[Sweeteners] Vol. 17 No.

6 June 2007

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The Sweet Life for Diabetics
By Sharon Palmer, R.D., Contributing Editor

Not long ago, diabetics were told to avoid sugar like the plague and depend on sugar substitutes to
sweeten up their foods. The diabetic sugar ban was imposed because it was once thought that sugar
was more rapidly absorbed into the bloodstream than starchy foods. But now we know differently.
Many carbohydrate sources can affect blood sugar in a similar way as sucrose does. It’s the total
amount of carbohydrates people consume, as well as their quality, that affect blood glucose levels.

The new era of diabetic dietary recommendations does not embrace blanket restrictions of simple
sugars. But you won’t find anyone advising the 20.8 million Americans (7% of the population) with
diabetes to fill up on sugary stuff, either. Today’s diabetic is counseled to balance carbohydrate intake
for the entire day with a focus on unprocessed, fiber-rich carbohydrates that tend to produce lower,
slower increases in the blood sugar compared to refined carbohydrates.

Controlling glucose

The overriding goal for diabetics is to manage their disease in order to prevent serious complications
down the road. Within this framework, tight glycemic control (as close to normal fasting and
postprandial glucose levels as possible) is a biggie, since it reduces complications like retinopathy,
nephropathy, neuropathy and, possibly, coronary vascular disease.

The recently updated position statement for standards of medical care in diabetes issued by The
American Diabetes Association (ADA), Alexandria, VA, and published in Diabetes Care in 2006
(29:S4-S42), reported that monitoring total grams of carbohydrates through tools like exchanges or
carbohydrate counting is key in achieving good glycemic control. Low-carbohydrate diets (less than
130 grams per day) are not recommended for diabetes management; instead 45% to 65% of total
calories should come from carbohydrates.

Putting sugar in its place

If a diabetic wants a sugar fix, they can fit it in. Foods containing simple sugars, such as white sugar,
brown sugar, honey and molasses, can be substituted for starchy carb sources like tortillas and
potatoes. One could skip a slice of bread in order to have two small cookies, since both contain
roughly 15 grams of carbohydrates.

But many sugar-containing foods are high in carbs and calories and may often be low in important
nutrients. Since the amount and type of carbohydrate influences blood glucose levels, choosing foods
that keep hyperglycemia at a minimum following a meal is recommended. Thus, attention to the
glycemic index or load can be helpful.

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How artificially sweet it is

Artificial sweeteners have had a long, sweet history with diabetics, starting with saccharin, the first
artificial sweetener, dating back to 1879. Diabetics have grown to count on an expanding number of
high-intensity sugar substitutes to satisfy their sweet cravings. These provide sweetness without the
calories or carbohydrates, because they are many times sweeter than sucrose and their caloric
contribution is negligible or zero.

But as the number of artificial sweeteners has swollen, so has the controversy surrounding their
safety. In reality, sugar substitutes are some of the most rigorously studied food ingredients on the
planet. According to the ADA, nonnutritive and reduced-calorie sweeteners are safe when consumed
within the acceptable daily intake levels established by FDA.

Five nonnutritive sweeteners have been approved by FDA in the United States:

• Acesulfame potassium, a nonmetabolized, high-intensity sweetener 200 times sweeter than

sucrose;

• Aspartame, a sweetener that is completely broken down by the body into its components and is 200
times sweeter than sucrose;

• Neotame, a high intensity sweetener that yields no calories because of its sweetness profile ( 7,000
to 13,000 times sweeter than sucrose), is a derivative of the dipeptide composed of the amino acids,
aspartic acid and phenylalanine;

• Saccharin, a nonmetabolized, stable sweetener 300 times sweeter than sucrose;

• Sucralose, a noncaloric sweetener, which the body does not metabolize, derived from sucrose that
is 600 times sweeter than sucrose.

Reduced-calorie sweeteners approved by FDA include the sugar alcohols (polyols) erythritol,
hydrogenated starch hydrolysates, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol and tagatose.
Unlike nonnutritive sweeteners, which sweeten in very small amounts, polyols are carbohydrates
used in the same quantity as sucrose, although their sweetness varies. Polyols provide fewer
calories, because they are absorbed slowly and incompletely from the intestine. “As a class, polyols
have reduced calories and reduced glycemic response when compared to most sugars and,
therefore, help in maintaining a stable blood glucose level,” says Tom Parady, associate program
coordinator of food applications, Roquette America, Keokuk, IA. Maltitol syrup (regular) has a GI of
52, hydrogenated starch hydrolysates has a GI of 39, xylitol has a GI of 13, sorbitol and isomalt have
a GI of 9, lactitol has a GI of 6, and erythritol and mannitol have a GI of 0. In some people, excessive
consumption of sugar alcohols may cause gastrointestinal symptoms, such as gas or laxative effects.

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Sugar subs in food

“The ADA recommendations for diabetics have been moving away from banning simple sugars for a
long time. Nevertheless, many diabetics continue too seek out reduced-sugar foods,” says Parady.

The sweetness profile created by sugar substitutes is sometimes different from sucrose, so blends
are often used in mixtures to create a natural sweet sensation or better mouthfeel. Artificial
sweeteners may be used in many products, including instant or ready-to-drink coffees, teas and other
drinks; cold cereals; chewing gum; breath mints; gelatins; puddings; frozen desserts; yogurt; baked
goods; candies; and pharmaceuticals.

With current diabetes rates exceeding the 60% global increase projected by the Geneva-based World
Health Organization between 1995 and 2030, the sugar-free food industry may be tasting sweet
success in the years to come.

Sharon Palmer is a registered dietitian with 16 years of experience in health-care and foodservice management. She
writes on food and nutrition for newspapers, magazines, websites and books. Palmer makes her home in Southern
California and can be reached at info@sharonpalmer.net.

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