Diabetes MellitusManual of Clinical Nutrition Management III- 33 Copyright © 2013 Compass Group, Inc.
“free” foods. Consumption of large amounts of fructose (15% to 20% of daily energy intake [90th percentile
of the usual intake]) has been shown to increase fasting total and low-density lipoprotein cholesterol in
subjects with diabetes (2). Therefore, consumption of fructose in large amounts may have adverse effects on
plasma lipids. Using fructose as a sweetening agent is not recommended for people with diabetes because of
this effect (2).
Sorbitol, mannitol, isomalt, maltitol, lactitol, and starch hydrolysates are considered polyols and are
frequently listed on the product’s nutrition facts label as “sugar alcohols” (2). Sugar alcohols are used in food
as sweeteners and bulking agents. Because sugar alcohols are only partially absorbed from the small
intestine, the claim of reduced energy values per gram is allowed (2). In some studies, ingestion of sugar
alcohols (approximately 50 g) by healthy and diabetic patients produced a lower glycemic response after
ingestion of fructose, sucrose, or glucose (2). Consumption in larger than recommended amounts of 10 to 15
g/day (eg, >30 g or greater of polyols or sugar alcohols including lactitol, isomalt, and xylitol) may result in
significant increases in flatulence, borborygmus, colic, defecation frequency, loose watery stools (Grade* III) (2,6).
Use of sugar alcohols as sweetners has also shown to reduce the risk of dental caries (2). Kilocalories from
sugar alcohols vary but average about two kcal/g on food labels. When calculating carbohydrate content of
foods containing sugar alcohols, substraction of half the sugar alcohol grams from total carbohydrate grams is
appropriate (2,7).
Nonnutritive sweeteners: Acesulfame-K (Sunette, Sweet One, Sweet & Safe), Aspartame (NutraSweet,
Equal, Sugar Twin), Luo han guo extract, neotame, saccharin (Sweet’n Low, Sweet Twin, Necta Twin), Stevia
(Truvia, PureVia) , sucralose (Splenda), are approved by the FDA for use in the United States (6). The FDA also
establishes the acceptable daily intake (ADI) for all food additives. It is defined as “the amount of a food
additive that can be safely consumed on a daily basis over a person’s lifetime without any adverse effects and
includes a 100-fold safety factor.” Actual intake by individuals with diabetes for all nonnutritive sweeteners
is well below the ADI (2). It is unknown whether use of nonnutritive sweeteners improves long-term glycemic
control or assists in weight loss (2). In a limited number of studies, nonnutritive sweetners had no effect on
changes in blood lipid profiles and glycemic response in adults with diabetes (Grade II)* (8). No studies in
children were identified (Grade III) (8). Studies to determine the effects of nonnutritive sweeteners during
pregnancy and lactation have been conducted in animals. No adverse effects have been reported (6,9).
Nonnutritive sweeteners are safe for people with diabetes when consumed within the ADI levels established
by the FDA (Grade II) (2,8). Limited research in humans, from peer reviewed journals, supports the safety of non-
nutritive sweeteners for the general population. Considering the lack of high quality studies, continuing post-
market surveillance of the safety of non-nutritive sweeteners is prudent (Grade III) (8). Using non-nutritive
sweeteners in either a calorie restricted or ad libitum diet will affect overall energy balance only if the non-
nutritive sweeteners are substituted for higher calorie food or beverages (Grade II) (8).
Technically, aspartame should not be listed as a noncaloric sweetener since it is equivalent in kilocalories
to table sugar. However, aspartame is so sweet (about 160 to 220 times sweeter than sucrose) that the small
amount consumed in normal use has virtually no kilocalories to consider (6). Aspartame is a dipeptide formed
by the synthetic combination of two amino acids. After it has been metabolized, aspartame converts into
phenylalanine, aspartic acid, and methanol. Because aspartame is a phenylalanine source, it should not be
consumed by individuals with phenylketonuria (6). Neotame is similar to aspartame but is 30 to 50 times
sweeter and does not require special labeling for phenylketonuria since a small percentage (<20%) of the
phenylalanine from the ingested neotame may be released into the plasma (6,10).
Use in pregnancy and during breastfeeding: The FDA has approved seven nonnutritive sweeteners for
general use: acesulfame K, aspartame, Luo han guo extract, neotame, saccharin, , stevia, and sucralose. The
studies of the effects of these sweeteners on the reproductive abilities of women and men, as well as on the
developing fetus, have been reviewed and deemed safe by numerous regulatory bodies and expert
committees around the world (6). Thus, consumption of these nonnutritive sweetners within the ADI levels is
safe during pregnancy and for lactating women (1,6). Although saccharin can cross the placenta and remain in
fetal tissues because of slow fetal clearance, there is no evidence that saccharin causes ill effects (11). If a
woman chooses to use saccharin during pregnancy, the evidence suggests it is safe (1,6). Aspartame does not
cross the placenta at intake levels less than enormous amounts (100 times normal) (12). Use of aspartame
within the FDA guidelines appears safe for pregnant women (6). Multigenerational studies of rats that
received acesulfame-K, neotame, and sucralose have shown no adverse effects on fertility, number of
offspring, birth weight, mortality, and fetal development, and thus both sweeteners are considered safe
during pregnancy (13).