If like me you are a diabetic, then you
have seen a number of products that cater to diabetics that are
labeled as 'sugar-free' the emphasis primarily being on candy and
snack foods. In addition, over the last few years as low carbohydrate
high fat (LCHF) and ketogenic (keto) ways of eating (WOE) have become
popular a number of companies have began to offer meal or energy
replacement bars which are touted as being 'sugar-free' or 'low
carbohydrate'. These products claim to offer all of the sweetness of
sugar without the side effects of raising sugar levels and or low net
carbohydrate counts to help keep you in ketosis. Essentially, the
companies that produce these products are telling consumers “you
can have your cake and eat it too” if it contains sugar alcohols
instead of sugar. Unfortunately, its not that simple.
Just exactly what are these sugar
alcohols that are being used to replace the sugar in these
'sugar-free' and low carbohydrate products? Sugar alcohols are
created from a variety of fruits, berries, and even corn. These
plants or plant products go through a chemical process in which the
natural sugars (carbohydrates) in the plant are altered to form a
sugar alcohol (polyol) that contains less carbohydrates than sugar,
but still maintains it's sweetening power. The most common sugar
alcohols derived from these plants that are found in commercially
made products include: erythritol, lactilol, maltitol,
mannitol, sorbitol, xylitol, isomalt, and hydrogenated starch
hydrolysates (HSH). Hydrogenated starch hydrolysates are mixtures of
high-order polyhydric sugar alcohols such as maltitol and sorbitol.
The following table lists some of the most common uses of sugar
alcohols in commercial products.
The Sugar
Alcohols
|
|||
Type
|
Calories
Per
Gram
|
Sweetness
Compared To Sucralose
|
Typical
Food Applications
|
Sorbitol
|
2.6
|
50
- 70%
|
Sugar-free
candies, chewing gums, frozen desserts and baked goods |
Xylitol
|
2.4
|
100%
|
Chewing gum,
gum drops and hard candy, pharmaceuticals and oral health
products, such as throat lozenges, cough syrups, children’s
chewable multivitamins, toothpastes and mouthwashes; used in foods
for special dietary purposes |
Maltitol
|
2.1
|
75%
|
Hard
candies, chewing gum, chocolates, baked goods and ice cream |
Isomalt
|
2.0
|
45
- 65%
|
Candies,
toffee, lollipops, fudge, wafers, cough drops, and throat lozenges |
Lactitol
|
2.0
|
30
- 40%
|
Chocolate,
some baked goods (cookies and cakes), hard and soft candy and
frozen dairy desserts |
Mannitol
|
1.6
|
50
- 70%
|
Dusting
powder for chewing gum, ingredient in chocolate-flavored coating
agents for ice cream and confections |
Erythritol
|
0
- 0.2*
|
60
- 80%
|
Bulk
sweetener in low calorie food |
HSH
|
3
|
25
- 50%
|
Bulk
sweetener in low calorie foods, provide sweetness, texture and
bulk to a variety of sugarless products |
* FDA
accepts 0.2 kcal/g, but some other countries, such as Japan and
the European Union, accept 0 kcal/g. |
Blood Sugar Effects
There are a quite a large variety of
candy and or sweet goods that are sold using sugar alcohols that are
touted as being sugar-free and sold as diabetic friendly. My father
who is a type two diabetic loves the little Russel Stover brand of
chocolate candies which are of course labeled “sugar-free”, but
contain large amounts of sugar alcohols. The question is are these
products really sugar free, and if so, do they keep your blood sugar
(insulin) levels from rising after they are consumed? According to
the American Diabetes Association “sugar alcohols provide fewer
calories than sugar and have less of an effect on blood glucose
(blood sugar) than other carbohydrates.” According to the
University Of California San Francisco (UCSF) Medical Center, sugar
alcohols may still have a significant impact of your blood sugar
levels “don’t be fooled – sugar alcohols are still a form of
carbohydrate, and they still affect your blood sugar levels, if not
as dramatically.” The Harvard
School of Medicine Joslin Diabetic Center on their website regarding
sugar alcohols state “Many so-called 'dietetic' foods
that are labeled 'sugar free' or 'no sugar added' in fact contain
sugar alcohols. People with diabetes MISTAKENLY think that foods
labeled as "sugar free" or 'no sugar added' will have no
effect on their blood glucose. Foods containing these sugar alcohols
need to have their calorie and carbohydrate contents accounted for in
your overall meal plan, as it is carbohydrates that raise blood
glucose levels.”
So what does this all mean? Well, sugar
alcohols are not sugar, but, depending on the type they can still
have a moderate effect on blood sugar levels. On their website for Diabetic Education the UCSF Medical Center
states that in order to
determine a more accurate impact of sugar alcohols on blood sugars
“when counting carbohydrates, include half of the sugar from the
sugar alcohol.” Therefore, when looking at nutritional labels of
products that contain sugar alcohols you should take the total amount
of the sugar alcohol and divide by two as about half of the sugar
alcohols will be absorbed and impact your blood sugar levels. So
let's take a look at the Millville Elevation Carb Conscious Caramel
Chocolate Peanut Nougat Bar that I myself have eaten.
Elevation Carb Conscious Caramel
Chocolate Peanut Nougat (2 Net Carbs per package)
Total carbohydrates – 20 grams
Dietary Fiber – 8 grams
Sugar alcohols – 10 grams
I have always learned that you should
take the total number of carbohydrates and subtract the dietary fiber
and all of the sugar alcohols to get the total net carbohydrate count
of the end product (total carbs – sugar alcohols – fiber = net
carbs). Following this formula, we see that the Elevation bar does
equate to 2 net grams of carbohydrates per bar. According to the UCSF
Medical Center, a more accurate way to determine the impact that sugar
alcohols have on your blood sugar is to divide the total number
of sugar alcohols by half, then subtract them from the total amount
of carbohydrates to determine net carbs. So when we take the sugar
alcohols which are listed as 10 grams and divide by half, we get a
total of 5 grams (10 / 2 = 5 grams). Now lets re-work our formula to
calculate the net carbohydrates of the Elevation bar in question. If
the total amount of carbohydrates is 20 grams, and the fiber is 8,
and revised sugar alcohol count is 5 grams, we get a total of 7 net
carbohydrates (20 – 8 – 5 = 7 grams), not 2 net carbs.
So while the package of the Elevation
bars lists net carbohydrates as 2 grams, according to UCSF Medical
Center formula, it actually has an impact on your blood sugar as if
you are consuming 7 grams of carbohydrates. While 7 grams of net
carbs does not seem like a lot, it is still three times more than
what is listed on the package. I must admit I was quite shocked, and
felt somewhat deceived by the manufacturers package labeling. It's
not just Millville and Atkins, it's all the manufacturers that
produce 'sugar-free' or 'no-sugar added' products that contain sugar
alcohols. They all follow the standard formula that total carbs –
fiber – sugar alcohols = net carbs, even though they know that
sugar alcohols have an impact on blood sugars.
Ketosis and Fat Burning
For those of us who have embraced a
LCHF / Keto way of eating (WOE), the big question is will the
consumption of sugar alcohols delay or interfere with ketosis and fat
burning? According to 'Ask The Nutritionist' on the Atkins website,
“Sugar alcohols are not fully absorbed by the gut, which means
they provide roughly half the calories that sugar does. Thanks to
this incomplete and slower absorption, there is a minimal impact on
blood sugar and insulin response. Because of this, sugar alcohols
don’t significantly interfere with fat burning.” What
is missing from this statement is that roughly half the calories also
means they contain roughly half the carbohydrates, and we know
carbohydrates impact blood sugar levels as well as ketosis.
Dr.
Andreas Eenfieldt from Dietdoctor.com during his communication with
the Atkins company regarding one of there products that they clam is
only 5 nets carbs responded “subtracting 100% of the
sugar alcohol from “net carbs” is misleading to your customers as
about half of the maltitol is absorbed.”
So the answer to this question seems pretty straightforward,
and that is that sugar alcohols can definitely blow you out of
ketosis. This is because most people look at a nutritional label and
think that sugar alcohols are carbohydrate free and as we have seen
they definitely are not. It is this misconception or lack of dietary
education that causes consumers to eat way to many hidden
carbohydrates which in turn blows them out of ketosis.
Look, I admit it, I knew better, and I
fell for the same marketing ploy and have on occasion eaten some of
these products. The worst part is that I am not new to the LCHF /
Keto way of eating. My wife and I adopted the ketogenic WOE more than
a year ago, so if you are new to the LCHF / Keto way of life, take
solace in the fact that even those of us who have been eating this
way for a while can still make mistakes. My advice to you is to omit
these products from your eating regimen, or at the very least, make
sure that you count the carbohydrates correctly. A snack bar that
contains 7 net carbs, may not seem like a lot if you are on a
moderate carbohydrate eating plan (50 grams of carbs or less per day), but can
definitely blow you out of ketosis if you are following a strict
carbohydrate eating plan (20 grams of carbs or less per day).
Bloating, GI Motility, and Diarrhea.
My experience with sugar alcohols is
somewhat limited, I generally do not eat sugar-free candies or
products that contain sugar alcohols. However, I have on occasion
eaten the 'Elevation Carb Conscious' bars made by Millville and sold
at Aldi which are similar to the Atkins bars. Depending on the flavor
of the bar, they contain 9 – 10 grams of sugar alcohols (primarily
maltitol) giving them a net carbohydrate count of 7 – 8 net carbs
per bar (see UCSF net carbs formula above).
As mentioned earlier, because sugar
alcohols are not totally absorbed by the gut, they have less of an
impact of blood sugars and the insulin response than sugar. It is
because sugar alcohols are not totally absorbed by the gut, they can
have some unwanted side effects which vary in severity depending on
the person. According to Ask The Nutritionist, “since a portion
of sugar alcohols aren’t fully absorbed in the gut, there is the
potential that consuming too much may produce a laxative effect or
cause some gastrointestinal problems. Most people can usually handle
20 to 30 grams a day.” Personally, I have found that while
sugar alcohols do not cause me to have abdominal cramping or
diarrhea, they do tend to cause me to have a lot more flatulence. My
wife, however, who has mild irritable bowel syndrome (IBS) tends to
have more complications with abdominal cramping and diarrhea as well
as flatulence when she consumes products that contain sugar alcohols.
According to the American Diabetes Association, “sugar alcohols
can have a laxative effect or other gastric symptoms in some people,
especially in children.” So my advice would be to avoid giving
your kids products such as Atkins or Millville's low carbohydrate
bars, or any candies that are labeled 'sugar-free' that contain sugar
alcohols. So if you have any friends or family members who are
diabetics make sure you educate them regarding the potential risks of
children and sugar alcohol consumption.
The one sugar alcohol that does not
seem to cause GI complications is erythritol. While erythritol is a
popular powdered replacement for sugar in the LCHF / Keto community,
it appears to be rarely used in commercial products. So why isn't
erythritol used more often in 'sugar free' and 'low carb' products?
Maybe it simply costs to much to be used as a primary sweetener in
ready made products, or maybe it is the 'cooling effect' it has on
the mouth which some consumers do not find appealing, I simply have no answer for that question.
Conclusion
The bottom line, sugar alcohols are
safe in moderation, and while they have a lower impact on blood
sugars, they still contain carbohydrates which can not only raise
your blood sugar, but knock you out of ketosis if they are not
consumed in moderation. I realize that not all sugar alcohols effect
blood sugars or ketosis in the same way, but I believe the UCSF
formula (total carbs – fiber – half of the sugar alcohols = net
carbs) for calculating the 'net carbs' of any products that contain
sugar alcohols is way more accurate than that proposed by food
manufacturers (total carbs – fiber – sugar alcohols = net carbs). This is especially important for those of us who are on a strict low carbohydrate (20 grams or less a day) regimen. Heck, if you ate two of the Akins or Elevation bars each day you would have actually consumed a total of about 14 net grams (7 per bar) of carbohydrates as opposed to the 4 net grams (2 per bar) as listed on the package. That's more than three times the carbohydrates!
While consumption of sugar alcohols affects each of us differently,
remember that when consumed in amounts of 30 grams or more a day they
may cause gastrointestinal discomfort and or diarrhea. This is
especially true for children, so my personal opinion would be to
avoid giving products with sugar alcohols to your little ones. Look, sugar alcohols have their place, I am not saying you should avoid them, but I am advising you to take care when consuming them in certain products. Of all the sugar alcohols erythritol,
and xylitol seem to have none or at least minimal GI side effects
(gastrointestinal discomfort, and or diarrhea), but at the end of the
day, they are still sugar alcohols so you should use them sparingly
until you can determine how they will affect you and your family.
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References:
Ask The Nutritionist: The Scoop On
Sugar Alcohols, www.Atkins.com,
accessed October 24, 2017.
Diabetes Education Online, University
Of California San Francisco Medical Center, 2007-2017. Accessed
October 1, 2017.
Diaz, Jessica, RD, What Do Sugar
Alcohols Mean In Carb Counting, www.livestrong.com,
October 3, 2017.
Eenfeldt, Andreas, MD, Atkins, Greed
And The Fairy Tale Cookies, www.Dietdoctor.com,
April 4, 2014.
Gunnars, Kris, Bsc, Are Atkins Low-Carb
Bars Healthy? A Critical Look, Authority Nutrition, October 3, 2013.
Modderman, JP., Safety Assessment Of
Hydrogenated Starch Hydrolysates, US National Library of Medicine
National Institutes of Health, August 1993.
Sisson, Mark, Sugar Alcohols:
Everything You Need To Know, Mark's Daily Apple, February 15, 2011.
Sugar Alcohol Facts, Ketogenic Diet
Resource, accessed October 20, 2017.
Sugar Alcohols, The American Diabetes
Association, May 14, 2014, accessed September 17, 2017.
Sugar Alcohols Fact Sheet, Food
Insight, October 14, 2009, Updated April 24, 2017, accessed October
25, 2017.
The Best And Worst Low Carbohydrate
Sweeteners, Ruled Me, accessed September 1, 2017
What Are Sugar Alcohols? Joslin
Diabetes Center, Harvard Medical School, accessed October 24, 2017.