Noncaloric Sweeteners in Children: A Controversial Theme

Maternal consumption and perinatal exposure to non-nutritive sweeteners: should we be concerned?

The context for this review is the rapid increase in the use of non-nutritive sweeteners (NNSs) instead of sugar in foods and beverages, a situation so prevalent in some countries that consumers are finding it increasingly challenging to access foods without NNSs. The benefits of consuming NNSs on obesity and diabetes are now being questioned, and studies have shown that they may exert physiological activities, sometimes independently of sweet taste receptor stimulation. Few studies, limited mainly to North American and European countries, have described the consumption of NNSs by pregnant or lactating women and infants. Most focus on beverages rather than foods, but all agree that consumption levels have increased dramatically. Although some studies report a negative impact of NNSs on the risk of preterm birth, increased birth weight and decreased gestational age, the level of evidence is low. Several studies have also reported increased weight gain in infancy, associated with maternal NNS intake. Interestingly, several NNSs have been detected in amniotic fluid and breast milk, usually (but not always) at concentrations below their established detection limit in humans. Unfortunately, the impact of chronic exposure of the fetus/infant to low levels of multiple NNSs is unknown. In conclusion, there is a stark contrast between the galloping increase in the consumption of NNSs and the small number of studies evaluating their impact in at-risk groups such as pregnant and lactating women and infants. Clearly, more studies are needed, especially in Latin America and Asia, to fill these gaps and update recommendations.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Evaluation of the Mexican warning label nutrient profile on food products marketed in Mexico in 2016 and 2017: A cross-sectional analysis

BACKGROUND

Different nutrient profiles (NPs) have been developed in Latin America to assess the nutritional quality of packaged food products. Recently, the Mexican NP was developed as part of the new warning label regulation implemented in 2020, considering 5 warning octagons (calories, sugar, sodium, saturated fats, and trans fats) and 2 warning rectangles (caffeine and non-nutritive sweeteners). The objective of this cross-sectional study was to evaluate the Mexican NP and other NPs proposed or used in Latin America against the Pan American Health Organization (PAHO) model.

METHODS AND FINDINGS

Nutrition content data of 38,872 packaged food products available in the Mexican market were collected in 2016 and 2017. The evaluation of the Mexican NP, including its 3 implementation phases of increasing stringency (2020, 2023, and 2025), was conducted by comparing the percentage of products classified as "healthy" (without warnings) or "less healthy" (with 1 or more warnings), as well as the number and type of warnings assigned to food products, against the PAHO NP. Using the calibration method, we compared the classifications produced by the PAHO model against those produced by the NP models of Ecuador, Chile (3 phases), Peru (2 phases), Uruguay, and Brazil. Kappa coefficients and Pearson correlations were estimated, and proportion tests were performed. We found that the 3 implementation phases of the Mexican NP had near to perfect agreement in the classification of healthy foods (Mexico NP models: 19.1% to 23.8%; PAHO model: 19.7%) and a strong correlation (>91.9%) with the PAHO model. Other NPs with high agreement with the PAHO model were the Ecuador (89.8%), Uruguay (82.5%), Chile Phase 3 (82.3%), and Peru Phase 2 (84.2%) NPs. In contrast, the Peru Phase 1, Brazil, and Chile Phase 1 NP models had the highest percentage of foods classified as healthy (49.2%, 47.1%, and 46.5%, respectively) and the lowest agreement with the PAHO model (69.9%, 69.3%, and 73%, respectively). Study limitations include that warnings considered by the Mexican NP models were evaluated as if all the warnings were octagon seals, while 2 out of the 7 were rectangular warnings (caffeine and non-nutritive sweeteners), and that our data are limited by the quality of the information reported in the list of ingredients and the nutrition facts table of the products.

CONCLUSIONS

The 3 implementation phases of the Mexican NP were useful to identify healthy food products. In contrast, the Peru Phase 1, Brazil, and Chile Phase 1 NP models may have limited usefulness for the classification of foods according to the content of ingredients of concern. The results of this study may inform countries seeking to adapt and evaluate existing NP models for use in population-specific applications.

Is There an Academic Bias against Low-Energy Sweeteners?

This perspective considers evidence of a common academic bias against low-energy sweeteners (LES). The core proposition is that this bias is manifested in research and reporting focused on generating and placing a negative spin on LESs, largely through selective citation, interpretation and reporting. The evidence centres on three inter-related points, which together may generate a misleading impression of the balance of evidence: (1) basic and mechanistic research on LES perpetuates “explanations” for unsubstantiated adverse effects of LES; (2) the literature on LES—particularly narrative reviews and commentaries—continually reprises hypotheses of adverse effects without acknowledging where these hypotheses have been rigorously tested and rejected; and (3) negative interpretations of the effects of LES largely rely upon selectively emphasising lower-quality research whilst ignoring or dismissing higher-quality evidence. The expert community should consider these issues in assuring scientific integrity and balance in the academic discourse on LES, and how this is translated into messages for public health and consumers.

Establishment of a Stable Acute Drug-Induced Liver Injury Mouse Model by Sodium Cyclamate

Objective

To establish a stable acute DILI mouse model and explore its possible pathogenesis.

Methods

Mice were randomly divided into control, low-dose, middle-dose and high-dose sodium cyclamate groups. Mice in the model group were intraperitoneally injected with corresponding doses of sodium cyclamate, and in the control group intraperitoneally injected with 0.9% normal saline. The toxic effects of sodium cyclamate on liver, heart, kidney were evaluated by biochemical index level and histomorphologically observed. The expression of TNF-α and IL-1β were measured by immunohistochemistry.

Results

1. The level of ALT in the low-dose and middle-dose groups at 24h, 72h, 120h and 168h were increased, also in the high-dose group at 24h, 72h and 120h. The level of AST in the low-dose group at 72h, 120h, 168h and in the middle-dose group at 168h were increased, also in the middle-dose and high-dose groups at 24h, 72h and 120h. The levels of CK, CK-MB and cTnT in the low-dose and middle-dose groups at 168h were increased, also in the high-dose group at 24h, 72h and 120h. 2. The damage of hepatocytes increased with the increase of sodium cyclamate dosage and treated time. 3. At 120h, the IOD/Area of TNF-α and IL-1β positive expression increased in the liver tissues with the increase of the dosage. In the heart and kidney tissues, the IOD/Area of TNF-α and IL-1β positive expression in the high-dose group increased significantly. In the kidney tissues, the IOD/Area of IL-1β positive expression in the middle-dose group increased significantly.

Conclusion

Sodium cyclamate-induced acute DILI mouse model can be established by intraperitoneal injection of 6000 mg/kg/day sodium cyclamate for 5 days successfully. The toxicity of sodium cyclamate to liver showed a dose-response and time-response relationship. Sodium cyclamate induced liver, heart and kidney injury closely related to the inflammatory response mediated by TNF-α and IL-1β.

Analysis of Caloric and Noncaloric Sweeteners Present in Dairy Products Aimed at the School Market and Their Possible Effects on Health

Over the past decades, Mexico has become one of the main sweetener-consuming countries in the world. Large amounts of these sweeteners are in dairy products aimed at the children’s market in various presentations such as yogurt, flavored milk, flan, and cheeses. Although numerous studies have shown the impact of sweeteners in adults, the current evidence for children is insufficient and discordant to determine if these substances have any risk or benefit on their well-being. Therefore, this study aimed to describe the sweeteners present in 15 dairy products belonging to the school-age children’s market in Mexico and their impact on health. These dairy products were selected through a couple of surveys directed at parents of school-age children. After that, the list of ingredients of each product was analyzed to identify their sweetener content. From there, exhaustive bibliographic research on sweeteners and their possible health effects was carried out, which included 109 articles and 18 studies. The results showed that at a neurological, endocrinological, cardiovascular, metabolic, osseous, renal, hepatic, dental, reticular, carcinogenic, and gut microbiota level; sucrose, fructose, high-fructose corn syrup, maltodextrins, sucralose, and acesulfame K, have a negative effect. While maltodextrins, stevia, polydextrose, and modified starch have a positive one. For these reasons, it is necessary to evaluate the advantages and disadvantages that the consumption of each sweetener entails, as well as a determination of the appropriate acceptable daily intake (ADI).

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.

Low-energy sweeteners and body weight: a citation network analysis

OBJECTIVE

Reviews on the relationship of low-energy sweeteners (LES) with body weight (BW) have reached widely differing conclusions. To assess possible citation bias, citation analysis was used to quantify the relevant characteristics of cited articles, and explore citation patterns in relation to review conclusions.

DESIGN

A systematic search identified reviews published from January 2010 to March 2020. Different characteristics (for example, type of review or research, journal impact factor, conclusions) were extracted from the reviews and cited articles. Logistic regression was used to estimate likelihood of articles with particular characteristics being cited in reviews. A qualitative network analysis linked reviews sub-grouped by conclusions with the types of articles they cited.

MAIN OUTCOME MEASURES

(OR; 95% CI) for likelihood that articles with particular characteristics were cited as evidence in reviews.

RESULTS

From 33 reviews identified, 183 different articles were cited (including other reviews). Narrative reviews were 62% less likely to be cited than systematic reviews with meta-analysis (OR 0.38; 0.16 to 0.86; p=0.03). Likelihood of being cited was higher for evidence on children than adults (OR 2.27; 1.59 to 3.25; p<0.0001), and with increased journal impact factor (OR 1.15; 1.00 to 1.31; p=0.04). No other factors were statistically significant in the main analysis, and few factors were significant in subgroup analyses. Network analysis showed that reviews concluding a beneficial relationship of LES with BW cited mainly randomised controlled trials, whereas reviews concluding an adverse relationship cited mainly observational studies.

CONCLUSIONS

Overall reference to the available evidence across reviews appears largely arbitrary, making citation bias likely. Differences in the conclusions of individual reviews map onto different types of evidence cited. Overall, inconsistent and selective use of the available evidence may account for the diversity of conclusions in reviews on LES and BW.

TRIAL REGISTRATION NUMBER

Prior to data analysis, the protocol was registered with the Open Science Framework (https://osf.io/9ghws).

Soft drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners?

The rapid increase in obesity, metabolic syndrome, and cardiovascular diseases (CVDs) has been related to the rise in sugar-added foods and sweetened beverages consumption. An interesting approach has been to replace sugar with alternative sweeteners (AS), due to their impact on public health. Preclinical and clinical studies, which analyze the safety of AS intake, are still limited. Major pathogenic mechanisms of these substances include ROS and AGEs formation. Indeed, endothelial dysfunction involving in the pathogenesis of micro- and macro-vascular diseases is mitochondrial dysfunction dependent. Hyperglycemia and endoplasmic reticulum stress together produce ROS, contributing to the development and progression of cardiovascular complications during type 2 diabetes (T2D), thus causing oxidative changes and direct damage of lipids, proteins, and DNA. Epidemiological studies in healthy subjects have suggested that the consumption of artificial AS can promote CV complications, such as glucose intolerance and predisposition to the onset of T2D, whereas natural AS could reduce hyperglycemia, improve lipid metabolism and have antioxidant effects. Long-term prospective clinical randomized studies are needed to evaluate precisely whether exposure to alternative sugars can have clinical implications on natural history and clinical outcomes, especially in children or during the gestational period through breast milk.

Trends in the Use of Low and No-Calorie Sweeteners in Non-Alcoholic Beverages in Slovenia

Excessive sugar intake and the associated increased obesity risk indicate that food reformulation is needed. Non-alcoholic beverages are often high in free sugars, making reformulation with low and no-calorie sweeteners (LNCS) a common choice. Our knowledge of the use of LNCS in the European food supply is, however, very limited. This study aimed to evaluate the trends in the use of LNCS in different non-alcoholic beverages in the Slovenian food supply over the course of two years. We assessed which LNCS are most used and how the use of LNCS affects energy and sugar content. We analyzed labeling information of non-alcoholic beverages in selected grocery stores, covering the majority of the Slovenian food supply. Selected grocery stores were located in the capital city (Ljubljana). LNCS were present in 13.2% and 15.5% of non-alcoholic beverages in the years 2017 and 2019, respectively. The use of LNCS has significantly increased only in energy drinks (p < 0.01). The most used LNCS in 2017 were acesulfame K, aspartame, and cyclamates. In 2019 the use of sucralose increased significantly (p < 0.01) to become the second most used LNCS. Energy and sugar content varied between subcategories, which depended on the presence of added sugar and LNCS. Comparison between the energy value and the presence of the LNCS showed an almost 50% lower energy content of beverages containing both added sugar and LNCS (E₂₀₁₇ = 92.8 kJ; E₂₀₁₉ = 96.2 kJ per 100 mL), compared with beverages with only added sugar (E₂₀₁₇ = 161.8 kJ; E₂₀₁₉ = 159.0 kJ per 100 mL). In beverages sweetened only with LNCS, the difference was even more noticeable (E₂₀₁₇ = 22.3 kJ; E₂₀₁₉ = 14.3 kJ per 100 mL). Results show that the use of LNCS can help producers reduce the energy value of non-alcoholic beverages. Still, compared to other countries, the offer of such products in the Slovenian food supply is relatively low. However, due to possible public health risks of excessive use of LNCS, producers should be further encouraged for reformulation and production of less sweet products without LNCS, enabling consumers to adapt to less sweet taste of beverages. Further monitoring of LNCS in the food supply is therefore recommended, preferably also with consideration of sales data.

Effects of Artificial Sweetener Consumption on Glucose Homeostasis and Its Association with Type 2 Diabetes and Obesity

Artificial sweeteners (ASs) are popular for their characteristic property of providing sweetness with few or no calories. They are frequently consumed to minimize energy intake and to combat obesity and its related adverse health effects. However, since their introduction, concerns have been raised regarding their safety. Extensive research has designed a number of studies to evaluate potential adverse effects, the top among them being interference with glucose homeostasis. Numerous studies have tried to prove that AS may contribute to the development of metabolic diseases including obesity and type 2 diabetes (T2D). The matter remains controversial and a favorite topic of research. The purpose of this review was to identify and discuss the published articles that have examined the effects of AS consumption on glucose homeostasis and its association with T2D and obesity. It was observed that studies have failed to present concrete evidence to establish a link between AS consumption and glucose homeostasis, obesity, or T2D. Most studies have flaws in the study design resulting in haphazard claims with no follow-up studies to confirm reliability. It is concluded that while it is not possible to claim that ASs are metabolically inert, at the moment the haphazard evidence is not enough to link their use with glucose metabolism, obesity or T2D. There is a need to design cohort and case-control studies with reliable sample sizes to establish a cause-effect relationship or to exclude claims of safety problems.

Consumption of non-nutritive sweeteners during pregnancy

In an effort to reduce sugar consumption to prevent diabetes mellitus and cardiovascular diseases, "sugar-free" or "no added sugar" products that substitute sugar with non-nutritive sweeteners (NNSs) (eg, Splenda, Sweet'N Low, and Stevia) have become increasingly popular. The use of these products during pregnancy has also increased, with approximately 30% of pregnant women reporting intentional NNS consumption. In clinical studies with nonpregnant participants and animal models, NNSs were shown to alter gut hormonal secretion, glucose absorption, appetite, kidney function, in vitro insulin secretion, adipogenesis, and microbiome dysbiosis of gut bacteria. In pregnant animal models, NNS consumption has been associated with altered sweet taste preference later in life and metabolic dysregulations in the offspring (eg, elevated body mass index, increased risk of obesity, microbiome dysbiosis, and abnormal liver function tests). Despite the accumulating evidence, no specific guidelines for NNS consumption are available for pregnant women. Furthermore, there are limited clinical studies on the effects of NNS consumption during pregnancy and postpartum and long-term outcomes in the offspring.

Overuse of Non-caloric Sweeteners in Foods and Beverages in Chile: A Threat to Consumers' Free Choice?

The prevalence of obesity among Chilean adults and children is one of the highest worldwide. To fight the constant increase of non-communicable diseases and the growing sales of sugar-sweetened beverages, the Chilean government recently enacted a new Law of Food Labeling and Advertising imposing the application of front-of-package warning labels in foodstuffs whose composition exceeds limits for critical nutrients including sugar. Accordingly, food companies have been reformulating their products, incorporating non-caloric sweeteners (NCSs) in partial or total replacement of sucrose. The number of NCS-containing foods and beverages, therefore, has been increasing in the last years. This study aims to identify the NCS-containing products from different food/beverage categories currently available on the Chilean market. Nineteen supermarkets and 13 food web pages were visited by trained dietitians to carry out a systematic search of ingredient information from the different food categories. Overall, 1,489 products were analyzed, of which 815 (55.5%) contained at least one NCS, being this proportion particularly high, compared to other countries. 67.1% of the dairy products, 31.5% of the cereal products, 49% of the processed fruits, 74.3% of the non-alcoholic beverages, and 46.2% of sweets and other desserts contained NCS. Considering the food categories more specifically oriented to children, NCSs were present in 98.8% of powder juices, 98.3% of the flavored milks, 91.2% of jellies, and 79% of the dairy desserts. Sucralose and steviol glycosides were the most widely used NCSs, these sweeteners being present, alone or mixed with other, in 73.5 and 39.7% of the NCS-containing products, respectively, while the use of saccharin and cyclamate was low. In addition, 80 tabletop NCSs were available in the local market, 91.2% of them being sucralose and steviol glycosides (alone or combined). The high number of food products containing steviol glycosides makes very plausible that the daily consumption of this NCS in the pediatric populations could exceed its acceptable daily intake (ADI). The fact that there are no NCS-free foods alternatives for certain food categories, especially for children, is worrying.

Intake of Non-Nutritive Sweeteners in Chilean Children after Enforcement of a New Food Labeling Law that Regulates Added Sugar Content in Processed Foods

After enforcement of a new food labeling law in 2016, Chile exhibits a greater offer to reduced sugar products with addition of non-nutritive sweeteners (NNS). Many of these products are consumed by children, who are at greater risk of reaching the acceptable daily intake (ADI) of these food additives. The objective of this study was to evaluate the intake levels of NNS in Chilean schoolchildren after the enactment of the aforementioned law. A total of 250 Chilean children 6-12 years old were surveyed. NNS intake was assessed through a food frequency questionnaire. All children evaluated consumed at least one NNS during the previous month. Sucralose had the highest consumption frequency reaching 99.2%, followed by acesulfame-K (92.8%), stevia (86.0%), and aspartame (85.2%). Aspartame showed the highest median intake, which came mainly from beverages (96%). No children exceeded the ADI of any NNS. Smaller children exhibited a higher body weight-adjusted intake of sucralose, acesulfame-K, stevia, and aspartame (p < 0.05). In Chile, a wide range of processed foods with NNSs is available and all schoolchildren evaluated consumed at least one product containing NNS. However, this consumption does not exceed defined ADIs for any of the six sweeteners authorized for food use in Chile.

When the beverage is sweet, how does the liver feel?

Purpose of review

The purpose of this paper is to both review the available data and also highlight the gaps in knowledge, regarding the link between pediatric NASH and different type of sweeteners including caloric sweeteners (CS) and non-caloric sweeteners (NCS).

Recent findings

Studies have demonstrated that patients with NASH generally have had an unhealthy diet, characterized by on overconsumption of carbohydrates especially fructose. Mechanistically, a high-fructose diet reduces hepatic lipid oxidation, increases proinflammatory response, increases intestinal permeability and decreases microbiome diversity. Consumption and availability of NCS has therefore been increasing dramatically. Most NCS are not considered to be metabolized in the body and therefore thought to be safe for consumption. It was reported that pharmacological properties of rebaudioside, a type of NCS, as a potential hepatoprotector are through anti-inflammatory and antifibrotic mechanisms, associated with enhancing glucose-induced insulin secretion and inducing the difference of microbiome diversity.

Summary

Diet is an important factor in the pathogenesis of NAFLD and popular dietary patterns are contributing to the increased replacement of natural sweeteners with NCS. Screening for NAFLD by pediatricians and counseling on the avoidance of sugar-sweetened beverages are recommended. We feel that the various NCS available to the consumer today merit further investigation, and may potentially have hitherto unknown effects on hepatic metabolic function.

Liquid Chromatography Analysis of Common Nutritional Components, in Feed and Food

Food and feed laboratories share several similarities when facing the implementation of liquid-chromatographic analysis. Using the experience acquired over the years, through application chemistry in food and feed research, selected analytes of relevance for both areas were discussed. This review focused on the common obstacles and peculiarities that each analyte offers (during the sample treatment or the chromatographic separation) throughout the implementation of said methods. A brief description of the techniques which we considered to be more pertinent, commonly used to assay such analytes is provided, including approaches using commonly available detectors (especially in starter labs) as well as mass detection. This manuscript consists of three sections: feed analysis (as the start of the food chain); food destined for human consumption determinations (the end of the food chain); and finally, assays shared by either matrices or laboratories. Analytes discussed consist of both those considered undesirable substances, contaminants, additives, and those related to nutritional quality. Our review is comprised of the examination of polyphenols, capsaicinoids, theobromine and caffeine, cholesterol, mycotoxins, antibiotics, amino acids, triphenylmethane dyes, nitrates/nitrites, ethanol soluble carbohydrates/sugars, organic acids, carotenoids, hydro and liposoluble vitamins. All analytes are currently assayed in our laboratories.