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

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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