Sweeteners and sugar alternatives in food technology edited by helen mitchell

Geoffrey Livesey 1.4 The glycaemic response now and in future nutrition 61.5 Measurement and expression of the glycaemic response 61.6 The acute glycaemic response to sugars and sweetene

Sweeteners and Sugar Alternatives in Food Technology

Edited by

Helen Mitchell

Food Technology

‘Knowing that love is to share, each one believing that love never dies …’

Here, There and Everywhere

byJohn Lennon and Paul McCartney (1966)

Sweeteners and Sugar Alternatives in Food Technology

Edited by

Helen Mitchell

All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted,

in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted

by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

First published 2006 by Blackwell Publishing Ltd

ISBN-13: 978-14051-3434-7

ISBN-10: 1-4051-3434-8

Library of Congress Cataloging-in-Publication Data

Sweeteners and sugar alternatives in food technology / edited by Helen Mitchell.

p cm.

Includes bibliographical references and index.

ISBN-13: 978-1-4051-3434-7 (hardback : alk paper)

ISBN-10: 1-4051-3434-8 (hardback : alk paper) 1 Sweeteners 2 Sugar substitutes 3 Sugars in human nutrition I Mitchell, Helen (Helen Lucy), 1960–

Printed and bound in India

by Replika Press Pvt Ltd, Kundli

The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy,

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Geoffrey Livesey

1.4 The glycaemic response now and in future nutrition 61.5 Measurement and expression of the glycaemic response 61.6 The acute glycaemic response to sugars and sweeteners 101.7 Long-term glycaemic control with sweeteners and bulking agents 111.8 Gastrointestinal tolerance in relation to the glycaemic response 13

2.3.9 Key points from the dental evidence for reduced calorie

2.4 High-potency (high-intensity) sweeteners 31

2.4.6 Key points from the dental evidence for high-potency

2.5.3 Key points from the dental evidence for bulking agents 35

4.2 Calorie control and its importance in weight management 55

Bernd Haber, Gert-Wolfhard von Rymon Lipinski and Susanne Rathjen

5.2.2 Blends of acesulfame K with other sweetening agents 66

5.5.5 Jams, marmalades, preserves and tinned fruit 78

7 Saccharin and Cyclamate 103

9.1.3 Non-caloric 151

10.2.2 Sweetness profiles versus sucrose 17810.2.3 Synergy and/or compatibility with other sweeteners 178

10.3.6 Hygroscopicity: moisture content at various relative humidities 18210.3.7 Water activity at various concentrations versus sucrose 183

11.5.2 Lactitol to treat hepatic encephalopathy 215

11.6.4 Ice cream and frozen desserts 219

Malcolm W Kearsley and Ronald C Deis

Malcolm W Kearsley and Ronald C Deis

14.3.1 Prebiotic properties: low-calorie value 268

14.4 Application: tagatose as a flavour enhancer 27514.4.1 Flavour enhancement in beverage systems 27514.4.2 Flavour enhancement in reaction flavour 276

14.5 Application: tagatose as a healthy bulk sweetener 284

PART FOUR: OTHER SWEETENERS 329

PART FIVE: BULKING AGENTS: MULTI-FUNCTIONAL

Michael Auerbach, Stuart Craig and Helen Mitchell

In some markets, replacing sugar in food and beverages is no longer just an economic tive The use of ingredients to improve the nutritional status of a food product is one of themajor driving forces for new product development, and this is likely to be the case well intothe future It is therefore important, as options for sugar replacement continue to increase,that expert knowledge and information is readily available This book provides the informa-tion needed for basic sweetening and functional solutions in order that processed foods notonly taste and perform as well as sugar-based products but can also offer consumer benefitsincluding calorie reduction, dental health benefits, digestive health benefits and improve-ments in long-term disease risk through strategies such as dietary glycaemic control.The following chapters provide some background information on nutrition and healthrelated to sugar replacement, and indicate how sweeteners and some sugar alternatives mayalso have important ‘nutritional’ roles However, knowing how to successfully formulatethese sugar alternatives into good-tasting food products is the key – if a food is not eaten ithas no nutritional value It is anticipated that the information contained in this book willhave a significant impact upon the ability of manufacturers to produce ‘better for you’ orhealthy products with better than ever taste and wider, more general appeal

incen-High-intensity sweeteners (high-potency sweeteners), reduced-calorie bulk sweetenersand bulking agents are valuable alternatives to sugar Some of these products can be used asfunctional ingredients in their own right or as a means of improving the carbohydrate andnutritional profile of many manufactured products It is hoped that the information con-tained in this volume will enable the professional to understand the alternative ‘sweetening’and ‘bulking’ choices from a technical, functional, physiological, nutritional, applications,safety and regulatory perspective

The taste experiences delivered by the intense sweeteners or reduced-calorie sweetenersare not identical to those delivered by sucrose The differences are related to time intensityand/or aftertaste characteristics of the individual sweeteners Although the potential bene-fits of blending sweeteners have been known for many years, recent developments in the use

of sweeteners have involved the search for a better understanding of how blends of ents can be used to deliver more sucrose-like tastes and sucrose-like profile Some of themore recent developments that include both intense and reduced-calorie sweetener blendsare outlined here

ingredi-A favourable legislative environment is essential if consumers are to take full advantage

of positive developments in food science, including the use of sweeteners and sugar natives Comprehensive information on global regulatory approvals of sweeteners and sugaralternatives is difficult to obtain and verify, and is also often subject to differences in inter-pretation The ever-changing regulatory processes make any attempt to summarise the leg-islative framework controlling these products as food ingredients very difficult Authors inthis book have attempted to cover some of the basic issues for individual products, but many

alter-countries have their own nutrition labelling regulations It is considered advisable, ever contemplating the launch of a new food product, to obtain local expert opinions as tothe relevant food regulations and appropriate labelling implications, particularly wherehealth claims are being considered Despite the difficulties surrounding the interpretation ofglobal food legislation, the Calorie Control Council (www.caloriecontrol.org) maintains adatabase of important regulatory information for commercially important sweeteners and is

when-a good source of bwhen-asic dwhen-atwhen-a

In attempting to place sweeteners and sugar alternatives into suitable groups for sion, the book has been structured as follows:

discus-Part One: Nutrition and health considerations: This part considers how sweeteners and

sugar alternatives may have some important physiological effects and subsequent healthbenefits such as improved glycaemic control, dental health, digestive health and caloriereduction An attempt has also been made to summarise the important role that legislationplays in providing the appropriate framework for the development of ‘healthy’ productsparticularly for calorie-reduced foods

Part Two: High-potency (high-intensity) sweeteners: This part describes some of the most

commercially successful sweeteners to date These sweeteners provide high sweetness potencywithout bulk and without any major impact on calories The authors have provided insightsinto blending opportunities for qualitative and quantitative sweetness improvement as well asexhaustive application opportunities

Part Three: Reduced-calorie bulk sweeteners: This part describes both the commercially

successful polyols and an emerging functional bulk sweetener, tagatose These sweet natives provide bulk with fewer calories than sugar

alter-Part Four: Other sweeteners: This part contains information on less well established

sweeteners that do not conform in all respects to what may be considered to be standardsweetening properties Some sweeteners described in this part exhibit some interestingnutritional and technological functionalities

Part Five: Bulking agents/multi-functional ingredients: This part deals with speciality

carbohydrates that have been developed as bulking agents, allowing greater flexibility when replacing sugar in formulations and complementing the use of high-intensity sweeteners,polyols and other sweeteners, including sugar These materials have important physiologi-cal benefits which are related, on the whole, to their soluble dietary fibre properties Theyare all, by definition, calorie reduced and in some cases they can even replace or partiallyreplace fat in applications Their chemistry allows for other technological benefits in for-mulations, and so they can therefore be considered truly multifunctional

The summary tables at the end of each chapter and the extensive references are meant toinspire those who wish to learn more

All the contributors deserve sincere thanks for their efforts and commitment in ing chapters for this book

prepar-Helen Mitchell

The Coca-Cola Company

Atlanta, GA, USA

Henna Mäkeläinen

Functional Foods ForumUniversity of TurukuTuruku, Finland

Helen Mitchell

Danisco SweetenersRedhill

Kay O’Donnell

Forum FoodsRedhillSurrey, UK

Arthur C Ouwehand

Danisco Innovation

Enteromix Research

Kantvik, Finland

Ulla Petersen Skytte

Arla Foods Ingredients

Mannheim, Germany

Julian Stowell

Danisco SweetenersRedhill, Surrey, UK

Kirsti Tiihonen

Danisco InnovationEnteromix ResearchKantvik, Finland

Gert-Wolfhard von Rymon Lipinski

Nutrinova Nutrition Specialities andFood Ingredients GmbH

Part One

Nutrition and Health

Considerations

1 Glycaemic Responses and Toleration

Geoffrey Livesey

Sugars and sweeteners have an important role in the human diet Choosing the right ones

in the right amounts can influence health Knowledge will enable good choices, and furtherresearch and understanding of the literature will confirm or deny how good our choices are,and where improvements are possible Choice is not simply a matter of which is the health-ier or healthiest; technological properties and economics of sugars and sweeteners impact

on which of them can be used suitably in a particular food

A wide range of potential influence on health is offered by sugars and sweeteners whenselected appropriately, as will be evident in detail from other chapters These include:

• A reduced risk of dental caries.1

• Potential for improved restoration of the early carious lesions.2

• A reduction in caloric value that may contribute towards a lower risk of over-consumption,obesity and improved survival.3,4

• Substrate for butyrate production, and potentially reduced risk of colon cancer.5

• The formation of osmolytes efficacious for laxation and lower risk of constipation oraccumulation of toxic metabolites.6

• Substrate for saccharolytic and acidogenic organisms in the colon that contribute to biosis and ‘digestive health’ potentially including improved immunological function.7

pre-Each of these can influence the choice of sugars and sweeteners Of particular relevancehere is their impact on the glycaemic response and control

Reducing post-prandial glycaemia and insulinaemia with sugars8and sweeteners,7togetherwith other low-glycaemic carbohydrates,9fibre, protein, lower energy intake and exercise,10can each potentially lower the prevalence or risk of developing metabolic diseases associatedwith high-glycaemic carbohydrate nutrition including metabolic syndrome, diabetes (and asso-ciated complications), heart disease, hypertension, stroke and certain cancers.11–14In those whoare susceptible, reduced glycaemia may also benefit appropriate weight gain during preg-nancy,15 allow favourable foetal growth patterns and fat accretion,16 reduce neural tubedefects17and aid recovery from surgery.18Reduced glycaemia might also be related to reducedbody weight in obesity19,20and improved survival during old age and so longevity as seen inanimal studies.4

The converse of all the above is that, given the right circumstances, a poor choice of typeand amount of sugars and sweeteners could augment ill-health Attributes of sugars andsweeteners affecting health via the glycaemic response are nutritional and need to be seen

in the context of the whole diet It is appropriate therefore to consider the glycaemic aspect

of diet and health from ancient to the present and future times so far as these can be tained, explained and envisaged

It is often argued that our genes might not cope with diets substantially different from thoseeaten by our ancestors.21–26Quite what these diets were or how tolerant ancient genes havebecome are matters of uncertainty Successful genes were in existence for both herbivorousand carnivorous diets prior to humankind; however no early diet appears to have been highglycaemic Those people who would normally consume ‘early’ or rudimentary diets, such

as recent hunter-gatherers, experience low levels of diabetes, and respond adversely to dietsthat we may now consider high glycaemic.22,27This is consistent with the notion that earlygenes were unadapted to high-glycaemic responses, but also consistent with a notion ofadaptation having occurred in the people of today’s relatively more glucose tolerant

‘Western’ cultures, at least among a large proportion of them Those not having adaptedcontribute to the prevalent diabetes and other conditions mentioned that are currently expe-rienced, which is far higher than in either hunter-gatherers or rudimentary horticulturalists

or simple agriculturalists or pastoralists.22For the people of these ‘basic’ cultures and for

‘unadapted’ Westerners (Easterners or Southerners or Northerners), a high-glycaemicresponse remains a health hazard, for which a variety of strategies exist to help them cope.10

Europe has a rich culture and a documented history of its foods, and so we can obtain someidea of how the glycaemic character of diets may have developed over time

Generally, we may assume diets to partly reflect the foods that can be found or are madeavailable to eat If this is so, examination of the inventory of foods identified in Europeanhistory may shed some light on what was eaten and is now supposed might be eaten for

0 5 10 15 20 25

genet-ically predisposed to non-communicable diseases provoked by today’s high-glycaemic diets Based on the history of foods in Europe, 28 with calculations by the present author (unpublished) A: agricultural revolu- tion; B: industrial revolution Open symbols show values post the industrial revolution.

optimal health Such an inventory is provided by Toussaint-Samat28from which an ment of the development in the glycaemia character of contemporary diets has been madetaking account of the protein, fat, fibre and sources of carbohydrate (Fig 1.1) The picturecannot be accurate but what is clear is a progressive increase in the glycaemic load, with amarkedly rapid increase in this load following industrialisation We cannot be sure of theprevalence of disease in Europe throughout the whole of this timescale, but we would notlikely dispute that the prevalence of obesity and metabolic disease is as high now as ever.Such a trend is argued to have occurred also throughout more recent times in the USA,21

assess-with recent emphasis on reducing the fat content of the diet, a doubling of flour tion during the 1980s, and an increase in sugar, corn syrup and dextrose consumption,29–31

consump-together with a lower dietary fibre content of foods,30all of which imply exposure to dietseliciting a high-glycaemic response

THE MILLENNIUM

Much of our understanding of the interplay between health and the glycaemic response tofoods has arisen from investigations into the dietary management of diabetes Whereas

very-low-glycaemic carbohydrate foods such as chana dahl were used in ancient India for

a condition now recognised as diabetes,32nineteenth century recommendations in Westerncultures were for starvation diets, which were of course non-glycaemic The drawback ofsuch is obvious and in 1921 high-fat (70%) low-carbohydrate (20%) diets were recom-mended,33which by definition would be low glycaemic A gradual reintroduction of carbo-hydrate into recommendations for diets for diabetics arose as carbohydrate metabolismcame under some control using drugs, but mainly as ‘dietary fat’ was recognised to have acausal role in coronary heart disease, to which diabetics and glucose-intolerant individualssuccumb, more readily in some than others.34–37 The metabolic advantages of replacingdietary fat (saturated fat) with high-fibre, high-carbohydrate diet was lower fasting gly-caemia, lower total-, high-density lipoprotein– and low-density lipoprotein–cholesterol andlower triglycerides.38–42Such benefits may in part be related to dietary fibre or its influence

on the glycaemic response.43,44 Certainly, the non-digestible carbohydrate in these dietswould ensure some degree of lower glycaemia for a given carbohydrate intake and supportbeneficial effects from lower-saturated fat intake

During these times, the adverse influence of higher glycaemia or more dietary drate was either unrecognised or the risk was accepted by the medical profession in fear of (orcompromise for) the adverse effects of ‘dietary fat’ (more particularly saturated fat) Theadverse influence of higher glycaemia may also have been overlooked due to the apparentbenefits of the non-digestible carbohydrate in the high-carbohydrate foods Indeed, theInstitute of Medicine has recently recommended high-fibre diets to combat coronary heartdisease,45and this builds upon the dietary fibre hypothesis that proposed higher prevalence ofdiabetes, heart disease and other conditions associate with diets deficient of fibre.46,47 Anabsence of fibre in high-sugar products left sugar (sucrose) vulnerable; nevertheless, this sugarremained preferable among nutritionists to high (saturated) fat, which it might displace fromthe diet, giving rise to the concept of the ‘sugar–fat-seesaw’ discussed elsewhere.48–50

carbohy-Throughout the whole of these times, the primary purpose of recommending energy fromcarbohydrate was to displace the intake of energy as fat In part this is because carbohydrate

supplies energy, but also because carbohydrate counters the insulin-desensitising influence

of both mobilised body fat and dietary fat.51–53This purpose for carbohydrate was retained

in the glycaemic index concept, whereby carbohydrate of low-glycaemic response furtherimproved glycaemic control in diabetics,9and possibly the plasma lipid profile.54

However, it must be considered whether carbohydrates have a long-term future as ameans to displace fats from the diet It is noteworthy that the increasing carbohydrate con-tent of diets throughout European history, which partly explains the higher-glycaemic load(Fig 1.1) has not adequately displaced ‘fats’ from the diet or prevented obesity Excess ofcarbohydrate prevents the use of fat stores and encourages dietary fat to be stored In gen-eral, elevating the consumption of mono- and polyunsaturated (bar trans) fats is consideredbeneficial in respect of diabetes, coronary heart disease and a variety of conditions55–58and

is consistent with early diets.59In addition, there is little or no evidence that carbohydrateingestion can selectively limit the ingestion of saturated fats Proponents of the Mediterraneandiet (high in mono- and polyunsaturated fats) would hold that use of carbohydrate for thepurpose of limiting fat intake is unsound

IN FUTURE NUTRITION

The general picture now for glycaemic control is that a high-fibre, low-glycaemic and low-saturated fat diet is optimal.41With obesity being a major problem and a risk factor fortype-2 diabetes and heart disease, then an appropriate energy balance has become of majorimportance.60Weight loss has for some time been recognised as important to the survival ofnewly diagnosed type-2 diabetics61and improvement in prognosis for cardiovascular dis-ease.62,63These are practical examples of how caloric restriction improves survival in at-riskgroups Of course, caloric restriction implies here a diet reduced in energy via lower-saturatedfat and lower-glycaemic load than generally consumed

It is clearly preferable to limit the intake of both saturated fat and high-glycaemic hydrate as energy sources to facilitate weight reduction, rather than simply to exchangeenergy sources Prior nutritional debates of ‘fat versus carbohydrate’ might now be viewed

carbo-as too imprecise in both the description of the food components and how the componentsare pitched against each other The nutrition debate needs to focus more on the adverseinfluence of ‘saturated fats plus high-glycaemic load’ in general nutrition Sugars andsweeteners provoke a range of glycaemic responses7,8,64and so may variably promote ordefer or help prevent ill-health

THE GLYCAEMIC RESPONSE

By 1929, the potential of carbohydrate to raise plasma glucose, which may spill over intourinary losses in diabetics, was indicated by its available carbohydrate content,65for which

a direct assay for use with the composition of foods was later refined.66Fibre was suitablefor diabetics as it provided no glucose, to either elevate plasma glucose concentrations orurinary losses Another measure of the glycaemic potential became known as the glycaemicindex.67Later the quantity called glycaemic load, the product of available carbohydrate andglycaemic index, was introduced68and validated as a measure of the glycaemic response.69

Glycaemic load can be assayed directly and without need for knowledge of the availablecarbohydrate content,69–71 about which assumptions are too often made.4 The glycaemicindex became widely known, and many glycaemic index testing centres have sprung up,meanwhile the glycaemic index has received helpful criticism because it does not meetmany useful criteria for inclusion in food tables or in communication with the consumer.72

The precision of the glycaemic index assay has been examined among five laboratoriesbased on capillary blood sampling, using high-carbohydrate foods73and has since been thetopic of discussion with the aim of standardisation.74Despite these efforts, the standardisedprotocol is no different to that used in the inter-laboratory study and so the assay remainsimprecise This raises a question of just how precise an assay needs to be for foods contain-ing carbohydrates including sugars and sweeteners

A useful point of reference when assessing a method’s adequacy for communicationwith the consumer is one often used in regulatory enforcement for substantiation of reported

or declared values Such enforcement often finds it generally practical to ‘accept’ an ‘error’

of no more than 20% in a nutrient value reported on a food label in comparison with an cially analysed value Such large ‘permitted’ discrepancy ensures the reported and officialanalytical values do not arise simply by chance due to imprecision of the assay method.Hence methods need to be sufficiently precise for the purpose of substantiation

offi-On the basis of the data in the published inter-laboratory study73and composition offoods,75and using the 20% criterion, the glycaemic index methodology is difficult to justify

as it is too imprecise (Fig 1.2) The discrepancy between any two of five laboratories for ahigh-carbohydrate food can be more than 20% and sometimes nearly twice the 20% criter-ion By contrast, when the glycaemic response is expressed as the glycaemic load, the dis-crepancy between any two of five laboratories is nearer a half the 20% criterion, makingglycaemic load a suitable measure and expression of the glycaemic response for the pur-poses of substantiation and communication with the consumer

The acute glycaemic response to glucose, sucrose, trehalose, isomaltulose and isomalt(Fig 1.3) illustrate how it is now possible to create bulk sweeteners, and so tailored foods,with almost any glycaemic response, likewise the insulin response (not shown) Otherexamples and insulin responses are given in Table 1.1

A numerical value for glycaemic index or load does not itself inform about whether thevalues are high or low compared with the range for foods eaten or compared with diets that associate prospectively with the incidence of disease or death To put information about the glycaemic response of foods into perspective, it has been classified according towhether it is high, intermediate, low (www.glycaemicindex.com) or very low,7as shown inTable 1.2 The classification also helps to communicate with the patient or consumer Forexample, it can be suggested that a consumer or patient selects food from a lower band

of glycaemic response (i.e lower class or two lower classes where possible) Further, should a high-glycaemic food be eaten at a meal for any reason (e.g enjoyment) any othercarbohydrate source eaten at the same time ought to come from a low-glycaemic band.Furthermore, diabetics have for years practiced carbohydrate exchange as part of dietarytherapy, for which a similar glycaemic response or similar insulin requirement was (andsometimes still is) presumed to arise from any food containing 10 g of carbohydrate.Diabetics can now update this approach by practicing exchanges based upon the glycaemicindex or load, while also attempting to reduce saturated fat intake The alternative may beemphasised, limit energy intake while still eating (or eating more) low-glycaemic carbohy-drate and mono- or polyunsaturated fats Some advantages of the glycaemic load over theglycaemic index have been emphasised.4,72Thus, glycaemic load can be used as a ‘virtual

0 20 40 60 80

Potato Bread Rice Spaghetti Barley

Glycaemic index (GI) (g GGE/100

Potato Bread Rice Spaghetti Barley 0

10 20 30 40

Maximum difference between any two of five testing laboratories

GI GL

0.50 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50

Time (min)

Glucose Sucrose Trehalose Isomaltulose Isomalt

ingredi-ents The response curves shown are for 50 g ingredient, relative to glucose in healthy people Information

on other low-glycaemic sweeteners and bulking agents is given in Table 1.1 together with references.

inter-laboratory study of Wolever et al.73 and the composition of foods 75

nutrient’ to be considered alongside all other nutrients when assessing the relation betweendiet and health.

The indication that glycaemic load should be limited to 120 g/day (Table 1.2) impliessome 40–60% of people in Western populations may be at risk of metabolic disease; this isconsistent with the high prevalence of coronary heart disease, obesity and diabetes

Starch hydrolysis products

Hydrogenated monosaccharide

Hydrogenated disaccharides

Non-digestible polysaccharides

a Sydney University Glycaemic Index Research Service.

b Macdonald and Williams 121 in article entitled, ‘Effects of ingesting glucose and some of its polymers on serum glucose and insulin levels in men and women’.

cFoster-Powell et al.64 in article entitled, ‘International table of glycemic index and glycemic load values’.

d Livesey 7 in article entitled, ‘Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties’.

e Authors review of the literature.

fDonner et al.82 in article entitled, ‘ D -tagatose, a novel hexose: acute effects on carbohydrate tolerance in subjects with and without type 2 diabetes’.

gOkuma et al.122 in article entitled, ‘Pyrolysis of starch and its digestibility by enzymes’.

hRumessen et al.83 in article entitled, ‘Fructans of Jerusalem artichokes: intestinal transport, absorption, fermentation, and influence on blood glucose, insulin, and C-peptide responses in healthy subjects’.

1.6 THE ACUTE GLYCAEMIC RESPONSE TO SUGARS AND SWEETENERS

Intense sweeteners are consumed in such small quantities that they have no glycaemicresponse of their own, additionally the structure of such sweeteners would normally not beexpected to yield glucose upon metabolism Generally too, none of the intense sweetenershave pharmacological actions to improve glycaemic control, an exception is stevioside.76Aspartame is a more typical example of an intense sweetener that is without acute gly-caemic response,77,78another is sucralose.79Clearly however, compared with maltodextrins,maltose, glucose and sucrose under controlled conditions then marked reductions in theacute glycaemic response would be expected for comparable sweetness Addition of intensesweeteners to foods or drinks that normally would not contain sugars for sweetness would,however, confer no glycaemic advantage

The use of intense sweeteners in place of glycaemic carbohydrates wherever bulk is sary for technological or organoleptic reasons requires the glycaemic response to bulkingagents to be considered here too The glycaemic (and insulinaemic) response to maltodex-trin, bulk sweeteners and bulking agents varies considerably (Table 1.1) The causes of thelower glycaemia are numerous.7Compared with glucose, the lower value for sucrose is duemainly to dilution within the molecule with a fructose moiety A similar situation occurswith maltiol, maltitol syrups and polyglycitol, where glucose moieties are ‘diluted’ with asorbitol moiety Fructose alone is low glycaemic due to both slow absorption and need forconversion to glucose in the liver prior to appearance in blood as glucose; in addition thecarbohydrate may be partly stored as glycogen rather than released into the circulation.Further still, the energy from fructose is conveyed in the circulation for oxidation in part aslactate more than is the case for glucose A similar situation occurs for sorbitol and xylitol,though slower absorption likely gives rise to less lactate; in addition a high proportionescapes absorption With isomalt and lactitol an even greater proportion escapes absorption,which gives these polyols the lowest-glycaemic response of all so far mentioned Anotherpolyol, erythritol, is almost unique in that although most is absorbed it is low glycaemic;this is because it is poorly metabolised in the tissues and escapes into the urine Mannitolbehaves similarly, though it is largely (75%) unabsorbed

neces-At the other end of the scale are maltodextrins, which can give rise to a glycaemicresponse as high as glucose, likewise maltose Trehalose, a rearrangement of sucrose, has aglycaemic response comparable to sucrose (Table 1.1) in terms of its glycaemic load (g gly-caemic glucose equivalents (GGE) per 100 g), though peaks less sharply and there is

a Based on www.glycaemicindex.com and Reference 7.

b Based on measurements with 25–50 g carbohydrate.

c Based on prospective epidemiology 68,99–101

d Based on a 10 g serving size (or exchange rates) noted in the international tables 64

persistence in the raised glycaemia that would likely help protect against hypoglycaemia insusceptible individuals Isomaltulose, also derived by rearrangement of sucrose, gives asimilar though lower profile, and so lower-glycaemic load; this although most of the iso-maltulose is absorbed Other low-glycaemic carbohydrates include tagatose, fructans(fructo-oligosaccharides and inulin), polydextrose and resistant maltodextrins The reduc-tion in glycaemia caused by sucrose replacing high-glycaemic starch is considered anadvantage.8Greater reductions would be possible on replacing maltodextrin, maltose, glu-cose and sucrose with alternative sweeteners, either partially or completely depending uponthe serving size of foods.

Among the studies undertaken with polyols (mainly with maltitol, isomalt and sorbitol)the glycaemic response versus glucose is similar in people with normal and abnormal carbo-hydrate metabolism, as exemplified by type-1 and -2 diabetics, provided insulin-dependentparticipants receive insulin via an artificial pancreas.7This is as experienced with carbohy-drate foods generally.64

In addition to having lower-glycaemic responses, polyols, low-digestible sugars andbulking agents can reduce the glycaemic response to other carbohydrates The magnitude ofthis effect is not great, but is not insignificant either and is in the order of 10–15%.7,80–82

However, no such effect is reported with fructans.83,84The important conclusion here is thatthe low-glycaemic character intrinsic to these carbohydrates is not lost when they are con-sumed with other carbohydrates (or other macronutrients)

A further reduction in acute post-prandial glycaemia can occur when fat is included inthe meal This is common to both digestible and non-digestible carbohydrate whether used

as sweeteners or not.7 It is accompanied by an elevation of insulinaemia via an incretinresponse A common view is that fats reduce glycaemia via stomach emptying, however thiswould not explain the elevated insulin response, thus both stomach emptying and a gas-trointestinal incretin response contribute to the lower glycaemia The implications of theelevated insulinaemia in such a circumstance remain to be researched However, sugar–fatmixture (and more generally high-glycaemic carbohydrate–fat mixtures) are not viewed asbeneficial and too high as insulin response may contribute to the development of obesity85

and coronary heart disease.86Hence, it may be particularly important to reduce the caemic response of fatty foods (and the fat content of high-glycaemic foods) In this respectthe present author notes the beneficial impact of low-glycaemic foods on long-term gly-caemic control in diabetics appears greater among consumers of moderate-fat (35–40%)rather than low-fat (25%) diets

gly-A question arises as to whether sweeteners affect the cephalic phase insulin response (i.e do sweeteners cause an elevation of insulin and so lowering of glycaemia, reflexively viathe brain?) This appears not to happen to a significant extent with the sweeteners aspartame orsaccharine.78,87Likewise, in diabetics, sweetness is reported to have no impact on food intakeand macronutrient composition other than perhaps for a lowering of sucrose ingestion.88,89

SWEETENERS AND BULKING AGENTS

Fructosamine and glycated haemoglobin (HbA1c) in blood are medium and long-term ers of day-long exposure to elevated blood glucose concentrations Non-, pre- or undiagnoseddiabetics as well as diabetics with elevated HbA1care at increased risk of coronary heart dis-ease, stroke and all cause mortality.90–92In diabetics, the elevation of HbA is associated

mark-also with higher risk of retinopathy, nephropathy, perivascular disease, limb amputation andperivascular deaths.90,92,93While markers of risk for cardiovascular disease in interventionalstudies have usually been limited to lipid markers, it is recognised that good glycaemic con-trol is of first importance in the control of diabetic hyperlipidaemia.94Possibly glycated pro-tein markers are underutilised as a tool to assess risk to health in both epidemiological andinterventional studies Mechanisms of increased risk are discussed elsewhere,95and indicategreater risk whenever antioxidant defences are low.

Of all the risk marker used often in intervention studies with diabetics, only, fastingblood glucose, fructosamine and HbA1cshow consistent improvement, in either directionalone or in both direction and statistical significance, due to replacement of high- with low-glycaemic carbohydrate foods.9,41It should not go unrecognised that replacement of sat-urated fat with high-fibre, high-carbohydrate diets also improves fasting blood glucose (totalcholesterol and triglycerides) in type-2 diabetics, and a role for non-digestible carbohydrate

in this response is evident.39

This risk to glycaemic control from high-glycaemic carbohydrate in type-2 diabetes isreduced by the use of several substrates used in place of carbohydrate, including protein,96thepolyol isomalt7and fructose97,98as well as low-glycaemic carbohydrates foods.9,41An impli-cation is that overall it is the glycaemic exposure in response to foods that associates with risk.However, glycaemic exposure is more than just load, while glycaemic load is more than justglycaemic index as noted previously.4This hierarchy requires careful understanding Here,high (saturated) fat diets elevate the glycaemic response to foods chronically via deterioration

in insulin sensitivity and beta-cell function, so amplifying the glycaemic response to drate foods rather than by supplying fuel for blood glucose formation In essence, both satu-rate fat and high-glycaemic carbohydrate each pose a risk to glycaemic control and health

carbohy-A further consideration is that when study participants already have good glycaemic control,then only two outcomes are possible by change of diet, either no effect or deterioration, whichmay take years before overt disease emerges A third possibility arises when glycaemic control

is poor; it may improve, and within weeks and months This is evident (in the author’s ment) for mixed groups of type-1 and -2 diabetics, for whom intervention with low-glycaemiccarbohydrates diets seems most effective in people with poor glycaemic control In such stud-ies, poor glycaemic control associates in the first instance with moderate- rather than low-fatingestion

assess-Based on the available evidence from intervention studies, low-glycaemic diets will rect about 30% of the deterioration in glycaemic response (author, unpublished), whichimplies an approximately 30% reduced risk of diabetic complications and heart disease.Interestingly, when looking at initially healthy people via prospective epidemiological stud-ies, high- versus low-glycaemic load diets appear to explain about 30–40% of type-2 dia-betes68,99,100and perhaps more of heart disease.13,101Interestingly too, use of an inhibitor ofcarbohydrate digestion in a pre-diabetic state can reduce the incidence of coronary heartdisease by up to 50%.102How much more effective life-long exposure to low-glycaemicdiets would be in current inactive societies remains uncertain On the basis of such data,there would appear to be a significant public health benefit from minimising high-glycaemiccarbohydrate consumption, and further benefit from the consumption of diets low in satu-rated fats It is reasonable therefore for food manufacturers to begin or continue to considerhow they can either replace or minimise either high-glycaemic carbohydrate or saturatedfats or both in foods, and in this sugars and sweeteners have a role

cor-Few recent studies have examined the impact of polyols One study examined the influence

of isomalt on both fasting and post-prandial plasma glucose and HbA in diabetics, showing

improvement in all three parameters103as shown by the author’s analysis of original tabulateddata.7The isomalt was consumed in such a way that it was likely to have reduced the intake ofsucrose In healthy people, by contrast, isomalt appears to have no influence on fructosamineconcentrations Again this is consistent with studies of other low-glycaemic carbohydratefoods, where severity of the disease condition impacts on the magnitude of effect.

Replacement of sucrose with fructo-oliogsaccharides (10 g/day) caused a relativereduction in fasting glucose in type-2 diabetic patients over 14 days by 10% in one study,104

and by 6% in another when exchanging 20 g sucrose with fructo-oligosaccharides for

4 weeks By contrast, no similar influence occurred in people without diabetes.105–108This

is consistent with the lower-glycaemic impact of fructans compared with sucrose Such aresult again mirrors an improvement in glycaemic control in diabetics but not those withnormal blood glucose concentrations when replacing high- with other low-glycaemic carbo-hydrate foods (note above)

The chronic effect of D-tagatose on blood glucose is unclear.109As might be predicted,

no influence was seen on fasting blood glucose in normal individuals over 8 weeks In eightdiabetic patients feeding supplemental tagatose had no effect on plasma glucose or HbA1c,though the study was under powered and it is unclear whether glycaemic load was signifi-cantly reduced Supplementation with similar amount of glucose would almost certainlyhave damaged glycaemic control Further information is needed

Randomly bonded glucose (polydextrose) had no influence on glycaemic control (HbA1c)

in normal subjects,110but 20 g daily (resistant maltodextrin) reduced fasting glucose in type-2diabetics,111again consistent with expectations with low-glycaemic carbohydrate foods.Given that reduction of dietary (saturated) fat and high-glycaemic carbohydrates will each lower HbA1c, it is not surprising that using a mixture of non-digestible carbohydrate and intense sweetener as a fat replacer should contribute to lower HbA1cconcentrations indiabetics.112Again, this observation plus those mentioned above reach for a conclusion thatimprovement in glycaemic control arises from both a lower ingestion of saturated fat andthe consumption of low-glycaemic carbohydrate including sweeteners and bulking agents

in preference to high-glycaemic counterparts However, intense sweeteners alone added to

a diet may have little or no direct influence on long-term glycaemic control, as shown withaspartame.79,113 Note, however, improvement in glycaemic control would be difficult toestablish in individuals without diabetes within a period of a few months114or in diabetics

in whom control was already well established, again within a period of a few months.115

Benefits for individuals at risk of diabetes, hypertension and coronary heart disease maytake years to develop as shown using pharmacological approaches to reducing post-prandialglycaemia.116

The observations to date support the view that sweeteners with a combination of glycaemic response and reduced energy value can contribute to an environment in whichobesity, diabetes and potentially coronary heart disease, and certain cancers are less likely

low-to develop

TO THE GLYCAEMIC RESPONSE

The topic of gastrointestinal tolerance has been considered in detail elsewhere.6,117,118Here,consideration is given to the impact of intolerance on the capacity for glycaemic load reduc-tion by exchange of sugars, sweeteners and bulking agents, selecting examples to illustrate

some key points Thus the greater the amount of carbohydrate that is exchanged, the greaterthe glycaemic load reduction that is possible; this until people consuming the alternativecarbohydrate turn away due to gastrointestinal intolerance, as indicated in Fig 1.4 For thispurpose, intolerance is assessed from the proportion of people in sampled populations thatexperience mild watery stools after alternative carbohydrate ingestion This proportion issummarised according to a model with binomial distribution that can be described by twoparameters: one is the highest dose at which no response is observed by any individual in

the population sample (threshold, D0) when intake is in divided doses, and the others is the

sharpness of the response (S) as the dose is increased further In the realistic range of intakes

in divided doses up to 50 g daily, both polydextrose and isomalt are well tolerated in adults,allowing considerable advantage in glycaemic load reduction to be gained from carbohy-drate exchange Although maltitol is well tolerated its glycaemic response is the highest sothat it gains less in terms of glycaemic load reduction up to the threshold Fructo-oligosac-charide, which has a low-glycaemic response, is evidently least well tolerated, and this limitsits potential for reduction of the glycaemic load Data such as these are essential whenexamining risk and benefit of alternative carbohydrates The outcomes illustrate, in addition

to the potential for glycaemic load reduction, that polyols are not inevitably more laxativethan oligo- and polysaccharides The latter suggests that laxation is dependent on the fer-mentation process as much as the amount of fermentable carbohydrate and its molecularweight Erythritol, another polyol, is not without effect on gastrointestinal tolerance, though

it is well tolerated due to it being mostly absorbed It is as effective at glycaemic load tion as shown for isomalt and polydextrose up to 50 g intake daily in divided doses Themagnitude of such reductions alone are of potential public health and clinical importance,and would certainly contribute to reductions managed by carbohydrate exchange in the diet

reduc-as a whole;7this more especially that some individuals are capable of tolerating able amounts of these carbohydrates, well above population threshold values

consider-0 10 20 30 40 50 60 70 80

selected alternative carbohydrates Curves are based on the author’s unpublished analysis of information from the literature on tolerance, 6,117,119,120 and glycaemia (Table 1.1) The arrows indicate thresholds of tolerance.

1.9 FINALLY

While non-communicable diseases are set to overburden private and governmental healthbudgets, there is need of preventive methods to maintain health Dietary change providesone such method and reducing the glycaemic response to diet via food selection, food modi-fication and ingredient use and development is a valuable objective There is now growingevidence from clinical data confirming the potential for reduced severity of disease, andfrom epidemiological data for reducing the risk of developing a variety of non-communica-ble diseases Incorporation of the low-glycaemic approach as one component of a ‘betterdiet’ is likely to remain important Strategies that combine reduced glycaemic load, reducedsaturated fat and reduced energy are likely to be most effective, and these attributes arefound in alternative sugars and sweeteners

Further, experimental evidence shows that even in foods where saturated fat cannot ily be lowered in amount, the use of alternative sweeteners in place of higher-glycaemicsugars and dextrins will elicit a diminished glycaemic and insulin response Enhancement

eas-of the latter by dietary fat is hardly possible with very-low-glycaemic sugars and ers thus reducing a possibility of atherogenic insulinaemia In such products a reduced gly-caemic and insulinaemic response due to the use of low-glycaemic carbohydrates is a valuableobjective, while use of additional saturated fats to reduce the acute glycaemic responseshould be avoided

sweeten-Lastly, the potentiation of hyperglycaemia-induced overproduction of superoxides fromthe mitochondrial respiratory chain provides a possible mechanism of oxidative damage,ageing, tumour formation, atherogenic endothelial damage and of diabetic complications.95Low-glycaemic carbohydrates may be especially valuable in avoiding these conditions,especially because some damage appears irreversible with contribution to a phenomenon of

‘hyperglycaemic memory’ in which some progressive damage occurs despite normalisation

of glycaemic control Health maintenance rather than therapeutic measures may thus prove

to be the better option

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Dental caries has been labelled man’s most common disease and is well recognised as anongoing problem Another dental condition, dental erosion, is recognised as an increasing prob-lem in individuals exposed to acids, other than those produced by bacteria in the mouth Thisexposure to acid may be either extrinsically through diet or environment, or intrinsically fromvomiting, reflux or regurgitation of stomach acid The main dietary sources of acid are fruitacids, ascorbic and phosphoric acid in frequently consumed acidic fruit juices, squashes andcarbonated beverages (full- and low-calorie) as well as pickles, sauces, lactovegetarian foodsand yoghurt Further discussion with regard to dental erosion is beyond the remit of this section,but in view of the role of sweeteners in the manufacture of potentially acidic soft drink, foodand confectionery products, the reader can find information on the aetiology, mechanisms andimplications of dental erosion,1and its management in relation to diet2elsewhere.

2.2.1 The problem

Dental caries is a common disease of affluence Its prevalence rose in developed countries

in parallel with the increased availability of sugar through refining and trade, reaching itshighest level between the 1950s and early 1970s.3–5Since the mid-1970s, caries prevalencehas declined in developed countries, but it is a serious and growing problem in disadvan-taged communities in both developing and industrialised societies6,7and is a major healthproblem, especially in economic terms.8,9 Additionally, the evidence of caries declineamong children and young people in a number of western societies seen in the 1970s and