Non-sugar substitutes can be up to 100 times more intense than regular sugar and using them in place of sugar results in fewer calories and carbohydrates. But it's difficult to sort through the confusing information about whether they are safe for cancer survivors.
Is it true non-sugar substitutes cause heart attacks? What about people diagnosed with diabetes - do these non-sugar substitutes really help? And the question clients often ask me: Do artificial sweeteners, even those derived from natural sources, cause cancer?
How sweet it is?
I've sorted through the research for you and this post will answer your important questions. I'll share why the headlines in the press don't tell you the whole story about non-sugar substitutes.
Why are non-sugar substitutes important?
The greatest source of added sugars in our diet (around 24% of all added sugars) are from sugar sweetened beverages. This includes soft drinks, fruit drinks, and sports and energy drinks. Sugar sweetened beverages are linked to higher risks of many cancers, including breast cancer. The average calorie intake of sugar sweetened beverages are 266 calories a day.
Desserts and sweet snacks, sweetened coffee and tea, and candy, make up half of all added sugars while contributing very little nutrition. The Dietary Guidelines for Americans (DGA), specify a 10 percent added sugar limit to allow for flexibility in food choices.
Added sugar at the table is not the same as added sugar in products
Added sugars are also linked to a growing rate of Type 2 diabetes. One in three Americans now have pre-diabetes (and 90% do not know it.) More than 34 million Americans live with Type 2 diabetes and it is among the leading causes, along with cancer, of disability and death. The current Dietary Guidelines for Americans states: "When added sugars in foods and beverages exceed 10 percent of calories, a healthy dietary pattern within calories limits is very difficult to achieve."
So it makes sense that replacing added sugars with non sugar sweeteners may reduce calorie intake in the short-term. The question remains if it's the best way to reduce our risk of cancer and other long-term diseases.
What are non-sugar substitutes?
Non-sugar substitutes are sometimes called artificial sweeteners, sugar substitutes, or non-nutritive sweeteners. Smaller amounts are needed to reach the same level of sweetness as sugar in food and generally will not raise blood sugar levels.
FDA approved non-sugar substitutes
The U.S. Food and Drug Administration (FDA) has tested and approved six artificial sweeteners:
Acesulfame potassium (also called acesulfame K)
Non-sugar substitutes are known by their brand names. Here they are:
Acesulfame Potassium: Sunnett, Sweet One
Aspartame (Blue) : Nutrasweet, Equal
Saccharin (Pink) : Sweet 'N Low, Sweet Twin, Sugar Twin
Sucralose (Yellow) : Splenda
Neotame : Newtame
Stevia (Green)* :A Sweet Leaf, Sun Crystals, Steviva,Truvia, PureVia
Nectresse, Monk Fruit in the Raw, PureLo are all monk fruit and generally recognized as safe by the FDA.
*Stevia is a highly purified product that comes from the stevia plant. It is several hundred times sweeter than sugar. It is generally recognized as safe by the FDA as a food additive and table top sweetener.
Non-sugar substitutes comparison
How do these sweeteners compare? These are the sweetener comparisons:
1 packet Splenda = 4 calories + 1 gram of carbohydrate
1 packet of Sugar Twin = 3 calories + 1 gram of carbohydrate
1 packet of Equal = 4 calories + 1 gram of carbohydrate
1 packet sugar = 11 calories + 3 grams of carbohydrate
Sugar alcohols: In a class by itself
Sugar alcohols are low-calorie sweeteners that are not as high intensity as others. They vary from 25% to 100% as sweet as sugar. They are slightly lower in calories than sugar and do not cause blood glucose to spike:
Examples of sugar alcohols* include:
Glycerol (also known as glycerin or glycerine)
Hydrogenated starch hydrolysates
*Sugar alcohols can have a laxative effect or other gastric symptoms in some people, especially in children.
Non-sugar substitutes: What does the research say?
The FDA regulates these "high-intensity sweeteners" as a food additive.
Based on current and available scientific evidence, the FDA says the specific sweeteners approved by FDA are "safe for the general population under certain conditions of use." However, consumers with phenylketonuria (PKU), a rare genetic disorder, should avoid or restrict aspartame and food products containing aspartame by looking at the label on such products, which must include a statement that the product contains phenylalanine.
The FDA has measured an acceptable daily intake (ADI) level, or the amount of a substance that is considered safe to consume each day over the course of a person’s lifetime. For each of these sweeteners, the estimated daily intake even for a high consumer of the substance would not exceed the ADI. An additive does not present safety concerns if the estimated daily intake is less than the ADI, according to the FDA.
One very small study has linked erythritol, a sugar alcohol, to cardiovascular event risks. The particular metabolite found associated with cardiovascular events and erythritol increases blood clot formation. This, in turn, could increase the risk of heart attack or stroke. The study calls for more research assessing the long-term safety of erythritol.
Usefulness for weight loss
New research confirms that replacing added sugars with non-sugar substitutes may not reduce calorie intake long-term or aid in weight management. "Questions remain about their effectiveness as a long-term weight management strategy, " states the DGA.
In fact, the World Health Organization (WHO) discourages the use of non-sugar substitutes for weight loss, because replacing free sugars with artificial sweeteners does not help with weight control in the long term. It does not link it to cancer concerns, rather, the WHO says there may be potential undesirable effects from long-term use, such as an increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults.
The recommendation applies to all people except individuals with pre-existing diabetes.
Link to cancer
Large studies looking on non-sugar substitutes have not demonstrated any conclusive evidence of a connection to a higher risk of cancer. These studies are observational, so cause and effect cannot be determined. According to the American Institute for Cancer Research, "Studies on artificial sweeteners, including saccharin and aspartame, have shown no convincing evidence of an association with cancer. Earlier cancer scares linked with certain sweeteners have been discredited."
In 2022, the NutriNet-Santé cohort study reported that adults who consumed higher amounts of aspartame were slightly more likely to develop breast cancer (1.22 times the risk), than those who did not consume aspartame. However, it has to be seen whether this was due to other factors, such as the function of body fat, rather than aspartame.
Cyclamate was banned in the United States in 1969 but later evaluation of additional data led scientists to conclude that cyclamate does not cause cancer. Still it has not been reapproved in the United States (although it is approved in many other countries).
Tips to reduce sugar without non-sugar substitutes
While non-sugar substitutes can be a good replacement for sugar, especially for individuals with prediabetes or diabetes, some people prefer to use the regular version of a food and cut back on the serving size. Non-sugar substitutes can be more expensive and there is concern that they may increase our preference for sweet things.
Limiting intake of foods and beverages high in added sugars is a first step. Use your hunger and fullness cues to guide you throughout the day. Set yourself a goal, such as, I choose to eat office pastry only on Tuesdays. Other strategies include reducing portions, consuming these items less often, and selecting options low in added sugars.
Ideally, both added sugar and non-sugar substitutes should be limited to make more room in the diet for healthy and nutritious foods. But there's no room for guilt when eating these foods, or thinking you can never eat them. While the Dietary Guidelines for Americans say these foods should be limited to occasional choices and consumed in small portions, nevertheless, individuals "should have some flexibility to choose a healthy dietary pattern within calorie limits that fits personal preferences and cultural traditions—and allows day-to-day flexibility to support a healthy dietary pattern over time."
What will you do?
Given the emerging research, you may choose to have non-sugar substitutes less often, while also reducing high-sugar containing foods. It's important not to absorb messages which promote guilt along with the occasional pastry, such as sugar causes cancer (it doesn't). There's always room for fun foods as part of our diets!
As a registered dietitian nutritionist who works with people experiencing cancer, I’d love to help. I offer clients support to plan, shop, and prepare more nutritious and healthy meals for yourself or your family. Here is my link to book a chat about making sure to meet your nutritional needs.
American Diabetes Association. (n.d.). Retrieved from http://www.diabetes.org/
Center for Food Safety and Applied Nutrition. (n.d.). Food Additives & Ingredients - High-Intensity Sweeteners. Retrieved from
Strawbridge, H. (2018, January 08). Artificial sweeteners: Sugar-free, but at what cost? Retrieved from