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Sugar Substitutes or Sugar: What's Better for Diabetes?

8 ways diabetics can enjoy sweets without relying on artificial sweeteners or added sugar.

With Sabyasachi Sen, MD, FRCP, FACP, FACE, and Christopher Gardner, PhD

That piece of chocolate cake is awfully tempting, but a little voice says, "not worth the sugar and calories." But as you're trying to walk away, a louder voice says, "go ahead. You had an aspartame-sweetened yogurt for breakfast and a diet soda with lunch so you're ahead of the game."

That kind of thinking is just one reason some experts are discouraging use of artificial sweeteners and sugar substitutes, especially if you have diabetes or noticed the weight creeping up. And the chorus is getting louder as the science points to reasons why you should think twice and then walk away from artificially sweetened foods.

For decades, we've relied on artificial sweeteners to deliver the taste without the calories or glucose rush, but it seems it's time to reconsider.

Researchers who presented new data at ENDO 2018, the 100th annual meeting of the Endocrine Society,1 in Chicago, say artificial sweeteners can promote ''metabolic dysregulation." If it sounds awful that because it is. Translations: just as sugar creates problems, so it seems do artificial sweeteners by messing up your body's normal response to glucose and insulin, complicate rather than help weight loss efforts, and make you more prone to prediabetes and diabetes, especially if you are currently overweight.

Fat Cells Treat Sucralose Just Like Sugar

In the study, led by Sabyasachi Sen, MD, associate professor of medicine at George Washington University School of Medicine and Health Sciences, in Washington, DC, the researchers first looked at human fat-derived stem cells in the lab, adding the sugar subsitute, sucralose, to some cell samples but not to others.1 (Sucralose, sold as Splenda and store brands, is in packets and used in numerous food products.) "We wanted to see if adding sucralose contributed to the process of making fat," Dr. Sen tells EndocrineWeb.

Stem cells can change into mature fat, muscle, cartilage, or bone cells. After about 12 days, ''we could actually see the sucralose-added dish had more fat accumulation compared to the ones that did not get it," Dr. Sen says.

Why did the cells accumulate fat? In the lab samples, Dr. Sen explains that the sucralose seemed to change the expression of a gene known as the glucose transporter gene. The glucose transporter gene helps sugar or in this case, sugar substitutes enter cells better.1 However, he says, when too much gets into the cells, it gets stored as fat.

Not what you’d expect. They found with the stem cell research that the low-cal sweeteners promoted additional fat accumulation within the cells, compared to cells not exposed to these sweeteners. And, the higher the concentration of sweeteners introduced to the cells, the more fat that was accumulated.1 "The cells perceive [sugar substitutes] as glucose," he says.

Next, Dr. Sen's team looked at human fat samples, collected from people who were normal weight and other who had obesity and used low-cal sweeteners. They found similar genetic changes occurring in the patients who were overweight.1 The increased gene expression was found when the sucralose in the samples reached a level similar to what would be found in the blood of people who drank four cans of diet soda a day, he says. However, Dr. Sen says, ''the difference in gene expression was statistically significant only in obese individuals, not in those who were at a healthy weight."

Artificial Sweeteners: No Better for Those with Thyroid Disease

Besides promoting fat accumulation, artificial sweeteners have been linked with the kind of hypothyroidism known as Hashimoto's thyroiditis, an autoimmune condition.2

In a study presented at the International Thyroid Congress in 2015,2 researchers reported a link between artificial sweetener use and Hashimoto’s disease. The research team looked at 100 patients with Hashimoto's thyroiditis and another 125 people with a healthy thyroid, and they found a strong link between use of sugar substitutes and a link to this thyroid condition. They note that sugar substitutes also have been linked with autoimmune problems in animals.

Best Not to Rely on Sugar Substitutes for a Sweet Fix

The evolving research on sucralose and fat accumulation offer an important warning, especially for those who are struggling with undesirable weight gain, says Christopher Gardner, PhD, professor of medicine at Stanford University and director of nutrition studies at the Stanford Prevention Research Center. The researchers found a plausible mechanism to explain a compelling downside to using artificial sweeteners, he tells EndocrineWeb.

Dr. Gardner chaired the 2012 scientific statement from the American Heart Association and American Diabetes Association scientific statement on nonnutritive sweeteners,3 as sugar substitutes are called. The expert panel concluded that data was insufficient to decide conclusively whether using them to displace caloric sweeteners in drinks and food works to reduce overall added sugars and carbohydrates or yields other benefits such as appetite, weight or metabolic risk factors. Some experts say the professional panel recommendation is due for an update. 

Dr. Gardner has researched and published extensively on artificial sweeteners. In a 2014 review, he weighed the risks and benefits of sugar substitutes.4 He noted that short-term studies suggest that the popular artificial sweeteners when taking the place of sugar, may reduce a person’s overall calories, but the benefits were very modest—and sometimes there was no benefit at all. "Compensatory eating behaviors such as when a person justifying having that slice of cake because she drank a diet soda earlier likely diminishes, and in some cases negates, potential [beneficial] effects," he wrote. Longer-term studies are needed, he says.

What's In the Glass Matters a Lot  

The health impact of sugar is even grimmer, at least when you drink it. In a study of 18,000 people across the United States who participated in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study,5 those who consumed the most beverages containing sugar—including soda (soft drinks), punch, fruit-flavored drinks, and fruit juices—had the greatest risk of dying from heart disease and other causes.

These individuals were followed for nearly seven years. and the findings held after the authors controlled for smoking, age, body weight, alcohol use, income, region of the country, and level of physical activity. The rate of death was highest, nearly double, that of people who consumed the least amount of sugar-laden drinks.5

What to do? It will take time to adjust so transition slowly and think creatively.

"Try to find beverages that satisfy your thirst and deliver in flavor but without the sugar or sugar substitutes,"  says Jodi Godfrey, MS, RD, a registered dietitian in New Jersey, "Lemon, lime and fruit-flavored iced teas offer another good option." For those who like soft drinks, flavor seltzer with lemon, lime, or a splash of your preferred juice. "An ounce of cranberry or orange juice will provide a hint of the taste you are looking for so let a little go a long way," she says.

FIll a pitcher with water, drop in 3-4 slices of fresh lemon, and leave it in the refrigerator. Since sugary drinks account for 47% of all added sugar in our diet, skip the liquid sugar, choosing instead a refreshing option that quenches your thirst so you are no longer pouring health risks into your glass.

To Satisfy a Sweet Tooth—Now What?!

"These products [with artificial sweeteners] are geared to those who are obese," Dr. Sen says, worse "It's giving them false hope." The message that comes with these product is, if you eat these sugar substitutes you won't put on weight.

"That's unfortunately just not true," Dr. Sen says, given the findings from his research.1 Yet, he is not saying to turn to sugar either, but rather to be aware of the downsides of both ''real'' sugar and its artificial substitutes.

"Try eating more whole foods,'' Dr. Gardner says. "I've never seen a food with an artificial sweetener that is not a junk food," he says. Fresh fruit delivers plenty of sweetness. Frozen berries that can be thawed and added still warm to oatmeal or yogurt for a very comforting meal.

How to give up the sugar substitute habit? Gradually, Dr. Gardner says. Think transition, not ''cold turkey." For instance, if you love yogurt sweetened with sucralose, gradually replace your yogurt with vanilla and added fruit, or looking for low sugar brands. Give it a couple of months, he says, to change your habit and retrain your palate.

8 Ways to Enjoy Sweets Without Added Sugar or Sugar Alternatives

  • Add a splash of unsweetened vanilla-flavored almond milk to your coffee
  • Grate some carrots into your tomato sauce or bake some moist carrot muffins
  • Slice some roasted beets into your salad or bake into a chocolaty “red velvet” cake.
  • Add a splash of fresh orange juice to your homemade salad dressing, or your French toast batter.
  • Stir some pineapple chunks into your stir-fry or top your chicken or fish with sliced pineapple or orange before baking.
  • Defrost frozen berries and add, still warm, to a bowl of oatmeal or mix into plain yogurt, and sprinkle with diced walnuts.
  • Top your burger—beef, turkey, salmon, veggie—with caramelized onions.
  • Dates, not terribly appealing to most of us on their own, have great qualities for replacing cane sugar in your favorite baked recipes; try brownies, peanut butter pie, or no-bake cheesecake.
  • Prepare your pancake batter with some unsweetened applesauce or grated apple.

As a last resort, Stevia, plant-based alternative sweetener, offers a very concentrated sugar like flavor when none of the options above work for you; just go sparingly and use only occasionally. The more you rely on intense added sweeteners, the more you may crave them and nothing else.

Dr. Sen and Dr. Gardner have no financial disclosures. 

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