Addressing the Fiber Gap

Posted by & filed under Fiber, Health Professionals.

Robyn Flipse, MS, MA, RDN — January 29, 2019

WHY IS SO MUCH FIBER MISSING FROM U.S. DIETS?
The Dietary Guidelines for Americans (DGA), first published in 1980 and revised every five years since, have each contained recommendations that provide ample sources of dietary fiber to meet every American’s needs.   If all Americans ate the recommended daily servings of whole grains; beans, peas and lentils; nuts and seeds; vegetables; and fruits there would be no “fiber gap,” or shortfall between our consumption of fiber and our requirements.  But Americans are not eating the recommended servings each day, or most days, of the foods rich in this indigestible carbohydrate that provides numerous health benefits (1).

The reasons Americans don’t consume enough dietary fiber are as diverse as the population itself. For some, it is simply a matter of taste preferences. Many who are “finicky eaters” in childhood grow up to be adults who still won’t eat broccoli.  For others, the reason is time constraints. Their schedules are so full they don’t believe they have the extra 20 minutes it takes to cook brown rice instead of white or slice a tomato for their sandwich.  Other reasons include perceived higher cost of high fiber foods, limited cooking skills to prepare them, lack of awareness about their options, and concern over digestive issues to name a few.

Whatever the reason for not eating enough fiber, the first step to closing the gap requires a change in one’s dietary pattern.

THE CHALLENGE OF DIETARY PATTERNS
The 2015-2020 DGA acknowledge that no individual food or nutrient is more important to our health than our overall dietary pattern (2). That is because dietary patterns reflect the amounts, variety and combinations of the different foods and drinks we regularly consume. Dietary patterns can also provide insight into where and when we eat, with whom, and how our food was prepared. (3). They are the key to knowing what our usual caloric and nutrient intake is over time.

If adequate amounts of fiber-rich foods are not part of someone’s dietary pattern, their habitual way of eating will have to be modified to incorporate them. This requires changes in long-established eating behaviors.

USING NUDGES FOR BEHAVIOR CHANGE
There is no one best way to help individuals, let alone entire populations, change their dietary patterns, but one method that has broad appeal is the use of “nudging” (4).  Nudge theory was popularized in the 2008 book, Nudge, co-authored by Richard Thaler and Cass Sunstein, and helped Richard Thaler win a Nobel Prize in Economics in 2017 (5).Simply stated, nudge theory encourages people to make decisions that are in their own best self-interest by making it easier for them to do so.

The current recommendations for fiber intake are 14 grams for every 1000 calories or a total of 25 – 38 grams a day for adults. These are difficult goals for most people to comprehend, let alone calculate. But if we nudge someone to eat just one more serving a day of a good source of fiber from choices that are already part of their dietary pattern, they have a goal that is both doable and sustainable.

For example, if someone eats lunch in their school or workplace cafeteria every Monday through Friday and makes a salad from the salad bar, we can encourage them to add one more serving of a fiber-rich food to their bowl. This could be 6 cherry tomatoes, ½ cup chickpeas or barley salad, or 2 tablespoons of sunflower seeds or dried cranberries. They don’t have to know how many grams of fiber they added or go out of their way to find these options. They just have to add one more serving of a vegetable, bean, grain, seed or fruit that they like and is right in front of them.

The next nudge to add one more serving could be to put an extra can of kidney beans in their homemade chili or mix a cup of frozen lima beans into a can of minestrone soup or blend some chopped walnuts with the bread crumbs they’re using to coat chicken cutlets. Little by little these nudges can help people increase their fiber intake by using foods that fit within the framework of their existing dietary pattern.

There are endless ways to “nudge” more sources of fiber into a dietary pattern by using higher fiber options in place of, or in addition to, the foods already being eaten, including the use of foods containing added fiber. The chart below provides examples of some ways to get started.

WAYS TO INCREASE FIBER IN THE DIET*
By replacing a Current Choice with the New Choice illustrated below, fiber intake can be nudged higher with each selection.

GRAINS

Current ChoicePortion SizeFiber (grams)New ChoicePortion sizeFiber (grams)
Bagel, pumpernickel3.5” diameter3Bagel, whole wheat3.5” diameter8
Bread, whole wheat1 ounce slice3Bread, whole wheat with added fiber1 ounce slice7
Pasta, white2 ounces dry1Pasta,  with added fiber2 ounces dry6
Corn Flakes1 ounce1Bran Flakes1 ounce5
Tortilla, flour1 ounce0Tortilla, whole wheat1 ounce2


VEGETABLES

Yam, cubed without skin½ cup2Yam, cubed with skin½ cup4
Spinach½ cup2Collard Greens½ cup4
Hearts of Palm, canned3 pieces2Artichoke Hearts, canned3 pieces3
Tomato Juice1 cup1Vegetable Juice1 cup2
Zucchini Squash1 cup2Acorn Squash1 cup6
Lima Beans½ cup4Edamame, shelled½ cup9


FRUITS

Strawberry Milkshake8 ounces< 1Strawberry Smoothie8 ounces3
Peachmedium2Pearmedium5
Pineapple1 cup2Kiwi1 cup5
Fruit Leather1 ounce0Apricots, dried1 ounce2
Grapes1 cup1Raspberries1 cup8
Jam, concord grape1 tablespoon0Jam, concord grape with added fiber1 tablespoon3


BEANS, NUTS & SEEDS

Tofu, firm½ cup3Split peas, cooked½ cup8
Peanuts1 ounce2Almonds1 ounce4
Black-eyed peas½  cup5Navy beans½ cup9
Sesame seeds1 tablespoon1Chia Seeds, dried1 tablespoon4
Sunflower Seeds1 ounce3Pumpkin Seeds1 ounce5
Butter, salted2 tablespoons0Peanut Butter, creamy2 tablespoons2

* Values are averages for similar items and rounded to nearest whole number

TIPS FOR DIETITIANS AND OTHER HEALTHCARE PROFESSIONALS 

  • Discuss the changes in bowel frequency and possible flatulence up front to avoid unexpected problems that could derail someone’s commitment.
  • Show respect for individual food preferences by basing recommendations on what clients like rather than the foods highest in fiber, many of which they may not like.
  • Avoid leading with the message that it is “easy” or “simple” to change one’s dietary pattern when it isn’t, but it can be done when the change is not too disruptive to one’s established routines.
  • Always include lower cost options in messaging, such as using canned, frozen and dried fruits and vegetables, to reinforce the fact all forms contribute needed fiber and other nutrients.
  • Make it clear the fiber in foods is not destroyed by preparation methods, such as chopping and pureeing or by temperature changes, such as boiling and freezing.
  • Suggest foods containing added fiber(s), such as granola bars, yogurts, and pasta, to replace lower fiber choices they may now be consuming.
  • Remind them that the claim “Made with Whole Grains” does not mean the food is a significant source of fiber so they must use the fiber information on the Nutrition Facts Panel to compare these foods to other products.
  • Look for the claims “High in Fiber” or “Good Source of Fiber” on product labels to easily find higher fiber foods.
  • Recommend fiber from a variety of food sources that contain different types of fiber since they have different benefits.
  • Encourage the use of QR scans and websites to find fiber information for foods that don’t have labels, like fresh fruits and vegetables and bulk grains and seeds.

REFERENCES:

  1. Hoy MK, Goldman JD. Fiber intake of the U.S. population What We Eat in America, NHANES 2009-2010. Food Surveys Research Group Dietary Data Brief No. 12. September 2014.
  2. S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 8th Edition. December 2015 https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf
  3. Tucker KL. Dietary patterns, approaches, and multicultural perspective. Appl Physiol Nutr Metab. 2010;35(2):211-218 doi: 10.1139/H10-010.
  4. Arno A, Thomas S. The efficacy of nudge theory strategies in influencing adult dietary behaviour: a systematic review and meta-analysis. BMC Public Health. 2016;16:676. doi:10.1186/s12889-016-3272-x.
  5. Thaler RH, Sunstein CS. Nudge. Improving Decisions About Health, Wealth, and Happiness. 2009, Penguin Books, London.

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Blending More Fiber into Meals

Posted by & filed under Fiber, Health Professionals.

Robyn Flipse, MS, MA, RDN — January 28, 2019

We’ve all seen the child who refuses to take even one bite of the steamed carrots on his or her plate, yet gobbles up the macaroni and cheese right next to it made with mashed carrots in the sauce. For many parents, this may feel like a nutrition success story, but is it really?  When children will only eat vegetables if they are hidden in something they like, they are missing an important lesson about the foods that make up a balanced diet. That is why I’ve always recommended “blending” instead of hiding foods to help children recognize and appreciate the contributions made by every food group to their health.  This lesson applies to teens and adults, as well.

Blending more vegetables (or other nutrient-dense food) into a recipe isn’t just a good way to enhance the nutritional value of a meal, it’s also a great way to extend the yield or lower the cost without significantly changing the look, texture or taste of the dish. It is also a valuable way to reduce food waste, like blending the heels of white and whole wheat bread to make bread crumbs for a meatloaf.

Another big benefit of blending is the way it can help close the gap in our intake of dietary fiber since many higher fiber foods blend well with the foods people regularly eat, such as smoothies, hamburgers and brownies. And since eating habits are so hard to change, blending a new food into an existing dietary pattern is a practical way to get more fiber into meals and snacks without having to give up the foods you already enjoy.

REVISE THE RATIO
A simple way to use blending to add more fiber to your diet is to increase the amount of one or more of the high fiber ingredients called for in a recipe while using a little less of something else that is lower in fiber. For example, you can “revise the ratio” by adding:

  • 1 ½ cups of raspberries to a smoothie and just ½ cup of melon cubes instead of one cup of each,
  • Swap another cup of beans in the chili to replace a cup of ground meat
  • Extra chia seeds on your yogurt and less granola
  • Add more cucumber and tomato slices into your salad and less lettuce

BLEND TO EXTEND
Blending is a great way to stretch or extend a recipe so you get a few more servings while increasing the fiber content. One way is to add a 15 ounce can of rinsed navy beans to a 28 ounce can of baked beans. There’s enough sauce in the baked beans to flavor the additional beans, but you’ll end up with ten half-cup servings instead of six, and each will all have more fiber and less sodium and added sugars than the original can of baked beans. Similarly, a cup of canned mixed vegetables can be blended into a can of vegetable soup to extend the servings from two to four while increasing the fiber content in them all.  And any recipe that starts with simmering diced vegetables, such as onions, carrots, and celery will taste even better and be higher in fiber if you extend the amounts of the vegetables called for. You can even add a cup or two of complementary frozen vegetables to a stew or soup simmering in a slow cooker during the last hour to extend the fresh ones added in the beginning.

BLEND TO ENHANCE
Ground meat, poultry or fish mixtures used to make things like meatballs, croquettes and fish cakes are an ideal place to blend in high fiber whole grain crumbs to “enhance” the fiber content. Crushed whole grain cereal or cracker crumbs can also be used or oatmeal. Stuffing mixtures made with white rice to fill peppers, acorn squash, and other hollowed vegetables can be blended with whole grains, such as brown rice, bulgur or barley to easily enhance the fiber content. And when making quick breads and muffins, part or all of the all-purpose flour called for can be blended with whole wheat or white whole wheat flour to boost the fiber content.

BLEND TO SWEETEN
Sweet potatoes are true to their name and the purple ones are even sweeter than the orange. When peeled, cooked and mashed they can be used to make much more than pie. Look for recipes that blend sweet potatoes into the batter for brownies, donuts, cookies and other sweet treats to replace some or all of the sugar and flour while increasing the fiber.  Sweetness and fiber are also available by blending pureed dates into recipes for granola bars, pudding, fudge and more. Don’t overlook the many ways to sweeten a smoothie without sugar and increase the fiber by using naturally sweet and fiber-rich fruits and vegetables like carrots, apples and mangoes.

BLEND TO BULK UP
Beans, peas and lentils are true superfoods due to the many vitamins and minerals they contain, the plant-based protein they provide and the great source of fiber they add to any diet. Even more important to their superfood status, they are inexpensive and available everywhere all year long. To bulk up the nutrition and fiber profile of any meal, all you have to do is blend in some beans. Try using pureed beans or lentils to thicken a soup or make a sauce. You can bulk up your Bolognese with kidney beans or your guacamole with green peas. Pureed beans can also be added to cake batter for a more moist and dense dessert. Popular recipes include black beans in brownies, cannellini beans in coconut cake and baked beans in spice cake. The options are endless!

In every example I’ve provided, and those you come up with on your own, it is important to remember that the goal is to celebrate the benefits of blending more high fiber foods into your meals, not to hide or disguise them.

RESOURCES

Get More Fiber in Your Diet

High Fiber Chef: Cooking Tips to Prepare High Fiber Foods Like a Pro

Finding Fiber in the Grocery Store

Robyn Flipse, MS, MA, RDN is a registered dietitian, cultural anthropologist and scientific advisor to the Calorie Control Council, whose 30+ year career includes maintaining a busy nutrition counseling practice, teaching food and nutrition courses at the university level, and authoring 2 popular diet books and numerous articles and blogs on health and fitness. Her ability to make sense out of confusing and sometimes controversial nutrition news has made her a frequent guest on major media outlets, including CNBC, FOX News and USA Today. Her passion is communicating practical nutrition information that empowers people to make the best food decisions they can in their everyday diets. Reach her on Twitter @EverydayRD and check out her blog The Everyday RD.

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Low- and No-Calorie Sweeteners and the Gut Microbiota: A Scientific Review

Posted by & filed under Health Professionals, Microbiome, Research Summaries, Uncategorized.

— Neva Cochran, MS, RDN, LD

Posted: January 23, 2019

Over the last five years, the potential impact of low and no calorie sweeteners (LNCS) on the microbiome has been a subject of debate. A new comprehensive review, “Assessing the in vivo data on low/no-calorie sweeteners and the gut microbiota,” published in the journal, Food and Chemical Toxicology1, is the basis of the following summary of the science on this issue.

Diet and Microbiome

Both long-term observational studies of population groups and short-term human intervention studies have shown that diet can affect gut microbial content. Poorly digested food components like fiber help regulate the microbiome, acting as substrates for microbial fermentation in the colon. Higher fiber intakes have been linked to increased fecal levels of certain bacteria. Higher protein and fat intake is associated with greater amounts of others,thus plant-based vs. animal-based diets can result in different gut microbiome.

Overall, studies suggest that dietary changes can modify the composition and function of the microbiome. Because there are important differences among individuals in the response of gut microbiomes to diet, researchers caution that it is difficult to generalize about the influence of specific dietary components. In interventional studies to assess the effects of different ingredients added to the diet in small amounts, the subjects’ usual diets should be determined and the intervention diets carefully controlled.

Low and No Calorie Sweeteners and the Microbiome

Concern about the effect of LNCS on the gut microbiome was prompted by a 2014 study by Israeli researchers2. The study concluded that consuming LNCS changes the composition and function of the gut microbiome, leading to an increased risk of glucose intolerance. But an expert review questioned the conclusions of the study based on limitations in the experimental design and the analysis and reporting of the data.

The authors of the new Food and Chemical Toxicology article1 reviewed 17 relevant primary research articles that investigated the effect of LNCS intake on the gut microbiome. The majority of these were animal studies, primarily with rodents. Only three were conducted with humans. A table in the paper provides a detailed summary of the studies.

There were limitations and confounding factors common in most of the studies including

  • lack of proper control groups,
  • use of LNCS doses in the animal studies that were far greater than the equivalent current acceptable daily intakes (ADIs) for humans
  • and the lack of relevance in applying results of animal studies to humans. Most of the bacteria present in mice do not exist in the human gut.

Of the three human trials, none accounted for habitual dietary intake. Therefore, any changes found in the gut microbiome were not necessarily due to the LNCS itself but could be related to dietary differences between the LNCS and non-LNCS groups.

In addition, the chemical structures and metabolism of LNCS preclude any effect they could have on the human microbiome.

  • Aspartame is a methyl ester of a dipeptide that is rapidly hydrolyzed into two amino acids and methanol, which are absorbed in the small intestine. So neither aspartame nor its metabolites ever reach the colon for direct interaction with the microbiome.
  • Although most of the sucralose consumed is not absorbed it is also not digested, so it is not a substrate for gut microbiome.
  • Saccharin and acesulfame K are not metabolized in the small intestine but are rapidly absorbed and excreted unchanged in the urine. So these LNCS do not come in contact with the colon microbiome to have any effect.
  • Steviol glycosides, including stevioside and rebaudioside A, pass unabsorbed through the GI tract and enter the colon intact. In the colon, the microbiome removes the sugar portion attached to the steviol backbone and use it for energy. But as total daily intake of steviol glycosides is very low it should not have a significant influence on the microbiome. The steviol backbone that remains after the sugar is removed is not a substrate for the intestinal microbiome and is absorbed from the colon virtually intact. While the gut microbiome actively acts on steviol glycosides, recent research showed that steviol glycosides, at levels comparable to the ADI, did not affect the gut microbiome.

Finally, because LNCS are so intensely sweet, the milligram amounts consumed will always be low and well below the levels necessary to produce a significant impact on the gut microbiome.

Conclusions and Applications for Practice

The authors of the review paper conclude that studies of LNCS to date do not establish any clear evidence of any adverse effect on the gut microbiome in amounts relevant to human use. They also assert that studies evaluating the relationship between food additive and ingredient consumption and the microbiome need to be conducted in animals or humans at relevant intakes and be carefully controlled to account for the confounding factors, including the habitual diet. Safety has been well-documented over decades for acesulfame K, aspartame, saccharin, sucralose, and steviol glycosides, indicating that these low or no-calorie sweeteners as a group, or individually, do not pose any safety concerns at their currently approved levels. Therefore, nutrition and health professionals can feel confident in recommending LNCS to patients, clients and consumers as an option for sweetening foods and beverages without the addition of sugar or calories.

  1. Lobach AR, Roberts A, Rowland IR. Assessing the in vivo data on low/no-calorie sweeteners and the gut microbiota. Food Chem Toxicol. 2019;124(December 2018):385-399. doi:10.1016/j.fct.2018.12.005
  2. Suez J, Korem T, Zeevi D, et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014;514(7521):181-186. doi:10.1038/nature13793


Neva Cochran, MS, RDN, LD is a registered dietitian nutritionist based in Dallas. She serves as a nutrition communications consultant to a variety of food and nutrition organizations, including the Calorie Control Council. She is passionate about promoting fact-based food and nutrition information to help people enjoy nutritious eating. Follow her on Twitter @NevaRDLD and check out her blog at www.NevaCochranRD.com.

Large Body of Science Points to Benefits of Low Calorie Sweeteners, Contrary to Recent Study

Posted by & filed under Media Room, Research Summaries.

Calorie Control Council statement in response to the Systematic Review by Toews et al.

(January 3, 2019) The recently published systematic review and meta-analysis by Toews et al1 reviewed existing studies evaluating the effects of low- and no-calorie sweeteners (LNCS) intake on a number of health outcomes in adults and children.  However, in contrast to the conclusions made by the study authors, the highest quality scientific evidence shows that the consumption of LNCS results in reductions in body weight, does not lead to weight gain and does not cause cravings leading to increased intake2,3. In fact, LNCS were found to be most beneficial to those who are overweight or obese4,5. Additionally, longer-term trials have shown consumption of LNCS to reduce weight in children and adolescents at 1-year follow-ups 6,7. Based on two randomized controlled trials included in the Toews’ review, the preference for sweet taste was slightly lower in the group receiving LNCS than in the group that did not.

A large body of evidence (International Journal of Obesity) evaluating more than 100 studies suggests LNCS play a role in reducing energy intake and body weight. Further, authors of The BMJ-published study cited research from Drs. Vanessa Perez and Paige Miller, who conducted a meta-analysis reviewing 35 years of independent studies on the relationship between LNCS and weight status and found that randomized control trials “resulted in statistically significant reductions in body weight, BMI, fat mass, and waist circumference.” LNCS continue to be a useful tool, along with diet and exercise, in helping to support weight management and weight loss.

As mentioned in the accompanying editorial by Vasanti Malik8, there are a number of significant limitations within the observational studies that have shown positive associations between LNCS consumption and weight gain. These limitations include reverse causality (meaning subjects are choosing LNCS to manage their weight after they have developed overweight/obesity) and residual confounding (the inability to control for factors that may influence the health outcome being studied).

In alignment with the conclusions made by Dr. Malik, the Calorie Control Council agrees that the highest quality science supports that LNCS can be consumed as part of a balanced diet and can assist with the reduction of cardiometabolic risk through the management of body weight and reduced caloric intake.

Given the proven safety and benefits of LNCS, consumers should continue to be confident in including these ingredients as part of a healthy diet.

  1. Toews I, Lohner S, Gaudry DK De, Sommer H, Meerpohl JJ. Association between intake of non-sugar sweeteners and health outcomes : systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies. 2018. doi:10.1136/bmj.k4718
  2. Rogers PJ, Hogenkamp PS, De Graaf C, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. Int J Obes. 2016. doi:10.1038/ijo.2015.177
  3. Miller PE, Perez V. Low-calorie sweeteners and body weight and composition: a meta-analysis of randomized controlled trials and prospective cohort studies. Am J Clin Nutr. 2014. doi:10.3945/ajcn.113.082826
  4. Pan A, Malik VS, Hao T, Willett WC, Mozaffarian D, Hu FB. HHS Public Access. 2014;37(10):1378-1385. doi:10.1038/ijo.2012.225.Changes
  5. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men. N Engl J Med. 2011;364(25):2392-2404. doi:10.1056/NEJMoa1014296
  6. De Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med. 2012;367(15):1397-1406. doi:10.1159/000356352
  7. Cara B. Ebbeling, Ph.D., Henry A. Feldman, Ph.D., Virginia R. Chomitz, Ph.D., Tracy A. Antonelli, M.P.H., Steven L. Gortmaker PD, Stavroula K. Osganian, M.D., Sc.D., and David S. Ludwig, M.D. PDA. A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight. N Engl J Med. 2012;367(15):1407-1416.
  8. Malik VS. Non-sugar sweeteners and health. Bmj. 2019;364:k5005. doi:10.1136/BMJ.K5005

Calorie Control Council Statement on ADA 2019 Standards of Medical Care in Diabetes

Posted by & filed under Uncategorized.

December 20, 2018 — The American Diabetes Association (ADA) recently published their 2019 Standards of Medical Care in Diabetes manual, which includes all of their current clinical practice recommendations. These standards are published annually and are intended to provide clinicians, patients, researchers, payers, and other interested parties with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The recommendations are based on a review of clinical diabetes literature, supplemented with input from ADA staff and the medical community at large.

The 2019 Standards of Medical Care acknowledges some, though not all, of the many benefits of non-nutritive sweeteners (NNS), including:

  • NNS serve as a substitute for caloric sweeteners such as sugar, honey, agave syrup.
  • NNS can reduce calorie and carbohydrate intake.
  • The highest quality of scientific evidence shows that NNS help with weight loss and weight management.

However, the ADA makes a final statement recommending that people decrease their intake of both sweetened and non-nutritive-sweetened beverages.  This statement is not supported by the current body of scientific literature nor does it align with the benefits that ADA describes initially.  Further, it is in contradiction to ADA’s previous statement (Gardener, et al., 2012) on the use of NNS. In 2012, the ADA expressed support of these ingredients in the management of both diabetes and body weight. However, the new standards recommend consuming more water and fewer sweetened beverages, including those containing NNS. Despite the ADA’s history of recognizing the well-documented role of NNS in the reduction of overall calorie and carbohydrate intake when substituted for caloric sweeteners, the ADA’s 2019 manual groups NNS together with caloric sweeteners and encourages a broad reduction in their use.

These updated recommendations send a confusing message to those living with diabetes, many of whom view NNS as a crucial part of their diet. For many years now, individuals with diabetes or prediabetes have depended on NNS and use them regularly to help manage their condition.  It is well established that NNS are safe to consume, help manage blood glucose levels, and assist in the management of caloric intake and body weight.

NNS as a Tool in Diabetes Management

Previously, the ADA and the American Heart Association issued a joint statement supporting the use of NNS as substitutes for sugar. Given that these sweeteners do not affect blood glucose levels and insulin secretion, they have the potential to aid in achieving and maintaining a healthy weight, and are also helpful for glucose control in people with diabetes.

From an international standpoint, following a thorough review of available scientific literature, the European Food Safety Authority (EFSA) Panel on Dietetic Products Nutrition and Allergies concluded that replacing sugar-containing foods with those containing NNS induces a lower post-prandial increase in blood glucose. Based on this finding, the European Commission based their authorization of a health claim communicating the benefits of NNS on post-prandial glucose levels.

NNS as a Tool in Weight Management

Almost 90 percent of people living with type 2 diabetes are overweight or obese, according to the Obesity Society. Ninety-five percent of those with diabetes have type 2. As a result, endocrinologists typically direct patients to lose weight as part of their treatment. There is a large of body of evidence supporting the role of NNS in reducing energy intake and body weight. Furthermore, studies have shown that the effect of beverages sweetened with NNS is similar to that of water on weight loss. The grouping of both caloric and non-caloric sweeteners in these recommendations suggests that products containing NNS have the same impact on BMI as sugar-sweetened products. This is not supported by the totality of available scientific evidence and ultimately deprives consumers of a useful and science-supported tool to help manage weight.

NNS are Safe

The categorization of NNS as a “short-term replacement strategy” in the updated recommendations suggests that there is some concern regarding their safety and long-term use. There is a substantial body of evidence (Sylvetsky and Rother, 2018) which includes findings from randomized controlled-trials conducted in humans, confirming the safety of both short and long-term use.

International scientific organizations and regulatory agencies, including the Joint FAO/WHO Expert Committee of Food Additives (JECFA), US Food and Drug Administration (FDA), and European Food Safety Authority (EFSA) have extensively reviewed NNS and have recognized their safety.

Conclusion

The beneficial effects of NNS are largely due to the replacement of sugar in the diet. Therefore, not only should they be addressed separately from sugar, they should also be recognized as a tool in weight and diabetes management, not a hindrance. Recommending the reduction of ingredients with substantial evidence to support their safety and health benefits may actually result in unintended consequences. Such consequences may include consumer confusion and the reduced availability of products important for the management of common diet-related diseases. Therefore, the Calorie Control Council cautions against the inclusion of NNS in recommendations to reduce caloric sweetener intake, and encourages the ADA to reconsider the recent update to their recommendations and continue to promote the incorporation of these ingredients and the products that contain them as part of healthy, balanced diet.

References:

Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D and Lichtenstein AH. Nonnutritive Sweeteners: Current Use and Health Perspectives. Circulation. 2012;CIR.0b013e31825c42ee

Commission, European. (2012). Commission Regulation (EU) No 432/2012 of 16 May 2012. Official Journal of the European Union. 1-40.

Nichol AD, Maxwell JH & Ruopeng A. (2018). Glycemic impact of non-nutritive sweeteners: a systematic review and meta-analysis of randomized controlled trials. European Journal of Clinical Nutrition. 72. 10.1038/s41430-018-0170-6.

Pan American Health Organization (PAHO) (2016) Pan American Health Organization Nutrient Profile Model. Washington, D.C.

Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC, Vander Veur SS et al. The effects of water and non-nutritive sweetened beverages on weight loss during a 12-week weight loss treatment program. Obesity 2014; 22: 1415–1421.

Rogers PJ, Hogenkamp PS, de Graaf C, Higgs S, Lluch A, Ness AR, Penfold C, Perry R, Putz P, Yeomans MR, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. Int J Obes (Lond) 2016;40:381–94.

Sylvetsky AC and Rother KI. Nonnutritive Sweeteners in Weight Management and Chronic Disease: A Review. Obesity 2018; 26, 635-640

Tate DF, Turner-McGrievy G, Lyons E, Stevens J, Erickson K, Polzien K et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr 2012; 95: 555-563

Ultra-processed food and drink products in Latin America: Trends, impact on obesity, policy implications. Washington D.C.: Pan American Health Organization, 2015

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