Sugar alcohols and diabetes

What Are the Effects of Sugar Alcohols?

Q1. I am confused about the effects of sugar alcohols. How do I figure them into my daily sugar intake?

— Penny, Ohio

Sugar alcohols (polyols) are carbohydrates that occur naturally in many fruits and vegetables. They are also made by food manufacturers from starches, glucose, and sucrose, and are commonly added to foods. Corn syrup is most commonly used to make polyols.

Sugar alcohols have a couple of properties that make them attractive for people who would like to reduce their carbohydrate intake but still enjoy sweets. Here are a few things to remember: First, polyols are slowly and not completely absorbed from the gut. This reduces the quantity of carbohydrates the body absorbs and converts into glucose in the bloodstream. Second, most polyols have fewer calories than table sugar.

The most common polyols are:

  • Sorbitol (2.6 calories per gram)
  • Maltitol (2.1 calories per gram)
  • Lactilol(2 calories per gram)
  • Erythritol (0.2 calories per gram)
  • Isomalt (2 calories per gram)
  • Hydrogenated starch hydrolysates (3 calories per gram)
  • Mannitol (1.6 calories per gram)
  • Xylitol (2.4 calories per gram)
  • Maltitol syrup (4.32 calories per gram)

These substances have been used extensively by food manufacturers to make sugar-free and reduced-carb products. Their texture and feel can help make artificial sweeteners palatable, and they’re often used as bulking agents. They are found in sugar-free candies, chewing gum, desserts, baked goods, chocolates, and ice cream. They’re also found in some over-the-counter medications, including throat lozenges, cough syrup, and chewable vitamins.

Many diabetics, in their efforts to reduce their carbohydrate consumption or lose weight, have turned to reduced-sugar, sugar-free, or low-carb food products. Although polyols can raise after-meal sugar levels, they raise them less than does table sugar.

To determine the amount of carbohydrates in polyols, you should look at a food’s nutrition label. The label will have a carbohydrate section under which the number of grams of polyols are listed. Reduce that number by 50 percent — divide by 2 — to arrive at the total amount of carbohydrate you will absorb. For example, if 10 grams of polyols are listed for one serving of a food, you will absorb about 5 grams. You should also consider the total number of calories in low-carb foods.

Ultimately, here’s what you should remember: You don’t need to completely eliminate natural sugar, including sugar alcohols, from your diet. Any kind of sugar should, however, be eaten in moderation and with consideration given for the total number of calories you’re consuming.

The long-term effect of polyols on people with diabetes is as yet unknown. They might be safe, but limiting them is prudent. And a word about low-carb diets that include polyols: These diets have not been shown to help diabetics lose weight, because the total number of calories in low-carb diets is high.

Q2. Why are my morning sugar levels higher than usual during the week before my menstrual cycle?

— Lynette, California

There are some common changes that can be observed in your sugar levels during your menstrual cycle. (Keep in mind that these changes will not be the same for all women.) Following are some changes that can affect the two phases of the menstrual cycle: the follicular phase, which starts the first day of menses and ends when ovulation occurs (around day 14), and the luteal phase, which begins after ovulation occurs and continues until the first day of menses.

Some women have high levels of glucose during the luteal phase and some have no significant change in either phase, while others see their glucose levels peak in both phases. The cause of this variation is not clear. There is no evidence that hormonal fluctuations (which regulate the menstrual cycle) directly cause high sugar levels. Keep in mind, however, that many women experience cravings for high-carbohydrate foods during the late luteal phase of their cycle. It is possible that your eating patterns change in the week before your menstrual cycle and affect your glucose levels. Keeping a food diary will help you evaluate if this is the reason for your premenstrual rise in glucose levels.

Q3. Is it dangerous to be pregnant with type 2 diabetes?

— Sally, California

Many potential complications of diabetes and pregnancy can be averted or managed with good care from a qualified health-care professional. Women with type 2 diabetes should consult with their doctors before becoming pregnant to determine their individual risk for complications and begin preconception care. Optimal glucose control before pregnancy with a combination of medicine, a healthy diet, and exercise is a prerequisite, as well as folic acid supplementation and other usual preconception and prenatal measures. Since the safety of many oral diabetes medicines to the fetus is not known, women should begin insulin treatment. Glucose control during pregnancy is difficult due to hormonal changes, so it’s also important to monitor your blood sugar closely and maintain normal levels. Finally, because obesity also makes sugar control difficult, overweight or obese women with diabetes should try to lose weight before becoming pregnant.

However, pregnancy in women with diabetes does carry a much greater risk than in non-diabetic women. Both mom and baby can develop complications, and some of these complications are life-threatening. Stillbirths are twice as common, and deaths during the first month and within a year are more than three times as common in infants born to mothers with type 2 diabetes. These babies also have more than 10 times the risk of congenital malformation and are often large for their gestational age, which puts them at a greater risk for developing diabetes later on in their lives. The mothers have greater odds of developing hypertension and toxemia of pregnancy and hemorrhaging after delivery. Some of these complications in both mom and baby occur more frequently if the mother’s sugar levels are not controlled or if she has diabetes-related kidney disease (diabetic nephropathy) or coronary artery disease. Another complication of diabetes, gastroparesis, causes sluggish absorption of nutrients from the mother’s gut, limiting their availability to both mom and the growing fetus.

Learn more in the Everyday Health Type 2 Diabetes Center.

By: Sue Cotey and Andrea Harris, RNs

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

If you have diabetes, you are likely a pro at reading food labels — checking carbohydrates is second nature. But what about products that use sugar alcohol as a sweetener?

This ingredient is increasingly popular in “diabetes-friendly” foods in the grocery store, but is it good for you? Here’s what you need to know.

Is it alcohol or sugar — or what?

Sugar alcohols, which occur naturally in fruits and vegetables, have a slightly deceptive name: They don’t contain either alcohol or sugar (though they sometimes come from different types of sugar).

Food manufacturers use the sweetener to reduce the amount of calories in a product while still providing sweetness. Unlike sugar, which has about 4 calories per gram, sugar alcohol has just over 2 calories per gram. You’ll often find it in baked goods and sugar-free gum.

Sugar alcohol converts to glucose more slowly than carbohydrates from things like honey, bread, rice and alcohol. It requires almost no insulin for metabolizing and doesn’t cause sudden blood sugar spikes.

Sounds good so far, but is there a catch?

Sugar alcohol is generally considered safe for consumption. There are, however, important things to keep in mind.

1. It’s not a good idea to binge on it. Even though labels on products sweetened with sugar alcohol say they are diabetes-friendly or sugar-free, they still contain carbohydrates.They can raise your blood sugar. And, you can also still gain weight when eating foods that contain sugar alcohol, especially if you eat them in excess.

2. It tends to have a laxative effect, particularly in children and people with IBS (irritable bowel syndrome). Instead of being fully absorbed in the stomach, sugar alcohols can linger in the intestines and ferment. (Doctors actually prescribe some types of sugar alcohols as laxatives.)

3. Some types cause intestinal discomfort. In a 2006 British study, researchers gave participants doses of sugar or one of two types of sugar alcohol (xylitol and erythritol). Those taking xylitol reported bloating, gas, stomach upset and diarrhea. Erythritol appeared to have a milder effect on the stomach, only increasing nausea and gas when given in large doses.

How do you recognize sugar alcohols on food labels?

Just as sugar lurks behind different terms on food labels, sugar alcohol also has many names. When you see one of these products on a label, here’s what you are getting:

  • Xylitol, often used in gum, is about as sweet as sugar. It comes from wheat straw and some cereals and is commercially made from corncobs.
  • Maltitol is about 75 percent as sweet as sugar and comes from corn syrup.
  • Erythritol is 60 to 80 percent as sweet as sugar. It is found in things like pears, soy sauce and watermelon and is manufactured by fermenting corn.
  • Mannitol is 50 to 70 percent as sweet as sugar. It is found in carrots, olives and asparagus and is manufactured from seaweed.
  • Isomalt is about 45 to 65 percent as sweet as sugar. It comes from beet sugar.
  • Sorbitol is about half as sweet as sugar. It is found in apples and pears and is manufactured from corn syrup.
  • Lactitol provides about 40 percent the sweetness of sugar. Manufacturers make it from milk.
  • Hydrogenated starch hydrolysates range between 40 and 90 percent as sweet as sugar. Manufacturers produce them by mixing different sugar alcohols.

As with most foods, it’s best to eat sugar alcohol only in moderation. However, if you are mindful of side effects, it can help reduce your carbohydrate intake when you eat it as part of a healthy diet.

Is it safe for a person with diabetes to eat sweets?

In the U.S., all packaged food and drink products display a Nutrition Facts label.

Knowing how to read this label can help people determine the potential impact food or drink may have on their blood glucose levels.

There is often a multitude of information on a Nutrition Facts label, but the three most important numbers are:

  • serving size
  • total carbohydrates
  • calories

We discuss each of these below.

If a food product contains any artificial sweeteners or other sugar substitutes, the manufacturer will include them an ingredients list directly below the Nutrition Facts box.

Serving size

The first figure to look at on a Nutrition Facts label is the serving size. Manufacturers base all other information on one serving of the food.

For example, a box of crackers may list 10 crackers as one serving. So, if someone eats 20 crackers, they will be consuming twice the calories and carbohydrates stated on the box.

Manufacturers base the serving size on common household measures that are appropriate to the food, such as:

  • cups
  • tablespoons
  • pieces
  • slices
  • jars

The label will also always include the serving size in grams (g) and the number of servings per container.

Calories

A Nutrition Facts label will also inform the customer about the total number of calories in one serving. These calories come from all sources, including fat, carbohydrate, protein, and alcohol.

Knowing daily calorie intake can be important for people wanting to lose weight or maintain a healthy weight. To lose weight, people need to eat fewer calories than they burn. They can achieve this by engaging in physical activity and exercise to activate metabolic processes.

Anyone who wishes to lose weight should speak to a doctor or dietician for advice on a diet plan.

Total carbohydrates

The figure for total carbohydrates states the amount of carbohydrate in grams that one serving contains. This number includes sugar, complex carbohydrate, and fiber.

For people with diabetes, it is critical to consider the total amount of carbohydrate and not just sugar. All types of carbohydrate can affect blood glucose levels.

A diabetes educator, dietitian, or diabetologist will create an individualized diet plan as part of managing glucose. The plan restricts carbohydrate intake to keep blood sugar within a normal range.

The ADA do not suggest a specific number of carbohydrates for people with diabetes. Instead, people should closely follow their doctor’s diet plan.

Some foods may contain little or no sugar but a lot of carbohydrate. By only looking at the amount of sugar on a label, a person may end up underestimating the food’s potential impact on their blood glucose.

Food manufacturers will sometimes also use terms such as “net carbs,” “impact carbohydrate,” or “digestible carbohydrate” on their packaging.

The FDA and the American Diabetes Association do not recognize these terms. They can be misleading about the total carbohydrates in a product.

Manufacturers often calculate these figures by subtracting the quantity of sugar alcohol and fiber from the total carbohydrate. However, this method can give the impression that the product has less carbohydrate than it does.

People with diabetes should always look at the number of total carbohydrates when deciding whether or not to eat a particular food.

BACKGROUND

Sugar alcohols or polyols, as they are also called, are sugar replacers and have a long history of use in a wide variety of foods. Recent technical advances have added to the range of sugar alcohols available for food use and expanded the applications of these sugar replacers in diet and health-oriented foods. They have been found useful in sugar-free and reduced-sugar products, in foods intended for individuals with diabetes, and most recently in new products developed for carbohydrate controlled eating plans.

Sugar alcohols are neither sugars nor alcohols. They are carbohydrates with a chemical structure that partially resembles sugar and partially resembles alcohol, but they don’t contain ethanol as alcoholic beverages do. They are incompletely absorbed and metabolized by the body, and consequently contribute fewer calories than most sugars. The commonly used sugar alcohols include sorbitol, mannitol, xylitol, maltitol, maltitol syrup, lactitol, erythritol, isomalt and hydrogenated starch hydrolysates. Their calorie content ranges from zero to three calories per gram compared to four calories per gram for sucrose or other sugars. Most sugar alcohols are less sweet than sucrose; maltitol and xylitol are about as sweet as sucrose.

Sugar alcohols occur naturally in a wide variety of fruits and vegetables, but are commercially produced from other carbohydrates such as sucrose, glucose, and starch. Along with adding a sweet taste, polyols (sugar alcohols) perform a variety of functions such as adding bulk and texture, providing a cooling effect or taste, inhibiting the browning that occurs during heating and retaining moisture in foods. Polyols neither prevent nor cause browning.

FORMS OF SUGAR ALCOHOLS

The table below shows commonly used sugar alcohols along with some of their food applications. The relative sweetness value fluctuates due to the fact that sweetness will vary depending on the product in which the polyol is used. Manufacturers frequently use sugar alcohols in combination with other polyols and with nutritive (caloric) sweeteners to attain the desired taste and sweetness level.

SUGAR ALCOHOLS AND HEALTH

Metabolism
Sugar alcohols are slowly and incompletely absorbed from the small intestine into the blood. Once absorbed they are converted to energy by processes that require little or no insulin. Some of the sugar alcohol is not absorbed into the blood. These pass through the small intestine and are fermented by bacteria in the large intestine. Thus, overconsumption may produce abdominal gas and discomfort in some individuals.(2) Total daily consumption should be considered since it is the total intake that may primarily drive GI disturbance or laxative effects. As a result, foods that contain certain sugar alcohols and that are likely to be eaten in amounts that could produce such an effect must bear the statement “Excess consumption may have a laxative effect.” The Academy of Nutrition & Dietetics advises that greater than 50g/day of sorbitol or greater than 20g/day of mannitol “may cause diarrhea.”(1)

Given the increasing availability of polyolsweetened foods due to the expanded number of lowcarbohydrate foods, the total daily intake needs to be considered since it is the total intake that may primarily drive laxative effects. Other important factors to consider include the time of day consumed, the amount eaten in one sitting, type of food, individual response, and adaptation over time. Finally, if you eat a product containing large amounts of polyols for breakfast on an empty stomach, you will probably experience a different effect than consuming the same product later in the day with a fuller stomach.

Diabetic Diets
The primary goal for nutritional management of diabetes is to maintain near-normal blood glucose levels. Due to their incomplete absorption, the polyol sweeteners may be useful in diabetic diets. The American Diabetes Association notes that “the total amount of carbohydrate in meals or snack is more important than the source or type.”(3) People with diabetes should consult their physician, dietitian or other health professional about incorporating sugar alcohols into their daily meal plans.

An A publication recommends that persons with diabetes managing their blood sugars using the carbohydrate counting method “count half of the grams of sugar alcohol as carbohydrates since half of the sugar alcohol on average is digested.”(4)

Reduced Calorie and Low Carbohydrate Diets
Because of their lower energy density (calories per gram) the replacement of other carbohydrates with sugar alcohols can reduce the energy density of food products and could play a useful role in weight management. Polyols also may have a role in reducing the overall glycemic challenge of the diet. Presently, researchers have no conclusive evidence that glycemic index is related to weight control.(5)

Health experts advise that excessive energy intake in any form leads to weight gain. Consumers should consider the total calorie content of the diet and should avoid over consumption of all foods including those containing sugar alcohols.

Tooth Decay
Sugar alcohols are not acted upon by bacteria in the mouth, and therefore do not cause tooth decay.(2) Xylitol has been found to inhibit oral bacteria, and is often used in sugarless mints and chewing gums for this reason. The FDA authorizes the use of a health claim in food labeling that sugar alcohols do not promote tooth decay.

LABELING

Consumers interested in the polyol content of foods can find relevant information in several places on the food label.

Ingredient List
The ingredient list will show the individual name of each polyol the product contains.

Nutrition Facts Panel
The Nutrition Facts panel shows the total carbohydrate content of a food that includes the amount of any sugar alcohols in the product. The manufacturer may also declare voluntarily the number of grams of polyols in a serving of the product. If the product label uses the terms “sugar free” or “no added sugar,” the polyol content must be declared separately under carbohydrates in the Nutrition Facts panel. If the product contains more than one polyol, the Nutrition Facts panel must use the term “sugar alcohol.”

Principal Display Panel
Consumers may see relatively new phrases such as “net carb,” “low carb,” or “impact carb” on the principal display panel of some products. These terms are not defined by the FDA. Generally, food manufacturers calculate “net carbohydrates” by subtracting the grams of fiber and sugar alcohols from the total carbohydrates.

Much like dietary fiber, even though sugar alcohols are technically carbohydrates, they have a lower energy density (calories per gram), because of their incomplete absorption and therefore, shouldn’t be counted as part of total carbohydrates.(6) This rationale is being debated in the scientific community.

The Bottom Line

An increasing variety of polyol-containing foods is appearing on supermarket shelves. Appropriately used, these products may have a role in weight management and in eating plans for people with diabetes. Long-term benefits have not been established for sugar alcohols and further research is needed to document their health effects. Sugar alcohols and foods containing them should be consumed as part of an overall healthy eating plan, such as that outlined by the Dietary Guidelines for Americans.

The Sugar Alcohols
Type Calories per gram Approximate Sweetness
(sucrose =100%)
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, 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 foods
Hydrogenated
Starch Hydrolysates
(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.

2. Wolever, T.M.S., et. al. Sugar alcohols and diabetes; a review. Canadian Journal of Diabetes 2002; 26:356.

4. Powers M. American Dietetic Association Guide to Eating Right When You Have Diabetes. Hoboken, NJ: John Wiley & Sons; 2003:130,139

6. Marcason, W. What do “net carb,” “low carb,” and “impact carb” really mean on food labels? Journal of the American Dietetic Association. Jan. 2004.

For more information on sugars, fibers and other carbohydrates, please see our additional resources below:

The Science of Sugars: A four-part, peer-reviewed series examining many aspects of the relationships between sugars and health. The review also summarizes nutrition and policy recommendations of the scientific community. The referenced papers are now published in the peer-reviewed journal, Nutrition Today.

Background on Carbohydrates & Sugars

Questions and Answers about Sugars

Sugars: 10 Facts You May Not Know

Fast Facts about High Fructose Corn Syrup

Fiber Fact Sheet

Whole Grains Fact Sheet

Facts About Low-Calorie Sweeteners

Sweet Taste, Without the Calories

What’s the Scoop on Low-Calorie Sweeteners Video Series

Ask the Expert
What are Sugar Alcohols?

Answers by Tami A. Ross, RDN, LD, CDE

Blue, pink, yellow, green, orange—there is a whole rainbow of colors for sugar substitutes offered today. The term “sugar substitutes” refers to high intensity sweeteners, artificial sweeteners, non-nutritive sweeteners, and other low-calorie sweeteners. Then there are sugar alcohols, such as erythritol, xylitol, and mannitol. Sugar alcohols are becoming more popular as “keto-friendly” sweeteners. But what are they? And are they a good option for people with diabetes?

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What Are Sugar Alcohols?

Most sugar substitutes taste much sweeter than sugar. Since they are so sweet, only a tiny amount is needed to give the same sweetness of sugar, with almost no calories.
Unlike other “high-intensity” sweeteners, sugar alcohols are less sweet than sugar, but they have fewer calories per gram, making them a “low-calorie” sweetener.
Don’t let the word “alcohol” confuse you, sugar alcohols are not the same as the alcohol that causes you to “get a buzz.” The word “alcohol,” in this case, is talking about to the shape of the molecule – so don’t worry, it’s just a chemistry thing.

How Are Sugar Alcohols Used?

Sugar alcohols are not usually used in home cooking or in packets at the coffee counter, but they can be found in many “sugar free” foods including chewing gum, candy, ice cream, and fruit spreads. They are also often used as a sweetener in toothpaste, mouthwash, and cough drops.

Products labelled “diet,” “sugar-free,” or “no sugar added” can also have sugar alcohols in the ingredients. If a product has sugar alcohols, you will see “Sugar Alcohol” listed under Total Carbohydrates on the Nutrition Facts label. You can then scan the ingredient list to see which sugar alcohols were added.

Common sugar alcohols that you may find are xylitol, erythritol, sorbitol, and maltitol (they usually end in the letters –ol, as does sugar “alcohol”, which can be helpful to quickly spot them in the ingredient list).

Do Sugar Alcohols Raise Blood Sugar?

Sugar Alcohols are a type of carbohydrate, and they can raise blood sugar. As you’ll notice in the Nutrition Facts label to the right, “sugar-free” foods that contain sugar alcohols are not carbohydrate- or calorie-free!
However, sugar alcohols are processed by the body in a different way than other carbohydrates, and some may raise your blood sugar by a little while others may not increase it at all.
For example, erythritol is a type of sugar alcohol that may not increase your blood sugar. For this reason, it has become very popular as an ingredient in low-carb “keto” foods. Erythritol can even be found in some stores and can be used for home cooking, so you may also see it as an ingredient in low-carb dessert recipes.

What Might Sugar Alcohols Do in Other Parts of The Body?

Unlike regular sugar, sugar alcohols do not promote cavities. As a matter of fact, xylitol, a type of sugar alcohol seen in sugar-free chewing gum, may help prevent cavities.
Many sugar alcohols can cause gas, bloating, and stomach aches, especially when eaten in large amounts, and some people may be more sensitive to this effect than others.
If you have an upset stomach when eating “sugar-free” or other foods sweetened with sugar alcohols, read the ingredients to see what kind of sugar alcohol is in the product. You may want to avoid foods that have that type of sugar alcohol, or cut back on how much you eat in one sitting.

BOTTOM LINE

Sugar alcohols are safe to eat and may be a good option for people with diabetes. However, they can cause stomach issues when eaten in large amounts, and some sugar alcohols can raise blood sugar.
“Sugar-free” does not mean carbohydrate-free! Read the label to see the carbohydrate content of sugar-free foods.
Sugar-free foods can fit in your eating plan as long as you count the carbohydrate. Check blood sugar 1 ½- 2 hours after eating a food with sugar alcohols to see how your blood sugar changes.
As always, your dietitian or diabetes health-care team can help you decide if including any type of sugar substitutes in your eating plan is the best choice for you.

Tami Ross is a registered dietitian, certified diabetes educator, and nationally recognized speaker, consultant, and health and nutrition writer. She is author of the best-selling book, What Do I Eat Now?. You can follow Tami on Twitter @tamirossrd or visit her website, www.tamirossrd.com

September 2019 Share

Sugar alcohols are sweeteners that have about half the calories of regular sugar. They occur naturally in certain fruits and vegetables, but some are man-made and are added to processed foods.

Many foods labeled “sugar free” or “no sugar added” have sugar alcohols in them. You might see these names on the ingredient list:

  • Erythritol
  • Maltitol
  • Mannitol
  • Sorbitol
  • Xylitol
  • Hydrogenated starch hydrolysates (HSH)
  • Isomalt

Food companies often combine sugar alcohols with artificial sweeteners to make foods taste sweeter. If you’re trying to lose weight, you might benefit from swapping sugar alcohols for sugar and other higher-calorie sweeteners.

Besides being lower in calories, sugar alcohols don’t cause cavities, which is why they’re used in sugar-free gum and mouthwash. Sugar alcohols also create a cooling sensation when used in large amounts, which works well with mint flavors.

You may see sugar alcohols as ingredients in many lower-calorie and sugar-free foods like energy bars, ice cream, pudding, frosting, cakes, cookies, candies, and jams. And in spite of their name, sugar alcohols aren’t alcoholic.

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