140
VOLUME 10 NUMBER 4 • NOVEMBER 2013
PATIENT INFORMATION LEAFLET
SA JOURNAL OF DIABETES & VASCULAR DISEASE
GOOD
Many healthcare practitioners have proposed that NNS provide a bene-
ficial effect in food and beverages.
11
According to the American Dietetic
Association (ADA) ‘Sugar alcohols and NNS are safe when consumed
within the daily intake levels established by the Food and Drug Adminis-
tration (FDA)’. For patients with diabetes, choosing an NNS rather than
sucrose can assist with regard to moderating carbohydrate intake.
5
The Academy of Nutrition and Dietetics concluded in a review con-
ducted in 2010 that NNS do not affect glycaemic response in people
with diabetes.
5
In patients with TD2M who had the NNS sucralose added
to their diet, fasting blood glucose and insulin responses were not af-
fected.
4
Hubrich stated that individuals who use NNS have an increased intake
of fruit and vegetables and a lower intake of fat, thereby indicative of
a healthier diet. Furthermore, in studies carried out in individuals with
TD2M, those drinking diet cool drinks were found to consume less re-
fined sugar, fats and processed meats.
6
Bellisle
et al
. conducted a meta-analysis of 16 randomised controlled
trials in which sugar was replaced with NNS. This resulted in a 10%
reduction in energy intake on a daily basis and an average of 0.2 g/week
of weight loss. There was also less weight gain after weight loss. A study
of individuals who had maintained > 10% weight loss for over five years
showed that they consumed less dietary fat and more artificially sweet-
ened beverages. These individuals were also more physically active.
6
In a study conducted by Mozaffarian
et al.
cited by Malik
et al
., it was
found that diet cool drink was associated with weight loss when com-
bined with changes in diet and lifestyle.
1,7
This is due to the fact that food
and lifestyle changes are intertwined.
3,9
This is supported by Grotz
et al
.,
who state that NNS can be used to decrease the energy intake of the
diet as well as assist in maintaining body weight.
8
As the management of
obesity is multifactorial, there is no conclusive evidence to suggest that
the use of NNS causes weight gain in adults.
2
More specifically, the NNS sucralose is safe to use during pregnancy
and thus may be a viable option for gestational diabetics attempting to
lose weight, as well as in assisting to achieve an improved glycaemic
control in this patient population.
8
Furthermore, no birth defects were
noted in mice that ingested high doses of sucralose.
8
BAD
Recent data suggest that NNS may have physiological effects that alter
appetite and or glucose metabolism.
12
There have been various epidemiological studies conducted using NNS,
primarily in the form of diet cool drinks
.4,12
Diet cool drinks are flavoured
with NNS such as aspartame, sucralose, saccharin, acesulfame potas-
sium and neotame.
1
Results of these studies demonstrated increased
weight gain, the metabolic syndrome and diabetes in subjects tested.
12
One possible explanation for the increase in weight is that the subjects
used in these studies might have been at risk for weight gain.Another expla-
nation is that substituting foods and beverages containing NNS with foods
containing nutritive sweeteners may cause the subjects to overeat.
1,12
A few studies have reported positive associations between the con-
sumption of diet cool drinks, weight gain and an increased risk of the
metabolic syndrome. However the authors state that these observations
may have been due to reverse causation, as diet cool drink consumption
is higher in individuals with T2DM than in those without T2DM.
1
According to Bellisle
et al
., NNS may have a lower satiety than sugar.
This could result in the body being tricked into overeating, or in the over-
stimulation of taste receptors, thereby creating a sweet-taste addiction.
6,13
This is particularly relevant to intense sweeteners that are 160–13 000
times sweeter than sucrose.
1
Malik
et al.
also state that diet cool drink
may enhance appetite by cephalic phase stimulation. This area however
remains controversial.
There have been some reports that long-term use of NNS can lead to
side effects such as dizziness, nausea, cancer (lung, bladder and brain
tumours) chronic respiratory disease, hallucination, hypersensitivity and
heart failure.
10
Another side effect of some NNS is that they are poorly
absorbed and are fermented in the gastrointestinal tract, leading to lower
intestinal fermentation byproducts such as gas.
8
This leads to abdominal
discomfort.
RECOMMENDATIONS
According to Shankar
et al.
, consumers do not have adequate informa-
tion to make informed choices with regards to NNS. Consumers should
be advised to be cautious with regard to the use of NNS. It is important
that symptoms related to allergies and intolerances be monitored, even if
NNS are consumed in small quantities.
2
The use of NNS in conjunction with dietary management of diabetes
is to optimise glycaemic control. This is widely practiced by healthcare
practitioners on a global scale.
2
To ensure optimal health, however, it is
recommended that minimal quantities of both NNS and sucrose be con-
sumed. More emphasis should be placed on a balanced diet that includes
whole grains, vegetables, fruits, legumes, low-fat dairy products and lean
meats. The use of processed foods should also be limited.
2,3
CONCLUSION
To date there is no conclusive evidence to support or refute the use of
NNS, particularly in the diabetic patient population. It is anticipated that
further long-term studies will be required in order to determine the toxicity
and carcinogenicity of NNS. Human studies would also be useful to con-
firm the safety of consuming NNS on a long-term basis. More specifically,
in the diabetic patient population, studies are required to assess whether
NNS have an effect on insulin sensitivity or glucose homeostasis.
