Title: Alternative Sweeteners

Xylitol 349
VIII. USE OF XYLITOL AS A SWEETENER IN DIABETIC DIETS
Historically, the first proposed application of xylitol concerned its use as a sugar
substitute for diabetic patients (175). Diabetes mellitus is a chronic metabolic
disorder characterized by fasting hyperglycemia and/or plasma glucose levels
above defined limits during oral glucose tolerance testing. It is caused either by
a total lack of insulin (type I, insulin-dependent diabetes mellitus) or by insulin
resistance in the presence of normal or even elevated plasma insulin levels (i.e.,
by a decreased tissue sensitivity or responsiveness to insulin [type II, non-insulin
dependent diabetes mellitus]).
The major goals of dietetic and drug-based management of diabetes mellitus
are to achieve normal control of glucose metabolism and glycemia, and
thereby to prevent macro- and microvascular complications. The recommended
treatment modalities are dietary modification, increased physical activity, and
pharmacological intervention with either an oral hypoglycemic agent or insulin.
Modification of the diet is the most important element in the therapeutic
plan for diabetic patients, and for some patients with type II diabetes, it is the
only intervention needed to control the metabolic abnormalities associated with
the disease.
A specific goal of medical nutrition therapy for people with diabetes is the
maintenance of as near-normal blood glucose levels as possible. This includes
balancing food intake with either endogenous or exogenous or oral glucose-lowering
medications and physical activity levels. It is the current position of the
American Diabetes Association that first priority be given to the total amount of
carbohydrates consumed rather than the source of the carbohydrate. According
to ADA, the calories and carbohydrate content of all nutritive sweeteners must
be taken into account in a meal plan and that all have the potential to affect blood
glucose levels. ADA recognizes, however, that polyols produce a lower glycemic
response than sucrose and other carbohydrates and have approximately 2 calories
per gram compared with 4 calories per gram from other carbohydrates (176).
Even an ‘‘ideal’’ diet plan is worthless if patients do not adhere to it. To
increase compliance, it seems therefore appropriate to use low glycemic or nonglycemic
sweeteners for the preparation of special diabetic products. Traditionally,
one may consider using nonnutritive, intense sweeteners for this purpose.
These compounds are noncaloric and have no deleterious effect on diabetic control.
Undoubtedly, they are most useful for the sweetening of beverages (soft
drinks, coffee, tea). However, incorporation of nonnutritive sweeteners into solid
foods causes a major technological problem. In normal products, sucrose represents
a considerable portion of bulk, and its replacement by nonnutritive sweeteners
in special products for diabetic patients requires the addition of bulking agents
(i.e., typically fat and/or starch). Because diabetic patients are predisposed to
macrovascular disease and are required to restrict their fat intake, products with