Position of the Academy of Nutrition and Dietetics:
Use of Nutritive and Nonnutritive Sweeteners
S
WEETENERSCANBEGROUPEDIN
various ways. For the purpose
of this article sweeteners
will be grouped as
nutritive and nonnutritive. Nutritive
sweeteners contain carbohydrate and
provide energy; they may be further
classified into monosaccharides or disaccharides,
which impart 4 kcal/g, or
sugar alcohols (polyols), which provide
an average of 2 kcal/g (1). Different
terms are used to refer to nutritive
sweeteners, including sugars, sugar, caloric
sweeteners, and added sugars. Sugars
occur naturally (intrinsic) in all
fruit, vegetables, and dairy foods or are
added (extrinsic) to foods during processing,
or in preparation for consumption
by an individual (2).
Sugars commonly found in foods in-
clude:
• Glucose A monosaccharide and
the primary source of energy for
body cells.
• Fructose A monosaccharide
found in fruit, honey, and some
vegetables. In nature, it is linked
with glucose as the disaccharide
sucrose. Fructose may be used as
a nutritive sweetener.
• Galactose A monosaccharide
that occurs in dairy products and
some plants.
• Sucrose A disaccharide that occurs
naturally in fruit and vegetables.
It is composed of approximately
equal parts glucose and
fructose and is used as a nutritive
sweetener and for its other functional
properties.
• Maltose A disaccharide composed
of two glucose units; it is
found in molasses and is used for
fermentation.
• Corn-based sweetener Refers to
many products made from corn.
They may be composed primarily
of glucose, fructose, or any combination
of the two. High-fructose
corn syrup (HFCS) is a mixture
of glucose and fructose and
is only available to food manu-
facturers.
• Agave nectar A nutritive sweetener
that contains fructans, oligosaccharides
of fructose and
glucose, and monosccharides of
fructose and glucose.
Sugar often refers to sucrose, which is
derived from sugar cane or sugar beets.
The US Department of Agriculture
(USDA) uses added sugars to refer to
sugars and syrups added to foods during
processing, preparation or before
consumption. In addition to imparting
a sweet taste, sugars have the following
functions that are important to safety
and quality in foods:
• Inhibit microbial growth by
binding water in jams and jellies.
ABSTRACT
It is the position of the Academy of Nutrition and Dietetics that consumers can safely
enjoy a range of nutritive sweeteners and nonnutritive sweeteners (NNS) when consumed
within an eating plan that is guided by current federal nutrition recommendations,
such as the Dietary Guidelines for Americans and the Dietary Reference Intakes, as
well as individual health goals and personal preference. A preference for sweet taste is
innate and sweeteners can increase the pleasure of eating. Nutritive sweeteners contain
carbohydrate and provide energy. They occur naturally in foods or may be added in food
processing or by consumers before consumption. Higher intake of added sugars is associated
with higher energy intake and lower diet quality, which can increase the risk for
obesity, prediabetes, type 2 diabetes, and cardiovascular disease. On average, adults in
the United States consume 14.6% of energy from added sugars. Polyols (also referred to
as sugar alcohols) add sweetness with less energy and may reduce risk for dental caries.
Foods containing polyols and/or no added sugars can, within food labeling guidelines, be
labeled as sugar-free. NNS are those that sweeten with minimal or no carbohydrate or
energy. They are regulated by the Food and Drug Administration as food additives or
generally recognized as safe. The Food and Drug Administration approval process includes
determination of probable intake, cumulative effect from all uses, and toxicology
studies in animals. Seven NNS are approved for use in the United States: acesulfame K,
aspartame, luo han guo fruit extract, neotame, saccharin, stevia, and sucralose. They
have different functional properties that may affect perceived taste or use in different
food applications. All NNS approved for use in the United States are determined to be
safe.
J Acad Nutr Diet. 2012;112:739-758.
POSITION STATEMENT
It is the position of the Academy of Nutrition
and Dietetics that consumers can safely enjoy
a range of nutritive and nonnutritive
sweeteners when consumed within an eating
plan that is guided by current federal
nutrition recommendations, such as the Dietary
Guidelines for Americans and the Dietary
Reference Intakes, as well as individual
health goals and personal preference.
2212-2672/$36.00
doi: 10.1016/j.jand.2012.03.009
FROM THE ACADEMY
Position Paper
© 2012 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 739
• Add texture, flavor, and color to
baked goods.
• Support the growth of yeast for
leavening or fermentation.
• Contribute volume in ice cream,
baked goods, and jams.
• Enhance the creamy consistency
of frozen desserts.
• Enhance the crystallization of
confectionary products.
• Balance acidity in salad dressings,
sauces, and condiments.
• Help to maintain the natural
color, texture, and shape of preserved
fruits (3).
Nonnutritive sweeteners (NNS) offer little
to no energy when ingested. They are
referred to as high-intensity sweeteners
because, as sweetening ingredients, they
are many times sweeter than sucrose.
NNS can replace the sweetness of sugar
or energy-containing sweeteners. However,
they do not have the same functional
properties such as browning, crystallization,
or microbial inhibition.
MECHANISM OF SWEET TASTE
Liking of sweet taste is innate, but perception
of sweetness and preferred
level of sweetness vary among individuals.
Taste perception begins on the
tongue and soft palate where taste receptors
interact with food or beverages.
Taste receptor cells are organized
into taste buds, which are distributed
throughout the tongue and on specialized
structures called papillae (4).
Sweet taste is elicited through interaction
with a sweet receptor, identified as
a dimeric G-protein coupled receptor
composed of T1R2 and T1R3 subunits
with multiple active sites (5). Li and colleagues
(6) showed that these receptors
(T1R2 and T1R3) responded to sugars
(ie, sucrose, fructose, galactose, glucose,
lactose, and maltose), amino acids
(ie, glycine and D-tryptophan), sweet
proteins (ie, monellin and thaumatin),
and NNS (ie, acesulfame K, aspartame,
cyclamate, dulcin, neotame, saccharin,
and sucralose), although specific preferential
binding sites may vary. Synergy
among sweeteners is because they
bind different subunits. Binding a single
subunit activates the sweet response,
whereas a second ligand binding another
subunit enhances the response
(7). A transduction mechanism translates
the sweet chemical message
through the nervous system to the perception
of sweet taste in the brain. The
characteristics of this transduction
pathway are not well defined (5). Margolski
(8) hypothesized that the pathway
for saccharide sweeteners uses
cAMP as a second messenger and the
pathway for nonsaccharide sweeteners
uses inositol 1,4,5-triphosphate and diacylglycerol
as second messengers.
Both mechanisms work through regulation
of Ca2ϩ and ion channels and are
thought to exist in the same taste receptor
cells. Some NNS compounds interfere
with signal termination in the
downstream elements of the transduction
pathway, resulting in a lingering
aftertaste (9,10).
Taste perception and food preference
are complex and differences in concentration
of papillae, number and type of
taste receptors, or gene sequencing of
signal transduction molecules contribute
to individual variation (7). Although
there is good evidence for the heredity
of bitter taste, studies in twins and
other family members have found few
similarities in perception of sweet taste
that could be attributed to genetics
(11). Preference for sweet taste may be
genetic; variations in a taste receptor
gene accounted for some differences in
sweet preference among children, but
not in adults (12). Differences in preference
for sweet taste are most likely due
to an interaction between genetics and
environmental exposure (4).
REGULATION OF NNS IN THE
UNITED STATES
In the United States, the responsibility
for evaluating the safety of NNS was
given to the Food and Drug Administration
(FDA) in 1958 under the Food Additives
Amendment to the Federal
Food, Drug, and Cosmetic Act. Throughout
the world, nations have their own
regulatory agencies or rely on other regional
or international governing bodies
and expert scientific committees,
including the Bureau of Chemical
Safety, in Health Canada’s Food Directorate
(13), the Scientific Committee on
Food of the European Commission, the
Joint Expert Committee on Food Additives
of the United Nations Food and
Agricultural Organization, and World
Health Organization (WHO) to evaluate
the safety of NNS.
The US Food Additives Amendment
of 1958 required all new food additives
to undergo a strict premarket approval
process unless the substance is generally
recognized as safe (GRAS) among
experts qualified by training and experience
to evaluate its safety under the
conditions of its intended use. Common
food ingredients that were used before
1958 were listed as GRAS and not included
in the definition of a food additive
(14), which is “any substance, the
intended use of which results or may be
expected to result, directly or indirectly,
in its becoming a component or
otherwise affecting the characteristics
of any food” (15).
Some sweeteners in the United
States are listed or affirmed as GRAS.
The GRAS exemption requires the same
standard of safety as food additives do,
that is “the reasonable certainty of no
harm.” Before passage of the Food Additive
Amendment in 1958, the FDA
provided to Congress a list of substances
that were considered GRAS and
added to that list between 1958 and
1973. To be listed, the substance must
have a history of consumption before
1958 by a significant number of people
or there must be consensus among exThis
Academy position paper includes the
authors’ independent review of the literature
in addition to systematic review
conducted using the Academy’s evidence
analysis process and information from the
Academy’s Evidence Analysis Library
(EAL). Topics from the EAL are clearly delineated
and references used in EAL sections
can be found on the EAL Web site.
The use of an evidence-based approach
provides important added benefits to earlier
review methods. The major advantage
of the approach is the more rigorous
standardization of review criteria, which
minimizes the likelihood of reviewer bias
and increases the ease with which disparate
articles may be compared. For a detailed
description of the methods used in
the Academy’s evidence analysis process, to
www.andevidencelibrary.com/eaprocess.
Conclusion Statements are assigned a
grade by an expert work group based on the
systematic analysis and evaluation of the
supporting research evidence. Grade I‫؍‬
Good; Grade II‫؍‬Fair; Grade III‫؍‬Limited;
Grade IV‫؍‬Expert Opinion Only; and
Grade V‫؍‬Not Assignable (because there
is no evidence to support or refute the
conclusion). Criteria for grades can be found
at www.andevidencelibrary.com/grades.
Evidence-based information for this and
other topics can be found at www.
andevidencelibrary.com and subscriptions
for nonmembers are available for
purchase at www.andevidencelibrary.
com/store.cfm.
FROM THE ACADEMY
740 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
perts qualified to evaluate product
safety that the use of the substance is
safe. In 1973, FDA initiated a GRAS affirmation
process, which encouraged
manufacturers to submit their GRAS
determinations to the agency for review.
In 1997, FDA replaced the affirmation
process with a GRAS notification
process (14). Manufacturers may
determine that use of a substance is
GRAS and will notify FDA of that conclusion.
FDA responds to the manufacturer
with one of three responses: it has
no questions about the petitioner’s
conclusion; the notice does not provide
a sufficient basis for a GRAS determination;
or the agency has, at the petitioner’s
request, ceased to evaluate the
GRAS notice. The Federal Register provides
a published explanation of the
GRAS exemption (16). It is important to
note that the GRAS exemption refers
specifically to the intended use of a sub-
stance.
For approval of a food additive, the
petitioner (the manufacturer, company,
or interested partner that wants
to market a sweetener) must assemble
and present to FDA all required safety
data relevant to the proposed use of the
additive in accordance with safety
guidelines published by the FDA (15).
To determine safety of a food additive,
FDA considers: probable intake, cumulative
effect from all uses, and toxicological
data required to establish safety.
Guidelines for toxicology studies to
document the safety of food additives
are published by FDA in Redbook 2000
(17) and are consistent with guidelines
from the International Conference on
Harmonisation of Technical Requirements
for Registration of Pharmaceuticals
for Human Use (18). Initial tests
should include pharmacokinetics and
metabolism to allow FDA scientists to
evaluate:
• extent of absorption;
• tissue distribution;
• pathways and rates of metabolism;
and
• rates of elimination of the substance
and any metabolites.
Information from these studies,
known collectively as absorption, distribution,
metabolism, and excretion, is
used to design toxicity studies and determine
potential mechanisms of toxicity.
Toxicity studies include short-term
and subchronic toxicity tests with rodents,
subchronic and long-term toxicity
tests with nonrodents, reproductive
and developmental toxicity and tests of
carcinogenicity (19). Some food additives
may generate questions beyond the
usual toxicology studies. These may include
the potential for allergic reactions,
interactions with medications, or effects
on nutritional status, blood glucose
control, or other clinical conditions. In
these cases, FDA may require a more
extensive evaluation procedure that
includes clinical studies with human
subjects. The safety evidence that
must be established before studies in
human subjects can be conducted
may exceed that required for clinical
trials of new drugs because there is no
anticipated health benefit from food
additives (17). If the use of the additive
is safe for most consumers, but
may present a risk for certain subpopulations
such as those with an allergy
or inborn error of metabolism,
FDA can require that an informational
label that alerts consumers to the
presence of that additive be placed on
all foods containing it. A detailed review
of the FDA food additive approval
and GRAS affirmation processes
can be found in Rulis and Levitt
(19).
Three safety concepts are integral to
the FDA food additive approval process.
The first concept is the highest no effect
level (HNEL). Any petition brought to
the FDA for use of a new food additive
must include information that allows
the FDA to determine the highest level
or threshold of intake at which no adverse
effect occurs. FDA scientists independently
review the results of the animal
toxicology studies to determine
the exposure at which there were no
adverse effects in the most sensitive of
animal studies. The second safety concept
is the acceptable daily intake
(ADI). With the HNEL, the FDA will determine
an ADI for human beings, generally
with a 100-fold safety factor to
account for the fact that the studies
were conducted in animals (10-fold)
and for normal, genetic variation (additional
10-fold). The HNEL, divided by
100, is consistent with the FDA standard
“reasonable certainty of no harm”
and is assigned as the ADI. The ADI represents
an amount considered safe to
consume every day over the course of a
lifetime without adverse effects. An ADI
for the food additive is communicated
by the regulatory agency for that country.
The FDA ADI may differ from the
ADI from regulatory bodies in other
countries. The third safety concept is
the estimated daily intake (EDI), derived
from the amount of the additive
to be added to foods, assuming 100% replacement
of sugars and other NNS and
the typical consumption of those foods
by people of different ages and health
status. The EDI generally overestimates
consumption because it assumes that
the new additive will replace all sweeteners
in the market (100% market penetration).
It is based on a consumption
levelequaltothe90thpercentilelevelfor
the foods that will contain the additive
and the assumption that all population
subgroups will consume the new additive.
The ADI is compared with the EDI to
confirm that the ADI is well in excess of
human exposure. See the final rule on sucralose
in Federal Register (20) for a good
example of the process the FDA used to
determine HNEL, EDI, and ADI.
Once a food additive receives final
FDA approval, that approval is published
in Federal Register. In the approval
documentation, FDA may request
that additional data on actual
consumption or other safety data be
collected by the petitioner during the
post-approval period. If the EDI is determined
to exceed the ADI, there may
be limitations placed on the use of the
additive. To date, this has not been documented
with any NNS. An FDA ruling
may be challenged after approval with
new evidence. The FDA will examine
the postmarket evidence with the same
rigor that premarket studies received
and will consider new data in context of
the entire body of evidence to ensure
appropriate risk analysis to protect the
public health.
NUTRITIVE SWEETENERS
Sugars Added to Foods and
Beverages
Added sugars, not naturally occurring
sugars, when considered with solid fats
and excess energy intake, have been
linked to health concerns, including
overweight and obesity, type 2 diabetes
or prediabetes, inflammation, and cardiovascular
disease (21). Added sugars
in processed foods can be identified by
reading the list of ingredients on the
food label (Figure) (21,22). Other added
sugars that can be found in foods but
are not recognized by FDA as ingredients
include cane juice, evaporated
FROM THE ACADEMY
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 741
corn sweetener, fruit juice concentrate,
crystal dextrose, glucose, liquid fructose,
sugar cane juice, and fruit nectar
(21,22).
HFCS is produced from corn syrup,
which is typically 100% glucose. This
syrup undergoes enzymatic processing
to increase fructose content and is then
mixed with glucose (23). HFCS can
range in percentage fructose from 42%,
which is most often used in baked
goods to 55%, which is used in beverages
and has a similar composition as
sucrose (2).
Agave nectar has received interest
from consumers as a way to sweeten
foods. Agave nectar is produced from
the heart of the agave plant (Agave tequilana
Weber var. azul.) (24), which is
also the starting material for the production
of tequila (25). Freshly extracted
agave juice is composed of
inulin, a fructan that is heated or treated
enzymatically to convert this complex
carbohydrate to monosaccharides
(25,26). The amount of sugar (mostly
fructose but with some glucose and
dextrose), will vary depending on the
pH, temperature, and length of heating
time (27).
Digestion and Absorption
Sucrose is hydrolyzed to fructose and
glucose by the ␣-glucosidase sucrase in
the sucrase-isomaltase complex of the
enterocytes in the small intestine. Lactose
digestion is accomplished by the
␤-galactosidase, lactase-phlorizin hydrolase
found in the brush-border of
the small intestine and yields glucose
and galactose (28).
Monosaccharides (ie, glucose, fructose,
and galactose) need a transporter
system for absorption. The systems
are present on the apical border
and basolateral cell membranes of the
enterocytes and work in concert. Glucose
and galactose use the same sodium-glucose
cotransporter 1 on the
apical membrane to pass into the enterocyte
linked with two sodium molecules.
Fructose absorption is facilitated
by glucose-fructose transporter
5. Once in the enterocyte, all three
monosaccharides pass into the portal
capillaries by a glucose transporter,
which is located on the basolateral
membrane (28).
Consumption of Sucrose, Glucose,
and Fructose
Different terms and methods used to
estimate the intake or availability of
sugars in the food supply complicate
monitoring of sugar consumption.
The National Health and Nutrition Examination
Survey (NHANES) (released
in 2-year waves since 1999-
2000) uses self-report to estimate
intake. Food availability data are provided
by the USDA Economic Research
Service (ERS).
Food Consumption Patterns of
Added Sugars
The 2010 Dietary Guidelines for Americans
(DGA) reported that added sugars
contributed approximately 16% of total
energy in the US population (21) or 21
tsp added sugars using NHANES 2005-
2006 data (21,29) (Table 1). More recently,
Welsh and colleagues (30)
found that added sugars provided
14.6% of total energy intake using 2007-
2008 NHANES data. The main contributor
of added sugar intake was soda and
energy/sports drinks sweetened with
nutritive sweeteners, providing 7.5 tsp/
day (29) or 35.7% of total added sugars
(31). The other top contributors were
grain-based desserts, fruit drinks, dairy
desserts, and candy (21,31). Based on
these added sugars intakes and after
adjusting the intake to 2,000 kcal, the
usual added sugars intake for adults
aged 19 years and older is 79 g or 20 tsp
(2,29). The USDA pattern for 2,000 kcal
recommends no more than 32 g (8 tsp
added sugars/day) (2) or 6% of 2,000
kcal.
The consumption of added sugars of
the US population decreased from
1999-2000 to 2007-2008 along
with a decreasing trend in total energy
intake of 76 kcal/day (P for
trendϭ0.004) for the US population
(30). There was a decreased added
sugars intake of 100.1 g (95% confidence
interval [CI]: 92.8 to 107.3 g;
401 kcal) in 1999-2000 to 76.7 g (95%
CI: 71.6 to 81.9 g; 307 kcal) in 2007-
2008 (P for trend Ͻ0.001). This was a
significant decrease in percentage of
total energy from added sugars of
18.1% (95% CI: 16.9%, 19.3%) to 14.6%
(95% CI: 13.7%, 15.5%) (P for trend
Ͻ0.001) during the same period for
the US population. The rank order of
food sources did not change and neither
did population groups who consumed
higher amounts of added sugars
over this time period (data
presented later in this article). Welsh
and colleagues (30) concluded that although
consumption of added sugars
decreased between 1999-2000 and
2007-2008, intake of added sugars are
still higher than recommended.
Intake by Different Population
Groups
NHANES data from 2005-2006 indicated
children aged 2 to 18 years consumed
23 tsp added sugar (29) or 365
kcal (32,33), which is 18% of total energy
needs (2,027 kcal/day) (34) (Table
1). Teenagers aged 9 to 13 years compared
with other life stages had the
highest proportion who consumed
more than 25% of total energy from
Figure. Ingredients on food labels consumers can use to identify added sugars.
FROM THE ACADEMY
742 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
added sugars (boys 31.2%, girls 27.8%)
(35).
Thompson and colleagues (36) examined
the relation between race and
socioeconomic status and added sugars
intake, using 2005 US National Health
Interview Survey Cancer Control Supplement
and the NHANES 2003-2004
data. Added sugars intake was higher in
men than in women. African-American
women had the highest added sugars
intake when compared with white or
Hispanic women, but African Americans
in general had the highest added
sugars intake. Those who had the highest
level of education (more than high
school) had the lowest added sugars intake.
As income decreased, added sugars
intake increased in men and
women. Thompson and colleagues (36)
concluded that adults with lower income
and less education and those in
ethnic minority groups are consuming
diets higher in added sugars, which
may put them at greater risk for chronic
disease.
Sources of Added Sugars by
Different Groups
Based on NHANES 2005-2006, rank order
of food sources of added sugars differed
by age and race/ethnic groups
(Tables 1 and 2). Fruit drinks sweetened
with nutritive sweeteners were
ranked second for children and third
for adults (Table 1) (31). The rank order
of foods that provide added sugars
differed by race/ethnic group, but did
not differ across income groups
(Յ130% poverty, 131% to 185% poverty,
Ն186% poverty) (37,38) (Table
2). Soda/energy/sports drinks provided
the most added sugars across all
race/ethnic and income groups. Mexican
Americans and non-Hispanic
blacks both differed from non-Hispanic
whites in that fruit drinks were
the second ranked food and grainbased
desserts was third.
Table 3 presents the top five sources
of added sugars by age (34). Energy
from added sugars increased from 197
kcal for those aged 2 to 3 years to 444
Table 1. Food sources of added sugar intake of total US population aged 2 to 18 years and 19 years or older, National
Health and Nutrition Examination Survey, 2005-2006a
Food group
All Persons 2-18 y >19 y
Tsp %b
Tsp % Tsp %
Mean intake of added sugars 21.0 100.0 23.0 100.0 20.0 100.0
Soda/energy/sports drinks 7.5 35.7 7.3 31.8 7.6 37.1
Grain-based desserts 2.7 12.9 2.5 10.9 2.8 13.7
Fruit drinks 2.2 10.5 3.4 15.0 1.8 8.9
Dairy desserts 1.4 6.6 1.8 7.9 1.2 6.1
Candy 1.3 6.1 1.6 6.8 1.2 5.8
a
Adapted from references 29 (tsp) and 31 (%).
b
Percentage of total added sugars from these various foods.
Table 2. Food sources of added sugar intake of total US population by racial groups and income, National Health and
Nutrition Examination Survey, 2005-2006a
Food group
Race/Ethnicity Household Income
Non-
Hispanic
White
Non-
Hispanic
Black
Mexican
American
<130%
Poverty
Level
131% to
185%
Poverty
Level >186% Poverty Level
tsp %b
tsp % tsp % tsp % tsp % tsp %
Mean intake of
added sugars
21.0 100.0 22.0 100.0 22.0 100.0 23.0 100.0 20.0 100.0 20.0 100.0
Soda/energy/sports
drinks
7.6 36.3 7.2 32.3 8.6 39.0 9.4 40.8 8.1 40.6 6.7 32.9
Grain-based desserts 2.8 13.4 2.6 11.6 2.5 11.5 2.5 10.6 2.6 13.2 2.8 13.6
Fruit drinks 1.7 8.2 4.4 19.4 3.4 15.4 2.6 11.2 1.8 9.2 2.1 10.5
Dairy desserts 1.5 7.0 1.3 6.0 1.0 4.6 1.3 5.5 1.2 6.1 1.5 7.2
Candy 1.3 6.1 1.5 6.4 1.1 4.9 1.5 6.4 1.2 5.9 1.2 6.0
a
Adapted from references 37 (household income) and 38 (race/ethnicity).
b
Percentage of total added sugars from these various foods.
FROM THE ACADEMY
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 743
kcal for those aged 14 to 18 years in
2003-2004 (32-34). Soda/energy drinks/
sport drinks or fruit drinks were the top
two sources of added sugars for all ages.
Fox and colleagues (39) reported that
44% of children aged 19 to 24 months
consumed either fruit drinks (38%) or
sodas (11%) once per day in 2002. Intake
of soda (nutritive sweeteners and
NNS) increased as children aged, with
the greatest increase happening at age
8 years (40).
Food Consumption Patterns of
Fructose
Fructose consumption patterns over
time are difficult to describe because
fructose intake has not always been
measured in large national surveys
(41). Bray and colleagues (42) calculated
fructose intake by taking half of
sucrose as fructose and adding to this
value fructose from HFCS. In more recent
work (41-43), the fructose content
of the foods was included in the nutrient
data base. Bray and colleagues (42)
estimated that fructose intake was 8.8%
of total energy in 1977-1978 and increased
to 11.5% in 1994-1998. Two
other researchers estimated fructose
intake was 10.2% (54.7 g) (41) or 9.1%
(43) of total energy using NHANES III
(1988-1994) or NHANES 1999-2004
data, respectively.
Food Availability Data and
Changes Over Time
Food availability data are compiled by
the ERS by estimating food supplies
from production to marketing. Another
term used for these data is food disappearance
data because they describe
how the food supply disappears as it
moves through the food marketing system.
The ERS takes the total annual
available supply of a commodity and
subtracts out measurable uses, such as
farm inputs (feed and seed), exports,
ending stocks, and industrial uses. This
total supply is divided by the US population
to get per capita availability.
Food availability data exceed actual intake
because not all waste or loss is estimated
(44).
Based on ERS data, nutritive sweeteners
available per capita were 119.1 lb
in 1970, 141.1 lb in 2005 (45), and 130.7
lb in 2009 (46). There were no changes
in availability of honey (1 lb) or edible
syrups (0.5 lb) between 1970 and 2009.
Refined cane and beet sugar decreased
from 101.8 lb in 1970 to 63.6 lb in 2009.
Dextrose decreased from 1970 to 2009
(4.6 lb to 2.7 lb, respectively). Availability
of other energy-containing sweeteners
increased. Between 1970 and
2005, the annual per capita availability
of corn sweetener increased 387% with
the HFCS share of corn sweeteners increasing
from 3% (0.5 lb) to 76% (59 lb),
whereas the per capita availability of
refined cane and beet sugar decreased
38% (from 102 lb to 63 lb) (45). Energycontaining
sweeteners provided the
following teaspoons per day and energy
per day in 2009 when adjusted for
loss (47): refined cane and beet sugar
(13.4 tsp, 214.2 kcal) (48), HFCS (10.6
tsp, 168.9 kcal) (49), and other sweeteners
(eg, glucose syrup, dextrose,
honey, and edible syrups) (3.6 tsp, 57.4
kcal) (50).
HFCS availability increased between
1970 and 1999 then began to decrease,
dropping by 59 lb by 2005 (51). HFCS
availability was 50.1 lb in 2009 (49).
Wells and Buzby (51) hypothesized
that this trend may be a reflection of the
increased availability of no-energy bottled
water and diet sodas; increased
cost of HFCS because of pressure to
make ethanol from corn; or increasing
use of sugar alcohols and NNS.
Guidance on Use of Nutritive
Sweeteners
Dietary Reference Intakes from the
Institute of Medicine. The Acceptable
Macronutrient Distribution Ranges for
carbohydrate is estimated at 45% to 65%
of energy (52). The Recommended Dietary
Allowance for carbohydrate is
130 g/day for adults and children. This
Table 3. Major sources of added sugars among children and adolescents in the United States (aged 2 to 18 years) by age
and race, National Health and Nutrition Examination Survey, 2003-2004a
Top 5 Sources
First
source %
Second
source % Third source %
Fourth
source % Fifth source %
Age group
All Soda 31.8 Fruit drinks 15.0 Grain desserts 10.9 Dairy desserts 7.9 Candy 6.8
2-3 y Fruit drinks 19.3 Soda 11.4 Grain desserts 11.3 Candy 8.5 Cold cereals 8.3
4-8 y Soda 19.9 Fruit drinks 17.0 Grain desserts 11.2 Dairy desserts 10.4 Cold cereals 8.3
9-13 y Soda 30.7 Fruit drinks 13.6 Grain desserts 12.4 Dairy desserts 8.8 Candy 7.8
14-18 y Soda 44.5 Fruit drinks 14.1 Grain desserts 9.4 Candy 5.6 Dairy desserts 5.5
Race
NHWb
Soda 34.7 Fruit drinks 12.2 Grain desserts 10.3 Dairy desserts 8.4 Candy 6.5
NHBc
Fruit drinks 24.3 Soda 21.8 Grain desserts 12.1 Candy 9.4 Dairy desserts 7.2
Mex Amc
Soda 31.5 Fruit drinks 19.0 Grain desserts 11.5 Candy 6.1 Dairy desserts 5.8
a
Adapted from reference 34.
b
NHWϭnon-Hispanic white.
c
NHBϭnon-Hispanic black.
d
Mex AmϭMexican American.
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is based on the average minimum
amount of glucose used by the brain.
The Institute of Medicine recommended
that the intake of added sugars
not exceed 25% of energy to ensure adequate
intake of essential micronutrients
that are typically not present in
foods high in added sugars.
American Heart Association. In
2006, the American Heart Association’s
Diet and Lifestyle Recommendations
stated to minimize the intake of beverages
and foods containing added sugars
(53). That recommendation was expanded
in 2009 to set an upper limit of
added sugars intake at half of the discretionary
energy allowance as determined
by the USDA food intake patterns
(54). The final statement of the
American Heart Association reads:
“Most American women should eat or
drink no more than 100 calories/day
(25 g or 6 tsp) from added sugars, and
most American men should eat or drink
no more than 150 calories/day (38 g or
10 tsp) from added sugars.”
WHO Recommendations. The WHO
Global Strategy on Diet, Physical Activity
and Health, endorsed at the 57th
World Health Assembly, includes limiting
the intake of free or added sugars
(55). In an earlier document, WHO recommended
that Յ10% of energy be
provided by added sugars (56).
2010 DGA and ChooseMyPlate. The
2010 DGA recommend intake of foods
to result in a more healthful diet (21).
The guidelines acknowledge that the
body metabolizes added sugars and
natural sugars found in fruits and dairy
foods the same, but typically foods high
in added sugars are higher in energy
and low in essential nutrients or dietary
fiber (21). Recommendations related to
added sugars include the following: reduce
the calories from solid fats and
added sugars (SoFAS); and limit the
consumption of foods that contain refined
grains, especially refined grain
foods that contain SoFAS and sodium.
The DGA advisory committee recognized
the need to obtain adequate nutrients
without overconsumption of
energy to reduce risk of common
chronic diseases such as obesity, cardiovascular
disease, and some cancers (2).
Using the MyFood-a-pedia Web site
(www.myfoodapedia.gov) one can
identify the SoFAS content of foods and
beverages and choose those with fewer
SoFAS, choose them less often, or
choose a smaller portion. Recommendations
include:
• Cut back on foods and drinks
with added sugars or energycontaining
sweeteners.
• Drink few or no regular sodas,
sports drinks, and fruit
drinks.
• Eat fewer grained-based or
dairy-based desserts, other desserts,
and candy or eat smaller
portions less frequently.
• Drink water, fat-free milk, 100%
fruit juice, or unsweetened tea or
coffee instead of sugar-sweetened
drinks.
• Drink 100% fruit juice instead of
fruit-flavored drinks.
• Eat fruit for dessert.
• Use the Nutrition Facts label to
choose breakfast cereals and
other packaged foods with less
sugar and use the ingredients list
to choose foods with little or no
added sugars.
ChooseMyPlate is part of a large communications
initiative sponsored by
the USDA to help consumers implement
the 2010 DGA recommendations.
The messages for consumers emphasize
foods to eat less often, including
foods that are high in SoFAS, and drinking
water instead of sugary drinks. The
plan presents a recommended daily
limit for empty energy such as SoFAS
that add energy to foods without adding
nutrients.
Polyols (Sugar Alcohols) and
Other Sweeteners
Polyols or sugar alcohols have been
used in food products for many years to
decrease the intake of carbohydrates
that raise blood glucose levels. Polyols
can be used alone but are more often
used in combination with other polyols
or NNS because of the bulking property
of some polyols. Energy provided by
polyols varies (Table 4) because of differences
in digestibility and because
polyols are typically absorbed slowly
and incompletely by passive diffusion
(57). Metabolism also varies (57). For
example, erythritol is completely absorbed
but is not metabolized. Many
polyols are found in nature but may be
manufactured from monosaccharides
or polysaccharides to be used as food
ingredients. Foods containing polyols
and no added sugars can be labeled as
sugar-free (1). Table 4 presents regulatory
status, EDI, and ADI for selected
polyols and other sweeteners, sweetness
compared with sucrose, and their
use in foods.
Trehalose and D-tagatose are other
sweeteners used in food (Table 4). Trehalose
is found naturally in foods such
as honey and unprocessed mushrooms.
The enzyme trehalase is present in the
brush-border membrane of the small
intestine and hydrolyzes the ␣-1,1
bond of trehalose into two glucose molecules
(58). D-tagatose is similar to
fructose in structure other than an inversion
of the hydroxyl and hydrogen
groups at the fourth carbon and is
found in many foods, including dairy
products (59). Only 15% to 20% of
D-tagatose is absorbed with much being
fermented in the colon (60). The
metabolism of absorbed D-tagatose is
the same as that of fructose. Both of
these other sweeteners are used with
other nutritive sweeteners and NNS in
foods.
NONNUTRITIVE SWEETENERS
Consumption Patterns
Since the discovery of saccharin in the
late 1800s, NNS have been used by consumers
to achieve a sweet taste, for reasons
of economics, blood glucose control,
or energy control. NNS approved
for use in the US have been tested and
determined to be safe at levels that are
within the ADI. Intake of food additives,
including NNS, is difficult to assess.
Studies of NNS intake need to have an
adequate number of subjects to include
consumers at the 95th percentile of intake
and should include groups who
may have higher than normal intakes
(eg, people with diabetes) or groups of
people with special concerns (pregnant
women or children) (61). Food products
may contain a blend of different
NNS, which further complicates estimation
of intake. Mattes and Popkin
(62) used existing data from US nutrient
monitoring systems to locate items
that contained NNS on food composition
tables to estimate NNS consumption.
Although consumption of NNS in
foods and beverages has increased
since 1965, only about 15% of the popFROM
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Table 4. Energy, regulatory status, and function in foods of polyols and other sweeteners
Type kcal/g Regulatory status Use in foods
Monosaccharide polyols
or other sweeteners
Sorbitol (117) 2.6 GRASa
label must state risk
of laxative effect
50%-70% as sweet as sucrose; bulk ingredient; humectant;
texturizing agent; noncariogenic; some individuals may
experience a laxative effect from a daily load of Ն50 g
Mannitol (118,119) 1.6 Approved food additive;
label must state risk of
laxative effect
50%-70% as sweet as sucrose; low-energy sweetener;
cooling effect to mask bitter taste; non-cariogenic; used
as dusting powder; some individuals may experience a
laxative effect from a daily load of Ն20 g
Xylitol (120,121) 2.4 Approved as food additive
for use in foods for
special dietary uses
As sweet as sucrose; bulk ingredient; cariostatic and
anticariogenic
Erythritol (122,123) 0.2 Independent GRAS
determinations
EDIb
mean: 1 g/d;
90th
percentile: 4 g/d
60%-80% as sweet as sucrose; bulk ingredient; flavor
enhancer, formulation aid, humectant, stabilizer and
thickener, sequestrant, and texturizer
D-Tagatose (59,60) 1.5 Independent GRAS
determinations
EDI mean: 7.5 g/d;
90th percentile: 15 g/d
ADIc
: 15 g/50 kg adult/d
75%-92% as sweet as sucrose; sweetness synergizer;
functions as a texturizer, stabilizer, humectants, and
formulation aid; flavor enhancer
Disaccharide polyols
Isomalt (124) 2.0 GRAS affirmation petition
filed
45%-65% as sweet as sucrose; bulk ingredient; flavor
enhancer; when heated does not lose sweetness
Lactitol (125) 2.0 GRAS affirmation petition
filed; September, 1993
30%-40% as sweet as sucrose; bulk ingredient; synergistic
with NNSd
; does not contribute to tooth decay
Maltitol (126) 2.1 GRAS affirmation petition
filed; December 23,
1986, Web site
90% as sweet as sucrose; bulk ingredient; can replace fat
because of adding creaminess to mouth feel; does not
contribute to tooth decay
Isomaltulose (127) 4.0 Independent GRAS
determinations
EDI mean: 3-6 g/d
50% as sweet as sucrose; used as a slow release
carbohydrate source
Trehalose (58,128) 3.6 Independent GRAS
determinations EDI
mean: 34 g/d
90th
percentile: 68 g/d
45% as sweet as sucrose; coloring adjuvant; flavor
enhancer; humectants; stabilizer; thickener; synergist;
texturizer
Polysaccharide polyols
Hydrogenated starch
hydrolysates (HSH;
maltitol syrup;
sorbitol syrups)
(129)
3.0 GRAS affirmation petition
filed
25%-50% as sweet as sucrose (depending on the
monosaccharide composition); bulk ingredient; viscosity
or bodying agents; humectants; crystallization modifiers;
cryoprotectants; rehydration aids; carrier for flavors,
colors and enzymes; synergistic with NNS
a
GRASϭgenerally recognized as safe.
b
EDIϭestimated daily intake.
c
ADIϭacceptable daily intake.
d
NNSϭnonnutritive sweetener.
FROM THE ACADEMY
746 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
ulation reported consuming any foods
or beverages with NNS in 2003-2004. A
systematic review of NNS intake data
indicated that average intakes by adults
are consistently well below their ADIs
(61).
Guidance on Use of NNS
2010 DGA. The DGA contains a minimal
number of statements related to
the use of NNS (21). A key recommendation
related to the use of NNS is to
control total energy intake and increase
physical activity to manage body
weight (21). Eating patterns that are
low in energy density improve weight
loss and weight maintenance, and may
be associated with a lower risk of type 2
diabetes in adults. Substituting NNS for
higher-energy foods and beverages can
decrease energy intake, but evidence of
their effectiveness for weight management
is limited.
American Diabetes Association. The
American Diabetes Association position
statement on nutrition recommendations,
last revised in 2008, states that,
“Sugar alcohols and nonnutritive
sweeteners are safe when consumed
within the daily intake levels established
by the Food and Drug Administration”
(63). Recommendations for
management of diabetes include
monitoring carbohydrates by carbohydrate
counting, choices, or experience-based
estimation to achieve glycemic
control (64). Choosing NNS
instead of nutritive sweeteners is one
method to assist with moderating
carbohydrate intake.
National Cancer Institute. The National
Cancer Institute updated a fact
sheet on NNS and cancer in 2009 and
noted that there is no clear evidence
that the NNS available commercially in
the United States are associated with
cancer risk in human beings (65).
NNS Approved in the United States
Thefollowingsectioncontainsinformation
about the structure and use of NNS approved
in the United States (Table 5). The
section regarding the Academy’s Evidence
Analysis Library contains information
about effects on dietary intake, energy balance,
and human health.
Acesulfame K. Acesulfame K (5,6-di-
methyl-1,2,3-oxathiazine-4(3H)-1,2,2dioxide)
is a combination of an organic
Table 5. Nonnutritive sweeteners (NNS) approved in the United States by the Food and Drug Adminisration
Name (chemical name)
Times sweeter
than sucrose ADIa
and EDIb
Use in foods
Acesulfame K (5,6-dimethyl-1,2,3oxathiazine-4(3H)-1,2,2-dioxide)
(66)
200 ADI: 15 mg/kg BWc
EDI: 0.2 to 1.7 mg/kg BW
Approved for general use, except
in meat and poultry. Combines
well with other NNS; stable at
baking temperatures
Aspartame (L-aspartyl-L-phenylalanine
methyl ester) (68)
160-220 ADI: 50 mg/kg BW
EDI: 0.2-4.1 mg/kg BW
Approved for general use.
Degrades during heating
Luo han guo extract (cucurbitane
glycosides, mogroside II, III, IV, V, VI) (70)
150-300 ADI: No ADI determined
EDI: 6.8 mg/kg BW
GRASd
. Intended for use as a
tabletop sweetener, a food
ingredient, and a component
of other sweetener blends
Neotame (N-[N-3,3-dimethylbutyl)-L-aaspartyl]-L-phenylalanine-1-methyl
ester)
(71)
7,000-13,000 ADI: 18 mg/kg BW
EDI: 0.05-0.17 mg/kg BW
Approved for general use, except
in meat and poultry. To date,
little used in food processing
Saccharin (1,1-dioxo-1,2-benzothiazol-3-one)
(14)
300 ADI: Prior sanctioned
food ingredient; no
ADI determined
EDI: 0.1-2 mg/kg BW
Limited to Ͻ12 mg/fl oz in
beverages, 20 mg/serving in
individual packages, or 30 mg/
serving in processed foods
Stevia (steviol glycosides, rebaudioside A,
stevioside) (74)
250 ADI: (determined by
JECFAe
) 4 mg/kg BW
EDI: 1.3-3.4 mg/kg BW
GRASd
. Intended for use as a
sweetener in a variety of food
products such as cereals,
energy bars, and beverages
and as a tabletop sweetener
Sucralose (trichlorogalactosucrose) (20) 600 ADI: 5 mg/kg BW
EDI: 0.1-2.0 mg/kg BW
General use; heat stable for
cooking and baking
a
ADIϭacceptable daily intake.
b
EDIϭestimated daily intake.
c
BWϭbody weight.
d
GRASϭgenerally recognized as safe.
e
JECFAϭJoint Expert Committee on Food Additives.
FROM THE ACADEMY
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 747
acid and potassium approved by the
FDA in 1988 for use in foods and as a
tabletop sweetener; in 1998 it was approved
for use in beverages and in 2003
it was approved as a general use sweetener,
which includes any food or beverage
category (66). It is 95% excreted unchanged
in the urine so it does not
provide energy or influence potassium
intake (67). It combines well with other
NNS, which is the most common way it
is currently used in the US food supply.
It is stable at baking temperatures.
Aspartame. Aspartame (L-aspartyl-Lphenylalanine
methyl ester) is a methyl
ester of aspartic acid and phenylalanine
dipeptide. It was discovered in 1965
and approved by the FDA in 1981 for
use in specific foods and in 1983 for use
in soft drinks. In 1996 it was approved
as a general use sweetener. Although
aspartame provides 4 kcal/g, the intensity
of the sweet taste means that very
small amounts are required to achieve
desired sweetness levels. In the intestine,
aspartame is hydrolyzed to aspartic
acid, methanol, and phenylalanine
(68). In the United States the largest use
of aspartame is to sweeten low-energy
beverages, but it is found in many products.
Despite the numerous products
containing aspartame, average consumption
even for the highest users remains
below the ADI (61,68). Because
aspartame yields phenylalanine when
it is hydrolyzed in the intestine, the FDA
requires any foods containing aspartame
to have an informational label
with the statement: “Phenylketonurics:
contains phenylalanine.” Individuals
with phenylketonuria had small but
not clinically significant increases in
phenylalanine after drinking 12 oz diet
soda sweetened with aspartame (69).
Aspartame is stable under dry conditions,
but in solutions, it degrades during
heating. The rate of degradation depends
on pH and temperature (68).
Luo han guo. Luo han guo is the common
name for Siraitia grosvenorii, or
Swingle fruit extract, a sweetener recently
approved as GRAS (70). Another
common name is monk fruit extract.
This product is a combination of several
different cucurbitane glycosides,
known as mogrosides. Mogroside V is
predominate and makes up Ͼ30% of the
product. Luo han guo is 150 to 300
times sweeter than sucrose depending
on the exact structure of the mogrosides
and number of glucose units. It
may have an aftertaste at high levels.
Neotame. Neotame (N-[N-3,3-dim-
ethylbutyl)-L-a-aspartyl]-L-phenylalanine-1-methyl
ester) is a derivative of
the dipeptide phenylalanine and aspartic
acid. The FDA approved neotame as
a general use sweetener in 2002 (71).
Neotame is partially absorbed in the
small intestine and rapidly metabolized
by esterases present throughout
the body. The resulting products are deesterified
neotame, which is rapidly excreted
in urine and feces, and an insignificant
amount of methanol (72).
Although neotame contains phenylalanine,
the amount used is very low because
of its high intensity sweetening
property and the amount released in
the body is negligible (72). To date,
neotame is rarely used in foods. It is stable
under dry storage conditions; stability
varies with pH in aqueous solutions
(72).
Saccharin. Saccharin (1,1-dioxo-1,2benzothiazol-3-one)
is the oldest NNS
approved for food and beverage use
(73). It is not metabolized in the body,
and is heat stable. It is approved as a
food additive for foods and beverages, a
tabletop NNS, and for use in gums, cosmetics,
and pharmaceuticals. Saccharin
was originally listed as GRAS. In 1977,
the FDA proposed a ban on saccharin
under the Delaney Clause because of an
association with bladder cancer in laboratory
animals. The Delaney Clause
was an amendment added by Congress
to the Food Drug and Cosmetic Act of
1958. It stated that no food additive
would “be deemed safe if it is found to
induce cancer when ingested by man or
animal” and prohibited the FDA from
approving such food additives—a zerorisk
standard. Congress imposed an 18month
moratorium on the FDA ban on
saccharin but required products containing
saccharin to carry a warning
that saccharin has been determined to
cause cancer in laboratory animals.
Congress asked the National Academy
of Sciences to lead a study on the safety
of saccharin. The National Institute for
Environmental Health Sciences determined
that the mechanism by which
saccharin caused bladder tumors in
rats was not relevant to human beings
and recommended that it be removed
from the list of human carcinogens. In
1996, the Delaney Clause was repealed
and the zero-risk standard changed to
one of “reasonable certainty of no
harm.” In 2000, Congress repealed the
requirement for a warning label. Saccharin
is widely used, often in combination
with other sweeteners. EDI of saccharin
is well below ADI for average
and high users (61).
Stevia. Steviol glycosides-rebaudioside
A and stevioside are extracted
from leaves of the plant Stevia rebaudiana
Bertoni. In 2008, the FDA allowed
GRAS status for purified rebaudioside A
followed by stevioside. These purified
glycosides should not be confused with
whole stevia leaves, which are sold as
dietary supplements under the Dietary
Supplement and Health Education Act
of 1994. Whole stevia leaves contain a
number of active components, not all of
them sweet (74). Steviol glycosides are
described as having a sweet, clean taste
at usual amounts but may be bitter at
higher amounts (75,76). They are shelfstable
in dry form and more stable than
aspartame or acesulfame K in liquid
form (75).
Sucralose. Sucralose (trichlorogalactosucrose)
is a disaccharide in which
three chlorine molecules replace three
hydroxyl groups on the sucrose molecule.
It was approved by the FDA for use
as a tabletop sweetener and in a number
of desserts and beverages in 1998
(20) and as a general use sweetener in
1999. Most sucralose (85%) is not absorbed
and is excreted unchanged in
feces. Sucralose that is absorbed is
excreted unchanged in urine (77).
Sucralose is heat stable in cooking and
baking.
NNS Approved in Other Nations,
but not in the United States
Alitame, cyclamate, neohesperidine,
and thaumatin are approved as NNS in
other nations, but not in the United
States. In 1986, a petition was submitted
to the FDA to approve alitame for
use as a tabletop sweetener and in
baked goods, beverages, and confections.
The petition was reviewed and
found to be deficient. Currently, the
FDA is not reviewing alitame for use as
a food additive. Cyclamate was banned
by the FDA as a food additive in 1969
under the Delaney Clause because one
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study found that a saccharin/cyclamate
mixture caused cancer in laboratory
rats. In 1982, the Cancer Assessment
Committee of the FDA reviewed the scientific
evidence and concluded that cyclamate
was not carcinogenic. This was
reaffirmed by the National Academy of
Sciences in 1985. It is 30 times sweeter
than sucrose and is used in more than
50 countries, including Canada. Neohesperidine
and thaumatin are GRAS
for use as flavor ingredients, but are not
approved or currently being considered
for use as NNS in the United States.
ACADEMY EVIDENCE ANALYSIS
LIBRARY (EAL)
This section includes the results of a
systematic review of literature conducted
using the Academy’s evidence
analysis process and information from
the Academy’s EAL. In this process, an
expert work group identified dietetic
practice related questions, performed a
systematic literature review, and developed
and rated a conclusion statement
for each question. The workgroup
used the Academy’s process to answer
a total of 60 questions related to the use
of nutritive sweeteners and NNS; one
question each on HFCS, polyols, and
steviol glycosides (stevia); and multiple
questions on aspartame, neotame,
saccharin, and sucralose. The workgroup
was unable to write a conclusion
statement on 34 questions because no
studies were identified that met the
search criteria (Grade VϭNot Assignable).
All of these questions, as well as
the full list of references used, may be
found on the EAL Web site (www.
andevidencelibrary.com). Most premarket
approval research studies on
the safety of NNS are animal studies
that are reviewed by the FDA before
granting approval or a GRAS determination.
The Academy’s EAL includes
only NNS that have been approved by
the FDA for use in the United States. The
Academy’s EAL does not evaluate safety;
however, it does evaluate available
human subjects research documenting
adverse effects for each NNS which
meets EAL criteria. Articles that were
reviewed for this process were published
in English, described human subjects
research, were peer-reviewed and
published in juried journals, and met
other specific inclusion criteria documented
in the Search Plan and also
published in the EAL.
To identify and select articles for review,
the National Library of Medicine’s
PubMed database was searched using
the terms obesity, appetite, metabolism,
adverse effects, and safety; the term nonnutritive
sweeteners and the names of
the specific NNS; specific terms for the
nutritive sweeteners, HFCS, fructose,
and sugar-sweetened beverages; and
polyols and sugar alcohols. Articles reviewed
were published within the past
10 years for HFCS, 20 years for polyols,
or between 2002 and 2009 for NNS.
Studies must have included at least
10 subjects in each treatment group
and have a dropout rate Ͻ20%. Articles
described clinical trials, randomized
controlled trials, reviews, or meta-
analyses.
Detailed search plans, including the
search criteria, a list of the articles included
and articles reviewed but excluded,
and reasons for exclusion are
linked to each conclusion statement on
the EAL Web site. Conclusion statements,
based on a synthesis of the findings
of all relevant studies, are assigned
grades through the use of predefined
criteria evaluating the quality of studies,
quantity of studies and subjects,
consistency of findings across studies,
the magnitude of effect, and the generalizability
of findings. A table defining
the criteria to determine each grade
level can be found at www.andevidence
library.com/grades.
Nutritive Sweeteners
HCFS. What is the evidence from human
subject research that consumption of
HFCS is associated with obesity and metabolic
and/or adverse effects in adults?
Conclusion Statement. Four shortterm
randomized controlled trials
(Akhaven 2007, Melanson 2007,
Soenen 2008, and Stanhope 2008), two
longitudinal studies (Monsivais 2007
and Streigel-Moore 2006), two crosssectional
studies (Duffy 2008 and
Mackenzie 2006), and five review articles
(Angelopoulos 2009, Bray 2004,
Forshee 2007, Melanson 2008, and
White 2009) examined the effects of
HFCS compared with other nutritive
sweeteners. These studies consistently
found little evidence that HFCS differs
uniquely from sucrose and other nutritive
sweeteners in metabolic effects (ie,
circulating glucose, insulin, postprandial
triglycerides, leptin, and ghrelin),
subjective effects (ie, hunger, satiety,
and energy intake at subsequent meals)
and adverse effect such as risk of
weight gain. Randomized trials dealing
specifically with HFCS were of limited
numbers, short duration, and of small
sample size; therefore, long-term data
are needed. Grade II‫؍‬Fair.
Polyols. What is the evidence from human
subject research that consumption
of polyols/sugar alcohols is associated
with metabolic and/or adverse effects in
adults?
Conclusion Statement. A total of six
studies met inclusion criteria. Five of
these were short-term randomized
controlled trials (Finney 2007, Gostner
2005, Koutsou 1996, Madsen 2006, and
Storey 2007) and one was a review article
(Grabitske 2009). The five randomized
controlled trials studied gastrointestinal
effects of polyols/sugar
alcohols and consistently found that in
moderate doses of up to 10 to 15 g/day,
polyols/sugar alcohols are tolerated. At
high doses (Ն30 g/day), consumption
of some polyols/sugar alcohols (including
lactitol, isomalt, and xylitol) may
result in significant increases in flatulence,
borborygmus, colic, defecation
frequency and loose/watery stools. The
review article (Grabitske 2009) examined
the use of sugar alcohols and concluded
that usual intake is below levels
that would result in significant gastrointestinal
side effects. One study (Gostner
2005) examined the effect of polyols/sugar
alcohols on total cholesterol
and triglycerides, and found no significant
differences between subjects consuming
isomalt or sucrose. None of the
other studies examined metabolic effects
of sugar alcohols, including glycemia.
Grade III‫؍‬Limited.
NNS
Aspartame. In adults, does using foods
or beverages with aspartame in an energy-restricted
or ad libitum diet affect energy
balance (weight)?
Conclusion Statement. Use of aspartame
and aspartame-sweetened products
as part of a comprehensive weight
loss or maintenance program by individuals
may be associated with greater
weight loss and may assist individuals
with weight maintenance over time.
Grade I‫؍‬Good.
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In adults, does using foods or beverages
with aspartame affect appetite or food in-
take?
Conclusion Statement. There is good
evidence that aspartame does not affect
appetite or food intake. Grade I‫؍‬Good.
In children, does using foods or beverages
with aspartame affect appetite or
food intake?
Conclusion Statement. Limited evidence
indicates that aspartame consumption
affects appetite or food intake
in children. The 2009 update did
not find new studies meeting the inclusion
criteria for this question and the
Nutritive and Nonnutritive Sweeteners
workgroup (2009) concurs with the
conclusion above formulated by the aspartame
workgroup (2008). Grade
III‫؍‬Limited.
What is the evidence from human subjects
research that aspartame consumption
is associated with adverse effects in
the general population?
Conclusion Statement. Aspartame
consumption is not associated with adverse
effects in the general population.
Studies have found no evidence of a
wide range of adverse effects of aspartame,
including hypersensitivity reactions,
elevated blood methanol or formate
levels, and hematopoietic or brain
cancers. Neurologic changes tested included
cognitive functions, seizures,
headaches, and changes in memory or
mood. The 2009 update did not find new
studies meeting the inclusion criteria for
this question and the Nutritive and Nonnutritive
Sweeteners workgroup (2009)
concurs with the conclusion above formulated
by the aspartame workgroup
(2008). Grade I‫؍‬Good.
What is the evidence from human subjects
research that aspartame consumption
is associated with adverse effects in
special populations, including children?
Conclusion Statement. A limited
number of human studies published in
peer-reviewed journals that involved
children or special adult populations
were available for this question. Limited
evidence from human studies suggests
that aspartame consumption is
not associated with detrimental effect
on blood methanol, eye problems, acne,
blood pressure, seizure disorder, or attention
deficit disorder in children.
There is limited evidence from human
studies for three special adult populations.
In people with diabetes, aspartame
consumption is not associated
with elevated plasma phenylalanine
and tyrosine levels, fasting glucose control,
intolerance to aspartame, ophthalmologic
effects, heart rhythm, or
weight. In people with chronic alcoholic
liver disease, portal systemic encephalopathy
index was unchanged.
Levodopa levels were not significantly
different in individuals with Parkinson
disease. The 2009 update did not find
new studies meeting the inclusion criteria
for this question and the Nutritive
and Nonnutritive Sweeteners
workgroup (2009) concurs with the
conclusion above formulated by the
aspartame workgroup (2008). Grade
III‫؍‬Limited.
To date, adequately powered studies
have not been conducted to evaluate
the effect of aspartame on preference
for sweet taste in adults and children or
the effect on energy balance in children.
Neotame. To date, no studies meeting
the inclusion criteria were identified to
evaluate 14 EAL questions related to
neotame consumption and appetite,
energy balance, estimated and acceptable
intake, nutrient quality, and health
risks and benefits.
Saccharin. In adults, does saccharin affect
food intake?
Conclusion Statement. Saccharin
does not increase food intake in adults.
Modest energy savings can result if saccharin-sweetened
foods replace sugarsweetened
products in a form that is
also lower in energy. The 2009 update
did not find new studies meeting the
inclusion criteria for this question; the
Nutritive and Nonnutritive Sweeteners
workgroup (2009) reviewed and accepted
the studies identified by the
NNS workgroup (2006). Grade III‫؍‬
Limited.
In adults, does using foods or beverages
with saccharin affect appetite?
Conclusion Statement. In short-term
studies, saccharin does not affect appetite
in adults. The 2009 update did not
find new studies meeting the inclusion
criteria for this question; the Nutritive
and Nonnutritive Sweeteners workgroup
(2009) reviewed and accepted
the studies identified by the NNS workgroup
(2006). Grade III‫؍‬Limited.
In adults, does using foods or beverages
with saccharin in a calorie-restricted or
ad libitum diet affect energy balance?
Conclusion Statement. Using saccharin
in either an energy-restricted or
ad libitum diet will affect overall energy
balance, only if the saccharinsweetened
foods are substituted for
higher-energy food or beverages. The
2009 update did not find new studies
meeting the inclusion criteria for this
question; the Nutritive and Nonnutritive
Sweeteners workgroup (2009) reviewed
and accepted the studies identified
by the NNS workgroup (2006).
Grade III‫؍‬Limited.
What is the estimated saccharin consumption
level and is it within ADI limits?
Conclusion Statement. Cross-sectional
research conducted outside the
United States, is consistent in finding
that saccharin intakes for adults and
children are below the ADI of 5 mg/kg
body weight set by the Joint Expert
Committee on Food Additives, an international
scientific expert committee
administered jointly by the Food and
Agriculture Organization of the United
Nations. Persons with diabetes and
young children had the highest saccharin
intakes, when expressed as milligrams
per kilogram body weight. Reported
intakes ranged from a mean
intake of 0.3 mg/kg body weight to a
95th percentile intake of 2.7 mg/kg
body weight; therefore, intake at the
95th percentile is well within the Joint
Expert Committee on Food Additives
ADI. The 2009 update did not find new
studies meeting the inclusion criteria
for this question; the Nutritive and
Nonnutritive Sweeteners workgroup
(2009) reviewed and accepted the
studies identified by the NNS workgroup
(2006). Grade II‫؍‬Fair.
In adults, can saccharin be used to
manage diabetes and glycemic response?
Conclusion Statement. In a limited
number of human studies, saccharin
had no effect on changes in lipid profiles
and glycemic response in adults
with diabetes. The Nutritive and
Nonnutritive Sweeteners workgroup
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750 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
(2009) reviewed and accepted the
studies identified by the NNS workgroup
(2006) and found one additional
article (Skokan and colleagues, 2007)
meeting the inclusion criteria for the
update of this question. Grade III‫؍‬
Limited.
In children with diabetes, what is the
intake of saccharin, and is this within the
ADI of NNS?
Conclusion Statement. In one study
conducted outside the United States,
children with diabetes were found to
have higher intakes of NNS, including
saccharin, compared with controls,
which did not exceed the ADI. The 2009
update did not find new studies meeting
the inclusion criteria for this question;
the Nutritive and Nonnutritive
Sweeteners workgroup (2009) reviewed
and accepted the studies identified
by the NNS workgroup (2006).
Grade III‫؍‬Limited.
In adults, can saccharin be used to prevent
and manage hyperlipidemia?
Conclusion Statement. Saccharin has
no significant effect on lipid profile in
short-term dietary intervention studies
in adults. The evidence to determine if
saccharin can be used to prevent and
manage hyperlipidemia is limited. The
2009 update did not find new studies
meeting the inclusion criteria for this
question; the Nutritive and Nonnutritive
Sweeteners workgroup (2009) reviewed
and accepted the studies identified
by the NNS workgroup (2006).
Grade III‫؍‬Limited.
What is the evidence from human subjects
research that saccharin consumption
is associated with adverse effects in
the general population?
Conclusion Statement. Limited research
in human beings, from peer reviewed
journals, did not find an association
between adverse effects and the
intake of saccharin in the general population.
No data from longitudinal cohort
studies were available for review.
The 2009 update did not find new studies
meeting the inclusion criteria for
this question; the Nutritive and Nonnutritive
Sweeteners workgroup (2009)
reviewed and accepted the studies
identified by the NNS workgroup
(2006). Grade III‫؍‬Limited.
To date, no studies were identified to
evaluate the effect of saccharin intake
on energy density, nutrient quality, or
behavior or cognitive changes in adults
or to evaluate the effects of saccharin in
children other than the acceptable
daily intake for children with diabetes.
Steviol Glycosides (Stevia). In adults,
is there evidence regarding the influence
of stevia on metabolic outcomes and/or
weight?
Conclusion Statement. Five randomized
controlled trials (Barriocanal and
colleagues, 2008, Maki and colleagues,
2008, Ferri and colleagues, 2006, Gregerson
and colleagues, 2004, andHsieh
and colleagues, 2003) examined the effects
of stevia compared with placebo
on metabolic outcomes or weight and
reported minimal, if any effects on
blood glucose and insulin levels, hypertension,
and weight. However, the majority
of trials was of small sample size
and used varying doses of stevia. One
trial (Barriocanal 2008) in subjects with
type 1 or type 2 diabetes or without diabetes
reported no significant changes
from baseline in serum glucose or hemoglobin
A1c levels. However, one trial
(Gregerson 2004) in subjects with type
2 diabetes reported a reduced postprandial
blood glucose and glucagon
response after a test meal of stevia vs
placebo. In subjects without diabetes,
one trial (Ferri 2006) reported both glucose
and insulin reductions in both the
stevia and placebo groups. Two trials
(Berriocanal 2008, Maki 2008) in subjects
with normal/low blood pressure
detected no significant changes from
baseline in blood pressure from stevioside
compared with controls. In subjects
with Stage 1 hypertension, no
anti-hypertensive effects of stevioside
compared with placebo were found
(Ferri 2006). A third study (Gregerson
2004) also reported no changes in
blood pressure from stevioside compared
with placebo However, a 2-year
trial in Chinese subjects with mild hypertension
reported decreases in blood
pressure from stevia compared with
placebo (Hsieh 2003). Only one trial
studied weight change and reported no
change (Hsieh 2003). Grade II‫؍‬Fair.
Sucralose. In adults, does sucralose affect
food intake?
Conclusion Statement. One randomized
controlled trial (Rodearmel and
colleagues, 2007) examined sucralose
and food intake in adults. Sucralose
does not increase food intake. Modest
energy savings can result if sucralose
replaces sugar-sweetened products in a
form that is also lower energy. This conclusion
statement developed by the
Nutritive and Nonnutritive Sweeteners
workgroup (2009) is consistent with
the previous statement on food intake
in adults developed by the NNS workgroup
(2006). Grade III‫؍‬Limited.
In children, does sucralose affect food
intake?
Conclusion Statement. One randomized
controlled trial (Rodearmel and
colleagues, 2007) examined sucralose
and food intake in children. Sucralose
does not increase food intake. Shortterm
studies suggest that modest energy
savings can result if sucralose replaces
sugar-sweetened products in a
form that is also lower energy. Longterm
studies need to assess if use of sucralose
in children helps to balance
energy intakes with energy expenditures.
This conclusion statement developed
by the Nutritive and Nonnutritive
Sweeteners workgroup (2009) is consistent
with the previous statement
on food intake in adults developed by
the NNS workgroup (2006). Grade III‫؍‬
Limited.
In adults, does using foods or beverages
with sucralose affect appetite?
Conclusion Statement. One crosssectional
study with a small sample
size of only women (Frank and colleagues,
2008) indicates that sucralose
does not affect appetite in adults. This
conclusion statement developed by the
Nutritive and Nonnutritive Sweeteners
workgroup (2009) is consistent with
the previous statement on food intake
in adults developed by the NNS workgroup
(2006). Grade III‫؍‬Limited.
In adults, does using foods or beverages
with sucralose in an energy-restricted or
ad libitum diet affect energy balance?
Conclusion Statement. One randomized
controlled trial (Rodearmel and
colleagues, 2007) examined sucralose
and energy balance in adults. Using sucralose
in either an energy-restricted or
ad libitum diet will affect overall enFROM
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May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 751
ergy balance only if the sucralose is
substituted for higher-energy food or
beverages. This conclusion statement
developed by the Nutritive and Nonnutritive
Sweeteners workgroup (2009) is
consistent with the previous statement
on food intake in adults developed by
the NNS workgroup (2006). Grade
III‫؍‬Limited.
In children, does using beverages with
sucralose in an energy-restricted or
ad libitum diet affect energy balance
(weight)?
Conclusion Statement. One randomized
controlled trial (Rodearmel and
colleagues, 2007) examined sucralose
and energy balance in children. The
study, using human subjects, supports
that the use of sucralose does not cause
weight gain among children and adolescents.
If non–energy-containing
beverages, including those containing
sucralose, are substituted for sugarsweetened
beverages, there is a potential
for energy savings in adolescents.
This conclusion statement developed
by the Nutritive and Nonnutritive
Sweeteners workgroup (2009) is consistent
with the previous statement on
food intake in adults developed by the
NNS workgroup (2006). Grade III‫؍‬
Limited.
In adults, can sucralose be used to
manage diabetes and glycemic response?
Conclusion Statement. Limited evidence
from three controlled trials
(Mezitis and colleagues, 1996; Reyna
and colleagues, 2003; and Grotz and
colleagues, 2003) showed little or no
effects of sucralose on metabolic effects,
including blood glucose in adults;
however, the trials were of small size
and used varying doses of sucralose for
different lengths of time. Two trials
(Mezitis and colleagues, 1996; and
Reyna and colleagues, 2003) found no
difference in measures of glycemic response
when sucralose was added to
diets compared with control diets. One
trial (Grotz and colleagues, 2003) found
decreased Hb A1c levels and fasting
plasma glucose levels from baseline in
adults with diabetes after consuming
sucralose for 3 months. The sucralose
group also had a statistically significant
decrease in fasting plasma glucose from
baseline compared with the control
group. The 2009 update did not find
new studies meeting the inclusion criteria
for this question; the Nutritive
and Nonnutritive Sweeteners workgroup
(2009) reviewed and accepted
these studies identified by the NNS
workgroup (2006). Grade III‫؍‬Limited.
In adults, can sucralose be used to prevent
and manage hyperlipidemia?
Conclusion Statement. One study of
short duration and small sample size in
men (Reyna and colleagues, 2003) indicated
that sucralose has no significant
effect on lipid profile in adults. The evidence
to determine whether sucralose
can be used to prevent and manage hyperlipidemia
is limited. The 2009 update
did not find new studies meeting
the inclusion criteria for this question;
the Nutritive and Nonnutritive Sweeteners
workgroup (2009) reviewed and
accepted the above study identified by
the NNS workgroup (2006). Grade
III‫؍‬Limited.
What is the evidence from human subjects
research that sucralose consumption
is associated with adverse effects in
the general population?
Conclusion Statement. Limited research
in human beings, from peer reviewed
journals, did not find an association
between adverse effect and the
intake of sucralose in the general population
No data from longitudinal cohort
studies were available for review. The
Nutritive and Nonnutritive Sweeteners
workgroup (2009) reviewed and accepted
the studies (Grice and Goldsmith,
2000; and Weihrauch and colleagues,
2004) identified by the NNS
workgroup (2006) and found one additional
article (Grotz and Munro, 2009)
meeting the inclusion criteria for the
update of this question. Grade III‫؍‬
Limited.
To date, no studies meeting the EAL
inclusion criteria were identified to
evaluate the effect of sucralose intake
on energy density, nutrient quality, or
behavior or cognitive changes in adult
or the ADI for persons with diabetes;
and no studies were identified to evaluate
the effects of sucralose on appetite
in children.
SWEETENER USE AND HEALTH
Both nutritive and NNS have generated
health concerns among health care providers
(42,78) and the public for many
years. Concerns related to safety of NNS
are addressed primarily in animal studies.
This EAL addresses many of the
common health concerns with sweetener
use in children and adults. Others,
specifically sweetener use during pregnancy
and effects on dental caries and
hyperactivity, are addressed in this sec-
tion.
Nutritive and NNS Use during
Pregnancy
Pregnancy is a time of special concern
because the focus is on maternal and
fetal health. All FDA-approved nutritive
sweeteners and NNS are approved for
use by the general public, which includes
pregnant and lactating women.
The position of the Academy is that use
of nutritive sweeteners is acceptable
during pregnancy (79). Safety of food
additives, including NNS, is based on
studies in animals as required by the
FDA approval process. Using an appropriate
animal model consistent with International
Conference on Harmonisation
protocols allows testing with large
amounts of the food additive that
would not be permitted in human subjects.
This testing is carried out over
several generations of the animal
model and includes tests on the reproductive
abilities in women and men
and effects on the developing fetus. Any
NNS that was found to be unsafe at any
stage of life would not be approved for
use (19).
One study on use of NNS during pregnancy
has been published after the EAL
on NNS was completed. In 2010, Halldorsson
and colleagues (80) reported
an association between intakes of NNSsweetened
carbonated and noncarbonated
soft drinks and preterm birth
among 59,334 Danish women in the
Danish National Birth Cohort. They excluded
women with gestational diabetes
and controlled for maternal age,
body mass index, smoking status, marital
status, parity, and social status.
Women who consumed one or more
NNS-sweetened soft drinks per day
were significantly more likely to deliver
preterm. The association was stronger
for carbonated than for noncarbonated
drinks. At the time of the study, aspartame
and acesulfame-K were used
most often for carbonated drinks and
saccharin and cyclamates were more
often used for noncarbonated drinks.
The authors concluded that daily intake
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752 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5
of beverages containing NNS may be associated
with an increased risk of preterm
delivery. It is important to point
out that the incidence of preterm birth
was low and the increased risk was due
mostly to medically induced preterm
birth. This finding has not been confirmed
in other studies.
Dental Caries
Dental caries are the localized destruction
of dental hard tissue by acidic material
from bacterial fermentation of dietary
carbohydrate (81). Factors that
influence the development of dental
caries include microbiological shifts in
the biofilm, salivary flow, buffering capacity
of saliva, frequency and kind of
dietary sugars consumed, length of
time oral bacteria have to ferment the
fermentable carbohydrate and make
organic acids, tooth susceptibility, preventive
behaviors such as cleaning of
teeth (82), and exposure to fluoride
(83). The American Academy of Pediatric
Dentistry recommends reducing between-meal
snacks and prolonged exposures
to any food, juice, or beverage
containing fermentable carbohydrate
during infancy, early childhood, and
adolescents (84-86). A child who consumes
more than three between meal
nutritive sweetener-containing snacks
or beverages per day is considered at
increased risk for dental caries (84).
Xylitol is considered cariostatic and
anticariogenic and aids in the prevention
of dental caries (87,88). Milgrom
and colleagues (89) concluded that a
minimum of 5 to 6 g xylitoland three
exposures per day are needed for clinical
effect. Studies of chewing gum containing
anticariogenic polyols and caries
reduction are confounded by the
fact that chewing gum stimulates salivary
flow and salivary flow may be as
important as the polyol in controlling
mouth pH and levels of Streptococcus
mutans to prevent caries (90). The FDA
regulates health claims on food labels
(91). The health claim that sweeteners
do not promote dental caries has been
approved for sugar alcohols (91), erythritol
(92), D-tagatose (93), sucralose
(94), and isomaltulose (95).
Behavior Disorders
The possible negative influence of
added sugars on behavior has received
attention over the years. Wolraich and
colleagues (96) in a meta-analysis on
the effect of sugar on behavior of children
concluded that sugar does not affect
the behavior or cognition of children,
including hyperactive children
and children who were “sugar reactors”
based on parent perception and normal
children. More recent reviews have also
stated that sugar does not affect behavior
or cognition in children with or
without attention-deficit hyperactivity
disorder (ADHD) (97). Research testing
the relation between refined sugars
and behavior has several design flaws.
Modifying the diet is one complementary
approach used often by parents for
their child with ADHD (98). Many sugar
behavior studies used a dose of sugar
that was lower than what children consume
on a regular basis. Levels used in
previous research included 1.75 to 2
g/kg body weight or 52.5g to 60 g (13 to
15 tsp) in a 30 kg child (99-102). Wolraich
and colleagues (103) found no effect
on behavior of 21.3 g (5 tsp) sucrose
per day in preschool children and 120 g
(30 tsp) sucrose per day in school-aged
children without ADHD. Children (aged
2 to 18 years) today consume, on average,
23 tsp added sugars per day (29,34)
with gram intake of added sugars being
52 g for 2- to 5-year-olds, 84 g for 6- to
11-year-olds, and 90 g for 12- to 17year-olds
(30).
Several researchers have concluded
(96,104,105) that parental expectations
and perception are major confounders
in many short- and long-term
studies of the effect of sugars on behavior
of children. Clinicians should use
caution when restricting the diet of
children who have ADHD even though
many parents believe diet affects their
child’s behavior (104). Clinical practice
guidelines regarding the treatment of
children with ADHD state there is a lack
of evidence that removing sugar from
the diet of a child with ADHD results in
fewer symptoms (106,107). The American
Academy of Child and Adolescent
Psychiatry does not address diet or
elimination diets in treatment of children
with ADHD (108). Diet-oriented
treatment is not appropriate for children
with behavioral problems; the
goal of diet treatment is to ensure a balanced
healthy diet with adequate energy
and nutrients for optimal growth
and normal body weight (109).
Recent work has focused on
whether or not refined sugars, even if
part of foods, are addictive (110-113).
This is of interest to consumers and to
scientists because of the linkage to
cravings, binge eating, and obesity
(110). The concept of addiction means
a psychological dependence and is a
cognitive as well as physical condition
(114). Sweet foods per se are not substances
as are drugs such as alcohol.
The literature is complex. It does not
always focus on added sugars alone
but includes all foods and is often
studied within the context of binge
eating behaviors (112).
To be dependent on or addicted to a
substance, any three of the following
seven criteria must be met at any time
in 1 year: tolerance, which means
more substance is needed for the
same effect; withdrawal; larger
amount of the substance taken or
taken for a longer period than intended;
a persistent desire for the substance
or an inability to reduce or control
its use; much time spent seeking
or consuming the substance or recovering
from its effects; use of the substance
interferes with important activities;
and use of the substance
continues despite adverse consequences
(110,115). Corwin and Grigson
(110) proposed that foods rich in
sugar can promote addictive-like behavior
and neuronal changes in certain
situations. These high-sugar
foods may not be addictive per se but
may become addictive if consumed in
a restrictive/binge-like pattern. This
may lead to other chronic conditions
such as obesity, depression, and an-
xiety.
Avena and colleagues (111,116)
have done much of the work in refined
sugar intake and addictive behavior
using animal models. Studies
using animal models to determine if
sugar is addictive use an excessive
binge-eating method and have found
that sugar may meet some of the criteria
for being a substance of abuse
using these animal models (116).
Changes in neurotransmitters of the
limbic system were similar to changes
seen when addictive drugs were provided
but at a much smaller magnitude.
It is hypothesized that when rats
are bingeing on sugar there is an increase
in extracellular dopamine that,
when the sugar is removed, results in
the addictive responses (111). Similar
changes in neurotransmitters were
observed in those with bulimia nerFROM
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vosa that may indicate an addictive
relation but it is not clear if this is
based on sugar intake alone (116).
Functional magnetic resonance imaging
trials in subjects with obesity may
indicate a craving situation in response
to palatable foods that may be
similar to a drug craving (116). That a
sugar addiction is present in human
beings has not been resolved based on
these animal studies. Avena and colleagues
(116) are hesitant to state
that these results support a sugar or
food addiction in human beings and
more high quality well controlled research
in human beings is needed.
Health and Added Sugars Intake
from Dietary Guidelines
The 2010 DGA Committee conducted
an evidence analysis to answer questions
that pertain to added sugars and
health (2):
• In adults, what is the association between
intake of sugar-sweetened
beverages and energy intake? Conclusion:
Limited evidence shows
that intake of sugar-sweetened
beverages is linked to higher energy
intake in adults.
• In adults, what is the association between
intake of sugar-sweetened
beverages and body weight? Conclusion:
A moderate body of epidemiologic
evidence suggests that
greater consumption of sugar-
sweetenedbeveragesisassociated
with increased body weight in
adults. A moderate body of evidence
suggests that under isocaloric
controlled conditions, added
sugars, including sugar-sweetened
beverages, are no more likely
to cause weight gain than any
other source of energy (2). Implications:
Added sugars, as found in
beverages with nutritive sweeten-
ers,arenotdifferentthanotherex-
traenergyinthedietforenergyintake
and body weight. Reducing
intake of all added sugars, including
sucrose, corn sweeteners, fructose,
HFCS, and other forms of
added sugars, is a recommended
strategy to reduce energy intake in
Americans. Intake of energy beverages,
including beverages
sweetened with nutritive sweeteners,
sweetened coffee and tea,
energy drinks, and other drinks
high in energy and low in nutrients
should be reduced in consumers
needing to lower body
weight.
The 2010 DGA also asked:
• How are NNSs related to energy intake
and body weight (2)? Conclusion:
Moderate evidence
shows that using a NNS will affect
energy intake only if they are
substituted for higher-energy
foods and beverages. A few observational
studies reported that
individuals who use NNS are
more likely to gain weight or be
heavier. This does not mean that
NNS cause weight gain; rather,
that they are more likely to be
consumed by individuals with
overweight or obesity. Implications:
The replacement of sugarsweetened
foods and beverages
with sugar-free products should
theoretically reduce body weight.
Yet many questions remain, as
epidemiologic studies show a
positive link with use of NNS and
body mass index (2).
Implications for Food and
Nutrition Practitioners and
Consumers
Consumers have a number of choices to
satisfy their innate desire for sweet
taste. Sugars occur naturally in foods or
may be added during processing or
preparation for consumption. The 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). NNS, when substituted
for nutritive sweeteners, may
help consumers limit carbohydrate and
energy intake as a strategy to manage
blood glucose or weight. Registered dietitians
and dietetic technicians, registered,
working under the supervision of
a registered dietitian, can help consumers
determine the energy allowance
that meets their needs based on age,
sex, physical activity, and nutritional
status. They can provide education and
guidance on use of nutritive sweeteners
and NNS within the ADI that give
the desired results in food preparation
and for use at the table. Registered dietitians
and dietetic technicians, registered,
have an important role in providing
evidence-based information about
the use of nutritive sweeteners and
NNS.
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FROM THE ACADEMY
May 2012 Volume 112 Number 5 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 757
This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on October 18, 1992, and reaffirmed
on September 6, 1996; June 22, 2000; and on December 18, 2008. This position is in effect until December 31, 2015. The Academy authorizes
republication of the position, in its entirety, provided full and proper credit is given. Readers may copy and distribute this paper, providing such
distribution is not used to indicate an endorsement of product or service. Commercial distribution is not permitted without the permission
of the Academy. Requests to use portions of the position must be directed to the Academy headquarters at 800/877-1600, ext. 4835, or
ppapers@eatright.org.
Authors: Cindy Fitch, PhD, RD, West Virginia University, Morgantown, WV; Kathryn S. Keim PhD, RD, LDN, Rush University, Chicago, IL.
Reviewers: Diabetes Care and Education dietetic practice group (Deborah J. Cincinelli-Timm, MSA, RD, The University of Michigan Medical Center,
Ann Arbor MI); Roger A. Clemens, DrPH, FACN (E.T. Horn, Inc, La Mirada, CA); Joan V. Czarnowski-Hill, RD, CDE, LDN (Hill Nutrition Consulting,
LLC, Natick MA); Nancy L. Knodracki, MS, RD, LDN (independent contractor, Greensboro, NC); Esther Myers, PhD, RD, FADA (Academy Research
& Strategic Business Development, Chicago, IL); Susan Raatz, PhD, RD (US Department of Agriculture Human Nutrition Research Center, Grand
Forks, ND); Mary Pat Raimondi, MS, RD (Academy Policy Initiatives & Advocacy, Washington, DC); Janelle M. Walter, PhD, RD (Baylor University,
Waco, TX).
Evidence Analysis Workgroup:
Marion J. Franz, MS, RD, (workgroup chair), Nutrition Concepts by Franz, Inc, Minneapolis, MN; Kristine S. Clark, PhD, RD, Penn State University,
University Park, PA; Molly Gee, Med, RD, LD, Baylor College of Medicine, Houston, TX; Janelle Marshall Walter, PhD, RD, Baylor University, Waco,
TX; Hope Warshaw, MMSc, RD, Alexandria, VA; Kyle L. Thompson, MS, RD, (lead analyst), Appalachian State University, Boone, NC; Tami
Piemonte, MS, RD, LDN, (project manager), consultant, St Petersburg, FL.
Academy Positions Committee Workgroup: Connie B. Diekman, MEd, RD, LD, FADA (chair); Cathy L. Fagen, MA, RD; Hope S. Warshaw, MMSc, RD
(content advisor).
The authors thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position
or the supporting paper.
FROM THE ACADEMY
758 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS May 2012 Volume 112 Number 5