Alternative sweeteners. My kids aren’t big water drinkers despite my biggest efforts. So I buy them flavored water. I buy different types and brands. Some have stevia, Splenda, and monk fruit. Even some of the dole brand packaged fruit cups have monk fruit. (I know real fruit is best but I buy convenience foods on occasion for, well, convenience.) Are these safe?


There are a variety of alternative sweeteners that food producers, chefs, and consumers utilize as substitutes for regular, refined table sugar. Denise Mann and Louise Chang, M.D.  explain why they are so popular:

Artificial sweeteners, also called sugar substitutes, are compounds that offer the sweetness of sugar without the same calories. They are anywhere from 30 to 8,000 times sweeter than sugar and as a result, they have much fewer calories than foods made with table sugar (sucrose). Each gram of refined table sugar contains 4 calories. Many sugar substitutes have zero calories per gram.


For people who are sugar- or calorie-conscious, sugar substitutes seemingly serve a role for those who want to lose weight or control their diabetes better. However, recent studies contradict the conventional wisdom that artificial sweeteners are useful aids in weight and diabetes management. Instead, there is research that suggests that artificial sweeteners disrupt intestinal bacteria and the microbiome enough to detrimentally affect the body’s metabolism of sugar, paradoxically leading to weight gain and abnormal blood sugar levels.

Alternative sweeteners for foods and beverages can be divided into four categories: natural sweeteners, artificial sweeteners, sugar alcohols, and novel sweeteners:


Natural Sweeteners — While “natural” products may be better than synthetic ones, many natural sweeteners are processed to some degree. For example, adding enzymes and heat to the sap of the agave cactus produces agave nectar. High fructose corn syrup is a natural sweetener that is derived from corn; molasses comes from refining cane sugar; monk fruit extract comes from an Asian fruit, has no calories, and is commonly used in Chinese foods and medicines. Other natural sweeteners include honey and maple syrup which, like other natural sweeteners such as fruit juice concentrates, coconut sugar, and date sugar, contain considerable calories.

Artificial Sweeteners — Examples of these non-nutritive (zero-calorie) synthetic sugar substitutes include acesulfame potassium (“Sunett”/”Sweet One”), aspartame (“Equal”/”NutraSweet”), neotamesaccharine (“SugarTwin”/”Sweet’N Low”), and sucralose (“Splenda”).  Artificial sweeteners have been scrutinized for decades regarding adverse health effects. In the 1970’s, saccharine earned a warning label after studies linked its use to bladder cancer. More recent research has found no such association with saccharine, or any other synthetic artificial sweeteners, and cancer, and so the warning label has since been removed. Furthermore, other studies have been unable to link any adverse health effects, including impacts on the immune system, to artificial sweeteners.

Sugar Alcohols — As a group, these sugar substitutes have fewer calories and are less sweet than regular table sugar. Sorbital and xylitol are commonly added to processed foods (especially diet foods) to increase sweetness. One benefit of these sweeteners is that they do not cause tooth decay so they are commonly used as flavoring in sugar-free chewing gums. While demonstrated to be safe in humans, sugar alcohols have been known to cause diarrhea when intake is high. Xylitol is highly toxic to dogs.

Novel Sweeteners — “Truvia” and “Pure Via” are zero-calorie sugar substitutes which are derived from leaves of the stevia plant. Tagatose (“Naturlose”) and Trehalose are other novel sweeteners.


Addressing safety issues regarding sugar substitutes requires us to take into account how much and how often they are consumed. It appears that the use of alternative sweeteners is safe in adults when used in moderation. When it comes to children, however, there are few studies that either confirm or call into question the safety of these food and beverage additives. As mentioned above, the jury is still out as to whether artificial sweeteners affect the gut’s microbiome in such a way as to cause harm.

Generally speaking, the American diet is a very sweet one. Added sugar is a key component of processed foods and is linked to the current obesity epidemic in the United States and around the world. As we’ve seen previously on The PediaBlog, the sugar content of our diet has significant health consequences, especially among children. We would really do our children (and ourselves) a favor by eating less processed foods and snacks laden with added sugar, and fewer sugar-sweetened beverages.

Some children don’t like their beverages unsweetened. As a result, parents may use various products, including fruit juices, to sweeten water, which later results in adults who don’t like their beverages unsweetened. This is certainly a major reason why Americans have acquired such a sweet tooth.

For most foods, a good rule of thumb parents should keep in mind is that if you serve it long enough, kids will accept it. The same holds true with regular, unsweetened water. Kids might not like it at first, but if you give them the choice of water or nothing, they will eventually come around and drink it. They may whine — even flip out — but they will, in time, accept it (and, also in time, probably prefer it). Sweetening water with sugar, juices, or artificial sweeteners is just asking for trouble as kids get older.



***Do you have a non-urgent, clinical or otherwise (but nothing personal!) question for your Pediatric Alliance doctor or provider? Send an email with your questions to and we’ll do our best to answer them and post them on The PediaBlog. You don’t have to include your child’s name, but an idea of their age is helpful. Also, please include the name of the division you go to and your doctor’s or provider’s name.

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