Sweetener vs. Sugar for Diabetes

Spoonful of sugar vs. sweetener

I have clients with diabetes who debate sweetener vs. sugar every morning when they drink their coffee. They worry that using sweeteners will cause them to have other health problems down the road. They’ve heard rumors that sweeteners are related to weight gain or even cancer. I don’t blame them a bit for wanting to be cautious, but I do want to help them (and you) make an informed decision about whether to use sugar or sweetener if you have diabetes.

The truth is, alternative and artificial sweeteners can add a whole lot of enjoyment to an eating plan that might not otherwise be so sweet. If you have diabetes, it’s OK to use some alternative sweeteners to add a little sweetness to your diet and your life.

Sweeteners used as sugar alternatives

Each of these sweeteners has very few or no calories and can be used to replace sugar. I’ve added some comments regarding each one for your review.

  • Aspartame: The blue one. FDA-approved as a general purpose sweetener in 1966. NOT safe for people with a genetic disorder called PKU. Personally, it gives me a headache. But that’s me.

  • Acesulfame K: FDA approved as a general purpose sweetener in 2003. This sweetener is heat-stable, which means it works well in baked goods.

  • Advantame: FDA approved as a general purpose sweetener in 2014. Heat-stable, so it bakes well.

  • Monk Fruit: Monk fruit is native to southern China. Monk fruit extract varies in sweetness, depending on the crop of fruit from which it is extracted. This is my pick for a table-top sweetener, although it won’t hold up in baked goods.

  • Neotame: FDA approved as a general purpose sweetener since 2002. Not heat-stable, so it doesn’t bake well.

  • Saccharine: The pink one. Per the USFDA, “In 2000, the National Toxicology Program of the National Institutes of Health concluded that saccharin should be removed from the list of potential carcinogens. Products containing saccharin no longer have to carry the warning label.”

  • Stevia: Like Monk fruit extract, pure stevia is also Generally Recognized as Safe (GRAS). Note that crude stevia is not GRAS and is not allowed to be imported into the US.

  • Sucralose: FDA approved as a general purpose sweetener in 1999. Bakes well, since it’s also heat-stable.

What research says about sweetener vs. sugar

What if I told you that eating margarine is associated with getting a divorce in Maine?  Would you believe that eating margarine causes divorce?  No…that would be silly.  It’s true that between the years 2000-2009, margarine consumption and divorce rates in the state of Maine were correlated by more than 99%, but that doesn’t mean that one caused the other.

Research tells us that people who regularly use alternative sweeteners are heavier than people who don’t.  Sometimes, people who hear this draw the conclusion that sweeteners cause weight gain.  That’s not necessarily true.  Just like with margarine and Maine divorces, sweetener consumption is associated with higher weight, but that doesn’t mean sweetener consumption is the cause of higher weight.  It could be that people who are already heavier tend to choose alternative sweeteners because they are trying to manage their weight.

Believing that sweeteners cause weight gain is like believing that margarine causes divorce.  We just don’t have any proof of that, and it’s silly.

In 2023, World Health Organization (WHO) issued a statement recommending that everyone except people with type 2 diabetes avoid alternative sweeteners and just consume a limited amount of regular sugar. The reason? Alternative sweeteners did not promote weight loss. For people with type 2 diabetes, WHO still recommended the use of alternative sweeteners in moderation. I think this is reasonable advice. 

Do sugar-sweetened drinks cause health problems?

A high intake of sweetened drinks is associated with heart disease, but they may not be the cause of that heart disease.  People who drink sugary beverages are more likely to have other not-so-healthy habits, like smoking or choosing not to exercise. Just because sugary drinks are associated with heart disease doesn’t mean that sugary drinks cause heart disease.

What we know for sure is that sugar is a form of carbohydrate and that all carbohydrates, especially simple carbs like sugar, will raise your blood sugar.  If you have diabetes, you probably don’t want to raise your blood sugar unless you’re experiencing hypoglycemia (low blood sugar.)  So…alternative sweeteners are the best choice for most people with type 2 diabetes.

Is it safe to use artificial sweeteners?

Some people worry that artificial sweeteners are going to cause them problems down the road. At this time, we don’t have any evidence to say that artificially sweetened drinks are associated with poor outcomes like heart disease or cancer. We do know that the consumption of artificial sweeteners is associated with higher weight. So, we can only make the best choice that we can make today. For me, as a person without diabetes, that comes down to drinking my tea completely unsweetened and my coffee chock full of stevia. Let’s face it, I’m addicted to my morning caffeine, but I really don’t like the taste of black coffee. I choose stevia because it is found in nature. Several other alternative sweeteners such as sucralose, aspartame, & saccharine are man-made. That doesn’t make them necessarily bad, but it does make me choose stevia instead.

Choosing sweetener vs. sugar if you have diabetes

If you have diabetes, we know that sugar raises your blood sugar right away. The only time we want to see a spike in your blood sugar is if you are experiencing a low. So, the only time that’s a good time to have a high-sugar food or drink is when you’re trying to treat a low blood sugar. Even then, the recommended amount is 15 grams of carbohydrate or about 4 ounces of juice or real soda.

Since routine consumption of regular sugar is out, people with diabetes who want something sweet should definitely go with the alternatively sweetened version. I’m not endorsing the idea of drinking diet soda all day long…I’m just saying that diet soda is the lesser of two evils if you are a person with diabetes, and everyone needs some “pleasure foods” in their life. So, having said all of that, it’s time for my coffee break…and I’m going to put some monk fruit sweetener in it!


Julie Cunningham is a Registered Dietitian and Certified Diabetes Care & Education Specialist. She believes food is the foundation of good health, and that our culture of obsession about body size is damaging to health, happiness, and productivity in far too many people. When not talking or writing about food and health, she can be found in the the mountains of western NC, where she lives with her family and four legged friends.

Julie Cunningham

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