Position statements

The term 'sweetener' is used to describe sucrose (sugar), fructose (fruit sugar), non-nutritive sweeteners (also known as artificial or intense sweeteners) and nutritive sweeteners (also known as bulk sweeteners). 

Different types of sweetener have different properties, different calorie contents and different effects on blood glucose levels. The choice of sweetener will therefore depend on the individual and on the context in which the sweetener is used.

Sucrose

People with diabetes used to be advised to avoid sucrose (as sugar and in sugary foods) and to eat a sugar free diet. It is now known that sugar does not raise blood glucose levels any higher than starch, provided the same amount of carbohydrate from sugar or starch is consumed.(1)

The current advice from Diabetes UK is that sugar can be included in the diet for people with diabetes provided that it is used in the context of a healthy diet and does not account for more than 10% of the total calories.(1) 

The diet for people with diabetes is based on the same guidelines for healthy eating that apply to everyone; that is, a diet which is low in fat, salt and sugar and which contains plenty of fruit and vegetables, with meals that include some starchy carbohydrate foods such as bread, pasta, potatoes, chapatis, yam and plantain.

Fructose

Naturally occurring fructose found in fruit and vegetables should not be avoided and people with diabetes should aim to eat at least 5 to 9 servings of fruit and vegetables every day.

Fruit sugar (fructose), when used as a sweetener, has no proven advantage over sucrose to people with diabetes.  It contains just as many calories as sucrose, still affects blood glucose levels, and when eaten to excess can cause a laxative effect. 

Non-nutritive sweeteners

There are five non-nutritive sweeteners which are permitted for use in the UK: aspartame, saccharin, acesulfame potassium (acesulfame K), cyclamate and sucralose. Only very small amounts are needed because they are so intensely sweet.  They are virtually free of calories, do not affect blood glucose levels and do not contribute to dental caries.

Intense sweeteners are used in a wide range of manufactured sugar-free, reduced sugar and low calorie foods and drinks and are also available as tablet, liquid and granulated sweeteners.  They can be helpful for people who are trying to manage their weight to sweeten drinks or as a table sweetener on cereal for example. Sugar-free, diet or low calorie drinks tend to be sweetened with non-nutritive sweeteners so make a good alternative to ordinary versions. 

Satisfactory baking results can be achieved using some intense sweeteners if the manufacturer’s instructions are followed. However, cakes, biscuits and confectionery that are made with intense sweeteners, may still have high fat and calorie contents, so should be limited as part of a healthy balanced diet.

Important note: People with phenylketonuria must not use products that contain aspartame. Ask your healthcare team if you are unsure.

Nutritive sweeteners

Nutritive sweeteners include polyols such as sorbitol, maltitol, xylitol, isomalt and mannitol. 

Polyols tend to be used in processed foods such as chocolate, confectionery, biscuits and chewing gum and most are labelled as sugar free.  Doing so could mean that they are perceived as being healthier. Some products such as chocolate and biscuits that contain polyols can be high in saturated fat and calories. 

Although polyols have fewer calories and less of an effect on blood glucose levels than sucrose, by using it as a replacement in a product you will only be making a limited calorie saving (a maximum of 40 calories from 20g of sweetener).

It is clear that polyols are better for dental health than sucrose but other potential long term health benefits (e.g. gut health) still need to be established.  Despite some benefits of polyols the amounts likely to be consumed in the diet may not be sufficient to benefit people with diabetes in terms of blood glucose control or weight.  Further research is needed. 

Products containing polyols are safe to consume but should be eaten in moderation.  Excessive consumption can cause diarrhoea, flatulence, and a laxative effect especially in young children because of their low body weight.  Individuals vary in their tolerance of polyols – check packaging for advice on excessive consumption. 

Reference

1 Diabetes UK. Implementation of nutritional advice for people with diabetes. Diabetic Medicine 2003; 20: in press

July 2007