Diabetes Mellitus
Manual of Clinical Nutrition Management III- 32 Copyright © 2013 Compass Group, Inc.
DIABETES MELLITUS: FAT REPLACERS
AND NUTRITIVE/NONNUTRITIVE SWEETENERS
Discussion
The goal of medical nutrition therapy for diabetes mellitus is to improve overall metabolic outcomes (glucose
and lipids levels), provide appropriate energy to maintain desirable body weight, and improve overall health
through optimal nutrition (1). The appropriateness of specific modified food products for a given individual
should depend on the relative priority of lipid management, control of carbohydrate intake, and the need for
weight management (2).
Fat Replacers
Fat replacers are compounds that replicate the functional and sensory properties of fats or mimic one or
more characteristics of fat in a food. There are four categories of fat replacers: carbohydrate-based molecules
composed of simple or complex carbohydrate, gums, and gels (also carbohydrate-based); protein-based
molecules composed of whey protein or milk and egg protein; fat-based molecules, which may include
chemical alteration of fatty acids to provide fewer calories or no calories; and a combination, usually
consisting of a carbohydrate and protein or carbohydrate and lipids (2,3). Fat replacers vary in energy density.
Carbohydrate-based fat replacers provide up to four kcal/g, but because they are often mixed with water they
typically provide one to two kcal/g (3). Protein-based replacers provide one to four kcal/g, while fat-based
replacers provide zero to nine kcal/g (3). Olestra, a noncaloric fat-based ingredient, was approved by the
Food and Drug Administration (FDA) in January 1996 as a fat substitute. Because the molecule used in
olestra is too large to be absorbed by the gastrointestinal tract, it adds no energy to food. For a period of time,
products that contained olestra, such as potato chips, were required to display a list of possible side effects.
These possible side effects included decreased absorption of certain nutrients (vitamins A, D, E, and K and
carotenoids), loose stools, and abdominal cramping (3). However, scientific review has led the FDA to
conclude that the warning is no longer warranted (3,4).
It is the position of the Academy of Nutrition and Dietetics that, within the context of a healthy dietary
pattern, fat substitutes, when used judiciously, may provide some flexibility in dietary planning, although
additional research is needed to fully determine their long-term health effects (2,3). Fat replacers that are
fibers, such as inulin, lupin fiber, or B-glucan, may increase diet quality in that they add to the intake of
dietary fiber (3). In one study of men with diabetes, diets encouraging foods containing fiber-based fat and
sugar replacers, together with lifestyle changes, caused a greater increase in high-density lipoprotein
cholesterol and larger decreases in hemoglobin A1C, weight, and body mass index than were seen with the
standard treatment plan (5). On a population level, replacing one to two g fat/day with fat replacers and fat-
modified foods can potentially prevent weight gain and associated chronic disease and assist in promoting
healthful eating behaviors (2,3). Although fat replacers are used to replace the fat content of foods, these foods
are not always consistently lower in energy content because some of the fat in the foods may be replaced by
increasing the sugar content of the food (3). Individuals with diabetes should be encouraged to self-monitor
their intake of fat-modified foods and become educated as to how these foods should be used in the context of
a well-balanced eating program (3).
Sweeteners
Sweetening agents may be categorized as nutritive (those containing energy) and nonnutritive (those that do
not contain energy). Nutritive sweeteners include glucose, galactose, maltose, sucrose, fructose, corn-based
sweetner, agave nectar and sugar alcohols (eg, sorbitol, mannitol, xylitol, isomalt, maltitol, lactitol, and starch
hydrolysates). Seven nonnutritive sweeteners have been approved by the FDA: acesulfame K, aspartame, Luo
han guo extract, neotame, saccharin, , stevia, and sucralose (6).
Nutritive sweeteners: The available evidence from clinical studies demonstrates that sucrose does not
increase glycemia any more than isocaloric amounts of starch (2,6). People with diabetes do not need to
restrict sucrose and sucrose-containing foods based on a concern about aggravating hyperglycemia.
However, if sucrose is included in the food or meal plan, it should be substituted for other carbohydrate
sources or, if added, be adequately covered with insulin or other glucose-lowering medication (2).
Fructose produces a smaller rise in plasma glucose than sucrose and other starches (2). Fructose reduces
postprandial glycemia when it replaces sucrose or starch in the diabetic diet (2). However, fructose-
sweetened products may make a major contribution of energy to the daily intake and cannot be considered