SWEETENERS… WHICH ONES SHOULD I USE IF I HAVE DIABETES?
The need for sweetness is said to be innate, however people differ in their preference for sweetness as well as how sweetness is perceived1. Today however, most of us are consuming way too much added sugar, especially “hidden” in foods such as sauces, sugar sweetened foods and beverages2. The WHO (2018) recommends that adults and children reduce their daily intake of free (added) sugars to less than 10% of their total energy intake, which works out to about 12 teaspoons of added sugar per day (based on a 2000 kcal diet)1. They recommended a further decrease to 5%, which is 6 teaspoons per day1. This guideline however does not refer to intrinsic or natural sugars found in fresh fruits, vegetables and milk3.
People living with Diabetes have to be extra careful with the amount of sugar and carbohydrates that they are consuming. For those who struggle with cutting out this sweetness, the use of Non Nutritive sweeteners (NNS) in foods and drinks is great way to help curb your cravings for something sweet without the calories and effect on blood sugar levels1,2. The American Diabetes Association (ADA) (2018) states that NNS (containing few or no calories) may be an acceptable substitute for nutritive sweeteners (those containing calories such as sugar, honey, agave syrup) when consumed in moderation4.
Sweeteners are divided into 2 categories, nutritive and non-nutritive1,2,5,6.
NUTRITIVE SWEETENERS
Nutritive sweeteners (NS) contain carbohydrates and provide energy. They are often referred to as sugars, caloric sweeteners and added sugars. Nutritive sweeteners provide 4 kcal per gram1,2,5,6. They are found naturally in foods such as fruit, vegetables and dairy. Examples include: Glucose (primary source of energy for body cells), Lactose (Dairy) Sucrose (table sugar), Fructose (found in fruit), Maltose (found in malt, beer and ales), Honey, Galactose and Agave Nectar1,2,6.
In their natural state, sugars from fruit, vegetables and milk can be included daily1,3. That being said it is still important to consider how much carbohydrate you are eating at once.
SUGAR ALCOHOLS OR POLYOLS
They are also classified as NS and can be found in nature, but are manufactured from different sugars2,5,6. They are absorbed slower, incompletely and provide an average of 2 kcal per gram1,2,5,6. E.g. Erythritol, Xylitol, Mannitol, Sorbitol, Isomalt, Lactitol, Maltitol and D – Tagatose1,2,5,6. The use of sugar alcohols appears to be safe however some e.g. mannitol and sorbitol have been known to cause gastrointestinal side effects (bloating, diarrhoea and cramps2,5,6, especially in children. Their use has also been shown to reduce the risk of dental caries2.
NON-NUTRITIVE SWEETENERS
Non-nutritive sweeteners are different to NS as they have little to no energy1,2,5,6. Other names for NNS include artificial sweeteners, low-calorie sweeteners, non-caloric sweeteners or intense sweeteners1. NNSs are many times sweeter than sucrose however do not have the same functional properties as sugar1,7. NNS when substituted for nutritive sweeteners, may help consumers limit carbohydrate and energy intake as a strategy to manage blood glucose or weight1,2,5,6,7.
There are currently six U.S Food and Drug Administration (FDA) approved Non-Nutritive Sweeteners. These are: Acesulfame potassium (Acesulfame K), Aspartame, Saccharin, Sucralose, Neotame and Advantame1,7. Stevia and Luo Han Guo fruit extracts have been given a Generally Recognised As Safe (GRAS) status. Most of these besides Neotame and Advantame are commonly used in South Africa. See the table below for more information on these Non-Nutritive Sweeteners1,2,7.
|
Non- Nutritive Sweetener |
Sweetness compared to sugar |
Information & examples |
Acceptable Daily Intake (ADI) milligrams per kilogram body weight per day (mg/kg bw/d) |
Number of Table top Sweetener Packets Equivalent to Acceptable Daily Intake (ADI)*** |
|
Saccharin |
200 to 700 times sweeter than sugar |
e.g. naTreen Classic, Clicks Saccharin Tablets - One of the oldest NNS - Used in beverages, fruit juice drinks, sugar substitute for cooking or table use, in processed foods. - Not metabolized in the body - Heat stable - Previously thought it was linked to cancer risk, 30 human studies disproved this and concluded it to be safe for human consumption. - EDI: 0.1-2 mg per kg body weight |
15 |
45 (sweetness intensity at 400 x sucrose) |
|
Aspartame (approved 1981 & 1983) |
200 times sweeter than sugar |
e.g. Canderel, EquiSweet Classic, Equal, Pick’n Pay, - General use sweetener (any food or beverage). - Provides 4 kcal / g however a small amount used to achieve desired sweetness - Not heat stable & loses its sweetness when heated - Contains phenylalanine, therefore avoid aspartame. - More than 100 studies supporting its Safety - EDI: 0.2 - 4.1mg per kg body weight |
50 |
75 |
|
Acesulfame potassium / Ace-K (approved 1988) |
200 times sweeter than sugar |
e.g. Huletts Sugarlite, Canderel, Selati sweetner, Equal - Used as general purpose sweetener and flavour enhancer in food, except meat & poultry - Heat stable – useful in baking - More than 90 studies support its safety. - EDI: 0.2 - 1.7 mg per kg body weight |
15 |
23 |
|
Sucralose (approved 1998 & 1999) |
600 times sweeter than sugar. |
e.g. Selati Sucralose low kiloJoule sweetener, Splenda, Canderel with Sucralose (yellow), EquiSweet Sucralose - General purpose sweetener that can be found in a variety of foods - Heat stable – useful in baking - 110 studies showing safety - EDI: 0.1 - 2.0 mg per kg body weight |
5 |
23 |
|
Stevia or steviol \ glycosides |
200 to 400 times sweeter than table sugar. |
e.g. EquiSweet Stevia, Canderel Green with Stevia - Extracted from the leaves of the plant species Stevia rebaudiana. It can be found in the form of fresh leaves, dried leaves (chopped or powdered) and processed leaf extract resulting in a powder or liquid.7 - Steviol glycosides-rebaudioside A & stevioside are extracted from leaves of Stevia rebaudiana Bertoni - GRAS status (Generally Recognised as safe) - ADI: 4mg per kg body weight - EDI: 1.3-3.4 mg per kg body weight |
4 (ADI established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) |
9 (sweetness intensity at 300 x sucrose) |
|
Neotame (Approved 2002) |
7,000 to 13,000 times sweeter than table sugar |
- General purpose sweetener and flavour enhancer in foods (except in meat and poultry) - Heat stable – useful in baking - EDI: 0.05-0.17 mg per kg body weight |
0.3 |
23 (sweetness intensity at 10,000 x sucrose) |
|
Advantame (approved 2014) |
20,000 times sweeter than table sugar |
- General purpose sweetener and flavour enhancer in foods (except in meat and poultry) - Heat stable – useful in baking - 37 studies showing safety |
32.8 |
4920 |
*** Number of Table top Sweetener Packets a 60 kg person would need to consume to reach the ADI. Calculations assume a packet of high-intensity sweetener is as sweet as two teaspoons of sugar.
WHAT ABOUT THE CONCERNS?
Cancer Risk
Regarding NNSs and cancer risk, there has always been a concern that the use of certain NNS causes cancer. Most of the studies showing an association have been done in animals8. Caution must be taken when attempting to extrapolate animal data to humans, as carcinogenic mechanisms do differ between humans and experimental animals, such as rats8. The Cancer Association of South Africa (CANSA), released a statement that said “at this time, due to the inconclusive evidence available and limited human studies, CANSA, continues to follow the research done on non-nutritive sweeteners, overall health during the lifecycle and the possible link to cancer risk in humans.”
Gut Influence
It was previously thought that NNS had no effect in the gut; however research is showing that this might not be the case. Sucralose, aspartame and saccharin, all widely used to reduce energy intake, promote satiety and encourage weight loss, have been shown to disrupt the balance and diversity of gut microbiota9. Other reported effects are elevated fasting glucose levels, impaired insulin tolerance and weight gain. Most of the research has been done in animal studies, with human studies showing both a positive and negative effect on glycaemic parameters10. Most of the research on the consumption of NNS, mainly in diet sodas, is associated with increased risk of obesity, metabolic syndrome, and type 2 diabetes, compared with those that do not consume ASB. With some saying that this risk is similar to those associated with Sugar Sweetened Beverages (SSB) intake10,11. In a recent review authors showed that there is no benefit for the use of NNS for weight management, and there may be associated with increased BMI and cardio metabolic risk12. However, researchers note that there is a place for ASB and that the negative consequences of ASB should not be interpreted to suggest that sugars should be consumed in preference11.
Another concern is that NNS as a replacement for sugar, interferes with the physiological mechanism of the sweet taste and therefore energy balance. The sweet taste tells your body that it can expect food and should prepare to breakdown the food for energy. By weakening this “sweet taste” and therefore this failure to anticipate calories and sugar appropriately when they do arrive could ultimately lead to impaired energy and body weight control11.
CONCLUSION
While the research is inconclusive, many organisations such as the American Diabetes Association (ADA), American Heart Association (AHA), CANSA and Society of Endocrinology, Metabolism and Diabetes of South Africa (SEMSDA) to name a few, all recommend the use of sugar alcohols and NNS as a replacement for sugar, when consumed within safe levels1,2,4,7. Another thing you have to consider is the Acceptable Daily Intake (ADI) and Estimated Daily Intake (EDI) when looking at NNS (all of which are listed in the table above). For most NNS it is difficult to reach the ADI as you would have to consume extremely large amounts e.g. 75 sachets per day for aspartame. However, if the ADI and EDI are similar like with Stevia, you only need to consume 9 sachets of stevia per day to get to ADI.
You must also be cautioned against viewing foods containing these sweeteners as “free” or healthy. Some may see the calories “saved” by drinking diet drinks as rationale to consume higher calorie food items later in the day. If you can get used to having no sugar or sweetener, that would be best. However, this is not always possible and, in that case,, sugar alcohols or NNS are a safe option for those living with diabetes. Therefore, it is recommended to alternate between different brands and be conscious about the total amount you are having throughout the day. If you have more questions on sweeteners, please chat to your local dietitian or diabetic nurse educator.
WHERE DOES FUTURELIFE® FIT IN
FUTURELIFE® we use a combination of carefully researched and internationally recognised sweeteners in our relevant products. FUTURELIFE® ZERO Smart foodtm FUTURELIFE® ZERO with OATS contains no added can sugar. Instead of using cane sugar to sweeten these products, they have been formulated with Smart Sweetness which is a combination of Stevia, Erythritol and Sucralose.
For more information on any of our products or other interesting articles and recipes, please visit our website www.futurelife.com
REFERENCES
Article adapted from “Sweeteners and Sugar Alternatives for People Living with Diabetes” By Ashleigh Everitt, FUTURELIFE® Dietitian (September 2016)
- Research Gate (2012). Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Non-nutritive Sweeteners. Available at: https://www.researchgate.net/publication/227341497 (Accessed: September 2016)
- ADA & Diabetes Care (2012). Non-nutritive Sweeteners: Current Use and Health Perspectives: A Scientific Statement From the American Heart Association and the American Diabetes Association. Available at: http://care.diabetesjournals.org/content/diacare/35/8/1798.full.pdf (Accessed: September 2016)
- World Health Organisation (2018). Reducing consumption of sugar-sweetened beverages to reduce the risk of unhealthy weight gain in adults. Available at: http://www.who.int/elena/titles/ssbs_adult_weight/en/ (Accessed: April 2018)
- ADA & Diabetes Care (2018). 4. Lifestyle Management: Standards of Medical Care in Diabetes—2018. Available at: http://care.diabetesjournals.org/content/41/Supplement_1/S38#T1 (Accessed: April 2018)
- Diabetes UK. Nutritive and Non-nutritive Sweeteners. Available at https://www.diabetes.co.uk/sweeteners/nutritive-and-nonnutritive-sweeteners.html (Accessed: April 2018)
- Pick’n Pay. Diabetes and Sweeteners. Available at: http://www.picknpay.co.za/healthy-eating-articles/diabetes-and-sweeteners (Accessed: April 2018)
- US Food & Drug Administration (2018). Additional Information about High-Intensity Sweeteners Permitted for Use in Food in the United States. Available at: https://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm397725.htm (Accessed: April 2018)
- CANCA (2017).Statement on Non-Nutritive Sweetener. Available at: http://www.cansa.org.za/files/2017/08/CANSA-STATEMENT-ON-NON-NUTRITIVE-SWEETENERS-August-2017.pdf (Accessed: April 2018)
- PubMed (2016).Reshaping the gut microbiota: Impact of low calorie sweeteners and the link to insulin resistance? Available at: https://www.ncbi.nlm.nih.gov/pubmed/27090230 (Accessed: April 2018)
- NCBI (2015). Metabolic effects of Non-Nutritive Sweeteners. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661066/ (Accessed: April 2018)
- Elsevier (2013). Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.689.8610&rep=rep1&type=pdf (Accessed: April 2018)
- CMAJgroup (2017). Non-nutritive sweeteners and cardio metabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies. Available at: http://www.cmaj.ca/content/189/28/E929. (Accessed: April 2018)
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