Acceptance of Stevia as A Sugar Substitute and its
Determinants among Health Educated |ndividuals
AFIQ MU’IZZUDDIN BIN SAHARUDIN, NORAZIRAH BINTI MOHD NAZRI, AQILAH
HANIM BINTI ROSLEE, MUHAMMAD HAZIQ BIN HAWI and SAW OHN MAR*
Faculty of Medicine, Universiti Kuala Lumpur Royal College of Medicine Perak, Malaysia.
Abstract
Introduction: Stevia is a safe, zero calorie, low glycaemic, natural sweetener
and is suitable for pre-diabetic and diabetic patients. This study investigated
the perceived effect of a stevia product on taste, satiety, appetite and
carbohydrate craving, and its acceptance as a sugar substitute.
Methodology: An exploratory study was conducted among the randomly
selected group of 73 medical students and eight lecturers. The participants
consumed commercially available stevia,replacing sugar, with their morning
drink for a week. Data was collected by face to face interview using a
standardized questionnaire pre and post stevia challenge.
Results: The Majority (66.7%) of respondents from student group liked
the taste of stevia,74.1% experienced after taste and 65.4% reported
taste change of the drink with stevia. During the challenge week, 34.6%
experienced early satiety, 8.6% had increased appetite and 16.0%
noted carbohydrate craving. The majority of respondents were willing
to continue with stevia for their health benefits and 95.1% wanted to
recommend it for diabetic patients. In contrary, 66.7% of participants from
lecturer group did not like the taste of stevia. Significant association was
found between the amount of stevia used and liking the taste of stevia
(p <0.05). Taste liking is positively (p <0.001)and perceived taste change of
the drink is negatively correlated to its acceptance ( p <0.05).
Conclusion: The majority of respondents demonstrated good acceptance
of commercially available stevia product.Liking sweet taste of stevia and
perceived taste change of their drink determined the acceptance of stevia
product among health educated individuals. Future research should focus on
effectiveness of natural sweeteners in reducing calorie intake to fight against
obesity to provide public health policy makers with more evidence based
information on use of non-caloric sweeteners.
Current Research in Nutrition and Food Science
www.foodandnutritionjournal.org
ISSN: 2347-467X, Vol. 08, No. (1) 2020, Pg. 226-237
CONTACT Saw Ohn Mar sawohnmar@unikl.edu.my Faculty of Medicine, Universiti Kuala Lumpur Royal College of Medicine
Perak, Malaysia.
© 2020 The Author(s). Published by Enviro Research Publishers.
This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY).
Doi: http://dx.doi.org/10.12944/CRNFSJ.8.1.21
Article History
Received: 8 November
2019
Accepted: 17 March 2020
Keywords
Acceptance;
Health Educated;
Stevia;
Taste Change;
Taste And Aftertaste.
227SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Introduction
Epidemic of type 2 diabetes and obesity continued to
increase in developing countries in all population and
ethnic groups. It has been proved that use of sucrose
is strongly linked with weight gain and increased
body fat mass when compared with artificial
sweeteners.1 Overconsumption of fructose is also
associated with dyslipidemia and lipid deposition
in healthy subjects.2 It is also related with visceral
fat deposition and insulin resistance in overweight
individuals.3 Consumption of sugar-sweetened foods
and beverages significantly influence the glycemic
index of each meal, as well as the diet as a whole.4
Moreover, excessive intake of high calorie, high
glycemic food can result in exaggerated postprandial
glucose and insulin levels, and potentially lead to
metabolic and hormonal changes that stimulate
hunger levels and promote fat deposition.5
The consumption of foods and beverages containing
artificial sweeteners has shockingly increased over
the past few years, and approximately 15% of the
U.S. population are estimated to consume artificial
sweeteners.6 According to Malaysian clinical practice
guidelines, sugar sweetened beverage should be
limited to less than two servings in a day.7
Stevia
The plant product sweetener, stevia, contains
no calorie and low glycemic index. Therefore,
it is suitable for pre-diabetic and diabetic and
hypertensive patients, and also for health conscious
individuals. Stevia is also a source of protein, ash
and crude which are essential for good health.8
High-purity stevia extracts which contains 95% or
more of steviol glycoside are approved by major
regulatory agencies, including the Joint Food and
Agriculture Organization/WHO Expert Committee
on Food Additives.9 An acceptable daily intake
(ADI) for steviol glycosides was established as
4 mg/kg bw/day.10 Japan was the first country in Asia
to market stevioside as a sweetener in the food and
drug industry. Since then, cultivation has expanded
to China, Malaysia, Singapore, South Korea, Taiwan,
and Thailand.11 In the United States, high-purity
stevia glycosides are considered safe and allowable
as ingredients in food products sold in 2017.12
Heat stable and PH range resistant stevia has
advantages over other artificial sweeteners because
there is no colour change after the cooking, thefore,
it can easily mix with juice or milk products.13 After
extensive review of the literature, Panghal and
Vikas summarized numerous health benefits of
Stevia such as anti-hyperglycemic, anti-cancer,
hepato-protective, antihypertensive, anti-caries,
antioxidant, and antimicrobial.14 The availability of
stevia-based products in the Malaysian markets
could possibly increases consumer awareness of
sugar alternatives,however, Malaysians have not
whole heartedly accepted such healthy alternative.
Information on the current situation of acceptance on
stevia and its consumption in Malaysia is limited.11
Effects of stevia on Taste and After Taste
Although stevia is incredibly sweet, at high
concentrations, it elicits liquorice-like aromas and a
bitter aftertaste.Chemical compounds found in the
stevia plant interact with both the sweet and bitter
receptors and the structure of glycoside molecules
plays a key role in determining sweetness or
bitterness in stevia.15 Compare to rebaudioside A,
rebaudioside M has a clean sweet taste with slight
bitter or liquorice aftertaste therefore has many
beneficial properties and abundant potential as a
sweetener in beverage and food products.16
Effects of Stevia on Satiety and Carbohydrate
Craving
In comparison to Stevia, other artificial sweeteners
(aspartame and sucralose), were associated
with increase postprandial hyperglycaemia and
postprandial insulin level indicating the possible
association of metabolic abnormalities.17 It was
reported that steviol glycosides does not have
effect on satiety but significantly decreased the daily
energy intake.17,18 Artificial sweeteners decreases
sugar consumption leading to less weight gain
among healthy school age children.19 However there
is limited information related to stevia’s effect on
carbohydrate craving.
Acceptance of Stevia
The result of a survey involving various nationalities
with a wide age range, indicated that stevia
awareness ranged from 8% to 35%, positive
impression of stevia (57% -87%) and acceptance
of stevia as “natural” product (48% - 86%) across
countries. There appeared to be a relation between
overall impression of stevia and the belief that stevia
is natural.20
228SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Role of artificial sweeteners has evolved from sugar
substitutes to health substitutes and are being
marketed to the public looking for substitution of
sugar. At the same time, we need to look into the
user’s acceptance of any alternative health product.
Although the effect of stevia on blood glucose level
appears promising, its acceptance has never been
confirmed by in this region.
The Need for Sugar Substitutes Malaysia
In Malaysia the prevalence of overweight and obesity
among adults were 30.0% and 17.7% respectively
in 2015 compared to 16.6% and 4.4% respectively
in 1996 and the childhood obesity rate was 11.9%
in 2015. Decreased productive years in both genders
that is directly linked to obesity and its related
diseases, costs the government high economically.
Again, in 2015, the prevalence of hypertension,
diabetes and hypercholesterolemia among men
and women aged above 18 were 30.3%, 17.5% and
47.7% respectively.21
High calorie food consumption is one of the main
causes of high obesity rate in Malaysia. The
Malaysian adult nutrition survey 2014 highlighted
that the rates of daily rice consumption (86.9%),
sugar consumption (55.9%) and sweetened
condensed milk consumption (29.3%) are still
high among urban and rural adults though the
rates became slightly lower than a decade ago.22
A recently published data suggested the high
prevalence of sugar-sweetened drinks consumption
among Malaysian school-aged adolescents with the
mean daily consumption amount more than 1000 ml,
equivalent to four servings per day.23
Therefore zero calorie sweeteners can be an
alternative to reduce the consumption of sugar or
condensed milk consumption. While the majority of
the respondents were willing to use Stevia-based
products as a sugar substitute, health benefits,
promotion, availability, and price were found to be
the most influential factors toward acceptance by
Malaysian consumers.11
According to a study that evaluate the consumer’
preference of artificial or natural sweeteners when
used in protein blends, the label-conscious segment
of consumers preferred beverages sweetened with
natural blends and the flavour-driven segment
of consumers conceptually preferred naturally
sweetened beverages but preferred sucralose-
sweetened beverages when primed. Therefore,
the taste of natural sweeteners either stevia or monk
fruit can be of one of the determining factor for the
consumer acceptance.24
Thus, the present study was designed to assess
the user’s perspective of stevia among health
educated individuals and health care professionals
after experiencing it by themselves who can be a
consumer as well as a prescriber of it.
Therefore this study was conducted with the aim
of investigating the effects of stevia on taste,
satiety, appetite and carbohydrate craving, and its
acceptance as sugar substitute among medical
students and medical lecturers in UniKL RCMP.
We also determined the factors associated with
acceptance of stevia product.
Materials And Methods
An exploratory study was conducted among
the medical students and medical lecturers of
University Kuala Lumpur Royal College of Medicine
Perak (UniKL RCMP) during the period between
18th March 2019 and 12th April 2019 with the approval
from Medical Research Ethics Committee of
University Kuala Lumpur Royal College of Medicine
(UniKL RCMP/MREC/2018/SRP-034).
The sample size for this study was estimated
81 assuming that 50% of the subjects would have
good acceptance of stevia as a sugar substitute
after having experience the taste of stevia and
change in taste of food or drink with a precision of
10% for 95% confident level based on previous study
findings of positive impression of stevia among the
respondents who did not take the challenge.20 In this
study, the lecturers and the students were to give
their impression on stevia after one week of stevia
challenge therefore we assumed 50% of them would
have positive response.During the study period,
there were 69 medical lecturers and 571 medical
students from five year medical program. Thus,
73 medical students and 8 lecturers were selected
by systematic random sampling to be able to get the
right student-lecturer ratio.
229SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Inclusion criteria were medical students or
medical lecturers from UniKL RCMP, age between
19 and 70 years, who regularly takes breakfast with
self-prepared drinks with normal sugar. When the
selected student or lecturer refused to participate
in this study or did not fulfil the criteria, the next
person from the name list was again approached.
Participation in this study was made voluntary and
written consent was obtained from each respondent
after explaining details of the purposes of study and
the steps involved. All identities and respondents’
responses are being kept confidential from any
public domain.
For the stevia challenge, we used commercialized
stevia products ( such as EQUALS) which comes
in 2 g sachets which contains active ingredients:
steviol glycoside, 0.83%, Erythritol and natural
flavorings. In one sachet amount of active ingredient
of steviol glycoside is only 16.6 mg.Each sachet per
contains 0 g of protein, fat, sugars, dietary fiber and
sodium while it contains 1.1 g of carbohydrate per
100 g.Therefore it provides 0 kcal.The safe amount
of steviol glycoside as approved by the governing
bodies of food and drug safety is 4 mg/ kg of body
weight/day.
According to the specification, one sachet provides
the same level of the sweetness from two teaspoonful
of sugar. We provided participants with the amount
they need for the sweetening of their morning drinks
but it should be lower than the safety level. Even for
the participants who use sugar much more than
ordinary amount, it will be much lower than the
recommended quantity of safety. Stevia sachets
were supplied to each participant according to their
requirement for one week of the challenge to prepare
the drink with stevia replacing the sugar. They can
continue with other meals as usual.
Table 1: Socio-demographic background of respondents and
information about the morning drink preparation (n=81)
Variable Students (n=73) Lecturer (n=8)
n (%) n (%)
Gender
Male 25 (34.2) 5 (62.5)
Female 48 (65.8) 3 (37.5)
Academic Year Educational Level
Year 1 19 (26.0) Degree 2 (25)
Year 2 12 (16.4) Masters 4 (50)
Year 3 12 (16.4) Ph D 2 (25)
Year 4 20 (27.4)
Year 5 10 (13.7)
Ethnicity
Malay 66 (90.4) 2 (25.0)
Chinese 1 (1.4) 0 (0)
Indian 3 (4.1) 3 (37.5)
Others 3 (4.1) 3 (37.5)
Type Of Drinks Taken During Breakfast
Coffee 30 (41.1) 3 (37.5)
Tea 33 (45.2) 5 (62.5)
Others 10 (13.7) 0 (0)
Amount Of Sugar Used Per Drink
1-2 tsp+ 53 (72.6) 8 (100.0)
3-4 tsp+ 17 (23.3) 0 (0)
5-6 tsp+ 3 (4.1) 0 (0)
+tsp-teaspoonful
230SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
The data was collected using a standardized
questionnaire by interviewing method. The
questionnaire consists of of two parts, Part I
(pre-stevia challenge) for demographic data and
some information about breakfast preparation and
eating interval and frequency and Part II (post-stevia
challenge) which consists three parts, Part A on
taste, after taste and change in taste Part B about
satiety, eating interval in response to hunger and
carbohydrate craving and part C about acceptance
of stevia.
Data was collected and analyzed according to
participants’ response on taste, satiety, meal
interval, carbohydrate craving and the perception
of stevia consumption. Data analysis was be done
by using the Statistical Package for Social Sciences
(SPSS 21).
Results
A total 73 students and eight lecturers participated in
stevia challenge and all signed the informed consent
form. The mean age of respondents from student
group was 22.0 ± 1.1 years. The majority were female
and from Malay ethnicity. The largest proportion of
respondents was from Year 4. For their breakfast
45.2% drink tea and 41.1% drink coffee. The majority
used 1-2 teaspoonful of sugar per serving.The mean
age of lecturer was 49.5 ±1.1 years and the majority
were males. Most respondents from lecturer group
preferred tea as their morning drink and all of them
took 1-2 teaspoonful of sugar per serving.
Our analysis showed no significant correlation
between demographic variables; age, gender,
academic year, and either type of drinks taken
during breakfast or amount of sugar usually used
per drink.(p >0.05)
During the challenge week, 7% of the respondents
used half sachet of stevia to prepare their drink,
60% used one sachet, 3% needed one and half
sachets and 30% preferred two sachets to achieve
the sweetness level of their liking.
Among respondents, 66.7% like the taste of the
stevia and 68.5% reported that they liked it because
of the sweet taste. Among those who dislike the taste
of stevia, 40.7% reported that it was because of
liquorice taste. While 74.1% reported the aftertaste,
68.3% had sweet aftertaste and 18.3% had bitter
aftertaste. When the drink was prepared with stevia,
change in taste of the drink was noted by 65.4% of
the respondents.
Only 22.2% of respondents reported that the taste
of food is different or changed after drinking with
coffee or tea with stevia and 33.3% stated it was due
to an aftertaste. Overall, 34.6% of the respondents
experienced early satiety, while only 8.6% have
reported change in their appetite. The minority (16%)
had increased carbohydrate craving during stevia
challenge. (Table-2)
The statement “Stevia can be used as a sugar
substitute in everyday consumption” was agreed by
71.6% of the respondents and the most common
reason given by 56.1% is “health benefits”. The
majority (80.2%) considered continuing stevia
for their health benefits and 95.1% would like
to recommend stevia for patients with diabetes.
(Table -3)
Result of our analysis for the correlation between
amount of stevia used and its effect on taste,
aftertaste, change in taste of the drink, satiety and
carbohydrate craving is shown in table 4. The only
significant association is between liking the taste
of stevia, and amount of stevia used (p<0.05). The
respondents who used half or two sachets of stevia
are more likely to like the taste of stevia.
The significant association was found between
acceptance of stevia and liking the taste (p <0.001)
or taste change of the drink when prepared with
stevia (p<0.05). The larger proportion of respondents
who like the taste of stevia demonstrate good
acceptance and the majority of the respondents
who perceived taste change with stevia exhibit poor
acceptance. (Table 5)
Discussions
In this study, we explored the user’s perspective
of stevia and determined the factors related to its
acceptance as a sugar substitute.
231SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Table 2: Taste of stevia product and its effect on the taste of drink
or food, satiety, appetite and carbohydrate craving (n=81)
Variable n (%) Reason n (%)
Taste of the stevia
Sweet 37 (68.5)
Aromatic 11 (20.4)
like
54(66.7) Others:
-Different taste 3 (5.5)
-Sweeter than sugar 2 (3.7)
-Same taste as sugar 1(1.9)
Bitter 5 (18.5)
Metallic 2 (7.4)
Liquorice-like taste 11 (40.8)
dislike
27 (33.3) Others:
-Too sweet 2 (7.4)
-Sweet aftertaste 2 (7.4)
-Taste different from normal sugar 5 (18.5)
Experience after taste of stevia
Bitter 11(18.3)
Yes 60 (74.1) Sweet 41(68.3)
Others 8(13.4)
No 21 (25.9)
Experience taste change of the drink with stevia
Yes 53 (65.4)
No 28 (34.6)
Experience taste change of the food after having a drink with stevia
After taste 6 (33.3)
Sweeter than with sugar 5 (27.8)
Different type of sweetness 2 (11.1)
Yes 18 (22.2) Weird taste 2 (11,1)
Aromatic 2 (11.1)
Less tasty 1 (5.6)
No 63 (77.8)
Experience early satiety
Yes 28 (34.6)
No 53 (65.4)
Experience appetite change
Increased 7 (8.6)
Yes 14 (17.3) Less 7 (8.6)
No 67 (82.7)
Experience carbohydrate craving
Increased 13 (16)
No change 68 (84)
232SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Table 3: Acceptance of stevia product as a sugar substitute(n=81)
Variables n (%) Reason n (%)
Do you agree that stevia can substitute sugar in everyday consumption?
Agree 58 (71.6) 1.Health benefits 33 (56.1)
2. Sweeter than sugar 11 (19)
3. Same taste as sugar 11 (19)
4.Cost 1 (1.7)
5.Minimal after taste 1 (1.7)
6.Approved clinically 1 (1.7)
Neutral 15 (18.5) 1.Different taste from sugar 5 (33.3)
2.Depends on the individual who consume it 4 (26.7)
3.Taste same as sugar 3 (20.0)
4.Too sweet 2 (13.3)
5.Good health benefits 1 (6.7)
Disagree 8 (9.9) 1.Different taste from sugar 3 (37.5)
2.Prefer normal sugar instead of stevia 2 (25.0)
3.Doubt that it is healthier 2 (25.0)
4.Tasteless 1 (12.5)
Do you consider continuing stevia for your health benefits?
Yes 65 (80.2)
No 16 (19.8)
Would you like to recommend stevia for a diabetic patient?
Yes 77 (95.1)
No 4 (4.9)
Table 4: Correlation between amount of Stevia used and its effect on taste,
after taste, taste different, satiety and carbohydrate craving (n=81)
Variable Half‡ One‡ One and Two‡ P-Value
n(%) n(%) a half‡ n(%) n(%)
Yes 5 (83.3) 28 (57.1) 0 21 (87.5)
Liking of taste 0.010*
No 1 (16.7) 21 (42.9) 2 (100) 3 (12.5)
Yes 4 (66.7) 36 (73.5) 1 (50.0) 19 (79.2)
After taste 0.775
No 2 (33.3) 13 (26.5) 1 (50.0) 5 (20.8)
Perceived taste Yes 5 (83.3%) 30 (61.2) 2 (100.0) 16 (66.7)
change of the No 1 (16.7) 19 (38.8) 0.511
drink with stevia
Yes 3 (50) 17 (34.7) 0 (0) 8 (33.3)
Early satiety 0.636
No 3 (50) 32 (65.3) 2 (100) 16 (66.7)
Yes 1 (16.7) 8 (16.3) 1 (50) 3 (12.5)
Carbohydrate craving 0.585
No 5 (83.3) 41 (83.7) 1 (50.0) 21 (87.5)
‡Sachets
233SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Among our respondents, the majority of them like the
taste of stevia and reported sweet aftertaste. This
finding is similar to that reported by Bartolotto25 and
different from the findings of Sontrunnarudrungsri &
Tejo,26 in which the majority of the respondents have
an aftertaste of bitter or astringent and undesirable.
The different finding might be the result of different
preparation of stevia used in our research, which is
a commercialized product and is mixed with other
substance whereas in the previous study a pure
extract from stevia leaves was used.
Table 5: Correlation between perception of liking of taste, after taste, taste change,
satiety and carbohydrate craving, and acceptance (n=81)
Variable Poor acceptance n (%) Good acceptance n (%) P-Value
Yes 12 (40.0) 42 (82.4) 0.000***
Liking of taste
No 18 (60.0) 9 (17.6)
After taste Yes 23 (76.7) 37 (72.5) 0.683
No 7 (23.3) 14 (27.5)
Perceived taste Yes 24 (80.0) 29 (56.9) 0.034*
change of the
drink with stevia No 6 (20.0) 22 (43.1)
Early satiety Yes 9 (30.0) 19 (37.3) 0.507
No 21 (70.0) 32 (62.7)
Carbohydrate craving Yes 6 (20.0) 7 (13.7) 0.458
No 24 (80.0) 44 (86.3)
More than half of our respondents reported no
change in satiety during stevia consumption, that
is similar to the findings of a previous study.27 In a
previous study, most of the respondents consume
less food after taking the stevia but our participants
reported same level of appetite during the challenge
week.27 We can assume that the appetite may be
reduced if the stevia is given in all three set course
meals consisting of breakfast, lunch and dinner as in
the previous research. At the same time,we have to
acknowledge the shortcoming of our data collection
method in which we only record the appetite change
at the end of the one-week stevia challenge which is
different from previous research which recorded the
appetite or hunger by using visual analogue scale
before and after each meal daily.
The majority of our respondents reported no change
in carbohydrate craving. This finding is adding the
evidences from previous studies which revealed
stevia does not increase or help in reducing
carbohydrate craving among consumers.25,28,29 No
report of decrease in carbohydrate craving among
our respondents, was also an expected finding as
this effect can be seen after two weeks up to a
month after consuming the stevia. The participants
who reported carbohydrate craving must be
compensating the amount of calories that they lost
during the breakfast as reported that low calories
sweetener, providing sweetness without energy,
confuse the body's regulatory mechanisms.30
In this modern era, consumers around the world
have increasing awareness about potential health
goodness by reducing calories and sugar intake
causing a shift in consumer preferences for healthier
low calorie and less sugar food and beverages. There
is limited research data on consumer and health care
professional perception and attitudes towards low or
no calories sugars.In our study, it shows that 71.6%
of respondents agree that stevia could substitute
sugar in everyday consumption. This result is very
similar to a study done in Malaysia, which shows
that the majority of their respondents willing to use
stevia-based products as a sugar substitute.11 Their
study findings also indicate a significant correlation
234SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
between consumer’s education level and their
willingness to change to stevia-based products.
However, in our study as majority of our respondents
are well health educated, MBBS degree students
and lecturers who hold Ph D and Master degrees
therefore we could not determine this association.
According to a study from California, most
participants stopped craving of sugar after six days
of sugar challenge by cutting all added sugars and
artificial sweeteners for two weeks.25 However,
the practicality of stopping sugar consumption
without using sweeteners are not supported by
the evidence provided by Li, Lopetcharat & Drake
which indicates the chocolate milk sweetened with
monk fruit and stevia leaf extract is more favoured
by the young adults than less sweetened skimmed
chocolate milk.31
Health benefits, promotion, availability, and price
were found to be the most influential factors
toward acceptance of Stevia-based products by
consumers.13 In our study, we differentiate poor
acceptance and good acceptance based on the
composite score calculated from the positive
or negative response to three strong statement
questions listed in table 3,one of which is related to
health benefits. In our study, liking the taste of stevia
has strong influence on acceptance.
Again, the after taste may play a role in accepting
any sugar substitute. It has been proved that a
bitter aftertaste was predominated with 20% or
higher level of rebaudioside A and it influence the
user’s acceptance.32 However, the results of our
analysis did not support their finding of the relation
of aftertaste and consumer’sacceptance. The
strong point behind it, is that we used the product
which contains flavourings and the majority of our
participants had sweet aftertaste which might be
quite acceptable for them.However, among our
participants, taste change of the drink while prepared
with stevia was negatively linked to the acceptance.
Based on the results, we agreed with the suggestion
made by Verruma-Bernardi et al to look into
optimization of sucrose levels to increase acceptance
while minimizing added calories as their study
findings indicate that chocolate milk which used
stevia alone was least preferred and that which
used of stevia and small amounts of sucrose was
most preferred among school age children. The
latter preparation saved 40 calories per serving
and increased taste acceptance of chocolate milk.33
Actually, while global community is fighting against
obesity epidemic, zero calorie natural sweeteners
become popular as a good substitution of sugar
or sugared products. A recent polish survey
showed nearly 40% of respondents reported to use
sweeteners and nearly half of them are regular users.
Among natural and artificial sweeteners, stevia and
xylitol are most commonly used and the usage is
strongly linked with university education, big city
residency and good financial situation.34
While stevia use is in rising trend, we need
to look at benefits and risks of long term use
including the safety of its use in pregnancy. A
recent review summarized anti- inflammatory, anti-
carcinogenesis, anti-atherosclerotic, anti-diabetic
and anti-hypertensive potential of stevia and a
growing scientific evidence of anticarcinogenic effect
of Stevia rebaudiana Bertoni by inhibition of DNA
replication in human cancer cell growth in vitro.35
Natural sweetener Stevia could also be a good
alternative to sugar for pregnant women with
diabetes as FDA rated as GRAS (generally
recognized as safe) based on the favourable results
from animals studies,36 while in-utero exposure
of artificial sweeteners could lead to potential to
congenital structural malformations and atypical
mammary gland structure as demonstrated in mice.37
Therefore our health care professionals must be
well updated with the evidence based knowledge
about the benefits and risks of the use of natural
sweeteners that penetrating to the international
market and at the same time should be ready to
explore more with observational research and
clinical trials based on human subjects. With the
support of Government and active participation of
health care professionals in promoting use of non-
caloric sweeteners in food production, there will
be voluminous change in public food consumption
pattern and high chance of winning in fight of rising
trend in obesity.
235SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
Limitations
The main limitation of our research was the time
constraint as we conducted this study as a student
research project which allowed only one month
to complete. Therefore, we could not perform the
stevia challenge more than one week. Furthermore,
we did our our stevia challenge only for the
breakfast therefore the findings are more accurate
for investigating the taste, after taste, change in
taste and satiety but not for carbohydrate craving.
Besides,we did not explore some possible factors
related to its acceptance such as cost, availability,
previous knowledge and promotion because our
sampling frame is in health educated environment.
Conclusion and Recommendations
The majority of our respondents liked the taste
of stevia and demonstrated good acceptance of
commercially available stevia product. Most of them
would recommend it to diabetic patients. Liking
sweet taste of stevia and perceived taste change
of the drink, determined the acceptance of stevia
product among health educated individuals. Future
research should focus on effectiveness of natural
sweeteners in reducing calorie intake to fight against
obesity to provide public health policy makers with
more evidence based information on use of non-
caloric sweeteners.
Acknowledgements
We would like to express our greatest appreciation
to all respondents who took stevia challenge and
responded the questions completely and accurately.
Funding
The author(s) did not receive any funding for this
project.
Conflict of interest
The authors have no personal, professional or
financial connection with any stevia product company.
Therefore we confirm that there are no known
conflicts of interest associated with this publication
and there has been no significant financial support
for this work that could have influenced its outcome.
References
1. Raben A., Vasilaras T.H., Moller A.C.,Astrup
A. Sucrose compared with artificial
sweeteners: different effects on ad libitum
food intake and body weight after 10 wk
of supplementation in overweight subjects.
Am J Clin Nutr.2002;76:721–729.
2. Le K.A., Ith M., Kreis R., Faeh D., Bortolotti
M., Tran C., Boesch C.,Tappy L. Fructose
overconsumption causes dyslipidemia and
ectopic lipid deposition in healthy subjects
with and without a family history of type 2
diabetes. Am J ClinNutr. 2009; 89(6):1760–5.
3. Stanhope K.L., Schwarz J.M., Keim N.J.,
Griffen S.C., Bremer A.A.,Graham J.L.
Consuming fructose-sweetened, not glucose
sweetened, beverages increases visceral
adiposity and lipids and decreases insulin
sensitivity in overweight/obese humans.
J Clin Invest. 2009; 119:1322–1334.
4. Willett W., Manson J., Liu S. (2002). Glycemic
index, glycemic load, and risk of type 2
diabetes. Am J Clin Nutr.2002; 76:274S–280S
5. O’Keefe J.H., Bell D.S. Postprandial
hyperglycemia/hyperlipidemia (postprandial
dysmetabolism) is a cardiovascular risk factor.
Am J Cardiol.2007;100:899–904.
6. Mattes R.D.,PopkinB.M..Nonnutritive
sweetener consumption in humans: effects
on appetite and food intake and their putative
mechanisms. Am J Clin Nutr.2009; 89:1–14.
7. Clinical Practice Guideline Malaysia Diabetes
Mellitus (2015, 5th Edition).
8. Panpatil V.V.,Polasa K. Assessment of stevia
(Stevia rebaudiana)-natural sweetener:
A review. J Food SciTechnol.2008;45:67-473.
9. JECFA (Joint FAO/WHO Expert Committee
on Food Additives). Compendium of Food
Additive Specifications. Monograph 5. Steviol
glycosides. 2008. http://www.fao.org/ag/agn/
jecfa-additives/details.html?id=898.Accessed
6-8-2019
10. EFSA Panel on Food Additives and Nutrient
Sources (ANS); Scientific Opinion on safety of
steviol glycosides for the proposed uses as a
food additive. EFSA Journal 2010;8(4):1537.
[85 pp.]. doi:10.2903/j.efsa.2010.1537
11. Kamarulzaman N. H., Jamal K., Vijayan G., Ab.
Jalil S. M. Will Consumers Purchase Stevia as
236SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
a Sugar Substitute? : An Exploratory Study
on Consumer Acceptance. J Food Prod Mark.
2014;20:122-139.
12. "Has Stevia been approved by FDA to be
used as a sweetener?". US Food and Drug
Administration. 28 April 2017. https://www.
fda.gov/about-fda/fda-basics/has-stevia-
been-approved-fda-be-used-sweetener
Accessed 6-8-2019
13. Tejo V. K., Karsodihardjo S.,Ananingsih V. K.
Stevia Rebaudiana: an Excellent
Natural Alternative for Sugar Replacer.
The Third International Congress on
Interdisciplinary Research and Development,
30 -31 May 2013, Thailand. www.ijcim.
com › SpecialEditions accessed Accessed
6-8-2019
14. Gandhi S., Gat Y., Arya S., et al. Natural
sweeteners: health benefits of stevia. Foods
and Raw Materials, 2018, vol. 6, no. 2, pp.
392–402.
15. TechnischeUniversitaetMuenchen. Bitter
taste receptors for Stevia sweeteners
discovered. https://www.sciencedaily.com/
releases/2012/05/120531102334. Accessed
6-8-2019
16. Prakash I.,Markosyan A.,Bunders C.
Development of Next Generation Stevia
Sweetener: Rebaudioside M. Foods (Basel,
Switzerland). 2014;3(1), 162–175.
17. Anton S. D., Martin C. K., Han H., Coulon
S., Cefalu W. T., Geiselman P., Williamson
D.A.Effects of stevia, aspartame, and sucrose
on food intake, satiety, and postprandial
glucose and insulin levels. Appetite.
2010;55(1), 37–43.
18. Tey S.L., Salleh N.B., Henry J., Forde C.G.
Effects of aspartame-, monk fruit-, stevia
and sucrose-sweetened beverages on
postprandial glucose, insulin and energy
intake. Int J Obes (Lond). 2017;41:450–7.
19. deRuyter J.C., Olthof M.R., Seidell J.C.,Katan
M.B. A trial of sugar-free or sugar-sweetened
beverages and body weight in children. N
Engl J Med.2012;367:1397-1406
20. Samuel P.,Okonneh A. Consumer awareness
and perception of sweeteners influences
food and beverage decisions: 21st IUNS
International Congress of Nutrition. Ann
NutrMetab. 2017;71 (abstr 144/2140).
21. Lum M. Malaysia is Asia’s fattest country.
Malaysia is Asia’s fattest country. 14 August
2018,https://www.thestar.com.my/lifestyle/
health/2018/08/14/fat-state-of-affairs/
Accessed 2-3-2020
22. Kasim NB, Ahmad MH, Shaharudin AB, Naidu
BM, Ying CY, Aris HT. Food choices among
Malaysian adults: Findings from Malaysian
Adults Nutrition Survey (MANS) 2003 and
MANS 2014. Malaysian Journal of Nutrition.
2018 Mar 1;24(1)
23. Gan WY, Mohamed SF, Law LS. Unhealthy
Lifestyle Associated with Higher Intake
of Sugar-Sweetened Beverages among
Malaysian School-Aged Adolescents. Int J
Environ Res Public Health. 2019;16(15):2785.
24. Parker MN, Lopetcharat K, Drake MA.
Consumer acceptance of natural sweeteners
in protein beverages. J Dairy Sci. 2018
Oct;101(10):8875-8889.
25. Bartolotto C. Does Consuming Sugar
and Artificial Sweeteners Change Taste
Preferences?.The Permanente journal.
2015;19(3): 81–84.
26. Soontrunnarudrungsri A.,Tejo V. K. Effect of
Color and Flavor on the Perceived Intensity
of Stevia (Stevia rebaudiana) in Sweetened
Beverage Products. 2013.
27. Bellisle F., Drewnowski A., Anderson G.H.,
Westerterp-Plantenga M., Martin C.K.
Sweetness, satiation, and satiety. J Nutr.
2012;142(6):1149S-54S.
28. Arora E., Khajuria V., Kumar S., Gillani Z., Sadiq
S.,Tandon V.R. Stevia: A promising herbal
sweeteners. JK science.2010;12(4):212.
29. Goyal S.K., Samsher G.R., Goyal R.K. Stevia
(Stevia rebaudiana) a bio-sweetener: a
review. Int J Food SciNutr. 2010; 1; 61(1):1-0.
30. Swithers S.E., Davidson T.L. A role for sweet
taste: calorie predictive relations in energy
regulation by rats. Behav. Neurosci.2008
Feb;122(1):161.
31. Li X., Lopetcharat K., Drake M. Parents’ and
Childrens Acceptance of Skim Chocolate
Milks Sweetened by Monk Fruit and Stevia
Leaf Extracts.J Food Sci. 2015; 80(5).
32. Cardello H.M., Da Silva M.A.,Damasio M.H.
Measurement of the relative sweetness of
stevia extract, aspartame and cyclamate/
saccharin blend as compared to sucrose
237SAHARUDIN et al., Curr. Res. Nutr Food Sci Jour., Vol. 8(1), 226-237 (2020)
atdifferent concentrations. Plant Foods Hum
Nutr. 1999; 54(2):119-30.
33. Verruma-Bernardi M.R., Lee K., Palchak
T.,Bordi P.L. Chocolate Milk Sweetened
With Stevia: Acceptance by Children.
J ObesOverweig.2015;1(1): 103.
34. Pielak M, Czarniecka-Skubina E, Trafiałek
J, Głuchowski A. Contemporary Trends and
Habits in the Consumption of Sugar and
Sweeteners-A Questionnaire Survey among
Poles. Int J Environ Res Public Health.
2019;16(7):1164.
35. Rojas E, Bermúdez V, Motlaghzadeh Y,
Mathew J, Fidilio E, Faria J et al. Stevia
rebaudiana Bertoni and Its Effects in
Human Disease: Emphasizing Its Role in
Inflammation, Atherosclerosis and Metabolic
Syndrome. Current Nutrition Reports. 2018;
7(3):161-170.
36. Pope E, Koren G, Bozzo P. Sugar substitutes
during pregnancy. Can Fam Physician.
2014;60(11):1003–1005.
37. Fatma M. Al-Qudsi & Manar M. Al-Hasan.
In utero exposure to commercial artificial
sweeteners affects mice development and
mammary gland structure. Environ Sci Pollut
R .2019;26:5054–5064
