Cutting out empty calories from added sugars, especially in the form of beverages, is one of the lowest hanging fruit in dietary efforts for improving health. Substituting artificially sweetened (non-nutritive sweeteners or NNSs) alternatives for sugar-sweetened drinks has been a common method for reducing energy intake for a long time now. Unfortunately, due to legitimate debate regarding the actual risks and benefits NNSs, even when discussing energy balance and obesity-related complications, there is confusion amongst the population causing some to feel sugar beverages are actually better.
In 2017, the DocsWhoLift wrote a review for MedpageToday following the publication of several studies sparking further interest in the debate. We concluded that despite concerns of adverse potential gut flora and observational correlation with obesity & cardiometabolic disease, the body of evidence shows that sugar substitutes lead to less weight gain or weight loss compared with their highly caloric sources of sugar. The bottom line is that those who struggle with drinking soda, juice, sweet tea, or high calorie specialty coffees can make great progress by switching to similar options that utilize a variety of low energy sweeteners.
In 2020, I was slated to debate a colleague in a “point – counterpoint” academic conversation comparing my endorsement of NNSs versus her cautionary approach at the national American Association of Clinical Endocrinologists’ annual meeting. Unfortunately, due to COVID-19, it was transformed into a virtual talk which should still be available if interested.
For this patient-facing article, I am hoping to share a brief version of my slides and commentary along with the main points for everyone to consider.
1 – Energy balance remains the key variable in body composition and the basis of obesity or adiposity-based chronic disease. If replacing calories from sugar with non-caloric sweet alternatives and all else remains the same, it benefits fat loss or at least maintenance.
2- Meta-analyses of interventional trials have shown that NNSs have favorable results for fat mass and abdominal obesity, lower energy intake and favorable weight changes versus sugar, and weight reduction especially in adults with obesity and unrestricted diets when replacing sugar.
3 – Incorporating artificially sweetened alternative beverages is a staple habit of those who have struggled with obesity, lost weight and maintained that weight loss according to the National Weight Control Registry.
4 – No evidence to support adverse effects on blood sugars in general. Meta-analyses have not shown an effect of NNSs on immediate blood sugar changes or appetite or glucose metabolism. The most recent analysis (including saccharin, sucralose, aspartame and stevia) concluded that ingestion of NNs alone or in combination with sugar has no acute effects on post-meal sugar or insulin responses compared with a control without difference between type/dose or baseline sugar/insulin. Of note, one recent study did show possible adverse effects of combining sucralose with maltodextrin (compared to sucralose or sugar alone) in regards to functional brain MRI activity and insulin sensitivity.
5 – Meal replacement protein shakes have been researched extensively proving to be very beneficial for weight loss and blood sugar improvement in type 2 diabetes. They are all flavored with a variety of artificial sweeteners.
While consumption of NNSs or artificial sweeteners is not encouraged, per se, they should be considered useful as sugar substitutes. This is especially true for replacing sugar-sweetened beverages (SSBs) like soda-pop, juice, sweet tea, alcoholic beverages, etc. Caution must be taken to pay personal attention to hunger, cravings and satiety to avoid compensation with increased calorically dense foods. We’d discourage sweet food consumption on a regular basis, regardless of source, other than for treats. Overall, it is more important to consider the context of the overall quality of the diet.