Artificial Sweeteners: Options for Chronic Kidney Disease Patients

Today, products with artificial sweeteners are more prevalent in grocery stores, restaurants, and offices. The use of artificial sweeteners and sugar substitutes is on the rise in everyday foods, and nephrology dietitians must be able to recommend products appropriately to patients with chronic kidney disease (CKD) or those on dialysis. Almost any food item on the shelf can be produced with an artificial sweetener, e.g., diet sodas, jams, and yogurts.1, 2, 3 Because of the significant range of foods that include artificial sweeteners, reading the ingredients is essential.

Replacing sugar with artificial sweeteners is simple and beneficial to patients. An artificial sweetener provides sweetness without adding calories, elevating blood sugar, or promoting dental caries. Because the substitutes are much sweeter than sugar (200 to 13,000 times sweeter), a smaller quantity may be used to achieve the same sweetness.1, 2

The Food and Drug Administration (FDA) approves and regulates the use of artificial sweeteners, and establishes their “acceptable daily intake” (ADI). The ADI is the maximum safe quantity consumed each day over a lifetime.2, 4 Five artificial sweeteners have been approved by the FDA.1 The focus of this Product Update involves the artificial sweeteners that are generally recognized as safe by the FDA,4 and their use by CKD patients.

Table 1 provides a catalog of the five artificial sweeteners generally recognized as safe by the FDA, to help familiarize clinicians with sugar substitutes' brand names, background information, food products, contraindications, and potassium content.1, 2, 3, 4, 5, 6

Table 1. FDA Approved Artificial Sweeteners

	Artificial Sweetener	Brand Name	Background Information	Food Products	Contraindications	Benefits	Calories	Potassium	Manufacturer and Address	Websites
	Acesulfame-K	Sunett, Sweet One	Calorie free; 200 times sweeter than sugar	Carbonated beverages, noncarbonated beverages, fruit juices, beverage concentrates, alcoholic beverages, tabletop sweeteners, dairy products, ice cream, desserts, gelatins, fruit and vegetable preserves, jam, jelly, marmalade, baked goods, confectionery, chewing gums, marinated fish, toothpaste, mouthwash, pharmaceuticals, yogurt, milk products, breakfast cereals, processed fruits and vegetables, salad dressings and sauces, condiments, relishes, snack foods, soups, and vitamins. Also found in Prostat Renal Care.	Generally recognized as safe; patients with kidney disease should limit potassium intake.	Does not affect blood sugar. Can be used in baking and cooking. The body cannot break it down during digestion; therefore, it is excreted from the body unchanged.	0/packet	10 mg/packet	Sweet One, Stadt Holdings Corp., Department WS, 60 Flushing Ave., Brooklyn, NY 11205.Sunett, Celanese Corp., Nutrinova, Inc., 1601 West LBJ Freeway, Dallas, TX 75234-6034.	http://www.sweetone.com/ http://www.celanese.com/index/productsmarkets_index/products_markets_food_ingredients/food_ingredients_products/food_ingredients_products_sunett.htm
	Aspartame	Equal, NutraSweet	Similar caloric value of sugar however; 200 times sweeter, so intake value is equivalent to calorie-free.	Tabletop, chewing gum, breakfast cereal, soft drinks.	Persons with phenylketonuria, a metabolic disorder that prevents a person from metabolizing phenylalanine, should not consume aspartame. Aspartame breaks down into aspartic acid and phenylalanine in the body and therefore, a restriction is imposed.	Does not affect blood sugar. Provides 4 calories per gram; however, sweetness is highly concentrated and quantities generally used make the caloric content insignificant. Perceived as a sweet flavor without an aftertaste.	0/packet	0 mg/packet	Equal, Merisant, 33 North Dearborn St., Suite 200, Chicago, IL 60602.NutraSweet, NutraSweet Co., 10 S. Wacker Dr., Chicago, IL 60606.	http://www.equal.com/home.html http://www.nutrasweet.com/
	Neotame		Calorie-free; 7000–13,000 times sweeter than sugar.	Baked goods, soft drinks, chewing gum, frosting, frozen desserts, jams, jellies, gelatins, puddings, processed fruit and fruit juices, toppings, syrups.	Structurally similar to aspartame. However, potential release of phenylalanine is limited; no warning is necessary.	Does not affect blood sugar. Can be used in baking and cooking.	0/packet	0	NutraSweet, NutraSweet Co., 10 S. Wacker Dr., Chicago, IL 60606.	http://www.neotame.com/
	Saccharin	Sweet'N Low, Sweet Twin, Necta Sweet	Calorie free; 200–700 times sweeter than sugar	Tabletop, chewing gum, soft drinks, baked goods, jams	Pregnant women are instructed to avoid saccharin because it can cross the placenta.	Does not affect blood sugar. Heat does not affect sweetness. Stable molecule: prolongs shelf-life of food products.	0/packet	0	Cumberland Packing Corp., 2 Cumberland St., Brooklyn, NY 11205.	http://www.sweetnlow.com/
	Sucralose	Splenda	Calorie-free; 600–700 times sweeter than sugar.	Approved as a general purpose sweetener in all foods, including tabletop, beverages, chewing gum, frozen desserts, fruit juices, and gelatins.	Generally recognized as safe.	Does not affect blood sugar. Easy for baking and cooking. The FDA concluded that there are no toxic or carcinogenic effects.	0/packet	0	McNeil Nutritionals, LLC, Ft. Washington, PA.	http://www.splenda.com/index.jhtml

Knowing the benefits of artificial sweeteners is advantageous because a significant number of patients with CKD have diabetes mellitus. Artificial sweeteners are a great option to sweeten foods because they do not affect blood sugar.1, 2 In fact, the National Kidney Foundation's guide, Planning for Emergencies, A Guide for People With Chronic Kidney Diseases, recommends purchasing an artificial sweetener as part of an emergency diet plan.7, 8

Although much speculation surrounds the thirst mechanism and artificial sweeteners, no peer-reviewed studies support claims indicating that sugar substitutes increase thirst. Further, current research does not identify any health risks associated with the consumption of the five approved artificial sweeteners for people with CKD.1, 5, 7 Nevertheless, because Acesulfame-K provides 10 mg of potassium per packet, it is essential to measure its consumption.

Although it is important to use artificial sweeteners in moderation, the American Dietetic Association's position is “that consumers can safely enjoy a range of nutritive and nonnutritive sweeteners when consumed in a diet that is guided by current federal nutrition recommendations, such as the Dietary Guidelines for Americans and the Dietary References Intakes, as well as individual health goals.”1

There are five primary artificial sweeteners, along with countless foods made with artificial sweeteners. Therefore, it is essential for dietitians and patients alike to be cognizant of their choices when selecting foods. For more information on artificial sweeteners, please see these Websites of interest: www.fda.gov, www.eatright.org, www.cancer.gov, http://www.acesulfamek.org/, http://www.aspartame.org/.