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International Journal of Dentistry
Volume 2016, Article ID 5967907, 16 pages
http://dx.doi.org/10.1155/2016/5967907
Review Article

Gastrointestinal Disturbances Associated with the Consumption of Sugar Alcohols with Special Consideration of Xylitol: Scientific Review and Instructions for Dentists and Other Health-Care Professionals

Institute of Dentistry, University of Turku, Lemminkäisenkatu 2, 20520 Turku, Finland

Received 15 June 2016; Revised 21 September 2016; Accepted 25 September 2016

Academic Editor: Vincent Everts

Copyright © 2016 Kauko K. Mäkinen. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Linked References

  1. K. K. Mäkinen, “Sugar alcohol sweeteners as alternatives to sugar with special consideration of xylitol,” Medical Principles and Practice, vol. 20, no. 4, pp. 303–320, 2011. View at Publisher · View at Google Scholar · View at Scopus
  2. K. K. Mäkinen, “Oral care gum products,” in Food Constituents and Oral Health, M. Wilson, Ed., pp. 435–454, Woodhead, Oxford, UK, 2009. View at Google Scholar
  3. U. C. Dubach, E. Feiner, and I. Forgó, “Oral tolerance of Xylit in subjects with normal metabolism,” Schweizerische medizinische Wochenschrift, vol. 99, no. 6, pp. 190–194, 1969. View at Google Scholar · View at Scopus
  4. K. K. Mäkinen and A. Scheinin, “Turku sugar studies VI. The administration of the trial and the control of the dietary regimen,” Acta Odontologica Scandinavica, vol. 33, supplement 70, pp. 105–127, 1975. View at Google Scholar
  5. S. Salminen, E. Salminen, and V. Marks, “The effects of xylitol on the secretion of insulin and gastric inhibitory polypeptide in man and rats,” Diabetologia, vol. 22, no. 6, pp. 480–482, 1982. View at Publisher · View at Google Scholar · View at Scopus
  6. S. Salminen, E. Salminen, P. Koivistoinen, J. Bridges, and V. Marks, “Gut microflora interactions with xylitol in the mouse, rat and man,” Food and Chemical Toxicology, vol. 23, no. 11, pp. 985–990, 1985. View at Publisher · View at Google Scholar · View at Scopus
  7. H. K. Åkerblom, T. Koivukangas, R. Puukka, and M. Mononen, “The tolerance of increasing amounts of dietary xylitol in children,” International Journal for Vitamin and Nutrition Research, vol. 22, pp. 53–66, 1982. View at Google Scholar · View at Scopus
  8. D. Storey, A. Lee, F. Bornet, and F. Brouns, “Gastrointestinal tolerance of erythritol and xylitol ingested in a liquid,” European Journal of Clinical Nutrition, vol. 61, no. 3, pp. 349–354, 2007. View at Publisher · View at Google Scholar · View at Scopus
  9. C. K. Yao, H.-L. Tan, D. R. van Langenberg et al., “Dietary sorbitol and mannitol: food content and distinct absorption patterns between healthy individuals and patients with irritable bowel syndrome,” Journal of Human Nutrition and Dietetics, vol. 27, no. 2, pp. 263–275, 2014. View at Publisher · View at Google Scholar · View at Scopus
  10. L. Beaugerie, B. Flourié, P. Marteau, P. Pellier, C. Franchisseur, and J.-C. Rambaud, “Digestion and absorption in the human intestine of three sugar alcohols,” Gastroenterology, vol. 99, no. 3, pp. 717–723, 1990. View at Publisher · View at Google Scholar · View at Scopus
  11. S. Nakamura, R. Hongo, K. Moji, and T. Oku, “Suppressive effect of partially hydrolyzed guar gum on transitory diarrhea induced by ingestion of maltitol and lactitol in healthy humans,” European Journal of Clinical Nutrition, vol. 61, no. 9, pp. 1086–1093, 2007. View at Publisher · View at Google Scholar · View at Scopus
  12. C. J. Tuck, J. G. Muir, J. S. Barrett, and P. R. Gibson, “Fermentable oligosaccharides, disaccharides, monosaccharides and polyols: role in irritable bowel syndrome,” Expert Review of Gastroenterology and Hepatology, vol. 8, no. 7, pp. 819–834, 2014. View at Publisher · View at Google Scholar · View at Scopus
  13. M. F. Nesterin, “Xylitol. Experimental and clinical investigations conducted in the USSR,” Zeitschrift für Ernährungswissenschaft, vol. 19, no. 2, pp. 88–94, 1980. View at Publisher · View at Google Scholar · View at Scopus
  14. J. Xiao, B. U. Metzler-Zebeli, and Q. Zebeli, “Gut function-enhancing properties and metabolic effects of dietary indigestible sugars in rodents and rabbits,” Nutrients, vol. 7, no. 10, pp. 8348–8365, 2015. View at Publisher · View at Google Scholar · View at Scopus
  15. P. de Cock, “Erythritol,” in Sweeteners and Sugar Alternatives in Food Technology, A. O'Donnell and W. Kearsley, Eds., pp. 215–241, Wiley-Blackwell, Oxford, UK, 2012. View at Google Scholar
  16. J. R. Biesiekierski, O. Rosella, R. Rose et al., “Quantification of fructans, galacto-oligosacharides and other short-chain carbohydrates in processed grains and cereals,” Journal of Human Nutrition and Dietetics, vol. 24, no. 2, pp. 154–176, 2011. View at Publisher · View at Google Scholar · View at Scopus
  17. J. G. Muir, R. Rose, O. Rosella et al., “Measurement of short-chain carbohydrates in common Australian vegetables and fruits by high-performance liquid chromatography (HPLC),” Journal of Agricultural and Food Chemistry, vol. 57, no. 2, pp. 554–565, 2009. View at Publisher · View at Google Scholar · View at Scopus
  18. P. Symons, M. P. Jones, and J. E. Kellow, “Symptom provocation in irritable bowel syndrome effects of differing doses of fructose-sorbitol,” Scandinavian Journal of Gastroenterology, vol. 27, no. 11, pp. 940–944, 1992. View at Publisher · View at Google Scholar · View at Scopus
  19. M. Georgieff, L. L. Moldawer, B. R. Bistrian, and G. L. Blackburn, “Xylitol, an energy source for intravenous nutrition after trauma,” Journal of Parenteral and Enteral Nutrition, vol. 9, no. 2, pp. 199–209, 1985. View at Publisher · View at Google Scholar · View at Scopus
  20. A. Scheinin and K. K. Mäkinen, “Turku sugar studies. An overview,” Acta Odontologica Scandinavica, vol. 33, supplement 70, pp. 345–348, 1975. View at Google Scholar
  21. P. R. Gibson and S. J. Shepherd, “Evidence-based dietary management of functional gastrointestinal symptoms: the FODMAP approach,” Journal of Gastroenterology and Hepatology, vol. 25, no. 2, pp. 252–258, 2010. View at Publisher · View at Google Scholar · View at Scopus
  22. S. Shepherd, Low FODMAP Recipes, Penguin, Melbourne, Australia, 2013.
  23. Low FODMAP Diet Application, [Mobile app] Monash University, Android version, http://www.med.monash.edu/cecs/gastro/fodmap/
  24. S. Magge and A. Lembo, “Low-FODMAP diet for treatment of irritable bowel syndrome,” Gastroenterology and Hepatology, vol. 8, no. 11, pp. 739–745, 2012. View at Google Scholar · View at Scopus
  25. W. S. Nanayakkara, P. M. L. Skidmore, L. O'Brien, T. J. Wilkinson, and R. B. Gearry, “Efficacy of the low FODMAP diet for treating irritable bowel syndrome: the evidence to date,” Clinical and Experimental Gastroenterology, vol. 9, pp. 131–142, 2016. View at Google Scholar
  26. A. Dahlqvist and U. Telenius, “The utilization of a presumably low-cariogenic carbohydrate derivative,” Acta Physiologica Scandinavica, vol. 63, pp. 156–163, 1965. View at Publisher · View at Google Scholar · View at Scopus
  27. E. B. Charney and J. N. Bodurtha, “Intractable diarrhea associated with the use of sorbitol,” The Journal of Pediatrics, vol. 98, no. 1, pp. 157–161, 1981. View at Publisher · View at Google Scholar · View at Scopus
  28. M. J. R. Ravry, “Dietetic food diarrhea,” Journal of the American Medical Association, vol. 244, no. 3, p. 270, 1980. View at Publisher · View at Google Scholar · View at Scopus
  29. C. J. McClain, J. P. Kromhout, L. Zieve, and W. C. Duane, “Effect of sorbitol on psychomotor function. Its use in alcoholic cirrhosis,” Archives of Internal Medicine, vol. 141, no. 7, pp. 901–903, 1981. View at Publisher · View at Google Scholar · View at Scopus
  30. H. Mehnert, K. Stuhlfauth, B. Mehnert, R. Lausch, and W. Seitz, “Vergleichende untersuchungen zur resorption von glucose, fructose und sorbit beim menschen,” Klinische Wochenschrift, vol. 37, no. 21, pp. 1138–1142, 1959. View at Publisher · View at Google Scholar · View at Scopus
  31. J. D. Gryboski, “Diarrhea from dietetic candies,” The New England Journal of Medicine, vol. 275, no. 13, p. 718, 1966. View at Google Scholar · View at Scopus
  32. L. D. Goldberg and N. T. Ditchek, “Chewing gum diarrhea,” The American Journal of Digestive Diseases, vol. 23, no. 6, p. 568, 1978. View at Publisher · View at Google Scholar · View at Scopus
  33. R. E. Hill and K. R. Kamath, “Pink’ diarrhoea from a sorbitol-containing vitamin C supplement,” Medical Journal of Australia, vol. 1, no. 9, pp. 387–389, 1982. View at Google Scholar · View at Scopus
  34. S. L. Taylor and B. Byron, “Probable case of sorbitol-induced diarrhea,” Journal of Food Protection, vol. 47, article 249, 1984. View at Google Scholar
  35. A. N. Payne, C. Chassard, and C. Lacroix, “Gut microbial adaptation to dietary consumption of fructose, artificial sweeteners and sugar alcohols: implications for host-microbe interactions contributing to obesity,” Obesity Reviews, vol. 13, no. 9, pp. 799–809, 2012. View at Publisher · View at Google Scholar · View at Scopus
  36. P. Mansueto, A. Seidita, A. D'Alcamo, and A. Carroccio, “Role of FODMAPs in patients with irritable bowel syndrome,” Nutrition in Clinical Practice, vol. 30, no. 5, pp. 665–682, 2015. View at Publisher · View at Google Scholar · View at Scopus
  37. F. W. Ellis and J. C. Krantz, “Sugar alcohols. XXII. Metabolism and toxicity studies with mannitol and sorbitol in man and animals,” Journal of Biological Chemistry, vol. 141, pp. 147–154, 1941. View at Google Scholar
  38. S. J. Shepherd, M. C. E. Lomer, and P. R. Gibson, “Short-chain carbohydrates and functional gastrointestinal disorders,” The American Journal of Gastroenterology, vol. 108, no. 5, pp. 707–717, 2013. View at Publisher · View at Google Scholar · View at Scopus
  39. F. Respondek, C. Hilpipre, P. Chauveau et al., “Digestive tolerance and postprandial glycaemic and insulinaemic responses after consumption of dairy desserts containing maltitol and fructo- oligosaccharides in adults,” European Journal of Clinical Nutrition, vol. 68, no. 5, pp. 575–580, 2014. View at Publisher · View at Google Scholar · View at Scopus
  40. M. Goebel-Stengel and H. Mönnikes, “Malabsorption of fermentable oligo-, di-, or monosaccharides and polyols (FODMAP) as a common cause of unclear abdominal discomfort,” Deutsche Medizinische Wochenschrift, vol. 139, no. 24, pp. 1310–1314, 2014 (German). View at Publisher · View at Google Scholar · View at Scopus
  41. M. El-Salhy, “Recent developments in the pathophysiology of irritable bowel syndrome,” World Journal of Gastroenterology, vol. 21, no. 25, pp. 7621–7636, 2015. View at Publisher · View at Google Scholar · View at Scopus
  42. J. Beaven, A. Bjørneklett, E. Jenssen, J. P. Blomhoff, and S. Skrede, “Pulmonary hydrogen and methane and plasma ammonia after the administration of lactulose or sorbitol,” Scandinavian Journal of Gastroenterology, vol. 18, no. 3, pp. 343–347, 1983. View at Publisher · View at Google Scholar · View at Scopus
  43. L. Beaugerie, B. Flourié, P. Pernet, L. Achour, C. Franchisseur, and J. C. Rambaud, “Glucose does not facilitate the absorption of sorbitol perfused in situ in the human small intestine,” Journal of Nutrition, vol. 127, no. 2, pp. 341–344, 1997. View at Google Scholar · View at Scopus
  44. H.-J. Zunft, J. Schulze, H. Gärtner, and F.-K. Grütte, “Digestion of maltitol in man, rat, and rabbit,” Annals of Nutrition and Metabolism, vol. 27, no. 6, pp. 470–476, 1983. View at Publisher · View at Google Scholar · View at Scopus
  45. D. M. Storey, G. A. Koutsou, A. Lee et al., “Tolerance and breath hydrogen excretion following ingestion of maltitol incorporated at two levels into milk chocolate consumed by healthy young adults with and without fasting,” Journal of Nutrition, vol. 128, no. 3, pp. 587–592, 1998. View at Google Scholar · View at Scopus
  46. A. Ruskoné-Fourmestraux, A. Attar, D. Chassard, B. Coffin, F. Bornet, and Y. Bouhnik, “A digestive tolerance study of maltitol after occasional and regular consumption in healthy humans,” European Journal of Clinical Nutrition, vol. 57, no. 1, pp. 26–30, 2003. View at Publisher · View at Google Scholar · View at Scopus
  47. M. Tsukamura, H. Goto, T. Arisawa et al., “Dietary maltitol decreases the incidence of 1,2-dimethylhydrazine- induced cecum and proximal colon tumors in rats,” Journal of Nutrition, vol. 128, no. 3, pp. 536–540, 1998. View at Google Scholar · View at Scopus
  48. H. Mineo, H. Hara, H. Kikuchi, H. Sakurai, and F. Tomita, “Various indigestible saccharides enhance net calcium transport from the epithelium of the small and large intestine of rats in vitro,” Journal of Nutrition, vol. 131, no. 12, pp. 3243–3246, 2001. View at Google Scholar · View at Scopus
  49. T. Goda, K. Kishi, I. Ezawa, and S. Takase, “The maltitol-induced increase in intestinal calcium transport increases the calcium content and breaking force of femoral bone in weanling rats,” Journal of Nutrition, vol. 128, no. 11, pp. 2028–2031, 1998. View at Google Scholar · View at Scopus
  50. M. Svanberg and M. Knuuttila, “Dietary xylitol retards bone resorption in rats,” Mineral and Electrolyte Metabolism, vol. 20, no. 3, pp. 153–157, 1994. View at Google Scholar · View at Scopus
  51. M. H. G. Dehghan, V. R. M. Gupta, S. M. Asif, Y. Darwis, M. Rizwan, and V. P. Mundada, “Assessment of isomalt for colon-specific delivery and its comparison with lactulose,” AAPS PharmSciTech, vol. 14, no. 1, pp. 53–59, 2013. View at Publisher · View at Google Scholar · View at Scopus
  52. A. Lee, A. Zumbe, and D. Storey, “Breath hydrogen after ingestion of the bulk sweeteners sorbitol, isomalt and sucrose in chocolate,” British Journal of Nutrition, vol. 71, no. 5, pp. 731–737, 1994. View at Publisher · View at Google Scholar · View at Scopus
  53. M. Finney, J. Smullen, H. A. Foster, S. Brokx, and D. M. Storey, “Effects of low doses of lactitol on faecal microflora, pH, short chain fatty acids and gastrointestinal symptomology,” European Journal of Nutrition, vol. 46, no. 6, pp. 307–314, 2007. View at Publisher · View at Google Scholar · View at Scopus
  54. S. S. Natah, K. R. Hussien, J. A. Tuominen, and V. A. Koivisto, “Metabolic response to lactitol and xylitol in healthy men,” American Journal of Clinical Nutrition, vol. 65, no. 4, pp. 947–950, 1997. View at Google Scholar · View at Scopus
  55. E. Cristofaro, F. Mottu, and J. J. Wuhrmann, “Involvement of the raffinose family of oligosaccharides in flatulence,” in Sugars in Nutrition, H. L. Sipple and K. W. McNutt, Eds., pp. 313–336, Academic Press, New York, NY, USA, 1974. View at Google Scholar
  56. Y. Hata, M. Yamamoto, and K. Nakajima, “Effects of soybean oligosaccharides on human digestive organs—estimation of fifty percent effective dose and maximum non-effective dose based on diarrhea,” Journal of Clinical Biochemistry and Nutrition, vol. 10, no. 2, pp. 135–144, 1991. View at Publisher · View at Google Scholar
  57. F. Askevold, “Investigations on the influence of diet on the quantity and composition of intestinal gas in humans,” Scandinavian Journal of Clinical and Laboratory Investigation, vol. 8, no. 2, pp. 87–94, 1956. View at Publisher · View at Google Scholar · View at Scopus
  58. S. E. Fleming, “A study of relationships between flatus potential and carbohydrate distribution in legume seeds,” Journal of Food Science, vol. 46, no. 3, pp. 794–798, 1981. View at Publisher · View at Google Scholar
  59. D. R. Saunders and H. S. Wiggins, “Conservation of mannitol, lactulose, and raffinose by the human colon,” The American Journal of Physiology, vol. 241, no. 5, pp. G397–G402, 1981. View at Google Scholar · View at Scopus
  60. A. N. Galiullin, “Evaluation of the caries-preventive action of xylitol,” Kazan Medical Journal, vol. 67, pp. 16–18, 1981 (Russian). View at Google Scholar
  61. T. Asano, M. D. Levitt, and F. C. Goetz, “Xylitol absorption in healthy men,” Diabetes, vol. 22, no. 4, pp. 279–281, 1973. View at Publisher · View at Google Scholar · View at Scopus
  62. J. J. Burns and J. Kanfer, “Formation of l-xylulose from l-gulonolactone in rat kidney,” Journal of the American Chemical Society, vol. 79, no. 13, pp. 3604–3605, 1957. View at Publisher · View at Google Scholar · View at Scopus
  63. O. Touster, “Metabolism and physiological effects of the polyols (alditols),” in Physiological Effects of Food Carbohydrates, A. Jeanes and and J. Hodge, Eds., pp. 123–124, American Chemical Society, Washington, DC, USA, 1975. View at Google Scholar
  64. O. Touster and D. R. D. Shaw, “Biochemistry of the acyclic polyols,” Physiological Reviews, vol. 42, pp. 181–225, 1962. View at Google Scholar · View at Scopus
  65. D. B. McCormick and O. Touster, “The conversion in vivo of xylitol to glycogen via the pentose phosphate pathway,” The Journal of Biological Chemistry, vol. 229, no. 1, pp. 451–461, 1957. View at Google Scholar · View at Scopus
  66. R. Ylikahri, “Metabolic and nutritional effects of xylitol,” Advances in Food Research, vol. 15, pp. 159–180, 1979. View at Google Scholar
  67. K. H. Bässler, “Biochemistry of xylitol,” in Xylitol, J. N. Counsell, Ed., pp. 35–41, Applied Science, Essex, UK, 1978. View at Google Scholar
  68. H. Förster, “Tolerance in the human, adults and children,” in Xylitol, J. N. Counsell, Ed., pp. 43–66, Applied Science Publishers, Barking, UK, 1978. View at Google Scholar
  69. M. Brin and O. N. Miller, “The safety of oral xylitol,” in Sugars in Nutrition, H. L. Sipple and K. W. McNutt, Eds., pp. 591–612, Academic Press, New York, NY, USA, 1974. View at Google Scholar
  70. Y.-M. Wang, S. J. Culbert, H. A. Fritsche Jr., and D. B. Carr, “Oral xylitol in humans,” Federations Proceedings, vol. 40, pp. 878–885, 1981. View at Google Scholar
  71. K. K. Mäkinen, R. Ylikahri, L. Mäkinen, E. Söderling, and M. Hämäläinen, “Turku sugar studies XXIII. Comparison of metabolic tolerance in human volunteers to high oral doses of xylitol and sucrose after long-term regular consumption of xylitol,” International Journal of Vitamin and Nutrition Research. Supplement, vol. 22, pp. 29–51, 1982. View at Google Scholar
  72. K. K. Mäkinen, “Effect of long-term, peroral administration of sugar alcohols on man,” Swedish Dental Journal, vol. 8, no. 3, pp. 113–124, 1984. View at Google Scholar · View at Scopus
  73. H. Förster, R. Quadbeck, and U. Gottstein, “Metabolic tolerance to high doses of oral xylitol in human volunteers not previously adapted to xylitol,” International Journal for Vitamin and Nutrition Research, vol. 22, pp. 67–88, 1982. View at Google Scholar · View at Scopus
  74. K. K. Mäkinen and K. K. Virtanen, “Effect of 4.5-year use of xylitol and sorbitol on plaque,” Journal of Dental Research, vol. 57, no. 3, pp. 441–446, 1978. View at Publisher · View at Google Scholar
  75. R. B. Shafer, A. S. Levine, J. M. Marlette, and J. E. Morley, “Effects of xylitol on gastric emptying and food intake,” The American Journal of Clinical Nutrition, vol. 45, no. 4, pp. 744–747, 1987. View at Google Scholar · View at Scopus
  76. J. Bánóczy, A. Scheinin, R. Pados, G. Ember, P. Kertész, and K. Pienihäkkinen, “Collaborative WHO xylitol Field studies in Hungary II. General background and control of the dietary regimen,” Acta Odontologica Scandinavica, vol. 43, no. 6, pp. 349–357, 1985. View at Publisher · View at Google Scholar · View at Scopus
  77. S. J. Culbert, Y.-M. Wang, H. A. Fritsche, D. Carr Jr., E. Lantin, and J. V. Eys, “Oral xylitol in American adults,” Nutrition Research, vol. 6, no. 8, pp. 913–922, 1986. View at Publisher · View at Google Scholar · View at Scopus
  78. M. Lam, C. A. Riedy, S. E. Coldwell, P. Milgrom, and R. Craig, “Children's acceptance of xylitol-based foods,” Community Dentistry and Oral Epidemiology, vol. 28, no. 2, pp. 97–101, 2000. View at Publisher · View at Google Scholar · View at Scopus
  79. J. L. Castillo, P. Milgrom, S. E. Coldwell, R. Castillo, and R. Lazo, “Children's acceptance of milk with xylitol or sorbitol for dental caries prevention,” BMC Oral Health, vol. 5, article 6, 2005. View at Publisher · View at Google Scholar · View at Scopus
  80. K. K. Mäkinen, K. P. Isotupa, P.-L. Mäkinen et al., “Six-month polyol chewing-gum programme in kindergarten-age children: a feasibility study focusing on mutans streptococci and dental plaque,” International Dental Journal, vol. 55, no. 2, pp. 81–88, 2005. View at Publisher · View at Google Scholar · View at Scopus
  81. L. Vernacchio, R. M. Vezina, and A. A. Mitchell, “Tolerability of oral xylitol solution in young children: implications for otitis media prophylaxis,” International Journal of Pediatric Otorhinolaryngology, vol. 71, no. 1, pp. 89–94, 2007. View at Publisher · View at Google Scholar · View at Scopus
  82. T. Oku and S. Nakamura, “Threshold for transitory diarrhea induced by ingestion of xylitol and lactitol in young male and female adults,” Journal of Nutritional Science and Vitaminology, vol. 53, no. 1, pp. 13–20, 2007. View at Publisher · View at Google Scholar · View at Scopus
  83. M. Seki, F. Karakama, T. Kawato, H. Tanaka, Y. Saeki, and Y. Yamashita, “Effect of xylitol gum on the level of oral mutans streptococci of preschoolers: block-randomised trial,” International Dental Journal, vol. 61, no. 5, pp. 274–280, 2011. View at Publisher · View at Google Scholar · View at Scopus
  84. US Department of Health and Human Services, Health Aspects of Sugar Alcohols and Lactose (Report Prepared for Center for Food Safety and Applied Nutrition, Food and Drug Administration, Contract No. FDA 223-83-2020), Life Sciences Research Office, Federation of American Societies for Experimental Biology, Bethesda, Md, USA, 1986.
  85. US Department of Health and Human Services, “Food Labeling: Health Claims; Sugar Alcohols and Dental Caries,” Food and Drug Administration, Federal Register 1996, August 23, vol. 61, no. 165, Rules and Regulations, pp. 43433–43447, Bethesda, Md, USA, 1996
  86. A. Bär, “Sugar alcohols in the diabetic diet,” in Sugars and Sweeteners, N. Kretchmer and C. B. Hollenbeck, Eds., pp. 131–150, CRC Press, Boca Raton, Fla, USA, 1991. View at Google Scholar
  87. K. K. Mäkinen, “Authorized EU health claims for xylitol and sugar-free chewing gum (SGFCG),” in Foods, Nutrients and Food Ingredients with Authorised EU Health Claims, M. J. Sadler, Ed., vol. 1, pp. 46–72, Woodhead Publishing, Cambridge, UK, 2014. View at Google Scholar
  88. M. T. Flood, M. H. Auerbach, and S. A. S. Craig, “A review of the clinical toleration studies of polydextrose in food,” Food and Chemical Toxicology, vol. 42, no. 9, pp. 1531–1542, 2004. View at Publisher · View at Google Scholar · View at Scopus
  89. P. de Cock and C.-L. Bechert, “Erythritol: functionality in noncaloric functional beverages,” Pure and Applied Chemistry, vol. 74, no. 7, pp. 1281–1289, 2002. View at Google Scholar · View at Scopus
  90. G. J. M. den Hartog, A. W. Boots, A. Adam-Perrot et al., “Erythritol is a sweet antioxidant,” Nutrition, vol. 26, no. 4, pp. 449–458, 2010. View at Publisher · View at Google Scholar · View at Scopus
  91. F. R. J. Bornet, A. Blayo, F. Dauchy, and G. Slama, “Gastrointestinal response and plasma and urine determinations in human subjects given erythritol,” Regulatory Toxicology and Pharmacology, vol. 24, no. 2, part 2, pp. S296–S302, 1996. View at Publisher · View at Google Scholar · View at Scopus
  92. W. Tetzloff, F. Dauchy, S. Medimagh, D. Carr, and A. Bär, “Tolerance to subchronic, high-dose ingestion of erythritol in human volunteers,” Regulatory Toxicology and Pharmacology, vol. 24, no. 2, pp. S286–S295, 1996. View at Publisher · View at Google Scholar · View at Scopus
  93. E. Jacqz-Aigrain, B. Kassai, C. Cornu et al., “Gastrointestinal tolerance of erythritol-containing beverage in young children: a double-blind, randomised controlled trial,” European Journal of Clinical Nutrition, vol. 69, no. 6, pp. 746–751, 2015. View at Publisher · View at Google Scholar · View at Scopus
  94. E. Arrigoni, F. Brouns, and R. Amadò, “Human gut microbiota does not ferment erythritol,” British Journal of Nutrition, vol. 94, no. 5, pp. 643–646, 2005. View at Publisher · View at Google Scholar · View at Scopus
  95. Y. Kim, S. C. Park, B. W. Wolf, and S. R. Hertzler, “Combination of erythritol and fructose increases gastrointestinal symptoms in healthy adults,” Nutrition Research, vol. 31, no. 11, pp. 836–841, 2011. View at Publisher · View at Google Scholar · View at Scopus
  96. L. Putkonen, C. K. Yao, and P. R. Gibson, “Fructose malabsorption syndrome,” Current Opinion in Clinical Nutrition and Metabolic Care, vol. 16, no. 4, pp. 473–477, 2013. View at Publisher · View at Google Scholar · View at Scopus
  97. S. Honkala, R. Runnel, M. Saag et al., “Effect of erythritol and xylitol on dental caries prevention in children,” Caries Research, vol. 48, no. 5, pp. 482–490, 2014. View at Publisher · View at Google Scholar · View at Scopus
  98. P. de Cock, K. Mäkinen, E. Honkala, M. Saag, E. Kennepohl, and A. Eapen, “Erythritol is more effective than xylitol and sorbitol in managing oral health endpoints,” International Journal of Dentistry, vol. 2016, Article ID 9868421, 15 pages, 2016. View at Publisher · View at Google Scholar
  99. T. Takeda, S. Takeda, A. Kakigi, R. Nishioka, and M. Nishimura, “Decompression effects of erythritol on endolymphatic hydrops,” Auris, Nasus, Larynx, vol. 36, pp. 146–151, 2009. View at Google Scholar