Non-nutritive sweeteners can aid weight management in diabetes

Issue: September 2017

BySusan Weiner, MS, RDN, CDN, CDCES, FADCES

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with Kristine Clark, PhD, RD, about counseling people with diabetes on the use of different sweeteners.

How do you define “low-calorie,” “reduced-calorie” and “calorie-free” sweeteners? Does scientific evidence support using these products for weight management?

Clark: Low-calorie sweeteners, or non-nutritive sweeteners, are very low in calories or contain no calories at all. Typically, non-nutritive sweeteners contain less than 2% of the calories in an equivalent amount of sugar. For comparison, table sugar or sucrose has 4 kcal/g, so 1 g of a non-nutritive sweetener typically has less than 0.08 kcal/g.

A scientific statement from the American Heart Association and American Diabetes Association concluded that non-nutritive sweeteners, when used carefully, may aid in reducing total energy intake and assist with weight loss or weight control while providing beneficial effects on related metabolic parameters.

A meta-analysis of 15 randomized clinical trials and nine prospective cohort studies evaluated research that examined the relationship between non-nutritive sweeteners and body weight and composition. Findings from the prospective cohort studies showed no association between non-nutritive sweetener intake and body weight or fat mass and a small positive association with BMI; however, data from randomized clinical trials, which provide the highest quality of evidence, show that substituting non-nutritive sweeteners for full-calorie options results in modest weight loss and that non-nutritive sweeteners may be a useful tool to improve compliance with weight loss or weight maintenance plans.

Are there risks or user-specific medical concerns associated with sweeteners?

Clark: An Academy of Nutrition and Dietetics position paper states that “consumers can safely enjoy a range of nutritive and non-nutritive sweeteners when consumed within an eating plan that is guided by current federal nutrition recommendations as well as individual health goals and personal preferences.” Although some recent animal and modeling studies have suggested that use of beverages with non-nutritive sweeteners may increase appetite or food intake, the in-depth analysis of available research, conducted by the Academy of Nutrition and Dietetics’ Evidence Analysis Workgroup found inadequate evidence to support this claim.

What advice would you give diabetes educators about discussing these products?

Clark: Diabetes educators should be confident in providing guidance to patients who want to use non-nutritive sweeteners to aid in calorie reduction and carbohydrate management. While research supports that non-nutritive sweeteners can reduce calorie intake, it is important to understand that most non-nutritive sweeteners lack sugar’s function. When reducing sugar with these products, additional ingredients can be needed to provide texture, bulking and volume to foods. Added fibers can be combined with non-nutritive sweeteners to replace sugar while maintaining taste and appeal.

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Regarding fiber, decades of research point to its health benefits, including supporting cardiovascular health, tempering of spikes in blood sugar and aiding weight management. Research also shows that added fibers provide similar benefits as fibers inherent in whole foods. Adding small amounts of fiber (2.5-5 g/serving) to low-fiber foods helps individuals to meet fiber requirements without exceeding calorie needs.

The federal 2015-2020 Dietary Guidelines for Americans encourages reduction of added sugars to 10% of total calories. For many people, this is a big request. The guideline, rather than advising an increase in the use of foods and beverages with non-nutritive sweeteners, recommends trying alternative patterns, such as sparkling water flavored with lemon instead of soda. In my practice, I encourage clients to try products with non-nutritive sweeteners as a first step in altering their calories.

Rare sugars are a recent category of sweetening agents. What are they, and are there advantages to having rare sugars in the food supply?

Clark: Rare sugars are found in nature in very small amounts and contain insignificant calories. One rare sugar that has gained traction recently is allulose; it is present in small quantities in fruits, such as figs and raisins. Allulose provides volume, bulking and texture, but has 0.2 kcal/g compared with sucrose at 4 kcal/g.

Structurally, this monosaccharide is absorbed by the body, but is not metabolized and is excreted intact primarily in urine. Studies of allulose have shown that this simple sugar does not raise blood glucose levels or insulin levels in healthy individuals or when consumed by people with type 2 diabetes. Allulose is generally recognized as safe by the FDA for use as a food and beverage ingredient, which means it is safe for people of all ages to consume. Rare sugars like allulose are not included in sweetener products in grocery stores yet, but the food industry produces them for use in a variety of products, including beverages, yogurt, ice cream and baked goods.

References:
FDA. Food Additives and Ingredients: High-Intensity Sweeteners. Available at: www.fda.gov/food/ingredientspackaginglabeling/foodadditivesingredients/ucm397716.htm. Accessed Aug. 7, 2017.
Fitch C, et al. J Acad Nutr Diet. 2012;doi:10.1016/j.jand.2012.03.009.
Gardner C, et al. Circulation. 2012;doi:10.1161/CIR.0b013e31825c42ee.
Iida T, et al. Metabolism. 2010;doi:10.1016/j.metabol.2009.07.018.
Miller PE, et al. Am J Clin Nutr. 2014;doi:10.3945/ajcn.113.082826.
Nicklas TA, et al. Food Nutr Sci. 2011;doi:10.4236/fns.2011.29126.
U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 8th Edition. 2015. Available at: www.health.gov/dietaryguidelines/2015/guidelines/. Accessed Aug. 7, 2017.