The research is piling up to show that sugar-sweetened drinks are just as bad as smoking. Drinking them every day increases your risk of death and disability from multiple causes.

Sugar-sweetened drinks include fruit drinks, soft drinks, sports drinks, sweet flavoured waters, energy drinks, electrolyte replacement drinks, and sweetened tea and coffee.

The Australian Medical Association (AMA) is calling for the government to impose heavy taxes on sugar-sweetened drinks, in the same way as cigarettes. The idea is to discourage their use on the grounds of health.

So many Australians, including children, are overweight or obese. This increases their risk of developing diabetes, heart disease, and even cancer. And sugary drinks are contributing to the problem in a big way. And sadly, this problem isn't confined to Australia. It extends to the rest of the world too.

The average 375 ml can of soft drink contains 8-12 teaspoons of sugar. According to the AMA, Australians drink over 2.4 billion litres of sugary drinks every year. That's the equivalent of 960 Olympic-sized swimming pools. Young men drink the highest amount of them.

What does the research show about sugar-sweetened drinks?

A recent study of nearly 99,000 post-menopausal women found that those who drank sugar-sweetened drinks every day had nearly double the risk of liver cancer compared to those who didn't (1).

Another piece of research looked at the relationship between early onset colorectal cancer (EO-CRC) and sugar-sweetened drinks. The incidence of EO-CRC, which appears in people under 50, has been rising in high-income countries over the past 20 years. The study found that drinking 2 or more sugar-sweetened drinks a day more than doubled the risk in adults compared with one drink a day. Even more worrying, each serving a day in people aged 13-18 increased their risk of EO-CRC by 32% (2).

It's especially concerning that younger people have such a high risk of EO-CRC because the figures show that their intake of these drinks is high. The figures internationally vary considerably, with China having the highest daily consumption (710 ml) and Australia having the lowest (115.1 ml), but consumption of these drinks is certainly very high in this age group (3).

A systematic review and meta-analysis of 17 studies involving over 557,000 people confirmed the significant link between colorectal cancers in all ages and sugar-sweetened drinks (4).

We tend to think that calories that we drink, rather than eat, don't count. Unfortunately, they do, and people who drink sugar-sweetened drinks often put on weight. With a higher BMI, they are more prone to certain cancers related to obesity, particularly colorectal, breast and prostate cancers. A comprehensive study confirmed the association between people who consume these drinks and obesity-related cancers (5). The same study also found an association between sugar-sweetened drinks and higher rates of kidney cancer (5). The researchers said that obesity wasn't the culprit here, and suggested that the chemicals used in food colouring and packaging might be to blame (5).

Are artificial sweeteners better than sugar?

There are various sweeteners on the market, some of which are better than others.

The ones we think of first are probably aspartame, acesulfame-K and sucralose. Food manufacturers love putting these into their products so that they can say they're sugar-free.

Then there are the sugar alcohols. These include xylitol, erythritol, sorbitol and maltitol, and sugar free sweets often contain them.

Lastly, there are sweeteners made from natural products. These include allulose, stevia and monk fruit.

Aspartame

Aspartame, also known as Equal™, Canderel®, NutraSweet®, additive number 951 or 952, has been the subject of research for years because there has been a suspicion that it is carcinogenic. Finally, in July 2023, the International Agency for Research on Cancer classified it as 'possibly carcinogenic to humans' (6).

Unfortunately, it's found in many different sugar-free foods and drinks, including artificially sweetened drinks. It will take a keen eye to spot it on ingredient labels because manufacturers know that it's unpopular. If it says on the label that phenylketonurics shouldn't use it, that's a sure sign that it contains aspartame.

Avoid this one as much as possible.

Acesulfame potassium (acesulfame-K)

Acesulfame-K is also known as Sweet One®, Sunett®, 962 and e950. This is another sweetener that has a reputation for being carcinogenic. Research on animals done in the 1970s suggested that it caused cancer. Mother's breast milk has also tested positive for it (7).

Again, it's widely used in processed foods, often in combination with aspartame.

Sucralose

Sucralose is also known as Splenda®, 955 and e955. It's used in a variety of products, from sugar-free drinks to baked goods, ice cream, sauces, chewing gum, protein powders and bars, yoghurt, lollies and even toothpaste. It's one of the most common artificial sweeteners in the US.

Sucralose is toxic to us in a variety of ways:

• It can increase insulin production and could trigger diabetes (8).

• It negatively affects the gut microbiota and leads to inflammation (9), which in turn can lead to IBS, ulcerative colitis and Crohn's disease (10, 11).

• When it's heated, sucralose produces chloropropanols (12), chemicals which are known to be carcinogenic (13). Given that it’s used in products that are cooked, like baked goods, this is very worrying.

All of these could lead to cancers starting.

Sugar alcohols

Sugar alcohols are rarely used in artificially sweetened drinks. They're most often found in sugar-free lollies and baked goods.

There's no evidence that they are carcinogenic, but some of them can disrupt the gut microbiome. This can cause diarrhoea. That's why they are required to show a notice saying that they can have a laxative effect in high doses. The exception to this is erythritol, which is metabolised in the small intestine.

One recent study showed that there was some evidence that erythritol could increase the risk of heart disease, but the human trials used just 8 participants, so this is yet to be confirmed (14). It would be wise to avoid using large amounts of it to sweeten your drinks until they carry out further safety studies.

Allulose

Allulose is a natural sugar that is found in maple syrup, figs, raisins and brown sugar. It's also made commercially from corn. It's found in a variety of processed foods, but not, as yet, in drinks or sodas.

Our guts absorb about 70% of the allulose that we consume, but unlike other sweeteners, it doesn't ferment in the gut, so it doesn't cause bloating or digestive problems. Instead, our kidneys filter it and excrete it in our urine.

Food manufacturers are now using it in sweetened yoghurts, snacks and granola bars, but as yet they aren't using it in beverages. But you could use it in hot and cold drinks that you make yourself.

It has some interesting side effects, all beneficial.

Animals fed a high sugar diet alongside allulose burn more energy and have less body fat than those who don't have the allulose (15).

Some studies also show that allulose also helps stabilise blood sugar and protect the pancreas of rats with type II diabetes (16).

More animal studies have found that allulose reduces fat storage in the liver. This might help protect against fatty liver disease, which can lead to cirrhosis and ultimately to liver cancer (17).

Allulose also has anti-inflammatory effects. Since inflammation is at the root of many cancers, this is great news. The research suggests that it reduces inflammation by increasing the gut bacteria that reduce inflammation, and downregulating the effects of certain genes (18).

It isn't as sweet as sugar or other sweeteners, so you need about 30% more of it to achieve the same sweetness. But it doesn't have any of the aftertaste of other sweeteners or the cooling effect. Because it's so new, the food regulatory authorities are yet to approve it for sale in Europe or Australia. But it is available from the US, where it's proving quite popular. Be warned, though, it is quite expensive.

If you choose to use allulose, make sure that it's made from non-GMO corn.

Stevia and monk fruit

I talked at length about the relative benefits of stevia and monk fruit in another article.

Manufacturers do sometimes use stevia in drinks instead of sugar, but I haven't seen any (yet) that contain monk fruit. However, you can, of course, use both of them to sweeten coffee and tea. Monk fruit is the better of the two.

Conclusion

I would suggest using allulose, monk fruit or stevia to sweeten your hot drinks if you want to avoid sugar and don't enjoy unsweetened drinks.

For cold drinks, why not try the following options in water?

• Mashed berries

• Other fresh fruit–think peaches, nectarines, melon, grapefruit, apple, orange

• Mint

• Cucumber

• Spices and herbs like rosemary, ginger, cinnamon and coriander (cilantro).

Or combine them. There are lots of ideas online if you search for 'natural water flavouring'.

For the zing that you get from sodas, try some of these ideas with sparkling mineral water instead of plain water.

There is a lot more information on the best drinks and much more besides in my book. To find out where you can buy the book, click the button below.

References

1. Zhao L, Zhang X, Coday M, et al. Sugar-sweetened and artificially sweetened beverages and risk of liver cancer and chronic liver disease mortality. JAMA. 2023;330(6):537. doi:10.1001/jama.2023.12618

2. Hur J, Otegbeye E, Joh H-K, et al. Sugar-sweetened beverage intake in adulthood and adolescence and risk of early-onset colorectal cancer among women. Gut. 2021;70(12):2330-2336. doi:10.1136/gutjnl-2020-323450

3. Ooi JY, Wolfenden L, Sutherland R, et al. A systematic review of the recent consumption levels of sugar-sweetened beverages in children and adolescents from the World Health Organization regions with high dietary–related burden of disease. Asia Pacific Journal of Public Health. 2021;34(1):11-24. doi:10.1177/10105395211014642

4. Feng L, Gao J, Xia W, et al. Association of sugar-sweetened beverages with the risk of colorectal cancer: A systematic review and meta-analysis. European Journal of Clinical Nutrition. 2023;77(10):941-952. doi:10.1038/s41430-023-01302-x

5. McCullough ML, Hodge RA, Campbell PT, Guinter MA, Patel AV. Sugar- and artificially-sweetened beverages and cancer mortality in a large US prospective cohort. Cancer Epidemiology, Biomarkers & Prevention. 2022;31(10):1907-1918. doi:10.1158/1055-9965.epi-22-0392

6. World Health Organization. Aspartame hazard and risk assessment results released. World Health Organization. July 14, 2023. Accessed December 5, 2023. https://www.who.int/news/item/14-07-2023-aspartame-hazard-and-risk-assessment-results-released.

7. Center for Science in the Public Interest. Acesulfame potassium. Center for Science in the Public Interest. January 4, 2021. Accessed December 5, 2023. https://www.cspinet.org/article/acesulfame-potassium.

8. Schiffman SS, Rother KI. Sucralose, a synthetic organochlorine sweetener: Overview of biological issues. Journal of Toxicology and Environmental Health, Part B. 2013;16(7):399-451. doi:10.1080/10937404.2013.842523

9. 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;14(8):1682. doi:10.3390/nu14081682

10. Rodriguez-Palacios A, Harding A, Menghini P, et al. The artificial sweetener Splenda promotes gut proteobacteria, dysbiosis, and myeloperoxidase reactivity in crohn's disease–like ileitis. Inflammatory Bowel Diseases. 2018;24(5):1005-1020. doi:10.1093/ibd/izy060

11. Li X, Liu Y, Wang Y, et al. Sucralose promotes colitis-associated colorectal cancer risk in a murine model along with changes in microbiota. Frontiers in Oncology. 2020;10. doi:10.3389/fonc.2020.00710

12. Rahn A, Yaylayan VA. Thermal degradation of sucralose and its potential in generating chloropropanols in the presence of glycerol. Food Chemistry. 2010;118(1):56-61. doi:10.1016/j.foodchem.2009.04.133

13. Andres S, Appel KE, Lampen A. Toxicology, occurrence and risk characterisation of the chloropropanols in food: 2-monochloro-1,3-propanediol, 1,3-dichloro-2-propanol and 2,3-dichloro-1-propanol. Food and Chemical Toxicology. 2013;58:467-478. doi:10.1016/j.fct.2013.05.024

14. Witkowski M, Nemet I, Alamri H, et al. The artificial sweetener erythritol and cardiovascular event risk. Nature Medicine. 2023;29(3):710-718. doi:10.1038/s41591-023-02223-9

15. Ochiai M, Onishi K, Yamada T, Iida T, Matsuo T. d-Psicose increases energy expenditure and decreases body fat accumulation in rats fed a high-sucrose diet. International Journal of Food Sciences and Nutrition. 2013;65(2):245-250. doi:10.3109/09637486.2013.845653

16. Hossain A, Yamaguchi F, Matsunaga T, et al. Rare sugar D-PSICOSE protects pancreas β-islets and thus improves insulin resistance in OLETF rats. Biochemical and Biophysical Research Communications. 2012;425(4):717-723. doi:10.1016/j.bbrc.2012.07.135

17. Nagata Y, Kanasaki A, Tamaru S, Tanaka K. d-psicose, an epimer of d-fructose, favorably alters lipid metabolism in Sprague–dawley rats. Journal of Agricultural and Food Chemistry. 2015;63(12):3168-3176. doi:10.1021/jf502535p

18. Han Y, Yoon J, Choi M. Tracing the anti‐inflammatory mechanism/triggers of d‐allulose: A profile study of microbiome composition and mrna expression in diet‐induced obese mice. Molecular Nutrition & Food Research. 2020;64(5):e1900982. doi:10.1002/mnfr.201900982