Truvia® natural sweetener and Gastrointestinal Symptoms
Problems with stomach aches, cramping, gassiness and changes in stool are common among people in daily life. We often assume symptoms are related to what we ate just before they started. This could be due to undigested food getting into the colon -- called malabsorption. The human colon has one of the most concentrated bacterial populations on earth. When starches, sugars and fiber reach the colon, they draw water with them, which may loosen the stool, something doctors call “osmotic diarrhea”. Once in the colon, bacteria digest carbohydrates. By-products of this fermentation include gas production and for some people this can cause abdominal symptoms.
There are other possible causes for abdominal symptoms related to foods. Celiac disease is a problem with the gluten portion of wheat, rye or barley grains, causing injury to the small intestine and, as a result, abdominal symptoms. Likewise some food allergies cause similar complaints. These are usually due to food proteins, but can be developed to other food ingredients, as well. Then there are abdominal symptoms not caused by the food, but rather due to injury to the stomach, small intestine or colon, such as Crohn’s disease, ulcerative colitis or infections. So even though foods or drinks may be associated with symptoms, they may not be the primary reason for them.
By definition, fiber is undigested in the upper intestine. Its’ health properties depend on the bacterial fermentation. And often fiber can cause symptoms of intolerance. Simple sugars, such as glucose, sucrose (table sugar) and fructose (fruit sugar) are well absorbed even at high doses. Lactose (milk sugar) is generally well absorbed during infancy, but with age some people, particularly Asians, Africans or African-Americans and those from Mediterranean descent, may lose their ability to digest lactose efficiently. Gastrointestinal symptoms following milk or dairy consumption is called lactose intolerance.
There are other types of foods that can end up in the colon and cause symptoms. One such class of ingredients is the sugar alcohols, which are used to replace sugar in chewing gum and sugar-free confections. Examples include xylitol, mannitol and sorbitol. They are commonly substituted for sugar because of their sweet taste, reduced calories and tooth friendly benefits. As a group, sugar alcohols have been associated with abdominal symptoms when people consume too much. But each one is different. Some are better tolerated than others and this has to do with how much of the sugar alcohol gets absorbed versus how much is left in the gut where it is osmotically active. Studies show that side effects are dose-dependent; that is, a person’s symptoms depend on how much an individual takes and how quickly (Grabitske 2009). But also it is important to note that symptoms depend on the individual being tested. In other words, everyone reacts to sugar alcohols in their own way.
Truvia® natural sweetener is comprised of very small amounts of sweetener from the stevia leaf combined with erythritol, as a bulking agent or carrier. Stevia is an intense sweetener so a tiny amount goes a long way. This is why tabletop sweeteners like Truvia® natural sweetener require a bulking agent. Erythritol was carefully chosen. It is different from all the other sugar alcohols. Like the sweetener in stevia, erythritol can be found in nature. Erythritol is present in small quantities in fruits such as grapes and pears. It has a sweet taste, but it is not as sweet as sucrose (table sugar) (Ichikawa 1989). It has no calories because it is not metabolized, so it produces no increase in blood sugar or release of insulin (Noda K 1994; Bornet FR 1996; Ishikawa M 1996). As a result, erythritol is safe for diabetics in daily use. It is absorbed in the upper small intestine and excreted in the urine. Even at single doses above 25 g, 90% gets absorbed (Noda K 1994; Munro IC 1998). As a comparison, one packet of Truvia® natural sweetener has the sweetness of 2 teaspoons of table sugar, but it only contains 3 grams of erythritol. And erythritol is unique in one other property: it is not fermented by bacteria, either in the mouth (no tooth decay) (Livesey 2003) or in the colon (no cramping or gas). Even after 24 hours of incubation, no gas is produced by bacteria (Arrigoni E 2005).
Studies with erythritol show almost no side effects reported unless very high doses are consumed at a single sitting in liquid form on an empty stomach(Bornet FR 1996). It took at least 4 times the amount of erythritol to generate looser stools, compared with the level of sorbitol, a very commonly used and well tolerated sugar alcohol (Oku T 1996). One study gave the test subjects 1 gram per kilogram (1 kilogram is equal to 2.2 pounds) for five days (Tetzloff W 1996). So a 220 pound person would be taking 100 grams of erythritol every day, or 33 packets of Truvia® natural sweetener. These doses are far beyond the expected daily use and were delivered in a way that is very unlike our normal eating pattern. Consumption of Truvia® natural sweetener typically would be in small doses throughout the day and often with food. However, despite its safety and the fact that its absorption is nearly total and that human colon bacteria do not ferment it, a few study subjects reported cramping, noisy stomach churning or, more commonly, loose stool after consuming it. This pattern has been seen with many types of sugars and carbohydrates. There are just some people who may have a limit to how much they can consume without having mild, brief symptoms.
Typical use patterns for Truvia® natural sweetener are not expected to result in gastrointestinal side effects, but in extremely rare cases, it is possible for an individual to report symptoms with erythritol. But there is a valuable lesson that doctors learned from studying patients with lactose intolerance. That is that many people who complained of abdominal symptoms after consuming a lactose-containing food were not found to show positive breath hydrogen studies, which meant that the lactose never entered the colon for fermentation. What was happening? For most the cause was probably irritable bowel syndrome (IBS).
IBS is a benign disorder with very similar symptoms to carbohydrate intolerance. It affects nearly 1 in 5 people, making it common enough to be confused with other dietary causes of abdominal discomfort. With IBS, some individuals have stomach aches, bloating, gassiness and cramping associated with diarrhea. For others the symptoms are tied to constipation and a third group shows alternating diarrhea and constipation. The specific cause is still a little unclear, but studies to date show overly sensitive intestinal pain to normal everyday bowel activity, along with an abnormal motility pattern (squeezing movement) in the small intestine and colon. The altered motility is what causes loose stool when fecal material moves through the colon too fast, or constipation if it moves through too slowly. As is true for lactose intolerance, the first line of therapy is dietary change, followed by stress reduction measures. For those with IBS, certain dietary items can result in worsening symptoms, such as the consumption of large meals, carbonated beverages or ingestion of caffeinated products, such as coffee, soda or energy drinks. Similarly, stress, depression or anxiety is frequently a trigger.
Like lactose intolerance and sensitivity to sugar alcohols, IBS benefits from dietary changes, including avoidance of the individual’s personal problem foods and beverages, coupled with stress reduction, such as good sleep habits, regular exercise, relaxation techniques and, in certain cases, medications.
The following article discusses symptoms and causes for common gastrointestinal maladies and the scientific evidence for gastrointestinal tolerance of Truvia® natural sweetener. Typical use patterns for Truvia® natural sweetener are not expected to result in gastrointestinal side effects such as gas, diarrhea, bloating. The bulking ingredient, erythritol, has been studied and does not result in side effects reported unless very high doses are consumed at a single sitting in liquid form on an empty stomach. Despite erythitol’s high level of tolerance in studies, everyone reacts to sugar alcohols in their own way.
About Dr. Murray
Dr. Murray spent his career as a professor in the Department of Pediatrics of the Ohio State University School of Medicine, located at Nationwide Children’s Hospital. In 2006, he became the Director of the Center for Healthy Weight and Nutrition. Previously, Dr. Murray had spent 20 years at in the field of Pediatric Gastroenterology and Nutrition, as well as the Director of the Borden Center for Nutrition and Wellness. He then served for 3 years as the Pediatric Medical Director for Ross Labs, a division of Abbott Labs before returning to Children’s to create the weight management program. Currently, Dr Murray is a member of the Department of Human Nutrition at Ohio State University and serves as a national consultant on projects involving pediatric nutrition and childhood obesity.
Dr Murray attended Indiana University School of Medicine and did his residency training in pediatrics at DeVos Children’s Hospital, Spectrum Health, in Grand Rapids, Michigan. He completed a fellowship in Pediatric GI and Nutrition at Columbus Children’s in 1985 and has remained on the faculty since. As the Director of the Borden Center for Nutrition and Wellness at Children’s, Dr. Murray worked on the issue of obesity prevention in children. He continues to be active at the local and state level in the areas of public policy, education and community-based research. Dr Murray is the former chair of the American Academy of Pediatrics Council on School Health and is a representative to the national Action for Healthy Kids initiative, promoting school policies that combat obesity.
Arrigoni E, B. F., Amadò R (2005). "Human gut microbiota does not ferment erythritol."
Br J Nutr 94(5): 643-646.
Bornet FR, B. A., Dauchy F, Slama G (1996). "Gastrointestinal response and plasma and urine determinations in human subjects given erythritol."
Regul Toxicol Pharmacol 24: S296-S302.
Bornet FR, B. A., Dauchy F, Slama G (1996). "Plasma and urine kinetics of erythritol after oral ingestion by healthy humans."
Regul Toxicol Pharmacol 24: S280-S285.
Grabitske, H. S., JL (2009). "Gastrointestinal effects of low-digestible carbohydrates."
Critical Reviews in Food Science and Nutrition 49: 327-360.
Ichikawa, T. S. Y. S. H. M. T. E. K. H. T. (1989). "Identification of erythritol by HPLC and GC-MS and quantitative measurement in pulps of various fruits."
Journal of Agricultural and Food Chemistry 37: 1474-1476.
Ishikawa M, M. M., Kawashima Y, Nakamura T, Saitou N, Modderman J (1996). "Effects of oral administration of erythritol on patients with diabetes."
Regul Toxicol Pharmacol 24: S303-S308.
Livesey, G. (2003). "Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties."
Nutr Res Rev 16(2): 163-191.
Munro IC, B. W., Borzelleca JF, Flamm G, Lynch BS, Kennepohl E, Bär EA, Modderman J (1998). "Erythritol: an interpretive summary of biochemical, metabolic, toxicological and clinical data."
Food Chem Toxicol 36(12): 1139-1174.
Noda K, N. K., Oku T (1994). "Serum glucose and insulin levels and erythritol balance after oral administration of erythritol in healthy subjects."
European Journal of Clinical Nutrition 48(4): 286-292.
Oku T, O. M. (1996). "Laxative threshold of sugar alcohol erythritol in human subjects."
Nutrition Research 16(4): 577-589.
Tetzloff W, D. F., Medimagh S, Carr D, Bär A. (1996). "Tolerance to subchronic, high-dose ingestion of erythritol in human volunteers."
Regul Toxicol Pharmacol 24: S286-S295.