Are Artificial Sweeteners A Good Choice for Kids?

Sugar substitutes are everywhere! Whether natural or artificial, non-sugar sweeteners are in more foods than ever before. They’re in things many kids eat daily. What’s a parent to do? Avoid them? Or, seek them out to replace sugar? Unfortunately, the research is not crystal clear. But, we do know enough to make a few general recommendations about sugar and sugar substitutes in kids’ diets.

Today, I’ll review what these sugar substitutes are and what we know about them. I’ll cover highlights from the American Academy of Pediatrics (AAP) policy statement about nonnutritive sweeteners, including for which children this information is most useful. Lastly, we’ll discuss some general suggestions and a promising “newer” sweetener on the market.

What are Nonnutritive Sweeteners?

Nonnutritive sweetener is a general term for some sugar substitutes. It adds a sweet flavor, but no or minimal calories. It does not affect blood sugar levels.

Regular table sugar has calories. It is addictive. And, we know it contributes to human health problems. We should limit added sugar whenever possible. Children over age 2 should have less than 25 grams per day of added sugar. Recently, nutrition labels in the United States have included a line specifying “added sugar.” (This is different than the natural sugars found in many foods like milk or fruit).

With the dangers of excess sugar in mind, it’s no wonder there are so many sugar substitutes. Below are the more common FDA-approved sweeteners in the U.S.

• saccharin (SweetN’Low)
• aspartame (Equal, Nutrasweet)
• acesulfame potassium (Sunett, Sweet One)
• sucralose (Splenda)
• stevia (Truvia, Pure Via)
• neotame (Newtame)
• advantame
• monk fruit extract aka luo han guo fruit

We also often talk about “sugar alcohols” when we talk about artificial sweeteners. They are also usually lower in calories than regular sugar, and can have less effect on blood sugar. Xylitol and erythritol are some of the more common ones. For today’s post, though, I’m going to focus mostly on the sweeteners listed above. (There may be more to say about sugar alcohols in a future post).

Which Foods Contain These Sugar Alternatives?

Sugar substitutes are in many foods, especially processed foods. In fact, this is one reason they’re so hard to study in humans! Food labels in the United States aren’t required to specify the amount of a nonnutritive sweetener in a specific product. Some studies showed that people who thought they had not eaten any artificially-sweetened foods still had the sweeteners show up in their lab tests. Common foods that contain some of these sweeteners include: yogurt, some “no sugar added” canned fruits, protein shakes, Lean Pockets, some sugarless gums, and diet sodas. For most people, drinks are the most common source.

Are Nonnutritive Sweeteners Safe?

They’re in many foods, so hopefully they’re safe, right? Well. In the amount most people eat, they’re considered safe enough for adults. A few years ago, there were concerns linking some sweeteners to cancer. Additional studies have not shown this link.

But. This is a lot of animal-based research. Because of how common the sweeteners are and how people consume them in unknown quantities (remember food labels don’t say how much is in any particular product?), it’s challenging to know the direct long-term impact. This is especially important when thinking about kids. We simply cannot say what the lifelong effects are. There just isn’t research to tell us.

Are Nonnutritive Sweeteners Useful?

For a few specific groups of children, these sweeteners can improve their health. This includes kids with diabetes and kids with obesity. Again, the research is pretty limited. And, generally speaking, the data are not clear for all kids everywhere.

For Children with Diabetes

Someone with diabetes mellitus needs to pay close attention to their blood sugar levels. This can include limiting added sugar in their diet. For these children, adding something sweet to their food that does not affect blood sugar can be very helpful! It can be part of their overall plan for controlling their illness. For these kids specifically, there are health benefits to using these sweeteners because the alternative of regular sugar can affect their blood levels. (Management of diabetes is beyond what we’re talking about today. Considering sugar substitutes is just a tiny part of a treatment plan).

For Children with Obesity

Just like everything else we’ve discussed so far with nonnutritive sweeteners, the research on kids with obesity is not complete. Overall though? The sweeteners may have a small benefit for a young person trying to lose or stabilize weight. This benefit is related to lowering calories overall. However, there are many variables in health, obesity, and weight. In real life, it’s hard to isolate a single cause and effect.

For example, some people eat more overall when they have sugar substitutes. The theory is that the substitute is less satisfying. In these cases, the sweeteners could be related to weight gain.

In general, the sweeter a food is, the more kids eat, compared to less sweet foods. This is something to consider when making food choices overall.

Nonnutritive Sweeteners, Obesity, & the Microbiome

One thing I’m excited to learn more about is the effect of nonnutritive sweeteners on the gut microbiome. The microbiome refers to the bacteria that live naturally in and on the body. We’re learning that it influences many aspects of overall health. (Several weeks ago, we discussed how it’s related to the immune system).

So, do the sweeteners change the microbiome? Early research in animals and adult humans suggests that they probably do, particularly saccharin. And, it seems to happen in such a way that it can lead to glucose intolerance. (Glucose intolerance can be related to obesity and pre-diabetes). In children, one study showed that the higher the intake of nonnutritive sweeteners, the higher the body fat. The correlation was thought to be related to the microbiome.

Again, I cannot emphasize enough how little long-term research exists. This is just the information we have now. I share so that we can all keep an eye on new information as it comes out.

For Children with Autism and ADHD

Current research shows no effect between nonnutritive sweeteners and autism or ADHD (attention deficit/hyperactivity disorder).

How Should We Approach Using Nonnutritive Sweeteners with Our Children?

Do you see a theme in all the information so far? More research is needed! And, good quality research in children would be challenging. The FDA has recommended “acceptable dietary intake” levels for many sweeteners, based on toxicity in animal studies. This means, to me, that we should limit them when possible. This is especially because we don’t often know exactly how much kids are consuming. Sugar substitutes could be useful for someone with obesity or diabetes who is specifically trying to reduce calories or sugar. For everyone else, the data are too unclear.

Humans naturally enjoy and crave sweet flavors. This is especially true for children. And, there may be benefits to enjoying sweet things on occasion. However, no one could argue that it’s healthy to eat a high sugar diet. So, my suggestion is this: we continue to enjoy good-tasting food in moderation. Whether it’s added sugar or a nonnutritive sweetener, we can eat it when it adds to our quality of life. I think of a popsicle on a hot summer day. Or birthday cake. Other times, it’s probably best to prepare foods with less added sweetness. And, we should try to avoid processed foods whenever possible.

The AAP recommends no added sugar for children under age 2. Avoiding sweetened and processed foods at these younger ages has many benefits. Kids are developing their taste preferences, and it’s a wonderful time to introduce a variety of healthier options.

And, as always, drinking mostly water is best. For children and adults.

Lastly, we should advocate for more complete food labels. When it comes to these sweeteners, knowing quantities is an important step in learning more overall.

A Quick Note on Allulose

This is a “newer” sweetener that we’ll continue to learn more about. It’s found in nature (figs, maple syrup, kiwi) and tastes similar to sugar. However, it’s not metabolized by the body in the same way, so it does not affect blood glucose levels. The FDA considers it “generally recognized as safe.” It was not included in most of the previously mentioned research. Available information shows that its main side effect in some people is GI discomfort, like bloating. There’s not enough good-quality information for me to recommend it wholeheartedly for kids, but it seems interesting.

Summary

Nonnutritive sweeteners are very common in our food supply. It’s difficult to accurately study long-term effects on children, and we do not have enough information to make strict recommendations. As we learn more, we should encourage eating in moderation, focusing on unprocessed foods. And, choosing water over any sweetened beverage is always a good choice.

On one hand, this is an unsatisfying conclusion. We have all this research. And yet, it’s still not enough to make a confident 100% safe recommendation for the general population.

On the other hand, it’s gratifying to know that the recommendation to eat a wide variety of healthy foods and drink mostly water is as timeless and true as ever.

Photo by Cristina Matos-Albers on Unsplash

References

Baker-Smith, C. M., de Ferranti, S. D., Cochran, W. J., & COMMITTEE ON NUTRITION, SECTION ON GASTROENTEROLOGY, HEPATOLOGY, AND NUTRITION (2019). The Use of Nonnutritive Sweeteners in Children. Pediatrics, 144(5), e20192765. https://doi.org/10.1542/peds.2019-2765

Mooradian A. D. (2019). In search for an alternative to sugar to reduce obesity. International journal for vitamin and nutrition research. Internationale Zeitschrift fur Vitamin- und Ernahrungsforschung. Journal international de vitaminologie et de nutrition, 89(3-4), 113–117. https://doi.org/10.1024/0300-9831/a000531

Wee, M., Tan, V., & Forde, C. (2018). A Comparison of Psychophysical Dose-Response Behaviour across 16 Sweeteners. Nutrients, 10(11), 1632. https://doi.org/10.3390/nu10111632

Han, Y., Choi, B. R., Kim, S. Y., Kim, S. B., Kim, Y. H., Kwon, E. Y., & Choi, M. S. (2018). Gastrointestinal Tolerance of D-Allulose in Healthy and Young Adults. A Non-Randomized Controlled Trial. Nutrients, 10(12), 2010. https://doi.org/10.3390/nu10122010

Noronha, J. C., Braunstein, C. R., Glenn, A. J., Khan, T. A., Viguiliouk, E., Noseworthy, R., Blanco Mejia, S., Kendall, C., Wolever, T., Leiter, L. A., & Sievenpiper, J. L. (2018). The effect of small doses of fructose and allulose on postprandial glucose metabolism in type 2 diabetes: A double-blind, randomized, controlled, acute feeding, equivalence trial. Diabetes, obesity & metabolism, 20(10), 2361–2370. https://doi.org/10.1111/dom.13374

allulose.org. What is Allulose and What is it Made From?

Harris, J. L., Schwartz, M. B., Ustjanauskas, A., Ohri-Vachaspati, P., & Brownell, K. D. (2011). Effects of serving high-sugar cereals on children’s breakfast-eating behavior. Pediatrics, 127(1), 71–76. https://doi.org/10.1542/peds.2010-0864

National Institutes of Health. (2014) Sweet Stuff: How Sugars and Sweeteners Affect Your Health. News in Health. via https://newsinhealth.nih.gov/2014/10/sweet-stuff