Prevalence of Diabetes Mellitus in

the Philippines and Medical

Recommendations for Use of
Alternative Sweeteners
How Much is Too Much?
Olive Q. De Guzman-Quizon, MD, MPH, DPAFP, DPBCN
Assistant Professor UERMMMC- Institute for Studies on Diabetes Foundation Inc
Family Medicine- Diabetes- Clinical Nutrition Consultant, Manila Doctors Hospital
Nutrition Support and Weight Management Center Consultant, St. Lukes Medical Center- QC
 Questions to answer
How big is the problem of Diabetes Mellitus?
Worldwide
Region
Philippines
How much do I have to consume?
Alternative sweeteners
Carbohydrates
Simple sugars
366 million
552 million
National Prevalence of Diabetes Mellitus, by age,
Philippines, 2008 (NNHeS)

Prevalence of Diabetes Mellitus

Age *Based on FBS a Based on 2Hour Based on the DM True Diabetes d
(y) Post Prandial Questionnaire c
Glucose b

20-29 0.4 0.4 0.5 0.9

30-39 3.2 1.1 1.4 3.8
40-49 5.7 3.9 4.2 8.2
50-59 9.0 5.0 8.1 13.0
60-69 9.1 5.9 9.5 15.9
>70 4.4 5.5 7.1 11.8
Overall 4.8 3.0 4.0 7.1
a Based on FBS level > 125 mg/dL
b Based on 2H-PPG= > 200 mg/dL
c Based on DM questionnaire = having a previous diagnosis by a nurse or physician OR on current medication
d True diabetes = positive in any of the three assessment methods : FBS, 2H-PPG and DM questionnaire.
 DM prevalence in the Philippines
% prevalence

year

National Nutrition Survey 1998, National Nutrition and Health Survey, 2003&2008. FNRI
How Much is Too Much?
How much do I consume?

Alternative Sweeteners
 Alternative Sweeteners
Non nutritive Nutritive
Artificial Natural Sugar alcohol
Acesulfame Date sugar Erythritol
potassium (Sunett, Grape juice Hydrogenated starch
Sweet One) concentrate hydrolysates
Aspartame (Equal, Honey Isomalt
NutraSweet) Maple sugar Lactitol
Neotame Maple syrup Maltitol
Saccharin (SugarTwin, Molasses Mannitol
Sweet'N Low) Agave nectar Sorbitol
Sucralose (Splenda) Xylitol
Stevia preparations
that are highly refined
(Pure Via, Truvia)
Sugar FDA Brand name Sweetness Acceptable Remarks
substitutes approval daily intake
(mg/kg/day)
Saccharin 2002 Sweet and 200-700 x 12 mg Crosses the
low, necta placenta;
sweet, slow fetal
sucaryl clearance;
caution
Aspartame 1983, 1996 Equal, nutra 160 -220 x 50 Hydrolyzed
sweet into
metabolites
Acesulfame 1988 Sweet and 200 x 15 Crosses the
safe, placenta but
sunnett, considered
sweet one safe
Sucralose 1999 Splenda 600 x 5 Poorly
absorbed
Neotame 2002 8000 x 18 Limited
studies in
pregnant
Managing pre-existing diabetes and pregnancy.. Technical reviews and consensus for
recommendation of care. Kitzmiller JL. Jovanovic L. Eds. 2008. American Diabetes Association
 Carbohydrates and DM
Artificial sweeteners are generally safe
acesulfame potassium, aspartame, neotame,
saccharin, and sucralose

All underwent rigorous scrutiny and were shown

to be safe when consumed by the public, including
people with diabetes and women during
pregnancy (Diabetes Care, Volume 31, Supplement
1, January 2008)
 Recommendation - ADA
Sugar alcohols and nonnutritive sweeteners
are safe when consumed within the daily
intake levels established by the Food and Drug
Administration (FDA). (A)

Nutrition Recommendations and Interventions for Diabetes. Position Statement

of American Diabetes Association. DIABETES CARE, VOLUME 31, SUPPLEMENT
1, JANUARY 2008
Classified as GRAS
 Generally Recognized As Safe
(GRAS)
For a GRAS substance, generally available data
and information about the use of the
substance are known and accepted widely by
qualified experts, and there is a basis to
conclude that there is consensus among
qualified experts that those data and
information establish that the substance is
safe under the conditions of its intended use.
1958 Food Additives Amendment to the Federal Food, Drug, and Cosmetic Act.
US FDA
 Alternative Sweeteners
Nutritive
Natural Sugar alcohol (1.5 kcal-3 kcal/gram)
2 kcal/grams
Date sugar Erythritol
Grape juice concentrate Hydrogenated starch hydrolysates
Honey Isomalt
Maple sugar Lactitol
Maple syrup Maltitol
Molasses Mannitol
Agave nectar Sorbitol
Xylitol
Stevia preparations that are highly
refined (Pure Via, Truvia)
 How much do I have to consume?

Carbohydrates

Complex Simple

Polysaccharides Disaccharides Monosaccharide

 2004 Recommendation: Carbohydrates
ADA- American Diabetes Association
CDA- Canadian Diabetes Association
NCEP National Cholesterol Education Program
50-60% Carbohydrates

EASD- European Association for the Study of Diabetes

45-60% Cholesterol

BDA- British Diabetic Association AHA- American Heart Association

50-55% Carbohydrates 45-55%

India Japan S. Africa

>65% Carbohydrates 60% Carbohydrates 55-60% Carbohydrates

James W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.
Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the
Evidence Journal of the American College of Nutrition, Vol. 23, No. 1, 517 (2004).
 Carbohydrate intake should be
lower than the recommended
intake?
RDA:130 g/day (Institute of Medicine: Dietary Reference Intakes:
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino
Acids. Washington, DC, National Academies Press, 2002)

No trials specifically in patients with

diabetes restricting total carbohydrate to
130 g/day
Carbohydrate are important sources of
energy, fiber, vitamins, and minerals and are
important in dietary palatability
sucrose lactose maltose

fructose galactose glucose

glucose glucose glucose

 2004 Recommendation:
Monosaccharide and Disaccharides
ADA- American Diabetes Association
No restriction
BDA- British Diabetic Association Japan India
<25g /day 1 serving of fruit From food

CDA- Canadian Diabetes Association

South Africa
10% added

EASD European Association for the Study of Diabetes

< 10% calories

AHA American Heart Association

NCEP National Cholesterol Education Program
No comment
James W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.
Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the
Evidence Journal of the American College of Nutrition, Vol. 23, No. 1, 517 (2004).
 Carbohydrate in diabetes
management
Sucrose-containing foods can be substituted for
other carbohydrates in the meal plan or, if
added to the meal plan, covered with insulin
or other glucose lowering medications. Care
should be taken to avoid excess energy intake.
(A)

Nutrition Recommendations and Interventions for Diabetes. Position

Statement of American Diabetes Association. DIABETES CARE, VOLUME
31, SUPPLEMENT 1, JANUARY 2008
 Carbohydrate in diabetes
management
Dietary sucrose does not increase glycemia
more than isocaloric amounts of starch
Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B,
Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence- based nutrition principles
and recommendations for the treatment and prevention of diabetes and related
complications. Diabetes Care 25:148 198, 2002

Intake of sucrose and sucrose containing foods

by people with diabetes does not need to be
restricted because of concern about
aggravating hyperglycemia.
 Recommendations added sugar
American Heart Association Dietary Guidelines for Americans
(1) (2)
Males: 9 teaspoon Drink water instead of regular soda,
Females: 6 teaspoon "vitamin-type" water, sports drinks,
coffee drinks, and energy drinks.

Eat less candy; dairy-based desserts

such as ice cream; and grain-based
desserts such as cookies, cakes, and
pies.

1. Johnson RJ, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, et al. Dietary Sugars Intake and Cardiovascular Health: A Scientific
Statement from the American Heart Association. Circulation. 2009;120:1011-1020.
2. United States Department of Agriculture. Center for Nutrition Policy and Promotion. Dietary Guidelines for Americans. 2010. National Academy
Press, Washington, DC, 2010.
FNRI Recommendation for Filipinos
Age group Sugar and sweets
(in teaspoons)
1-6 4-5
7-12 5-6
Teens 5-6
Adults 5-8
Elderly 5-6
Pregnant 6
Lactating 6
http://www.fnri.dost.gov.ph/index.php?option=content&task=view&id=1275
 Comparison of Mean One Day per
Capita Sugar/ Syrup consumption
Sugar consumption grams/day

year
Facts and Figure 2001, 2003, 2005. FNRI
 1 sugar exchange = 5 g CHO
20 Kcal
1 pc banana chip
1 tsp table sugar
(white, brown, pure 1 pc hard candy, sampaloc
cane, syrup) candy, toffee candy,
caramel candy, chewing
1 tsp honey
gum, bubble gum,
1 tsp panutsa marshmallow
1 tsp matamis na bao 2 tbsp nata de coco
1 pc bukayo 1 pc pastillas (durian, gatas,
2 tsp condensed milk langka)
2 tsp jam, jellies, cup taho with syrup and
preserves sago
1 tsp ube halaya
Food Exchange List , FNRI 1 pc yema
 Type of carbohydrate contributes
more in post prandial glucose than
the total amount of carbohydrates

Primary determinant of post

prandial response: amount of
carbohydrate ingested
 Types of sugar
Sucrose
Dietary sucrose does not increase glycemia more than
isocaloric amounts of starch (Diabetes Care 25:148 198, 2002)

Fructose
Fructose produces a lower postprandial glucose
response when it replaces sucrose or starch but fructose
may adversely affect plasma lipids (Diabetes Care 25:148 198,
2002)
Intakes above 25% of total energy consumed will cause
hypertriglyceridemia and gastrointestinal symptoms
(Position of the American Dietetic Association: use of nutritive and nonnutritive
sweeteners. J Am Diet Assoc 2004, 104:255-275.)
Fructose Metabolism
 Types of sugar
Sugar alcohol
no evidence that the amounts of sugar alcohols likely to be
consumed will reduce glycemia,energy intake, or weight (Diabetes
Care, Volume 31, Supplement 1, January 2008)
greater than 50 grams/day of sorbitol or greater than 20
grams/day of mannitol may cause diarrhea (American Dietetic
Association)

Resistant starch (high amylose)

no published long-term studies in subjects with
diabetes to prove benefit from the use of resistant
starch (Diabetes Care, Volume 31, Supplement 1, January 2008)
 Other Variables influencing effect of CHO-containing
food on blood glucose response

Specific type of food Fasting or preprandial

ingested blood glucose level
Type of starch (amylose Macronutrient
versus amylopectin) distribution of the meal
style of preparation in which the food is
(cooking method and consumed
time, amount of heat or Available insulin
moisture used) Degree of insulin
Ripeness resistance.
Degree of processing
Intrinsic variables Extrinsic variables
 Eat only food with low
glycemic index?
lowglycemic index diet trials in diabetic subjects
showed that such diets produced a 0.4%
decrement in A1C when compared with high
glycemic index diets (Brand-Miller J, Hayne S, Petocz P, Colagiuri S: Low-
glycemic index diets in the management of diabetes: a meta-analysis of randomized
controlled trials. Diabetes Care 26:22612267, 2003)

A low-GI diet can improve glycemic control

in diabetes without compromising
hypoglycaemic events (Thomas D, Elliott EJ. Low glycaemic index,
or low glycaemic load, diets for diabetes mellitus. Cochrane Database of Systematic
Reviews 2009, Issue 1. Art. No.: CD006296.DOI:10.1002/14651858. CD006296.pub2)
 2004 Recommendation: Glycemic Index

CDA- Canadian Diabetes Association

EASD European Association for the Study of Diabetes
Japan
Recommended to be included in meals

ADA- American Diabetes Association

Not recommended for general use
BDA- British Diabetic Association India
Discusses Quotes references

AHA American Heart Association

NCEP National Cholesterol Education Program
No comment
James W. Anderson, MD, FACN, Kim M. Randles, Cyril W. C. Kendall, PhD, FACN, and David J. A. Jenkins, MD, PhD, DSc, FACN.
Carbohydrate and Fiber Recommendations for Individuals with Diabetes: A Quantitative Assessment and Meta-Analysis of the
Evidence Journal of the American College of Nutrition, Vol. 23, No. 1, 517 (2004).
 ADA recommendation (2011)
Use of the glycemic index and glycemic load
may provide a modest additional benefit for
glycemic control over that observed when
total carbohydrate is considered alone. (B)

DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011

 High glycemic Index 70
Watermelon Cheerios
Dried dates Bagel, white
Physical form Cooking
Instant mashed potatoes Soda crackers
Soluble fiber Baked white potato Jellybeans method/ time
Fat &Protein Parsnips French fries Ripeness
content Rutabaga Ice cream Temperature
Instant rice Digestive cookies
Acidity Corn Flakes Table sugar (sucrose) Alkalinity
Amylose Rice Krispies Amylopectin
Medium glycemic Index 56-69
Banana Brown rice
Pineapple Couscous
Raisins Basmati rice
New potatoes Shredded wheat cereal
Popcorn Whole wheat bread
Split pea or green pea soup Rye bread
Low glycemic Index 55
Skim milk All-Bran
Plain Yogurt Converted or Parboiled rice
Soy beverage Pumpernickel bread
Apple/plum/orange Al dente (firm) pasta
Sweet potato Lentils/kidney/baked beans
Oat bran bread Chick peas
Oatmeal (slow cook oats)
 GI and GL values coconut sugar
Coconut Serving size Available Glycemic Glycemic
product CHO (g) Index Load (GL)
(GI)
Coconut sap bottle, 12 68 (medium) 9 (low)
80 grams
Coconut sap 2 tsp, 7 35 (low) 2 (low)
sugar 1 7 grams
Coconut sap 2 tsp, 6 42 (low) 2 (low)
sugar 2 7 grams
Coconut sap 2 tsp, 5 39 (low) 2 (low)
syrup 2 7 grams
Coconut 250 ml 12 45 (low) 6 (low)
water

Glycemic index of commonly consumed carbohydrates foods in the Philippines FNRI 2011
What is wrong with this?
 How Much is Too Much?

and in the context of a healthy diet

 In summary....
How Much is Too Much?
Thank you for your kind
attention!