Sugar Substitutes: What's Their Real Value?

About 15 percent of Americans use sugar substitutes to cut calories, control diabetes, or prevent cavities. Yet just how much is safe to consume?

Sugar-free foods and drinks are lower in calories than their full sugar alternatives, but are they good options for weight loss? While sugar substitutes are generally safe, the debate about how they should be used continues.

Sugar Substitutes: A Short and Sweet History
The first sugar substitute, saccharin, was discovered in the late 1800s and gained prominence in manufacturing during the World Wars, when sugar was rationed. The business of sugar-free foods and drinks began to boom in the 1960s when clinicians realized the importance of controlling weight gain in the management of diabetes.
Since then, as people became more health-conscious and wanted to shun sugar, manufacturers responded with a host of sugar substitutes. They are:
• Aspartame, approved in 1981 by the U.S. Food and Drug Administration (FDA) and now in more than 6,000 foods and drinks
• Acesulfame-K, FDA-approved in 1988
• Sucralose (Splenda, SucraPlus), approved in 1998 for limited use and in 1999 for general use
• Neotame, approved in 2002
Other sugar substitutes are being developed, and many products contain a mix of sugar substitutes to enhance flavor. Each sugar substitute is several thousand times sweeter than sugar, but has a slightly different flavor. Whether you reach for the pink, blue, or yellow packet to sweeten your coffee is a matter of personal taste. Sugar substitutes are now so common that many people use them without consciously considering their use as a weight-loss strategy.

Sugar Substitutes: Their Role in Your Diet
As part of an overall healthy diet, sugar substitutes are believed to reduce calories and the risk of cavities. Interestingly, controlled studies that compare weight loss between people who use sugar substitutes and those who consume sugar show very little difference in weight loss between the two groups, although over the long term, sugar substitutes can help maintain weight loss.
Conscious calorie-cutting strategies can include sugar-free products. Replacing a sugary drink with a sugar-free drink will reduce your calorie intake, and cutting back by just one full sugar soda a day could result in losing over 1.4 pounds in 18 months. The key to losing weight using sugar-free products is to use them strategically.

Sugar Substitutes: How Much Can You Have?
A big question surrounding sugar substitutes is how much diet soda is safe to drink. Though you might never consider consuming this much in a day, the FDA says these are the maximum amounts allowable for daily consumption, listed by type of sugar substitute:
• Aspartame: 18 to 19 cans of diet soda
• Saccharin: 9 to 12 packets
• Acesulfame-K: 30 to 32 cans of diet soda
• Sucralose: 6 cans of diet soda

Sugar Substitutes: Reality Check
A realistic use of sugar-free products looks quite different.
A regular amount for a sugar substitute is two servings a day, says dietitian Liz Weinandy, RD, MPH, a dietitian in the non-surgical weight-loss program at Ohio State University Medical Center in Columbus. “My concern comes when people do multiple servings, like a six-pack of diet pop a day. Many times they are trying to use a sugar substitute in place of food. Some are very nutritious, like light yogurt, but while sugar-free soda doesn’t have calories, it also doesn’t have stuff in it that’s good for you.”
Further, consuming a lot of sugar-free drinks could hurt your weight-loss strategy. Studies show that when a sugar substitute is added to a product that has no other nutritional content (such as water), it increases hunger. This is true regardless of the type of sugar substitute used. Sugar substitutes in foods do not have this effect.

Sugar Substitutes: Who Should Avoid Them
While sugar substitutes are generally considered safe, Weinandy advises against giving children sugar-free foods and drinks — unless a doctor has said otherwise — and says pregnant women also should be cautious. “Drink water or fruit juice during pregnancy,” Weinandy suggests. “Limit diet pop to one per day at most.”
Additionally, people who have the disease phenylketonuria need to avoid aspartame, which contains phenylalanine, one of the amino acids in protein. Phenylketonuria is a genetic disorder in which the body cannot fully break down phenylalanine. If levels of it get too high in the blood, mental retardation could result.
For most people, sugar substitutes are a safe alternative to sugar. They may be helpful, in reasonable amounts, with weight loss and weight management when they are part of a balanced, healthy diet.

By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

Motivating a Teen With Type 1 Diabetes

Q: My 16-year-old son is having difficulty staying motivated to consistently take care of his diabetic needs like checking his blood sugar often and keeping a log book. His doctor hospitalized him at the start of school to establish better control — his first hospitalization since diagnosis with type 1 10 years ago. He is active in sports, likes to stay up late, eats only 15 to 30 carbs for breakfast, and is on a regimen of Lantus twice daily and Humalog for meals and highs (injections, no pump.) His last A1c was 10.3. Do you have suggestions for helping him be motivated to care for himself?
— Janelle, Nebraska

A:
That's a tough situation indeed. Many of my colleagues who care for teenaged patients have similar moments of exasperation. As you know so well, the teen years are filled with layers of complexities for kids themselves and their families. There are many issues that become priorities in any teenager's life, among them the challenges presented by their own growth and development. These issues become even more complicated for a teenager with diabetes.

Adolescence is a time of great change, and with physical growth come greater insulin requirements. And with rebellion, experimentation and the need for peer acceptance comes greater non-adherence. In addition, while trying to find and assert their own identity, teens become less reliant on mom and dad. The challenge for parents is equally great and the solutions, unfortunately, are usually time-consuming and labor-intensive.

Your son is doing certain things for which he should be congratulated, including getting involved in sports, carbohydrate counting and injecting his insulin several times a day. These are feats that many of my adult patients do not accomplish.

Motivating your son further might require one or more of the following:
1. Understanding his attitude towards frequent glucose checks and his coping and problem-solving skills will help you in identifying specific ways to help him change his behavior.

2. Assessing his knowledge-base about the need to check his sugar levels and his knowledge of glucose and insulin balance during athletic engagements can identify gaps, which can be easily addressed.

3. Understanding his priorities and academic responsibilities and showing empathy to these daily challenges can help you provide a structure that is conducive to checking blood glucose levels and diabetes self-management.

4. Exploring the barriers of checking his sugar level at school, as well as the challenges he might face from his peers about having diabetes, doing frequent glucose checks and injecting insulin, might uncover issues that he finds difficult to discuss. Since you live in a small town, there might not be many other kids living with diabetes. Perhaps your son can connect with other kids with diabetes via the Internet for peer support. A good place to start is the American Diabetes Association.

5. More importantly, understanding your communication pattern with your son and assessing its effectiveness will help you find a happy medium between too much involvement and too little engagement. Empathy is important, but so is leaving him room to make his own decisions. In other words, asking him how he can meet the challenge of good glucose control might also be more effective than telling him to make a specific change in his behavior.

6. When exploring these areas, you should enlist the help of your son's doctor as well as a psychologist or diabetes educator in your area. In addition, if you find that there are barriers at school that prevent your son from checking glucose, you should involve the school and teachers. Some teens like taking leadership roles in teaching others about diabetes, advocating for students with diabetes and organizing groups. This gives them the motivation for also managing their diabetes better. Teachers can be recruited to stage such a forum for your son and perhaps other teens. Other possible venues you might explore include religious organizations, social clubs, and community fitness centers.

Finally, this might be time to consider the insulin pump, which many teens like because it allows them better control. I wish you much luck and hope you will write back with further questions or to tell us how you and your son are doing.