Q&A: (Sweeteners Part 1) What’s the Bitter Truth About Natural and Added Sugars?

Take-Home Messages 🔑   

Introduction 📚🍇

A comprehensive understanding of the full spectrum of sugars and sweeteners in the diet is essential for making informed, health-conscious nutritional choices. From naturally occurring sugars such as fructose in fruit and lactose in milk, to so-called “alternative” sweeteners such as honey and coconut sugar, and extending to refined sugars and high-intensity artificial sweeteners commonly found in processed foods—each type has distinct physiological and metabolic effects.

In this first of two instalments, we will explore:

• Naturally occurring carbohydrates or simple sugars in fruits, vegetables and milk.

• Added sugars concealed in processed foods and beverages and their contribution to excess energy intake with minimal satiety.

• Alternative sweeteners such as honey, coconut sugar and date syrup—their flavour appeal and trace nutrients, alongside the metabolic reality that they still count as added sugars.

• Practical strategies for identifying and reducing added sugars in the diet without sacrificing flavour or enjoyment.

Understanding the many names under which sweeteners appear on food labels is crucial for navigating today's food environment—yet doing so can be confusing, as labelling terminology is often inconsistent or misleading.

The second instalment will delve into the world of low- and no-energy sweeteners—both artificial and naturally derived—to assess whether they truly provide a guilt-free sweet fix.

Carbohydrates and natural sugars: The basics 🥦🍎🥛

Carbohydrates are a fundamental component of our diets. In dietary terms, simple carbohydrates or natural sugars are organic molecules that consist of carbon, hydrogen and oxygen atoms (CHO). They are naturally present in foods i.e. fruits, milk and vegetables or added during food processing. Each gram of carbohydrate and protein provides 17 kilojoules (4 calories). 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 because they arrive bundled in a whole-food package that changes how our bodies handle them.

Table: Whole-food features that turn natural sugars into a health bonus

Natural 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). They are broken down in the digestive tract into monosaccharides (mainly glucose), then absorbed into the bloodstream. Blood sugar refers to the concentration of glucose circulating in the bloodstream, which serves as a readily available source of energy for the body’s cells. Its levels are tightly regulated by hormones—primarily insulin and glucagon—to maintain metabolic balance. Glycogen is the stored form of glucose in the liver and muscles, used to maintain blood sugar levels or fuel physical activity when needed.

Guidelines for carbohydrate intake 📊🍞

The recommended dietary allowance (RDA i.e. the daily intake level to meet the requirements of nearly all healthy individuals) 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 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. In addition research highlights a more specific concern: fructose malabsorption occurs more often in patients with irritable bowel syndrome (IBS) than in healthy controls, suggesting that it may play a role in IBS symptoms and intake must be managed in those with IBS (4).

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.

Guidelines for free sugar intake 🚫🍭

Dietitians distinguish between natural sugars and free sugars (which include added sugars) to guide healthier choices. Free sugars encompass all added sugars as well as sugars naturally present in honey, syrups, and fruit juices. Added sugars are therefore a subset of free sugars, referring specifically to sugars or sweeteners incorporated into foods and beverages during processing, preparation, or at the table, rather than those occurring naturally in whole foods. Focusing only on “added sugars” can overlook hidden sources such as fruit juice or honey, which are classified as free sugars but not always labelled as added. Free sugars contribute to excess energy intake without providing essential nutrients—often referred to as “empty kilojoules” or “empty calories”—and should be limited for better health outcomes.

Given the limitations in methodological rigor and evidence quality highlighted by a systematic review (5), current sugar intake guidelines should be improved in the future. However, current intake are far above the recommendations (6). 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. For context, the average American consumes approximately three times the recommended daily intake of added sugar, while South Africans are also reported to exceed these guidelines (9).

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN, 2017) recommends that children and adolescents (2–18 years) consume less than 5% of energy from free sugars, while infants and toddlers under 2 years should consume "less"—ideally avoiding free sugar altogether during this critical developmental period (10). Encouragingly, following the implementation of South Africa’s sugar tax, young children's intake of sugar-sweetened beverages decreased, independent of socioeconomic or body composition factors (11).

Risk of excessive sugar intake

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 (12, 13). Restricting free sugars reduces body fat mass and lowers low density lipoprotein cholesterol (LDL-c) with minimal impact on energy expenditure, metabolism or the gut microbiome (14). Also, refined sugar can even contribute to the development of certain cancers (17).

A systematic review and meta-analysis of 40 studies (1,212,107 participants) found that higher dietary sugar intake was associated with a 21% increased risk of depression, with women being more affected than men, while no significant association was observed with anxiety risk (15). In a cohort study of 932 participants (405 with Major Depressive Disorder and 527 healthy controls), soft drink consumption was associated with both the diagnosis and severity of depression—especially in women (16). Among women, higher intake correlated with increased levels of the gut bacterium Eggerthella, which partially mediated the link between soft drink intake and depressive outcomes (explaining ~3.8–5.0% of the effect). No significant changes were observed in Hungatella abundance. Importantly, the study (16) did not differentiate between sugar-sweetened and artificially sweetened beverages, treating soft drinks as a single, undifferentiated category. Thus, the specific contribution of each type of soft drink to depression risk remains unclear.

Furthermore, added sugars have been implicated in cognitive decline (12, 17). Also, frequent consumption of a high-fat, high-sugar diet is linked to poorer spatial navigation ability in young adults, independent of body weight or general cognitive performance (18).

Drawing on a natural experiment from post–World War II UK, researchers demonstrated that early-life sugar restriction—particularly after six months of age—conferred long-term protective health benefits, including a lower risk of developing type 2 diabetes and hypertension, as well as delayed disease onset later in life (19). Children in the "Food, Fun and Family" intervention reduced screen time and sugar intake, which led to a decrease in sleep bruxism (involuntary teeth grinding)(20). Efforts to reduce added sugar consumption can play a vital role in improving overall health and reducing the risk of chronic diseases.

Added and sugar Alternatives: Hidden kilojoules in everyday foods 🧃🍬

Added industrial sugars are energy containing sweeteners that have been refined or manufactured through industrial processes—such as table sugar (refined sucrose from cane or beet), high-fructose corn syrup (HFCS), glucose–fructose syrups, invert sugar, dextrose, maltose and similar syrups.

Table: Added sugars and sweetener alternatives

Traditional (energy containing/caloric) sugar alternatives: A halo with strings attached 🍯🌴🍁

Although marketed as “more natural,” most whole-food-based sweeteners supply almost the same energy as sucrose. Their advantages lie mainly in flavour complexity and trace nutrients, not in dramatic metabolic benefits.

Table: Traditional sugar alternatives

Beyond the familiar added sugars a growing number of “niche” sugar alternatives are marketed as healthier or more functional options. These sweeteners vary widely in origin, chemistry, and metabolic effects. Some are promoted for their low glycaemic index, others for retaining whole‑food components, and still others for novel properties such as reduced energy yield or prebiotic potential. The table below outlines several of these alternatives.

For example, allulose (D-psicose) is a rare, low-energy sugar (~0.84 kJ/g) with about 70% the sweetness of sucrose. Allulose is found in trace amounts in foods such as figs, raisins and wheat. However, natural food sources are too limited for large-scale use, so most allulose on the market is made by enzymatically converting fructose (usually from corn or beet) into allulose. Allulose is mostly excreted unmetabolised, and shown to reduce postprandial blood glucose levels in healthy adults (29), though further human studies are needed to confirm its long-term metabolic effects, gut microbiota impact, and safety at typical intake levels (30).

Table: Niche sugar alternatives (21)

Brown rice syrup is often mistaken as healthier, but its brown colour comes from Maillard reactions—chemical interactions between sugars and amino acids during heating that create browning and flavour compounds—rather than whole‑grain rice. The polysaccharides in brown rice syrup rapidly break down into glucose, raising blood sugar faster than table sugar. It’s one advantage is the absence of fructose, making it a possible alternative for people with fructose malabsorption.

Understanding added sugar: A practical guide🔍🥤

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.

Table: Sweet treats and their sugar equivalent per serving (4 g)

Below I provide practical guidance with specific examples and tips for decoding food labels, empowering consumers to make informed choices about free/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).

Several health claims related to sugar appear on food packaging, but are easily misunderstood or misleading without proper context. For example, a product labelled “no added sugar” means no sugars or sweeteners were added during processing, yet it may still contain naturally occurring sugars from ingredients such as fruit purée, milk or fruit juice concentrate. Similarly, “reduced sugar” indicates at least 25% less sugar than the standard version of the product, but the original may have been high in sugar to begin with. “Sugar-free” products contain less than 0.5 grams of sugar per serving, though they often include sugar alcohols or artificial sweeteners and may not be low in energy. “Unsweetened” means no sugars or sweeteners have been added, but the item may still contain natural sugars. The terms “light” or “lite” can refer to reductions in fat, kilojoules or sugar, but must be clarified on the label. Claims such as “naturally sweetened” and “no refined sugar” are not legally defined and can be misleading—such products often contain energy containing/caloric sweeteners such as honey, coconut sugar or fruit juice concentrates that still contribute to total sugar intake and affect blood glucose. Finally, “low sugar” is not formally regulated in many countries, allowing manufacturers to use the term loosely. Interpreting food and drink labels can be challenging, especially in South Africa, where many products—despite containing high levels of sugar or artificial sweeteners—lack clear warning labels (31), leaving consumers without the necessary information to make informed choices. For these reasons, it is essential to look beyond front-of-pack claims and examine the nutrition label and ingredients list to make informed choices.

Conclusion 📝🍯

Understanding the distinction between natural, free and added sugars empowers individuals to make healthier dietary choices. While natural sugars found in whole foods come with beneficial nutrients such as fibre, vitamins and minerals, added sugars contribute excess energy without added nutritional value and are linked to an increased risk of chronic diseases. By becoming more aware of the sources of added sugars, reading food labels carefully, and prioritising whole foods, we can better manage our sugar intake and promote long-term health and well-being. Small, informed changes can have a lasting impact on our overall health.

Reflections to Raise Awareness of Sugar Intake

1. Examine the labels of processed foods e.g. sauces, dressings, cereals and condiments, as well as beverages e.g. 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 e.g. still or sparkling water, unsweetened tea or coffee without cream?
3. Even small portions of sweet treats can 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 intake guidelines.
4. Focus on gradually reducing overall sweetness in your diet to retrain your palate. Discover and savour the inherent sweetness in whole foods e.g. 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 or with citrus (lemon or limes), adding depth without extra sweetness. Are you intentionally reducing sweetness in your daily choices, rather than replacing sugar with artificial alternatives or other sweeteners? Just because something contains a “natural” sweetener doesn’t make it a healthy choice. Focus on whole, minimally processed foods where possible.

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