According to the Centers for Disease Control, more than 30 million Americans — nearly 10% of the entire population — are living with diabetes, and perhaps as many as 85 million more are living with prediabetes. Those diagnosed as prediabetic have a strong likelihood of being diagnosed with type 2 diabetes within five years if the condition is not managed.

In addition, it is estimated that more than 7 million people have diabetes but have not been diagnosed with the disease. Diabetes is a risk factor for, and one of the leading causes of, cardiovascular, nerve, and kidney diseases, as well as vision loss and amputations.

When discussing diabetes and nutrition, the 95% or so of diabetics who have type 2 of the disease are the typical targets, as those with type 1 diabetes manage their disease medically. Dietary intervention remains a primary management tool for controlling blood sugar for most persons with diabetes, and it’s the first line of attack for managing blood sugar for prediabetics. And one of the first steps in dietary intervention for these conditions is limiting sugar intake.

Weight management, too, is the unavoidable pathway to effective and permanent blood sugar control for many, as 85% of persons with diabetes are overweight (and a third of people who are overweight have diabetes). But today’s consumer has a far more sophisticated palate than ever before, with global input and a never-ending stream of influences and flavor attractions. Formulators of foods and beverages serving those in need of blood sugar management must bring their “A” game.

Sweet News

While developers of foods and drinks for diabetics must keep flavor and authenticity foremost, the need to reduce sugar and total calories remains at the center of crafting products targeting diabetes management. In that respect, ingredient technology has opened the door to many opportunities.

Top of the list for blood sugar management products has traditionally belonged to glucose and sucrose replacers, especially zero-calorie sweeteners. Although the debate continues as to whether such high-intensity sweeteners (HIS) can help lower the risk of increased blood sugar, have no effect on blood sugar, or actually raise the risk of increased blood sugar, the fact remains that when dealing with a disease defined by an inability to properly metabolize glucose, sugar must be replaced. Since HIS options provide virtually no calories, they are powerful tools for the formulator.

The controversy about HIS has to do with satiety cues. Studies are mixed, with some indicating that this sort of “fooling” the body into thinking it has had sugar can act as a cue to help increase satiety. Other studies suggest the possibility that by stimulating the body into thinking it has had calories that never come could trigger a stronger demand for compensatory energy input. It has even been suggested that HIS can inadvertently train the palate to disfavor or avoid better options such as water or other unsweetened beverages over diet soda or other sweetened beverages.

One relatively new glucose/sucrose substitute that’s showing impressive promise is allulose. A naturally occurring type of sugar molecule, allulose is about 70% as sweet as table sugar (sucrose), with a flavor that is identical to fructose. Yet, because of its chemical structure, the body does not metabolize about 90-95% of it, translating to just 0.2-0.4 kcals/g vs. sucrose’s 4.0 kcals/g. Even better, allulose’s performance in food and beverage applications also is like that of sucrose, including its bulking, browning (via the Maillard reaction), foaming, and freeze-point lowering properties.

Multiple studies have revealed that allulose will not impact blood glucose levels and can even dampen the glycemic response to other carbohydrates. Results from a study published last year in the journal Diabetes, Obesity & Metabolism demonstrated that 10g of allulose helped lower blood sugar following a glucose tolerance test in which subjects ingested 75g glucose with the allulose.

Last spring, the FDA permitted allulose to be used as a low-calorie sweetener and excluded from total and added sugars counts on Nutrition and Supplement Facts labels, thus allowing formulators to take advantage of allulose’s clean, sucrose-like sweetness in beverages, bakery items, confections, and dairy products. At a price point similar to erythritol and other polyols, allulose is poised to solve multiple challenges — with greater success than other sweeteners, too.

Fruit Help

Other sweeteners increasingly applied to foods and beverages for people with diabetes have a proven track record going back decades. Using the natural sweetness of fruits, as juices, concentrates, and purées, while old school, has distinct advantages. Common contenders include raisins, prunes, dates, figs, and apples. But other fruits, vegetables, and roots are being pressed into service as well.

Yacon (Smallanthus sonchifolius), a perennial plant native to parts of South America, is a recent example and adds advantages beyond its natural sweetness when it comes to helping out in diabetes formulations. The tuber is versatile; it has traditionally been eaten raw, cooked, or juiced. Furthermore, it often is made into syrup or powder to use as a sugar substitute. Yacon’s appeal for diabetes products is that it has a high fructo-oligosaccharide (FOS) content.

Fructo-oligosacharides are indigestible, linear fructose short-chain fibers and do not stimulate a glycemic response. They are naturally synthesized from sucrose in the cell vacuoles of the plant’s leaves, stems, and roots, and they promote the growth of healthy gut bacteria. The high content of FOS in yacon root offers numerous health benefits. According to a 2016 study published by the National Institutes of Health (NIH), those benefits include “regulating glucose homeostasis.”

The NIH study indicates that yacon root consumed as a dietary supplement could help reduce the risk of and even be used in the treatment of a number of chronic conditions, including obesity and high blood cholesterol. Yacon has been referred to as a “superfood for diabetics.”

Diet du Jour

Often, popular diets are connected to blood sugar balance. And, of course, the goal behind most diets is weight loss. Although the FDA still has not ruled on a formal definition of “low carb,” the American Diabetes Association supports a “low-carb diet” in its “Standards of Medical Care in Diabetes — 2019.” Yet, even that group does not define the amount or percentage of carbs in the diet to support their definition of “low carb.” The organization largely supports a more moderate carbohydrate diet (44-46% calories from carbs), based on studies that support this range as being the most typical of the diabetic patients studied.

While pushed and promoted for all, some of today’s popular low-carb diets are better suited for diabetes mitigation even in cases where they would be less effective for healthy persons. The so-called “keto” diet, in its moderate form, is a good example. All ketogenic diets are much higher, proportionately, in fat and protein than carbohydrate.

The classic ketogenic diet was a severe one, developed in the 1920s to treat epilepsy. It derived 90% of its calories from fat. Less extreme but still nutritionally problematic was the original version of the highly popular Atkins “high protein” diet of the 1970s. It glamorized eating unlimited amounts of fatty meat, eggs, and butter, while demonizing carbs in general. The hallmarks of even the not so extreme keto-style diets of recent years are the emphasis on fat and protein and the positioning of calories from processed carbohydrate as to be largely avoided.

Products promoted in today’s keto plans range from lean meat jerky to coconut-based everything. Bhu Foods Corp. claims its refrigerated keto bars are “high in fiber and healthy fats and low in carbs and sugar to help people manage their weight.” Bhu is a Sanskrit word that means “of the earth.” The company’s mission is to “create superfood alternatives to sugary snacks at prices that are affordable for everyone.”

Bhu’s line of five cookie dough-flavored keto bars features ingredients such as organic nuts and palm oil and is sweetened with monkfruit. The bars derive about 73% of their calories from fat and have less than 15g carbohydrate per serving. Although the product line is not targeted toward diabetics, it is recognized that many persons with diabetes seek diets and products that are “low carb,” which includes the keto diet.

Dried fruits and syrups from dried fruits, such as from raisins, figs, dates, and berries, not only provide slowly metabolized sweeteners but lots of beneficial fiber.
PHOTO COURTESY OF: Sun-Maid Growers of California (www.sunmaid.com)

Cave Carbo

The so-called “paleo” diet is purported to be the ketogenic diet of our hunter-gatherer ancestors. Although the principles of paleo are similar to other diets that promote maintaining the body in a state of ketosis, the paleo regimen is largely free of dairy, grains, and legumes. Virgin or unrefined coconut oil is allowed and often featured in paleo recipes and product formulations.

Results of clinical trials reported by the Mayo Clinic suggest paleo might provide some benefits over traditional diabetic or Mediterranean diets. The diet purportedly leads to greater weight loss, improved glucose tolerance, mitigation of high blood pressure, better appetite management, and reduced serum triglycerides. However, eliminating food groups also eliminates the micronutrients in those foods and could lead to nutrient deficiencies long term. 

One of the benefits of the paleo diet is the inclusion of a variety of nuts, seeds, and dried fruit. Fruit sweeteners such as pineapple syrup and clarified pineapple juice concentrate also are promoted.

NuGo Nutrition, Inc., has marketed a popular line of high-protein nutrition bars for more than 10 years, touting “only clean, high quality ingredients.” The company includes Sugar Free Peanut Butter Crunch and Chocolate Black Cherry bars under its “Smarte Carb” category. Both offerings are presented as a “delicious choice for low carb and diabetic diets” and are sweetened with maltitol and sucralose.

Although NuGo Nutrition buckets these two flavors for diabetic appeal, its NuGo Slim bars, including Brownie Crunch, Roasted Peanut, and Raspberry Truffle varieties, also are low in sugar — that sugar residing primarily in the dark chocolate coating.

A wealth of research supports that following a Mediterranean diet can help reduce the risk for diabetes for those who are also at high risk for heart disease. The traditional Mediterranean diet is a largely plant-based diet that emphasizes extra virgin olive oil and nuts as the primary sources of fat calories. It also is rich in fruits and vegetables, whole grains, and legumes. Fish and other seafood are consumed more frequently than other sources of animal protein.

As the Mediterranean region itself becomes more westernized, the term “Mediterranean-style diet” is used to emphasize the healthiest components of the traditional diet. Although not specifically marketed as diabetic friendly, frozen meals such as Kraft-Heinz Co.’s SmartMade and Smart Ones lines are aligned with the renewed interest in Mediterranean cuisine.

The SmartMade Mediterranean-Style Chicken Bowl, for example, features chickpeas, kale, sundried tomato, and quinoa. All these ingredients have been studied for beneficial effects in blood sugar and weight management.

BistroMD Co., founded by physician Caroline Cederquist, MD, has a frozen meal delivery program called Silver Cuisine that serves seniors and their caregivers. The line includes more than 100 different meals that are advertised as “diabetic friendly.” All the company’s meals are chef-prepared with fresh ingredients. The meals are frozen and shipped in environmentally friendly insulated coolers.

Most of the company’s diabetic meals contain at most 25g of carbohydrates. The company also takes some of its cues from the Mediterranean diet, with offerings such as Roasted Cauliflower and Lentils with Charred Red Pepper Sauce and Pork Tenderloin with Olive Tapenade. In addition, it offers a sugar-free Berry Blast Shake that has only 70 calories and includes hydrolyzed gelatin, whey protein concentrate, and sucralose.

Vitamin D(iabetes)

Certain vitamins and minerals have been receiving greater focus of late in relation to blood sugar management effects. All potential positive health outcomes, ranging from well-established bone mineralization to other possible indicators of health status, including glycemic control and reduced risk of hypertension and certain types of cancer, are among the wealth of benefits vitamin D has gained attention for in recent years.

A randomized clinical trial published in 2014 demonstrated that vitamin D supplementation not only lowered blood glucose levels, but also increased insulin sensitivity. In 2010, results were released of an 11-year cohort follow-up to a 1994 study that supported the positive effects of vitamin D on diabetes-related conditions. The benefits included helping to decrease incidence of diabetic retinopathy and peripheral neuropathy in patients previously diagnosed with type 2 diabetes.

Numerous studies concur that vitamin D supplementation can improve insulin resistance, at least in the short term, for persons with type 2 diabetes. Other studies, while still preliminary and not yet considered strong enough evidence to provide full agreement, suggest a possible correlation between vitamin D intake and prevention of diabetes.

Serum 25-hydroxycholecalciferol levels [25 (OH) D] serve as a biomarker for vitamin D exposure, inclusive of the sun, dietary intake, and supplementation. The Endocrine Society states that a minimum serum concentration of 25 (OH) D at 75 nmol/L or 30 ng/mL is desirable for maximum effect of the vitamin on calcium, bone, and muscle metabolism. This translates, approximately, to a general dietary guideline of at least 1,500-2,000 IU (37.5-50 µg) per day for adults.

Vitamin D2 (ergocalciferol) and D3 (cholecalciferol) are the two most chemically similar and bioavailable forms of the vitamin used for supplements and fortification. Changes to FDA labeling in 2016 stipulated that vitamin D values must be added to the Nutrition Facts panels of retail foods. Food manufacturers with more than $10 million in sales must comply by 2020, and smaller manufacturers by 2021. (Foods and beverages currently fortified with vitamin D already declare those values.)

Vitamin D is fairly limited in the food supply, available for most diets primarily via cold-water fatty fish, such as mackerel, tuna, and salmon, egg yolks, and milk-based products. Certain strains of yeast are a source of the vitamin, and mushrooms, too, especially those treated with ultraviolet light. In fact, UV-treated mushrooms can yield 400 IU (10µg) of D per 100g. Milk analog beverages, such as those from nuts, seeds, grains, and soy and other legumes, typically are fortified with vitamin D2, often from yeast.

For product makers targeting persons with diabetes in the vegan/vegetarian community, several options exist for natural vitamin D sources. Blue Diamond Growers’ Unsweetened Original Almond Milk contains more vitamin D per cup (25% DV, based on a DV of 20µg) than many fluid dairy milks, which often are voluntarily fortified within a range of 10% -25% DV.

Danone North America's So Delicious brand of non-dairy coconut-based yogurt is fortified with 25% DV vitamin D per 5.3oz cup. Note that the DV of 20 mcg for mandatory vitamin D labeling will replace the previous 400 IU voluntary labeling guideline. Fortified foods are always required to disclose proof of fortification. All dairy products and their non-dairy replacements, including yogurts, butters, and edible oils, can increasingly provide logical avenues for vitamin D fortification for the future.

The Optics on Fiber

In addition to their vitamin D content, mushrooms are a natural source of a number of types of healthy polysaccharides, including beta-glucans. A study published last April demonstrated that natural polysaccharides, including beta-glucans from certain types of mushrooms, can improve insulin sensitivity and lipid metabolism.

In fact, significant research is lending support to the potential for beta-glucans to treat diabetes and reduce risk for associated complications, including hyperglycemia, hypertension, and hyperlipidemia. 

These conditions also are root causes of cardiovascular disease. Beta-glucans have been studied for their ability to boost immunity and be protective against certain types of cancers, in addition to having an antidiabetic effect.

Oats, barley, and other dietary sources of soluble fiber have long been recognized for their cholesterol-lowering effect, with the active component of that fiber being beta-glucans. Other soluble dietary fibers that are similarly resistant to digestive enzymes include inulin, resistant starch, pectins, psyllium, and gums, such as guar.

The next big intervention for diabetes might just be cannabis. Research indicates that cannabidiols — the nonpsychoactive but strongly bioactive components of cannabis — could help improve glucose tolerance.
PHOTO COURTESY OF: Layn Corp. (www.layncorp.com)

Plant-based Possibilities

Studies of all of these fibers and gums have yielded interesting data to support their role as effective ingredients for foods and beverages that can help consumers manage blood sugar. Research also has been blossoming in the realm of botanical help for blood sugar management.

Omega fatty acids, especially omega-3 and omega-6 oils, have been recognized for decades as playing a role in moderating and mitigating blood sugar disorders and the symptoms of diabetes. While the focus has been predominantly on the anti-inflammatory capacity and reduced cardiovascular disease risk, a growing body of research also has shown direct effects of omega-3 intake on fasting blood glucose levels.

Another omega fatty acid, omega-7 (palmitoleic acid), is attracting attention for its ability to help fight diabetes and its symptoms. Omega-7 oils are monounsaturated fatty acids, naturally found in breast milk, some animal fats, vegetable oils, and marine oils. Macadamia nut oil (Macadamia integrifolia) and sea buckthorn oil (Hippophae rhamnoides) are two botanical sources with high concentrations of omega-7.

Although most studies of omega-7 have been conducted on animals, the fatty acid has been found to reduce inflammation (as measured by C-reactive protein) and reduce insulin resistance. One such animal study, published in 2017 in the Journal of Agricultural and Food Chemistry, is particularly promising in demonstrating the ability of sea buckthorn fruit oil extract to alleviate type 2 diabetes through the PI3K/Akt signaling pathway in HepG2 cells.

Extracted from the leaves, berries, and seeds of the shrub-like sea buckthorn plant, the oil has been used for thousands of years in traditional Ayurvedic and Chinese medicines. Expanded study of these traditional medicine sources has also yielded scientific support for such ancient remedies as Indian gooseberry called amla (Emblica officinalis), purslane (Portulaca oleracea) and bitter melon (Momordica charantia), which contains polypeptide-p, also known as “p-insulin.”

The High Road

Of all the botanicals being scrutinized for possible glucose management, the most talked about one today is likely cannabis (Cannabis sativa). What role can cannabis play in the management of diabetes? A cross-sectional, case-control study was jointly conducted in 2012 by the Clinical Research Center, National Institutes of Health (NIH) and the Johns Hopkins Behavioral Pharmacology Research Unit. Results suggested that chronic, daily cannabis use may have differential tissue-specific effects on insulin sensitivity.

The study determined that, “the lack of adverse effects of chronic cannabis use on glucose tolerance is consistent with the lower prevalence of type 2 diabetes in heavy marijuana smokers.” The study cited several limitations, though, including small cohort size and accuracy of self-reported dietary information and actual marijuana use. In addition, “the relative amounts and activities of non-THC cannabinoids (e.g., cannabidiol [CBD], cannabigerol, and tetrahydrocannabivarin) and even noncannabinoids such as terpenoids on glucose metabolism (was) an unavoidable limitation.”

A 2015 study, “Cannabis Smoking and Diabetes Mellitus: MetaAnalysis with Eight Independent Replication Samples,” took the question further, speculating on the ability of cannabis smoking to reduce incidence of diabetes. The researchers noted that cannabinoids might “inhibit the release of inflammation mediators, thus reducing the level of chronic inflammation common to those with diabetes and which also serves as a risk factor for the development of the disease.”

It should be noted that persons with type 1 diabetes who use marijuana could significantly increase their risk of developing diabetic ketoacidosis, according to the American Diabetes Association. Diabetic ketoacidosis is a potentially life-threatening condition where the body lacks the insulin it needs to use its glucose, resulting in the body resorting to using fat for energy, which, in turn, creates ketones in the blood, making the blood more acidic.

As diabetes and obesity continue to involve such a large and multi-demographic population, processors can play a big part in providing solutions for the issues associated with the disease and its adjuncts, metabolic syndrome and prediabetes. There is unquestionably a mutual benefit in the continued development of foods and beverages to serve these tens of millions of consumers.