July 2017 Issue
Diabetes Management & Nutrition Guide: Best Sweeteners for People With Diabetes
By Densie Webb, PhD, RD
Vol. 19, No. 7, P. 48
Research suggests there's no one sweetener that's best for people with diabetes, but dietitians can advise patients to use a variety of nonnutritive sweeteners to reduce intake of added sugars.
The prevalence of diabetes and obesity has increased substantially over the last few decades, and with it has come an increase in consumption of nonnutritive sweeteners.1 As defined by the American Diabetes Association, nonnutritive sweeteners, also known as very low-calorie sweeteners, artificial sweeteners, noncaloric sweeteners, and intense sweeteners, have a higher intensity of sweetness per gram than caloric sweeteners such as sucrose, corn syrups, and fruit juice concentrates.2 Because they provide virtually no calories or carbohydrates, people with diabetes frequently use them to provide a sweet taste without affecting blood sugar.
Currently, there are seven nonnutritive sweeteners that either have been FDA approved, given GRAS (generally recognized as safe) status, or simply allowed for use in the United States: acesulfame K, aspartame, monk fruit (luo han guo fruit extract), neotame, saccharin, stevia, and sucralose. To be clear, while all artificial sweeteners are nonnutritive sweeteners, not all nonnutritive sweeteners are artificial sweeteners (eg, stevia and monk fruit). But are any of these nonnutritive sweeteners better than others for people with diabetes?
While some studies have suggested that consumption of nonnutritive sweeteners, especially artificial sweeteners (eg, acesulfame K, aspartame, neotame, saccharin, and sucralose), contributes to cancer, infertility, cardiovascular disease, and, ironically, increased appetite, ultimately the FDA and Health Canada have determined they all are safe.3 In addition, the European Food Safety Authority3 has approved these and a few other sweeteners, including cyclamates, thaumatin, and neohesperidine DC. While the FDA hasn't officially reviewed monk fruit for GRAS status, the agency hasn't questioned the sale of the sweetener by companies requesting GRAS status.4
Blood Sugar Management
Despite their safety determination, one study suggested that artificial sweeteners could lead to diabetes by causing changes in gut microbes. While this research was conducted in animals and focused only on artificial sweeteners, not stevia or monk fruit extract, it has raised questions.5 However, another part of the study examined the artificial sweetener intakes of 381 people and found significant positive correlations between artificial sweetener consumption and several metabolic syndrome–related clinical parameters, including increased weight and waist-to-hip ratio and higher fasting blood glucose, glycosylated hemoglobin, and glucose tolerance test. In a much smaller group, seven healthy volunteers who normally didn't consume artificial sweeteners or foods containing artificial sweeteners consumed artificial sweeteners for one week. During this week, participants consumed the FDA's maximal acceptable daily intake of saccharin divided into three daily doses, equivalent to 120 mg, and were monitored by continuous glucose measurements and daily glucose tolerance tests. In this short-term, seven-day test, most individuals (four out of seven) developed significantly poorer glycemic responses five to seven days after artificial sweetener intake compared with their individual glycemic responses beforehand.
Further muddying the waters are the findings from a recent systematic review of several studies that examined the association between intake of nonnutritive sweeteners, which included artificial sweeteners, and the development of metabolic diseases, mainly type 2 diabetes. Many of the subjects in the studies were overweight or obese.6
If artificial sweeteners do indeed cause weight gain, as suggested by the study mentioned above, the findings are difficult to interpret (ie, did artificial sweeteners contribute to weight issues or were people who were overweight or obese more likely to use artificial sweeteners?). The same problem exists when interpreting the findings to determine whether other nonartificial nonnutritive sweeteners, such as stevia or monk fruit, are associated with negative effects on appetite regulation. The review concluded that, based on the available evidence, an effect of nonnutritive sweeteners as a whole on glucose metabolism hasn't been established.
When it comes to taste, preferences vary greatly and are determined in part by genetics.7 This is evidenced by the fact that, in addition to eliciting sweet sensations, many nonnutritive sweeteners also can have objectionable side tastes, such as bitterness, that are experienced by some, but not all, individuals.8 Concerns also have been raised regarding those who perceive these nonnutritive sweeteners as sweet, rather than bitter, and therefore regularly include nonnutritive sweeteners in the diet, possibly resulting in a conditioning for sweet taste and increasing the likelihood that sugar-containing foods and beverages will be consumed.7 Further complicating the taste issue, is that people with either type 1 or type 2 diabetes tend to have a blunted sensation of the sweet taste, potentially creating a preference for sweet-tasting foods.9,10 An older study found that taste was impaired among 73% of a group of patients with type 1 diabetes, compared with 16% of those without the disease.11 However, animal studies have found that nonnutritive sweeteners don't produce the same preference for sweetness that sucrose and fructose do.12
Substituting nonnutritive sweeteners for sugar isn't a one-for-one substitution, and it isn't the same across the board. Some work best in cold beverages, some only in acidic drinks like lemonade, and others work best in baked goods. The best source of information on using any of the nonnutritive sweeteners will be each of the manufacturers' websites. Nonnutritive sweeteners behave differently than sugar, not only in providing a sweet taste but also in browning, rising, and tenderness, so it's important to use them correctly. Sugar also helps retain moisture, so baked goods made with nonnutritive sweeteners tend to grow stale more quickly. Though preferences are quite personal, according to Angela Ginn-Meadow, RD, LDN, CDE, a spokesperson for the Academy of Nutrition and Dietetics, "My clients consume a variety of sweeteners, but they report sucralose to be the most versatile."
No one sweetener can be singled out as a best choice for people with either type 1 or type 2 diabetes, but experts generally advise using a variety of nonnutritive sweeteners to lower dietary intake of any one particular sweetener and reduce potential risk and intake of added sugars in the diet. "I advise clients to use an 80/20 rule—80% of the time consume foods in their natural form without added sweeteners or nonnutritive sweeteners, and 20% of the time use a nonnutritive sweetener to enhance the sweetness of foods you feel you can't live without," Ginn-Meadow says. In addition, she says to ensure clients and patients know that "sugar-free" doesn't equal "carbohydrate-free."
— Densie Webb, PhD, RD, is a freelance writer, editor, and industry consultant based in Austin, Texas.
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2. Gardner C, Wylie-Rosett J, Gidding SS, et al. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care. 2012;35(8):1798-1808.
3. Low calorie sweeteners regulations and safety. International Sweeteners Association website. http://www.sweeteners.org/category/11/sweeteners/56/low-calorie-sweeteners-regulation-and-safety. Updated October 10, 2016. Accessed May 5, 2017.
4. Agency response letter GRAS notice GRN 000301. FDA website. https://www.fda.gov/Food/IngredientsPackagingLabeling/GRAS/NoticeInventory/ucm200326.htm. Updated December 8, 2014. Accessed May 8, 2017.
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