It is quite common for people with diabetes or those seeking to lose weight to look to non-caloric and low-calorie sweeteners. While earlier versions of artificial sweeteners like saccharin and cyclamates (and later aspartame) were embroiled with controversy over their safety, some of the newer sweeteners appear to be considerably safer. In addition, there are natural sweeteners that are even better choices. In fact, my top choice is stevia - a natural sweetener extracted from the Stevia rebaudiana plant.

Stevia contains a molecules known as stevioside that is 300 times sweeter than sugar and has an excellent safety profile.1 Stevia products are used around the world for its incredible sweetening properties. However, since it has not passed Food and Drug Administration testing it cannot be advertised as a sweetener here. It is sold instead as "a dietary supplement" Preliminary studies in animal models show it to lower blood glucose levels and blood pressure - two effects of prime importance in dealing with diabetes. There are several different brands of stevia - each with a slightly different taste. The ones that I particularly enjoy are the Sweet Leaf and Stevita brands.

Another acceptable class of sweeteners is the "polyol" sweeteners like xylitol, sorbitol, mannitol, and maltitol. These sweeteners found in numerous food products - especially sugar-free chewing gum because it has a smooth feel in the mouth with a sweet, cool and pleasant taste. It is also used in many sugar-free or "dietetic" candies, cake mixes, syrups, and other foods. Polyols in general are about 60 percent as sweet as sucrose with one-third fewer calories (2.6 calories per gram versus 4.0 for sugar). They do not cause cavities (in fact, xylitol actually prevents cavity formation) and because they are absorbed quite slowly and have a low glycemic index, polyols are fantastic sweeteners for diabetics.

Polyol sweeteners are extremely safe at moderate dosages. However, because they are poorly absorbed at higher dosages (e.g., greater than 10 grams daily) they can cause gastrointestinal symptoms ranging from mild discomfort to severe diarrhea. Children, because of their smaller size, may be affected by even smaller amounts. Currently, the FDA requires a laxative notice only on the few products that may lead to the consumption of 50 grams or more of sorbitol daily, though some companies voluntarily label additional products.

The newest member of sweeteners is tagatose (Naturlose), a low-calorie, natural sugar found in milk. It has recently attained GRAS (Generally Recognized As Safe) status allowing it to be included in foods as a sweetener. Tagatose is a sugar molecule very similar to fructose that is poorly absorbed. It actually appears to be able to actually block the absorption of other sugars including glucose. When tagatose was given to diabetics prior to an oral glucose tolerance test, blood glucose levels were significantly reduced.2 I expect to see tagatose gaining a lot of attention as it enters the crowded sweetener category.

The table below provides a ranking of the sweeteners along with a brief description and a recommended use level of liberal, moderate, conservative, or restrictive based upon available safety data.

Sweetener	Other Names	Recommended use level	Quick Comments
Stevia	Sweet Leaf Stevita	Liberal	A natural sweetener extracted from the Stevia rebaudiana plant, it is 300 times sweeter than sucrose. Technically a dietary supplement because it has not been evaluated or approved by the FDA as a sweetener. Preliminary studies show blood sugar lowering and blood pressure lowering effects.
Xylitol and other polyols (maltitol, sorbitol, mannitol, erythritol)		Moderate	Polyols are roughly 60% as sweet as sucrose. They are poorly absorbed and do not break down when heated. At higher dosages (e.g., single dosage of more than 10 to 30 g or a daily intake of more than 40 to 80 g) may produce laxative effect.
Tagatose		Moderate	A naturally occurring sugar in milk that is 92% as sweet as sugar, but is absorbed poorly. It does have some caloric value, about 1/3 the amount of sugar. Studies show that tagatose actually blunts the glycemic response to sugar.
Sucralose	Splenda	Moderate	Actually made from sugar (sucrose with newly attached chlorine molecules). It is 600 times sweeter than sucrose and does not break down when heated.
Aspartame	NutraSweet, Equal	Conservative	A controversial sweetener that is reported to receive more complaints at the FDA than any other food substance. Made from two amino acids naturally found in foods, phenylalanine and aspartic acid; it is 200 times sweeter than sucrose. Aspartame loses sweetness when heated.
Acesulfame K	Sunett, Sweet One	Restrictive	Made from vinegar, is not broken down by body. It is 200 times sweeter than sucrose. Structurally related to saccharin.
Saccharin	Sweet 'n Low	Restrictive	Initially removed from market over fears that it was a carcinogen. It is 300 times sweeter than sucrose. Because of safety concerns, it is not recommended during pregnancy.

A Quick Look at Fructose as a Sweetener

Fructose or fruit sugar is the primary carbohydrate in many fruits, maple syrup, and honey. In fact, the fructose content of most fruits and many vegetables is roughly 10% of their dry weight. Fructose is very sweet and is roughly 1.75 times sweeter than sucrose (white sugar). Although fructose has the same chemical formula as glucose (C6H12O6), its structure (shape) is quite different. In order to be utilized by the body, fructose must be converted to glucose within the liver.

At appropriate levels, less than 10 g per serving fructose is an acceptable sweetener. Because fructose must be changed to glucose in the liver in order to be utilized by the body, blood glucose levels do not rise as rapidly after fructose consumption compared to other simple sugars or even complex carbohydrates. For example, the glycemic load calculation for 10 grams of fructose it would be only 2. In comparison, the glycemic load for a slice of bread is 10, an apple is 7, and a cup of white rice 26.

So, you can see that 10 grams of fructose is not a problem even for people with diabetes or hypoglycemia. In fact, one of the latest studies with fructose in type 2 diabetes is quite interesting. The title of the article is "Acute fructose administration improves oral glucose tolerance in adults with type 2 diabetes." The study was conducted at Vanderbilt University and was published in Diabetes Care. 2001 Nov;24(11):1882-7. Basically, what the study demonstrated was that low-dose fructose administration actually improves the glycemic control in adults with type 2 diabetes.4

Fructose in Powdered Formulas from Natural Factors

Choosing an acceptable sweetener for the health food market is a difficult proposition. Nobody wants to ingest unnecessary sweeteners or calories, but failure to use a sweetener makes the product considerably less appealing. The solutions are limited.

For example, while something as natural sounding as "rice syrup solids" may sound and look good on a label it is really not an acceptable choice. The chief components of rice syrup solids are glucose and maltose. These sugars are immediately absorbed in the body. The glycemic load of 10 g these sugars is 10 (remember fructose was 2), but because they are not as sweet as fructose higher levels are usually required. It basically takes at least three times as much rice syrup solids to impart the same amount of sweetness as fructose. That would result in tremendous stress on blood sugar control.

After weighing all available options, at Natural Factors we have chose to use fructose alone or in combination with stevia extract and/or xylitol as the sweetening agent in our powdered drink mixes like RevitalX, DetoxiTech, Learning Factors, and WellBetX. While the amount of fructose in the formulas is clinically insignificant, it often raises the question as to why it is included in the formulas. The key point to remember is that that issues with fructose relate entirely to dosage. Remember that because fructose is 1.75 times sweeter than sucrose, it requires significantly less to impart sweetness - especially when combined with xylitol and/or stevia. In addition, as explained above low dosages of fructose actually enhances blood sugar control.

Here is some more information as to why fructose at appropriate levels makes sense. It is also very effective in staving off the appetite. While studies have consistently shown aspartame (Nutrasweet, Equal), glucose, and sucrose to actually increase appetite, fructose consumption has been shown to decrease the amount of calories and fat consumed. Typically, the studies will give the subjects food or drink containing an equivalent amount of fructose or other sweetener 30 minutes to 2 1/2 hours before a meal and then allow them to consume as much food as they desire at a dinner buffet. The studies are designed in a "double-blind" fashion so that neither the observers nor participants know who has been given what. Consistently, subjects receiving the fructose sweetened food or drink will eat substantially fewer calories and fat compared to the groups receiving aspartame, sucrose or glucose.5,6 This clearly indicates that fructose at appropriate levels can reduce appetite and make weight loss much easier to achieve.

Final Comments

In formulating the various powdered drink mixes for Natural Factors, one of the key goals has been to make sure that the level of soluble fiber was quite high. Soluble fiber produces many health benefits useful in all of the applications that the formulas are specifically designed for whether it is to improve the leaky gut syndrome, aid detoxification, improve blood sugar control, or suppress the appetite. The amount of soluble fiber in the formulas make us even less concerned by the insignificant amount of fructose. The soluble fibers in the formula bind to the water in the stomach and small intestine to form a gelatinous, viscous mass which slows down gastric emptying and the absorption of simple sugars. In particular, our proprietary blend PGX(tm) (short for PolyGlycopleX) lowers after meal blood glucose levels by approximately 20% and also lowers insulin secretion by approximately 40% producing a whole body insulin sensitivity index improvement of nearly 50% - a phenomenal accomplishment that is unequalled by any drug, other fiber source or natural health product.

Key References:

1. Kinghorn AD, Kaneda N, Baek NI, Kennelly EJ, Soejarto DD. Noncariogenic intense natural sweeteners. Med Res Rev 1998;18:347-60.
2. Jeppesen PB, Gregersen S, Rolfsen SE, et al. Antihyperglycemic and blood pressure-reducing effects of stevioside in the diabetic Goto-Kakizaki rat. Metabolism 2003;52:372-378.
3. Levin GV. Tagatose, the new GRAS sweetener and health product. J Med Food 2002;5:23-36.
4. Moore MC, Davis SN, Mann SL, Cherrington AD. Acute fructose administration improves oral glucose tolerance in adults with type 2 diabetes. Diabetes Care 2001;24(11):1882-7.
5. Rodin J. Comparative effects of fructose, aspartame, glucose, and water preloads on calorie and macronutrient intake. Am J Clin Nutr 1990;51:428-35.
6. Spitzer L, Rodin J. Effects of fructose and glucose preloads on subsequent food intake. Appetite 1987;8(2):135-45.

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Michael T. Murray, N.D., is widely regarded as one of world's leading authorities on natural medicine. A prolific author, Dr. Murray has written over 20 books on health and nutrition including the best-selling Encyclopedia of Natural Medicine and his latest book The Encyclopedia of Healing Foods. Dr. Murray is also Director of Product Development and Education for Natural Factors one of the leading manufacturers of natural products.