• Role of Artificial Sweeteners in Diabetes

Dr. M. Uwais Ashraf

JN Medical College, AMU Aligarh

An introduction to sugars

Going back to 327 BC, the people of India used raw sugar.

Since then, humans have an acquired taste for sugar.

Sugar can be a GOOD thing or a BAD thing. It has it’s pros and cons.

+ poor judgment =

What is sugar?

Sugar is derived from sucrose. Sucrose is complex carbohydrate that is made up two sometimes more simple sugars that are attached together.

Carbs in sugar = DisaccharidesThe

carbohydrates in sugar are called disaccharides. Disaccharides are groups or

compounds that have a link

together between carbon in one sugar and a

hydroxyl group from any

position on the other sugars

TYPES OF SUGAR

Refined Sugar

Refined sugar is sugar that has been purified through a process. We call that pure cane sugar.

Raw Sugar

Raw sugar is the pre stage of final refined sugar. Raw sugar is cane sugar in its middle form before being refined. The raw sugar is made in a sugar cane milling area, and is tan colored in appearance due to the evaporation of disinfected sugar cane juice.

Brown Sugar

Brown sugar crystals are sugar crystals that have a molasses coating with its natural flavor and color. Another way is when the molasses is spun with the

white sugar crystals until it has become dry. The excess molasses syrup is what gives the sugar the

brown color. Turbinado Sugar

Turbinado sugar is the raw sugar crystal that have gone through the refinery stage to give it the light tan color by having it placed in a centrifuge machine to take out the molasses contained on the surface.

Sweeteners

• Definition : food additive which adds the basic taste of

sweetness to a food, provides texture, bulking properties,

aroma and color.

• Sugar is a major sweeteners in food industry.

• Sugar is used to prolong or extend food shelf life

ex : fruits and vegetables, cooking spices.

• Sugar is also used in bakery, confectionery, jelly, soft

drinks and fermented beverages.

• Sweeteners that aren't purely sugar are sugar substitutes.

Types of Sweeteners

• "Nutritive" and “Non-nutritive" :

• Nutritive: The amount of energy provided is

around 4 kcal/g.

• Sugar alcohols or polyols: Less energy per

gram (2 kcal/g); not fully absorbed from the

gut

• Non-nutritive sweeteners offer no energy (or

insignificant energy): high-intensity

sweeteners

Nutritive Sweeteners

• Crystal (Sucrose, Dextrose, Fructose, Glucose,

Lactose)

• Honey

• Fruits

• Invert Sugar (by sucrose hydrolisis)

• Syrups :

Glucose, Maple, birch, pine, palm, sugar beet, sorghum,

corn, cane, barley malt, molasses, brown rice, etc.

• Sugar alcohols :

Sorbitol, xylitol, manitol, polyol, etc

Nutritive Sweeteners

• Crystal (Sucrose, Dextrose, Fructose, Glucose,

Lactose)

• Honey

• Fruits

• Invert Sugar (by sucrose hydrolisis)

• Syrups :

Glucose, Maple, birch, pine, palm, sugar beet, sorghum,

corn, cane, barley malt, molasses, brown rice, etc.

• Sugar alcohols :

Sorbitol, xylitol, manitol, polyol, etc

Nutritive Sweeteners

• Occupy large portion of the space on grocery

store shelves worldwide.

• Satisfy consumer’s desire for sweetness

• Play other important role in food ex : provide

texture, stability, and color.

• Increasing concern about tooth decay,

obesity and diabetes.

• Foods and drinks that use artificial sweeteners areanother option that may help curb cravings forsweet.

• Sometimes artificial sweeteners are also calledlow-calorie sweeteners, sugar substitutes, or non-nutritive sweeteners.

• Their sweetening power is at least 100 times moreintense than regular sugar, so only a small amountis needed.

• Also, with the exception of aspartame, all of thesweeteners known so far cannot be broken down bythe body.

• They pass through our systems without being digestedso they provide no extra calories

• There are five artificial sweeteners that have beentested and approved by the U.S. Food and DrugAdministration (FDA):

– Acesulfame potassium (also called acesulfame K)

– Aspartame

– Saccharin

– Sucralose

– Neotame

• These sweeteners are used by foodcompanies to make diet drinks, bakedgoods, frozen desserts, candy, lightyogurt, and chewing gum.

• Many people feel that using artificialsweeteners instead of sugar is thehealthier choice.

• But, researchers are now saying theopposite may be true.

• The American Heart Association suggests

that people should avoid added sugars,

which are sugars and syrups put in foods

during preparation, processing etc.

• They been linked to obesity, type 2

diabetes and metabolic syndrome, which

includes risk factors for heart disease and

stroke.

• An opinion article published on July 2010

in Trends in Endocrinology and Metabolism

reveals that artificial sweeteners like

aspartame, sucralose and saccharin may not

be as good as one may have thought.

• About 30 percent of adults and 15 percent of

children in the U.S. currently use artificial

sweeteners

Overconsumption of sucrose:

• The most common problem is dental caries or tooth decay.

• Oral bacteria convert sugars (sucrose) into acids attack tooth enamel.

• Obesity

• Sucrose, is a pure carbohydrate, high foodenergy content 4 kcals per gram or 17kilojoules per gram) hypercaloric

• Raises blood glucose

• Can cause problems for people suffering fromdefects in glucose metabolism, such aspersons with hypoglycemia or diabetesmellitus.

Sugar-sweetened beverages are associated with

increased weight gain and increased risk for

development of type 2 diabetes in women. The

authors suggest that the association may be the

result of excessive calorie intake from sugar-

sweetened beverages and increased availability of

large amounts of rapidly absorbable sugars.

Schulze MB, Manson JE, Ludwig DS, Colditz GA, Stampfer MJ, Willett WC, Hu

FB: Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in

young and middle-aged women. JAMA292 : 927-934,2004

Relative Sweetness

Sweeteners Relative

Sweetness

Sweeteners Relative

Sweetness

Fructose 114 Maltose 40

Sucrose 100 Lactose 39

Invert Sugar 95 Cyclamate 3000

Glucose 69 Saccharin 30000

Sorbitol 51

GLYCEMIC INDEX

• The Glycemic Index is an indication of how

quickly a specified amount of food will

cause a rise in blood sugar level.

• The glycemic index for sweeteners is a

function of three things:1. The amount of carbohydrate present.

2. The type of carbohydrate present.

3. The presence of other substances (soluble fiber for

example) that slow metabolism of carbohydrates.

• Glucose has a glycemic index (GI) of 100

and fructose is 25.

• Sucrose (Ordinary sugar) which is made

up of a combination of these two has a GI

of 65.

– Rating System for Glycemic Index:

Below 55 - low GI.

56 to 69 - medium GI.

Above 70 -high GI.

• Common Glycemic Indices• Glucose 100

• Sucrose 65

• Maltose 105

• Honey 50

• Fructose 25

• Glycerol 5

• Sorbitol 4

• Aspartam 0

• Cyclamate 0

• Saccharin 0

Glycemic Index of Various Sugars

Nonnutritive sweeteners

• Adenosine monophosphate (AMP)

• Acesulfame potassium/sunett

• Alitame/Aclame

• Aspartame/nutrasweet

• Anethole

• Cyclamate

• Clycyrrhizin

• Inulin

Non Nutritive Sweeteners

• Lo han guo

• Neotame

• Perillartine

• Saccharin

• Selligueain

• Stevioside

• Sucralose

Nonnutritive Sweeteners

5 non-nutritive sweeteners approved by FDA

• Aspartame

• Acesulfame potassium

• Saccharin

• Sucralose

• Neotame (most recently)

• Some studies have indicated that zero calorie

sweeteners do not help reduce weight, and

this may explain the reason. However this does

not take into account several useful aspects of

zero calorie sweeteners:

1. They do not cause a blood sugar spike and this alone is

beneficial to health.

2. They are suitable for diabetics who would otherwise have a

limited choice of sweet things.

3. They are harmless to teeth.

4. All things being equal they contain no calories and should be of

assistance in a diet plan.

Saccharin

• In 1977, FDA proposed a ban on use of saccharin because it wasreported to be a carcinogen in rats

• In 2001, products with saccharin no longer need to carry awarning of its use associated with causing cancer in laboratoryanimals

• ADI for saccharin to 5 mg/kg bw/day

• Despite the decline in usage since a peak in1982, saccharin is the largest volume, lowestcost, high-intensity sweetener used in theworld

• It is approved for use in over 100 countries andhas shown increased popularity in India

• Ammonium saccharin, Ca-saccharin, and Na-saccharin forms are available

Aspartame

• A dipeptide (L-α-aspartyl-L-phenylalanine methyl ester)

• Intestinal esterases hydrolyze aspartame to aspartic acid, methanol,and phenylalanine.

• Metabolized to provide 4 kcal/g,

• Only minute amounts need to be added, theamount of energy derived is egligible.

• In 1981, approved by FDA

• FDA requires that foods that contain aspartamehave the prominent display of the followinglabel:

"PHENYLKETONURICS: CONTAINS PHENYLALANINE"

Acesulfame-K (ACE-K )

• 5,6-dimethyl-1,2,3-oxathiazine-4(3H)-one-2,2-dioxide

• Pharmacokinetic studies: 95% excreted unchanged inurine and does not provide any energy

• Consumption of acesulfame-K does not influenceintake of potassium

• Acesulfame-K can withstand hightemperatures.

• FDA first approved acesulfame-K in 1988, andit is currently approved as a general-purposesweetener.

• ADI of up to 15 mg/kg bw/day

Acesulfame Application

• Low calorie beverages

• Sweets / candy

• Ice cream

• Jam, marmalade

Nonnutritive Sweeteners Characteristics

Obesity

• There is no current evidence supporting a "direct link"between increasing obesity and increasing sweetenerintakes (energy)

• High intakes of fructose increase energy intake andobesity risk through the blunting of circulating insulin andleptin levels.

• Nonnutritive sweeteners have the potential to save theconsumer up to 16 kcal/tsp of sweetening.

• Replacing intake of added sugars with nonnutritivesweeteners could result in a deficit of 380 cal/day or 1pound of weight loss in 9 to 10 days, if intake was at 95 g(24 tsp) daily

Diabetes and glycemic response

• Current evidence does not indicate that, in isocaloric amounts,glycemic response to nutritive sweeteners differs from dietarystarch

• Intakes as high as 60 g fructose or sucrose per day may notadversely affect glycemic or lipid response in persons withtype 2 diabetes However, because there exists concern forincreased blood lipid levels with high intakes of fructose,addition of fructose as a sweetening agent is not recommendedfor people with diabetes

• Polyols produce a lower glycemic responsethan fructose, glucose, or sucrose, most likelybecause of their incomplete absorption.

• Nutritive sweeteners need not necessarily berestricted, but, if consumed, they should besubstituted for other carbohydrate sources

• Nonnutritive sweeteners do not affectglycemic response and can be safely used bythose with diabetes

Effects of Artificial Sweeteners in Diabetic Patients

• Whereas, sweeteners have been found to be detrimental for non-diabetic patients, they have been found to be useful in diabetic patients:

– They act as substitutes for sugars which impair glycemiccontrol in diabetic patients.

– Have been shown to improve metabolic andanthropometric variables in well controlled Type 2 Diabeticpatients*

* Nadia Y Reyna, Climaco Cano et al. Sweeteners and Beta Glucans Improve Metabolicand Anthropometric Variables in Well Controlled Type 2 Diabetic Patients. AmericanJournal of Therapeutics 10, 438-443 (2003)

• Effects of Artificial Sweeteners in Non-Diabetic Patients

• Artificial sweeteners are present in a variety of beveragesknown as SSBs Sugar-Sweetened Beverages.

• It includes soft drinks, fruit drinks etc.

• They have been shown to increase the risk of obesity inhealthy subjects*

• They have also been shown to increase the incidence of type2 diabetes mellitus in hitherto non-diabetic patients*

*Vasanti S Malik, Frank B Hu. Sweeteners and Risk of Obesity and Type 2 Diabetes: The Role of Sugar Sweetened Beverages.

Curr Diab Rep, 2012. 12:195-203

CONCLUSION:

• Artificial sweeteners are a good substitute tosugars in diabetic patients

• They reduce the calorie intake and reducecraving for sugars in diabetic patients

• They have also been shown to improveglycemic control in diagnosed cases of type 2diabetes

• However, they have been shown to increasethe incidence of obesity and type 2 diabetesin non-diabetic patients

NO QUESTIONS !!!!!!!!