August 2009 Issue

Spoonfuls of Evidence on Sweeteners
By Jenna A. Bell-Wilson, PhD, RD, CSSD
Today’s Dietitian
Vol. 11 No. 8 P. 16

Is sugar the way to a woman’s heart? Perhaps, but not always in a good way. Sugar-sweetened beverages may raise the risk of heart disease in women, according to recently published results of a large-scale prospective study. Two or more servings of sugar-sweetened beverages per day increased women’s risk of heart disease by 35% (p < 0.001) compared with those who drank less than one serving per month, even after accounting for unhealthy lifestyle and dietary factors.1

Calorie-free sweeteners, also known as nonnutritive sweeteners, were not associated with coronary heart disease (CHD) risk. The researchers pointed out that sugar-free drinks benefit from their lack of fructose, a sugar that has been linked to increased triacylglycerol concentrations, a known risk factor for CHD.1 Reducing the intake of sugar-sweetened beverages, which are often discretionary calories from soda and juice, may also help with overweight, another known risk factor for CHD.

As nutrition experts, we know the evidence overwhelmingly supports reducing the intake of added sugars. While calorie-free sweeteners may help satisfy the American sweet tooth (without the extra calories or possible increased risk of CHD that comes with sugar), clients may be confused by negative headlines. Be ready for the questions on sweeteners and health from your clients and patients.

Q: Are added sugars really that unhealthy for me?
Experts agree on this one, and the answer is yes, in significant quantities. The Dietary Guidelines for Americans recommends “foods and beverages with little added sugars or caloric sweeteners.” The American Dietetic Association’s (ADA) Evidence Analysis Library reviewed the literature and supports this recommendation. The ADA position statement indicates that a person’s diet quality suffers when nutritive sweeteners contribute more than 25% of total energy intake.2

And many RDs agree. “Consuming less sugar has a lot of benefits. Helping stave off women’s No. 1 killer is a big one,” says Maggie Moon, MS, RD. “Sugary drinks are a major source of added sugars, and cutting back can only help.”

Pamela M. Nisevich, MS, RD, CSSD, LD, a specialist in sports dietetics, sees the role sugar-sweetened beverages play in overweight and obesity. “From calorie-rich coffee drinks to syrupy energy drinks to so-called fruit juices, I see countless patients who could easily whittle their waistlines and reduce their [weight-related] risk of chronic diseases by simply choosing reduced-calorie or sugar-free drinks instead.”

Q: What did the study say about disease risk and sugar-sweetened beverages?
The 2009 study appeared in The American Journal of Clinical Nutrition. The authors knew that previous research found associations between sugar-sweetened beverages and weight gain, as well as an increased risk of type 2 diabetes. They decided to look at sugar-sweetened beverage intake and the risk of CHD in women.1

The study followed 88,520 women aged 34 to 59 from the Nurses’ Health Study from 1980 to 2004 to see how sugar-sweetened beverage intake affected CHD risk. At the start of the study, the women did not have CHD, stroke, or diabetes. After 24 years and seven food frequency questionnaires, researchers found 3,105 new cases of CHD. Having one serving of sugar-sweetened beverage per day translated into a 23% increased risk; two or more per day equaled the 35% increased risk noted previously. The researchers adjusted for body mass index, energy intake, and new cases of diabetes. Drinks sweetened with nonnutritive sweeteners were not associated with CHD.1

Q: Are nonnutritive sweeteners safe?
Many nonnutritive sweeteners have been more thoroughly researched than some drugs or food additives currently on the market. In total, there have been more than 200 toxicological and clinical studies conducted over 30 years on aspartame alone. The ADA Evidence Analysis Library reviewed the evidence on the safety and effects of this common nonnutritive sweetener and concluded that consuming aspartame is “not associated with adverse effects in the general population.”2

The report further states, “Studies have found no evidence of an effect of aspartame on a wide range of adverse effects, including hypersensitivity reactions, elevated blood methanol or formate levels, hematopoeitic or brain cancers. Neurological changes tested included cognitive functions, seizures, headaches and changes in memory or mood.”2 The data from peer-reviewed journals suggest the same safety rating is true of other FDA-approved nonnutritive sweeteners.

The ADA adds that scientists have evaluated these sweeteners for many attributes, including sensory qualities (eg, clean, sweet taste; no bitterness; odorless), safety, effect on appetite (no effect), compatibility with other food ingredients, and stability in different food environments.2

Q: Will nonnutritive sweeteners make me fat?
This common misinterpretation of a clinical study out of the psychology department at Purdue University warrants a closer look. The animal study compared a saccharin-sweetened diet to a glucose-sweetened one. Since straight glucose is not very palatable, the rats consumed more of the saccharine-sweetened foods. Therefore, overall calorie intake was higher in the saccharin group. Simply put, they ate more, and that’s why they gained weight.3

Q: Are nonnutritive sweeteners healthy?
The ADA suggests that calorie-free sweeteners may assist in weight management, blood glucose control, and preventing cavities. Essentially, when replacing calorie-rich beverages and foods with low-calorie alternatives, research suggests that patients and consumers stand to benefit from lower overall energy intake and better blood glucose control, reduced risk of heart disease, and more.

As another strategy, if adding nonnutritive sweeteners to nutrient-dense food choices such as fruit will help improve palatability for some, it has the potential to boost overall diet quality by increasing fruit intake.

Q: Which ones are FDA approved?
Nonnutritive sweeteners on the market must be approved as safe by the FDA, which regulates artificial sweeteners as food additives. See the accompanying table for an overview of five common nonnutritive sweeteners, including the zero-calorie sweeteners made from the stevia plant that were added to the safe list in 2008. To date, the approved nonnutritive sweeteners are acesulfame potassium/acesulfame-K, aspartame, neotame, saccharin, sucralose, and stevia.4

Q: Should I believe everything I read online about nonnutritive sweeteners?
While the Internet is a wonderful educational tool, consumers may have trouble sorting out what’s credible from convincing but nonetheless anecdotal evidence. Steer clients toward Web sites run by trustworthy organizations, such as the ADA or the American Heart Association. The Harvard School of Public Health provides guidance on choosing healthy drinks at www.hsph.harvard.edu/nutritionsource/healthy-drinks.

Q: Why should I believe you?
Remind clients that RDs and other health professionals are trained to focus on credible, evidence-based research. Encourage them to ask RDs questions about sweeteners and safety issues.

The ADA backs us up on this one: “It is the position of the American Dietetic Association that consumers can safely enjoy a range of nutritive and nonnutritive sweeteners when consumed in a diet that is guided by current federal nutrition recommendations, such as the Dietary Guidelines for Americans and the Dietary Reference Intakes, as well as individual health goals. Dietetics professionals should provide consumers with science-based information about sweeteners and support research on the use of sweeteners to promote eating enjoyment, optimal nutrition, and health.”2

— Jenna A. Bell-Wilson, PhD, RD, CSSD, is cofounder of Swimbikeruneat.com and a nutrition communications consultant living in the Boston area.

Common Nonnutritive Sweeteners

Sweetener and Calories	Brand Name(s)	Sweet-ness Factor	Cooking and Baking Ability	Notes	Safety Information
Acesulfame potassium Calorie free	Sunett, Sweet One	200x sweeter than sugar	Heat stable; suitable for cooking and baking	Often blended with other low-calorie sweeteners	Approved for use in more than 90 countries; approved by the FDA as a general purpose sweetener.
Aspartame Metabolized as protein but needed in very small amounts; typically provides insignificant calories	NutraSweet, Equal	160 to 200x sweeter than sugar	Not heat stable; not suitable for (lengthy) cooking or baking, but may be added to an end product	Actually comprised of two amino acids. Since only small amounts are needed to impart sweetness, items provide few calories.	FDA has approved for use as a general purpose sweetener. Prior to approval, aspartame underwent rigorous scientific review and is considered by many to be one of the most widely tested ingredients in the food supply. Not for use by individuals with phenylketonuria.
Saccharin Calorie free	Sweet‘N Low, Sweet Twin, SugarTwin	300x sweeter than sugar	Heat stable; suitable for cooking and baking	Oldest low-calorie sweetener; discovered in 1878	Approved for use in more than 100 countries; approved by the FDA. Saccharin use is permitted in specific amounts in specific food products, including beverages, processed foods, and as a tabletop sweetener.
Stevia/Rebiana Calorie free	PureVia, Truvia	250 to 300x sweeter than sugar	No information available	Derived from the leaves of a South American plant	FDA has approved and considers stevia generally recognized as safe as a general purpose sweetener.
Sucralose Calorie free	Splenda	600x sweeter than sugar	Heat stable; commonly used in cooking and baking	Derived from sugar; made via a patented, multistep process that selectively substitutes three chlorine atoms for three hydrogen-oxygen groups on the sugar molecule	Approved by the FDA as a general purpose sweetener. Safe per 110 animal studies.

— Table compiled using information from references 2, 4, and 5

References
1. Fung TT, Malik V, Rexrode KM, et al. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89(4):1037-1042.

2. American Dietetic Association. Position of the American Dietetic Association: Use of nutritive and nonnutritive sweeteners. J Am Diet Assoc. 2004;104(2):255-275.

3. Swithers SE, Davidson TL. A role for sweet taste: Calorie predictive relations in energy regulation by rats. Behav Neurosci. 2008;122(11):161–173.

4. Kroger M, Meister K, Kava R. Low-calorie sweeteners and other sugar substitutes: A review of the safety issues. Comp Rev Food Sci Food Safety. 2006;5:35-47.

5. Food and Drug Administration, Health and Human Services. Artificial sweeteners: No calories … sweet! FDA Consumer Magazine. July-August 2006. Available at: http://www.fda.gov/fdac/features/2006/406_sweeteners.html