November 2010 Issue

Sugar Substitutes — Useful Ingredients in Effective Diabetes Management
By Christin L. Seher, MS, RD, LD
Today’s Dietitian
Vol. 12 No. 11 P. 12

It is a sentiment commonly overheard in conversations with patients newly diagnosed with diabetes mellitus: “I have to give up cake, give up sweets, give up (fill-in-the-blank with favorite food). What the heck am I going to eat?”

Well, good news: Unlike in years past, when healthcare professionals recommended that patients with diabetes eliminate foods with sugars from their diet, today’s clinical management guidelines include some wiggle room when it comes to allowing for our patients’ favorite sweet treats. These foods are no longer the ubiquitous “bad guys” and can be successfully incorporated into a diabetes management plan when consumed in moderation and included wisely.

Sweet Options
Foods are most commonly sweetened with natural sources of sugar. Effective diabetes management includes accounting for such sugars, whether found organically in foods or added by choice. These natural sugars include table sugar (sucrose), fructose, honey, brown sugar, molasses, maple syrup, and agave nectar and are considered nutritive sweeteners, supplying 4 kcal per gram to the diet. Sugars of this type are also metabolically active, raising blood glucose upon consumption and making prudent intake crucial for successful diabetes management.

In the United States, recommendations to consumers via the Dietary Guidelines for Americans, MyPyramid, and the Dietary Reference Intakes suggest individuals who elect to consume natural sources of sugar that contribute energy to the diet maintain their intake at roughly 10% to 25% of total daily kilocalories for optimal health.1 Cautions to minimize added sugars allow for total calories to remain within recommended ranges, contributing to weight management and glycemic control efforts and allowing dietary quality to remain relatively high.

It is important to note that the glycemic response to sugar does not differ from that of other carbohydrates (eg, starches) when it comes to diabetes management. While sugars may elicit a quicker metabolic response, it is total carbohydrate intake that is the predominant factor in blood glucose management, of which sugar intake is only one component.

Over the past 15 years, there has been an increase in artificial products designed to help consumers avoid the calories and metabolic effects of nutritive sugars, thus making them useful tools for diabetes management. These nonnutritive sweeteners (also known as sugar substitutes) can help individuals with diabetes manage their blood glucose more easily while allowing them to consume many of their favorite foods.

Sugar substitutes can be roughly broken down into two categories: artificial sweeteners and sugar alcohols. Artificial sweeteners include aspartame, saccharin, acesulfame potassium, sucralose, and neotame. These products contribute no calories to the diet, pack high-intensity sweetness in a small amount of product, and elicit a negligible glycemic response, making them attractive to those with diabetes.

A new type of sweetener recently introduced to the market is derived from the stevia leaf, a plant native to Central and South America. One compound isolated from the stevia plant (Reb A) is calorie free (allowing it to be used like a sugar substitute) and 200 to 300 times sweeter than sugar, and it received Generally Recognized as Safe status from the FDA in 2008.2 However, it differs from artificial sweeteners in that claims can be made that it is from a “natural” plant source. These properties make sweeteners derived from Reb A an attractive alternative to nutritive sweeteners for those with diabetes; studies indicate that sweeteners derived from Reb A are just as effective as other artificial sweeteners. A panel of experts from the World Health Organization recommends intake of 0 to 4 mg/kg of body weight as a safe daily intake.

Sugar alcohols (eg, sorbitol, mannitol, xylitol) are reduced-calorie sweeteners that still provide calories (approximately 2 kcal/g) yet are less energy dense than natural sources of sugar due to their incomplete metabolism. They are not without side effects, though; because sugar alcohols are not completely digested and absorbed, they can lead to gastrointestinal distress for some individuals. For many consumers, however, sugar alcohols are acceptable substitutes for the real thing.

But Are Sugar Substitutes Safe?
According to the American Dietetic Association’s (ADA) position statement on the use of nutritive and nonnutritive sweeteners, there are several benefits to using sugar substitutes. Aside from minimizing the metabolic effects to blood glucose levels that occur with the consumption of nutritive sugars, sugar substitutes can be extremely useful for weight management efforts, which in turn can help keep blood glucose levels in check. Particularly appealing is sugar substitutes’ ability to add palatability to some low-calorie foods without substantially increasing caloric content.

Despite their benefits, many consumers are hesitant about incorporating sugar substitutes into their diet based on early scientific data suggesting a possible link to cancer. (This was an issue specifically with aspartame.) According to the National Cancer Institute, there are currently no substantial data linking the consumption of moderate quantities of FDA-approved artificial sweeteners (amounts that fall within the Acceptable Daily Intake levels set by the Dietary Reference Intakes) to cancer in human epidemiological studies conducted thus far.

Some research, however, indicates that individual tolerance for these products can vary, with some individuals reporting negative side effects (eg, headaches) with consumption. As with all foods, personal tolerance should be a consideration when deciding whether to incorporate these products into the diet. Dietitians seeking further discussion on the safety of sugar substitutes that is applicable to dietetics practice can refer to the ADA’s position statement.1

Additionally, the American Diabetes Association cautions that using sugar substitutes comes with a few additional concerns, including an often higher price tag for prepared products, a higher fat content for palatability, significant amounts of carbohydrates remaining in the product despite advertised claims, and potential gastrointestinal side effects (especially with sugar alcohols). For these reasons, some individuals with diabetes choose to consume foods without sugar substitutes; for those with this preference, the ADA recommends these foods be consumed in small quantities and balanced with other carbohydrate intake.

Practice Tips for RDs
The ADA encourages dietitians to dialogue with the public about the uses of both nutritive and nonnutritive sweeteners using science-based evidence and keeping in mind total diet quality rather than individual foods or food products.1

According to Tammy Randall, MS, RD, LD, CDE, director of education at the Diabetes Association of Greater Cleveland and current Ohio Dietetic Association president, one of the best ways RDs can help clients with diabetes successfully incorporate sugar substitutes into their diet is by educating them on how to accurately evaluate the foods they consume and not make choices based on manufacturer packaging. “It is vital to teach patients how to use the Nutrition Facts label,” she says. “If they just read the big print on the front of the package, they often make misinformed decisions about what foods to purchase.”

For example, “Sugar alcohols, although often used in ‘sugar-free’ products, are not calorie and carbohydrate free, so patients should read the Nutrition Facts labels carefully,” says Randall, and pay attention to the total carbohydrate content of a food product to achieve optimal blood glucose management.

By helping their clients determine whether or not these products are in line with their disease management goals and personal preferences, RDs can assist those with diabetes in achieving better glycemic control without placing undue restrictions on the types of foods consumed.

— Christin L. Seher, MS, RD, LD, is founder of Strategic Health Solutions, LLC, serving northeastern Ohio.


1. American Dietetic Association. Position of the American Dietetic Association: Use of nutritive and nonnutritive sweeteners. J Am Diet Assoc. 2004;104(2):255-275.

2. American Dietetic Association. Hot topic: Stevia. June 2009. Available at:  Accessed October 8, 2010.