Benefits for people with diabetes
Low/no calorie sweeteners cause a lower rise in blood glucose levels after meals (post-prandially) if consumed instead of sugar and they do not otherwise affect blood glucose control or insulin secretion. The benefit of low/no calorie sweeteners on post-prandial glucose has also been recognised as a health claim by EFSA: “Consumption of foods containing low/no calorie sweeteners instead of sugar induces a lower blood glucose rise after their consumption compared to sugar-containing foods”1.
Low/no calorie sweeteners offer more “sweet” food choices to people with diabetes
Diabetes is one of the fastest growing health challenges of the 21st century, with the number of adults living with diabetes having more than tripled since 2000. Based on the latest figures released by the International Diabetes Federation (IDF) in 2021, it is estimated that globally 1 in 10 adults aged 20-79 years, a staggering 537 million people, are currently living with diabetes. If trends continue, IDF estimates that the number of adults living with diabetes worldwide will rise to 783 million by 2045. A further 1.2 million children and adolescents under the age of 20 live with type 1 diabetes.2
Low/no calorie sweeteners offer people with diabetes broader food choices by providing the pleasure of sweet taste without raising blood glucose.3,4 As low/no calorie sweeteners have no impact on insulin and blood sugar levels and do not provide calories, they can also have a role to play in weight loss and weight control for people with type 2 diabetes. 5-11
The role of low/no calorie sweeteners in diabetes
Over the last decade, numerous diabetes-related organisations worldwide, including the American Diabetes Association (ADA), the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes (EASD), Diabetes UK, Diabetes Canada, and the Latin-American Association of Diabetes (Asociación Latinoamericana de Diabetes – ALAD) have issued clinical practice and nutritional guidelines, position statements or consensus reports about the use of low/no calorie sweeteners in diabetes.
For example, a Position Statement on low/no calorie sweeteners (LNCS)6 by Diabetes UK concludes that: “LNCS are shown to be safe and they can be used as part of a strategy for adults and children in the management of weight and diabetes”.
Similarly, a consensus of the Latin-American Association of Diabetes (Asociación Latinoamericana de Diabetes (ALAD))7 acknowledges that the consumption of low/no calorie sweeteners is safe within the Acceptable Daily Intake (ADI) levels and further concludes that their use can have benefits in calorie reduction, weight loss and glucose control, when used to replace sugar in the context of a structured dietary plan.
A similar benefit is acknowledged by the Diabetes Canada Clinical Practice Guidelines Expert Committee who pointed out in the Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada 8 that the evidence from systematic reviews and meta-analyses of randomised controlled trials (RCTs), which give a better protection against bias, have shown a weight loss benefit when low/no calorie sweeteners are used to displace excess calories from added sugars.
More recently, in 2023, the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD) published updated European recommendations for the nutritional management of diabetes9 with the aim to provide health professionals with evidence-based guidelines. The European guidelines recommend the use of low/no calorie sweeteners to replace sugars in foods and beverages, while the intake of free or added sugars should be below 10% of total energy intake.9 The latest European recommendations on sweeteners are based on a series of systematic reviews and meta-analyses of RCTs10 and prospective cohort studies11 assessing the impact of low/no calorie sweetened beverages on cardiometabolic health in people with or at risk of developing diabetes. The two studies concluded that low/no calorie sweetened beverages, when replacing sugar-sweetened beverages, reduce body weight and cardiometabolic risk factors in people with or at risk for diabetes10 and are associated with reductions in the risk of obesity and cardiovascular outcomes in participants inclusive of people with diabetes, with reductions similar to those seen with the standard of care, water.”11
Finally, in the 2023 update of Medical Nutrition Therapy recommendations12, the American Diabetes Association (ADA) supported that: “The use of non-nutritive sweeteners as a replacement for sugar-sweetened products may reduce overall calorie and carbohydrate intake as long as there is not a compensatory increase in energy intake from other sources. There is evidence that low- and no-calorie sweetened beverages are a viable alternative to water.”
For more information on the role of low/no calorie sweeteners in diabetes management we invite you to download the ISA factsheet Sweet talk on diabetes. How can low calorie sweeteners help? and the ISA infographic Low Calorie Sweeteners in Diabetes.
You may also find interesting to check the online materials developed over the years as part of the ISA online campaigns in support of World Diabetes Day, which include inspirational videos, animations and interesting infographics providing further information on key lifestyle and dietary guidelines for people with diabetes, including on the role of low/no calorie sweeteners in this context. Please click here to access these materials, also available in multiple languages.
- EFSA NDA (EFSA Panel on Dietetic Products Nutrition and Allergies). Scientific opinion on the substantiation of health claims related to intense sweeteners and contribution to the maintenance or achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA 2011 Journal 9: 2229
- IDF, Diabetes Atlas 10th edition 2021. Available at: https://diabetesatlas.org/atlas/tenth-edition/
- Greyling A, Appleton KM, Raben A, Mela DJ. Acute glycemic and insulinemic effects of low-energy sweeteners: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2020;112(4):1002-1014
- Nichol AD, Holle MJ, An R. Glycemic impact of non-nutritive sweeteners: a systematic review and meta-analysis of randomized controlled trials. Eur J Clin Nutr 2018;72(6):796-804
- Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, Mitri J, Pereira RF, Rawlings K, Robinson S, Saslow L, Uelmen A, Urbanski PB, Yancy Jr. WS. Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019 May;42(5):731-754
- Diabetes UK. The use of low or no calorie sweeteners. Position Statement (Updated December 2018). Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/food-nutrition-lifestyle/use-o…
- Laviada-Molina H, Escobar-Duque ID, Pereyra E, Romo-Romo A, Brito-Córdova G, Carrasco-Piña E, González-Suárez R, López-García R, Molina-Seguí F, Mesa-Pérez JA. Consenso de la Asociación Latinoamericana de Diabetes sobre uso de edulcorantes no calóricos en personas con diabetes [Consensus of the Latin-American Association of Diabetes on low calorie sweeteners in persons with diabetes]. Rev ALAD. 2018;8:152-74
- Sievenpiper JL, Chan CB, Dworatzek PD, Freeze C, Williams SL. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Nutrition Therapy. Can J Diabetes 2018;42(Suppl 1):S64-S79
Reynolds A; Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD). Evidence-based European recommendations for the dietary management of diabetes. Diabetologia. 2023 Apr 17. https://doi.org/10.1007/s00125-023-05894-8
McGlynn ND, Khan TA, Wang L, Zhang R, Chiavaroli L, Au-Yeung F, Lee JJ, Noronha JC, Comelli EM, Blanco Mejia S, Ahmed A, Malik VS, Hill JO, Leiter LA, Agarwal A, Jeppesen PB, Rahelic D, Kahleová H, Salas-Salvadó J, Kendall CWC, Sievenpiper JL. Association of Low- and No-Calorie Sweetened Beverages as a Replacement for Sugar-Sweetened Beverages With Body Weight and Cardiometabolic Risk: A Systematic Review and Meta-analysis. JAMA Netw Open 2022;5(3):e222092
Lee JJ, Khan TA, McGlynn N, Malik VS, Hill JO, Leiter LA, Jeppesen PB, Rahelić D, Kahleová H, Salas-Salvadó J, Kendall CWC, Sievenpiper JL. Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies. Diabetes Care 2022;45(8):1917-1930
ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Young-Hyman D, Gabbay RA. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023. Diabetes Care 2023;46(Supplement_1):S68-S96