Reported Consumption of Low-Calorie Sweetener in Foods, Beverages, and Food and Beverage Additions by US Adults: NHANES 2007-2012

Cross-sectional associations between consumption of non-nutritive sweeteners and diet quality among United States adults in the Cancer Prevention Study-3

BACKGROUND

Non-nutritive sweeteners (NNS) are used to replace added sugar, yet whether NNS consumers have better or worse diet quality compared to nonconsumers is unclear.

OBJECTIVE

To investigate cross-sectional associations between NNS consumption and diet quality.

METHODS

Data from participants in the American Cancer Society (ACS) Cancer Prevention Study-3 cohort were used for this analysis. NNS intake was estimated using self-reported consumption of NNS-containing beverages, packets, and yogurt from a validated food frequency questionnaire. Participants were categorized into nonconsumers, <1 serving, 1 to <2 servings and ≥2 servings per day. Diet quality was assessed using the ACS diet score (2020) and Healthy Eating Index (HEI-2015). Analysis of variance was used to compare diet quality scores across NNS consumption groups, and multivariable linear regression was used to examine associations between NNS consumption and diet quality. Multivariable logistic regression was used to evaluate the odds of low diet quality across NNS consumption groups.

RESULTS

Data from 163,679 participants [median age 53 y (IQR 45-60), 78.9% females, mean NNS intake 1.0 ± 1.5 servings/d, mean HEI-2015 score 75.4 ± 10.2] were included. NNS consumers had lower diet quality for ACS diet score (6.8 ± 0.03 among nonconsumers compared with 6.5 ± 0.03, 6.3 ± 0.03, and 6.1± 0.03 for consumers of <1 serving, 1 to <2 servings, and ≥2 servings of NNS per day, respectively, P-trend < 0.0001) and HEI-2015 (76.3 ± 0.1 among nonconsumers compared with 76.7 ± 0.1, 75.6 ± 0.2, and 72.7± 0.2 for consumers of <1 serving, 1 to <2 servings, and ≥2 servings of NNS per day, respectively, P-trend < 0.0001). Odds of low diet quality were higher among NNS consumers and were higher with higher NNS consumption (3%, 17%, and 43% higher odds of low diet quality among those who consumed <1 serving, 1 to <2 servings and ≥2 servings of NNS per day).

CONCLUSIONS

NNS consumers have lower diet quality in a large cohort of adults in the United States.

Sugar-Sweetened Beverages, Artificially Sweetened Beverages and Sugar Forms With Long-Term Risk of Irritable Bowel Syndrome: A Large-Scale Prospective Cohort Study

We aimed to examine the prospective association of sugar-sweetened beverages (SSB), artificially sweetened beverages (ASB), natural juice, and sugar forms with irritable bowel syndrome (IBS). Participants free of IBS, celiac disease, inflammatory bowel disease, and any cancer at recruitment were included (N = 178,711, 53.1% female). SSB, ASB, natural juice, and different sugar forms' consumption were measured via a 24-h dietary recall questionnaire. The primary outcome was incident IBS. A Cox proportional hazard model adjusting for age, sex, BMI, Townsend deprivation index, education, ethnicity, smoking, alcohol drinking, physical activity, total energy intake, type 2 diabetes, depression, and anxiety was conducted to assess the relationship. Mean consumption of SSB, ASB, and natural juice was 90.0, 72.4, and 105.7 g/day, respectively. During a median of 11.3-year follow-up, 2690 participants developed IBS. Every 100 g/day SSB increment was associated with a 3% higher IBS risk (HR = 1.03, 95% CI: 1.01-1.05). Compared with no SSB intake, the highest quartile was associated with an increased risk of IBS (HR = 1.19, 1.03-1.37; p trend = 0.017). Regarding ASB and natural juice, no significant association was detected in those who consumed the highest quartile versus no intake (ASB: HRQ4 VS no intake = 1.12, 0.95-1.31, p trend = 0.062; Natural juice: HRQ4 VS no intake = 1.01, 0.87-1.18, p trend = 0.363). Considering different sugar forms, increased IBS risk was detected in added sugar (HRQ4 VS Q1 = 1.20, 1.05-1.36, p trend = 0.001), instead of naturally occurring sugar (HRQ4 VS Q1 = 0.99, 0.88-1.11, p trend = 0.869). Higher intake of SSB, rather than ASB and natural juice, is associated with increased IBS risk. Higher consumption of added sugar, instead of naturally occurring sugar, is associated with higher IBS risk. These findings highlight the importance of limiting SSB consumption in diets to reduce the modifiable burden of IBS.

Associations of saccharin intake with all-cause, cardiovascular and cancer mortality risk in USA adults

Saccharin is a widely used sugar substitute, but little is known about the long-term health effects of saccharin intake. Our study aimed to examine the association between saccharin intake and mortality in diabetic and pre-diabetic population and overweight population from NHANES 1988-1994. Cox proportional hazard models were used to evaluate the association between saccharin intake and CVD, cancer and all-cause mortality. After multivariable adjustment, increased absolute saccharin intake was associated with the risk of all-cause mortality (hazard ratio (HR): 1·41, 95 % CI: 1·05, 1·90), CVD mortality (HR: 1·93, 95 % CI: 1·15, 3·25) and cancer mortality (HR: 2·26, 95 % CI: 1·10, 4·45) in diabetic and pre-diabetic population. Among overweight population, higher absolute saccharin intake was associated with the risk of cancer mortality (HR: 7·369, 95 % CI: 2·122, 25·592). Replacing absolute saccharin intake with total sugar significantly reduced all-cause mortality by 12·5 % and CVD mortality by 49·7 % in an equivalent substitution analysis in the diabetic and pre-diabetic population. Aspartame substitution reduced all-cause mortality by 29·2 % and cancer mortality by 30·2 %. Notably, the relative daily intake of saccharin also had similar effects as the absolute intake on all-cause, cardiovascular and cancer mortality in all analyses. This was despite the fact that the relative daily intake in our study was below the Food and Drug Administration limit of 15 mg/kg. In conclusion, our study showed a considerable risk of increased saccharin intake on the all-cause, CVD mortality and cancer mortality.

Consumption of Low-Calorie Sweeteners among Children Aged 6 Months to 5 Years in the United States, NHANES 2017-2020

BACKGROUND

Although the American Academy of Pediatrics advises against low-calorie sweeteners (LCS) consumption by children <5 y due to potential health and development concerns, the extent of this consumption among these children is unknown.

OBJECTIVES

The objective of this study was to describe the intake, sources, and dietary patterns associated with LCS consumption among United States infants and preschoolers.

METHODS

We used cross-sectional 24-h dietary recall data (day 1) among 1497 children aged 6 mo to 5 y from the National Health and Nutrition Examination Survey 2017-2020 prepandemic. Complex survey procedures and sampling weights were applied to compare LCS consumption patterns (prevalence and frequency [times/day] of any LCS, any LCS-containing beverages [LCSBs], and any LCS-containing foods [LCSFs], with each occurrence of consumption = 1 "serving") across demographic subgroups and to assess the associated nutrients and % of total energy intake (TEI).

RESULTS

Thirty-one percent of children aged 6 mo to 5 y consumed ≥1 LCSB and/or LCSF on a given day. The prevalence of LCS consumption increased with age, 10.5% (6 to <12 mo) to 34.3% (2-5 y). Among LCS consumers, mean serving frequency was 1.4 times/d, with no differences by age or sex. Of all LCSBs servings consumed, 64.0% were fruit drinks; 57.8% of all LCSFs servings were non-Greek yogurt. As consumption levels increased from no LCS to >1 serving/d, intake of the following also increased: total sugar (+1.8% TEI, P-trend = 0.04), added sugar (+1.1%, P-trend = 0.048), sodium (+304 mg, P-trend = 0.04), and fiber (+0.8 g, P-trend = 0.01). In contrast, protein intake was lower (-0.7% TEI, P-trend = 0.02). Those consuming 1 LCS serving/d consumed more total energy than LCS nonconsumers (1606 compared with 1401 kcal), but TEI did not increase further with >1 LCS serving/d (1607 kcal). LCS consumption was not associated with carbohydrate or fat intake.

CONCLUSIONS

LCS consumption, primarily from fruit drinks and non-Greek yogurt, is prevalent among United States preschoolers, and this consumption is associated with greater intake of total sugar, added sugar, and sodium.

Serum Metabolomic Markers of Artificially Sweetened Beverage Consumption

BACKGROUND

The consumption of artificially sweetened beverages is on the rise. Use of artificial sweeteners has been associated with adverse health outcomes. There is a need to identify novel objective biomarkers of artificially sweetened beverages in order to improve dietary assessment and to provide insight into their metabolic impact.

OBJECTIVES

We aimed to identify serum metabolites that are associated with artificially sweetened beverage consumption.

METHODS

In the Atherosclerosis Risk in Communities (ARIC) study, consumption of artificially sweetened beverages was assessed using a food frequency questionnaire and fasting serum samples were collected during the first study visit (1987-1989). Participants were categorized as nonusers if they reported almost never consumption of artificially sweetened beverages, moderate users for 1 glass/mo to 6 glasses/wk, and heavy users for ≥1 glasses/d. Untargeted metabolomic profiling was conducted in 2 subgroups (subgroup 1: n = 1866, profiled in 2010; subgroup 2 profiled in 2014: n = 2072), and 360 metabolites were analyzed. In this secondary data analysis, multivariable linear regression models were used, adjusting for demographics, health behaviors, health status, and dietary factors. Analyses were conducted in each subgroup and results meta-analyzed.

RESULTS

In a meta-analysis of 3938 generally healthy participants (mean age, 54 y; 60% women; 62% Black participants) from ARIC study visit 1, 11 serum metabolites were significantly associated with artificially sweetened beverage consumption. Heavier consumption of artificially sweetened beverages was associated with higher concentrations of 10 metabolites (saccharin, threonate, erythronate, glycerate, gluconate, mannitol, glucose, tryptophan betaine, trehalose, and N6-acetyllysine) and lower concentrations of glycocholenate sulfate.

CONCLUSIONS

Eleven serum metabolites are related to artificially sweetened beverage intake, which consist of known sugar substitutes, processed food additives, glucose-related compounds, and gut microbiome-related metabolites. These findings enhance our knowledge of the metabolic activity of artificial sweeteners and suggests new biomarkers for monitoring intake.

Could Insulin Be a Better Regulator of Appetite/Satiety Balance and Body Weight Maintenance in Response to Glucose Exposure Compared to Sucrose Substitutes? Unraveling Current Knowledge and Searching for More Appropriate Choices

BACKGROUND

Insulin exerts a crucial impact on glucose control, cellular growing, function, and metabolism. It is partially modulated by nutrients, especially as a response to the intake of foods, including carbohydrates. Moreover, insulin can exert an anorexigenic effect when inserted into the hypothalamus of the brain, in which a complex network of an appetite/hunger control system occurs. The current literature review aims at thoroughly summarizing and scrutinizing whether insulin release in response to glucose exposure may be a better choice to control body weight gain and related diseases compared to the use of sucrose substitutes (SSs) in combination with a long-term, well-balanced diet.

METHODS

This is a comprehensive literature review, which was performed through searching in-depth for the most accurate scientific databases and applying effective and relevant keywords.

RESULTS

The insulin action can be inserted into the hypothalamic orexigenic/anorexigenic complex system, activating several anorexigenic peptides, increasing the hedonic aspect of food intake, and effectively controlling the human body weight. In contrast, SSs appear not to affect the orexigenic/anorexigenic complex system, resulting in more cases of uncontrolled body weight maintenance while also increasing the risk of developing related diseases.

CONCLUSIONS

Most evidence, mainly derived from in vitro and in vivo animal studies, has reinforced the insulin anorexigenic action in the hypothalamus of the brain. Simultaneously, most available clinical studies showed that SSs during a well-balanced diet either maintain or even increase body weight, which may indirectly be ascribed to the fact that they cannot cover the hedonic aspect of food intake. However, there is a strong demand for long-term longitudinal surveys to effectively specify the impact of SSs on human metabolic health.

Substituting Low-Calorie Sweetened Beverages for Sugar-Sweetened Beverages to Prevent Obesity and Cardiometabolic Diseases: Still a Good Idea?

Low-calorie sweeteners (LCSs) and LCS-containing beverages have been proposed as appropriate substitutes for caloric sugars in recent years. In this Perspective, we highlight the recent findings from observational and interventional studies, focusing on obesity, gut microbiome, and cardiometabolic health. We provide public health actors and health care professionals with an insightful overview of recent evidence to bridge the gap between research and practice.

Sweetened Beverages, Genetic Susceptibility, and Incident Atrial Fibrillation: A Prospective Cohort Study

BACKGROUND

An association between sweetened beverages and several cardiometabolic diseases has been reported, but their association with atrial fibrillation (AF) is unclear. We aimed to investigate the associations between consumption of sugar-sweetened beverages (SSB), artificially sweetened beverages (ASB), and pure fruit juice (PJ) and risk of consumption with AF risk and further evaluate whether genetic susceptibility modifies these associations.

METHODS

A total of 201 856 participants who were free of baseline AF, had genetic data available, and completed a 24-hour diet questionnaire were included. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During a median follow-up of 9.9 years, 9362 incident AF cases were documented. Compared with nonconsumers, individuals who consumed >2 L/wk of SSB or ASB had an increased risk of AF (HR, 1.10 [95% CI, 1.01-1.20] and HR, 1.20 [95% CI, 1.10-1.31]) in the multivariable-adjusted model. A negative association was observed between the consumption of ≤1 L/wk of PJ and the risk of AF (HR, 0.92 [95% CI, 0.87-0.97]). The highest HRs (95% CIs) of AF were observed for participants at high genetic risk who consumed >2 L/wk of ASB (HR, 3.51 [95% CI, 2.94-4.19]), and the lowest HR were observed for those at low genetic risk who consumed ≤1 L/wk of PJ (HR, 0.77 [95% CI, 0.65-0.92]). No significant interactions were observed between the consumption of SSB, ASB, or PJ and genetic predisposition to AF.

CONCLUSIONS

Consumption of SSB and ASB at >2 L/wk was associated with an increased risk for AF. PJ consumption ≤1 L/wk was associated with a modestly lower risk for AF. The association between sweetened beverages and AF risk persisted after adjustment for genetic susceptibility to AF. This study does not demonstrate that consumption of SSB and ASB alters AF risk but rather that the consumption of SSB and ASB may predict AF risk beyond traditional risk factors.

Levels, consumption, and variations of eight artificial sweeteners in the wastewater treatment plants of Dalian city, China

Artificial sweeteners (ASs) are emerging contaminants in the environment, primarily derived from wastewater treatment plant (WWTP) effluents. In this study, the influents and effluents of three WWTPs in the Dalian urban area, China, were analyzed for the distribution of 8 typical ASs to investigate their seasonal fluctuations in the WWTPs. The results showed that acesulfame (ACE), sucralose (SUC), cyclamate (CYC), and saccharin (SAC) were both detected in the influent and effluent water samples of WWTPs, with concentrations ranging from not detected (ND) to 14.02 μg·L-1. In addition, SUC was the most abundant ASs type, accounting for 40 %-49 % and 78 %-96 % of the total ASs in the influent and effluent water, respectively. The WWTPs revealed high removal efficiencies of CYC, SAC, and ACE, while the SUC removal efficiency was poor (26 % ± 36 %). The ACE and SUC concentrations were higher in spring and summer, and all ASs showed lower levels in winter, which may be caused by the high consumption of ice-cream in warmer months. The per capita ASs loads in the WWTPs were determined in this study based on the wastewater analysis results. The calculated per capita daily mas loads for individual ASs ranged from 0.45 g·d-1·1000p-1 (ACE) to 2.04 g·d-1·1000p-1 (SUC). In addition, the relationship between per capita ASs consumption and socioeconomic status showed no significant correlation.

Evaluating the Association Between Artificial Sweetener Intake and Indicators of Stress and Anxiety

The purpose of this study was to evaluate the association between non-nutritive sweetener (NNS) consumption and stress and anxiety, among a sample of college students. Two-hundred and twenty-seven students from a large mid-western university participated in this cross-sectional study. Students completed an online survey that evaluated NNS using a validated food frequency questionnaire. Stress and anxiety were evaluated using previously validated instruments. Most students reported very low/low/average concern for stress (63.9%), and had low/moderate anxiety (82.3%). Participants experiencing high and very high levels of stress had significantly higher NNS consumption compared to those with a very low and low risk, and concern for stress (p < .046; d = 0.28). There was no difference however for NNS intake and anxiety. Reduction of artificial sweetener intake may be associated with stress levels among college students. However, more research is needed to examine any causal relationship between artificial sweetener intake and stress.

Low- and no-calorie sweetener intakes from beverages - an up-to-date assessment in four regions: Brazil, Canada, Mexico and the United States

The current assessment estimated exposure to four low- and no-calorie sweeteners (LNCS) (aspartame, acesulfame potassium (AceK), steviol glycosides and sucralose) from beverages in Brazil, Canada, Mexico and the United States, using up-to-date nationally representative consumption data and industry reported-use level information. Two modelling scenarios were applied - the probabilistic model was guided by reported use level data, with estimated intake for an individual leveraging market-weighted average use level of a particular LNCS in any given LNCS-sweetened beverage type, while the distributional (brand-loyal) model assumed consumer behaviour-led patterns, namely that an individual will be brand loyal to a pre-determined beverage type. Consumer-only and general population intake estimates were derived for the overall population and individual age categories, and compared to the respective acceptable daily intake (ADI) as established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) for each LNCS. The mean, 90th percentile and 95th percentile intake estimates were substantially lower than the ADI in both modelling scenarios, regardless of the population group or market. In the probabilistic model, the highest consumer-only intake was observed for AceK in Brazilian adolescents (95th percentile, 12.4% of the ADI), while the highest 95th percentile intakes in the distributional model were observed for sucralose in Canadian adults at 20.9% of the ADI. This study provides the latest insights into current intakes of LNCS from water-based non-alcoholic LNCS-sweetened beverages in these regions, aligning well with those published elsewhere.

Trends and amounts of consumption of low-calorie sweeteners: A cross-sectional study

BACKGROUND AND AIMS

White sugar has been blamed to cause health consequences including diabetes and obesity. With the increased need to decrease sugar intake, attention was shifted towards sugar alternatives also known as low-calorie sweeteners. Low-calorie sweeteners are ubiquitous within food products, but their consumption among Lebanese adults isn't well elucidated. Our study aims to investigate the trends and amounts of low-calorie sweeteners' consumption in addition to their main sources among a sample of Lebanese adults.

METHODS

A cross-sectional study was conducted over 384 adult Lebanese individuals from both genders residing in Beirut and Mount-Lebanon from February to August 2020. After excluding eight individuals, 376 completed the survey. To assess the trends, frequency and quantity of low-calorie sweeteners' consumption, a questionnaire was filled by trained and licensed dietitians in addition to a previously validated food frequency questionnaire adapted to the most widely known products in the Lebanese market. Food products were divided into categories, amount of sweeteners in each item was obtained from the label, and analysis was performed according to the type of sweetener they are made of. Frequencies were converted into numbers of servings per day and multiplied by the standard portion size. Daily individual consumption of each sweetener apart was obtained by multiplying the amount of sweetener in each item consumed by total daily consumption. The amount in mg/kg was obtained by dividing total consumption of each sweetener apart by the mean weight of our population. The Statistical Package for Social Sciences (SPSS) was used for data entry and analysis.

RESULTS

Results showed that 94.4% were consuming an artificially-sweetened item at least once in the last six months. While weight loss and healthy lifestyle constituted the main reasons for past and current consumption respectively, safety and unpleasant taste affected consumption trends. Pills and powders' consumption was significantly associated with gender (p = 0.032) and dieting (p = 0.000) but not with age (p = 0.831), educational level (p = 0.294), living district (p = 0.421) or income (p = 0.828) where women and dieters used significantly more pills and powders than their counterparts. "Food and beverages" consumption was independent of all factors except age (p = 0.001); it peaked at 26-40 and declined thereafter. Consumption of low-calorie sweeteners came mainly from beverages and was as follows while remaining within the acceptable daily intake limits: aspartame: 98.9 mg/d (1.38 mg/kg/d); sucralose: 22.19 mg/d (0.31 mg/kg/d); acesulfame-K: 39.12 mg/d (0.55 mg/kg/d); stevia 3.28 mg/d (0.05 mg/kg/d). Food and beverages were consumed more than pills and powders due to unintentional consumption.

CONCLUSION

Despite that safety and unpleasant taste affected consumption of low-calorie sweetened products, intake of such products was found to be highly prevalent in the studied population. While remaining within the acceptable daily intake limits, consumption of food and beverages exceeded that of pills and powders due to unintentional consumption making awareness a necessity to help consumers make an informed decision. Moreover, a nation-level study is needed to generalize the results.

The Effect of Artificial Sweeteners Use on Sweet Taste Perception and Weight Loss Efficacy: A Review

Excessive consumption of sugar-rich foods is currently one of the most important factors that has led to the development of the global pandemic of obesity. On the other hand, there is evidence that obesity contributes to reduced sensitivity to sweet taste and hormonal changes affecting appetite, leading to an increased craving for sweets. A high intake of sugars increases the caloric value of the diet and, consequently, leads to weight gain. Moreover, attention is drawn to the concept of the addictive properties of sugar and sugary foods. A potential method to reduce the energy value of diet while maintaining the sweet taste is using non-nutritive sweeteners (NNS). NNS are commonly used as table sugar substitutes. This wide group of chemical compounds features high sweetness almost without calories due to its high sweetening strength. NNS include aspartame, acesulfame-K, sucralose, saccharin, cyclamate, neohesperidin dihydrochalcone (neohesperidin DC), neotame, taumatin, and advantame. The available evidence suggests that replacing sugar with NNS may support weight control. However, the effect of NNS on the regulation of appetite and sweet taste perception is not clear. Therefore, the review aimed to summarize the current knowledge about the use of NNS as a potential strategy for weight loss and their impact on sweet taste perception. Most studies have demonstrated that consumption of NNS-sweetened foods does not increase sweetness preference orenergy intake. Nonetheless, further research is required to determine the long-term effects of NNS on weight management.

Peter JV. Sugars and Sweet Taste: Addictive or Rewarding?

The notion of food "addiction" often focuses on the overconsumption of sweet tasting foods or so-called sugar "addiction". In the extreme, some have suggested that sugar and sweet tastes elicit neural and behavioral responses analogous to those observed with drugs of abuse. These concepts are complicated by the decades long uncertainty surrounding the validity and reproducibility of functional magnetic resonance imaging (fMRI) methodologies used to characterize neurobiological pathways related to sugar and sweet taste stimuli. There are also questions of whether sweet taste or post-ingestion metabolic consequences of sugar intake would lead to addiction or excessive caloric intake. Here, we present a focused narrative review of literature related to the reward value of sweet taste which suggests that reward value can be confounded with the construct of "addictive potential". Our review seeks to clarify some key distinctions between these constructs and questions the applicability of the addiction construct to human over-eating behaviors. To adequately frame this broad discussion requires the flexibility offered by the narrative review paradigm. We present selected literature on: techniques used to link sugar and sweet tastes to addiction neurobiology and behaviors; sugar and sweet taste "addiction"; the relationship of low calorie sweetener (LCS) intake to addictive behaviors and total calorie intake. Finally, we examined the reward value of sweet tastes and contrasted that with the literature describing addiction. The lack of reproducibility of fMRI data remains problematic for attributing a common neurobiological pathway activation of drugs and foods as conclusive evidence for sugar or sweet taste "addiction". Moreover, the complicated hedonics of sweet taste and reward value are suggested by validated population-level data which demonstrate that the consumption of sweet taste in the absence of calories does not increase total caloric intake. We believe the neurobiologies of reward value and addiction to be distinct and disagree with application of the addiction model to sweet food overconsumption. Most hypotheses of sugar "addiction" attribute the hedonics of sweet foods as the equivalent of "addiction". Further, when addictive behaviors and biology are critically examined in totality, they contrast dramatically from those associated with the desire for sweet taste. Finally, the evidence is strong that responses to the palatability of sweets rather than their metabolic consequences are the salient features for reward value. Thus, given the complexity of the controls of food intake in humans, we question the usefulness of the "addiction" model in dissecting the causes and effects of sweet food over-consumption.

Low-calorie sweeteners and human health: a rapid review of systematic reviews

INTRODUCTION

Low-calorie sweeteners are increasingly prevalent in the food supply and their consumption has increased in recent decades. Although low-calorie sweeteners approved for use are considered safe from a toxicological perspective, their short- and long-term impacts on chronic disease risk remain uncertain. The aim of this review was to summarize the evidence from systematic reviews on low-calorie sweetener use and chronic conditions and risk factors in children and adults.

METHODS

MEDLINE and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews of randomized and nonrandomized studies that considered low-calorie sweeteners in relation to type 2 diabetes, cardiovascular disease, cancer, anthropometric measures, hypertension, hyperglycemia, hyperlipidemia, insulin resistance, and dental caries. Data were extracted from 9 reviews deemed of moderate or high quality on the basis of AMSTAR-2.

RESULTS

Narrative synthesis suggested inconsistent evidence on low-calorie sweetener use in relation to chronic conditions and associated risk factors, with nonrandomized studies suggesting positive associations and randomized studies suggesting negative or no associations.

CONCLUSION

Continued research on the long-term health impacts of low-calorie sweeteners across all life stages is warranted.

Dietary and Health Correlates of Sweetened Beverage Intake: Sources of Variability in the National Health and Nutrition Examination Survey (NHANES)

Recent studies using data from the National Health and Nutrition Examination Survey (NHANES) have used inconsistent approaches to identify and categorize beverages, especially those containing low-calorie sweeteners (LCS), also referred to as low-calorie sweetened beverages (LCSBs). Herein, we investigate the approaches used to identify and categorize LCSBs in recent analyses of NHANES data. We reviewed published studies examining LCS consumption in relation to dietary and health outcomes and extracted the methods used to categorize LCS as reported by the authors of each study. We then examined the extent to which these approaches reliably identified LCSBs using the Internet Archive Wayback Machine to examine beverage ingredients lists across three NHANES cycles (2011–2016). None of the four general strategies used appeared to include all LCSBs while also excluding all beverages that did not contain LCS. In some cases, the type of sweetener in the beverage consumed could not be clearly determined; we found 9, 16, and 18 of such “mixed” beverage identifiers in the periods 2011–2012, 2013–2014, and 2015–2016, respectively. Then, to illustrate how heterogeneity in beverage categorization may impact the outcomes of published analyses, we compared results of a previously published analysis with outcomes when “mixed” beverages were grouped either all as LCSBs or all as sugary beverages. Our results suggest that caution is warranted in design and interpretation of studies using NHANES data to examine dietary and health correlates of sweetened beverage intake.

Effects of Unsweetened Preloads and Preloads Sweetened with Caloric or Low-/No-Calorie Sweeteners on Subsequent Energy Intakes: A Systematic Review and Meta-Analysis of Controlled Human Intervention Studies

Effects of isocaloric (sweetness differences but constant calories) preloads and isosweet (caloric differences but constant sweetness) preloads, as well as preloads that were neither isosweet nor isocaloric (sweetness and caloric differences) on subsequent ad libitum meal and total (preload + ad libitum) energy intakes were investigated. Thirty-five crossover studies were eligible for inclusion, representing 116 comparisons (41, isocaloric; 41, isosweet; and 34, neither isosweet nor isocaloric). References of existing reviews and literature from 4 databases were searched. The calculated raw mean differences in ad libitum and total energy intakes were pooled in meta-analyses using a random-effects model and the inverse of the variance as the weighting factor. Energy intakes at an ad libitum meal were significantly lower for low-/no-calorie sweetener (LNCS)-sweetened compared with unsweetened preloads in the isocaloric comparison (-55.5 kcal; 95% CI: -82.9, -28.0 kcal; P < 0.001); however, the difference in energy intake was not significant in additional sensitivity analyses (i.e., removal of comparisons where the matrix was a capsule and when xylitol was the LNCS). For the isosweet comparison, although the pooled energy intake at the ad libitum meal was significantly greater with the LNCS-sweetened preload compared with the caloric sweetener (CS)-sweetened preload (58.5 kcal; 95% CI: 35.4, 81.7 kcal; P < 0.001), the pattern was reversed when total energy intake was considered (-132.4 kcal; 95% CI: -163.2, -101.6 kcal; P < 0.001), explained by only partial compensation from the CS-sweetened preload. The results were similar when assessing ad libitum and total energy intakes when unsweetened compared with CS-sweetened preloads were consumed. Unsweetened or LNCS-sweetened preloads appear to have similar effects on intakes when compared with one another or with CS-sweetened preloads. These findings suggest that LNCS-sweetened foods and beverages are viable alternatives to CS-sweetened foods and beverages to manage short-term energy intake.

Effect of sucralose and aspartame on glucose metabolism and gut hormones

Non-nutritive sweeteners are thought to be useful replacements for caloric sweeteners in sweet food and beverages, since the reduction in energy and carbohydrate intake may lead to health benefits stemming from weight management and glycemic control. However, the potential effects of non-nutritive sweeteners on glucose metabolism and gut hormones have not been determined definitively. Here, the available evidence of the effects of aspartame and sucralose consumption on glucose metabolism and gut hormones is reviewed. A majority of studies have found that consumption of aspartame or sucralose has no effect on concentrations of blood glucose, insulin, or gut hormones; however, 2 trials have shown that aspartame consumption affects glucose, insulin, and glucagon-like peptide 1 concentrations, while only a few trials have shown that sucralose consumption affects glucose, insulin, and glucagon-like peptide 1 concentrations. One study found higher glucose concentrations after sucralose consumption, while 3 studies found lower concentrations and 33 studies found no change in glucose concentrations. Moreover, only 4 studies reported increased concentrations of glucagon-like peptide 1. Three studies reported decreased insulin sensitivity following sucralose consumption, while 1 trial reported an increase in insulin sensitivity. In summary, the evidence from the clinical trials conducted to date is contradictory because of the different protocols used.

Consumption of sweeteners at different stages of life: effects on body mass, food and drink intake in male and female Wistar rats

The consumption of non-nutritive sweeteners has increased in the last decades. However, there are doubts about its consumption and its impact on body mass and metabolic alterations. For this reason, this study investigates the effects of the consumption of nutritive and non-nutritive sweeteners on body mass in different life stages of male and female Wistar rats: Childhood, adolescence, young adult, adulthood, and aged. For this purpose, 8 groups of male and female rats were used (10 per group/gender): sucrose 10%, glucose 14%, fructose 7%, acesulfame K 0.05%, aspartame:acesulfame mixture 1.55%, sucralose 0.017%, saccharin 0.033%, and a control group. Only in aged male rats (504 days) there were significant differences in body mass. In both genders, there were differences in food, drink, and energy intake along all life stage. It is concluded that non-nutritive sweeteners when consumed together with a balanced diet did not cause a greater body mass gain.

Consumption of Beverages Containing Low-Calorie Sweeteners, Diet, and Cardiometabolic Health in Youth With Type 2 Diabetes

BACKGROUND

Low-calorie sweetened beverages (LCSBs) are commonly used as a lower-calorie alternative to sugar-sweetened beverages (SSBs) by individuals with type 2 diabetes. However, little is known about how intake of LCSBs is related to dietary intake and cardiometabolic health, particularly among youth.

OBJECTIVE

To test the hypothesis that having higher baseline LCSB intake and increasing LCSB intake over 2 years of follow-up are associated with poorer dietary intake and higher cardiometabolic risk factors among youth enrolled in the Treatment Option for Type 2 Diabetes in Adolescents and Youth (TODAY) study.

DESIGN

Secondary, exploratory, analysis of baseline and longitudinal data from the TODAY study, which was a randomized, multisite trial conducted from 2004 to 2012, to compare effects of 3 interventions (metformin alone, metformin + rosiglitazone, and metformin + intensive lifestyle intervention) on glycemic control in youth with type 2 diabetes.

PARTICIPANTS/SETTING

The study included 476 children and adolescents (10-17 years, mean body mass index 34.9 ± 7.8 kg/m²), who were participants in the multicenter (n = 15) TODAY study.

MAIN OUTCOME MEASURES

Diet was assessed using a food frequency questionnaire. Differences in energy intake, macronutrients, food group intakes, and cardiometabolic biomarkers were evaluated in 3 groups of LCSB consumers at baseline (low [1-4 servings/wk], medium [5-11 servings/wk], and high [≥12 servings/wk]), each compared with nonconsumers, and between 4 groups of change in LCSB intake (nonconsumption at start of study and nonconsumption after 2 years, increase in consumption after 2 years, decrease in consumption after 2 years, and high consumption at start of study and high consumption after 2 years).

STATISTICAL ANALYSES PERFORMED

Multivariable linear regression was performed at baseline and longitudinally over 2 years of follow-up.

RESULTS

Energy (kilocalories), fiber, carbohydrate, total fat, saturated fat, and protein intake (grams) were higher among high LCSB consumers compared with nonconsumers at baseline. No associations were observed between LCSB consumption and cardiometabolic risk factors at baseline. Change in LCSB intake between baseline and follow-up was not associated with change in energy intake or cardiometabolic risk factors. Participants who decreased LCSB consumption reported greater increases in sugar intake (18.4 ± 4.8 g) compared with those who increased LCSB consumption (5.7 ± 4.9 g) or remained high LCSB consumers (5.9 ± 7.4 g), but this trend was not statistically significant after a correction for multiple testing.

CONCLUSIONS

LCSB consumption was associated with higher energy intake in youth with type 2 diabetes, with the highest energy intakes reported in high LCSB consumers. Those who reduced LCSB consumption tended to report greater increases in sugar intake during follow-up, but further studies are needed to better understand this trend.

Tiered intake assessment for low- and no-calorie sweeteners in beverages

A tiered intake assessment approach is presented and applied to derive the maximum potential global low- and no-calorie sweeteners (LNCS) intake estimates. The US and Uk markets served as representative for the world and the EU region, respectively, to determine the maximum potential exposure for acesulfame potassium (AceK), aspartame, saccharin, steviol glycosides, and sucralose in various subpopulations, including brand-loyal consumers. Conservative intake estimates for LNCS used in non-alcoholic beverages were calculated for the general population 2 + y, toddlers (12-35 months (US) or 18-35 months (UK)), young children 3-9 y, adolescents 10-17 y, adults 18-64 y, elderly 65-74 y, and very elderly 75 + y based on assumed uses in high beverage consumption markets, leveraging either the 2-day food consumption data from the 2013-2016 US National Health and Nutrition Examination Survey or the 4-day food consumption data from the 2008-2017 UK National Diet and Nutrition Survey Rolling Programme. Strong concordance between the refined budget method and the brand-loyal deterministic approach was shown, the latter assumes the maximum industry-reported global LNCS use level is present in 100% of non-alcoholic beverages. This study shows that safety of LNCS in beverages at proposed use levels can be supported for any geography, with all intake estimates falling below the acceptable daily intake in refined assessments. Importantly, this study shows the refined budget method to be a valid first-tier screening assessment in prioritising those LNCS that may benefit from more refined intake assessments when warranted.

High-dose saccharin supplementation does not induce gut microbiota changes or glucose intolerance in healthy humans and mice

BACKGROUND

Non-caloric artificial sweeteners (NCAS) are widely used as a substitute for dietary sugars to control body weight or glycemia. Paradoxically, some interventional studies in humans and rodents have shown unfavorable changes in glucose homeostasis in response to NCAS consumption. The causative mechanisms are largely unknown, but adverse changes in gut microbiota have been proposed to mediate these effects. These findings have raised concerns about NCAS safety and called into question their broad use, but further physiological and dietary considerations must be first addressed before these results are generalized. We also reasoned that, since NCAS are bona fide ligands for sweet taste receptors (STRs) expressed in the intestine, some metabolic effects associated with NCAS use could be attributed to a common mechanism involving the host.

RESULTS

We conducted a double-blind, placebo-controlled, parallel arm study exploring the effects of pure saccharin compound on gut microbiota and glucose tolerance in healthy men and women. Participants were randomized to placebo, saccharin, lactisole (STR inhibitor), or saccharin with lactisole administered in capsules twice daily to achieve the maximum acceptable daily intake for 2 weeks. In parallel, we performed a 10-week study administering pure saccharin at a high dose in the drinking water of chow-fed mice with genetic ablation of STRs (T1R2-KO) and wild-type (WT) littermate controls. In humans and mice, none of the interventions affected glucose or hormonal responses to an oral glucose tolerance test (OGTT) or glucose absorption in mice. Similarly, pure saccharin supplementation did not alter microbial diversity or composition at any taxonomic level in humans and mice alike. No treatment effects were also noted in readouts of microbial activity such as fecal metabolites or short-chain fatty acids (SCFA). However, compared to WT, T1R2-KO mice were protected from age-dependent increases in fecal SCFA and the development of glucose intolerance.

CONCLUSIONS

Short-term saccharin consumption at maximum acceptable levels is not sufficient to alter gut microbiota or induce glucose intolerance in apparently healthy humans and mice.

TRIAL REGISTRATION

Trial registration number NCT03032640 , registered on January 26, 2017. Video abstract.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Acute glycemic and insulinemic effects of low-energy sweeteners: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

It has been suggested that low-energy sweeteners (LES) may be associated with an increased risk of metabolic diseases, possibly due to stimulation of glucose-responsive mechanisms.

OBJECTIVE

We conducted a systematic review and meta-analysis of human intervention studies examining the acute effect of LES intake on postprandial glucose (PPG) and postprandial insulin (PPI) responses, in order to comprehensively and objectively quantify these relations.

METHODS

We systematically searched the Medline, OVID FSTA, and SCOPUS databases until January 2020. Randomized controlled trials comparing acute postprandial effects on PPG and/or PPI after exposure to LES, either alone, with a meal, or with other nutrient-containing preloads to the same intervention without LES were eligible for inclusion. PPG and PPI responses were calculated as mean incremental area under the curve divided by time. Meta-analyses were performed using random effects models with inverse variance weighing.

RESULTS

Twenty-six papers (34 PPG trials and 29 PPI trials) were included. There were no reports of statistically significant differences in the effects of LES on PPG and PPI responses compared with control interventions. Pooled effects of LES intake on the mean change difference in PPG and PPI were -0.02 mmol/L (95% CI: -0.09, 0.05) and -2.39 pmol/L (95% CI: -11.83, 7.05), respectively. The results did not appreciably differ by the type or dose of LES consumed, cointervention type, or fasting glucose and insulin levels. Among patients with type 2 diabetes, the mean change difference indicated a smaller PPG response after exposure to LES compared with the control (-0.3 mmol/L; 95% CI: -0.53, -0.07).

CONCLUSIONS

Ingestion of LES, administered alone or in combination with a nutrient-containing preload, has no acute effects on the mean change in postprandial glycemic or insulinemic responses compared with a control intervention. Apart from a small beneficial effect on PPG (-0.3 mmol/L) in studies enrolling patients with type 2 diabetes, the effects did not differ by type or dose of LES, or fasting glucose or insulin levels. This review and meta-analysis was registered at PROSPERO as CRD42018099608.

Daily Eating Frequency in US Adults: Associations with Low-Calorie Sweeteners, Body Mass Index, and Nutrient Intake (NHANES 2007-2016)

Studies of relationships between eating frequency and/or timing and energy intake have not examined associations with low-calorie sweeteners (LCS). We assessed the frequency of eating behavior related to LCS consumption emphasizing timing, calorie intake, and body mass index (BMI) among United States (US) adults aged ≥19 years. Using the National Health and Nutrition Examination Survey (NHANES) 2007-2016, we defined eating episodes as food and/or beverage intake within 15 min of one another over the first 24-h dietary recall. We coded items ingested during episodes (n = 136,938) and assessed LCS presence using US Department of Agriculture (USDA) food files. Episode analysis found intakes of foods only (27.4%), beverages only (29.5%), and foods with beverages (43.0%). LCS items were consumed without concurrent calories from other sources in fewer than 2.7% of all episodes. Within participants having normal weight (29.4%), overweight (33.6%) and obese (37.1%) BMIs, LCS consumers (35.2% overall) evidenced: more episodes/day; and fewer: calories, carbohydrates, fats, and protein per episode. Per person, those consuming LCS had lower total calories and higher fiber intake per day. LCS consumption was associated with higher BMI. Number of eating episodes/day and longer hours when eating episodes occurred were also consistently associated with higher BMI. Consuming LCS did not modify these relationships. These results did not show that LCS consumption was associated with increased caloric intake from other dietary sources.

Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions

A consensus workshop on low-calorie sweeteners (LCS) was held in November 2018 where seventeen experts (the panel) discussed three themes identified as key to the science and policy of LCS: (1) weight management and glucose control; (2) consumption, safety and perception; (3) nutrition policy. The aims were to identify the reliable facts on LCS, suggest research gaps and propose future actions. The panel agreed that the safety of LCS is demonstrated by a substantial body of evidence reviewed by regulatory experts and current levels of consumption, even for high users, are within agreed safety margins. However, better risk communication is needed. More emphasis is required on the role of LCS in helping individuals reduce their sugar and energy intake, which is a public health priority. Based on reviews of clinical evidence to date, the panel concluded that LCS can be beneficial for weight management when they are used to replace sugar in products consumed in the diet (without energy substitution). The available evidence suggests no grounds for concerns about adverse effects of LCS on sweet preference, appetite or glucose control; indeed, LCS may improve diabetic control and dietary compliance. Regarding effects on the human gut microbiota, data are limited and do not provide adequate evidence that LCS affect gut health at doses relevant to human use. The panel identified research priorities, including collation of the totality of evidence on LCS and body weight control, monitoring and modelling of LCS intakes, impacts on sugar reduction and diet quality and developing effective communication strategies to foster informed choice. There is also a need to reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede low-energy product development and reformulation.

Non-nutritive Sweeteners and Glycaemic Control

PURPOSE OF REVIEW

The consumption of foods and beverages containing non-nutritive sweeteners (NNS) has increased worldwide over the last three decades. Consumers' choice of NNS rather than sugar or other nutritive sweeteners may be attributable to their potential to reduce weight gain.

RECENT FINDINGS

It is not clear what the effects of NNS consumption are on glycaemic control and the incidence of type 2 diabetes. This review aims to examine this question in epidemiological, human intervention and animal studies. It is not clear that NNS consumption has an effect on the incidence of type 2 diabetes or on glycaemic control even though there is some evidence for the modification of the microbiome and for interaction with sweet taste receptors in the oral cavity and the intestines' modification of secretion of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), ghrelin and glucose-dependent insulinotropic polypeptide (GIP), which may affect glycaemia following consumption of NNS. In conclusion, long-term studies of NNS consumption are required to draw a firm conclusion about the role of NNS consumption on glycaemic control.

Consumption of low-calorie sweetened beverages is associated with higher total energy and sugar intake among children, NHANES 2011-2016

OBJECTIVE

To examine associations between consumption of low-calorie sweetened beverages (LCSBs), sugar, and total energy intake in children in the United States.

METHODS

We used 24-hour dietary recalls from 7026 children enrolled in the National Health and Nutrition Examination Survey (NHANES) 2011 to 2016 to assess energy and macronutrient intake among LCSB (≥4 oz LCSB, <4 oz SB), SB (≥4 oz SB, <4 oz LCSB), and LCSB + SB consumers (≥4 oz each) compared with water consumers (≥4 oz water, <4 oz LCSB and SBs). Sample weights and complex survey procedures were used for all analyses.

RESULTS

Adjusting for body mass index (BMI) percentile, LCSB, SB, and LCSB + SB consumption was associated with 196, 312, and 450 more total calories and 15, 39, and 46 more grams of added sugar, which amounts to 60, 156, 184 more calories from added sugar, compared with water consumers (P < .05 for all pairwise comparisons). No differences in energy intake were observed between LCSB and SB consumers. [Correction added on 28 May 2019, after first online publication: In the preceding sentence, quantities of added sugar reported are in grams. The corresponding calories have also been specified in this version.] CONCLUSIONS: These findings challenge the utility of LCSB for weight management in children and adolescents.

Non-Nutritive (Artificial) Sweetener Knowledge among University Students

This study determined non-nutritive sweetener (NNS; artificial sweetener) depth of knowledge among university health and science students. An online survey was delivered to 1248 science students and completed by 493 respondents (19.0 ± 2.2 years old), evaluating ability to provide an NNS description/definition, examples of NNS from memory, and evaluate NNS word familiarity with a click-drag-box to identify six NNS by chemical name (CN) and six NNS by trade name (TN), relative to six decoy NNS, six caloric sweeteners, and six food items (mean ± standard deviation). NNS definitions contained 1.1 ± 1.1 of four previously defined elements suggestive of knowledge depth, with highest scores among self-described non-NNS users and food ingredient label users. Knowledge depth was not correlated with gender, age, American College Test score, or history of weight loss attempts. Without prompting, respondents could name 0.9 ± 1.1 NNS from memory, with highest scores among self-described non-NNS users (1.4 ± 0.8) and food ingredient label users (1.4 ± 0.8). NNS example memory was not correlated with gender, age, ACT score, or history of weight loss attempts. With the click-drag-box exercise, NNS were correctly identified 4.9 ± 1.0 times by TN and significantly less by CN (3.9 ± 1.9 times). Decoy NNS were incorrectly identified as being a real NNS 4.7 ± 1.3 times, while caloric sweeteners and food items were incorrectly identified as NNS 1.7 ± 1.7 times and 1.0 ± 1.5 times, (TN and Decoy NNS > CN > caloric sweetener and food item). NNS knowledge among university students may be inadequate for understanding what NNS are, if they consume NNS, or whether NNS are important for dietary health.

Comparisons of Nutrient Intakes and Diet Quality among Water-Based Beverage Consumers

Americans are encouraged to reduce intake of sugar-sweetened beverages (SSB). Zero and low-calorie water-based beverages can provide alternative options to SSB, though limited data are available to understand measures of diet quality across different beverage consumer groups. The purpose of this cross-sectional study was to quantify intake of added sugars, total sugars, carbohydrates, and diet quality among consumers of zero-calorie unsweetened beverages (ZCUB) compared to SSB; and, separately, among consumers of low- and no-calorie sweetened beverages (LNCSB) when compared to SSB. Dietary data from the 2009–2016 National Health and Nutrition Examination Survey (NHANES) were analyzed among three life stages by SSB, ZCUB, and LNCSB consumer groups and adjusted for participant characteristics and energy intake. Across all life stages, ZCUB and LNCSB consumers had lower mean intakes of total sugars, added sugars, and carbohydrates when compared to SSB consumers. Diet quality as measured by the Healthy Eating Index 2015 (HEI-2015) was also higher among ZCUB and LNCSB consumers compared to SSB consumers in analyses adjusted for participant characteristics. These results indicate that reduction of SSB from dietary patterns and replacement with ZCUB or LNCSB could help Americans improve overall diet quality.