Upcoming Issue Highlights

Sugar Alternatives

Phase 2

It’s no secret that Americans consume too much sugar. In fact, by 2010 Americans consumed 66 pounds of refined sugar per person.Add to that the consumption of 64.5 pounds of corn-derived sweeteners and 1. 5 pounds of honey and edible syrups; the total annual sweetener consumption per person is 132 pounds (excluding artificial sweeteners and alternative sweeteners such as stevia).1 To focus on sugar alternatives, or more specifically, natural sugar alternatives, it’s important to first define sugar, and consider why we should reduce sugar consumption.

Sugar Defined and Overconsumption 

Monosaccharides are “single” sugars (i. e. composed of one sugar). Examples include glucose (aka, dextrose or blood sugar), fructose (aka, fruit sugar) and galactose (predominantly found as part of the disaccharide lactose).

Disaccharides are “double” sugars (i. e. composed of two sugars). Examples include sucrose or table sugar (composed of glucose and fructose), lactose or milk sugar (composed of glucose and galactose), and maltose (composed for two units of glucose).2 Most caloric, natural sweeteners provide one or more of these sugars.

If asked, virtually anyone can probably name at least one negative effect of sugar overconsumption. But just for the record, the industrialization of food processing in the twentieth century has led to sugar overconsumption with ramifications including a major contribution to the current obesity epidemic.In addition, excess sugar consumption contributes toward diabetes,3 dental caries (cavities), a compromised immune system, kidney damage, atherosclerosis, oxidative stress and cancer.4 

Furthermore, even short-term overconsumption can result in problems.Research shows that blood drawn from normal human subjects after they consumed glucose, fructose, sucrose, honey, or orange juice demonstrated a significantly reduced capacity of neutrophils (the most abundant type of white blood cell produced by the immune system) to engulf bacteria.5 Also, a diet high in simple sugars and refined carbohydrates may slow bowel transit time, increase fermentation6 and increase exposure to potentially toxic bowel contents.7 This could provide a similar inhospitable environment for friendly microflora.

Reducing Consumption of Sugar 

Given the ramifications of sugar overconsumption, it clearly makes sense to reduce sugar intake—which is not as easy as it sounds. Sugar has addictive properties that involve the same dopamine receptors in the pleasure centers of the brain as for cocaine, nicotine and alcohol.8 Nevertheless, one good way to reduce sugar consumption is by using sugar alternatives.

The following discussion will address two types of natural sugar alternatives: non-caloric and caloric. Regarding the latter, great care must be taken in making choices to assure that the sugar alternative doesn’t turn out to be a variation on the same sugar theme.

Non-caloric, Natural Sugar Alternatives 

Currently, there are two natural sugar alternatives that are non-caloric and GRAS (generally regarded as safe): stevia (or more specifically its compound, rebaudioside A) and luo han guo.Here’s a closer look at both: 


Native to subtropical and tropical regions from western North America to South America, stevia is a genus of herbs and shrubs in the sunflower family.Stevia rebaudiana, commonly known as just stevia, is grown for the sweetness of its leaves. Stevia’s sweetness occurs more slowly and lasts longer than sugar. The limitation of stevia is that its extracts generally have a bitter aftertaste, sometimes described as licorice-like. The compounds in stevia providing its sweet taste are called steviol glycosides, and provide up to 300 times the sweetness of sugar. The major steviol glycosides are stevioside and rebaudioside A (aka, RebA).9 It is important to note that whole-leaf stevia or crude stevia extracts have not had GRAS approval as a food additive.Rather, Sweet Green Fields, Blue California, McNeil Nutritionals, Cargill, and Whole Earth Sweetener/Merisant have all received GRAS approval for concentrated rebaudioside A products derived from stevia.10 

In addition to its functioning as a sugar alternative, stevia may offer other health benefits. Human research indicates that stevioside (750-1500 mg/day) may be effective in lowering blood pressure in hypertensive patients.10 Other clinical research suggests that stevioside (1000 mg/day) might reduce postprandial glucose levels by 18 percent in people with type 2 diabetes.12 However, since the GRAS approved stevia compound is rebaudioside A, it is not clear that commercially available products will have the same effects.

Luo Han Guo 

Luo han guo, or monk fruit (Siraitia grosvenorii), is native to southern China and northern Thailand, and has been used for hundreds of years in China as a natural sweetener and as a traditional medicine for the treatment of pharyngitis, pharyngeal pain, as well as an antitussive remedy.13 The dried fruit is used in whole, in powder form or in blocks for beverages, seasoning, in herbal soups, teas, cakes and candy. A naturally produced lou han guo fruit concentrate that is non-caloric and is 300 times sweeter than sugar was developed, accepted by the FDA and registered as GRAS.14 The sweet taste of this fruit is primarily a result of a group of triterpene glycosides called mogrosides that make up about 1 percent of the flesh of the fresh fruit. Via extraction, a fruit powder containing 80 percent mogrosides can be produced.15 

In addition to its effects as a sweetener, luo han guo extract was shown in animal research to have significant antifatigue effects.16 Recent research suggests isolated mogrosides have antioxidant properties17 and, as with stevia compounds, were shown to inhibit skin cancer in animal research.18-19 In-vitro research has also shown that mogrosides inhibit induction of the Epstein- Barr virus.20 

Caloric Sugar Alternatives 

In the context of this discussion, caloric sugar alternatives will be defined as sugar alcohols or natural sources of sugars that have undergone less refinement than their refined counterparts. In the case of the latter, it does not mean that there are no ramifications for their overuse, but it does mean that if they are used sparingly they do offer a better option as sweeteners than highly refined sugars.

Sugar alcohols 

Sugar alcohols are compounds that occur naturally and can be found in many fruits, vegetables, and other plant sources. Examples of sugar alcohols include erythritol, mannitol, sorbitol and xylitol. The primary advantages of sugar alcohols are that they do not contribute to tooth decay,21 and they offer more sweetening for fewer calories.However, sugar alcohols may cause bloating and diarrhea when consumed in excessive amounts,22 so their use as a sugar alternative is really limited to inclusion in small amounts; an exception, however, is erythritol.

About 90 percent of erythritol is absorbed into the bloodstream in the small intestine (and then for the most part excreted unchanged in the urine), while about 10 percent enters the colon.23 Because most of it does not enter the large intestine, it does not tend to cause the laxative effects found with the higher consumption of other sugar alcohols.24 Nevertheless, consumption over 50 grams (1.8-oz.) can still cause a significant increase in nausea and stomach rumbling.25 


Produced by honey bees, honey is composed of fructose (38.2 percent), glucose (31.3 percent), maltose (7.1 percent), sucrose (1.3 percent), water (17. 2 percent) and other carbohydrates (1. 5 percent).26 It contains only trace amounts of vitamins or minerals,27 as well as tiny amounts of several compounds thought to function as antioxidants. 28 Furthermore, honey scores 55 on the glycemic index, which is fairly low for a sweetener (glucose scores 100) . In fact, it’s actually slightly lower than oatmeal at 58 on the glycemic index.29 In addition, honey may offer some health benefits.

In clinical research, one half to two teaspoons of honey at bedtime significantly reduced nighttime cough frequency and severity, and improved sleep compared to placebo in children ages two years and older with upper respiratory infections.30 In fact, honey was at least as effective or more effective than dextromethorphan (a cough suppressant) typically found in over-thecounter medications, as well as the antihistamine diphenhydramine.31-32 Some research even found that honey might normalize blood sugar following exercise and improve performance when given during exercise.33 In addition, in research comparing the antioxidant content of different sweeteners, honey showed intermediate antioxidant activity. The significance of this is, based on an average intake of 130 g/day refined sugars and the antioxidant activity measured in typical diets, substituting honey could increase antioxidant intake to a level similar to the amount found in a serving of berries or nuts.34 

Maple syrup 

A long-time favorite to accompany pancakes and waffles, maple syrup is available in grades of Fancy, A Medium, A Dark, and B. Depending on the grade, maple syrup contains about 66 to 67 percent sugars, most of which is sucrose. Less than 1 percent is fructose or glucose.35 Like honey, maple syrup’s score on the glycemic index is relatively low for a sweetener: 54.36 Also like honey, maple syrup may offer some health benefits.

In animal research, maple syrup did not increase blood glucose levels as much as sucrose. This lead the researchers to conclude that when used as an alternative to sucrose, the lower glycemic index of maple syrup “may help in the prevention of type 2 diabetes” 37 (although this should not be interpreted to mean that maple syrup can be used with impunity by diabetics).In addition, two in-vitro studies38-39 demonstrated that maple syrup had selective antiproliferative activity against cancer cells. It will be interesting to see if it has the same effect in human studies. Further, as with honey, maple syrup has also demonstrated intermediate antioxidant activity.40 

Poor Choices for Sugar Alternatives 

There are some sweeteners marketed as sugar alternatives, which are not good choices from a health standpoint. Two of those are fructose and agave syrup.


Fructose is sugar, not a sugar alternative.Although refined fructose is slightly sweeter than sucrose, it may actually do more harm. Human research shows that fructose is more likely to raise triglyceride levels.41-42 For this reason, it is not recommended as a sweetener for diabetics.43 Also, research on the metabolic and endocrine effects of dietary fructose suggest that increased consumption of this sugar may promote weight gain and metabolic indexes associated with the insulin resistance.44 This was observed in various human studies.45-47 In-vitro research has suggested that fructose consumption may even increase the risk of pancreatic tumor cells.48 In addition, research presented in 2003 at the annual meeting of the American College of Gastroenterology (ACG)49 found that fructose contributes to symptoms of irritable bowel syndrome (IBS).

Agave syrup 

Agave syrup (aka, agave nectar) is produced from several species of the agave plant, including Agave tequilana and Agave salmiana. Sweeter and less viscous than honey, agave syrup is about 84 percent fructose.50 In animal research, triglyceride levels were higher in those fed agave syrup, leading the researchers to conclude that even moderate consumption “may lead to the onset of unfavorable changes in the plasma lipid profile and one marker of liver health. ”51 Furthermore, in research comparing the antioxidant content of different sweeteners, refined sugar, corn syrup and agave syrup contained the least.Even raw cane sugar was a more effective antioxidant than agave syrup.52 To be clear, although “natural,” agave syrup is really just a more diluted form of fructose.

Brown rice syrup 

Brown rice syrup, a sweetener with a similar consistency to molasses, is not overly sweet and has mild caramel undertones. It is comprised of 45 percent maltose, 3 percent glucose and about 50 percent maltodextrins (maltotriose). Because of the higher proportion of maltodextrins, some claims have been made that brown rice syrup is metabolized more slowly, and may be lower on the glycemic index. However, research has shown that, after consumption of brown rice syrup, blood glucose levels are increased in about the same time that they are by consuming glucose (37. 5 minutes and 40.5 minutes, respectively).53 

A more significant concern is research indicating that brown rice syrup may contribute unsafe levels of arsenic.54 In one study,55 an organic toddler milk formula containing brown rice syrup as the primary ingredient had arsenic concentrations up to six times the U.S. Environmental Protection Agency safe drinking water limit. Cereal bars and high-energy foods containing brown rice syrup also had higher arsenic concentrations than equivalent products that did not contain brown rice syrup. Until such time as the arsenic issue is effectively addressed in brown rice syrup, I recommend caution in its use.


The overconsumption of sugar has serious health ramifications. Efforts should be undertaken to curtail intake, especially of refined sugar products such as table sugar, fructose, high-fructose corn syrup, etc. Stevia and luo han guo are viable, non-caloric sugar alternatives that can be used in this effort. Caloric sugar alternatives such as sugar alcohols, honey and maple syrup, may also be used, but more sparingly. 


[1] Huntrods D, Koundinya V. Sugarcane profile. Agricultural Marketing Resource Center Developed June 2008 and updated by Geisler M, May 2012. Retrieved April 12, 2014 from http://www.agmrc.org/commodities__products/grains__oilseeds/sugarcane_profile.cfm.

[2] Whitney E, Rolfes RR. Understanding Nutrition, 11th ed. Belmont, CA: Thompson Learning; 2008.

[3] Gardner C. Non-nutritive sweeteners: evidence for benefit vs. risk. Curr Opin Lipidol. 2014 Feb;25(1):80-4.

[4] Bilton R. Averting comfortable lifestyle crises. Sci Prog. 2013;96(Pt 4):319-68.

[5]Sanchez A, Reeser JL, Lau HS, Yahiku PY, Willard RE, McMillan PJ, Cho SY, Magie AR, Register UD. Role of sugars in human neutrophilic phagocytosis. Am J Clin Nutr. 1973;26(11):1180-4.

[6] Kruis W, Forstmaier G, Scheurlen C, Stellaard F. Effect of diets low and high in refined sugars on gut transit, bile acid metabolism, and bacterial fermentation. Gut 1991;32:367-371.

[7] Lewis SJ, Heaton KW. The metabolic consequences of slow colonic transit. Am J Gastroenterol 1999;94:2010-2016.

[8] Bilton R. Averting comfortable lifestyle crises. Sci Prog. 2013;96(Pt 4):319-68.

[9] Abdullateef RA, Osman M. Studies on effects of pruning on vegetative traits in Stevia rebaudiana Bertoni (Compositae). International Journal of Biology. 2012;4(1):146-153.

[10] What refined Stevia preparations have been evaluated by FDA to be used as a sweetener? U.S. Food and Drug Administration. Last updated 04/10/2014. Retrieved April 13, 2014 from http://www.fda.gov/AboutFDA/Transparency/Basics/ucm214865.htm.

[11] Ulbricht C, Isaac R, Milkin T, et al. An evidence-based systematic review of stevia by the Natural Standard Research Collaboration. Cardiovasc Hematol Agents Med Chem. 2010 Apr;8(2):113-27.

[12] Gregersen S, Jeppesen PB, Holst JJ, Hermansen K. Antihyperglycemic effects of stevioside in type 2 diabetic subjects. Metabolism 2004;53:73-6.

[13] Li C, Lin LM, Sui F, et al. Chemistry and pharmacology of Siraitia grosvenorii: A review. Chin J Nat Med. 2014 Feb;12(2):89-102.

[14] Lim TK. Edible Medicinal And Non-Medicinal Plants: Volume 2, Fruits. Springer Sceince+Business Media B.V.; 2012:392-400.

[15] Dharmananda S. Luo han guo: Sweet fruit used as sugar substitute and medicinal herb. Institute for Traditional Medicine Online. 2004. Retrieved April 12, 2014 from http://www.itmonline.org/arts/luohanguo.htm.

[16] Liu DD, Ji XW, Li RW. Effects of Siraitia grosvenorii Fruits Extracts on Physical Fatigue in Mice. Iran J Pharm Res. 2013 Winter;12(1):115-21.

[17] Shi H, Hiramatsu M, Komatsu M, Kayama T. Antioxidant property of fructus momordicae extract. Biochemistry and Molecular Biology International. 1996;40 (6):1111–1121.

[18] Konoshima T, Takasaki M. Cancer-chemopreventive effects of natural sweeteners and related compounds. Pure Applied Chemistry. 2002;74 (7):1309–1316.

[19] Katiyar SK, Mukhtar H. Tea antioxidants in cancer chemoprevention. Journal of Cellular Biochemistry. 1997;27:59–67.

[20] Akihisa T, Hayakawa Y, Tokuda H, et al. Cucurbitane glycosides from the fruits of Siraitia gros venorii and their inhibitory effects on Epstein-Barr virus activation. Journal of Natural Products. 2007;70(5) 783–8.

[21] Role of Sugar-Free Foods and Medications in Maintaining Good Oral Health. American Dental Assoiation. 2002-06-05. Retrieved April 13, 2014 from http://www.ada.org/1874.aspx.

[22] Eat any sugar alcohol lately? Yale-New Haven Hospital. 2005-03-10. Retrieved April 13, 2014 from http://www.ynhh.org/about-us/sugar_alcohol.aspx.

[23] Arrigoni E, Brouns F, Amadò R. (Nov 2005). Human gut microbiota does not ferment erythritol. Br J Nutr. 2005; 94 (5): 643–6.

[24] Munro IC, Berndt WO, Borzelleca JF, et al. (December 1998). Erythritol: an interpretive summary of biochemical, metabolic, toxicological and clinical data. Food Chem. Toxicol. 1998;36 (12): 1139–74.

[25] Storey D, Lee A, Bornet F, Brouns F. (Mar 2007). Gastrointestinal tolerance of erythritol and xylitol ingested in a liquid. Eur J Clin Nutr.2007;61 (3): 349–54.

[26] White JW, Doner LW. Honey Composition and Properties. Beekeeping in the United States. Agriculture Handbook Number 335. 1980: 82–91.

[27] Nutrient data for Honey. USDA Nutrient Data Laboratory.

[28] Gheldof N, Wang X, Engeseth N. Identification and quantification of antioxidant components of honeys from various floral sources. J Agric Food Chem. 2002;50(21):5870–7.

[29] Glycemic Index. Self Nutrition Data. Retrieved April 14, 2014 from http://nutritiondata.self.com/topics/glycemic-index.

[30] Paul IM, Beiler J, McMonagle A, et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-6.

[31] Paul IM, Beiler J, McMonagle A, et al. Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-6.

[32] Shadkam MN, Mozaffari-Khosravi H, Mozayan MR. A comparison of the effect of honey, dextromethorphan, and diphenhydramine on nightly cough and sleep quality in children and their parents. J Altern Complement Med 2010:16:787-93.

[33] Lancaster S, Krieder RB, Rasmussen C, et al. Effects of honey on glucose, insulin and endurance cycling performance. Abstract presented 4/4/01 at Experimental Biology 2001, Orlando, FL.

[34] Phillips KM, Carlsen MH, Blomhoff R. Total antioxidant content of alternatives to refined sugar. J Am Diet Assoc. 2009 Jan;109(1):64-71.

[35] van den Berg A, Perkins T, Isselhardt M. Sugar profiles of maple syrup grades. Maple Syrup Digest. 2006;18A(4):12-13.

[36] Maple syrup, pure Canadian (Queen Foods, Australia). University of Sydney. Retrieved April 16, 2014 from http://www.glycemicindex.com/foodSearch.php

[37] Nagai N, Ito Y, Taga A. Comparison of the enhancement of plasma glucose levels in type 2 diabetes Otsuka Long-Evans Tokushima Fatty rats by oral administration of sucrose or maple syrup. J Oleo Sci. 2013;62(9):737-43.

[38] Legault J, Girard-Lalancette K, Grenon C, Dussault C, Pichette A. Antioxidant activity, inhibition of nitric oxide overproduction, and in vitro antiproliferative effect of maple sap and syrup from Acer saccharum. J Med Food. 2010 Apr;13(2):460-8.

[39] González-Sarrías A, Ma H, Edmonds ME, Seeram NP. Maple polyphenols, ginnalins A-C, induce S- and G2/M-cell cycle arrest in colon and breast cancer cells mediated by decreasing cyclins A and D1 levels. Food Chem. 2013 Jan 15;136(2):636-42.

[40] Phillips KM, Carlsen MH, Blomhoff R. Total antioxidant content of alternatives to refined sugar. J Am Diet Assoc. 2009 Jan;109(1):64-71.

[41] Bantle JP, Raatz RK, Thomas W, Georgopoulos A. Effects of dietary fructose on plasma lipids in healthy subjects. Amer J Clin Nutr 2000;72(5):1128-1134.

[42] Karen L. Teff, Sharon S. Elliott, Matthias Tschöp, et al. Dietary Fructose Reduces Circulating Insulin and Leptin, Attenuates Postprandial Suppression of Ghrelin, and Increases Triglycerides in Women. J Clin Endocrinol Metab. 2004;89(6):2963-72.

[43] Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002;25: 148–198.

[44] Elliott SS, Keim NL, Stern JS, Teff K, Havel PJ. Fructose, weight gain, and the insulin resistance syndrome. Am J Clin Nutr 2002;76(5):911-922.

[45] Karen L. Teff, Sharon S. Elliott, Matthias Tschöp, et al. Dietary Fructose Reduces Circulating Insulin and Leptin, Attenuates Postprandial Suppression of Ghrelin, and Increases Triglycerides in Women. J Clin Endocrinol Metab. 2004;89(6):2963-72.

[46] Parks EJ, Skokan LE, Timlin MT, Dingfelder CS. Dietary Sugars Stimulate Fatty Acid Synthesis in Adults. Journal of Nutrition 2008;138:1039-1046.

[47] Bocarsly ME, Powell ES, Avena NM, Hoebel BG. High-fructose corn syrup causes characteristics of obesity in rats: Increased body weight, body fat and triglyceride levels. Pharmacol Biochem Behav. 2010;97(1):101-106.

[48] Cancer cells slurp up fructose, US study finds. Reuters. 2010, Aug 2. Retrieved on January 18, 2012 from http://www.reuters.com/article/2010/08/02/cancer-fructose-idAFN0210830520100802.

[49] Fructose intolerance?  NUTRAingredients-usa.com. 2003 13-Oct. Retrieved on January 18, 2012 from http://www.nutraingredients.com/content/view/print/9794.

[50] Willems JL, Low NH. Major carbohydrate, polyol, and oligosaccharide profiles of agave syrup. Application of this data to authenticity analysis. J Agric Food Chem. 2012 Sep 5;60(35):8745-54.

[51] Figlewicz DP, Ioannou G, Bennett Jay J, Kittleson S, Savard C, Roth CL. Effect of moderate intake of sweeteners on metabolic health in the rat. Physiol Behav. 2009 Dec 7;98(5):618-24.

[52] Phillips KM, Carlsen MH, Blomhoff R. Total antioxidant content of alternatives to refined sugar. J Am Diet Assoc. 2009 Jan;109(1):64-71.

[53] Farnum K. Whole  Food: Brown  Rice  Syrup. University of Washington. 4/2012. Retrieved April 13, 2014 from http://depts.washington.edu/nutr/student_projects/dietetic/WholeFoods/2012/Brown%20Rice%20Syrup_2012.pdf.

[54] Holtcamp W. Suspect sweetener: arsenic detected in organic brown rice syrup. Environ Health Perspect. 2012 May;120(5):A204.

[55] Jackson BP, Taylor VF, Karagas MR, Punshon T, Cottingham KL. Arsenic, organic foods, and brown rice syrup. Environ Health Perspect. 2012 May;120(5):623-6.