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4.5 Diabetes in Canada
Diabetes is a growing healthcare problem in Canada. More than 2.4 million Canadians are currently estimated to
have diabetes and this number is expected to increase to three million by 2010.12 It is estimated that by 2010,
diabetes will cost the Canadian healthcare system $15.6 billion a year and that number will rise to $19.2 billion by
2020.13 Funding for programs focused on the prevention and treatment of diabetes is a priority for federal and
provincial governments. Aboriginal populations in Canada have three to five times greater risk for developing
diabetes than the general population. Information for the Aboriginal Diabetes Initiative for First Nations, Inuit and
diabetes.
As noted in Section 2.2 of the Canadian Information in this Instructor’s Manual, the CDA has published Beyond the
Basics: Meal Planning for Healthy Eating, Diabetes Prevention and Management to help Canadians manage their
4.6 Diet, Sugar Alcohols, and Dental Caries in Canada
The following diet-related health claims are permitted for use on labels of foods containing sugar alcohols:15
• Won’t cause cavities.
• Does not promote tooth decay.
• Does not promote dental caries.
• Non-cariogenic.
In accordance with the Food and Drug Regulations, use of the term “toothfriendly” is not permitted in diet-related
health claims.
In 2004, Health Canada approved Erythritol, a sugar alcohol similar to Xylitol for use in food items such as dietetic
beverages, cookies and wafers, soft and hard candies, and chewing gums.16 Artificial sweeteners are considered food
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Highlight 4: Carbs, kCalories, and Controversies
Eating Well with Canada’s Food Guide recommends Canadians consume plenty of vegetables and fruit and grain
products each day, as well as legumes often—all carbohydrate-rich foods.
Data from the 2004 CCHS show the obesity rate in Canadian adults increased substantially during the previous 25
years. The last survey of a nationally representative sample of measured height and weight data of Canadian adults,
the 1978/79 Canada Health Survey, showed the age-adjusted obesity rate for adults was 14%, far below the rate of
23% found in the 2004 CCHS. The increase was evident in each of the three obesity categories, especially Class II
and Class III. The proportion of adults in Class II went from 2.3% to 5.1% and in Class III, from 0.9% to 2.7%.17
Sweeteners used as ingredients in foods must be listed by their common names as outlined in Annex 2-2 of the
Guide to Food Labelling and Advertising.20 For example, the term “sugar” is the common name for sugar, liquid
sugar, invert sugar, or liquid invert sugar; the term “glucose–fructose” is the common name for glucose syrups
containing less than 60% fructose, such as high–fructose corn syrup; and, the term “fructose syrup” is the common
name for glucose syrups containing more than 60% fructose.
Canadian Web-Based Resources
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Worksheet 4-1: Hidden Sugars—What Is Your Sugar IQ?
For each of the following food items, indicate the relative sugar (carbohydrate) content, amount of kcalories that are
provided, and whether or not you consider the item to be a significant source of sugar in your diet (circle “Yes” or
“No”). Use the Food Composition Table in the back of your textbook.
Food item
Relative sugar content
Amount of kcal
Significant source of
sugar in your diet?
12-oz. cola/soda
Yes No
7 Triscuits
Yes No
Apple cinnamon Power
Bar
Yes No
1 cup Heartland Natural
with raisins cereal
Yes No
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Worksheet 4-2: Glycemic Index and Glycemic Load
Glycemic Index
Factors
Glycemic Load
A method of classifying foods according to
their potential for raising blood glucose as
determined by the rate of their absorption.
Definition
A method of using the glycemic index as the
basis for understanding the inter-related effects
of glucose and insulin.
Calculated value in response to the ingestion of
a specific food product that indicates the
relative increase in blood glucose levels that is
Calculation
Calculated value using the glycemic index
multiplied by the amount of carbohydrates
ingested per serving to arrive at a numerical
For the following foods, please calculate the glycemic load (GL) and indicate whether it is low or high.
Glycemic Load (GL) = Glycemic Index (GI) of food/100 x Net carbs (# of grams of CHO per serving)
Food
GI
Net Carbs
GL
GI Level
Apple (1 med.)
38
16
Watermelon (1 c.)
72
11
White rice (1 c.)
64
52
Sugar (1 Tbsp.)
68
12
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Worksheet 4-3: Check Your Carbohydrate Choices
Most of the energy we receive from foods comes from carbohydrates. Healthy choices provide complex
carbohydrates or naturally occurring simple carbohydrates, rich in water-soluble vitamins and dietary fiber. A diet
that is consistently low in dietary fiber and high in added sugar can lead to health problems. Look at these examples
of related foods and identify which are most similar to your food choices.
Intermediate
Low in fiber/
high in added sugar
Applesauce, sweetened
Fruit drink, 10% apple juice
1. Do you select whole-grain products and fresh fruits and vegetables regularly?
Pumpernickel bread
Bagel, plain
Danish pastry
Corn on the cob
Creamed corn
Frosted corn flakes
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Worksheet 4-4: Chapter 4 Crossword Puzzle
Across
Down
2. an older name for glucose
7. the monosaccharides important in nutrition; they
have the formula C6H12O6
8. an animal polysaccharide composed of glucose; it is
1. a monosaccharide; sometimes known as fruit sugar
or levulose
3. a monosaccharide; sometimes known as blood sugar
or dextrose
1
2
4
3
5
6 7
8
9
10
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Worksheet 4-5: Carbohydrate Basics (Internet Exercise)
On the website, click on Carbohydrates to answer questions 1 through 3.
1. “Bad carbs” and “good carbs” are terms that are used in the Dietary Guidelines for Americans 2005.
2. An example of insoluble fiber is oatmeal.
3. Match the term with the best explanation.
a. Complex carbohydrate
b. Simple carbohydrate
c. Added sugar
4. Which of the following are considered to be basic building block elements of carbohydrates?
a. Carbon, hydrogen, and oxygen
b. Glucose, dextrose, and sucrose
c. Carbon, hydrogen, and nitrogen
d. Carbon and oxygen
5. Fructose has a strong effect on blood sugar.
6. Inclusion of whole grains in one’s dietary pattern will lead to improved health.
a. True
b. False
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Handout 4-1: Alternatives to Sugar
Almost everyone finds pleasure in sweet foods—after all, the taste preference for sweets is inborn. To a child, the
sweeter the food, the better. In adults, this preference is somewhat diminished, but most adults still enjoy an
occasional sweet food or beverage. Because they want to control weight gain, blood glucose, and dental caries,
many consumers turn to alternative sweeteners to help them limit kcalories and minimize sugar intake. In doing so,
they encounter two sets of alternative sweeteners: artificial sweeteners and sugar replacers.
Artificial Sweeteners
The Food and Drug Administration (FDA) has approved the use of several artificial sweeteners—saccharin,
aspartame, acesulfame potassium (acesulfame-K), sucralose, and neotame. Two others are awaiting FDA
approval—alitame and cyclamate. Another—tagatose—did not need approval because it is generally recognized as a
safe ingredient. These artificial sweeteners are sometimes called nonnutritive sweeteners because they provide
virtually no energy. Table 1 provides general details about each of these sweeteners.
Table 1: Sweeteners
Sweeteners
Relative
Sweetness a
Energy
(kcal/g)
Acceptable
Daily
Intake
Average Amount
to Replace 1 tsp
Sugar
Approved Uses
potassium or
Acesulfame-K
(Sunette, Sweet
One, Sweet ‘n
Safe)
body
weight d
gelatins, chewing gum, candies,
baked goods, desserts,
beverages
Sucralose
General purpose sweetener for
jams and jellies, syrups
confections, dairy products,
dietary supplements, health
bars, tabletop sweetener
Sweeteners with Approval Pending
Proposed Uses
Alitame
2000
4 e
—
Beverages, baked goods,
tabletop sweeteners, frozen
desserts
Cyclamate
30
0
—
Tabletop sweeteners, baked
goods
Approved Sweeteners
range of foods, beverages,
cosmetics, and pharmaceutical
products
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a Relative sweetness is determined by comparing the approximate sweetness of a sugar substitute with the sweetness of pure
sucrose, which has been defined as 1.0. Chemical structure, temperature, acidity, and other flavors of the foods in which the
substance occurs all influence relative sweetness.
Some consumers have challenged the safety of using artificial sweeteners. Considering that all substances are toxic
at some dose, it is little surprise that large doses of artificial sweeteners (or their components or metabolic by–
products) have toxic effects. The question to ask is whether their ingestion is safe for human beings in quantities
people normally use (and potentially abuse).
Saccharin
Saccharin, used for over 100 years in the United States, is currently used by some 50 million people—primarily in
soft drinks, secondarily as a tabletop sweetener. Saccharin is rapidly excreted in the urine and does not accumulate
in the body.
Aspartame
Aspartame is a simple chemical compound made of components common to many foods: two amino acids
(phenylalanine and aspartic acid) and a methyl group (CH3). Figure 1 shows its chemical structure. The flavors of
the components give no clue to the combined effect; one of them tastes bitter, and the other is tasteless, but the
combination creates a product that is 200 times sweeter than sucrose.
Figure 1: Structure of Aspartame
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Because this sweetener contributes phenylalanine, products containing aspartame must bear a warning label for
people with the inherited disease phenylketonuria (PKU). People with PKU are unable to dispose of any excess
phenylalanine. The accumulation of phenylalanine and its by-products is toxic to the developing nervous system,
causing irreversible brain damage. For this reason, all newborns in the United States are screened for PKU. The
treatment for PKU is a special diet that must strike a balance, providing enough phenylalanine to support normal
growth and health but not enough to cause harm. The little extra phenylalanine from aspartame poses only a small
risk, even in heavy users, but children with PKU need to get all their required phenylalanine from foods instead of
from an artificial sweetener. The PKU diet excludes such protein– and nutrient-rich foods as milk, meat, fish,
poultry, cheese, eggs, nuts, legumes, and many bread products. Consequently, these children have difficulty
obtaining the many essential nutrients—such as calcium, iron, and the B vitamins—found along with phenylalanine
in these foods. Children with PKU cannot afford to squander their limited phenylalanine allowance on the
phenylalanine of aspartame, which contributes none of the associated vitamins or minerals essential for good health
and normal growth.
Figure 2: Metabolism of Aspartame
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decrease their threshold for seizures; this does not appear to be a problem when intakes are within recommended
amounts.
Acesulfame-K
Because acesulfame potassium (acesulfame-K) passes through the body unchanged, it does not provide any energy
nor does it increase the intake of potassium. Acesulfame–K is approved for use in the United States, Canada, and
more than 60 other countries.
Sucralose
Sucralose was introduced only a decade or so ago, but it now leads in annual sales, with over 60 percent of the
Neotame
Like aspartame, neotame also contains the amino acids phenylalanine and aspartic acid and a methyl group. Unlike
aspartame, however, neotame has an additional side group attached. This simple difference makes all the difference
to people with PKU because it blocks the digestive enzymes that normally separate phenylalanine and aspartic acid.
Consequently, the amino acids are not absorbed and neotame need not carry a warning for people with PKU.
Tagatose
The FDA granted the fructose relative tagatose the status of “generally recognized as safe,” making it available as a
low-kcalorie sweetener for a variety of foods and beverages. This monosaccharide is naturally found in only a few
Alitame and Cyclamate
FDA approval for alitame and cyclamate is still pending. To date, no safety issues have been raised for alitame, and
it has been approved for use in other countries. In contrast, cyclamate has been battling safety issues for 50 years.
Approved by the FDA in 1949, cyclamate was banned in 1969 principally on the basis of one study indicating that it
caused bladder cancer in rats.
Acceptable Daily Intake
The amount of artificial sweetener considered safe for daily use is called the Acceptable Daily Intake (ADI). The
ADI represents the level of consumption that, if maintained every day throughout a person’s life, would still be
considered safe by a wide margin. It usually reflects an amount 100 times less than the level at which no observed
effects occur in animal research studies.
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Table 2: Average Aspartame Contents of Selected Foods
Food
Aspartame (mg)
12 oz diet soft drink
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Artificial Sweeteners and Weight Control
The rate of obesity in the United States has been rising for decades. Foods and beverages sweetened with artificial
sweeteners were among the first products developed to help people control their weight. Using intense sweeteners,
such as aspartame, instead of sugar lowers the energy density of foods and beverages. Most studies find no
difference in hunger and no compensation in food intakes when diet soft drinks replace regular ones.4 In this way,
people who eat or drink artificially sweetened products can lower their energy intakes and expect modest weight
losses.5
explains).
Stevia—An Herbal Alternative
The FDA has backed its approval or denial of artificial sweeteners with decades of extensive research. Such research
is lacking for the herb stevia, a shrub whose leaves have long been used by the people of South America to sweeten
their beverages. In the United States, stevia is sold in health-food stores as a dietary supplement. The FDA has
Sugar Replacers
Some “sugar–free” or reduced-kcalorie products contain sugar replacers.6 The term sugar replacers describes the
sugar alcohols or polyols—familiar examples include erythritol, mannitol, sorbitol, xylitol, maltitol, isomalt, and
lactitol—that provide bulk and sweetness in cookies, hard candies, sugarless gums, jams, and jellies. These products
8 oz powdered drink
100
8 oz sugar-free fruit yogurt
124
4 oz gelatin dessert
1 packet sweetener
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Table 3: Sugar Replacers
Sugar Alcohols
Relative Sweetness
Energy (kcal/g)
Approved Uses
Erythritol
0.7
0.4
Beverages, frozen dairy desserts, baked goods,
chewing gum, candies
Isomalt
0.5
2.0
Candies, chewing gum, ice cream, jams and
jellies, frostings, beverages, baked goods
health products
Sugar alcohols evoke a low glycemic response. The body absorbs sugar alcohols slowly; consequently, they are
slower to enter the bloodstream than other sugars. Common side effects include intestinal gas, abdominal
discomfort, and diarrhea. For this reason, regulations require food labels to state “Excess consumption may have a
laxative effect” if reasonable consumption of that food could result in the daily ingestion of 50 grams of a sugar
alcohol.
Figure 3: Sugar Alternatives on Food Labels
For persons choosing to use artificial sweeteners, the American Dietetic Association wisely advises that they be used
in moderation and only as part of a well-balanced nutritious diet. The dietary principles of moderation and variety
help to reduce the possible risks associated with any food. The sugar replacers, like the artificial sweeteners, can
occupy a place in the diet, and provided they are used in moderation, they will do no harm. In fact, they can help, by
providing an alternative to sugar for people with diabetes, by inhibiting caries–causing bacteria, and by limiting
energy intake. People may find it appropriate to use all three sweeteners at times: artificial sweeteners, sugar
replacers, and sugar itself.
References
1. M. Soffritti and coauthors, Aspartame induces lymphomas and leukaemias in rats, European Journal of
Oncology 10 (2005): 107-116.
Lactitol
0.4
2.0
Candies, chewing gum, frozen dairy desserts,
jams and jellies, frostings, baked goods
Maltitol
Particularly good for candy coating
Mannitol
Bulking agent, chewing gum
Sorbitol
Special dietary foods, candies, gums
Xylitol
1.0
2.4
Chewing gum, candies, pharmaceutical and oral
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4. F. Bellisle and A. Drewnowski, Intense sweeteners, energy intake and the control of body weight, European
Journal of Clinical Nutrition 61 (2007): 691–700; P. Monsivais, M. M. Perrigue, and A. Drewnowski, Sugars
and satiety: Does the type of sweetener make a difference? American Journal of Clinical Nutrition 86 (2007):
116–123.