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Sugars and Sweeteners: Their Health Effects, Compared

Written by Dr. Michael Ruscio, DC on September 6, 2024

Written by Dr. Michael Ruscio, DC on September 6, 2024 — Reviewed by Hannah Wright

Which Sugars and Sweeteners are Best and Worst For Your Health?

• Pros & Cons|
• Whole-Food Sugars|
• Unrefined Natural Sugars|
• Natural Bulk Sweeteners|
• Refined Sugars|
• Nonnutritive Sweeteners|
• How Much is Too Much?|
• Sugars and Sweeteners in Popular Diets|
• The Bottom Line|

As humans, we have a natural preference for sweet flavors. Human breast milk is higher in lactose (a sugar found in milk) than other animal milks (like cow and goat), and studies have found newborns exhibit a stronger sucking response when given pacifiers flavored with sucrose (white table sugar) 1. It makes sense from an evolutionary standpoint as sugar tends to equal energy-dense (or calorie-dense), and these types of foods likely improved the odds of survival for early humans. But with the average American adult consuming 22 teaspoons of added sugar every day, have we gone too far 2?

Sugars and sweeteners of all kinds have recently been in the spotlight, and many healthcare professionals and influencers recommend avoiding them (even natural sugar from fruit) at all costs. Yet not all sugars and sweeteners are equal. While there’s no doubt that excess sugars and sweeteners can have negative health effects, it’s important to view these in the right context 3.  Research suggests consuming too many artificial sweeteners and refined and added sugars may negatively affect your health, but unrefined sugar and whole foods that contain natural sugars do have health benefits 4 5 6 7 8.

In this article, I’ll compare and share the facts about the five types of sugars and sweeteners, including what the research says about the pros and cons as they relate to health, and how they compare to each other. I’ll also dive into how some popular dietary patterns compare when it comes to sugars and sweeteners, and explain why it’s important to strive for balance in your dietary approach. Let’s get started with an overview of the different sugars and sweeteners.

What are Sugars and Sweeteners?

While we don’t want to consume any sugars or sweeteners in excess, they’re not all the same. They all have different effects on the body, so I want to group sugars and sweeteners into five general categories, and then summarize what the research says about each with regard to gut health, inflammation, metabolism and blood sugar, and overall health.

Here’s a chart detailing the five different groups, common examples, and their health-related pros and cons:

As you can see, there are a wide variety of sugars and sweeteners to choose from. Whole-food sugars, unrefined sugars, and bulk sweeteners all have evidence of health benefits, but whole-food sugars are the only group with no obvious detrimental impact. Added sugars (meaning sugars that aren’t naturally present in a food) make foods and beverages sweeter, but they also come with potentially negative health consequences. 

Sugars and Sweeteners: Compared

Before we get into the specifics of each, let’s take a look at how each type of sugar and sweetener stacks up in several key areas and overall health:

As you can see, whole food sugars are the only category with beneficial impacts in all of these areas of health. Unrefined natural sugars may have beneficial effects overall when consumed in moderation. Natural sugar alcohols may have a detrimental impact on gut health, but beneficial or neutral effects when it comes to inflammation, blood sugar, and overall health. Nonnutritive sweeteners may be beneficial for blood sugar, but may have other detrimental health effects,. And refined sugars definitely negatively impact blood sugar control, and possibly contribute to poor gut health, and poor overall health. Now let’s take a closer look at each category and further review what the research says about how they may affect your health.   

Whole-Food Sugars and Health

Whole-food sugars simply refer to the natural sugars that are found in fruits, vegetables, and dairy products. This group is the only category of sugars that have beneficial effects on gut health 4, inflammation 6, metabolism and blood sugar control 5 9 25 26, and overall health 10 27 28. 

Along with natural sugar, these types of foods provide valuable nutrients, water, and fiber, so they’re generally good for you when consumed in the context of a balanced diet 2. In fact, a meta-analysis of 82 randomized controlled trials found eating more than 3 servings of fruits and vegetables per day can improve triglycerides, blood pressure, and cholesterol levels (all of which impact cardiovascular disease risk) 27. And observational studies have found people who eat at least 5 servings of whole fruits and non-starchy vegetables each day have a reduced risk of death from all causes 28.

Part of the benefit may be related to plant tissues themselves, like fiber, which may limit the amount of sugar we can absorb from these foods 10. But the health benefits of fruits and vegetables may also be due to favorable effects on gut health, inflammation, and metabolic health. Here’s what randomized controlled trials have found:

• Gut health – people who eat higher amounts and varieties of fruits and vegetables seem to have favorable shifts in their gut bacteria when compared to those who eat less 4 29.
• Inflammation – overweight and obese people who increased whole grains, fruits, and vegetables improved their metabolic parameters and inflammation when compared to people eating refined grains 6.
• Metabolic health and blood sugar control – people with type 2 diabetes who ate bananas (up to 4 medium bananas) for breakfast for 12 weeks experienced no negative blood glucose and cholesterol effects. And people with high cholesterol had better blood sugar and cholesterol levels 5. Other studies have found eating an apple before meals may improve the glycemic response in people with impaired blood sugar, and apples can also improve LDL cholesterol in healthy people 9 25 26.

The point I want to make here is that the current messaging from some influencers and healthcare practitioners discourages patients with diabetes, obesity, and cardiovascular disease from eating whole-food sources of sugar like fruits when the research clearly doesn’t support this. On the contrary, the sugar found in these whole foods seems to have no negative health impact, and when you eliminate these foods, you’re missing out on their awesome health benefits 28. Now let’s move on to the options for added sugars in the diet.

Unrefined Natural Sugars and Health

Unrefined natural sweeteners like honey, date palm, and coconut sugar haven’t been highly processed like refined sugars have. These types of sugars contain polyphenols that act as antioxidants, and they’ve been found to reduce disease-causing bacteria in the mouth when compared to refined grains and sugars, which may be protective against tooth decay 7. Interestingly, honey may have prebiotic-like effects—boosting good gut bacteria, but we need more human studies to know for sure 30.

These possible benefits don’t mean you can consume unlimited amounts, though. Unrefined sugars are still considered added sugars, and they may be easier to absorb than sugars that are found in whole foods. In excess, these types of sugars may contribute to metabolic dysregulation, weight gain, and obesity 10.

Natural Bulk Sweeteners and Health

Natural bulk sweeteners are typically sugar alcohols like xylitol and erythritol. They are about as sweet, or slightly less sweet, than refined white sugar. They’re normally used as preservatives, but they’re also food additives that provide bulk and texture. These sweeteners have become popular since they can reduce the caloric content of a food or beverage 31. For example, xylitol contains only 6% of the calories that sugar does. 

Many sugar alcohols are polyols, so they’re slowly and incompletely absorbed in the small intestine, and when eaten with other carbohydrates, their absorption is even further reduced 8. This means they have less impact on blood sugar levels, and this is why they are found in “low-sugar” and “sugar-free” products.

When it comes to gut health, some bulk sweeteners like xylitol and erythritol can have beneficial prebiotic effects on your gut microbes 8. Bulk sweeteners may slow down digestion (which can improve your absorption of nutrients), and they also increase gut hormones that signal fullness, which may be helpful for people trying to lose body weight 12 13. However, if you eat these in excess, or if you have irritable bowel syndrome (IBS), these polyols (and other sugar alcohols) can cause digestive symptoms like bloating, gas, and abdominal discomfort 8.

Other research into bulk sweeteners has found:

• Xylitol (often found in chewing gum) can reduce gum inflammation 11.
• Erythritol and xylitol may be good alternatives to refined sugars for people with obesity as they don’t appear to significantly impact glucose absorption (which is higher in this population) 32.
• Tagatose (at intakes of 45g/day) may reduce blood sugar without any side effects 31.

Overall, these types of sweeteners pose no health risks, but they’re still considered to be added sugars, so they should be limited 31.

Refined Sugars and Health

Refined and processed sugars include white table sugar and high fructose corn syrup (HFCS). Both of these get a lot of negative press, but it’s difficult to say whether these types of sugars in isolation definitely have negative health effects 17. What the research does show is when they are chronically consumed in excess, refined sugars can promote obesity 16, and possibly shift the gut microbiome to one that promotes weight gain 14. For example, drinking more sugar-sweetened beverages (which often contain high amounts of HFCS) is associated with developing metabolic syndrome 18. And one meta-analysis found sugar-sweetened beverages (like soft drinks) negatively impact body composition in kids and teens 16.

Additionally, refined sugars in excess increase:

• LDL cholesterol levels 17
• Insulin resistance 17
• Uric acid levels (higher levels are associated with disease risk) 17

Nonnutritive Sweeteners and Health

Nonnutritive sweeteners (NNS), also called sugar substitutes, have an intensely sweet taste (300–13,000 times sweeter than sucrose), have fewer calories to no calories, and they’re used in a wide variety of foods, supplements, and medicines 33. While NNS are considered to be generally safe by the Food and Drug Administration (FDA), the research on their health effects is mixed 33.  

Observational research has found high amounts of certain NNS may increase the risk of heart disease 22 33 chronic kidney disease 23, and cancer 24. But these risk relationships could be because people with these health conditions tend to consume more NNS 33. 

Other trials suggest (but can’t confirm) that consuming these sugar-free alternatives could negatively impact blood sugar. In one study, participants who consumed an NNS before eating glucose had greater blood sugar and insulin imbalances than when they didn’t consume the NNS 33 34 35. Part of the reason may be related to the effects of NNS on the gut microbiome. Healthy people who consumed NNS experienced significant changes to their fecal and oral microbiomes, which may have contributed to significantly impaired blood sugar 20. 

On the other hand, in a randomized controlled trial of healthy men, high doses of sucralose (Splenda) didn’t affect blood sugar, insulin resistance, or the gut microbiome 36. And a meta-analysis found NNS had no acute effects on metabolic or endocrine dysfunction 19.

While there are mixed results, the bulk of the evidence has found no conclusive relationship between the regular use of NNS and an array of health conditions 37. 

Now that you’ve seen the pros and cons of sugars and sweeteners, you may be wondering how much of these you can consume without negatively impacting your health. Let’s take a look at what the experts recommend.

Sugars and Sweeteners: How Much Should You Consume?

I want to make it clear that added sugars (not the natural sugars found in whole foods) are not necessary for good health 3.  But let’s face it, they do add enjoyment, and sometimes, you just need a little something sweet. While the amount of sugars and sweeteners you can tolerate is individualized, in general, the United States Department of Agriculture (USDA) recommends limiting added sugars to less than 6–10% of your daily calories 3. For reference, the average American is currently consuming around 15% of their daily calories from added sugars (mostly in the form of soda, energy drinks, and sports drinks) 2. 

To see how you stack up to this recommendation, you can use an app like Cronometer to keep track of the foods you’re eating for a few days, and this will give you an idea of how much added sugar you’re currently consuming. You can also read food labels and add up the total number of grams of added sugars you’re taking in. To determine what percentage of your calories are added sugars, use the following formula:

• Take the grams of added sugar you ate in a day and multiply by 4 (the amount of calories in a gram of sugar).
• Take that number and divide it by the total number of calories you consumed for the day.
• Multiply that number by 100 and you’ll end up with the percentage of calories from added sugar.
• Here’s an example: If you ate 20 grams of added sugar and had 2,000 calories for the day. 20 times 4 equals 80 calories from added sugar. 80 divided by 2,000 = 0.04. 0.04 x 100 = 4% of your calories that came from added sugar, which is below the limit set by the USDA.

If your intake of added sugar ends up being above 10% of your calories for the day, then it’s time to make some adjustments. When it comes to NNS, the FDA has set the acceptable daily  intake (ADI) at different levels, and it’s based on your weight. Here’s a chart of common NNS and the current recommendation. Even though NNS are low-calorie sweeteners, it’s probably best to keep these to a minimum. 

Now let’s take a look at some popular diets and what they recommend.

Sugars and Sweeteners Content of Popular Diets

If you’re following a particular meal plan, you may wonder how it stacks up against other popular plans when it comes to sugar and sweeteners.  Here’s a chart of some common meal plans and what they recommend:

As you can see, many of these plans minimize or completely eliminate artificial sweeteners and refined and added sugars. 

Limit Sugars and Sweeteners Overall

Sugars and sweeteners are pervasive in the U.S. food supply, but it’s important to understand the different types that are available in order to make informed decisions. Whole-food sugars found in milk, fruits, and vegetables are your best bet as they come along with nutrients and fiber that have a multitude of health benefits. Whole-food sugars are generally good for you when consumed as part of a balanced diet. 

When it comes to added sugars (which include refined, unrefined, NNS, and bulk sweeteners), research is clear that consuming too many added sugars is detrimental to health. Excess amounts of refined sugar increase your risk of developing cardiovascular disease, diabetes, and obesity. While unrefined natural sugars can provide some beneficial compounds like antioxidants and minerals, if consumed in excess, they can contribute to the same issues you find with refined sugars. The research on nonnutritive sweeteners is mixed, but they may not be innocuous. These types of sweeteners possibly contribute to gut microbiome shifts, which can affect disease risk. And while bulk sweeteners have some pros, they may also cause GI distress in some people. 

It’s important to remember that moderation and balance are key when it comes to sugars and sweeteners. Most healthy, whole-foods-based eating plans will cut out most added sugars and artificial sweeteners, but you don’t need to stress yourself out over having a little sugar intake here and there. Keep in mind that stress and anxiety around food tend to cause more harm than good. Focus on choosing a quality dietary pattern on the whole, and you’ll be on the right track. 

If you’d like to learn more about creating a lifestyle that supports great health, check out my book Healthy Gut, Healthy You.  If you’d like a more personalized plan, contact us at the Ruscio Institute for Functional Health.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.