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Diabetes and Nutrition The Role of Low-calorie Sweeteners in Diabetes Craig A Johnston, 1,2 Brian Stevens 2 and John P Foreyt 1 1. Department of Medicine, Baylor College of Medicine, Houston, Texas, US; 2. United States Department of Agriculture/Agricultural Research Service (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics-Nutrition, Baylor College of Medicine, Houston, Texas, US. Abstract As the incidence and prevalence of type 2 diabetes continue to rise, the identification of components that contribute to or are associated with this disease has become a priority. One of the main factors that has been linked to type 2 diabetes is excessive weight gain, and reduction in weight has been recommended for both diabetes prevention and management. Low-calorie sweeteners (LCS) provide an alternative to added sugars and may facilitate weight loss or maintenance by limiting caloric intake. Considerable attention has been given to the role of LCS and their relationship to type 2 diabetes. Research suggests that LCS can serve an important role in diabetes prevention and management. Substituting sugars with LCS provides patients with type 2 diabetes considerable flexibility in their health goals and personal dietary preferences. Keywords Type 2 diabetes, low-calorie sweeteners Disclosure: The authors have no conflicts of interest to declare. Received: 8 April 2013 Accepted: 5 May 2013 Citation: European Endocrinology, 2013;9(2):96–8 Correspondence: Craig A Johnston, Assistant Professor, USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics-Nutrition and Department of Medicine, Baylor College of Medicine, Houston, Texas, US. E: caj@bcm.edu Support: The publication of this article was supported by The Coca-Cola Company. The views and opinions expressed are those of the authors. A dramatic global increase in the number of adults suffering from type 2 diabetes has been observed in the last 30 years. 1 Between 1980 and 2008, the prevalence of type 2 diabetes more than doubled, and it is estimated that the prevalence will be more than 500 million by 2030. 1–3 Additionally, type 2 diabetes has considerable healthcare cost and significantly impacts quality of life. 4,5 All of these factors have led to an increased focus on diabetes prevention and management. The rise in diabetes is multifactorial. 4,6,7 Proposed variables that have led to an increase in prevalence include an ageing population, dietary changes and increasing levels of urbanisation and sedentary lifestyles. 1,3,8–10 Additionally, genetics has been suggested to play a large role. For example, a high concordance rate of diabetes between monozygotic twins and an increased likelihood of first-degree relatives developing the disease support evidence for a genetic component. 11–14 However, one of the most salient associations of type 2 diabetes is excessive weight gain. 15–17 As a result, considerable attention has been given to weight management through the promotion of healthy lifestyles. 18 used to help prevent and control weight gain. 8,20 LCS are used as an alternative to sugar because they contain less calories. 21,22 Several LCS are available on the market today. Aspartame is possibly the most well known of these. Other LCS are tagalose, neotame, sucralose, saccharin, luo han guo extract, stevia and acesulfame K. 23,24 Reasons for Use Reduction in Caloric Intake LCS offer a practical method for promoting a reduction in caloric intake. 8,20 They also offer a preventative measure to combat excessive weight gain in at-risk individuals. Foods and beverages that contain LCS offer a better alternative for individuals trying to both prevent and lose excessive weight by making a relatively simple dietary change. 8,20 Small changes such as this have been hypothesised to impact the high prevalence of obesity. 25–27 For example, changes as small as 100 calories a day have been suggested to reverse the trends in the obesity epidemic. 26 The replacement of added sugars with LCS is consistent with this approach. Treatment of Diabetes Based on this association of weight gain and diabetes, one of the primary ways to prevent or delay the onset of type 2 diabetes is to prevent excessive weight gain. 18,19 For individuals who have type 2 diabetes, weight loss is also highly recommended. 18 For example, a remission in type 2 diabetes has been observed in patients who have lost weight and maintained these changes. 19 Added sugars have received considerable attention due to their association with weight gain. For this reason, strategies to reduce added sugars have been developed. Non-caloric or low-calorie sweeteners (LCS) have been 96 Because added sugars are a source of increased carbohydrate intake, safe and easy ways to decrease their consumption is central to treatment. The use of LCS offers a practical approach to support the reduction of carbohydrate intake for patients with type 2 diabetes. By replacing added sugars with LCS, individuals with diabetes and prediabetes may better be able to manage their blood glucose levels and reduce their bodyweight. The Academy of Nutrition and Dietetics, the American Heart Association and the American Diabetes Association consider US Food and Drug Administration (FDA)-approved LCS to be © Touch ME d ical ME d ia 2013