Non-sugar sweeteners are on the rise as superior sugar substitutes. Do they live up to the expectations?

Global sugar consumption has soared threefold in the last 50 years (from ~60 million tonnes in the 70s to almost 180 million in 2024). This increase in sugar consumption is attributable to increased production, availability, and accessibility of high-sugar, calorie-dense, ultra-processed foods (UPFs) worldwide. In Indonesia alone, UPF consumption takes up about 19.5% of total energy intake and has contributed to the growing mortality rate related to non-communicable diseases (NCDs) (eg, stroke, coronary heart disease, diabetes), approximately totaled 69% in 2019. 

Recognizing the desire for sweet flavors amidst the rising incidence of obesity, diabetes, and metabolic syndrome, the food industry has developed low-calorie sugar-free alternative ingredients, commonly labeled as sugar substitutes, artificial sweeteners, non-nutritive sweeteners (NNS), or non-sugar sweeteners (NSS). These ingredients are food additives either sourced naturally from plants or produced synthetically to sweeten foods, beverages, drugs, and mouthwashes.

In Indonesia, several NSSs have been approved by the Indonesian Food and Drug Authority (Badan Pengawas Obat dan Makanan or BPOM), including natural sweeteners like sorbitol, mannitol, isomalt, thaumatin, steviol glycosides, maltitol, lactitol, xylitol, and erythritol, as well as artificial sweeteners like Acesulfame-K, aspartame, cyclamic acid, saccharin, sucralose, and neotame. 

Marketed as low-calorie options, products with NSSs that are between 30 to 700 times sweeter than sugar and contain little to no calories per gram (±2.4 kcal/g as opposed to 4 kcal/g in sugar) may mislead consumers into thinking that the products are “healthier” and “safer” than its nutritive counterpart.

But are they?

What the science says about NSS and human health

A narrative review in 2021 reported that stevia, a sugar substitute 50 to 300 times sweeter than sugar, contains flavonoids and fatty acids that stimulate insulin production in diabetics, improve polycystic kidney disease, treat cancer, and have antibacterial, antioxidant, and immune-boosting properties. More broadly, a 2022 systematic review and meta-analyses of cohort studies (n = 416,830 participants) found that substituting sugar for NSS in sugary drinks is associated with lower weight, as well as lower risk of obesity, coronary heart disease, cardiovascular mortality, and total mortality. 

However, other studies are showing the opposite results.

A 2021 systematic review and random-effects and dose-response meta-analysis of prospective cohort studies looking at the association between sugary drinks and different mortalities revealed that consuming beverages with NSS increases the risk of all-cause and cardiovascular disease mortalities by 4% every 250 ml/day. Further, more recent narrative reviews in 2022 and 2023 suggested that consuming NSS can disrupt gut microbiota and promote glucose intolerance in healthy individuals, potentially leading to type 2 diabetes mellitus. 

In some studies, the health impacts of NSS are simply inconclusive.

Results of a 2022 systematic review and meta-analyses showed that consuming more NSSs helps reduce body weight and BMI among adults in the short term (3 months or less) compared to those who consumed less or no NSS. The benefits on weight were mostly seen when NSS intake replaced free sugars, leading to lower overall calorie consumption. No significant effects were found on blood sugar, insulin levels, or blood lipids, which are proxies for a couple of NCDs like diabetes and heart diseases.

In the long term (up to 10 years), the results are contradictory, where higher NSS consumption was linked to increased BMI and a higher risk of obesity, type 2 diabetes, cardiovascular diseases, and death. 

This trend is consistent in other studies examining the health outcomes of NSS consumption in both healthy and comorbid subjects (ie, with diabetes and hypertension).

Inconclusive evidence on the health outcomes of NSS consumption signifies that it is still premature to decide whether NSS is “healthier” or “safer” than traditional sugar for reducing the risk of NCDs. 

This indicates that any recommendations on the consumption of NSSs should be taken with caution, especially for vulnerable populations (ie, children, pregnant women, and the elderly) as well as populations with pre-existing metabolic diseases (eg, diabetes or obesity). 

The research needs to be expanded. More research to focus on the impacts of NSS on populations with pre-existing metabolic diseases via longer-duration observational studies is needed. Instead of specifying a single type of NSS, future studies should explore the combined use of various NSS types, which is more reflective of real-life scenarios where multiple NSS types are consumed within a single product or along with regular sugar. Studies comparing the health outcomes related to different doses of NSS, such as higher versus lower doses, are also lacking and thus need to be explored further.

But NSS is at least more environmentally sustainable, right?

While the global warming potential (GWP) from the production of 1kg of aspartame, neotame, and stevia is much lower than that of sugar (10.5-18.4%, 0.4-0.7%, and 5.7%-10.2%, respectively), studies on the impact of NSS on the environment remains divided. 

Among many environmental matrices, surface water is the most studied matrix involving NSS. A 2019 narrative review of 24 studies conducted worldwide reported the occurrence of NSS in surface water, tap water, groundwater, seawater, lakes, and the atmosphere. For example, Acesulfame-K, sucralose, saccharin, and cyclamate are among the most commonly marketed non-biodegradable NSS found to persist in the aquatic environment. A 2021 narrative review supported these findings and found that NSS poses a threat to water systems because they are resistant to wastewater treatment processes. 

One exception is found for aspartame, a type of NSS that can be metabolized by our bodies and thus reduces its potential as a persistent pollutant in water. This is further mitigated by the efficient removal of this particular type of NSS in wastewater treatment facilities. 

These conflicting results raise some questions about tradeoffs across other environmental and ecosystem health indicators, such as habitat, resources, and species diversity. 

There are still many unanswered questions and gaps in our scientific knowledge about the environmental and ecological outcomes of NSS consumption.

Is persistent NSS considered hazardous chemicals? Does stevia or aspartame have the same impact as other less-studied NSSs on soil and water ecosystems? How does NSS impact biodiversity? Are there any differences between natural and synthetic NSS in their environmental and ecological impacts?

Science has only scratched the surface.

Optimize sugar taxation policies, rewire our palate, or break sugar habits?

The decision to choose NSS over regular sugars becomes increasingly relevant because more types of NSS are slowly dominating the world market.

In many countries, policies related to NSS are often paired with sugar-sweetened beverage (SSB) taxes to address public health issues. This is because NSS and SSB consumption impact overall health outcomes, such as obesity and diabetes. Combining both ensures a comprehensive approach to reducing overall sugar intake and promoting healthier dietary habits across the board.

This is particularly true for Indonesia, as the plan to implement SSB taxation policies is underway without the integration of NSS, which may lead to partly effective nutrition outcomes misaligned with public health goals. 

To be optimal, sugar taxation policies should be combined with other measures, such as socializing sugar intake recommendations, providing clear nutrition labeling, and promoting healthy consumption patterns. This can send a powerful message to the public that SSBs and artificially sweetened beverages (ASBs), while sweet and low in calories, do not have beneficial nutrients like vitamins, fiber, minerals, or antioxidants and thus should not be considered part of a healthy and nutritious diet. This approach supports behavior change at the individual level and can reduce sugar intake in the population. 

As mentioned in our previous article about sugar, the more we eat sugars, the more our brains crave them. This also applies to NSS. With between 30 to 700 times more sweetness than sugar, NSS produces only partial activation of food reward pathways and potentially increases appetite and food-seeking behavior, which could lead to uncontrolled consumption of sweet foods and weight gain. 

So the next time our sugar cravings occur, find a bottle of iced (infused) water as opposed to sugary drinks (psst, sugary drinks are counterproductive and can make us more thirsty!). Reserve some cakes and cookies for special occasions and opt for the sweetest fruits like dates, mangoes, or watermelons (diabetic patients should always consult a healthcare professional). If you bake some homemade goods, try and play around with spices like cinnamon, nutmeg, and ginger, as they elevate the sweetness of foods. On the days when we simply need some cheap, convenient, and fast sweets and snack foods, learn the nutrition labels carefully and purchase wisely.

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