Sweet Nothings

Artificial sweeteners (AS) are attractive alternatives to sugar because they virtually add no calories to your diet. Moreover, you need only add a fraction of AS compared to the normal amount of sugar you would use for sweetness. Today, AS and other sugar substitutes are found in a variety of food and beverages marketed as "sugar-free" or "diet", including soft drinks, chewing gum, jellies, baked goods, candy, fruit juice, and ice cream and yogurt. Also AS are popular for home use. Some can be even used when baking or cooking. Because of the advent of AS, people with Diabetes have an option to satisfy their sweet tooth. Replacing sugar with AS not only makes a diabetic meal plan more flexible, enhancing the pleasure of eating a variety of foods but also helps in reducing calorie intake.

How do AS work?

The degree of sweetness we taste depends on how well the receptors in our tongue interact with the molecules. The stronger the interaction, the sweeter we perceive the taste. Scientists have identified the taste bud receptor that is responsible for finding what we consider "sweet". Sugar and artificial sweeteners bind to this receptor, creating the sweet sensation that we get when we eat them. The receptors are found on the surfaces of cells all over the tongue and inside the mouth. They send messages to the brain to tell it that we're eating something sweet. Artificial sweeteners are compounds that have been found to elicit the same (or a similar) "sweet" flavour we get from sugars.

Some are low-calorie because they are extremely sweeter than sugar that only a tiny amount is needed. Others are low-calorie (or no calorie) because our bodies can't metabolise them. They simply pass through our digestive system without being absorbed. This makes them one of the best options for people who have Diabetes, want to lose weight and are calorie conscious.

The degree of sweetness we taste depends on how well the receptors in our tongue interact with the molecules. The stronger the interaction, the sweeter we perceive the taste. Scientists have identified the taste bud receptor that is responsible for finding what we consider "sweet". Sugar and artificial sweeteners bind to this receptor, creating the sweet sensation that we get when we eat them. The receptors are found on the surfaces of cells all over the tongue and inside the mouth. They send messages to the brain to tell it that we're eating something sweet.

Artificial sweeteners are compounds that have been found to elicit the same (or a similar) "sweet" flavour we get from sugars. Some are low-calorie because they are extremely sweeter than sugar that only a tiny amount is needed. Others are low-calorie (or no calorie) because our bodies can't metabolise them. They simply pass through our digestive system without being absorbed. This makes them one of the best options for people who have Diabetes, want to lose weight and are calorie conscious.

The sugar substitutes can be classified as:

Low calorie sweeteners: These are usually carbohydrates, providing approximately 4 Kcals per gram, just like carbohydrates and proteins. Common examples of nutritive sweeteners include sucrose (table sugar) fructose (kind of sugar found in fruits), honey and sugar alcohols.

Sugar alcohols: Also known as reduced calorie sweeteners, include polyols such as sorbitol, mannitol, malitol, xylitol etc. which provide fewer calories (2Kcal/gm) than sugar. Mostly used in chewing gums, candies, ice creams, cakes, pastries and cookies. Excess consumption is known to have a laxative effect, especially in young children.

Artificial sweeteners: Also known as artificial sweeteners or intense sweeteners. They are not a significant source of nutrition. They are synthetic sugar substitutes. They sweeten your foods but do not provide calories that come from sugar. Also they are many times sweeter than sugar, hence are required in very small amounts to give the sweetening effect. Artificial sweeteners do not affect blood sugar levels; they are generally counted as "free foods". These sweeteners are used in many food items that range from sugar free, reduced or low calorie beverages, diet drinks, "light" foods & snacks.

The Food & Drug Administration (FDA) approved non-nutritive sweeteners, regulated as food additive include:

Aspartame: Aspartame is marketed under the brand name Equal, NutraSweet, Sugar free Gold. It is made up of two amino acids – aspartic acid and phenylalanine and is 200 times sweeter than sugar. Aspartame provides very small amount of calories but the amount is negligible based on intense sweetness. There is a limitation of aspartame for its use in cooking. It generally becomes less sweet when heated at high temperatures. The use of aspartame has been controversial. However claims about its negative health effects have been disputed and it has been finally approved by the regulatory agencies for its use as a sweetener. Aspartame is not meant for use for people who are diagnosed with phenylketonuria (PKU), a rare heredity disease where the body is unable to breakdown essential amino acid phenylalanine; and excess accumulation of this amino acid causes brain damage. Also in those who suffer chronic headaches or migraines, aspartame can trigger these painful occurrences. It is recommended that you keep a food diary to see if you are sensitive to foods containing this sugar substitute.

The FDA recommends that you should consume no more than 50 mg of aspartame per kilogram of your total body weight, daily.

Saccharin: Saccharin sold as Sweet n low, Sweet Twin, Sweetex is the world's oldest AS. It is 300 times sweeter than sugar with a slightly bitter/metallic taste. It contains no food energy i.e. it does not provide energy or calories. Saccharin is widely used in foods and beverages, consumer products like cosmetics and pharmaceuticals. Saccharin also has been a subject of debate, ever since it was discovered, but now after several research studies it has been labelled as safe for use.

Advantages

• This sweetener can be used in baking and cooking, as well as for sweetening beverages and cereal.

Disadvantages

• The most common complaint about saccharin is its bitter aftertaste.

• Saccharin is also categorised as a sulfonamide and can result in allergic reactions for those who cannot consume sulfa drugs.

Furthermore, it may pose health risks for the average consumer as saccharin was linked with the development of bladder cancer.

The FDA has defined the acceptable daily intake of saccharin as 5 mg/kg body weight, equivalent to 9-12 packets of sweetener.

Acesulfame potassium: is marketed under the name Sweet One, Sunett. It is nearly 200 times sweeter than the same quantity of table sugar. It withstands heating well and can be used in cooking. It is commonly used in beverages, jams, sweets and baked goods. More than 90 studies have demonstrated the safety of this sweetener.

The FDA has defined the acceptable daily intake of saccharin as 5 mg/kg body weight, equivalent to 9-12 packets of sweetener.

The ADI established by FDA for Acesulfame potassium is 15mg/kg body weight, equivalent to 30-32 cans of diet soda per day.

Sucralose: approved as a general all-purpose sweetener is marketed for commercial use as Splenda, Sugar free natura, Sweetos. It's a more recent non-nutritive sweetener available in the market and is 600 times sweeter than the same quantity of table sugar. It is heat stable and can be used in cooking and baking without losing its sweetness.

The ADI set for sucralose is 5mg/kg body weight.

Advantages

• Just as with Equal, there's no "saccharin" aftertaste, making it ideal for those with Diabetes who want to satisfy their sweet tooth.

• It can be used for baking, as it is more potent than sugar.

Disadvantages

If you have a sensitive digestive system, you may suffer from gas, bloating and diarrhoea if you consume too much. In addition, there has been some debate about the fact that the sucralose molecule contains three atoms of chlorine and whether that is safe for human consumption.

Neotame: is relatively a new sweetener without calories, about 7000 to 13000 times sweeter than sugar. It is similar in structure to aspartame. It was approved for general use as a sweetener and flavour enhancer in foods and beverages in 2002 by the U.S. Food and Drug Administration (FDA).

Non-nutritive sweeteners that are not approved:

Alitame – a compound of aspartic acid, D-alanine and an amide; is 2000 times sweeter than sugar.

Cyclamate- about 30 times sweeter than sugar. It was shown to cause cancer in laboratory rats when combined with saccharin. Although cyclamate by itself was found by the National Academy of Sciences not to be a carcinogen in 1985 and is approved for use in over 50 countries, it has not been reinstated by the FDA for use.

Neohesperidine dihydrochalcone – a compound that is about 1500 times sweeter than sugar. It adds a slight liquorice flavour to foods and beverages. The FDA considers neohesperidone as a GRAS (generally recognized as safe) a flavouring but not as a sweetener.

Thaumatin – an intensely sweet mixture of proteins that also acts as a flavour enhancer. The FDA has given thaumatin a GRAS status as a flavour adjunct but has not approved it as a sweetener as of 2007.

How is it good for people with Diabetes?

Sugar substitutes can sweeten without adding calories because they offer a concentrated dose of sweetness and are generally calorie-free. Plus, the body does not fully absorb AS, so the few calories they may contain do not affect blood sugar levels.

Sweeteners can be incorporated as part of healthy diet. But remember "Moderation is always the key". A diet drink (with sweetener) doesn't mean you can have any number of bottles a day. They can still be significant source of calories.

Follow a healthy eating plan and stay physically active!

Tushima Mashelkar and Gauri Kukade are Consultant Nutritionists at Chellaram Diabetes Institute, Pune.

Pros and Cons of AS

Pros

1. Children and teenagers – there is a strong link between the intake of sugary beverages and the occurrence of obesity or overweight issues in children. Therefore, replacing sugary beverages with an alternative low calorie/no calorie beverage may help in combating overweight and obesity issues in children and teenagers

2. Adults – replacing sugary foods and beverages with AS prevents unwanted weight gain. In addition, AS does not raise blood sugar levels compared to sugar as the former does not contain carbohydrates, thereby aiding people with Diabetes maintain their blood sugar levels. Although it is a good alternative for people with Diabetes, it is advised that you check with your dietician on the consumption of AS. AS also helps people normalise their blood pressure levels and improve cholesterol levels.

3. Sorbitol and mannitol are commonly added to toothpaste, mouthwash, breath mints, cough drops, cough syrups, sugarless gum, liquid antacids and personal oral care products which minimise the risk of tooth decay and cavities.

4. As are also used in manufacturing baked goods, beverages, syrups and other food products to improve texture, add bulk, retard spoilage, or as part of a fermentation process.

Cons –

1. Sugar alcohols – such as mannitol, xylitol, sorbitol can have a laxative effect which can cause diarrhoea, bloating, intestinal gas when consumed in amounts greater than 10g.

2. Certain natural sugar alternatives can affect blood sugar just like regular table sugar brown rice syrup, barley malt syrup, black strap molasses, evaporated cane juice and organic sugar, which makes them an undesirable alternative for people with Diabetes.

3. High consumption of beverages and synthetic drinks can cause kidney damage.

Experts Speak!

According to International Sweetener Association, "All approved sweeteners are safe for use by the consumer. A newly discovered sweetener goes through years of costly research and development to make sure that it's safe. Before a sweetener comes to market and is available to consumers, it must get the approval of regulatory authorities. In giving approval, these authorities rely on the safety evaluations of independent scientific advisory bodies such as the European Food Safety Authority (EFSA), the United States Food and Drug Association (FDA), and the United Nations Joint FAO/WHO Expert Committee on Food Additives (JECFA) and then subsequently allow its consumption". Most of this process takes many years of intense scrutiny to make sure that they are safe.

According to National Cancer Institute, "Before approving these sweeteners, the FDA reviews more than 100 safety studies that were conducted on each sweetener, including studies to assess cancer risk. The results of these studies showed no evidence that these sweeteners cause cancer or pose any other threat to human health.

Six artificial sweeteners are commonly used in a Diabetes diet

• Sucralose – safe in people with Type 1 Type 2 Diabetes, prediabetes and gestational Diabetes

• Saccharin – safe in people with Type 1 and Type 2 Diabetes with recommended dosage However this sweetener should be avoided if you are pregnant or have gestational Diabetes

• Stevia – safe for types of Diabetes

• Aspartame – contraindicated in people with phenylketonuria disorder

• Neotame – safe in people with Diabetes with recommended dosage

• Acesulfame potassium – used in Type 1 and Type 2 Diabetes as well as in people with prediabetes and gestational Diabetes. However this sweetener should be used in moderation

Most popularly used AS in India, especially in people with Diabetes

• Aspartame

• Acesulfame k

• Saccharin

• Sucralose

These common or popular sweeteners are approved for use in India by FSSAI (Indian regulatory body).

Some common terms used in Diabetes

• Glucometer – a device that measures blood sugar levels. It allows the user flexibility to monitor their blood glucose level at home.

• Hypoglycaemia (low sugar feeling) – occurs when the sugar levels dip below the normal levels. The common symptoms include dizziness, anxiety, sweating, nervousness.

• Hyperglycaemia (high sugar feeling) – occurs when the sugar levels are above the normal levels. The common symptoms include blurred vision, dry and itchy skin, weight loss, increase in appetite and thirst.

• HBa1c – is a test conducted that measures your average glucose level over the past three months. It is a tool used by doctors to assess your blood glucose control over a period of time. An elevated A1C level may signal the need for a change in your insulin regimen or meal plan. Your target A1C goal may vary depending on your age and various other factors. However, for most people with Diabetes, the American Diabetes Association recommends an A1C of below 7 per cent. Check with your doctor what your A1C target should be.

• Impaired glucose tolerance – implies that your blood glucose levels are higher than normal but not high enough to say that you have Diabetes. However, this condition puts you at higher risk of developing Diabetes later in life if not treated in time.

• Ketoacidosis – a condition often caused by an infection or other illness like dehydration, or from taking too little insulin; when the body begins to break down muscle and fat for needed energy, ketones are released into the urine and blood, leading to diabetic ketoacidosis.

• Ketones – the chemical substance made by your body when there isn't enough insulin in your blood; a build-up of ketones can lead to serious illness or coma.

• Nephropathy – a diabetic kidney disease in which protein is spilled into the urine; it can progress over time and result in significant kidney damage.

• Neuropathy – Diabetes-caused nerve damage, typically in the feet and hands; major organs can also be affected.

• Retinopathy – is an eye disease that occurs in someone with Diabetes when the small blood vessels of the retina become swollen and leak liquid into the retina, blurring vision; it can sometimes lead to blindness.

Some frequently asked question by patients with Diabetes

I'm an 18 year old gal with Type 1 Diabetes. Can I have artificial sweeteners?

Depending on your blood glucose and Hba1c (average 3 months sugar levels) you may use artificial sweeteners. However if your blood glucose levels are high then artificial sweeteners may not be recommended. Also it is recommended that you check your thyroid levels. If your sugar control is adequate you may have a minimum of two tablets and maximum of four tablets a day of artificial sweeteners. The recommended brans would be Stevia, Splenda and Natura.

I'm a 60 year old man with Type 2 Diabetes and renal failure can I have artificial sweeteners?

Continuous monitoring of your renal parameters, especially creatinine levels, will enable your nutritionist to recommend artificial sweeteners. However it is best to avoid beverages to limit your intake as these drinks contain high amounts of artificial sweeteners and can aggravate your renal condition. Also it is advised to maintain your diet and lifestyle. If all your parameters are normal and your nephrologist advises you can start using artificial sweeteners but limit your intake to not more than four tablets a day and 1/4th teaspoons three to four times a day.

I'm a 35 year old woman with Type 2 diabetes and expecting is artificial sweeteners safe for me?

Artificial sweeteners are allowed in pregnancy. Recommended artificial sweeteners that you can use are Splenda and Natura. Avoid artificial sweeteners which contain cyclamet and saccharin as the former has been linked to cancer and the latter crosses the placenta and cannot be cleared by the developing foetus and may result in long-term ill effects. Also, it is best to avoid aerated beverages and opt for healthier options instead. Based on your blood sugar levels and Hba1c test your Diabetologist and Nutritionist may initiate using artificial sweeteners and restrict your intake to not more than two tablets a day.