This might be one of my favorite blog posts to date, partly because I’m always getting asked about the safety of artificial sweeteners, non-nutritive sweeteners, and sugar alcohols, especially their impact on the gut microbiome. I’m excited to enlighten you on the safety, impact to the gut microbiome, as well as impacts on your weight, fertility, mood, and so much more.

I could have spent an entire semester of graduate school digging into this topic for the time I’ve spent combing through the research on these sweeteners. As a nutrition nerd and Registered Dietitian, it’s actually been fun and I’m looking forward to sharing all the information I dug up with you.

We’ve all heard that sugar doesn’t have many beneficial impacts to our health. I want to be clear when I’m talking about “sugar” I’m referring to refined sugar sources such as table sugar and high fructose corn syrup. I’m not referring to the natural sugars found in complex carbohydrates like fruit, vegetables, and whole grains. The long-term high levels of sugar consumption can lead to weight gain and elevated risk for some of the most common chronic disease, including metabolic syndrome, type 2 diabetes, cardiovascular disease, liver disease, dementia, and Alzheimer’s disease.

Yet, it’s hard to deny the “yum factor” that sugar offers us, as well as it’s ubiquitous presence throughout our food system. As humans, we’re biologically wired to enjoy and seek out sweet tasting things, especially during times of hunger or stress. Sugar offers us a substance that is highly rewarding for our brains and in some cases, our energy levels, but is also a substance that can accelerate disease and mortality.

A seemingly reasonable solution to this conflict of enjoying sweet tasting food and adverse health consequences would be artificial/non-nutritive sweeteners and other sugar substitutes, which are a class of compounds that offer us a sweet taste without the calories.

It makes sense why these sugar substitutes are so popular. If you look at the food industry as a whole, it’s booming with low carb paleo and keto products. To make that food more palatable without introducing carbohydrates, companies are adding in these sugar substitutes to many foods across the industry. While these sugar substitutes are prolific throughout our food system, they are controversial and don’t come without any consequences.

In this blog post, I’ll share the research to provide you with unbiased and evidence-based education on these sugar substitutes. I will also share my professional and personal experience with these sugar substitutes in working with many different patients and clients as a Registered Dietitian. This is not about labeling these sweeteners as “good” or “bad,” but more about informing you what they are and how they interact in our body so you can be a more informed consumer.

Personally, I tend to steer away from products that contain these sugar substitutes because I know first-hand my body does not like them, and I don’t particularly enjoy the taste. However, I’d be lying if I said that I didn’t have a beverage or a bar at some point that contained stevia or monk fruit in it on occasion. I’m simply here to present the education and research around how they might be interacting with your body in a negative way, how they can impact the gut microbiome, and hopefully clear up and create awareness that if you’re struggling with health issues, then this is a topic you should have the privilege of learning about.

The History of Sugar Substitutes

So why are these sweeteners being added to food? Ira Remzon, a chemist, was credited with the discovery of saccharin in 1879, which was the first artificial sweetener. He was in his lab trying to conjure up something totally unrelated. He went home, ate a sandwich, and noticed something sweet was on his hands. It was actually by accident these artificial sweeteners were introduced to the food industry!

Artificial sweeteners are used in a variety of foods to enhance and sweeten the flavor. They’re popular because they’re minimal or zero calorie, so they don’t affect our blood glucose levels. This seems way too good to be true! For someone who is trying to manage weight or their blood sugars, this is a very attractive option. As humans, we’re also prone to overindulging on occasion. Who wouldn’t want to indulge in something sweet without the calories, and without the health implications associated with a dramatic spike in blood sugar?

The Food and Drug Administration (FDA) has approved eight artificial sweeteners to date, including Acesulfame K, Aspartame, Saccharin, Sucralose, Neotame, Advantame, Lou Hong Guo (Monk fruit), and Stevia. These are much sweeter than table sugar on a volume basis, so you only need a small amount. Because there continues to be a large public concern about how artificial food additives (including sugar substitutes) impact our health, there’s been a good amount of research done on this sugar substitutes.

The FDA regulates general food additives by first submitting them to a premarket review, unless it’s already been Generally Recognized as Safe (GRAS). If a product has been recognized as GRAS, then they’re able to go through the available scientific evidence and determine if a sugar substitute should be approved for the general population under certain conditions of use.

The FDA establishes what is called the acceptable daily intake (ADI) for these products, which is the level of these sugar substitutes that even the most sensitive person could consume on a daily basis for the rest of their life that would not cause any harm. They find the highest dietary level of an additive that has no adverse reactions in a study, then they take that number and divide it by a safety factor that is usually about 100. This leaves a much larger margin of error, which suggests they’re being very cautious. Overall, this is a good thing!

When I explain the research on each sugar substitute, I’ll be sharing the ADI based on a 130-pound person and how much that person would need to consume for a long period of time seeing health implications. For example, Stevia’s ADI is 9 packets per day. This was actually a bit shocking to me because this is relatively low compared to the other sweeteners I’ll be sharing. Some of these sugar substitutes do not yet have an ADI established.

The Science of Sugar Substitutes

We detect sweetness when sugar molecules bind to and activate sweet taste receptors T1R2 and T1R3 on the tongue, triggering neural signals leading to the perception of “sweet.” These receptors, which have multiple binding sites, can be activated by sucrose (a combination of the simple sugars glucose and fructose), by other sugars (including individual molecules of glucose and fructose), and by sugar substitute compounds. Many of these sugar substitutes bind to these receptors more strongly and tightly than table sugar does, which is why we perceive them as being significantly sweeter, in some cases by as much as 100 to 1,000 times more in order of magnitude. This allows us to use less of these sugar substitutes to achieve the same level of sweetness table sugar would provide us.

So what about how our body metabolizes sugar substitutes? We taste the sweetness of sugar substitutes in the same way we taste the sweetness of table sugar, but we do not metabolize these compounds in the same way. In the case of sucrose (which is table sugar), our bodies absorb the components in the gut, where they’re metabolized by the liver and other tissues throughout our body to provide us with energy. In contracts, zero-calorie sweeteners are either not absorbed or are absorbed but then excreted without generating energy for the body. Some sugar substitutes are considered low calories because they’re only partially absorbed or metabolized. Aspartame, a popular artificial sugar found in diet sodas, actually provides us the same number of calories as table sugar gram for gram. However, because aspartame is about 200 times sweeter than table sugar, it’s considered low calorie because it’s used in much smaller quantities than table sugar.

Let’s dive into some of the research and specifics on some of the most popular sugar substitutes.

Stevia

Stevia is a plant that is native to South America. Many people assume because Stevia is derived from a plant, it must be healthy and good for us. It’s also known as Truvia, Stevia in the raw, Sweet Leaf, and Sun Crystals. It’s about 200 to 300 times sweeter than table sugar. There has been a 25 percent increase in the number of products using Stevia between 2008 to 2017. I believe this is because many manufacturers are catering to the vulnerability of consumers to the term “natural.” When we see the term “natural” on food labels, we assume the product is healthier, but this is not always the case.

Stevia is in everything. It’s in tea, soft drinks, yogurt, granola bars, toothpaste, chewing gum, salad dressings, candy, vitamins, pharmaceuticals, cereals, and alcoholic beverages. Most of the time, when you see a product that is labeled as “Zero Sugar Added” or “Sugar Free,” it’s a warning sign for you to check the ingredient label if you’re trying to avoid these sugar substitutes.

So, what are the potential positives associated with Stevia? To start, you have the sweetness without the calories, which can help someone manage their weight and their blood sugar. And that’s about it. It’s a non-nutritive sweetener, so the list of pros for Stevia is relatively short because it doesn’t provide us with any sort of nutrition.

What are the potential cons? It’s a diuretic, so it increases the speed at which our body expels water and electrolytes through our urine. Coffee and alcohol are also diuretics. There are some studies that link Stevia to infertility. A 2021 study found that administration of stevioside, a major component of Stevia, to rats induced reactive oxygen species (ROS) production in sperm and led to sperm dysfunction. Another big concern is the impact of Stevia on our gut microbiome. There have been studies that show stevia can decrease the amount of Lactobacillus strain in the GI tract, which is a negative implication on our gut health because this strain is really important for overall human health.

Another thing to keep in mind is that Stevia supplements and extracts are being found to contain counterfeit ingredients such as maltodextrin, sodium saccharin, and aspartame. You’re not always getting pure Stevia! Processing stevia is also really complex. Companies are using methane as a way to extract Stevia rather than using ethanol to cut corners. When you use methane, you can do the extraction more quickly. The quality of the product decreases, but the company benefits from reduced manufacturing cost.

There have been reports of several adverse gastrointestinal (GI) effects such as nausea, indigestion, diarrhea, bloating, and excess gas. When my clients come to me with digestive issues, I advise limiting products that contain Stevia for this very reason. There have also been reports of people having headaches and dizziness when ingesting Stevia.

Monk Fruit

Monk fruit is a little green fruit that has been used in China for about 1,000 years. It contains zero calories and is about 10 to 250 times sweeter than table sugar. The fruit itself has long been regarded as the longevity fruit thanks to its high antioxidant content. When we use it as an artificial sweetener, it doesn’t appear to have these same favorable clinical effects. The ADI for monk fruit has not been specified at this time.

When it comes to GI health, there are the same concerns when it comes to any artificial sweetener. Symptoms include gas, constipation, and diarrhea. Like Stevia, it can also induce headaches and dizziness. Research is somewhat limited on monk fruit in comparison to Stevia.

Neotame

This sweetener is not used as often as Stevia or monk fruit. It’s about 7,000 to 13,000 times sweeter than table sugar! The ADI for neotame in the US is 18 mg/person/day. It’s a synthetic sweetener developed by Monsanto, a major herbicide and chemical producer. It’s made by adding 3-dimethyl-butyl, a chemical that the EPA lists as hazardous, to aspartame.

If an ingredient comprises less than one percent of that item, then the FDA does not require that ingredient be listed on a food label. This is one reason why food manufacturers love using neotame. They can put it in a product to develop the sweetness of a product without listing it as an ingredient. The consumer won’t even know it’s in a product they’re consuming!

Most of the research done on neotame is sponsored by Monsanto, so the controversy extends despite the FDAs assertions that both neotame and aspartame are safe to eat.

Aspartame

Aspartame, also known as Equal or Nutrisweet, is about 200 times sweeter than table sugar. It’s used in drugs like vitamins, supplements, and laxatives. The biggest concern is for people with PKU, which is a rare genetic disorder where they lack the enzyme that breaks down phenylalanine, an amino acid. The ADI for aspartame is 75 packets per day. This is a lot! If someone is consuming this much aspartame daily, I think we have an even larger concern than their consumption of aspartame.

Some studies report consumption of aspartame leads to neurological and behavioral disturbances in individuals. Many of my clients have reported migraines and headaches when they ingest aspartame. A review of aspartame’s metabolism in the human body found that aspartame breaks down into three components in the human body: methanol, aspartic acid, and phenylalanine. Although methanol further breaks down into formaldehyde, which is toxic to the human body, research has established the consumption of products containing aspartame will not lead to toxic levels of methanol because of the small amounts we normally consume.

You might ask why would we consume something that could potentially be toxic to the body? From my unbiased perspective (I’m really trying to be unbiased when presenting this research), if you drink too much water you could die. Too much of anything can be toxic to the body, regardless of what it is. Keeping things in perspective is always important when reading through scientific research.

Overall, aspartame is widely regarded as safe, but there are some doubts about its safety remaining. There are some studies showing aspartame causing inhibition of brain serotonin and dopamine, which are both really important for our mental health. Since studies on drugs that raise dopamine levels in the brain have been proven effective for headaches and migraines, it makes sense that consumption of aspartame could lead to headaches and migraines in sensitive individuals. Based on this research, if you’re someone who suffers from headaches or migraines, you should consider checking the labels of your food and avoiding aspartame.

Acesulfame-K

You will see Acesulfame-K being sold as Sunnet and Sweet One. This is generally used in combination with other artificial sweeteners. This is often used in sugar free sodas, so please be mindful of reading those ingredient labels. Research is limited on this artificial sweetener.

Saccharin

This is the oldest artificial sweetener on the market and is often found in a pink packet. It’s about 200 to 700 times sweeter than table sugar. The ADI is 45 packets per day. In the early 1970s, saccharin was linked with bladder cancer in lab rats. The FDA tried to ban it, which led to congress mandating additional studies for saccharin and the addition of warning labels on the product until the warning could be shown to be unnecessary. Since then, more than 40 human studies have shown the results found in rats were not relevant to humans and that saccharin in safe for human consumption.

In 2000, the National Toxicology Program of the National Institute for Health concluded that saccharin should be removed from the list of potential carcinogens. Products containing saccharin no longer have to carry that warning label.

Sucralose

Sucralose is also known as Splenda and Equal. People often use this product for baking and is commonly found in baked goods, canned goods and syrups on the market. It’s about 600 times sweeter than table sugar. It’s often found in the yellow packet. The ADI is 23 packets daily.

I actually found sucralose hiding in a can of baked beans with the label on the front reading “low sugar.” If there’s anything you take away from this article, let it be that you read those ingredient labels!

Advantame

This is the newest artificial sweetener on the market that has been approved by the FDA. It’s about 20,000 times sweeter than table sugar!! Wow!! I can’t begin to fathom what that would taste like. It’s not commonly used at this time. The ADI is 32.8 packets per day.

Effects to The Brain

Anecdotally, I’ve heard many of my clients mention they don’t find these sugar substitutes very satisfying. The research is clear that sugar substitutes don’t drive intake preferences, motivate consumption, or trigger satiation in the way that table sugar is capable of doing. Human studies have shown that sucralose (Splenda) results in significantly less activation of the brain’s reward circuitry than table sugar.

While all sweeteners share the ability to bind to our sweetness receptors in our mouth and our gut, a glucose transporter known as SGLT1 (sodium-glucose co-transporter 1) is more specific to glucose. Recent research has shown SGLT1 is critical for the transmission of post-ingestive sugar signals from the gut to the areas of the brain involved in driving sugar preference and motivating sugar intake. In essence, this is showing us that no matter how much we boost the sweetness of foods with this sugar substitutes, they will never satisfy our innate biological craving for sugar.

There was a study published showing a connection between consumption of diet sodas and drinks made with artificial sugars with a higher risk of depression in adults. If you suffer from mental health issues, I would highly recommend looking at how much off these sweeteners are in your diet.

Effects to the Gut Microbiome

These sugar substitutes are not absorbed in our upper GI tract the way table sugar or natural sugars are absorbed. When they reach the lower GI tract, or our colon, our gut microbes cleave off the glucose molecules and use them as an energy source. This is why it’s such a concern if you have gut health issues.

If we know for a fact these artificial sweeteners are making their way to the digestive tract that sugar normally wouldn’t be going to, then they’re definitely going to have an impact on our gut health. Is that impact positive or negative? In my professional opinion, it depends on the person and their overall diet. For some people who don’t regularly consume fruits and vegetables that contain beneficial fiber to feed our gut bacteria, maybe this could be a good thing. However, I would argue the glucose from the artificial and non-nutritive sweeteners may not be a preferable fuel source option for our gut microbiota.

We know for a fact that gut health has to be optimal in order to maintain a healthy immune system and healthy metabolism. Multiple studies in animals suggest artificial sweeteners exert measurable effects on our gut microbiome. However, impacting the microbiome might not be a bad thing for everyone. Regardless, as a Registered Dietitian, I still prefer that someone get their fiber or probiotics from food versus consuming these artificial sweeteners because we know there’s nutritional value to those foods verses artificial sweeteners which offer us no nutritional value.

Suez et. al. assessed the effect of artificial sweeteners on the human body in an observational study of 381 non-diabetic humans who reported regular consumption of artificial sweeteners. They used a Food Frequency Questionnaire (FFQ), which does have its limitations because you’re relying on self-reported data. They observed a correlation between non-nutritive sweetener consumption and an increase in central obesity, fasting blood glucose levels, hemoglobin A1c, glucose tolerance test, and alanine amino transferase, which are all negative things. There were 172 randomly selected individuals from this study which showed intestinal microbial changes characterized by an increase in certain gut bacteria which would be associated with negative health implications.

A study from the Institute of Microbiology and Biotechnology found that stevia kills a large number of the lactobacillus strains, which are beneficial for our overall health. It’s important to note when we’re doing studies in rats, we’re giving them much larger doses of these artificial sweeteners than the ADI. In 2014, a landmark study by Suez et al. provided definitive evidence that non-nutritive sweeteners caused alterations in the mouse microbiome, which secondarily drove the development of glucose intolerance. As in previous studies, the authors reported that experimental groups taking artificial sweeteners (specifically, saccharin, aspartame, and sucralose) became glucose intolerant and had altered microbiome compositions, while table sugar- and water-treated control groups did not exhibit either of these effects.

Whether in rats, mice or humans, the diet-induced changes in microbiome species composition tend to be fairly rapid. But for humans, many of the downstream effects of these changes on host health and metabolism may take months or years to compound to a level that they become measurable or clinically relevant.

This presents challenges for studying the long-term implications of sweetener-induced microbiome effects in human populations, as the independent variable of microbial composition is likely to change on far shorter timescales than the dependent variables, such as our risk for developing Type 2 Diabetes. Research is still in the early stages of understanding the gut microbiome’s complex and varied interactions with human hosts, but animal data certainly implicate it as a likely pathway through which sugar substitutes might result in metabolic dysfunction.

Sugar Substitutes and Metabolic Health

So what about research related to metabolic health? Studies have shown short term weight loss, but they’re lacking any long-term results. There has been a positive dose relationship between artificial sweeteners and long-term weight gain. Such an association does not establish causality, but it does highlight artificial sweeteners can be associated with weight gain. We should also consider that someone who regularly orders a diet beverage with their meal, may also still be consuming other food sources that are more energy-dense (calorie dense).

A systematic review found the balance of evidence that use of these sweeteners in place of sugar in children and adults could lead to reduction in energy intake and body weight. It could be that people are getting the sweetness they’re craving, so they end up eating less and therefore losing weight.

There’s also some research showing that stevia and monk fruit could be beneficial for managing diabetes and controlling blood sugar and weight. There are a few different mechanisms that could be happening here. It could be related to the alterations in their gut microbiome or the fact that they are simply consuming less calories or that they’re not having the insulin stimulation you typically would if you ingest carbohydrates.

When compared to consumption of foods or beverages sweetened with table sugar, consumption of foods and beverages sweetened by sugar substitutes have been reported to improve glycemic control, such as postprandial (after a meal) glucose and insulin levels. In contrast, when control groups are given water or other unsweetened products as a placebo, experimental groups given sugar substitutes tend to exhibit glycemic control that was poorer than or comparable to that of controls by the end of the intervention period.

These results suggest that sugar substitutes have metabolic benefits when used to replace table sugar or other calorie-providing sugars that would otherwise have been consumed, but may have the opposite effect when used in addition to whatever sweeteners or sugars would normally be present in the diet. In other words, for someone who routinely drinks a couple of cans of regular Coca-Cola every day, switching to a couple of cans of Diet Coke might improve metrics of glucose metabolism, but for someone who drinks soda water at baseline instead of Coca-Cola, switching to an artificially sweetened beverage may actually be harmful.

What About Sugar Alcohols?

Sugar alcohols are a type of carbohydrate also known as polyols which are added as sweeteners and bulking agents to foods. They’re naturally occurring in foods but most of them are manufactured in a lab. They include erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, and hydrogenated starch hydrolysate.

We typically find these in products that are labeled sugar free, low sugar, diabetic friendly, low carb, paleo, or keto. You can find these hiding in so many different foods and products in the grocery store, so here I am yet again reminding you to read those labels!

The biggest concern when it comes to gut health is these sugar alcohols are polyols. They are the P in low FODMAP. For someone who is following a low FODMAP diet to support symptoms related to IBS, ingesting high amounts of these sugar alcohols can further exacerbate your symptoms because they’re poorly digested.

This sugar alcohols do contain some calories when ingested, but they’re lower calorie than sugar. Some of the pros of these include these sugar alcohols contain less calories per gram than sugar, they don’t contribute to tooth decay the way sugar does, they add a favorable texture to foods, and they can offer a way for someone with diabetes or blood sugar issues to still enjoy a sweet treat without impacting their blood sugar.

When you eat too many of these sugar alcohols, they are likely to cause gas, stomach pains, and diarrhea. They can produce a laxative effect in the body. In addition, some of these sugar alcohols are often made from genetically modified corn. All of the sugar alcohols are highly refined, so keep this in mind when consuming these products.

When it comes to gut health, sugar alcohols have the potential to disrupt the lining of our gut. The body’s inability to breakdown the sugar alcohols is what causes them to arrive to the colon, just like the non-nutritive sweeteners. At that point, the process of passive diffusion occurs. The sugar alcohols draw water into our colon, which is why they have that laxative effect. This results in only partially breaking down the sugar alcohol. The unmetabolized part of it begins to rot/ferment, creating the perfect environment for undesirable bacteria to feed and grow.

To Summarize

While all these artificial sweeteners, sugar alcohols, and non-nutritive sweeteners have been generally recognized as safe, there’s no rigorous long-term studies that have been performed to date. In my professional opinion as a Registered Dietitian, all refined food products should be limited in our diet, especially if you’re actively healing an inflamed gut or suffering from any chronic illness.

Some people might argue with me that we have rising cases of diabetes and obesity in the United States, and it’s possible that a zero-calorie sugar alternative that carries some risk might be a healthier alternative to sugar. I hear this opinion, but at the same time, we’ve seen a rise in these products over the past decade, yet the obesity and diabetes rates have not declined as a result.

I prescribe to moderation when it comes to anything nutrition related. I agree with the United States Dietary Guidelines for America, which advises limiting added sugars to less than 10 percent of our daily calories. We’re human, and we will find ourselves enjoying sugar, but we should be mindful of how much we’re consuming.

I hope you found this article on sugar substitutes enlightening. My goal is for you to create your own opinion on how and when you’d like to consume products with these sugar substitutes in them based on the scientific evidence. Feel free to reach out to me with any follow-up questions!

References

Warner DJ. Ira Remsen, saccharin, and the linear model. Ambix. 2008;55(1):50-61. doi:10.1179/174582308X255415

Dolan DG, Naumann BD, Sargent EV, Maier A, Dourson M. Application of the threshold of toxicological concern concept to pharmaceutical manufacturing operations [published correction appears in Regul Toxicol Pharmacol. 2006 Mar;44(2):189]. Regul Toxicol Pharmacol. 2005;43(1):1-9. doi:10.1016/j.yrtph.2005.06.010

Arumugam B, Subramaniam A, Alagaraj P. Stevia as a Natural Sweetener: A Review. Cardiovasc Hematol Agents Med Chem. 2020;18(2):94-103. doi:10.2174/1871525718666200207105436

Minamiyama Y, Takemura S, Ichikawa H. Food additive-induced oxidative stress in rat male reproductive organs and hippocampus. Arch Biochem Biophys. 2021;701:108810. doi:10.1016/j.abb.2021.108810

Kasti AN, Nikolaki MD, Synodinou KD, Katsas KN, Petsis K, Lambrinou S, Pyrousis IA, Triantafyllou K. The Effects of Stevia Consumption on Gut Bacteria: Friend or Foe? Microorganisms. 2022 Mar 30;10(4):744. doi: 10.3390/microorganisms10040744. PMID: 35456796; PMCID: PMC9028423.

Gerasimidis K, Bryden K, Chen X, et al. The impact of food additives, artificial sweeteners and domestic hygiene products on the human gut microbiome and its fibre fermentation capacity. Eur J Nutr. 2020;59(7):3213-3230. doi:10.1007/s00394-019-02161-8

Shivani, Thakur BK, Mallikarjun CP, et al. Introduction, adaptation and characterization of monk fruit (Siraitia grosvenorii): a non-caloric new natural sweetener. Sci Rep. 2021;11(1):6205. Published 2021 Mar 18. doi:10.1038/s41598-021-85689-2

Chattopadhyay S, Raychaudhuri U, Chakraborty R. Artificial sweeteners - a review. J Food Sci Technol. 2014 Apr;51(4):611-21. doi: 10.1007/s13197-011-0571-1. Epub 2011 Oct 21. PMID: 24741154; PMCID: PMC3982014.

Shaher SAA, Mihailescu DF, Amuzescu B. Aspartame Safety as a Food Sweetener and Related Health Hazards. Nutrients. 2023 Aug 18;15(16):3627. doi: 10.3390/nu15163627. PMID: 37630817; PMCID: PMC10459792.

Czarnecka K, Pilarz A, Rogut A, Maj P, Szymańska J, Olejnik Ł, Szymański P. Aspartame-True or False? Narrative Review of Safety Analysis of General Use in Products. Nutrients. 2021 Jun 7;13(6):1957. doi: 10.3390/nu13061957. PMID: 34200310; PMCID: PMC8227014.

Elcock M, Morgan RW. Update on artificial sweeteners and bladder cancer. Regul Toxicol Pharmacol. 1993;17(1):35-43. doi:10.1006/rtph.1993.1004

Del Pozo S, Gómez-Martínez S, Díaz LE, Nova E, Urrialde R, Marcos A. Potential Effects of Sucralose and Saccharin on Gut Microbiota: A Review. Nutrients. 2022 Apr 18;14(8):1682. doi: 10.3390/nu14081682. PMID: 35458244; PMCID: PMC9029443.

Del Pozo S, Gómez-Martínez S, Díaz LE, Nova E, Urrialde R, Marcos A. Potential Effects of Sucralose and Saccharin on Gut Microbiota: A Review. Nutrients. 2022 Apr 18;14(8):1682. doi: 10.3390/nu14081682. PMID: 35458244; PMCID: PMC9029443.

May CE, Rosander J, Gottfried J, Dennis E, Dus M. Dietary sugar inhibits satiation by decreasing the central processing of sweet taste. Elife. 2020;9:e54530. Published 2020 Jun 16. doi:10.7554/eLife.54530

Guo X, Park Y, Freedman ND, et al. Sweetened beverages, coffee, and tea and depression risk among older US adults. PLoS One. 2014;9(4):e94715. Published 2014 Apr 17. doi:10.1371/journal.pone.0094715

Deniņa I, Semjonovs P, Fomina A, Treimane R, Linde R. The influence of stevia glycosides on the growth of Lactobacillus reuteri strains. Lett Appl Microbiol. 2014;58(3):278-284. doi:10.1111/lam.12187

Pang MD, Goossens GH, Blaak EE. The Impact of Artificial Sweeteners on Body Weight Control and Glucose Homeostasis. Front Nutr. 2021;7:598340. Published 2021 Jan 7. doi:10.3389/fnut.2020.598340

Wilk K, Korytek W, Pelczyńska M, Moszak M, Bogdański P. The Effect of Artificial Sweeteners Use on Sweet Taste Perception and Weight Loss Efficacy: A Review. Nutrients. 2022;14(6):1261. Published 2022 Mar 16. doi:10.3390/nu14061261

Tobiassen PA, Køster-Rasmussen R. Substitution of sugar-sweetened beverages with non-caloric alternatives and weight change: A systematic review of randomized trials and meta-analysis. Obes Rev. Published online October 25, 2023. doi:10.1111/obr.13652

Mejia E, Pearlman M. Natural Alternative Sweeteners and Diabetes Management. Curr Diab Rep. 2019;19(12):142. Published 2019 Nov 21. doi:10.1007/s11892-019-1273-8