Position of the Academy of Nutrition and Dietetics Use of Nutritive and Nonnutritive Sweeteners

7/27/2019 Position of the Academy of Nutrition and Dietetics Use of Nutritive and Nonnutritive Sweeteners

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Position of the Academy of Nutrition and Dietetics:

Use of Nutritive and Nonnutritive Sweeteners

SWEETENERS CANBE GROUPEDINvarious ways. For the pur-

pose of this article swee-

teners will be grouped asnutritive and nonnutritive. Nutritive

sweeteners contain carbohydrate and

provide energy; they may be furtherclassified into monosaccharides or di-

saccharides, which impart 4 kcal/g, or

sugar alcohols (polyols), which providean average of 2 kcal/g (1). Different

terms are used to refer to nutritivesweeteners, including sugars, sugar, ca-

loric sweeteners, and added sugars. Sug-ars occur naturally (intrinsic) in all

fruit, vegetables, and dairy foods or areadded (extrinsic) to foods during pro-

cessing, or in preparation for consump-tion by an individual (2).

Sugars commonly found in foods in-

clude:

Glucose A monosaccharide andthe primary source of energy forbody cells.

Fructose A monosaccharidefound in fruit, honey, and some

vegetables. In nature, it is linkedwith glucose as the disaccharidesucrose. Fructose may be used asa nutritive sweetener.

Galactose A monosaccharide

that occurs in dairy products andsome plants.

Sucrose A disaccharide that oc-cursnaturally in fruit andvegeta-bles. It is composed of approxi-

mately equal parts glucose andfructose and is used asa nutritivesweetener and for its other func-tional properties.

Maltose A disaccharide com-posed of two glucose units; it is

found in molasses and is used forfermentation.

Corn-based sweetener Refers tomany products made from corn.

They maybe composed primarilyof glucose, fructose, or any com-bination of the two. High-fruc-tose corn syrup (HFCS) is a mix-ture of glucose and fructose andis only available to food manu-facturers.

Agave nectar A nutritive sweet-ener that contains fructans, oli-gosaccharides of fructose andglucose, and monosccharides offructose and glucose.

Sugar often refers to sucrose, which isderived from sugar cane or sugar beets.The US Department of Agriculture(USDA) uses added sugars to refer tosugars and syrups added to foods dur-ing processing, preparation or beforeconsumption. In addition to impartinga sweet taste, sugars have the followingfunctions that are important to safetyand 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 safelyenjoy a range of nutritive sweeteners and nonnutritive sweeteners (NNS) when con-sumed within an eating plan that is guided by current federal nutrition recommenda-

tions,such as the Dietary Guidelines forAmericansand the Dietary Reference Intakes, aswell as individual health goals and personal preference. A preference for sweet taste isinnate and sweeteners can increase the pleasure of eating. Nutritive sweeteners containcarbohydrate 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 asso-ciated 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 inthe United States consume 14.6% of energy from added sugars. Polyols (also referred toas sugar alcohols) add sweetness with less energy and may reduce risk for dental caries.Foods containing polyols and/orno added sugarscan, withinfood labeling guidelines, belabeled 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 orgenerally recognized as safe. The Food and Drug Administration approval process in-cludes determination of probable intake, cumulative effect from alluses, 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. Theyhave 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 besafe.J Acad Nutr Diet. 2012;112:739-758.

POSITIONSTATEMENT

It is the position of the Academy of Nutritionand Dietetics that consumers can safely en-

joy a range of nutritive and nonnutritivesweeteners when consumed within an eat-ing plan that is guided by current federalnutrition recommendations, such as the Di-etary Guidelines for Americans and the Di-etary Reference Intakes, as well as individualhealth goals and personal preference.

2212-2672/$36.00

doi: 10.1016/j.jand.2012.03.009

FROM THE ACADEMYPosition Paper

2012 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 739


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Add texture, flavor, and color tobaked goods.

Support the growth of yeast forleavening 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 dress-

ings, sauces, and condiments. Help to maintain the natural

color, texture, and shape of pre-served fruits (3).

Nonnutritive sweeteners (NNS) offer lit-tle to no energy when ingested. They arereferred to as high-intensity sweetenersbecause, as sweetening ingredients, theyare many times sweeter than sucrose.

NNS can replace the sweetness of sugaror energy-containing sweeteners. How-ever, they do not have the same func-tional properties such as browning, crys-tallization, or microbial inhibition.

MECHANISM OF SWEET TASTE

Liking of sweet taste is innate, but per-ception of sweetness and preferredlevel of sweetness vary among individ-uals. Taste perception begins on thetongue and soft palate where taste re-ceptors interact with food or bevera-

ges. Taste receptor cells are organizedinto taste buds, which are distributedthroughout the tongue and on special-ized structures called papillae (4).Sweet taste is elicited through interac-tion with a sweet receptor, identified asa dimeric G-protein coupled receptorcomposed of T1R2 and T1R3 subunitswith multiple activesites (5).Liandcol-leagues (6) showed thatthese receptors(T1R2 and T1R3) responded to sugars(ie, sucrose, fructose, galactose, glu-cose, lactose, andmaltose), amino acids(ie, glycine and D-tryptophan), sweetproteins (ie, monellin and thaumatin),and NNS (ie, acesulfame K, aspartame,cyclamate, dulcin, neotame, saccharin,and sucralose), although specific pref-erential binding sites may vary. Syn-ergyamong sweeteners is because theybind different subunits. Binding a singlesubunit activates the sweet response,whereas a second ligand binding an-other subunit enhances the response(7). A transduction mechanism trans-lates the sweet chemical messagethrough the nervous system to the per-

ception of sweet taste in the brain. The

characteristics of this transductionpathway are not well defined (5). Mar-golski (8) hypothesized that the path-way for saccharide sweeteners usescAMP as a second messenger and thepathway for nonsaccharide sweetenersuses inositol 1,4,5-triphosphate and di-acylglycerol as second messengers.Both mechanisms work through regu-lationof Ca2 andion channels andarethought to exist in the same taste re-ceptor cells. Some NNS compounds in-terfere with signal termination in thedownstream elements of the transduc-tion pathway, resulting in a lingeringaftertaste (9,10).

Taste perception and food preferenceare complex and differences in concen-tration of papillae, number and type oftaste receptors, or gene sequencing ofsignal transduction molecules contrib-uteto individual variation(7). Althoughthere is good evidence for the heredityof bitter taste, studies in twins andother family members have found fewsimilarities in perception of sweet tastethat could be attributed to genetics

(11). Preference for sweet taste may begenetic; variations in a taste receptorgene accounted for some differences insweet preference among children, butnot in adults (12). Differences in prefer-ence for sweet taste are most likely dueto an interaction between genetics and

environmental exposure (4).

REGULATION OF NNS IN THE

UNITED STATES

In the United States, the responsibilityfor evaluating the safety of NNS wasgiven to the Food andDrug Administra-tion (FDA) in 1958 under the Food Ad-ditives Amendment to the FederalFood, Drug, andCosmetic Act. Through-out the world, nations have their ownregulatory agencies or rely on other re-gional or international governing bod-

ies and expert scientific committees,including the Bureau of ChemicalSafety, in Health Canadas Food Direc-torate (13), the Scientific Committee onFood of the European Commission, theJoint Expert Committee on Food Addi-tives of the United Nations Food andAgricultural Organization, and WorldHealth Organization (WHO) to evaluatethe safety of NNS.

The US Food Additives Amendmentof 1958 required all new food additivesto undergo a strict premarket approvalprocess unless the substance is gener-

ally recognized as safe (GRAS) amongexperts qualified by training and expe-rience to evaluate its safety under theconditions of its intended use. Commonfood ingredients that were used before1958 were listed as GRAS and not in-cluded in the definition of a food addi-tive (14), which is any substance, theintended use of which results or maybeexpected to result, directly or indi-rectly, in its becoming a component orotherwise affecting the characteristicsof any food (15).

Some sweeteners in the UnitedStates are listed or affirmed as GRAS.The GRAS exemption requires the samestandard of safety as food additives do,that is the reasonable certainty of noharm. Before passage of the Food Ad-ditive Amendment in 1958, the FDAprovided to Congress a list of sub-stances that were considered GRAS andadded to that list between 1958 and1973. To be listed, the substance musthave a history of consumption before1958 by a significant number of peopleor there must be consensus among ex-

This Academy position paper includes theauthors independent review of the liter-ature in addition to systematic reviewconducted using the Academys evidenceanalysis process and information from theAcademys Evidence Analysis Library(EAL). Topics from the EAL are clearly de-lineated and references used in EAL sec-

tions can be found on the EAL Web site.The use of an evidence-based approachprovides important added benefits to ear-lier review methods. The major advan-tage of the approach is the more rigorousstandardization of review criteria, whichminimizes the likelihood of reviewer biasand increases the ease with which dispa-rate articles may be compared. For a de-tailed description of the methods used inthe Academys evidence analysis process, towww.andevidencelibrary.com/eaprocess.

Conclusion Statements are assigned agrade by an expert work group based on thesystematic analysis and evaluation of the

supporting research evidence. Grade IGood; Grade II Fair; Grade III Limited;Grade IV Expert Opinion Only; andGrade V Not Assignable (because thereis no evidence to support or refute theconclusion). Criteria for grades can be foundatwww.andevidencelibrary.com/grades.

Evidence-based information for this andother topics can be found at www.andevidencelibrary.com and subscrip-tions for nonmembers are available forpurchase at www.andevidencelibrary.com/store.cfm.

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perts qualified to evaluate productsafety that the use of the substance issafe. In 1973, FDA initiateda GRAS affir-mation process, which encouragedmanufacturers to submit their GRASdeterminations to the agency for re-view. In 1997, FDA replaced the affir-

mation process with a GRAS notifica-tion process (14). Manufacturers maydetermine that use of a substance isGRAS and will notify FDA of that con-clusion. FDA responds to the manufac-turer with oneof three responses: it hasno questions about the petitionersconclusion; the notice does not providea sufficient basis for a GRAS determina-tion; or the agency has, at the petition-ers request, ceased to evaluate theGRAS notice. The Federal Register pro-vides a published explanation of theGRAS exemption (16). It is important to

note that the GRAS exemption refersspecifically to theintendeduse of a sub-stance.

For approval of a food additive, thepetitioner (the manufacturer, com-pany, or interested partner that wantsto market a sweetener) must assembleand present to FDA all required safetydata relevant to the proposed use of theadditive in accordance with safetyguidelines published by the FDA (15).To determine safety of a food additive,FDA considers: probable intake, cumu-lative effect from all uses, and toxico-logical data required to establishsafety.Guidelines for toxicology studies todocument the safety of food additivesare published by FDA in Redbook 2000(17) and are consistent with guidelinesfrom the International Conference onHarmonisation of Technical Require-ments for Registration of Pharmaceuti-cals for Human Use (18). Initial testsshould include pharmacokinetics andmetabolism to allow FDA scientists toevaluate: extent of absorption;

tissue distribution; pathways and rates of metabo-

lism; and rates of elimination of the sub-

stance andanymetabolites.

Information from these studies,known collectively as absorption, dis-tribution, metabolism, and excretion, isused to design toxicity studies and de-termine potential mechanisms of toxic-ity. Toxicity studies include short-termand subchronic toxicity tests with ro-dents, subchronic and long-term toxic-

ity tests with nonrodents, reproductiveand developmental toxicity and tests ofcarcinogenicity (19). Some food addi-

tivesmay generate questions beyond theusual toxicology studies. These may in-clude the potential for allergic reactions,interactions with medications, or effects

on nutritional status, blood glucosecontrol, or other clinical conditions. Inthese cases, FDA may require a moreextensive evaluation procedure that

includes clinical studies with humansubjects. The safety evidence thatmust be established before studies inhuman subjects can be conducted

may exceed that required for clinicaltrials of new drugsbecausethere is noanticipated health benefit from foodadditives (17). If the use of the addi-

tive is safe for most consumers, butmay present a risk for certain sub-

populations such as those with an al-lergy or inborn error of metabolism,

FDA can require that an informationallabel that alerts consumers to thepresence of that additive be placed onall foods containing it. A detailed re-

view of the FDA food additive ap-proval and GRAS affirmation pro-cesses can be found in Rulis and Levitt

(19).Three safety concepts are integral to

the FDA food additive approval process.The first concept is thehighest no effect

level (HNEL). Any petition brought tothe FDA for use of a new food additivemust include information that allowsthe FDA to determine the highest level

or threshold of intake at which no ad-verse effect occurs. FDA scientists inde-pendently review the results of the an-imal toxicology studies to determine

the exposure at which there were noadverse effects in the most sensitive ofanimal studies. The second safety con-cept is the acceptable daily intake

(ADI). With the HNEL, the FDA will de-termine an ADI for human beings, gen-

erally with a 100-fold safety factor toaccount for the fact that the studieswere conducted in animals (10-fold)and for normal, genetic variation (addi-

tional 10-fold). The HNEL, divided by100, is consistent with the FDA stan-dard reasonable certainty of no harmand is assigned as the ADI. The ADI rep-resents an amount considered safe to

consume every day over the course of alifetime without adverse effects. An ADIfor the food additive is communicatedby the regulatory agency for that coun-

try. The FDA ADI may differ from theADI from regulatory bodies in othercountries. The third safety concept isthe estimated daily intake (EDI), de-rived from the amount of the additiveto be added to foods,assuming 100% re-placement of sugars and other NNS and

the typical consumption of those foodsby people of different ages and healthstatus. The EDI generally overestimatesconsumption because it assumes thatthe new additive will replace all sweet-eners in the market (100% market pen-etration). It is based on a consumptionlevel equal tothe 90thpercentilelevelforthe foods that will contain the additiveand the assumption that all populationsubgroups will consume the new addi-tive. The ADI is compared with the EDI toconfirm that the ADI is well in excess ofhumanexposure. Seethe final rule on su-

cralose in Federal Register(20) for a goodexample of the process the FDA used todetermine HNEL, EDI, and ADI.

Once a food additive receives finalFDA approval, that approval is pub-lished in Federal Register. In the ap-proval documentation, FDA may re-quest that additional data on actualconsumption or other safety data becollected by the petitioner during thepost-approval period. If the EDI is de-termined to exceed the ADI, there maybe limitations placed on the use of theadditive. To date, this has not been doc-umented with any NNS. An FDA rulingmay be challenged after approval withnew evidence. The FDA will examinethepostmarket evidence with the samerigor that premarket studies receivedand will consider newdata in context ofthe entire body of evidence to ensureappropriate risk analysis to protect thepublic health.

NUTRITIVE SWEETENERS

Sugars Added to Foods and

Beverages

Added sugars, not naturally occurringsugars, when considered with solid fatsand excess energy intake, have beenlinked to health concerns, includingoverweight and obesity, type 2 diabetesor prediabetes, inflammation, and car-diovascular disease (21). Added sugarsin processed foods can be identified byreading the list of ingredients on thefood label (Figure) (21,22). Other addedsugars that can be found in foods butare not recognized by FDA as ingredi-ents include cane juice, evaporated

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corn sweetener, fruit juice concentrate,crystal dextrose, glucose, liquid fruc-tose, sugar cane juice, and fruit nectar(21,22).

HFCS is produced from corn syrup,which is typically 100% glucose. Thissyrup undergoes enzymatic processingto increase fructose content and is thenmixed with glucose (23). HFCS canrange in percentage fructose from 42%,which is most often used in bakedgoods to 55%, which is used in bever-ages and has a similar composition assucrose (2).

Agave nectar has received interestfrom consumers as a way to sweetenfoods. Agave nectar is produced fromthe heart of the agave plant (Agave te-quilana Weber var. azul.) (24), which isalso the starting material for the pro-duction of tequila (25). Freshly ex-tracted agave juice is composed ofinulin, a fructan that is heated or trea-ted enzymatically to convert this com-plex carbohydrate to monosaccharides(25,26). The amount of sugar (mostlyfructose but with some glucose anddextrose), will vary depending on the

pH, temperature, and length of heatingtime (27).

Digestion and Absorption

Sucrose is hydrolyzed to fructose andglucose by the -glucosidase sucrase inthe sucrase-isomaltase complex of theenterocytes in the small intestine. Lac-tose digestion is accomplished by the-galactosidase, lactase-phlorizin hy-drolase found in the brush-border ofthe small intestine and yields glucoseand galactose (28).

Monosaccharides (ie, glucose, fruc-tose, and galactose) need a trans-porter system for absorption. The sys-tems are present on the apical borderand basolateral cell membranes of theenterocytes and work in concert. Glu-cose and galactose use the same sodi-um-glucose cotransporter 1 on theapical membrane to pass into the en-terocyte linked with two sodium mol-ecules. Fructose absorption is facili-tated by glucose-fructose transporter5. Once in the enterocyte, all threemonosaccharides pass into the portal

capillaries by a glucose transporter,which is located on the basolateralmembrane (28).

Consumption of Sucrose, Glucose,

and Fructose

Different terms and methods used toestimate the intake or availability ofsugars in the food supply complicatemonitoring of sugar consumption.The National Health and Nutrition Ex-amination Survey (NHANES) (re-leased in 2-year waves since 1999-

2000) uses self-report to estimateintake. Food availability data are pro-vided by the USDA Economic Re-search Service (ERS).

Food Consumption Patterns of

Added Sugars

The 2010 Dietary Guidelines for Amer-icans (DGA) reported that added sugarscontributed approximately 16% of totalenergy in the US population (21) or 21tsp added sugars using NHANES 2005-2006 data (21,29) (Table 1). More re-

cently, Welsh and colleagues (30)

found that added sugars provided

14.6% of total energyintake using 2007-

2008 NHANES data. The main contribu-

tor 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

aged19 years and older is79 g or20 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 from1999-2000 to 2007-2008 along

with a decreasing trend in total en-

ergy intake of 76 kcal/day (P for

trend0.004) for the US population

(30). There was a decreased added

sugars intake of 100.1 g (95% confi-

dence 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 0.001). 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

0.001) during the same period for

the US population. The rank order of

food sources did not change and nei-

ther did population groups who con-

sumed higher amounts of added sug-

ars over this time period (data

presented later in this article). Welsh

and colleagues (30) concluded that al-

though 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 indi-

cated children aged 2 to 18 years con-

sumed 23 tsp added sugar (29) or 365

kcal (32,33), which is 18% of total en-

ergy needs (2,027 kcal/day) (34) (Table

1). Teenagers aged 9 to 13 years com-

pared 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.

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added sugars (boys 31.2%, girls 27.8%)(35).

Thompson and colleagues (36) ex-amined the relation between race andsocioeconomic status and added sugarsintake, using 2005 US National HealthInterview Survey Cancer Control Sup-plement and the NHANES 2003-2004data. Added sugarsintake was higher inmen than in women. African-Americanwomen had the highest added sugarsintake when compared with white orHispanic women, but African Ameri-cans in general had the highest addedsugars intake. Those who had the high-est level of education (more than highschool) hadthe lowest added sugars in-take. As income decreased, added sug-

ars intake increased in men andwomen. Thompson and colleagues (36)concluded that adults with lower in-come and less education and those inethnic minority groups are consumingdiets higher in added sugars, whichmayput them at greater risk for chronicdisease.

Sources of Added Sugars by

Different Groups

Based on NHANES 2005-2006, rank or-der of food sources of added sugars dif-fered by age and race/ethnic groups(Tables 1 and 2). Fruit drinks sweet-ened with nutritive sweeteners wereranked second for children and third

for adults (Table 1) (31). The rank or-der of foods that provide added sugarsdiffered by race/ethnic group, but didnot differ across income groups(130% poverty, 131% to 185% pov-erty, 186% poverty) (37,38) (Table2). Soda/energy/sports drinks pro-vided the most added sugars across allrace/ethnic and income groups. Mex-ican Americans and non-Hispanicblacks both differed from non-His-panic whites in that fruit drinks werethe second ranked food and grain-based desserts was third.

Table 3 presents the top five sourcesof added sugars by age (34). Energyfrom added sugars increased from 197kcal 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, NationalHealth 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 20.0 100.0Soda/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

aAdapted from references 29 (tsp) and 31 (%).bPercentage 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 andNutrition Examination Survey, 2005-2006a

Food group

Race/Ethnicity Household Income

Non-

Hispanic

White

Non-

Hispanic

Black

Mexican

American

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

aAdapted from references 37 ( household income) and 38 (race/ethnicity).bPercentage of total added sugars from these various foods.

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kcal for those aged 14 to 18 years in2003-2004 (32-34). Soda/energy drinks/sport drinks or fruit drinks were the toptwo sources of added sugarsfor allages.Fox and colleagues (39) reported that44% of children aged 19 to 24 monthsconsumed either fruit drinks (38%) orsodas (11%) once per day in 2002. In-

take of soda (nutritive sweeteners andNNS) increased as children aged, withthe greatest increase happening at age8 years (40).

Food Consumption Patterns of

Fructose

Fructose consumption patterns overtime are difficult to describe becausefructose intake has not always beenmeasured in large national surveys(41). Bray and colleagues (42) calcu-lated fructose intake by taking half ofsucrose as fructose and adding to thisvalue fructose from HFCS. In more re-cent work (41-43), the fructose contentof the foods was included in the nutri-ent data base. Bray and colleagues (42)estimated that fructose intake was 8.8%of total energy in 1977-1978 and in-creased to 11.5% in 1994-1998. Twoother researchers estimated fructoseintake was 10.2% (54.7 g) (41) or 9.1%(43) of total energy using NHANES III(1988-1994) or NHANES 1999-2004data, respectively.

Food Availability Data and

Changes Over Time

Food availability data are compiled by

the ERS by estimating food suppliesfrom production to marketing. Another

term used for these data is food disap-pearance data because they describe

how the food supply disappears as itmoves through the food marketing sys-

tem. The ERS takes the total annual

available supply of a commodity andsubtracts out measurable uses, such as

farm inputs (feed and seed), exports,ending stocks, and industrial uses. This

total supply is divided by the US popu-lation to get per capita availability.

Food availability data exceed actual in-take because not all waste or loss is es-

timated (44).Based on ERS data, nutritive sweet-

eners available per capita were 119.1 lb

in1970,141.1lbin2005(45), and130.7lb in 2009 (46). There were no changesin 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). Availabil-ity of other energy-containing sweet-eners increased. Between 1970 and

2005, the annual per capita availabilityof corn sweetener increased 387% with

the HFCS share of corn sweeteners in-

creasing from 3% (0.5 lb) to 76% (59 lb),whereas the per capita availability ofrefined cane and beet sugar decreased38%(from 102lb to63 lb) (45). Energy-containing sweeteners provided thefollowing teaspoons per day and en-ergy per day in 2009 when adjusted forloss (47): refined cane and beet sugar

(13.4 tsp, 214.2 kcal) (48), HFCS (10.6tsp, 168.9 kcal) (49), and other sweet-eners (eg, glucose syrup, dextrose,honey, and edible syrups) (3.6 tsp, 57.4kcal) (50).

HFCS availability increased between1970 and 1999 then began to decrease,dropping by 59 lb by 2005 (51). HFCSavailability was 50.1 lb in 2009 (49).Wells and Buzby (51) hypothesizedthatthis trend may bea reflectionof theincreased availability of no-energy bot-tled water and diet sodas; increasedcost of HFCS because of pressure tomake ethanol from corn; or increasinguse of sugar alcohols and NNS.

Guidance on Use of Nutritive

Sweeteners

Dietary Reference Intakes from theInstitute of Medicine. The AcceptableMacronutrient Distribution Ranges forcarbohydrateis estimatedat 45%to 65%of energy (52). The Recommended Di-etary Allowance for carbohydrate is130 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 ageand 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

aAdapted from reference 34.bNHWnon-Hispanic white.cNHBnon-Hispanic black.dMex AmMexican American.

FROM THE ACADEMY



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is based on the average minimumamount of glucose used by the brain.The Institute of Medicine recom-mended that the intake of added sugarsnot exceed 25% of energy to ensure ad-equate intake of essential micronutri-ents that are typically not present in

foods high in added sugars.

American Heart Association. In2006, the American Heart AssociationsDiet and Lifestyle Recommendationsstated to minimize the intake of bever-ages andfoods containing added sugars(53). That recommendation was ex-panded in 2009 to set an upper limit ofadded sugars intake at half of the dis-cretionary energy allowance as deter-mined by the USDA food intake pat-terns (54). The final statement of theAmerican Heart Association reads:Most American women should eat ordrink no more than 100 calories/day(25 g or 6 tsp) from added sugars, andmost American menshould eat or drinkno more than 150 calories/day (38 g or10 tsp) from added sugars.

WHO Recommendations. The WHOGlobal Strategy on Diet, Physical Activ-ity and Health, endorsed at the 57thWorld Health Assembly, includes limit-ing the intake of free or added sugars(55). In an earlier document, WHO rec-

ommended that 10% of energy beprovided by added sugars (56).

2010 DGA and ChooseMyPlate. The2010 DGA recommend intake of foodsto result in a more healthful diet (21).The guidelines acknowledge that thebody metabolizes added sugars andnatural sugars found in fruits and dairyfoods the same, but typically foods highin added sugars are higher in energyandlow in essentialnutrients or dietaryfiber (21). Recommendations related toadded sugars include the following: re-duce the calories from solid fats andadded sugars (SoFAS); and limit theconsumption of foods that contain re-fined grains, especially refined grainfoods that contain SoFAS and sodium.The DGA advisory committee recog-nized the need to obtain adequate nu-trients without overconsumption ofenergy to reduce risk of commonchronic diseases such as obesity, cardio-vascular disease, and some cancers (2).

Using the MyFood-a-pedia Web site(www.myfoodapedia.gov) one can

identify the SoFAS content of foods andbeverages and choose those with fewerSoFAS, choose them less often, orchoose a smaller portion. Recommen-dations include: Cut back on foods and drinks

with added sugars or energy-

containing sweeteners. Drink few or no regular so-

das, sports drinks, and fruitdrinks.

Eat fewer grained-based ordairy-based desserts, other des-serts, and candy or eat smallerportions less frequently.

Drink water, fat-free milk, 100%fruit juice, or unsweetened tea orcoffee instead of sugar-sweet-ened drinks.

Drink 100% fruit juice instead offruit-flavored drinks.

Eat fruit for dessert. Use the Nutrition Facts label to

choose breakfast cereals andother packaged foods with lesssugar and use the ingredients listto choose foods with little or noadded sugars.

ChooseMyPlate is part of a large com-munications initiative sponsored bythe USDA to help consumers imple-ment the 2010 DGA recommendations.The messages for consumers empha-size foods to eat less often, including

foods that are high in SoFAS, and drink-ing water instead of sugary drinks. Theplan presents a recommended dailylimit for empty energy such as SoFASthat add energy to foods without add-ing nutrients.

Polyols (Sugar Alcohols) and

Other Sweeteners

Polyols or sugar alcohols have beenused in food products for many years todecrease the intake of carbohydratesthat raise blood glucose levels. Polyolscan be used alone but are more oftenused in combination with other polyolsor NNS because of the bulking propertyof some polyols. Energy provided bypolyols varies (Table 4) because of dif-ferences in digestibility and becausepolyols are typically absorbed slowlyand incompletely by passive diffusion(57). Metabolism also varies (57). Forexample, erythritol is completely ab-sorbed but is not metabolized. Manypolyols are found in nature but may bemanufactured 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 regula-

tory status, EDI, and ADI for selected

polyols and other sweeteners, sweet-

ness compared with sucrose, and their

use in foods.Trehalose and D-tagatose are other

sweeteners used in food (Table 4). Tre-

halose 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 trehaloseinto twoglucose mol-

ecules (58). D-tagatose is similar to

fructose in structure other than an in-

version of the hydroxyl and hydrogen

groups at the fourth carbon and is

found in many foods, including dairyproducts (59). Only 15% to 20% of

D-tagatose is absorbed with much be-

ing 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 con-

sumersto achieve a sweet taste,for rea-

sons of economics, blood glucose con-

trol, or energy control. NNS approved

for use in the US have been tested and

determined to be safe at levels that are

withinthe 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 in-

take and should include groups who

may have higher than normal intakes

(eg, people with diabetes) or groups ofpeople with special concerns (pregnant

women or children) (61). Food prod-

ucts may contain a blend of different

NNS, which further complicates esti-

mation of intake. Mattes and Popkin

(62) used existing data from US nutri-

ent monitoring systems to locate items

that contained NNS on food composi-

tion tables to estimate NNS consump-

tion. Although consumption of NNS in

foods and beverages has increased

since 1965, only about 15% of the pop-

FROM THE ACADEMY

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8/20

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 GRAS

a

label must state riskof 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 of50 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 of20 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 decayMaltitol (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

aGRASgenerally recognized as safe.bEDIestimated daily intake.cADIacceptable daily intake.dNNSnonnutritive sweetener.

FROM THE ACADEMY



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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 NNS2010 DGA. The DGA contains a mini-mal number of statements related to

the use of NNS (21). A key recommen-

dation related to the use of NNS is to

control total energyintake andincrease

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 witha lower risk of type 2

diabetes in adults. Substituting NNS for

higher-energy foods and beverages can

decrease energy intake, but evidence oftheir effectiveness for weight manage-ment is limited.

American Diabetes Association. TheAmerican Diabetes Association posi-tion statement on nutrition recommen-dations, last revisedin 2008, statesthat,

Sugar alcohols and nonnutritivesweeteners are safe when consumedwithin the daily intake levels estab-lished by the Food and Drug Adminis-

tration (63). Recommendations formanagement of diabetes includemonitoring carbohydrates by carbo-hydrate counting, choices, or experi-ence-based estimation to achieve gly-

cemic control (64). Choosing NNSinstead of nutritive sweeteners is onemethod to assist with moderatingcarbohydrate intake.

National Cancer Institute. The Na-tional 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

Thefollowing sectioncontainsinformation

about the structure and use of NNS ap-

proved in the United States (Table 5). The

section regarding the Academys Evidence

Analysis Library contains information

about effectson dietaryintake, energy bal-

ance, andhuman health.

Acesulfame K. Acesulfame K (5,6-di-methyl-1,2,3-oxathiazine-4(3H)-1,2,2-

dioxide) 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-1,2,3-

oxathiazine-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-a-

aspartyl]-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 sanctionedfood ingredient; no

ADI determined

EDI: 0.1-2 mg/kg BW

Limited to 12 mg/fl oz inbeverages, 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


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


General use; heat stable for

cooking and baking

aADIacceptable daily intake.bEDIestimated daily intake.cBWbody weight.dGRASgenerally recognized as safe.eJECFAJoint Expert Committee on Food Additives.

FROM THE ACADEMY



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acid and potassium approved by theFDA in 1988 for use in foods and as atabletop sweetener; in 1998 it was ap-proved for use in beverages and in 2003it was approved as a general use sweet-ener, which includes anyfood or bever-age category (66). It is 95% excreted un-

changed in the urine so it does notprovide energy or influence potassiumintake (67). It combines well with otherNNS, which is the most common way itis currently used in the US food supply.It is stable at baking temperatures.

Aspartame. Aspartame (L-aspartyl-L-phenylalanine methyl ester)is a methylester of aspartic acid andphenylalaninedipeptide. It was discovered in 1965and approved by the FDA in 1981 foruse in specific foods and in 1983 for usein soft drinks. In 1996 it was approvedas a general use sweetener. Althoughaspartame provides 4 kcal/g, the inten-sity of the sweet taste means that verysmall amounts are required to achievedesired sweetness levels. In the intes-tine, aspartame is hydrolyzed to aspar-tic acid, methanol, and phenylalanine(68). In theUnited States thelargest useof aspartame is to sweeten low-energybeverages, but it is found in many prod-ucts. Despite the numerous productscontaining aspartame, average con-sumption even for the highest users re-

mains below the ADI (61,68). Becauseaspartame yields phenylalanine whenit is hydrolyzed in theintestine, theFDArequires any foods containing aspar-tame to have an informational labelwith the statement: Phenylketonu-rics: contains phenylalanine.Individu-als with phenylketonuria had small butnot clinically significant increases inphenylalanine after drinking 12 oz dietsoda sweetened with aspartame (69).Aspartame is stable under dry condi-tions, but in solutions, it degrades dur-ing heating. The rate of degradation de-

pends on pH and temperature (68).

Luo han guo. Luo han guo is the com-mon name for Siraitia grosvenorii, orSwingle fruit extract, a sweetener re-cently approved as GRAS (70). Anothercommon name is monk fruit extract.This product is a combination of seve-ral different cucurbitane glycosides,known as mogrosides. Mogroside V ispredominate and makes up30% of theproduct. Luo han guo is 150 to 300times sweeter than sucrose depending

on the exact structure of the mogro-sides and number of glucose units. Itmay have an aftertaste at high levels.

Neotame. Neotame (N-[N-3,3-dim-ethylbutyl)-L-a-aspartyl]-L-phenylala-nine-1-methyl ester) is a derivative of

the dipeptide phenylalanine and aspar-tic acid. The FDA approved neotame asa general use sweetener in 2002 (71).Neotame is partially absorbed in thesmall intestine and rapidly metabo-lized by esterases present throughoutthebody. Theresultingproductsare de-esterified neotame, which is rapidly ex-creted in urine and feces, and an insig-nificant amount of methanol (72).Although neotame contains phenylala-nine, the amount used is very low be-cause of its high intensity sweeteningproperty and the amount released inthe body is negligible (72). To date,neotame israrelyusedin foods.It is sta-ble under dry storage conditions; sta-bility varies with pH in aqueous solu-tions (72).

Saccharin. Saccharin (1,1-dioxo-1,2-benzothiazol-3-one) is the oldest NNSapproved for food and beverage use(73). It is not metabolized in the body,and is heat stable. It is approved as afood additive for foods and beverages, atabletop NNS, and for use in gums, cos-

metics, and pharmaceuticals. Saccharinwas originally listed as GRAS. In 1977,the FDA proposed a ban on saccharinunder the Delaney Clause because of anassociation with bladder cancer in lab-oratory animals. The Delaney Clausewas an amendment added by Congressto the Food Drug and Cosmetic Act of1958. It stated that no food additivewould be deemed safe if it is found toinduce cancer when ingested by manoranimal and prohibited the FDA fromapproving such food additivesa zero-risk standard. Congress imposed an 18-month moratorium on the FDA ban onsaccharin but required products con-taining saccharin to carry a warningthat saccharin has been determined tocause cancer in laboratory animals.Congress asked the National Academyof Sciences to lead a study on the safetyof saccharin. The National Institute forEnvironmental Health Sciences deter-mined that the mechanism by whichsaccharin caused bladder tumors inrats was not relevant to human beingsand recommended that it be removed

from the list of human carcinogens. In1996, the Delaney Clause was repealedand the zero-risk standard changed toone of reasonable certainty of noharm. In 2000, Congress repealed therequirement for a warning label. Sac-charinis widelyused,oftenin combina-

tion with other sweeteners. EDI of sac-charin is well below ADI for averageand high users (61).

Stevia. Steviol glycosides-rebaudio-side A and stevioside are extractedfrom leaves of the plant Stevia rebaudi-ana Bertoni. In 2008, the FDA allowedGRAS status for purified rebaudioside Afollowed by stevioside. These purifiedglycosides should not be confused withwhole stevia leaves, which are sold asdietary supplements under the DietarySupplement and Health Education Act

of 1994. Whole stevia leaves contain anumber of active components, not allofthem sweet (74). Steviol glycosides aredescribed as having a sweet, clean tasteat usual amounts but may be bitter athigher amounts (75,76). They are shelf-stable in dry form and more stable thanaspartame or acesulfame K in liquidform (75).

Sucralose. Sucralose (trichlorogalac-tosucrose) is a disaccharide in whichthree chlorine molecules replace three

hydroxyl groups on the sucrose mole-cule. It was approved bythe FDA for useas a tabletop sweetener and in a num-ber of desserts and beverages in 1998(20) and as a general use sweetener in1999. Most sucralose (85%) is not ab-sorbed and is excreted unchanged infeces. Sucralose that is absorbed isexcreted unchanged in urine (77).Sucralose is heat stable in cooking andbaking.

NNS Approved in Other Nations,

but not in the United States

Alitame, cyclamate, neohesperidine,and thaumatin are approved as NNS inother nations, but not in the UnitedStates. In 1986, a petition was submit-ted to the FDA to approve alitame foruse as a tabletop sweetener and inbaked goods, beverages, and confec-tions. The petition was reviewed andfound to be deficient. Currently, theFDA is not reviewing alitame for use asa food additive. Cyclamate was bannedby the FDA as a food additive in 1969under the Delaney Clause because one

FROM THE ACADEMY



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study found that a saccharin/cyclamatemixture caused cancer in laboratoryrats. In 1982, the Cancer AssessmentCommittee of theFDA reviewed thesci-entific evidence and concluded that cy-clamate was not carcinogenic. This wasreaffirmed by the National Academy of

Sciences in 1985. It is 30 times sweeterthan sucrose and is used in more than50 countries, including Canada. Neo-hesperidine and thaumatin are GRASfor use as flavor ingredients, but are notapproved or currently being consideredfor use as NNS in the United States.

ACADEMY EVIDENCE ANALYSIS

LIBRARY (EAL)

This section includes the results of asystematic review of literature con-ducted using the Academys evidence

analysis process and information fromthe Academys EAL. In this process, anexpert work group identified dieteticpractice related questions, performed asystematic literature review, and de-veloped and rated a conclusion state-ment for each question.The workgroupused the Academys process to answera total of 60questions related to the useof nutritive sweeteners and NNS; onequestion each on HFCS, polyols, andsteviol glycosides (stevia); and multi-ple questions on aspartame, neotame,saccharin, and sucralose. The work-

group was unable to write a conclusionstatement on 34 questions because nostudies were identified that met thesearch criteria (Grade VNot Assign-able). All of these questions, as well asthe full list of references used, may befound on the EAL Web site (www.andevidencelibrary.com). Most pre-market approval research studies onthe safety of NNS are animal studiesthat are reviewed by the FDA beforegranting approval or a GRAS determi-nation. The Academys EAL includesonly NNS that have been approved bythe FDA for use inthe UnitedStates. TheAcademys EAL does not evaluate saf-ety; however, it does evaluate availablehuman subjects research documentingadverse effects for each NNS whichmeets EAL criteria. Articles that werereviewed for this process were pub-lished in English, described human sub-jects research, were peer-reviewed andpublished in juried journals, and metother specific inclusion criteria docu-mented in the Search Plan and alsopublished in the EAL.

To identify and select articles for re-view, theNationalLibrary of MedicinesPubMed database was searched usingthe terms obesity, appetite, metabolism,adverse effects, and safety;theterm non-nutritive sweeteners and the names ofthe specific NNS; specific terms for the

nutritive sweeteners, HFCS, fructose,and sugar-sweetened beverages; andpolyols and sugar alcohols. Articles re-viewed were published within the past10 years for HFCS, 20 years for polyols,or between 2002 and 2009 for NNS.Studies must have included at least10 subjects in each treatment groupand have a dropout rate 20%. Articlesdescribed clinical trials, randomizedcontrolled trials, reviews, or meta-analyses.

Detailed search plans, including thesearch criteria, a list of the articles in-

cluded and articles reviewed but ex-cluded, and reasons for exclusion arelinked to each conclusion statement onthe EAL Web site. Conclusion state-ments, based on a synthesis of the find-ings of all relevant studies, are assignedgrades through the use of predefinedcriteria evaluating the quality of stud-ies, quantity of studies and subjects,consistency of findings across studies,the magnitude of effect, and the gener-alizability of findings. A table definingthe criteria to determine each gradelevel can be found at www.andevidencelibrary.com/grades.

Nutritive Sweeteners

HCFS. What is the evidence from humansubject research that consumption ofHFCS is associated with obesity and met-abolic and/or adverse effects in adults?

Conclusion Statement. Four short-term randomized controlled trials(Akhaven 2007, Melanson 2007,Soenen 2008, and Stanhope 2008), twolongitudinal studies (Monsivais 2007and Streigel-Moore 2006), two cross-sectional studies (Duffy 2008 andMackenzie 2006), and five review arti-cles (Angelopoulos 2009, Bray 2004,Forshee 2007, Melanson 2008, andWhite 2009) examined the effects ofHFCS compared with other nutritivesweeteners. These studies consistentlyfound little evidence that HFCS differsuniquely from sucrose and other nutri-tive sweeteners in metabolic effects (ie,circulating glucose, insulin, postpran-dial triglycerides, leptin, and ghrelin),

subjective effects (ie, hunger, satiety,and energyintake at subsequent meals)and adverse effect such as risk ofweight gain. Randomized trials dealingspecifically with HFCS were of limitednumbers, short duration, and of smallsample size; therefore, long-term data

are needed. Grade II Fair.

Polyols. What is the evidence from hu-man subject research that consumptionof polyols/sugar alcohols is associatedwith metabolic and/or adverse effects inadults?

Conclusion Statement. A total of sixstudies met inclusion criteria. Five ofthese were short-term randomizedcontrolled trials (Finney 2007, Gostner2005, Koutsou 1996, Madsen 2006, andStorey 2007) and one was a review ar-ticle (Grabitske 2009). The five ran-domized controlled trials studied gas-trointestinal effects of polyols/sugaralcohols and consistently found that inmoderate doses of up to 10 to 15g/day,polyols/sugar alcohols are tolerated. Athigh doses (30 g/day), consumptionof some polyols/sugar alcohols (includ-ing lactitol, isomalt, and xylitol) mayresult in significant increases in flatu-lence, borborygmus, colic, defecationfrequency and loose/watery stools. Thereview article (Grabitske 2009) exam-

ined the use of sugar alcohols and con-cluded that usual intake is below levelsthat would result in significant gastro-intestinal side effects. One study (Gost-ner 2005) examined the effect of poly-ols/sugar alcohols on total cholesteroland triglycerides, and found no signifi-cant differences between subjects con-suming isomalt or sucrose. None of theother studies examined metabolic ef-fects of sugar alcohols, including glyce-mia. Grade III Limited.

NNS

Aspartame. In adults, does using foodsor beverages with aspartame in an ener-gy-restricted or ad libitum diet affect en-ergy balance (weight)?

Conclusion Statement. Use of aspar-tame and aspartame-sweetened prod-ucts as part of a comprehensive weightloss or maintenance program by indi-viduals may be associated with greaterweight loss and may assist individualswith weight maintenance over time.Grade I Good.

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In adults, does using foods or beverageswith aspartameaffectappetite or food in-take?

Conclusion Statement. There is goodevidence thataspartamedoes not affectappetite or food intake. Grade I Good.

In children, does using foods or bever-ages with aspartame affect appetite orfood intake?

Conclusion Statement. Limited evi-dence indicates that aspartame con-sumption affects appetite or food in-take in children. The 2009 update didnot find new studies meeting the inclu-sion criteria for this question and theNutritive and Nonnutritive Sweetenersworkgroup (2009) concurs with theconclusion above formulated by the as-

partame workgroup (2008). GradeIII Limited.

What is the evidence from human sub-jects research that aspartame consump-tion is associated with adverse effects inthe general population?

Conclusion Statement. Aspartameconsumption is not associated with ad-verse effects in the general population.Studies have found no evidence of awide range of adverse effects of aspar-tame, including hypersensitivity reac-

tions, elevated blood methanol or for-mate levels, and hematopoietic or braincancers. Neurologic changes tested in-cluded cognitive functions, seizures,headaches, and changes in memory ormood. The 2009 update did not find newstudies meeting the inclusion criteria forthis question and the Nutritive and Non-nutritive Sweeteners workgroup (2009)concurs with the conclusion above for-mulated by the aspartame workgroup(2008). Grade I Good.

What is the evidence from human sub-jects research that aspartame consump-

tion is associated with adverse effects inspecial populations, including children?

Conclusion Statement. A limitednumber of human studies published inpeer-reviewed journals that involvedchildren or special adult populationswere available for this question. Lim-ited evidence from human studies sug-gests that aspartame consumption isnot associated with detrimental effecton blood methanol, eyeproblems,acne,blood pressure, seizure disorder, or at-

tention deficit disorder in children.There is limited evidence from humanstudies for three special adult popula-tions. In people with diabetes, aspar-tame consumption is not associatedwith elevated plasma phenylalanineand tyrosine levels, fasting glucose con-

trol, intolerance to aspartame, ophthal-mologic effects, heart rhythm, orweight. In people with chronic alco-holic liver disease, portal systemic en-cephalopathy index was unchanged.Levodopa levels were not significantlydifferent in individuals with Parkinsondisease. The 2009 update did not findnew studies meeting the inclusion cri-teria for this question and the Nutri-tive and Nonnutritive Sweetenersworkgroup (2009) concurs with theconclusion above formulated by theaspartame workgroup (2008). Grade

III Limited.

To date, adequately powered studieshave not been conducted to evaluatethe effect of aspartame on preferencefor sweet taste in adults andchildren ortheeffect on energybalance in children.

Neotame. To date, no studies meetingthe inclusion criteria were identified toevaluate 14 EAL questions related toneotame consumption and appetite,energy balance, estimated and accept-able intake, nutrient quality, andhealth

risks and benefits.

Saccharin. In adults, does saccharin af-fect food intake?

Conclusion Statement. Saccharindoes not increase food intake in adults.Modest energy savings canresult if sac-charin-sweetened foods replace sugar-sweetened products in a form that isalso lower in energy. The 2009 updatedid not find new studies meeting theinclusion criteria for this question; the

Nutritive and Nonnutritive Sweetenersworkgroup (2009) reviewed and ac-cepted the studies identified by theNNS workgroup (2006). Grade IIILimited.

In adults, does using foods or beverageswith saccharin affect appetite?

Conclusion Statement. In short-termstudies, saccharin does not affect appe-tite in adults. The 2009 update did notfind new studies meeting the inclusioncriteria for this question; the Nutritive

and Nonnutritive Sweeteners work-group (2009) reviewed and acceptedthe studies identified by the NNS work-group (2006). Grade III Limited.

In adults, does using foods or beverageswith saccharin in a calorie-restricted orad libitum diet affect energy balance?

Conclusion Statement. Using sac-charin in either an energy-restricted orad libitum diet will affect overall en-ergy balance, only if the saccharin-sweetened foods are substituted forhigher-energy food or beverages. The2009 update did not find new studiesmeeting the inclusion criteria for thisquestion; the Nutritive and Nonnutri-tive Sweeteners workgroup (2009) re-viewed and accepted the studies iden-tified by the NNS workgroup (2006).

Grade III Limited.What is the estimated saccharin con-

sumption level andis it withinADI limits?

Conclusion Statement. Cross-sec-tional research conducted outside theUnited States, is consistent in findingthat saccharin intakes for adults andchildren are below the ADI of 5 mg/kgbody weight set by the Joint ExpertCommittee on Food Additives, an inter-national scientific expert committeeadministered jointly by the Food andAgriculture Organization of the UnitedNations. Persons with diabetes andyoung children had the highest saccha-rin intakes, when expressed as milli-grams per kilogram body weight. Re-ported intakes ranged from a meanintake of 0.3 mg/kg body weight to a95th percentile intake of 2.7 mg/kgbody weight; therefore, intake at the95th percentile is well within the JointExpert Committee on Food AdditivesADI. The 2009 update did not find newstudies meeting the inclusion criteriafor this question; the Nutritive and

Nonnutritive Sweeteners workgroup(2009) reviewed and accepted thestudies identified by the NNS work-group (2006). Grade II Fair.

In adults, can saccharin be used tomanage diabetes and glycemic response?

Conclusion Statement. In a limitednumber of human studies, saccharinhad no effect on changes in lipid pro-files and glycemic response in adultswith diabetes. The Nutritive andNonnutritive Sweeteners workgroup

FROM THE ACADEMY



13/20

(2009) reviewed and accepted the

studies identified by the NNS work-

group (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 theintake of saccharin, and is this within the

ADI of NNS?

Conclusion Statement. In one studyconducted 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 meet-

ing the inclusion criteria for this ques-

tion; the Nutritive and Nonnutritive

Sweeteners workgroup (2009) re-viewed and accepted the studies iden-

tified by the NNS workgroup (2006).

Grade III Limited.

In adults, can saccharin be used to pre-

vent and manage hyperlipidemia?

Conclusion Statement. Saccharin hasno 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 studiesmeeting the inclusion criteria for this

question; the Nutritive and Nonnutri-

tive Sweeteners workgroup (2009) re-

viewed and accepted the studies iden-

tified by the NNS workgroup (2006).

Grade III Limited.

What is the evidence from human sub-

jects research that saccharin consump-

tion is associated with adverse effects in

the general population?

Conclusion Statement. Limited re-

search in human beings, from peer re-viewed journals, did not find an associ-

ation between adverse effects and the

intake of saccharin in the general pop-

ulation. No data from longitudinal co-

hort studies were available for review.

The 2009 update did not find new stud-

ies meeting the inclusion criteria for

this question;the Nutritive andNonnu-

tritive 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 random-ized controlled trials (Barriocanal and

colleagues, 2008, Maki and colleagues,

2008, Ferri and colleagues, 2006, Gre-

gerson and colleagues, 2004, andHsieh

and colleagues, 2003) examined the ef-

fects of stevia compared with placebo

on metabolic outcomes or weight andreported minimal, if any effects on

blood glucose andinsulin levels, hyper-

tension, and weight. However, the ma-

jority 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 di-

abetes reported no significant changes

from baseline in serum glucose or he-

moglobin A1c levels. However, onetrial

(Gregerson 2004) in subjects with type

2 diabetes reported a reduced post-

prandial blood glucose and glucagon

response after a test meal of stevia vs

placebo. In subjects without diabetes,

one trial (Ferri 2006) reported both glu-

cose and insulin reductions in both the

stevia and placebo groups. Two trials

(Berriocanal 2008, Maki 2008) in sub-

jects with normal/low blood pressure

detected no significant changes from

baseline in blood pressure from stevio-

side compared with controls. In sub-

jects with Stage 1 hypertension, no

anti-hypertensive effects of stevioside

compared with placebo were found

(Ferri 2006). A third study (Gregerson2004) also reported no changes in

blood pressure from stevioside com-

pared with placebo However, a 2-year

trial in Chinese subjects with mild hy-

pertension 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 af-fect food intake?

Conclusion Statement. One random-ized controlled trial (Rodearmel andcolleagues, 2007) examined sucraloseand food intake in adults. Sucralosedoes not increase food intake. Modestenergy savings can result if sucralosereplaces sugar-sweetened products in a

form that is also lower energy. This con-clusion statement developed by theNutritive and Nonnutritive Sweetenersworkgroup (2009) is consistent withthe previous statement on food intakein adults developed by the NNS work-group (2006). Grade III Limited.

In children, does sucralose affect foodintake?

Conclusion Statement. One random-ized controlled trial (Rodearmel andcolleagues, 2007) examined sucralose

and food intake in children. Sucralosedoes not increase food intake. Short-term studies suggest that modest en-ergy savings can result if sucralose re-places sugar-sweetened products in aform that is also lower energy. Long-term studies need to assess if use of su-cralose in children helps to balanceenergy intakes with energy expendi-tures. This conclusion statement deve-loped by theNutritive andNonnutritiveSweeteners workgroup (2009) is con-sistent with the previous statementon food intake in adults developed by

the NNS workgroup (2006). Grade IIILimited.

In adults, does using foods or beverageswith sucralose affect appetite?

Conclusion Statement. One cross-sectional study with a small samplesize of only women (Frank and col-leagues, 2008) indicates that sucralosedoes not affect appetite in adults. Thisconclusion statement developed by theNutritive and Nonnutritive Sweetenersworkgroup (2009) is consistent with

the previous statement on food intakein adults developed by the NNS work-group (2006). Grade III Limited.

In adults, does using foods or beverageswith sucralose in an energy-restricted orad libitum diet affect energy balance?

Conclusion Statement. One random-ized controlled trial (Rodearmel andcolleagues, 2007) examined sucraloseand energy balance in adults. Using su-cralose in either an energy-restricted orad libitum diet will affect overall en-

FROM THE ACADEMY



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ergy balance only if the sucralose issubstituted for higher-energy food orbeverages. This conclusion statement

developed by the Nutritive and Nonnu-tritive Sweeteners workgroup (2009) isconsistent with the previous statementon food intake in adults developed by

the NNS workgroup (2006). GradeIII Limited.

In children, does using beverages withsucralose in an energy-restricted orad libitum diet affect energy balance(weight)?

Conclusion Statement. One random-ized controlled trial (Rodearmel andcolleagues, 2007) examined sucralose

and energy balance in children. Thestudy, using human subjects, supportsthat the use of sucralose does not cause

weight gain among children and ado-lescents. If nonenergy-containingbeverages, including those containingsucralose, are substituted for sugar-sweetened beverages, there is a poten-

tial for energy savings in adolescents.This conclusion statement developedby the Nutritive and NonnutritiveSweeteners workgroup (2009) is con-

sistent with the previous statement onfood intake in adults developed by theNNS workgroup (2006). Grade III

Limited.

In adults, can sucralose be used tomanage diabetes and glycemic response?

Conclusion Statement. Limited evi-dence from three controlled trials(Mezitis and colleagues, 1996; Reynaand colleagues, 2003; and Grotz and

colleagues, 2003) showed little or noeffects of sucralose on metabolic ef-fects, including blood glucose in adults;however, the trials were of small sizeand used varying doses of sucralose for

different lengths of time. Two trials(Mezitis and colleagues, 1996; and

Reyna and colleagues, 2003) found nodifference in measures of glycemic re-sponse when sucralose was added to

diets compared with control diets. Onetrial (Grotz andcolleagues,2003)founddecreased Hb A1c levels and fastingplasma glucose levels from baseline inadults with diabetes after consuming

sucralose for 3 months. The sucralosegroup also had a statistically significantdecrease in fasting plasmaglucose frombaseline compared with the controlgroup. The 2009 update did not find

new studies meeting the inclusion cri-teria for this question; the Nutritiveand Nonnutritive Sweeteners work-group (2009) reviewed and acceptedthese studies identified by the NNSworkgroup (2006). Grade III Limited.

In adults, can sucralose be used to pre-

vent and manage hyperlipidemia?

Conclusion Statement. One study ofshort duration and small sample size inmen (Reyna and colleagues, 2003) indi-cated that sucralose has no significanteffect on lipid profile in adults. The ev-idence to determine whether sucralosecan be used to prevent and manage hy-perlipidemia is limited. The 2009 up-date did not find new studies meetingthe inclusion criteria for this question;the Nutritive and Nonnutritive Sweet-

eners workgroup (2009) reviewed andaccepted the above study identified bythe NNS workgroup (2006). GradeIII Limited.

What is the evidence from human sub-jects research that sucralose consump-tion is associated with adverse effects inthe general population?

Conclusion Statement. Limited re-search in human beings, from peer re-viewed journals, did not find an associ-ation between adverse effect and theintake of sucralose in the general popu-lation No data from longitudinal cohortstudies were available for review. TheNutritive and Nonnutritive Sweetenersworkgroup (2009) reviewed and ac-cepted the studies (Grice and Gold-smith, 2000; and Weihrauch and col-leagues, 2004) identified by the NNSworkgroup (2006) and found one addi-tional article (Grotz and Munro, 2009)meeting the inclusion criteria for theupdate of this question. Grade IIILimited.

To date, no studies meeting the EAL

inclusion criteria were identified toevaluate the effect of sucralose intakeon energy density, nutrient quality, orbehavior or cognitive changes in adultor the ADI for persons with diabetes;and no studies were identified to eval-uate the effects of sucralose on appetitein children.

SWEETENER USE AND HEALTH

Both nutritive and NNS have generatedhealth concerns among health care pro-viders (42,78) and the public for many

years. Concerns related to safetyof NNSare addressed primarily in animal stud-ies. This EAL addresses many of thecommon health concerns with sweet-ener use in children and adults. Others,specifically sweetener use during preg-nancy and effects on dental caries and

hyperactivity, are addressedin this sec-tion.

Nutritive and NNS Use during

Pregnancy

Pregnancy is a time of special concernbecause the focus is on maternal andfetal health. All FDA-approved nutritivesweeteners and NNS are approved foruse by the general public, which in-cludes pregnant and lactating women.The position of the Academy is that useof nutritive sweeteners is acceptable

during pregnancy (79). Safety of foodadditives, including NNS, is based onstudies in animals as required by theFDA approval process. Using an appro-priateanimal model consistent with In-ternational Conference on Harmonisa-tion protocols allows testing with largeamounts of the food additive thatwould not be permitted in human sub-jects. This testing is carried out overseveral generations of the animalmodel and includes tests on the repro-ductive abilities in women and menand effects on thedeveloping fetus.Any

NNS that was found to be unsafe at anystage of life would not be approved foruse (19).

One study on use of NNS duringpreg-nancy has been published after the EALon NNS was completed. In 2010, Hall-dorsson and colleagues (80) reportedan association betweenintakes of NNS-sweetened carbonated and noncarbon-ated soft drinks and preterm birthamong 59,334 Danish women in theDanish National Birth Cohort. They ex-cluded women with gestational diabe-tes and controlled for maternal age,body mass index, smoking status, mar-ital status, parity, and social status.Women who consumed one or moreNNS-sweetened soft drinks per daywere significantly more likelyto deliverpreterm. The association was strongerfor carbonated than for noncarbonateddrinks. At the time of the study, aspar-tame and acesulfame-K were usedmost often for carbonated drinks andsaccharin and cyclamates were moreoften used for noncarbonated drinks.Theauthors concludedthat daily intake

FROM THE ACADEMY



15/20

of beveragescontaining NNSmay be as-sociated with an increased risk of pre-term delivery. It is important to pointout that the incidence of preterm birthwas low and the increased risk was duemostly to medically induced pretermbirth. This finding has not been con-

firmed in other studies.

Dental Caries

Dental caries are the localized destruc-tion of dental hard tissue by acidic ma-terial from bacterial fermentationof di-etary carbohydrate (81). Factors thatinfluence the development of dentalcaries include microbiological shifts inthe biofilm, salivary flow, buffering ca-pacity of saliva, frequency and kind ofdietary sugars consumed, length oftime oral bacteria have to ferment thefermentable carbohydrate and makeorganic acids, tooth susceptibility, pre-ventive behaviors such as cleaning ofteeth (82), and exposure to fluoride(83). The American Academy of Pediat-ric Dentistry recommends reducing be-tween-meal snacks and prolonged ex-posures to any food, juice, or beveragecontaining fermentable carbohydrateduring infancy, early childhood, andadolescents (84-86). A child who con-sumes more than three between mealnutritive sweetener-containing snacksor beverages per day is considered at

increased risk for dental caries (84).Xylitol is considered cariostatic andanticariogenic and aids in the preven-tion of dental caries (87,88). Milgromand colleagues (89) concluded that aminimum of 5 to 6 g xylitoland threeexposures per day are needed for clini-cal effect. Studies of chewing gum con-taining anticariogenic polyols and car-ies reduction are confounded by thefact that chewing gum stimulates sali-vary flow and salivary flow may be asimportant as the polyol in controllingmouth pH and levels of Streptococcus

mutans to prevent caries (90). The FDAregulates health claims on food labels(91). The health claim that sweetenersdo not promote dental caries has beenapproved for sugar alcohols (91), eryth-ritol (92), D-tagatose (93), sucralose(94), and isomaltulose (95).

Behavior Disorders

The possible negative influence ofadded sugars on behavior has receivedattention over the years. Wolraich andcolleagues (96) in a meta-analysis on

the effect of sugar on behavior of chil-dren concluded that sugar does not af-fect the behavior or cognition of chil-

dren, including hyperactive childrenandchildren whowere sugar reactorsbased on parent perception and normalchildren.More recentreviews have also

stated that sugar does not affect behav-ior or cognition in children with orwithout attention-deficit hyperactivitydisorder (ADHD) (97). Research testing

the relation between refined sugarsand behavior has several design flaws.Modifying the diet is one complemen-tary approach used often by parents for

their child with ADHD (98). Manysugarbehavior studies used a dose of sugarthat was lower than what children con-sume on a regular basis. Levels used in

previous research included 1.75 to 2g/kgbody weightor 52.5g to60 g (13 to

15 tsp) in a 30 kg child (99-102). Wol-raich and colleagues (103) found no ef-

fecton behavior of 21.3 g (5 tsp) sucroseper day in preschool children and 120 g(30 tsp) sucrose per day in school-aged

children without ADHD. Children (aged2 to 18 years) today consume, on aver-age,23 tsp added sugarsper day (29,34)with gram intake of added sugars being

52 g for 2- to 5-year-olds, 84 g for 6- to11-year-olds, and 90 g for 12- to 17-year-olds (30).

Several researchers have concluded

(96,104,105) that parental expecta-tions and perception are major con-founders in many short- and long-termstudies of the effect of sugars on behav-

ior of children. Clinicians should usecaution when restricting the diet ofchildren who have ADHD even thoughmany parents believe diet affects their

childs behavior (104). Clinical practiceguidelines regarding the treatment ofchildren with ADHD state thereis a lackof evidence that removing sugar from

the diet of a child with ADHD results infewer symptoms (106,107). The Amer-

ican Academy of Child and AdolescentPsychiatry does not address diet orelimination diets in treatment of chil-

dren with ADHD (108). Diet-orientedtreatment is not appropriate for chil-dren with behavioral problems; thegoal of diet treatment is to ensure a bal-anced healthy diet with adequate en-

ergy and nutrients for optimal growthand normal body weight (109).

R ecent work has f ocu sed onwhether or not refined sugars, even ifpart of foods, are addictive (110-113).

This is of interest to consumers and toscientists because of the linkage tocravings, binge eating, and obesity

(110). The concept of addictionmeansa psychological dependence and is acognitive as wellas physical condition(114). Sweet foods per se are not sub-

stances as are drugs such as alcohol.The literature is complex. It does notalways focus on added sugars alonebut includes all foods and is often

studied within the context of bingeeating behaviors (112).

To be dependent on or addicted to asubstance, any three of the following

sevencriteria must be met at any timein 1 year: tolerance, which meansmore substance is needed for thesame effect; withdrawal; larger

amount of the substance taken ortaken for a longer period than intend-

ed; a persistent desire for the sub-stance or an inability to reduceor con-trol its use; much time spent seekingor consuming the substance or recov-ering from its effects; use of the sub-

stance interferes with important ac-tivities; and use of the substancecontinues despite adverse conse-quences (110,115). Corwin and Grig-

son (110) proposed that foods rich insugar can promote addictive-like be-havior and neuronal changes in cer-tain situations. These high-sugar

foods may not be addictive per se butmay become addictive if consumed ina restrictive/binge-like pattern. Thismay lead to other chronic conditions

such as obesity, depression, and an-xiety.

Avena and colleagues (111,116)have done much of the work in re-

fined sugar intake and addictive be-havior using animal models. Studiesusing animal models to determine ifsugar is addictive use an exce

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Position of the Academy of Nutrition and Dietetics Use of Nutritive and Nonnutritive Sweeteners

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