GDM: Use of Non-Nutritive Sweeteners 2006
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
GDM: Use of Non-Nutritive Sweeteners
If pregnant women, including those with gestational diabetes mellitus (GDM), choose to consume products containing non-nutritive sweeteners, the Registered Dietitian (RD) should inform them that only FDA-approved non-nutritive sweeteners should be consumed and that moderation is encouraged. Research in this area is extremely limited.
Risks/Harms of Implementing This Recommendation
Nonnutritive sweeteners are generally safe when consumed during pregnancy within the acceptable daily intake (ADI) levels established by the Food and Drug Administration (FDA), with the exception of saccharin due to slowed fetal clearance and aspartame in women with phenylketonuria.
Conditions of Application
This recommendation applies to pregnant women with gestational diabetes mellitus (GDM) who choose to consume non-nutritive sweeteners.
Potential Costs Associated with Application
While there are recognizable benefits of the use of nonnutritive sweeteners with the maintenance of blood glucose control, to date there is limited evidence to support the use or nonuse of nonnutritive sweetners (NNS) in pregnancy, and even less evidence addressing this issue specifically in gestational diabetes mellitus (GDM).
The FDA has approved aspartame, acesulfame potassium, sucralose, saccharin and neotame for general use, while stevia has not been approved.
The use of FDA-approved nonnutritive sweeteners during pregnancy is acceptable with the exception of aspartame for pregnant women with hyperphenylalanine in the blood and phenylketonuria (Levy et al, 1983).
The American Medical Association suggests avoiding saccharin during pregnancy due to possible slow fetal clearance (Council on Scientific Affairs of the American Medical Association, 1985).
- American Diabetes Association Recommendation: Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake (ADI) levels established by the Food and Drug Administration (Grade A).
Recommendation Strength Rationale
- Conclusion Statement was given Grade IV
- Risks/Harms of Implementing This Recommendation
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the evidence regarding the use of nonnutritive sweeteners such as saccharin, aspartame, acesulfame potassium, sucralose, neotame and stevia in women with GDM?
What are the estimated non-nutritive sweetener consumption levels (saccharin, aspartame, acesulfame-K, sucralose, neotame) and are they within acceptable daily intake limits?
Council on Scientific Affairs, American Medical Association. Saccharin: Review of safety issues. JAMA 1985;254(18):2622-4.
Levy HL, Waisbren SW. Effects of untreated maternal phenylketonuria and hyperphenylalaninemia on the fetus. N Engl J Med 1983;309(21):1269-1274.
Arcella D, Le Donne C, Piccinelli R, Leclercq C. Dietary estimated intake of intense sweeteners by Italian teenagers. Present levels and projections derived from the INRAN-RM-2001 food survey. Food and Chemical Toxicology, 42 (April 2004) 677-685. PMID: 15019193.
Bar A, Biermann C. Intake of intense sweeteners in Germany. Z Ernahrungswiss. 1992 Mar; 31 (1): 25-39.
Butchko HH, Stargel WW, Comer CP, Mayhew DA, Benninger C, Blackburn GL, de Sonneville LM, Geha RS, Hertelendy Z, Koestner A, Leon AS, Liepa GU, McMartin KE, Mendenhall CL, Munro IC, Novotny EJ, Renwick AG, Schiffman SS, Schomer DL, Shaywitz BA, Spiers PA, Tephly TR, Thomas JA, Trefz FK. Aspartame: review of safety. "Intake of Aspartame vs Acceptable Daily Intake" Regul Toxicol Pharmacol. 2002 Apr;35(2 Pt 2):S1-93.
Chung MS, Suh HJ, Yoo W, Choi SH, Cho YJ, Cho YH, Kim CJ. Daily intake assessment of saccharin, stevioside, D-sorbitol and aspartame from various processed foods in Korea. Food Addit Contam. 2005 Nov; 22 (11): 1,087-1,097. PMID: 16332631 [PubMed - indexed for MEDLINE].
Garnier-Sagne I, Leblanc JC, Verger P. Calculation of the intake of three intense sweeteners in young insulin-dependent diabetics. Food Chem Toxicol. 2001 Jul; 39 (7): 745-749.
Ilback NG, Alzin M, Jahrl S, Enghardt-Barbieri H, Busk L. Estimated intake of the artificial sweeteners acesulfame-K, aspartame, cyclamate and saccharin in a group of Swedish diabetics. Food Additives and Contaminates, 2003 Feb; 20 (2): 99-114.
Leclercq C, Berardi D, Sorbillo MR, Lambe J. Intake of saccharin, aspartame, acesulfame K and cyclamate in Italian teenagers: present levels and projections. Food Addit Contam. 1999 Mar; 16 (3): 99-109.
Renwick AG. The intake of intense sweeteners-an update review. Food Additives and Contaminants, 2006 April; 23 (4): 327-338.
Toledo MC, Ioshi SH. Potential intake of intense sweeteners in Brazil. Food Addit Contam. 1995 Nov-Dec; 12 (6): 799-808.
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2007;30 Suppl 1:S48-65.
Wylie-Rosett J, Albright AA, Apovian C, Clark NG, Delahanty L, Franz MJ, Hoogwerf B, Kulkarni K, Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler M. 2006-2007 American Diabetes Association Nutrition Recommendations: issues for practice translation. J Am Diet Assoc 2007;107(8):1296-304.