Sugar Alcohols: The Sweet Truth

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.

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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.