Do people with diabetes benefit from low- and no-calorie sweetened beverages?

People with diabetes get almost as much benefit from replacing sugar-sweetened beverages with low- or no-calorie sweetened beverages as they do from water. This is good news for people with diabetes and those wanting to lose weight but who want a wider choice in beverages. A systematic review and meta-analyses by Canadian researchers found that people who used low- or no-calorie sweetened beverages (LNCSBs) as a substitute for sugar-sweetened beverages (SSBs) tended to reduce their body weight, BMI, percentage of body fat, and intrahepatocellular lipid (IHCL) levels. But generally, the direction of association favoured water in all cases, according to a study recently published in JAMA Open Network by Canadian researchers. Read: Fruit OK, pop not, in review of effects of sugars on glycemic control “For habitual consumers of sugar-sweetened beverages with overweight or obesity, who are at risk for or have type 2 diabetes, and who are unable or don’t want to switch to water, LNCSBs may provide a viable alternative,” said Dr. John Sievenpiper, study coauthor, and associate professor of nutrition sciences and medicine at the University of Toronto. The study was conducted because there are mixed recommendations around LNCSBS in patients with or at-risk for diabetes, and obesity; as well as mixed information on whether the beverages help or worsen the conditions they are intended to prevent. Also, the findings will be used to help update the recommendations of the European Association for the Study of Diabetes. “Neither the dietary guidelines for Americans nor Canada’s food guide supports the use of LNCSBs, and instead both recommend replacing SSBs with water. (But) the American Heart Association supports a narrow indication for LNCSBs…(while) diabetes associations in the U.K., U.S., and Canada support LNCSBs insofar as they are used to displace calories from sugars and SSBs,” the authors wrote. Canada’s food guide supports the use of water over LNCSBs. A total of 17 randomized controlled trials with 24 trial comparisons were included. Three prespecified substitutions were considered: LNCSBs for SSBs (intended substitution with caloric displacement); water for SSBs (standard-of-care substitution with caloric displacement); and LNCSBs for water (reference substitution without caloric displacement). Randomized controlled trials of at least two weeks duration that investigated the association of LNCSBs, SSBs, and/or water with cardiometabolic risk factors were included. Trials of multimodal interventions or which did not use comparator groups were excluded, as were those using fortified or nutrient-dense beverages (such as milk and juice). The trials included a total of 1,733 adults who had a mean age of 33.1 years; 1,341 (77.4%) were women and 392 were men (22.6%) with overweight or obesity who were at risk for or had diabetes. Most subjects were overweight or obese with a median BMI of 31—nine trials included only participants who were overweight or obese and one trial included participants with type 2 diabetes. Overall, LNCSBs were a substitute for SSBs in 12 trials (601 people), water was a substitute for SSBs in three trials (429 people), and LNCSBs were a substitute for water in nine trials (974 people). The substitution of LNCSBs for SSBs was associated with reduced body weight a mean loss of 1.06 kgs. There was a mean 0.32 drop in BMI; a mean 6% drop in body fat; and a standardized mean difference of 0.42 lowering of intrahepatocellular lipids. Substituting water for SSBs was not associated with any outcome, the researchers reported. There was also no association found between substituting LNCSBs for water with any outcome – except glycated hemoglobin A1c a mean difference of 0.21%, and systolic blood pressure drop of a mean 2.63mmHg. Neither LNCSBs nor water, when used as a substitute for SSBs, were associated with significant improvements in glycemic control, blood pressure, uric acid, or other aspects of lipid profiles or non-alcoholic fatty liver disease (NAFLD) markers. “But the directions of the association favored LNCSBs or water in nearly all cases,” the study said. Overall, the findings were consistent with the mechanism of LNCSBs being associated with weight loss because they were a factor in reducing net energy intake. The researchers noted that “The certainty of the evidence was moderate (substitution of LNCSBs for SSBs) and low (substitutions of water for SSBs and LNCSBs for water) for body weight and was generally moderate for all other outcomes across all substitutions.” According to the 2018 Clinical Practice Guidelines from Diabetes Canada. evidence shows “a weight loss benefit when non-nutritive sweeteners are used to displace excess calories from added sugars (especially from SSBs) in overweight children and adults without diabetes, a benefit that has been shown to be similar to that seen with other interventions intended to displace excess calories from added sugars, such as water.” Dr. Sievenpiper was lead author of the nutrition therapy section of the guidelines. Joanne Lewis, a spokesperson for Diabetes Canada, stated that to help reduce sugar intake from beverages, it is recommended that people should limit intake of free sugars to less than 10% of total daily calorie (energy) intake. This is approximately 50g (12 teaspoons) of free sugars consumption per day based on a 2000-calorie diet. The guidelines also state that most artificial or non-nutritive sweeteners, which feature in low and no-calorie sweetened beverages, “have been shown to be safe when used by people with diabetes; however, there are limited data on the newer sweeteners, such as neotame and thaumatin in people with diabetes.” They also advise to avoid sugar-sweetened beverages and drink water in their place, and to eat whole foods and reduce free sugars for overall health. “For people who struggle to replace sugary drinks with water, they can try soda water or adding lemon or lime to their water,” said Lewis.

Do people with diabetes benefit from low- and no-calorie sweetened beverages?

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