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Recommendations Summary

DM: Nutritive Sweeteners (2015)

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.


  • Recommendation(s)

    DM: Educate on Substitution of Nutritive Sweeteners for Other Carbohydrates

    The registered dietitian nutritionist (RDN) should educate adults with diabetes that intake of nutritive sweeteners, when substituted isocalorically for other carbohydrates, will not have a significant effect on A1C or insulin levels. Research reported no significant impact of consuming nutritive sweeteners (such as isomaltulose and sucrose), independent of weight loss, on A1C or insulin levels. However, mixed results were reported regarding fasting blood glucose.

    Rating: Fair
    Imperative

    DM: Advise Against Excessive Intake of Nutritive Sweeteners

    The registered dietitian nutritionist (RDN) should advise adults with diabetes against excessive intake of nutritive sweeteners to avoid displacing nutrient-dense foods and to avoid excessive caloric and carbohydrate intake. Higher intake of added sugars may contribute to higher energy intake.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

       

    • Conditions of Application

      None.



       

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Studies regarding the consumption of nutritive sweeteners (such as isomaltulose and sucrose) as a replacement for carbohydrate, when maintaining consistent carbohydrate intake and an isocaloric diet, reported no significant effect on A1C. However, research regarding the impact of consuming nutritive sweeteners on fasting blood glucose reports mixed results (Buysschaert et al, 1987; Nadeau et al, 2001; Brunner et al, 2012). Grade II
      • Limited research regarding the consumption of nutritive sweeteners (such as isomaltulose and sucrose) as a replacement for carbohydrate, when maintaining consistent carbohydrate intake and an isocaloric diet, reported no significant effect on exogenous or endogenous insulin levels in adults with diabetes (Buysschaert et al, 1987; Brunner et al, 2012). Additional intervention studies are needed to ascertain an impact of consuming nutritive sweeteners on insulin levels in adults with diabetes. Grade III
      • Studies regarding the consumption of nutritive sweeteners (such as isomaltulose and sucrose) as a replacement for carbohydrate, when maintaining consistent carbohydrate intake and an isocaloric diet, reported no significant effect on HDL-cholesterol levels in adults with diabetes. However, research regarding the impact of consuming nutritive sweeteners on total cholesterol, LDL-cholesterol and triglycerides reports mixed results (Buysschaert et al, 1987; Nadeau et al, 2001; Brunner et al, 2012). Subjects did not have or were not described as having any disorders of lipid metabolism or hypertension, and none of the studies reported on blood pressure. Additional intervention studies are needed to ascertain an impact of consuming nutritive sweeteners on lipid profile and blood pressure in adults with diabetes, especially those with disorders of lipid metabolism and hypertension. Grade III
      From the 2013 American Diabetes Association Nutrition Therapy Recommendations
      • While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices. Grade A
      • Fructose consumed as “free fructose” (i.e., naturally occurring in foods such as fruit) may result in better glycemic control compared with isocaloric intake of sucrose or starch (Grade B), and free fructose is not likely to have detrimental effects on triglycerides as long as intake is not excessive (higher than 12% energy). (Grade C)
      • People with diabetes should limit or avoid intake of SSBs (from any caloric sweetener including high fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk profile. Grade B
      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization
      • While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices. Grade A
      • People with diabetes and those at risk should limit or avoid intake of sugar-sweetened beverages to reduce risk for weight gain and worsening of cardiometabolic risk profile. Grade B
       

    • Recommendation Strength Rationale

      • Conclusion Statements in support of this recommendation were given Grades II and III
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades A, B and C
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A and B.

       

       

    • Minority Opinions

      Consensus reached.