Artificial Sweeteners

Artificial Sweeteners Review

Artificial sweeteners, also called high-intensity sweeteners or sugar substitutes, are substances that are used instead of sucrose (table sugar) to sweeten foods and beverages. Because artificial sweeteners are many times sweeter than table sugar, smaller amounts are needed to create the same level of sweetness. Today artificial sweeteners and other sugar substitutes are found in a variety of food and beverages; they’re marketed as “sugar-free” or “diet,” including soft drinks, chewing gum, jellies, baked goods, candy, fruit juice, and ice cream and yogurt.

In order to make these artificial sweeteners look similar to sugar, additional ingredients are added to the pure sweeteners for texture and volume. These ingredients (some common ones are dextrose and maltodextrin) will also add a small amount of calories and carbohydrate to the product.

One teaspoon or one packet of artificial sweetener is usually considered a serving.

Artificial sweeteners are used as an alternative to table sugar may reduce calorie intake in the short-term, yet questions remain about their effectiveness as a long-term weight management strategy.

The other benefit of artificial sweeteners is that they don’t contribute to tooth decay and cavities.

Artificial sweeteners are regulated by the U.S. Food and Drug Administration (FDA) and 6 artificial sweeteners have been approved by the FDA ¹. This means that there is reasonable certainty of no harm under the intended conditions of use because the estimated daily intake is not expected to exceed the acceptable daily intake for each sweetener. The FDA has determined that the estimated daily intake of these high-intensity sweeteners would not exceed the acceptable daily intake, even for high consumers of each substance.

Extensive scientific research has demonstrated the safety of the six low-calorie sweeteners currently approved for use in foods in the U.S. and Europe (stevia, acesulfame-K, aspartame, neotame, saccharin and sucralose), if taken in acceptable quantities daily.

FDA approved artificial sweeteners ¹ include:

1. Aspartame (Equal and NutraSweet): 220 times sweeter than sucrose (table sugar); loses its sweetness when exposed to heat. It is best used in beverages rather than baking. Aspartame is an amino-acid compound that is absorbed from the intestine and metabolized by the liver to form phenylalanine, aspartic acid and methanol. Aspartame can contribute to weight gain, obesity, insulin resistance, and type 2 diabetes mellitus ². Recently, Brown et al. ³ showed that artificial sweeteners may trigger the secretion of glucagon-like peptide (GLP)-1 by the digestive tract, and thereby curb appetite and calorie intake.
2. Sucralose (Splenda): 600 times sweeter than sucrose (table sugar); used in many diet foods and drinks, chewing gum, frozen dairy desserts, fruit juices, and gelatin. Works well in baked foods because it’s heat stable.
3. Saccharin (Sweet ‘N Low, Sweet Twin, NectaSweet): 200 to 700 times sweeter than sucrose (table sugar); used in many diet foods and drinks; may have a bitter or metallic aftertaste in some liquids; not used in cooking and baking
4. Acesulfame K (Sunett and Sweet One): an artificial sweetener most similar to table sugar in taste and texture; its about 200 sweeter than sucrose (table sugar) and it’s heat-stable, so can be used in cooking and baking; this sweetener can be added to food at the table; used together with other sweeteners, such as saccharin, in carbonated low-calorie beverages and other products.
5. Neotame (Newtame): artificial sweetener that is 7,000 to 13,000 sweeter than sucrose (table sugar); used in many diet foods and drinks; used as a tabletop sweetener.
6. Advantame : FDA approved as a general-purpose sweetener and flavor enhancer in food, except meat and poultry. Its about 20,000 sweeter than sucrose (table sugar).
7. Stevia (Truvia, Pure Via, Sun Crystals, Rebaudioside A, Reb A, rebiana): non-caloric plant-based sweetener; made from the plant Stevia rebaudiana, which is grown for its sweet leaves; common names include sweetleaf, sweet leaf, sugarleaf, or simply stevia. FDA approved as generally recognized as safe (GRAS) as a food additive and table top sweetener. Stevia is 150 to 200 times sweeter than sucrose (table sugar).
8. Monk Fruit (Nectresse and Luo Han Guo): the powdered extract of monk fruit, a round green melon that grows in central Asia; 150 to 200 times sweeter than sucrose (table sugar); heat stable and can be used in baking and cooking and is more concentrated than sugar (¼ teaspoon or 0.5 grams equals the sweetness of 1 teaspoon or 2.5 grams sugar). FDA approved as generally recognized as safe (GRAS) as a food additive and table top sweetener.

The table below lists the brand names seen in stores for low-calorie artificial sweeteners:

Table 1. FDA Approved Artificial Sweeteners and Brand Names

Artificial Sweeteners and Weight Gain

In a recent (published 17 July 2017) systematic review and meta-analysis of randomized controlled trials and prospective cohort studies on the effects of non-nutritive sweeteners (artificial sweeteners) and cardio-metabolic health being conducted by Dr. Azad et al. ¹⁰ found that non-nutritive sweeteners (artificial sweeteners) had no significant effect on BMI (body mass index) on participants, in fact in the included cohort studies, consumption of non-nutritive sweeteners was associated with a modest increase in BMI. In the cohort studies, consumption of non-nutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events ¹⁰. Theories about why artificial sweeteners might not help weight loss tend to revolve around two schools of thought, Dr. Azad said. One school holds that the sweeteners might influence dieters’ behavior in unhealthy ways. For example, a person drinking a no-calorie soda might feel free to eat calorie-laden foods, Azad noted. Artificial sweeteners also might sharpen the person’s sweet tooth, making them more likely to indulge in sugary foods. The other school holds that artificial sweeteners might influence the body itself in some as-yet-unknown way, Azad said. The artificial sweeteners could alter the way that gut microbes function in the digestion of food, or possibly change the body’s metabolism over time by sending repeated false signals that something sweet has been ingested ¹¹. Another plausible explanation for why the study subjects gained weight and have higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events, is that the study population involved people who are already overweight, obese, have metabolic syndrome, hypertension or suffer from type 2 diabetes ¹¹.

Artificial sweeteners are many times sweeter than natural sugar and as they contain “no calories”, they may be used to control weight and obesity. Artificial sweeteners are also considered “no-calorie” because they have 5 calories or less per serving, so in reality artificial sweeteners do contain calories. When you use a large amount of these products, the calories can start to add up. As with all foods, it is important not to go overboard.

Comparison of some different sweeteners to regular sugar below:

1 packet Sugar = 11 calories + 3 grams of carbohydrate

or

1 packet Splenda (Sucralose) = 4 calories + < 1 gram of carbohydrate

or

1 packet of Sugar Twin (Aspartame) = 3 calories + < 1 gram of carbohydrate

or

1 packet of Equal (Aspartame) = 4 calories + < 1 gram of carbohydrate

or

1 teaspoon of Agave = 21 calories + 5.3 to 5.7 grams carbohydrate

or

1 teaspoon of Sugar (brown, powdered, raw, and white) and Maple syrup have 2.5 to 4.6 grams of carbohydrate per teaspoon and 10 to 18 calories.

or

1 teaspoon of Powdered Sugar = 10 calories + 2.5 grams carbohydrate

or

1 teaspoon of Maple syrup = 10 to 18 calories + 2.5 to 4.6 grams of carbohydrate

or

1 teaspoon of Honey = 21 calories + 5.3 to 5.7 grams carbohydrate

When you use a large amount of these products, it can start to add up. As with all foods, it is important not to go overboard.

Still, many foods containing low-calorie sweeteners will provide some calories and carbohydrate from other ingredients. That means foods that carry claims like “sugar-free,” “reduced sugar” or “no sugar added” are not necessarily carbohdyrate-free or lower in carbohydrate than the original version of the food. Always check the nutrition facts panel, even for foods that carry these claims.

Seventy-three percent of people who consume low- or no-calorie sweeteners say they use these products to reduce their total daily calories. Products containing low- or no-calorie sweeteners may help with weight loss if they are used in place of their full-calorie counterparts—provided you don’t eat or drink those calories (or more) through other sources ⁶.

For example, drink a can of diet soda instead of the sugar-sweetened alternative, and you’ll save 150 calories. But if you drink that calorie-free soda and then indulge in a 150-calorie (or more) snack, you lose the potential weight-loss benefit ⁶.

Although the research isn’t conclusive—and, in fact, is somewhat controversial—some scientists believe that consuming food and beverages with artificial sweeteners can increase hunger, appetite, and calorie intake by decreasing the feeling of fullness or by training your taste buds to like sweet things so that you’ll then eat more of them. The bottom line: If you want to use nonnutritive sweeteners to help you lose weight, don’t eat more of something else to make up for the calories saved ⁶.

Although there are concerns that consumption of nonnutritive sweeteners contributes to obesity, a critical review of the literature by Mattes and Popkin ¹³ found no supportive evidence for mechanisms that would produce weight gain. In fact, the majority of studies examining the use and effect of nonnutritive sweeteners on weight in adults have indicated that nonnutritive sweeteners may help reduce caloric intake, yield a few pounds of weight loss, and help prevent unwanted weight gain.

However, in another study ¹⁴ to find the effects of these sugar substitutes on humans, where a team of researchers collected data from 381 non-diabetic individuals. They found that long-term consumption of artificial sweeteners resulted in increased weight and higher fasting blood glucose levels, among other negative health effects. Even short-term consumption of artificial sweeteners resulted in glucose intolerance and pronounced changes in microbiota composition. Individuals’ response varied, leading researchers to consider developing personalized methods to improve the quality of nutritional intake as a future research direction.

In a series of experiments Suez J et.al, ¹⁴ fed a group of mice natural products of water, glucose (made when the body breaks down starches such as carbohydrates) and sucrose (table sugar) separately, and another group of mice with three of the most popular commercial sugar substitutes – saccharin (Sweet N’ Low), aspartame (Equal) and sucralose (Splenda), which are available in U.S. When tested for metabolic differences, the latter group of mice showed elevated blood glucose levels within two hours of consumption. Normally, blood glucose levels increase slightly after eating. This increase causes the pancreas to release insulin so that blood glucose levels do not get too high. Blood glucose levels that remain high over time can damage the eyes, kidneys, nerves and blood vessels and, ultimately, can lead to diabetes.

They repeated the experiment with mice being fed a high fat diet to see if obesity might alter their findings, administered pure saccharin instead of Sweet N’ Low, used a different breed of mice and even transplanted feces of the initial groups into germ-free mice to compare results. In all cases, mice fed with artificial sweeteners had elevated glucose intolerance.

The change essentially stimulated gut bacteria growth and helped calories turn into body fat more efficiently. Using the Human Microbiome Project reference genome database, the researchers were able to identify and compare the microbiota compositions of the mice, and found major changes in microbe species abundance in those fed with artificial sweeteners. Even more concerning was the discovery of changes in the genes in gut microbiota that have been associated with pathways leading to obesity in mice and humans.

Many people consider artificial sweeteners to be a good diet option for weight loss and controlling blood glucose levels. However, this study suggests that artificial sweeteners have the opposite effect in mice. The question is what happens in rodents does not necessarily happen in humans. So additional research needs to be done on human subjects. It’s too soon to draw any conclusions about artificial sweeteners causing obesity or type 2 diabetes. The American Diabetes Association consider artificial sweeteners a reasonable choice over sugar for weight and blood glucose management.

Epidemiological studies in humans ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹ and lab studies in animals ²⁰, ²¹, ²² both suggest an association between use of artificial sweeteners and body weight gain. Epidemiological studies also demonstrated that artificial sweetener use increased the risk for metabolic syndrome, type 2 diabetes, hypertension, and cardiovascular disease ²³. Most human epidemiological studies have not distinguished among the different types of artificial sweeteners (e.g., sucralose, saccharin, acesulfame-K, aspartame, neotame, stevioside, and rebaudioside) but rather treated them as a group. One exception is the Nurses’ Health Study cohort ²⁴, which did specifically associate saccharin use with weight gain. This finding is consistent with recent animal experiments ²⁰, ²¹ in which saccharin intake was related to weight gain in rats.

On available scientific data thus far, although the research isn’t conclusive and in fact, is somewhat controversial, some scientists believe that consuming food and beverages with artificial sweeteners can increase hunger, appetite, and calorie intake by decreasing the feeling of fullness or by training your taste buds to like sweet things so that you’ll then eat more of them. And that artificial sweeteners if used excessively, they can increase weight, promote obesity, and impairment of normal metabolic responses due to changes in your gut microbiome (gut bacteria).

A good goal is no more sugar from all sources than the equivalent of 6 teaspoons for women and 9 teaspoons for men each day as per the American Heart Association and the USDA’s Dietary Guidelines for Americans 2015-2020.

Can Artificial Sweeteners Cause Diabetes ?

Last year, a team of researchers published their controversial findings that artificial sweeteners may lead to obesity and type 2 diabetes in mice by changing the bacteria in their intestines that affect metabolism ²⁵ . The change essentially stimulated gut bacteria growth and helped calories turn into body fat more efficiently.

The study went something like this (see above for more details): Researchers fed saccharin, sucralose, or aspartame to a group of mice every day. They gave a control group of mice glucose or sucrose daily. After 11 weeks, the mice fed artificial sweetener had abnormally high blood glucose levels whereas the sugar-eating mice did not. When the researchers killed off the gut bacteria in the artificial sweetener–eating mice, blood glucose levels went back to normal.

The researchers wondered whether the same connection could be true in humans, too. So they tracked blood glucose levels in seven people who normally didn’t eat or drink artificially sweetened products. The volunteers were given the FDA’s acceptable daily intake of saccharin for six days. By the end of the study, blood glucose levels had risen in four of the seven participants and their intestinal bacteria had changed.

There are many criticisms of the study, including its design (what happens in rodents does not necessarily happen in humans), size, length, and the quantity of artificial sweetener used in the study (much greater than the average daily intake).

So what does all of this mean for you ? It’s too soon to draw any conclusions about artificial sweeteners causing obesity or type 2 diabetes. Although additional research is needed, artificial sweeteners are still considered a reasonable choice over sugar for weight and blood glucose management.

Artificial Sweeteners and Diabetes

Sugary drinks consumption is associated with increased risk of obesity and type 2 diabetes. Thereby, artificial sweeteners consumption became increasingly popular and were introduced largely in people’s diet in order to reduce their calorie intake and normalise blood glucose levels without altering our taste for “sweetness”.

Using artificial sweeteners does not appear to affect blood glucose or lipids in adults with diabetes; no studies were found examining this issue in children. Individuals with diabetes must consider total carbohydrate consumed. People with diabetes may improve their glycemic control and better manage their weight with the use of nonnutritive sweeteners when foods with sugar, starch, and fat are also reduced ²⁶,²⁷.

The Evidence Analysis Library (EAL) of the Academy of Nutrition and Dietetics recently examined the evidence related to the use of artificial sweeteners and potential effects on weight, appetite, food intake, glycemic control, and other health issues. The conclusion of the EAL workgroup was that sucralose, aspartame, and saccharin have no effect on appetite in adults ²⁸.

According to the American Diabetes Association ²⁹, foods and drinks that use artificial sweeteners are another option that may help diabetics curb their cravings for something sweet.

However, according to the American Heart Association news report 7th October 2014 ³⁰, a recent scientific study published in the science journal Nature ³¹, a study on the effects of artificial sweeteners on blood glucose homeostasis and gut microbiota. The study was conducted largely on mice and included an experiment on seven people who did not normally consume artificial sweeteners. The researchers primarily used saccharin in the experiments, however some of the experiments also included aspartame and sucralose. They found that some mice and people had a two- to four-times increase in blood sugars and changes in the types of microbes in their intestines. In summary, their results suggest that artificial sweeteners consumption in both mice
and humans enhances the risk of glucose intolerance and that these adverse metabolic effects are mediated by modulation of the composition and function of the gut microbiota. Notably, several of the bacterial taxa that changed following artificial sweeteners consumption were previously associated with type 2 diabetes in humans ³¹. The findings counter the perception that artificial sweeteners, which are not meant to be absorbed by the digestive tract, don’t affect blood sugar or glucose tolerance – which can be a harbinger of diabetes ³⁰. Moreover, the study’s authors, Eran Elinav and Eran Segal of the Weizmann Institute of Science in Israel, said more information and confirmation of their results are needed ³¹.

The American Heart Association and the American Diabetes Association reviewed the safety of artificial sweeteners in a 2012 statement and concluded they should be used “judiciously” as a way to reduce sugar intake. The findings of the American Heart Association research “at this time, there are insufficient data to determine conclusively whether the use of non-nutritive sweeteners (artificial sweeteners) to displace caloric sweeteners in beverages and foods reduces added sugars or carbohydrate intakes, or benefits appetite, energy balance, body weight, or cardiometabolic risk factors. There are some data to suggest that non-nutritive sweeteners (artificial sweeteners) may be used in a structured diet to replace sources of added sugars and that this substitution may result in
modest energy intake reductions and weight loss. The impact of incorporating non-nutritive sweeteners (artificial sweeteners) and non-nutritive sweeteners-containing beverages and foods on overall diet quality should be included in assessing the overall balance of benefits and risks. Apparent from the available literature is the paucity of data from well-designed human trials exploring the potential role of non-nutritive sweeteners in achieving and maintaining a healthy
body weight and minimizing cardiometabolic risk factors. The evidence reviewed suggests that when used judiciously, non-nutritive sweeteners could facilitate reductions in added sugars intake, thereby resulting in decreased total energy and weight loss/weight control, and promoting beneficial effects on related metabolic parameters. However, these potential benefits will not be fully realized if there is a compensatory increase in energy intake from other sources ³².

Is there an association between artificial sweeteners and cancer ?

Questions about artificial sweeteners and cancer arose when early studies showed that cyclamate in combination with saccharin caused bladder cancer in laboratory animals. However, results from subsequent carcinogenicity studies (studies that examine whether a substance can cause cancer) of these sweeteners have not provided clear evidence of an association with cancer in humans. Similarly, studies of other FDA-approved sweeteners have not demonstrated clear evidence of an association with cancer in humans ³³.

What have studies shown about a possible association between specific artificial sweeteners and cancer ?

1) Saccharin

Studies in laboratory rats during the early 1970s linked saccharin with the development of bladder cancer. For this reason, Congress mandated that further studies of saccharin be performed and required that all food containing saccharin bear the following warning label: “Use of this product may be hazardous to your health. This product contains saccharin, which has been determined to cause cancer in laboratory animals.”

Subsequent studies in rats showed an increased incidence of urinary bladder cancer at high doses of saccharin, especially in male rats. However, mechanistic studies (studies that examine how a substance works in the body) have shown that these results apply only to rats. Human epidemiology studies (studies of patterns, causes, and control of diseases in groups of people) have shown no consistent evidence that saccharin is associated with bladder cancer incidence.

Because the bladder tumors seen in rats are due to a mechanism not relevant to humans and because there is no clear evidence that saccharin causes cancer in humans, saccharin was delisted in 2000 from the U.S. National Toxicology Program’s Report on Carcinogens, where it had been listed since 1981 as a substance reasonably anticipated to be a human carcinogen (a substance known to cause cancer). More information about the delisting of saccharin is available at  (Source ³⁴) on the Internet. The delisting led to legislation, which was signed into law on December 21, 2000, repealing the warning label requirement for products containing saccharin.

2) Aspartame

Aspartame, distributed under several trade names (e.g., NutraSweet® and Equal®), was approved in 1981 by the FDA after numerous tests showed that it did not cause cancer or other adverse effects in laboratory animals. Questions regarding the safety of aspartame were renewed by a 1996 report suggesting that an increase in the number of people with brain tumors between 1975 and 1992 might be associated with the introduction and use of this sweetener in the United States. However, an analysis of then-current National Cancer Institute (NCI) statistics showed that the overall incidence of brain and central nervous system cancers began to rise in 1973, 8 years prior to the approval of aspartame, and continued to rise until 1985. Moreover, increases in overall brain cancer incidence occurred primarily in people age 70 and older, a group that was not exposed to the highest doses of aspartame since its introduction. These data do not establish a clear link between the consumption of aspartame and the development of brain tumors.

In 2005, a laboratory study found more lymphomas and leukemias in rats fed very high doses of aspartame (equivalent to drinking 8 to 2,083 cans of diet soda daily) (Source ³⁵). However, there were some inconsistencies in the findings. For example, the number of cancer cases did not rise with increasing amounts of aspartame as would be expected. An FDA statement on this study can be found at Source ³⁶ on the Internet.

Subsequently, NCI examined human data from the NIH-AARP Diet and Health Study of over half a million retirees. Increasing consumption of aspartame-containing beverages was not associated with the development of lymphoma, leukemia, or brain cancer (Source ³⁷).

3) Acesulfame potassium, Sucralose, and Neotame

In addition to saccharin and aspartame, three other artificial sweeteners are currently permitted for use in food in the United States:

Acesulfame potassium (also known as ACK, Sweet One®, and Sunett®) was approved by the FDA in 1988 for use in specific food and beverage categories, and was later approved as a general purpose sweetener (except in meat and poultry) in 2002.
Sucralose (also known as Splenda®) was approved by the FDA as a tabletop sweetener in 1998, followed by approval as a general purpose sweetener in 1999.

Neotame, which is similar to aspartame, was approved by the FDA as a general purpose sweetener (except in meat and poultry) in 2002.

Before approving these sweeteners, the FDA reviewed more than 100 safety studies that were conducted on each sweetener, including studies to assess cancer risk. The results of these studies showed no evidence that these sweeteners cause cancer or pose any other threat to human health.

4) Cyclamate

Because the findings in rats suggested that cyclamate might increase the risk of bladder cancer in humans, the FDA banned the use of cyclamate in 1969. After reexamination of cyclamate’s carcinogenicity and the evaluation of additional data, scientists concluded that cyclamate was not a carcinogen or a co-carcinogen (a substance that enhances the effect of a cancer-causing substance). A food additive petition was filed with the FDA for the reapproval of cyclamate, but this petition is currently being held in abeyance (not actively being considered). The FDA’s concerns about cyclamate are not cancer related.

Are there any Dangers of taking Artificial Sweeteners ?

There is some ongoing debate over whether artificial sweetener usage poses a health threat. Based on the available scientific evidence, these high-intensity sweeteners have been determined to be safe for the general population. Research on five approved artificial sweeteners supports safety when used under FDA recommendations.

However, on available scientific data thus far, although the research isn’t conclusive and, in fact, is somewhat controversial, some scientists believe that consuming food and beverages with artificial sweeteners can increase hunger, appetite, and calorie intake by decreasing the feeling of fullness or by training your taste buds to like sweet things so that you’ll then eat more of them. And that artificial sweeteners if used excessively, they can increase weight, promote obesity, and impairment of normal metabolic responses.

In studies on mice fed with non-caloric artificial sweeteners, they demonstrated that consumption of commonly used non-caloric artificial sweeteners formulations drives the development of glucose intolerance through alterations to the intestinal microbiota (gut bacteria). These non-caloric artificial sweeteners-mediated deleterious metabolic effects are abolished by antibiotic treatment. They identify artificial sweeteners altered microbial metabolic pathways that are linked to host susceptibility to metabolic disease, and demonstrate similar artificial sweeteners induced microbial imbalance and glucose intolerance in healthy human subjects. Collectively, their results link artificial sweeteners consumption,  gut microbial imbalance and metabolic abnormalities, thereby calling for a reassessment of massive artificial sweeteners usage.

The Academy of Nutrition and Dietetics ³⁸ says that people can safely enjoy a range of artificial sweeteners when they are part of 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. The Academy does state, however, that there is not enough research on the safety of artificial sweeteners during pregnancy or in the case of gestational diabetes.

Although artificial sweeteners can be used in place of sugar in many foods, thus lowering the calorie and carbohydrate content, this does not necessarily mean those foods are carb free, sugar free, or calorie free. A good goal is no more sugar from all sources than the equivalent of 6 teaspoons for women and 9 teaspoons for men each day as per the American Heart Association and the USDA’s Dietary Guidelines for Americans 2015-2020.

Lastly, artificial sweeteners don’t contribute to tooth decay and cavities.

1. U.S. Food and Drug Administration. Additional Information about High-Intensity Sweeteners Permitted for use in Food in the United States. https://www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397725.htm[↩][↩][↩][↩][↩][↩][↩]
2. Is aspartame really safer in reducing the risk of hypoglycemia during exercise in patients with type 2 diabetes? Ferland A, Brassard P, Poirier P. Diabetes Care. 2007 Jul; 30(7):e59. https://www.ncbi.nlm.nih.gov/pubmed/17596482/[↩]
3. Ingestion of diet soda before a glucose load augments glucagon-like peptide-1 secretion. Brown RJ, Walter M, Rother KI. Diabetes Care. 2009 Dec; 32(12):2184-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782974/[↩]
4. Joint Expert Commission on Food Additives of the World Health Organization and the Food and Agriculture Organization. http://www.codexalimentarius.net/web/jecfa.jsp[↩]
5. American Diabetes Association. Using Sugar Substitutes in the Kitchen. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/artificial-sweeteners/using-sugar-substitutes.html[↩]
6. American Diabetes Association. 5 Must-Know Facts About Sweeteners. http://www.diabetesforecast.org/2016/jan-feb/5-must-know-facts-about-sweeteners.html[↩][↩][↩][↩][↩][↩]
7. American Academy of Family Physicians. Sugar Substitutes. https://familydoctor.org/sugar-substitutes[↩]
8. Position of the Academy of Nutrition and Dietetics:Use of Nutritive and Nonnutritive SweetenersJ Acad Nutr Diet. 2012;112:739-758[↩]
9. MDText.com, Inc.; 2000-.2015 May 31. Nutritional Recommendations for Individuals with Diabetes. https://www.ncbi.nlm.nih.gov/pubmed/25905243[↩]
10. Azad MB, Abou-Setta AM, Chauhan BF, et al. Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies. CMAJ : Canadian Medical Association Journal. 2017;189(28):E929-E939. doi:10.1503/cmaj.161390. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515645/[↩][↩]
11. U.S. National Library of Medicine. Medline Plus. Could Artificial Sweeteners Raise Your Odds for Obesity ?. https://medlineplus.gov/news/fullstory_167249.html[↩][↩]
12. American Diabetes Association. Not Completely Carbohydrate and Calorie-Free. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/artificial-sweeteners/not-completely-carbohydrate.html[↩]
13. Mattes RD, Popkin BN: Nonnutritive sweetener consumption in humans: effects on appetite and food intake and their putative mechanisms. Am J Clin Nutr 89:1–14, 2009[↩]
14. Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, Israeli D, Zmora N, Gilad S, Weinberger A, Kuperman Y, Harmelin A,Kolodkin-Gal I, Shapiro H, Halpern Z, Segal E, Elinav E. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature, 514(7521):181-6. 2014. Available online at https://www.nature.com/nature/journal/v514/n7521/abs/nature13793.html[↩][↩]
15. Fueling the obesity epidemic? Artificially sweetened beverage use and long-term weight gain. Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP. Obesity (Silver Spring). 2008 Aug; 16(8):1894-900. https://www.ncbi.nlm.nih.gov/pubmed/18535548/[↩]
16. Artificial sweetener use and one-year weight change among women. Stellman SD, Garfinkel L. Prev Med. 1986 Mar; 15(2):195-202. https://www.ncbi.nlm.nih.gov/pubmed/3714671/[↩]
17. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Dhingra R, Sullivan L, Jacques PF, Wang TJ, Fox CS, Meigs JB, D’Agostino RB, Gaziano JM, Vasan RS. Circulation. 2007 Jul 31; 116(5):480-8. https://www.ncbi.nlm.nih.gov/pubmed/17646581/[↩]
18. Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Lutsey PL, Steffen LM, Stevens J. Circulation. 2008 Feb 12; 117(6):754-61. https://www.ncbi.nlm.nih.gov/pubmed/18212291/[↩]
19. Gain weight by “going diet?” Artificial sweeteners and the neurobiology of sugar cravings: Neuroscience 2010. Yang Q. Yale J Biol Med. 2010 Jun; 83(2):101-8. https://www.ncbi.nlm.nih.gov/pubmed/20589192/[↩]
20. A role for sweet taste: calorie predictive relations in energy regulation by rats. Swithers SE, Davidson TL. Behav Neurosci. 2008 Feb; 122(1):161-73. https://www.ncbi.nlm.nih.gov/pubmed/18298259/[↩][↩]
21. General and persistent effects of high-intensity sweeteners on body weight gain and caloric compensation in rats. Swithers SE, Baker CR, Davidson TL. Behav Neurosci. 2009 Aug; 123(4):772-80. https://www.ncbi.nlm.nih.gov/pubmed/19634935/[↩][↩]
22. High-intensity sweeteners and energy balance. Swithers SE, Martin AA, Davidson TL. Physiol Behav. 2010 Apr 26; 100(1):55-62. https://www.ncbi.nlm.nih.gov/pubmed/20060008/[↩]
23. Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements. Swithers SE. Trends Endocrinol Metab. 2013 Sep; 24(9):431-41. https://www.ncbi.nlm.nih.gov/pubmed/23850261/[↩]
24. Patterns of weight change and their relation to diet in a cohort of healthy women. Colditz GA, Willett WC, Stampfer MJ, London SJ, Segal MR, Speizer FE. Am J Clin Nutr. 1990 Jun; 51(6):1100-5. https://www.ncbi.nlm.nih.gov/pubmed/2349925/[↩]
25. Suez J, Korem T, Zeevi D, Zilberman-Schapira G, Thaiss CA, Maza O, Israeli D, Zmora N, Gilad S, Weinberger A, Kuperman Y, Harmelin A,Kolodkin-Gal I, Shapiro H, Halpern Z, Segal E, Elinav E. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. https://www.nature.com/nature/journal/vaop/ncurrent/pdf/nature13793.pdf[↩]
26. Academy of Nutrition and Dietetics Evidence Analysis Library: Effect of nonnutritive sweeteners on energy balance (weight) in adults [article online] Available from http://www.adaevidencelibrary.com/topic.cfm?cat=4615. Accessed 25 February 2012[↩]
27. Academy of Nutrition and Dietetics Evidence Analysis Library: The truth about artificial sweeteners or sugar substitutes: how much is too much? [article online]. Available from http://www.adaevidencelibrary.com/files/Docs/nonnutritivesweetenersResource-Draft3.pdf. Accessed 25 February 2012[↩]
28. Academy of Nutrition and Dietetics Evidence Analysis Library : Effect of nonnutritive sweeteners on appetite in adults [article online]. Available from http://www.adaevidencelibrary.com/topic.cfm?cat=4612. Accessed 25 February 2012[↩]
29. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/artificial-sweeteners/[↩]
30. American Heart Association. Artificial sweeteners may increase blood sugar. http://news.heart.org/artificial-sweeteners-may-increase-blood-sugar/[↩][↩]
31. Nature doi:10.1038/nature13793. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. https://www.nature.com/nature/journal/vaop/ncurrent/pdf/nature13793.pdf[↩][↩][↩]
32. A Scientific Statement From the American Heart Association and the American Diabetes Association. Nonnutritive Sweeteners: Current Use and Health Perspectives. http://circ.ahajournals.org/content/circulationaha/126/4/509.full.pdf[↩]
33. https://www.cancer.gov/about-cancer/causes-prevention/risk/diet/artificial-sweeteners-fact-sheet[↩]
34. http://ntp.niehs.nih.gov/ntp/roc/eleventh/append/appb.pdf[↩]
35. Soffritti M, Belpoggi F, Esposti DD, Lambertini L. Aspartame induces lymphomas and leukaemias in rats. European Journal of Oncology 2005; 10(2):107–116.[↩]
36. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm108650.htm[↩]
37. Lim U, Subar AF, Mouw T, et al. Consumption of aspartame-containing beverages and incidence of hematopoietic and brain malignancies. Cancer Epidemiology, Biomarkers and Prevention 2006; 15(9):1654–1659.[↩]
38. http://www.diabetesforecast.org/2016/jan-feb/5-must-know-facts-about-sweeteners.html?loc=morefrom[↩]