Effect of high levels of intense sweetener intake in insulin dependent diabetics on the ratio of dietary sugar to fat: a case–control study

Health outcomes of non-nutritive sweeteners: analysis of the research landscape

BACKGROUND

Food products containing non-nutritive sweeteners (NNSs) instead of sugar have become increasingly popular in the last decades. Their appeal is obviously related to their calorie-free sweet taste. However, with the dramatic increase in their consumption, it is reasonable and timely to evaluate their potential health benefits and, more importantly, potential adverse effects. The main aim of this scoping review was to map the evidence about health outcomes possibly associated with regular NNS consumption by examining the extent, range, and nature of research activity in this area.

METHODS

We systematically searched Ovid MEDLINE, EMBASE and the Cochrane CENTRAL databases for studies on NNSs (artificial sweeteners or natural, non-caloric sweeteners, either used individually or in combination) using text terms with appropriate truncation and relevant indexing terms. All human studies investigating any health outcomes of a NNS intervention or exposure were eligible for inclusion. No studies were excluded based on language, study design or methodological quality. Data for each health outcome were summarized in tabular form and were discussed narratively.

RESULTS

Finally, we included 372 studies in our scoping review, comprising 15 systematic reviews, 155 randomized controlled trials (RCTs), 23 non-randomized controlled trials, 57 cohort studies, 52 case-control studies, 28 cross sectional studies and 42 case series/case reports. In healthy subjects, appetite and short term food intake, risk of cancer, risk of diabetes, risk of dental caries, weight gain and risk of obesity are the most investigated health outcomes. Overall there is no conclusive evidence for beneficial and harmful effects on those outcomes. Numerous health outcomes including headaches, depression, behavioral and cognitive effects, neurological effects, risk of preterm delivery, cardiovascular effects or risk of chronic kidney disease were investigated in fewer studies and further research is needed. In subjects with diabetes and hypertension, the evidence regarding health outcomes of NNS use is also inconsistent.

CONCLUSIONS

This scoping review identifies the needs for future research to address the numerous evidence gaps related to health effects of NNSs use.It also specifies the research questions and areas where a systematic review with meta-analyses is required for the proper evaluation of health outcomes associated to regular NNSs consumption.

Sugar-fat seesaw: a systematic review of the evidence

Further to reports of a reciprocal relationship between sugar and fat intakes, this review aimed to provide an in-depth analysis and to determine the likely influence of this relationship on the achievement of population dietary guidelines. Using systematic methods, relevant literature was selected according to preset criteria. A strong and consistent inverse association was found between total sugars and total fat intakes expressed as percentage energy. Fewer studies considered absolute intakes and these reported a positive relationship, which may be influenced by confounding with energy intakes. Evidence for an inverse relationship between percentage energy from fat and extrinsic sugars was weaker and less consistent than for fat and total sugars. Reciprocal relationships were also observed for sugar-saturated fat, sugar-protein, sugar-alcohol, and sugar-starch expressed as percentage energy. Under-reporting of dietary intakes had no major influence on the findings. This review confirms the existence of the sugar-fat seesaw on a percentage energy basis and concludes that it is most likely explained by a combination of mathematical and food compositional effects. This finding is relevant because dietary guidelines are expressed as percentage energy and implies that at the population level multiple guidelines may be difficult to achieve in practice.

High saturated-fat and low-fibre intake: a comparative analysis of nutrient intake in individuals with and without type 2 diabetes

OBJECTIVE

The aim of dietary modification, as a cornerstone of type 2 diabetes (T2DM) management, is to optimise metabolic control and overall health. This study describes food and nutrient intake in a sample of adults with T2DM, and compares this to recommendations, and to intake in age, sex, body mass index (BMI) and social-class matched adults without T2DM.

DESIGN

A cross-sectional analysis of food and nutrient intake in 124 T2DM individuals (64% male; age 57.4±5.6 years, BMI 32.5±5.8 kg m(-2)) and 124 adults (age 57.4±7.0 years, BMI 31.2±5.0 kg m(-2)) with no diabetes (ND) was undertaken using a 4-day semiweighed food diary. Biochemical and anthropometric variables were also measured.

RESULTS

While reported energy intake was similar in T2DM vs ND (1954 vs 2004 kcal per day, P=0.99), T2DM subjects consumed more total-fat (38.8% vs 35%, P0.001), monounsaturated-fat (13.3% vs 12.2%; P=0.004), polyunsaturated-fat (6.7% vs 5.9%; P<0.001) and protein (18.6% vs 17.5%, P0.01). Both groups exceeded saturated-fat recommendations (14.0% vs 13.8%). T2DM intakes of carbohydrate (39.5% vs 42.9%), non-milk sugar (10.4% vs 15.0%) and fibre (14.4 vs 18.9 g) were significantly lower (P<0.001). Dietary glycaemic load (GL) was also lower in T2DM (120.8 vs 129.2; P=0.02), despite a similar glycaemic index (59.7 vs 60.1; P=0.48). T2DM individuals reported consuming significantly more wholemeal/brown/wholegrain breads, eggs, oils, vegetables, meat/meat products, savoury snacks and soups/sauces and less white breads, breakfast cereals, cakes/buns, full-fat dairy, chocolate, fruit juices, oily fish and alcohol than ND controls.

CONCLUSION

Adults with T2DM made different food choices to ND adults. This resulted in a high saturated-fat diet, with a higher total-fat, monounsaturated-fat, polyunsaturated-fat and protein content and a lower GL, carbohydrate, fibre and non-milk sugar content. Dietary education should emphasise and reinforce the importance of higher fibre, fruit, vegetable and wholegrain intake and the substitution of monounsaturated for saturated-fat sources, in energy balanced conditions.

The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults

This article reviews the evidence and nutrition practice recommendations from the American Dietetic Association's nutrition practice guidelines for type 1 and type 2 diabetes in adults. The research literature was reviewed to answer nutrition practice questions and resulted in 29 recommendations. Here, we present the recommendations and provide a comprehensive and systematic review of the evidence associated with their development. Major nutrition therapy factors reviewed are carbohydrate (intake, sucrose, non-nutritive sweeteners, glycemic index, and fiber), protein intake, cardiovascular disease, and weight management. Contributing factors to nutrition therapy reviewed are physical activity and glucose monitoring. Based on individualized nutrition therapy client/patient goals and lifestyle changes the client/patient is willing and able to make, registered dietitians can select appropriate interventions based on key recommendations that include consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardioprotective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data. The evidence is strong that medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes.