey, which may lose these during heating. However, even processed honey should never be given to infants under one year old due to the risk of botulism (6).

Guidelines for Added Sugar Intake 🚫🍭

Dietitians distinguish between natural and added sugars to encourage healthier choices. Added sugar refers to any sugar or sweetener that is added to foods or beverages during processing, preparation or at the table. Added sugars must be limited for health reasons. According to guidelines from the World Health Organisation (7) and the American Heart Association (AHA, https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sugar/added-sugars)(8), added sugars should make up no more than 5–10% of daily energy intake. For most individuals, this translates to approximately 9 teaspoons (36 g) per day for men, 6 teaspoons (24 g) for women, and 3–6 teaspoons (12–24 g) for children. A standard serving size of sugar is often measured as 1 teaspoon (4 g). Practical examples include a serving of soft drink containing ~10 teaspoons (40 g) of sugar. Given the limitations in methodological rigor and evidence quality highlighted by a systematic review (9), current sugar intake guidelines should be improved in the future. Readers are encouraged to stay informed about updates to these guidelines as new, higher-quality research becomes available.

The table below highlights how small servings of common sweet treats, widely recognised as significant sources of sugar, and condiments, often overlooked as contributors, can quickly add up to a substantial sugar intake. By visualising sugar content in terms of teaspoons (4 g), this guide raises awareness about hidden sugars in everyday foods, empowering individuals to make more informed dietary choices. This is particularly important, as excessive consumption of added sugars has been strongly associated with a range of adverse health outcomes. These include an increased risk of chronic conditions such as obesity, type 2 diabetes, cardiovascular disease and non-alcoholic fatty liver disease (10). Furthermore, added sugars have been implicated in cognitive decline and may even contribute to the development of certain cancers (10, 11). For context, the average American consumes approximately three times the recommended daily intake of added sugar (12), while South Africans are also reported to exceed these guidelines (13). Efforts to reduce added sugar consumption can play a vital role in improving overall health and reducing the risk of chronic diseases.

Table: Sweet Treats and Their Sugar Equivalent per Serving (4 g)

Understanding Added Sugar: A Practical Guide🔍🥤

In the table below I provide practical guidance with specific examples and tips for decoding food labels, empowering consumers to make informed choices about added sugars in their diet. Added sugars, distinct from natural sugars found in fruits and dairy, are often hidden in ingredient lists under various names. Understanding how to interpret food labels can help limit excessive sugar intake and promote healthier dietary habits.

Table: Tips for Understanding Added Sugar on Food Labels 🍪

Footnote: The Daily Value (DV) on a food label is a reference number that indicates the recommended amount of a nutrient you should consume each day, based on a standard diet of 8,400 kilojoules (2,000 calories).

Artificial Sweeteners, Sugar alcohols and Stevia: Sweetness Without Adding Energy🍃🧪

In addition to sugar, alternative sweeteners such as artificial sweeteners and sugar alcohols offer options for reducing energy intake and managing blood sugar levels (14). Artificial sweeteners are synthetic or naturally derived compounds that provide intense sweetness—hundreds to thousands of times sweeter than sugar—without adding energy. Therefore, they are also referred to as non-nutritive sweeteners. Common examples include aspartame, sucralose, saccharin and acesulfame K.

The Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA) rigorously test artificial sweeteners to ensure their safety at typical consumption levels, regulating them with acceptable daily intake (ADI) limits. These sweeteners are commonly used in diet soft drinks and sugar-free products. Though marketed as healthier sugar alternatives, artificial sweeteners have been linked to several negative health effects. Artificial sweeteners may impact gut microbiota, potentially leading to glucose intolerance, metabolic disorders, and dysbiosis (15-17), with some evidence linking them to cardiovascular risk (18-20), non-alcoholic fatty liver disease (21), weight gain (22, 23) and appetite disruption (22, 24). An umbrella meta-analysis revealed that, in observational studies specifically, artificial sweeteners were associated with a 61% increased risk of obesity and overweight, a finding not observed in other study designs (25). A prospective study of 210339 adults found that both sugar sweetened beverages but especially artificially sweetened beverages was associated with higher risk of chronic obstructive pulmonary disease (COPD), asthma and asthma with COPD. For every 250 ml (8-ounce) increase in artificially sweetened beverages intake, the risks of COPD, asthma, and asthma with COPD rose by 98%, 65%, and 184%, respectively (26). A systematic review highlights a positive association between artificial sweetener consumption, particularly from artificially sweetened beverages, and an increased risk of ischaemic strokes, especially in women and black populations (20). Nutritionists believe that the direct effects of artificial sweeteners, as well as their association with poor dietary quality (27), both contribute to the development of disease. Concerns also include neurological effects (28, 29), potential risks during pregnancy (30, 31) and the development of preferences for overly sweet foods (32), that must be investigated further. Early cancer fears, based on high-dose animal studies, have largely been dismissed for typical consumption levels with several meta-analyses showing no associations (33-37). Additionally, individuals with phenylketonuria (PKU) must avoid aspartame due to its phenylalanine content, which can have dire consequences (38). While considered safe in moderation, their long-term effects require further study.

Table: Factors Linking Artificial Sweetener Intake to Poor Dietary Quality

In addition to artificial sweeteners, sugar alcohols, or polyols, are another category of sugar substitutes. These carbohydrates, found naturally in some fruits and vegetables or manufactured from sugars, provide reduced-energy sweetness, typically 25–100% as sweet as sugar. Examples include sorbitol, mannitol, maltitol, xylitol and erythritol often used in chewing gums, breath mints, toothpastes, mouthwashes and cough syrups. Sugar alcohols provide fewer kilojoules (2–3 kJ per gram, with erythritol being non-caloric) and offer additional oral health benefits. Studies indicate that sugar alcohols such as xylitol and erythritol can reduce the incidence of dental caries by facilitating enamel repair and strengthening teeth (39). Among sugar alcohols, erythritol and xylitol show the greatest potential for preventing caries and promoting remineralisation, likely due to their chemical structure and interaction with oral microbiota (39). This makes them not only a lower-energy sweetener but also a functional choice for oral health. However, excessive consumption can cause digestive discomfort, as they are only partially absorbed in the gut. A case report documented severe allergic urticaria following erythritol consumption, underscoring the importance of considering artificial sweeteners and sugar alcohols when diagnosing allergic reactions (40).

Stevia, derived from the sweet-tasting leaves of the Stevia rebaudiana plant native to semi-arid regions of Central and South America and cultivated in areas such as the southwestern United States, is a versatile and natural alternative to sugar (41). Its sweetness, attributed to steviol glycosides, is up to 200–300 times greater than table sugar, making it a potent low-energy sweetener suitable for replacing sucrose. Steviol glycosides are stable, heat-resistant and highly soluble, making stevia a reliable sweetener for various food applications (42). It can partially or fully replace sucrose, often combined with other additives to preserve texture and flavour (42). Advanced processing enhances its taste by reducing unpleasant aftertastes (42). Stevia supports the "clean label" trend, appealing to health-conscious consumers and offers additional benefits such as antioxidant properties and uses as an emulsifier, texturiser and colouring agent, making it ideal for functional and health-promoting products.

The roles of sugar, artificial sweeteners and sugar alcohols differ, catering to various dietary needs. Sugar provides quick energy but lacks nutritional benefits, while artificial sweeteners, sugar alcohols and natural alternatives i.e. stevia offer lower-energy options for those aiming to reduce energy intake or manage conditions such as diabetes. Stevia is heat-stable, making it suitable for baking and cooking. However, aspartame, lose their sweetness when heated and may become chemically unstable, leading to bitterness over time. By understanding these distinctions and considerations, individuals can make informed choices to support a balanced and healthy diet.

Table: Comparison of Artificial Sweeteners: Sweetness, Safety, and Side Effects

Conclusion 🧁💡

Choosing between sugar, artificial sweeteners and sugar alcohols should be guided by individual health goals and dietary needs. While sugar provides quick energy, it offers little nutritional value and, when consumed in excess, contributes to chronic health conditions. Artificial sweeteners and sugar alcohols present lower-energy alternatives suitable for managing energy intake and conditions like diabetes, but they come with specific limitations, such as potential health risks and digestive side effects. Natural options like stevia, known for its antioxidant properties and low-energy profile, offer additional functional benefits for health-conscious consumers. To balance sweetness with wellness, individuals with diabetes are advised to use artificial sweeteners sparingly as a substitute for sugar, while non-diabetics should focus on minimising the use of both natural and artificial sweeteners. Emphasising a well-balanced, nutrient-rich diet, rather than relying on sweeteners to replace sugar, is key to supporting overall health and wellbeing.

Reflections to Raise Awareness of Sugar Intake

1. Examine the labels of processed foods like sauces, dressings, cereals, and condiments, as well as beverages like sodas, juices, and energy drinks, which often contain surprising amounts of added sugar. Are you making informed choices by selecting lower-sugar alternatives and limiting these hidden sources in your diet?
2. Be aware of the sugar content in your drinks by visualising it: 4 grams of sugar equals a teaspoon. For example, a single soda may contain 10 teaspoons of sugar. Could you replace sugary beverages with healthier options like water, unsweetened tea, or coffee?
3. Even small portions of sweet treats can significantly impact your sugar intake. Are you aware of how much sugar you're consuming per serving and its cumulative effect over the day? Consider limiting portion sizes and avoiding multiple servings in one sitting to stay within recommended guidelines.
4. If you are diabetic artificial sweeteners and sugar alcohols can help reduce sugar intake, but moderation is key. Experiment with different options—try sweeteners in coffee, baking or smoothies, or even better reduce sweetness altogether to adapt your palate (see Reflection 5).
5. Focus on gradually reducing overall sweetness in your diet to retrain your palate. Discover and savour the inherent sweetness in whole foods like fresh fruit and vegetables (corn and carrots) and milk, allowing you to appreciate the subtle, natural flavours they offer. Enhance the taste of drinks naturally with spices such as cinnamon or vanilla, adding depth without extra sweetness. Are you intentionally reducing sweetness in your daily choices, rather than replacing sugar with artificial alternatives or other sweeteners?

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In developing this work, the author utilised ChatGPT-4 to assist with language editing.