Some of the most frequent questions we receive at Diabetic Living are about sugar substitutes. The topic is polarizing: some of you love them, some of you hate them. Some of you are concerned about their safety, and some of you want tips for how to use them more. For many people with diabetes, sugar substitutes -- which include artificial and natural sweeteners -- provide solutions for cutting out excess calories and carbohydrate while still being able to enjoy sweet treats.
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Sugar substitutes are among the world's most scientifically tested food products, and the U.S. Food and Drug Administration (FDA) has deemed them "generally recognized as safe." The one sweetener that still carries a warning on its label is aspartame (the sweetener in Equal Classic and NutraSweet) because a small group of people -- about 1 in 25,000 in the United States -- has a genetic condition that prevents the metabolizing of phenylalanine, an amino acid in aspartame.
While there is still a lot of testing to be done as new products enter the market, we know a lot more about sweeteners now than we did when the first sugar substitute, saccharin, was discovered more than 100 years ago.
Q. Is it better for a person with diabetes to use real sugar or sugar substitutes?
A. It depends. Both can fit in a healthful eating plan, but you should limit your intake of both as well. In terms of heart health, short-term studies suggest diet soda is better than regular soda, says Kimber Stanhope, Ph.D., RD, at the University of California, Davis. Recently, a small study in Denmark found that healthy people who drank about 4 cups a day of sugar-sweetened cola for 6 months had significant increases in belly fat, cholesterol, and triglycerides compared with those who drank aspartame-sweetened cola. Most artificially sweetened foods still contain calories and carbohydrate, so fit them in your daily calorie and carb counts just as you would any other food or drink.
Q. Why do some people say artificial sweeteners cause cancer?
A. "The idea of artificial sweeteners causing cancer arose when early studies showed that high doses of a sweetener named cyclamate, which is currently banned from U.S. food products, in combination with saccharin caused bladder cancer in laboratory animals," says Kantha Shelke, Ph.D., at Corvus Blue LLC, a food science and research firm in Chicago. The FDA has since deemed artificial sweeteners used in the United States to be safe based on extensive animal and human studies. Furthermore, studies have not documented adverse effects related to the intake of sugar substitutes, even when human subjects have consumed relatively large amounts. Few studies have been done in humans to evaluate the long-term effects of using sugar substitutes, however. The FDA has set acceptable daily intake (ADI) limits for each artificial sweetener. One study shows that the average daily intake of the heaviest users of aspartame was only 5-10 percent of the ADI.
Q. Which sugar substitute should I use for baking?
A. In the Better Homes and Gardens Test Kitchen, we test recipes first using regular granulated and/or brown sugar. When we achieve great results with those, we move on to test with a variety of sugar substitutes. We have the most success with baking blends, such as Splenda Sugar Blend or C&H Light, and limited success with other brands, depending on the length of cooking or baking time. Splenda Granular has proved successful in many recipes, and we have some success with Sweet'N Low, Truvia, and Equal.
Q. What are some of the newer sugar substitutes on the market?
A. Monk fruit extract (or luo han guo fruit concentrate) is a natural sweetener increasingly used by natural-foods manufacturers. "The sweetener is extracted from a small Asian melon that looks a bit like kiwifruit and has a licoricelike aftertaste," Shelke says. Because of its taste profile, you may see it used in one flavor of a product but not another. A relatively new artificial sweetener is neotame, which is made from aspartame (but unlike aspartame, it can be used by people with the medical condition phenylketonuria). Neotame is used in products such as sugar-free pancake syrup and lower-sugar protein bars.
Q. What is typically inside a packet of sugar substitute?
A. "Most sugar substitutes are much sweeter than sugar, so just a tiny amount is needed to match sugar's sweetness," Shelke says. "But people like it when substitutes look and measure the same as sugar, so manufacturers make up the difference with fillers, such as maltodextrin." Maltodextrin is a starch that supplies carbohydrate (that yields glucose), but because the amount per packet is less than 5 calories, the sweetener can be labeled with 0 calories, Shelke says. Some substitutes also have added fiber, but she says this isolated fiber does not provide the same benefits as fiber in whole foods.
Q. Are honey and agave nectar better than sugar substitutes?
A. Honey (but not agave nectar) is moderately higher in antioxidants than refined white sugar. Honey also has small amounts of minerals important for good blood glucose control, including chromium, copper, and zinc. And generally, agave nectar and pure honey have a lower glycemic index (GI) than table sugar, so they may impact blood glucose less, says Jennie Brand-Miller, Ph.D., coauthor of several books on GI. "However, both of these sweeteners have much the same calorie content as sugar, so if you eat excessive quantities of any of them, you run the risk of a weight-gain creep," she says.
Q. What are sugar alcohols?
A. Sugar alcohols, also called polyols, are sugar replacers that have about half the calories of sugar and a low glycemic index. Food manufacturers currently use several different polyols, and most of their names end in "ol," such as sorbitol. A small 12-week study of people with type 2 diabetes suggests that moderate amounts of polyols regularly added to meals may help improve A1C, or average blood glucose. Consuming too much of certain polyols (especially sorbitol), however, could cause digestive issues, including loose stools, but moderate amounts of 10-15 grams per day are generally well tolerated.
Sugar substitutes -- especially sucralose, acesulfame-K, and aspartame -- are used in thousands of U.S. products, including foods, beverages, dental products, and medicines. Here's a sampling of items that contain each type of sweetener, though many products contain more than one sweetener because some sugar substitutes enhance the flavor of others.
Sweetened with Equal
Generic sweetener name: Aspartame
Sweetened with Nectresse
Generic sweetener names: Monk Fruit Extract, Luo Han Guo Fruit Concentrate
Sweetened with Splenda
Generic sweetener name: Sucralose
Sweetened with Sweet'N Low
Generic sweetener name: Saccharin
Sweetened with Sweet One
Generic sweetener names: Acesulfame-K, Acesulfame-Potassium
Sweetened with Truvia
Generic sweetener name: Stevia, Rebiana, Reb-A