Understanding Caloric Sweeteners & Health

Understanding Caloric Sweeteners & Health

The role of sugars and other carbohydrates in the diet is of much public health and scientific debate, particularly in relation to health outcomes, such as heart disease, type 2 diabetes, dental caries and optimal body weight, and obesity.

Caloric sweeteners, including cane and beet sugar, high fructose corn syrup, fructose (fruit sugar), and lactose (milk sugar) are a prominent part of the food supply. They occur naturally in fruits, vegetables, and milk products and are also manufactured and added to foods and beverages to contribute various sensory, functional and food safety properties.

A systematic review of sugars and body weight, commissioned by WHO, was published in January 2013. The authors concluded, “The data suggest that the change in body fatness that occurs with modifying intake of sugars results from an alteration in energy balance rather than a physiological or metabolic consequence of monosaccharides or disaccharides.” When calories in the form of added sugars from soft drinks were either added or removed from the diet, small effects on weight were observed.” (Te Morenga et al., 2012) The authors also found no consistent associations overall between sugar intake and obesity in children. (Te Morenga et al., 2012) These results suggest that it’s the calories that contribute to weight gain, not anything unique about sugar. (Sievenpiper and de Souza, 2013) Weight management is about energy balance – learning how to keep the number of calories consumed in foods and beverages in equilibrium with the number of calories the body burns each day for basic metabolism and to fuel physical activity.

Mental Performance and Behavior

Numerous studies with different populations show that sugar consumption does not affect hyperactivity, attention span, or cognitive performance in children. According to the Academy of Nutrition and Dietetics, recent reviews have found that sugar does not affect behavior or cognition in children with or without attention-deficit hyperactivity disorder (ADHD), and that parental expectations and perception are major confounders in many short- and long-term studies of the effect of sugars on behavior of children.

Athletic Performance

According to the American College of Sports Medicine, performance and endurance during prolonged physical activity is limited not only by dehydration, but also by declines in blood sugar levels and depletion of the muscle’s carbohydrate (glycogen) stores. Consuming simple sugars as the carbohydrate source during prolonged physical activity can delay fatigue and improve performance by providing fuel directly to the brain and working muscles while sparing muscle and liver glycogen use. Most commercial sports drinks contain a blend of carbohydrate sources such as the sugars sucrose, glucose, and fructose that provide the 13- to 19-grams of carbohydrates per 8 fluid ounces (240 ml) recommended by the American College for Sports Medicine for optimal performance.

Diet Quality

Two reviews in the United States and England aimed to quantify associations between dietary added sugars (as a percentage of energy) and micronutrient intake. A 2010 review by Marriott and colleagues using data from the 2003 – 2006 National Health and Nutrition Examination Survey (NHANES) found mean added sugars intake and food sources of added sugars were comparable to the mid-1990s. However, the authors noted that while higher intake of added sugars was associated with more individuals not meeting average nutrient requirements, these high levels, “occur only among a small proportion of the population and cannot explain the existing problem of poor nutrient intake in the US population as a whole.” A 2009 review by Gibson and Boyd using data from the National Diet and Nutrition Survey from 1688 British children aged 4-18 years found the “impact of added sugars on micronutrient intakes appears modest overall but may have relevance for children consuming inadequate amounts of nutrient-rich foods coupled with a diet high in added sugars (approximately 23%).”

In its examination of the data regarding sugars and micronutrient intakes for the 2002 Dietary Reference Intakes (DRI) report on carbohydrates in the diet, the U.S. Institute of Medicine found that very high and very low intakes of added sugars were associated with lower micronutrient intakes. The report suggested an intake level of 25% or less of calories (energy) from added sugars in the total diet based on data showing decreased intake of some micronutrients in some population groups exceeding this level.

The Academy of Nutrition and Dietetics (formerly the American Dietetic Association) has issued a position statement on the importance of the total diet as part of a healthful eating style: “It is the position of the Academy of Nutrition and Dietetics that the total diet or overall pattern of food eaten is the most important focus of healthy eating. All foods can fit within this pattern, if consumed in moderation with appropriate portion size and combined with physical activity. The Academy strives to communicate healthy eating messages that emphasize a balance of food and beverages within energy needs, rather than any one food or meal.” (AND, 2013)

Weight Management

There is widespread consensus that weight gain is primarily the result of an imbalance of energy, specifically too many calories consumed versus expended. The World Health Organization states, “The fundamental cause of obesity and overweight is an energy imbalance between calories consumed and calories expended,” due to a global increased intake of energy-dense foods and an increase in physical inactivity. (WHO, 2015)

  • A systematic review of sugars and body weight, commissioned by WHO, was published in January 2013. The authors concluded, “The data suggest that the change in body fatness that occurs with modifying intake of sugars results from an alteration in energy balance rather than a physiological or metabolic consequence of monosaccharides or disaccharides.” When calories in the form of added sugars from soft drinks were either added or removed from the diet, small effects on weight were observed.” (Te Morenga et al., 2012) The authors also found no consistent associations overall between sugar intake and obesity in children. (Te Morenga et al., 2012) These results suggest that it’s the calories that contribute to weight gain, not anything unique about sugar. (Sievenpiper and de Souza, 2013) Weight management is about energy balance – learning how to keep the number of calories consumed in foods and beverages in equilibrium with the number of calories the body burns each day for basic metabolism and to fuel physical activity.

  • The authors of a 2015 review concluded that it is difficult for people to reduce their intakes of fat and sugar at the same time. They researched this topic because dietary guidelines recommendations typically include both. In a press release, the first author, Dr. Sadler noted, “This study highlights the need to focus dietary messages on eating a healthy balanced diet and not categorising individual nutrients as good or bad, which could result in unbalanced dietary habits.” (Sadler et al., 2015)

  • A review of international dietary recommendations for sugar intakes revealed that the considerable variability of recommendations can create confusion for not only consumers, but for dietetic/nutrition practitioners as well. The authors concluded, “Clearly, excess energy intake in any form results in weight gain; therefore, moderating sugar intake so as to not exceed daily energy requirements can help to reduce the risk for obesity. It is not clear however, if diets lower in added sugars necessarily result in better or more balanced diets based on currently available scientific evidence.” (Hess et al., 2012)

  • CDC has noted that “Overweight and obesity result from an energy imbalance. This involves eating [and drinking] too many calories and not getting enough physical activity…When it comes to maintaining a healthy weight for a lifetime, the bottom line is – calories count! Weight management is all about balance – balancing the number of calories you consume with the number of calories your body uses or ‘burns off.’ … To remain in balance and maintain your body weight, the calories consumed…from foods [and beverages] must be balanced by the calories used (in normal body functions, daily activities, and exercise).” (CDC, 2011)

  • The Academy of Nutrition and Dietetics (formerly the American Dietetic Association) position statement on the use of nutritive and non-nutritive sweeteners notes “(t)he body does not differentiate between naturally occurring sugars and those added to foods, but those that are added to foods are most often associated with low nutrient-dense foods. Consumers should limit these empty sources of energy to help achieve or maintain a healthy weight. Consumers who want a sweet taste without added energy can choose from seven FDA-approved NNS based on their personal taste preference and the intended use (eg, for cooking or for tabletop use).”

Because sugars provide calories, it’s important to manage intake in the context of the overall diet, which should meet nutrition needs without providing excess calories to avoid weight gain. Being mindful of portion sizes and considering options that contain low-and no-calorie sweeteners are two strategies that individuals can use to help satisfy a desire for sweet tastes and manage calorie intake from sugar.

Diabetes

Diabetes is a metabolic disorder that occurs when the body cannot regulate blood glucose levels properly. In type 1 diabetes the pancreas does not make insulin, the hormone needed to help the body use glucose for energy. In type 2 diabetes, the body does not make enough insulin or cannot respond normally to the insulin that is made.

There are many potential risk factors in the development of diabetes and genetics, along with environmental and metabolic risk factors, all appear to play a role. Overweight or obesity and lack of exercise are also major risk factors in susceptibility to type 2 diabetes. Eating and drinking too many calories, including from soft drinks, can contribute to weight gain, which in turn increases the risk of diabetes.

The key to successful weight management is ensuring that calories taken in are balanced by calories burned through movement and physical activity. Because sugars provide calories, it’s important to manage intake in the context of the overall diet, which should meet nutrition needs without providing excess calories to avoid weight gain. Being mindful of portion sizes and considering options that contain low-and no-calorie sweeteners are two strategies that individuals can use to help satisfy a desire for sweet tastes and manage calorie intake from sugar.

Anyone concerned about the risk of diabetes should contact their doctor.

Dental Health

Sugars and cooked starches (e.g. bread, pasta, crackers, and chips) are fermentable carbohydrates that contribute to the risk for dental caries (tooth decay). Tooth decay can develop when fermentable carbohydrates are exposed to bacteria on the teeth, with the bacteria producing acids which gradually break down the hard enamel structure of the tooth. The degree of risk for tooth decay is related to several factors such as exposure time of oral bacteria to fermentable carbohydrates, poor dental hygiene practices, the strength of the tooth enamel, the presence of deep pits and fissures, the flow and composition of the saliva, and the type and amount of bacteria in the mouth.

However, risk can be decreased through the proper use of fluoride, along with good oral hygiene that includes regular dental checkups.

Dental erosion is the loss of minerals from the tooth’s enamel due to frequent exposure of the tooth to acids. It is unrelated to the bacterial action that occurs due to the action of oral bacteria. Dental erosion generally occurs from exposure of the tooth surface to acids, including acids found in various foods and beverages, stomach acids (Gastroesophageal Reflux Disease -GERD), and even chlorine from water. Any food or beverage that is high in food acids can contribute to dental erosion if it is consumed frequently, or if a person allows the acidic food or beverage to remain in his or her mouth for relatively long periods of time. Although many sparkling beverages are acidic in nature, they are similar in acid content to many fruit juices, including orange, apple, and grape juice.

Summary

As the main energy source for the body, carbohydrates are an important part of a healthful diet. Currently, experts agree that carbohydrates and sugars in foods and beverages can be enjoyed as part of a balanced lifestyle as long as they are consumed in moderation.

References

Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomized controlled trials and cohort studies. BMJ. 2012;346:e7492. (full-text)

Sadler MJ, McNulty H, Gibson S. Sugar-fat seesaw: a systematic review of the evidence. Crit Rev Food Sci Nutr. 2015;55(3):338-56. (full-text) Accessed June 2, 2015.

Rippe JM and Angelopoulos. Sucrose, High-Fructose Corn Syrup, and Fructose, Their Metabolism and Potential Health Effects: What Do We Really Know? Adv Nutr. 2013; 4(2): 236–245. (full-text) Accessed June 2, 2015.

Flora S and Polenick C. Effects of sugar consumption on human behavior and performance. The Psychological Record. 2013; 63:513-524. (full-text) Accessed June 22, 2015.

Sievenpiper JL and de Souza RJ. Are sugar-sweetened beverages the whole story? Am J Clin Nutr. 2013; 98(2):261-3. doi: 10.3945/ajcn.113.067215. (full-text) Accessed June 22, 2015.

WHO (World Health Organization). January 2015. Obesity and Overweight. Fact Sheet No 311. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed June 22, 2015.

American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc. 2009 Mar;41(3):709-31. doi: 10.1249/MSS.0b013e31890eb86. http://journals.lww.com/acsm-msse/Fulltext/2009/03000/Nutrition_and_Athletic_Performance.27.aspx Accessed June 22, 2015.

Use of Nutritive and Non-nutritive Sweeteners. Position of the Academy of Nutrition and Dietetics. J Acad Nutr Diet. 2012;112:739-758. (full-text) Accessed June 22, 2015.

Hess J, Latulippe ME, Ayoob K, Slavin J. The confusing world of dietary sugars: definitions, intakes, food sources and international dietary recommendations. Food Func. 2012;3,477. (abstract) Accessed June 22, 2015.

Welsh JA, et al. Consumption of Added Sugars Is Decreasing in the United States. Am J Clin Nutr. Published ahead of print, July 13, 2011. doi:10.3945/ajcn.111.018366. (full-text) Accessed June 22, 2015.

Marriott BP, et al. Intake of added sugars and selected nutrients in the United States, National Health and Nutrition Examination Survey (NHANES) 2003-2006. Crit Rev Food Sci Nutr. 2010;50(3):228-258. (abstract)

Scientific Opinion on Dietary Reference Values for Carbohydrates and Dietary Fibre. EFSA Journal. 2010; 8(3):1462 [77 pp.]. (full-text) Accessed June 22, 2015.

Nutrition and Athletic Performance. Med Sci Sports Exerc. 2009;41(3)709-731. (full-text) Accessed June 22, 2015.

Gibson S, Boyd A. Associations between added sugars and micronutrient intakes and status: further analysis of data from the National Diet and Nutrition Survey of Young People aged 4 to 18 years. Br J Nutr. 2009;101(1):100-7. Epub 2008 Jul 8. (full-text) Accessed June 22, 2015.

Dietary Reference Intakes Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. (2005) Institute of Medicine, Food and Nutrition Board (FNB) (full-text) Accessed June 22, 2015.

White JW and Wolraich M. Effect of sugar on behavior and mental performance. Am J Clin Nutr. 1995;62(1 Suppl):242S-247S; discussion 247S-249S. (full-text) Accessed June 22, 2015.