With gestational diabetes, we cannot process sugars as well as we normally would, leaving blood glucose levels too high and forcing the growing baby to increase insulin production to process the sugar. Therefore it is advisable for women with diabetes in pregnancy to avoid sugars, with even natural sugars found in things like fruit, dried fruits, honey and natural syrups being problematic for many, causing high blood sugar levels. This means that many will turn to using sweeteners in pregnancy instead.
Are sweeteners safe for consumption in pregnancy?
In the UK sweeteners are deemed as being safe for use in pregnancy. In the Policy Statement, The Use of Artificial Sweeteners1, The BDA (The British Dietetic Association) states:
Artificial sweeteners are considered safe for consumption during pregnancy. However, foods and drinks containing artificial
sweeteners should not replace more nutritious options (e.g., the consumption of ‘diet’ drinks in replacement of milk-based drinks or fruit juice).
The European Food Safety Authority2 (EFSA) states:
From a safety perspective, scientific reviews have shown LNCS [low and no calorie sweeteners] to be safe for children and pregnant women.
However research suggests links between consumption of artificially sweetened soft drinks and the risk of pre-term delivery in Danish pregnant women3.
More recent evidence-based research is showing a concern related to the consumption of artificial sweeteners in pregnancy and the impact on the child
Whilst sweeteners in pregnancy may be deemed safe for consumption, there is increasing evidence suggesting that consuming artificial sweeteners in pregnancy leads to changes in metabolism and gut microbiome causing metabolic modifications which can lead to increased BMI and increased insulin resistance in the child born to the mother who has consumed them4.
Association Between Artificially-Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index
A study that used data from the Canadian Healthy Infant Longitudinal Development (CHILD) Study, a population-based birth cohort that recruited 3033 healthy pregnant women from 2009 to 2012 where women completed dietary assessments during pregnancy, and their infants’ BMI were measured at 1 year of age found that the mean infant BMI score at 1 year of age was 0.19, and 5.1% of infants were overweight.5
29.5% of mothers consumed artificially sweetened beverages (ASBs) during pregnancy, including 5.1% who reported daily consumption.
Intake of ASBs was determined from reported consumption of “diet soft drinks or pop” (1 serving = 12 oz or 1 can) and “artificial sweetener added to tea or coffee” (1 serving = 1 packet). Sugar-sweetened beverage (SSB) intake was similarly determined by the consumption of “regular soft drinks or pop” (1 serving = 12 oz or 1 can) and “sugar or honey added to tea or coffee” (1 serving = 1 teaspoon or 1 packet). Beverage intakes were classified according to the number of servings per week as never, fewer than 1 per month, 1 or more per week, 2 to 6 per week, or 1 or more per day.
Conclusion: Maternal consumption of ASBs during pregnancy is associated with higher infant BMI and an increased risk of infant overweight at 1 year of age. Infant birth weight was not affected, suggesting that maternal ASB consumption influenced postnatal weight gain rather than fetal growth. Compared with no ASB consumption during pregnancy, daily ASB consumption was associated with a 0.2-unit increase in infant BMI score and a 2-fold increased risk of infant overweight at 1 year. These associations were independent of maternal BMI, diabetes, total energy intake, diet quality, and other known obesity risk factors. No comparable associations were identified for SSB consumption.5Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index
In another study of 918 mothers with singleton births, half of the women reported consuming ASBs (artificially-sweetened beverages) during pregnancy and 9% consumed them daily. During pregnancy, daily consumption of ASBs was positively associated with offspring large-for-gestational-age, and overweight/obesity at 7 years of age6.
Increased consumption of artificially-sweetened beverages during pregnancy is associated with infant gut microbiota and metabolic modifications
Whilst numerous animal and human studies7–10 have shown artificial sweeteners consumed during pregnancy to cause obesity in the offspring until recently we have not been able to understand the reason and causes of this. This impact has been studied in mice11, however, this new research publication12 has looked into underlying mechanisms in humans.
The study was in 100 infants from the prospective Canadian CHILD Cohort Study, selected based on maternal ASB consumption during pregnancy (50 non-consumers and 50 daily consumers). BMI was higher among ASB-exposed infants.
Infant stool and urine samples were acquired at 3–4 months and 12 months. Four microbiome clusters were identified, two recapitulated the maturation trajectory of the infant gut bacterial communities from immature (Cluster 1) to mature (Cluster 4) and two deviated from this trajectory (Clusters 2 and 3). Maternal ASB consumption did not differ between clusters but was associated with community-level shifts in infants gut bacterial taxonomy structure and depletion of several Bacteroides species. Urine succinate and spermidine levels at 3 months were higher in ASB-exposed infants, and urine succinate was positively associated with BMI at one year old. Succinate was found to mediate 29% of the effect of ASB exposure on BMI at one year old, revealing a potential role of this metabolite in increased infant weight linked to gestational ASB consumption.
Conclusion: artificial sweetener consumption may be associated with atypical infant microbiome maturation, and it is linked to increased infant BMI via succinate, a gut microbiome metabolite detectable in urine.12Maternal consumption of artificially sweetened beverages during pregnancy is associated with infant gut microbiota and metabolic modifications and increased infant body mass index
Are sweeteners better for blood sugar levels?
A study published in Nature in 201413, found that adding aspartame, sucralose, or saccharin to drinking water given to mice caused glucose intolerance and altered the gut microbes. When the experiment was trialled in humans they found the same results. The sweeteners caused glucose intolerance and altered the gut microbes in a way that increased the risk of metabolic diseases such as Type 2 diabetes in some of the participants.
In this study in 381 non-diabetic individuals in an ongoing clinical nutritional study we found significant positive correlations between non-caloric artificial sweeteners (NAS) consumption and several metabolic-syndrome-related clinical parameters, including increased weight and waist-to-hip ratio; higher fasting blood glucose, glycosylated haemoglobin (HbA1C%) and glucose tolerance test, and elevated serum alanine aminotransferase (ALT, measure of hepatic damage that is likely to be secondary, in this context, to non-alcoholic fatty liver disease). The HbA1C levels, indicative of glucose concentration over the previous 3 months, were significantly increased when comparing a subgroup of high NAS consumers (40 individuals) to non-NAS consumers (236 individuals). As an initial assessment of whether the relationship between human NAS consumption and blood glucose control is causative, we followed seven healthy volunteers (5 males and 2 females, aged 28–36) who do not normally consume NAS or NAS-containing foods for 1 week. During this week, participants consumed on days 2–7 the FDA’s maximal acceptable daily intake (ADI) of commercial saccharin (5 mg per kg (body weight)) as three divided daily doses equivalent to 120 mg, and were monitored by continuous glucose measurements and daily GTT. Notably, even in this short-term 7-day exposure period, most individuals (4 out of 7) developed significantly poorer glycaemic responses 5–7 days after NAS consumption (hereafter termed ‘NAS responders’), compared to their individual glycaemic response on days 1–414Artificial sweeteners induce glucose intolerance by altering the gut microbiota
All of us have a microbiome made up of trillions of organisms. Everybody’s microbiome is a little different. The ways our microbiomes respond to what we eat can vary, too. In this study, the researchers found that as mice and people started consuming artificial sweeteners, some types of bacteria got pushed out, and other types of bacteria began to proliferate. It could be that for some people who responded negatively to the artificial sweetener, the bacteria that got pushed out were helping to normalise blood sugar levels.
Not all sweeteners are equal
The research studies above are all on the use of artificial, synthetic, non-nutritive sweeteners.
Below I share the different types of sweeteners used in food and beverages.
Artificial (non-nutritive or non-calorific) sweeteners
Artificial sweeteners are chemically made, synthetic products, that can be added to foods and drinks to make them taste sweet but with far fewer calories than sucrose (table sugar) hence they are often used in calorie-controlled diets.
Most commonly used artificial sweeteners include:
- Acesulfame K
Aspartame and Acesulfame K (usually the red-lidded jars and branded product Canderel)
Aspartame and Acesulfame K (acesulfame potassium) are artificially made sweeteners. Canderel is the branded product and comes in tablet, granulated and liquid forms. Aspartame and Acesulfame K are around 200 times sweeter than table sugar. It must be avoided by people with the genetic condition phenylketonuria (PKU)
This type of sweetener is commonly found in many diet or sugar-free products such Diet and Zero Coke, Pepsi-Max, Zero Fanta, Zero Dr Pepper, Zero Lilt, Schweppes Diet Lemonade, Robinsons No Added Sugar Fruit Squashes, No Added Sugar Ribena, Mullerlight yogurts, Options hot chocolate, Hartley’s No Added Sugar and 10 cal Jellies.
These type of sweeteners have been reported to aggravate or worsen those who suffer from migraines and can cause bloating, cramping, flatulence and cause laxative effects in some individuals, especially when consumed in larger amounts.
High-fructose corn syrup (Fr) and artificial sweetener acesulfame potassium (AS) consumption were associated with maternal metabolic dysfunction in mice. AS was also associated with reduced fetal growth and fetal hypoglycemia. Therefore, artificially-sweetened beverages may not be a beneficial alternative to sugar-sweetened beverages during pregnancy.15Consumption of the Artificial Sweetener Acesulfame Potassium throughout Pregnancy Induces Glucose Intolerance and Adipose Tissue Dysfunction in Mice
Saccharin (usually tablet or sachet sweeteners for hot drinks)
Hermesetas, Sweetex and Sweet N Low (saccharin) are all well-known brands of these artificial sweeteners. Saccharin is around 400 times sweeter than table sugar and is known to leave a bitter aftertaste, especially when consumed in high amounts. With tablet sweeteners, usually, one tablet is equivalent to one teaspoon of sugar.
Some small studies16 comparing saccharin to stevia now suggest that these types of sweeteners can alter the gut bacteria that may cause increased insulin resistance and may raise blood sugar levels14.
Sucralose (usually the yellow-lidded jars and branded product Splenda)
Sucralose can be up to 1,000 times sweeter than table sugar and so very small amounts are needed to achieve sweetness. Sucralose keeps its flavour and taste even when baked at high temperatures, hence it can be a popular choice for baking and recipes to replace sugar.
This type of sweetener is commonly found in diet drinks such as stores own brand No Added Sugar fruit squashes, stores own brand fizzy diet drinks, stores own brand low sugar sauces eg. ketchup, No Added Sugar Crusha, Cadbury Highlights Hot Chocolate, No Added Sugar Angel Delight, No Added Sugar Vimto and Activia yogurts.
Sucralose has been reported to cause bloating, cramping, flatulence and cause laxative effects in some individuals, usually when consumed in larger amounts.
Steviosides, steviol glycosides, stevia (usually the green-lidded jars)
Steviosides, steviol glycosides, or stevia as it’s better known, is a sweetener derived from the extraction from the sweet leaves of the stevia plant (Stevia rebaudiana), native to Brazil and Paraguay.
Stevia can be around 200-400 times sweeter than table sugar. There are many different grades of stevia and also different methods of extraction.
IMPORTANT NOTE: Stevia is usually mixed with other bulking agents such as maltodextrin (which has a higher GI value than table sugar and spikes blood glucose levels rapidly), or other sweeteners such as artificial sweeteners like sucralose, or sugar alcohols (polyols) such as erythritol. Meaning the strength of stevia in the product being consumed can vary vastly from one to another, and you are rarely using a true stevia sweetener or a ‘natural’ sweetener as you may have been led to believe.
Pure stevia is much more expensive, whilst bulked stevia products with very small amounts of steviol glycosides (around 1-2%) only cost a fraction of the price and can be found in the majority of shops and supermarkets.
Stevia products can leave a bitter aftertaste, especially cheaper stevia sweeteners which contain very small amounts of stevia.
Non-nutritive sweeteners absorption, distribution, and excretion during pregnancy and lactation
Absorption of NNSs [non-nutritive sweeteners] into the bloodstream occurs in the small intestine and can be transferred to a fetus through the placenta and to an infant through breast milk. Although some NNSs are fully degraded (aspartame), most of them (sucralose, acesulfame K, saccharin) circulate in the body unmetabolized and are found in the blood, urine, and faeces17.
Another type of sweetener: Sugar Alcohols (Polyols)
Sugar Alcohols, also known as Polyols are small-chain carbohydrates that occur naturally in certain fruits, vegetables and plants. They do not contain sugar or alcohol as the name ‘sugar alcohols’ would suggest. The name comes from their chemical structure which resembles sugar and is similar to alcohol.
Polyols are slowly digested. They are not fully absorbed by the small intestine and into the bloodstream meaning they do not raise blood sugar levels the same way sugar does, they contain fewer calories and are tooth-friendly as they do not cause tooth decay18 meaning they are helpful in low calorie and low carbohydrate diets. Learn more about polyols here19.
|Polyol||Natural sources||Commercial production method||GI value*|
|Erythritol||Naturally derived from some fruits, mushrooms and fermented foods||Produced by fermentation of yeasts and lactic acid bacteria||0|
|Isomalt||Naturally derived from sugar beet||Produced by enzymatic transglucosidation of sucrose into maltose then hydrogenated into isomalt||9|
|Lactitol||Naturally derived from milk||Produced by catalytic hydrogenation with Raney nickel||6|
|Maltitol||Naturally derived from maltose found in cereals, certain fruits and sweet potatoes||Produced from starch by hydrogenating maltose||35|
|Mannitol||Naturally derived from fruits and vegetables||Produced through catalytic hydrogenation of a glucose/fructose mixture; second fermentation step by using lactic acid bacteria||0|
|Sorbitol||Naturally derived from fruits, berries, and vegetables||Produced through catalytic hydrogenation of glucose/sucrose with hydrogen gas and a nickel catalyst or through electrochemical reduction of dextrose||9|
|Xylitol||Naturally derived from fruits, vegetables and hardwood (birch and beech)||Produced by hydrogenation of xylose derived mostly from hardwood sources||7-13|
*What is the glycaemic index (GI)? The glycaemic index is a rating system for foods containing carbohydrates. It shows how quickly each food affects your blood sugar (glucose) level when that food is eaten on its own. The GI of glucose is 100 and table sugar (sucrose) is 65.
Only small amounts of polyols are absorbed in the small intestines, therefore polyols largely remain intact when entering the large intestines. The absorption rate is influenced by many factors such as the type of polyol, the amount that is eaten (no more than 20g should be consumed at a time), and intestinal disorders such as IBS, IBD and celiac disease20:
Polyols attract water as they move through the small intestine by a process called osmosis. This occurs whether polyols are absorbed, or not, but it can lead to pain and motility problems (typically, diarrhoea) for people who are more sensitive to the pressure this fluid exerts on the intestinal walls. Polyols that are not absorbed in the small intestine enter the large intestine where they are fermented by gut bacteria. The gas produced as a by-product of this bacterial fermentation distends the bowel, causing additional pain, bloating, and altered bowel habits in susceptible individuals. Certain polyols (notably erythritol21,22) are better tolerated than others because they are more efficiently absorbed in the small intestine. This reduces both the osmotic effect they exert in the small intestine and the amount of intact polyol molecules available for fermentation in the large intestine.23Polyols & Gut Symptoms
Polyols showing as carbs on nutritional labels
It can be confusing to see a product which states it is ‘sugar-free’ but has high amounts of carbohydrates on the nutritional information label.
Polyols are listed under carbohydrates on nutritional labels, however, not all carbs from polyols are digestible, therefore some polyols can be deducted from the total carb amount when looking at the carbs that impact blood sugar levels depending on the polyol type.
Erythritol & Mannitol: If the polyols used in the food or beverage are from erythritol or mannitol then this amount of carbs can be deducted from the total carbs as they have a GI value of 0.
Lactitol, Isomalt & Sorbitol: The GI values of lactitol, isomalt, and sorbitol are fairly low meaning the carbs from these polyols shouldn’t impact blood sugar levels too much and therefore can be deducted from the total carb amounts.
Xylitol: The GI value of xylitol varies from one product to another. The xylitol that is most widely found in UK stores and that I use in some of my Gestational Diabetes UK recipes is Total Sweet xylitol which has a GI value of 7. As this brand of xylitol does not cause spikes in blood sugar levels, I deduct the carbs found in xylitol in my recipes.
Maltitol: The GI value of maltitol is much higher at 35, therefore it is important to recognise that this sweetener will impact blood glucose levels more. In the knowledge that the GI of table sugar is 65, you could halve the carbs found in polyols from maltitol to give an estimate of the impact the carbs could have.
Polyols benefit to gut microbiome
As opposed to the negative impact non-nutritive sweeteners have on the gut microbiome, some polyols have been found to have positive effects, increasing the probiotic bacterias found in the gut after consumption
Effects of polyols on gut microbiota composition. Erythritol, sorbitol, and mannitol do not affect the composition of the gut microbiota; however, lactitol, isomalt, xylitol, and maltitol provoke shifts in the gut microbiome, increasing bifidobacteria numbers in healthy people.24Effects of Sweeteners on the Gut Microbiota: A Review of Experimental Studies and Clinical Trials
The sugar-free sweets effect! #readthegummybearsreviews
The majority of these products contain high amounts of sweeteners, some contain polyols BUT and this is the biggest issue we see: These sugar-free sweets/biscuits can have a laxative effect, causing bloating, cramping, flatulence and diarrhoea. In fact, we’ve had a few ladies in our support group think they are going into labour after eating these!
So please be warned, if you want some sugar-free sweets do not risk more than two or three individual sweets at a time, or you could end up regretting the decision to have a treat! You may want to reconsider giving these sugar-free sweets and treats to children as a supposedly ‘healthier’ alternative too.
If you don’t believe me and fancy a bit of a giggle #readthegummybearsreviews *Please note, I am NOT advertising these sugar-free sweets to try, this is a link to forewarn you of the impact of eating too many sugar-free sweets!
Following gestational diabetes diagnosis, many ladies jump to thinking that ‘natural’ sugar alternatives like honey, maple syrup or dried fruit may be a good healthy alternative to table sugar for sweetening things.
Honey in particular is raised in my Facebook support group as something that many perceive as being a natural alternative to cane or beet (table) sugar, however, raw honey still spikes blood sugar levels.
These are all forms of SUGAR and will still spike blood sugar levels. Some may have a lower GI (Glycaemic Index) than table sugar, but they will still all raise blood sugar levels:
|Sugar type||GI value|
Agave nectar is very similar to honey or syrup as it is a runny texture which can be used for drizzling. Agave nectar or syrup is produced commercially in Mexico and South America from the agave plant (the tequila plant).
Although agave nectar has a much lower GI value than table sugar, honey and many syrups it should only be used in very small amounts due to the very high fructose content (70-90%)
Agave is commonly marketed as a slow-release carbohydrate with a low glycaemic index. This is true as it contains mainly fructose and only low amounts of glucose. Although fructose doesn’t raise blood sugar levels in the short-term, it can contribute to insulin resistance when consumed in large amounts. This can cause major increases in long-term blood sugar and insulin levels, strongly raising the risk of metabolic syndrome and type 2 diabetes. The liver metabolises fructose, but when overloaded it starts turning the fructose into fat globules, which raise blood triglycerides. Having a high level of triglycerides in your blood can increase your risk of heart disease.25The unbearable sweetness of sugar (and sugar alternatives), Elaine Gardner, BDJ Team, Nature
Take home message
Some sweeteners in pregnancy are safer than others, with some artificial sweeteners being linked to concerns for both the health of the mother and the child in later life.
If you would like to use sweeteners in pregnancy as an alternative to sugars due to diabetes, the safest options are naturally derived sweeteners. Opt for 100% pure stevia, or stevia and erythritol blended products such as Natvia, Truvia and Pure Via, and/or polyols such as pure erythritol such as NKD Living erythritol, or Sukrin, and Total Sweet xylitol which have no or little impact on blood glucose levels, do not cause a negative impact on the gut microbiome and have shown no negative impacts to the longer-term health of the mother or child.
Watch out for artificially sweetened foods and beverages such as diet and zero drinks, consuming them as ‘treats’ rather than part of your typical daily diet. Beware of consuming sweeteners in large amounts as the majority will cause gastric upset.
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