Awareness and Knowledge about Sugar Substitutes among Population in Riyadh Region.

BACKGROUND: The food we consume will have sugar in one or the other form, which is not ideal for our teeth. This can be replaced by the use of sugar substitutes available in the market. Sugar substitutes have beneficial and adverse effects on health. In spite of their beneficial effects, long-term use of sugar substitutes is not recommended because of their health-related complications. Therefore, before consuming any sugar substitutes, everyone needs to know about both health benefits and their health hazards; hence, the present study was designed to assess the awareness, knowledge, and utilization of sugar substitutes among the general population in Riyadh Region, Kingdom of Saudi Arabia.
OBJECTIVES: The aim is to assess the awareness and knowledge about sugar substitutes.
METHODOLOGY: Questionnaire consisting of demographic details, awareness, and knowledge about sugar substitutes were sent through social media and it was in the Arabic and English Language. After completing the questionnaire, participants are requested to send the link to their friends and relatives.
RESULTS: About 60.20% of participants were aware of sugar substitutes. Statistically significant difference was observed for gender and awareness of sugar substitutes (P < 0.05). About 31.5% of the participants are of the view that sugar substitutes have got side effects. About 61.9% of participants are of the view that Sugar substitute reduces the chance of occurrence of dental caries.
CONCLUSIONS: Overall, 60.2% of study participants were aware of sugar substitutes, but the controversy on most of the artificial sweeteners cannot be ignored. Hence, the safety of these sweeteners is of prime importance for scientists. Any usage of sugar substitutes should be weighed against the adverse effects. Copyright:

INTRODUCTION

Sugar is an unavoidable part of the food we consume though excess of it is not ideal for our teeth and the body as it have an important role in certain degenerative diseases.[1] So artificial sweeteners or artificially sweetened products attract consumers. A sugar substitute (artificial sweetener) is a food additive with less food energy but duplicates the effect of sugar in taste. Due to urbanization, sedentary lifestyles and excessive consumption of sugary foods along with increased fat consumption there will be an energy imbalance leading to obesity in Indian population. Obesity being a primary factor behind type II diabetes, India may become a diabetic capital of the world by 2030.2[2]

Sugar substitutes are classified as natural and artificial. The food and beverage industries are replacing sugar or corn syrup with artificial sweeteners in a range of products. This will be regulated by the US Food and Drug Administration as food additives. And food additives must be approved by the FDA, which publishes a Generally Recognized as Safe (GRAS) list of additives.[1]

High-intensity sweeteners are commonly used as sugar substitutes or sugar alternatives because they are many times sweeter than sugar but contribute only a few to no calories when added to foods. High-intensity sweeteners, like all other ingredients added to food in the United States, must be safe for consumption. Six high-intensity sweeteners are FDA-approved as food additives in the United States: saccharin, aspartame, acesulfame potassium (Ace-K), sucralose, neotame, and advantame.[3]

With increased consumer interest in reducing energy intake, food products containing non-sugar sweeteners (NSSs) rather than simple sugars (monosaccharides and disaccharides) have become increasingly popular.[4]

These sugar substitutes differ from sugars not only in their taste properties, but also in how the body metabolizes them[5] and how they in turn affect physiological processes.[6] NSSs are generally sweeter than sucrose, but contain far fewer or no calories. Each sweetener is unique in its sweetness intensity, persistence of the sweet taste, coating of the teeth, and aftertaste effect.[7]

Hence, a study was designed to assess the awareness and knowledge of sugar substitutes among population aged18 years and above in Riyadh Region.

METHODOLOGY

A self-administered questionnaire consisting of 11 questions regarding awareness and about sugar substitutes was developed. The questionnaire was reviewed by the guide and staff of Dental Public Health. The questionnaire was initially prepared in the English language and translated into Arabic. Again the same was translated into English to validate the questionnaire.

Ethical approval from the Institutional Review Board and permission was obtained from the College of Dentistry, Prince Sattam Bin Abdul Aziz University. The survey was conducted on a total of 327subjects. Subjects in the age group of 20–30 years of both the gender were included. Participants were explained about the nature and purpose of the survey. Those participants who are not willing are excluded from the survey. The link of questionnaire was sent through social media, i.e., WhatsApp, snap chat people are requested to send link to their friends and family after answering the questions.

All the completed questionnaires were entered into data base system. Descriptive statistics and Chi-square evaluation was done using SPSS statistical software. IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N.Y., USA).

RESULTS

Table 1 shows the characteristics of the study population. Out of 327 subjects, male participants were 152 (45.66%) and female participants were 175 (53.5%). The age group was from above 18 years, majority of participants were belonging to 18–25 years of age (42.8%). 64.2% of the participants had a bachelor's degree and 14.1% of participants had a health-care background.

Table 1

The distribution of study population according to gender, educational status and age group

	Frequency (%)
Age group (years)
18-25	140 (42.8)
26-35	78 (23.9)
36-45	53 (16.2)
46-55	38 (11.6)
Above 55	18 (5.5)
Gender
Male	152 (46.5)
Female	175 (53.5)
Education
Up to secondary	57 (17.4)
Diploma	34 (10.4)
Bachelor	210 (64.2)
Masters	26 (8.0)
Health care background
Health care field	46 (14.1)
Non health care field	281 (85.9)

Table 2 awareness about sugar substitutes among the study participants, out of 327 study participants, 197 (60.20%) participants were aware of sugar substitute 130 (39.8%) of the study population were not ware. Statistically significant difference was observed for gender and awareness of sugar substitutes (P < 0.05). Age, education, and healthcare background did not yield statistical significance (P > 0.05). Further analysis was considered for those participants who were aware of sugar substitutes.

Table 2

Awareness about sugar substitutes among the study participants according to age, gender, education, and health-care background (n=327)

Questions	Response	Frequency (%)	Age (χ2, P)	Gender (χ2, P)	Education (χ2, P)	Healthcare background (χ2, P)
Awareness about sugar substitutes	Aware	197 (60.2)	4.39, 0.35 (NS)	6.87, 0.09 (S)	3.56, 0.31 (NS)	2.95, 0.10 (NS)
	Not aware	130 (39.8)

P<0.05. NS: Nonsignificant, S: Significant

Figure 1 shows utilization of sugar substitutes among study subjects who were aware of sugar substitutes (n = 197). Among 197 participants, 80% have used the sugar substitutes.

Figure 1

Utilization of sugar substitutes among study participants

Figure 2 shows the source of information about sugar substitutes among study subjects.

Figure 2

Source of information of sugar substitutes among study participants

Media (52.8%) was the main source of information followed by the physician (38.6%).

Table 3 shows the knowledge-based questions and responses among study participants. Knowledge from the participants varied greatly and for almost all the questions, 70%–80% of the participants answered yes. Only 31.5% of the participants are of the view that sugar substitutes have got side effects. About 61.9% of participants are of the view that Sugar substitute reduces the chance of occurrence of dental caries. About 75.1% of the study participants have answered that a person with diabetes can enjoy varied diet with the help of sugar substitutes.

Table 3

The knowledge-based questions and responses among study participants about sugar substitutes (n=197)

Question	Yes, n (%)	No, n (%)	Don’t know, n (%)
Do you think sugar substitutes help in reducing weight	133 (67.5)	30 (15.2)	34 (17.3)
Sugar substitute reduces the chance of occurrence of dental caries	122 (61.9)	34 (17.3)	41 (20.8)
Person with diabetes can enjoy varied diet with the help of sugar substitutes	148 (75.1)	17 (8.6)	32 (16.2)
Taste of sugar substitute is similar to sugar	138 (70.1)	47 (23.9)	12 (6.1)
Cost of sugar substitute is less than sugar	16 (8.1)	150 (76.1)	31 (15.7)
Sugar substitutes can be natural and artificial	170 (86.3)	27 (13.7)	0 (0.0)
Sugar substitutes have got any side effect	62 (31.5)	48 (24.4)	87 (44.2)

Table 4 shows the response of participants about the side effect of sugar substitutes 31.47% of participants answered that they think sugar substitutes have got some side effects. 35.5% of participants answered that they do not know the type of side effect associated with sugar substitutes. 37.1% think as GIT problems. 16.1% as liver problems.

Table 4

The response of participants about side effect of sugar substitutes (n=62)

Side effects	Frequency (%)
Liver problem	10 (16.1)
Kidney problems	7 (11.3)
GIT problems	23 (37.1)
Don’t know	22 (35.5)
GIT: Gastrointestinal

DISCUSSION

A sugar substitute is a food additive which has the taste of sugar with less food energy. Some sugar substitutes are natural and some are synthetic. Those that are not natural are, in general, called artificial sweeteners.[1]

Majority of approved sugar substitutes for food use are artificially synthesized compounds. However, some bulk natural sugar substitutes are known, including sorbitol and xylitol, which are found in berries, fruit, vegetables, and mushrooms.

In the present study the knowledge and utilization of sugar substitutes have been evaluated.

In the present study an overall 60.2% of study subjects were aware of sugar substitutes. As such there are no other studies to compare the awareness of sugar substitutes among different population. Information about them is mainly by the media (52.8%).

One of the uses of sugar substitute is to help in weight loss – by replacing high-energy sugar or corn syrup with other sweeteners having little or no food energy. This allows them to lose weight and avoid other problems associated with excessive caloric intake.

Of the many factors that contribute to the development of dental caries, diet plays an important role.[8] Sugar substitutes are tooth-friendly and are not fermented by the microflora of the dental plaque. An Example is xylitol& it works by adhering to the tooth surface, preventing plaque formation and eventually decay as it cannot be fermented by these bacteria thus helping to prevent plaque formation.[9]

Among the therapeutic uses of sugar substitutes weight loss has been listed. 67.5% of people agreed that sugar substitutes helps in reducing weight so they replace their sugar with sugar substitutes and think that they have reduced excessive calories this is in disagreement with the study results conducted by University of Texas Health Science (2005) which reported that, rather than promoting weight loss, sugar substitutes increases weight gain and obesity. This was proven by animal studies.[1011]

The advantage for dental caries prevention is because of inability to ferment these sugar substitutes by the microorganisms of dental plaque. Hence dentists may prescribe or recommend sugar substitutes.[1213] 61.9% of study subjects agreed that sugar substitutes reduces dental caries in this current study.

75.1% of the study subjects were of the view that shifting to sugar substitutes, diabetic patients will have varied diet. Some sugar substitutes do release energy, but are metabolized more slowly, allowing blood sugar levels to remain more stable overtime.[14] but in contrast Israeli research reported that artificial sweeteners may aggravate Type 2 diabetes.[15]

When compared, sugar substitutes are cheaper than sugar because of their long shelf-life and high sweetening intensity. This made alternative sweeteners to be used in products that will not perish after a short period of time.[16] 76.1% of study subjects think sugar substitutes are more costly than sugar.

31.5% of study participants told that sugar substitute's usage poses health risks. 44.2% told that they do not know about health risks. Extensive scientific research by the US and Europe, has shown the safety of the six low-calorie sweeteners (stevia, acesulfame-K, aspartame, neotame, saccharin, and sucralose) with an acceptable daily intake. Many studies have been carried out to confirm the safety of artificial sweeteners, but some studies have also noted their carcinogenicity. Animal studies have proved that it causes weight gain, brain tumors, bladder cancer, and many other health hazards. A large number of studies have been carried out with conclusions ranging from “safe under all conditions” to “unsafe at any dose.” Hence, any usage of sugar substitutes should be weighed against the adverse effects.

CONCLUSIONS

Sugar substitutes in various food and beverages are very popular in many countries and have been confirmed in their safety usage. Still, controversies exist regarding the safe use of sugar substitutes, which ranges from “safe under all conditions” to “unsafe at any dose.” In Saudi, 60% of subjects are aware of sugar substitutes, and utilization rate is also high. Awareness should be created among the general public regarding safe the use of sugar substitutes should be weighed against adverse effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.