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Natural Alternative Sweeteners and Diabetes Management Current Diabetes Reports (2019) 19:142 https://doi.org/10.1007/s11892-019-1273-8 LIFESTYLE MANAGEMENT TO REDUCE DIABETES/CARDIOVASCULAR RISK (B CONWAY AND H KEENAN, SECTION EDITORS) Natural Alternative Sweeteners and Diabetes Management Emily Mejia1 & Michelle Pearlman2 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review The goal of this review is to discuss the data on natural alternative sweeteners and their effects on glucose homeostasis and other metabolic parameters within the past five years. We sought to answer whether common natural alternative sweeteners have a positive or negative effect on glucose control in both human and animal models, and whether the data supports their widespread use as a tool to help reduce the prevalence of diabetes and associated comorbid conditions. Recent Findings Recent studies suggest that natural alternative sweeteners may reduce hyperglycemia, improve lipid metabo- lism, and have antioxidant effects particularly in those that have baseline diabetes. Summary Diabetes and metabolic syndrome have become a global healthcare crisis and the sugar overconsumption plays a major role. The use of artificial sweeteners has become more prevalent to improve insulin resistance in those with diabetes, obesity, and metabolic syndrome, although the evidence does not support this result. There are however some promising data to suggest that natural alternative sweeteners may be a better alternative to sugar and artificial sweeteners. Keywords Natural alternative sweeteners . Diabetes . Stevia . Sugar alcohols . Rare sugars Introduction retinopathy, nephropathy, cerebrovascular disease, peripheral vascular disease, and cardiovascular disease [2–4]. Type 2 Diabetes mellitus (DM) is a metabolic disorder that results DM (T2DM) often coexists with other metabolic disorders from glucose dysregulation. Insulin resistance and/or de- including hypertension and dyslipidemia, a phenomenon creased production of insulin from pancreatic β cells re- also known as metabolic syndrome which is associated sults in chronic hyperglycemia and is considered a pro- with visceral adiposity and obesity. Nutrition therapy de- inflammatory state [1]. Sedentary lifestyles and an over- signed to lower serum glucose, triglycerides, blood pres- abundance of sugar-laden processed food and beverage sure, and plaque-forming cholesterol is essential in the consumption are some of the main culprits associated management of T2DM and improve morbidity and mor- with this trend. Long-term complications of this disease tality [4]. result from biochemical changes from increased oxidative stress. Complications include, but are not limited to This article is part of the Topical Collection on Lifestyle Management to Epidemiology Reduce Diabetes/Cardiovascular Risk The prevalence of T2DM has dramatically increased. * Michelle Pearlman According to the Center for Disease Control (CDC), the [email protected] prevalence of obesity in the USA was 39.8% which is a Emily Mejia significant risk factor for the development of T2DM, [email protected] (93.3 million obese Americans) between 2015 and 2016 1 [5].AccordingtotheWorldHealthOrganization’s (WHO) University of Miami Miller School of Medicine, Miami, FL 33146, USA Global Report on Diabetes, it is estimated that 422 million 2 adults were living with diabetes worldwide in 2014, and Department of Medicine, Division of Gastroenterology & Hepatology, University of Miami Health Systems, Miller School of the global prevalence has nearly doubled since 1980, from Medicine, 1120 NW 14th Street, Miami, FL 33136, USA 4.7to8.5%[6]. 142 Page 2 of 10 Curr Diab Rep (2019) 19:142 Nutrition Therapy The Effects of Stevia in Humans The American Diabetes Association (ADA) recommends re- There have been several studies that evaluated the effects of ducing total daily caloric, limiting carbohydrate consumption, stevia in humans although many are quite small. Tey et al. and incorporating non-nutritive sweeteners to help maintain a compared the effects of AS, NAS, and sucrose on 24-h glu- healthful eating pattern and promote weight loss [4]. cose control in 10 healthy men. Each participant was given a Interestingly, despite the widespread use of sugar substitutes, beverage containing aspartame, monk fruit, stevia, or a su- the prevalence of T2DM continued to increase while the prev- crose. Twenty-four-hour glucose measurements were obtained alence of obesity has remained stable. This article discusses to calculate the mean 24-h glucose, incremental area under the natural alternative sweeteners (NAS) and their effects on body curve (iAUC), total area under the curve (AUC) for glucose, weight, glucose homeostasis, lipid metabolism, and antioxi- and 24-h glycemic variability. Overall, the study showed that dant properties in human and animal models. there were no significant differences in 24-h glucose measure- ments after ingestion of sucrose compared with those who were given AS or NAS [9]. In a subsequent study, Tey et al. studied the effects of as- Types of Natural Alternative Sweeteners partame, monk fruit, stevia, and sucrose on energy intake, blood glucose, and insulin in 30 healthy men. Beverages were Non-nutritive sweeteners (NNS) are commonly used as sugar administered 1 h prior to lunch. Individuals were asked to rate substitutes and are either not metabolized by the host or pro- their desire to eat, hunger, and prospective food consumption vide a negligible amount of energy. Although sugar substitutes using a visual analog scale. The study showed no significant are marketed as healthier alternatives to sugar, some data sug- difference in total energy intake between those that consumed gest that they may have similar effects on metabolic derange- NNS versus sucrose. The energy saved by consuming a NNS ments and glucose homeostasis when compared with their compared with a sucrose-containing beverage was fully com- sugar counterparts. This review will focus on NAS that in- pensated for by the end of the day. Additionally, desire to eat, clude stevia, rare sugars, sugar alcohols, and monk fruit and hunger, and prospective consumption ratings were higher after will not discuss other sugar substitutes like artificial sweet- consumption of the NNS beverage compared with sucrose. eners (Table 1). Blood glucose and insulin levels spiked within the first hour post-sucrose consumption; however, glucose and insulin levels post-lunch were higher in those that consumed the NNS. As a result, the AUC for glucose was similar amongst Stevia all four groups [10]. Ritu et al. investigated the effects of stevia on daily caloric Stevia rebaudiana (SR) is a native plant found in South intake using dietary recall, blood glucose, and lipids in 20 America that has long been used for medicinal purposes. individuals with T2DM for 60 days. Individuals either re- Steviol glycosides, which include stevioside and rebaudioside ceived 1 g of stevia leaf powder per day or no intervention. A, are metabolites responsible for its sweet taste and are main- Though not statistically significant, the mean daily caloric ly found in the plant’s leaves [7]. Stevia is 200–300 times consumption was higher in males who received stevia com- sweeter than sucrose and is used in popular foods and bever- pared with the control group despite the control group having ages and has been used for therapeutic purposes such as an a greater carbohydrate intake. The stevia group had a statisti- antacid, antimicrobial, antioxidant, and diuretic [3, 8]. cally significant reduction in fasting and post-prandial blood Table 1 Examples of non- nutritive sweeteners Non-Nutritive Sweeteners Intense Sweeteners Bulk Sweeteners Artificial Natural Carbohydrates Sugar Alcohols -Aspartame -Stevia -Fructose -Sorbitol -Sucralose -Monk fruit -Sucrose -Erythritol -Saccharin -Rare sugars -Hydrogenated fructose corn syrup -Xylitol -Dextrose -Mannitol Curr Diab Rep (2019) 19:142 Page 3 of 10 142 glucose, total cholesterol (TC), triglyceride (TG), and very- significant decrease in the number of islets in diabetic rats. low-density lipoprotein (VLDL) compared with the control However, both stevia and pioglitazone groups demonstrated group [11]. significant regeneration of islets [15]. Onakpoya et al. performed a systematic review and meta- Antihyperglycemic effects of minor steviol glycosides analysis (nine studies, n = 756 non-diabetic and diabetic indi- were also studied in non-diabetic and STZ-induced diabetic viduals) on the effects of steviol glycosides (stevioside and Wistar rats. Rats were given metformin; rebaudioside B, C, or rebaudioside A) on cardiovascular risk factors. The analysis D; dulcoside A, or steviolbioside which were incorporated in showed that steviol glycosides were associated with non- food pellets. Intraperitoneal glucose tolerance test (IPGTT) significant reductions in systolic blood pressure (SBP) and was administered before and after 28 days of treatment. The significant reductions in diastolic blood pressure (DBP) and study showed that acute intraperitoneal or chronic oral admin- fasting blood glucose. However, studies using only pure istration of minor steviol glycosides at 20 mg/kg had no rebaudioside A showed non-significant changes in DBP and antihyperglycemic effects in normoglycemic or diabetic rats. SBP. A sub-analysis of six studies (n = 521) including dia- These results are in accordance with previous research and betics and non-diabetics revealed a non-significant difference suggest that minor glycosides may
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