Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.

Artificial sweetener as a historical window to culturally situated health

This article employs the history of artificial sweetener consumption in the United States as a window onto the ways in which American women defined health as a physical and cultural construct in the mid-20th century. It uses, as an evidentiary basis, two consumer case studies: the initial adoption of saccharin and cyclamates in the 1950s, and the defense of saccharin in the wake of pending FDA restrictions in 1977. These instances suggest that individuals have historically based their assessment of healthy food products on both their understanding of the products' physical impact and their set of held values, attitudes, and beliefs particular to a historical moment. They also suggest that gender, class, and geographic location are formative influences on how those values, attitudes, and beliefs are constructed. The history of artificial sweetener consumption points to the importance of considering health from a physical and cultural point of view in attempts to shape nutrition practice and policy in the United States.

[Restless legs due to ingestion of 'light' beverages containing saccharine. Results of an N-of-1 trial]

To determine whether there was a connection between the complaint of restless legs and the ingestion of artificial sweeteners in a patient with these symptoms after drinking certain 'light' beverages, a randomised, double-blind, placebo-controlled N-of-1 trial with a crossover design was used. During a period of 48 days, the patient took 4 capsules per day containing either 150 mg of cyclamate, 22.5 mg of saccharine, both sweeteners, or placebo on two successive days. Between each of these 2-day periods there was a 2-day rest period during which no capsules were taken. The hospital pharmacist had prepared the capsules and determined the sequence of the 2-day periods on a random basis. The patient did not know which capsules he was taking. Every day on arising, starting 3 weeks before the trial period, the patient noted the intensity and duration of the symptoms in the late evening and previous night. For this notation he used an 11-point scale, from 0 (= no restless legs) to 10 (= almost total inability to sleep because of restless legs). A score of 1-3 corresponded to mild symptoms that had no effect on the patient's sleep; at a score of 4-6 his sleep was disturbed and at a score of 7-10 the patient hardly slept at all. The patient had symptoms more often while using saccharine or the combination of saccharine and cyclamate than when taking the placebo (4 and 4 versus 2 of the 6 nights); moreover, the average score was then statistically significantly higher (5.2 and 5.8 versus 3-3). It was concluded that there was a connection between the patient's complaints of restless legs and the use of saccharine, but not the use of cyclamate.

[Restless legs due to ingestion of 'light' beverages containing saccharine; results of an N-of-1 trial]

OBJECTIVE

To determine whether there was a connection between the complaint of restless legs and the ingestion of artificial sweeteners in a patient with these symptoms after drinking certain 'light' beverages.

DESIGN

Randomised, double-blind, placebo-controlled N-of-1 trial with a cross-over design.

METHOD

During a period of 48 days, the patient took 4 capsules per day containing either 150 mg of cyclamate, 22.5 mg of saccharine, both sweeteners, or placebo on two successive days. Between each of these 2-day periods there was a 2-day rest period during which no capsules were taken. The hospital pharmacist had prepared the capsules and determined the sequence of the 2-day periods on a random basis. The patient did not know which capsules he was taking. Every day on arising, starting 3 weeks before the trial period, the patient noted the intensity and duration of the symptoms in the late evening and previous night. For this notation he used an 11-point scale, from 0 (= no restless legs) to 10 (= almost total inability to sleep because of restless legs).

RESULTS

A score of 1-3 corresponded to mild symptoms that had no effect on the patient's sleep; at a score of 4-6 his sleep was disturbed and at a score of 7-10 the patient hardly slept at all. The patient had symptoms more often while using saccharine or the combination of saccharine and cyclamate than when taking the placebo (4 and 4 versus 2 ofthe 6 nights); moreover, the average score was then statistically significantly higher (5.2 and 5.8 versus 3.3).

CONCLUSION

There was a connection between the patient's complaints of restless legs and the use of saccharine, but not the use of cyclamate.

Artificial sweeteners--do they bear a carcinogenic risk?

Artificial sweeteners are added to a wide variety of food, drinks, drugs and hygiene products. Since their introduction, the mass media have reported about potential cancer risks, which has contributed to undermine the public's sense of security. It can be assumed that every citizen of Western countries uses artificial sweeteners, knowingly or not. A cancer-inducing activity of one of these substances would mean a health risk to an entire population. We performed several PubMed searches of the National Library of Medicine for articles in English about artificial sweeteners. These articles included 'first generation' sweeteners such as saccharin, cyclamate and aspartame, as well as 'new generation' sweeteners such as acesulfame-K, sucralose, alitame and neotame. Epidemiological studies in humans did not find the bladder cancer-inducing effects of saccharin and cyclamate that had been reported from animal studies in rats. Despite some rather unscientific assumptions, there is no evidence that aspartame is carcinogenic. Case-control studies showed an elevated relative risk of 1.3 for heavy artificial sweetener use (no specific substances specified) of >1.7 g/day. For new generation sweeteners, it is too early to establish any epidemiological evidence about possible carcinogenic risks. As many artificial sweeteners are combined in today's products, the carcinogenic risk of a single substance is difficult to assess. However, according to the current literature, the possible risk of artificial sweeteners to induce cancer seems to be negligible.

Cyclamate intake and cyclohexylamine excretion are not related to male fertility in humans

Cyclamate and its metabolite cyclohexylamine affect male fertility in high dose animal studies, but this affect has not been investigated in epidemiological studies. This paper reports the first epidemiological study designed to investigate the possibility of a relationship between cyclamate and cyclohexylamine and male fertility in humans, in which 405 cases of clinically defined infertility in men and 379 controls were surveyed. Semen evaluation, urine analysis for cyclamate and cyclohexylamine and dietary questionnaires were compared between cases and controls. No evidence was found of a significant association between cyclamate intake and male infertility; neither high cyclamate nor high cyclohexylamine excretion were associated with elevated risk. The lack of association remained after adjusting by age, area of residence, education, total energy intake and other variables. No significant correlations were observed between cyclamate intake, metabolism or excretion, and sperm count and motility. The results demonstrate no effect of cyclamate or cyclohexylamine on male fertility at the present levels of cyclamate consumption.

[Artificial sweeteners--are they potentially carcinogenic?]

BACKGROUND

Artificial sweeteners have rapidly evolved over the last 20 years and are added to a broad variety of food, drinks, drugs, and hygiene products. Since their introduction, especially mass media have reported about potential cancer risks, which has attributed to undermine the people's sense of security. It can be assumed that every citizen of the western countries is using artificial sweeteners--knowingly or not. A cancer-inducing activity of one of these substances would mean a health risk to an entire population.

STUDIES

This article gives an overview about the most important publications dealing with the cancerogenic potential of artificial sweeteners.

Use of artificial sweeteners to promote alcohol consumption by rats

Cirrhosis may be reliably produced in rats by exposing them intermittently to low levels of carbon tetrachloride vapour while feeding alcohol in the Lieber-DeCarli liquid diet. Providing the alcohol in drinking water that has been sweetened with sucrose is a cheaper and more convenient method but it does not yield reliable results. This study aimed to determine whether alcohol in drinking water sweetened with artificial sweeteners would give adequate alcohol intake to achieve the desired hepatic effects. Rats were fed alcohol (8% v/v) in drinking water sweetened with sucrose (5% w/v) (n = 12), or with one of the artificial sweeteners aspartame (0.025%), saccharin (0.025%) or cyclamate (0.05%) (n = 8 per agent). During the alcohol treatment the animals were exposed to carbon tetrachloride vapour, 40 ppm, six hours per night for five nights per week, over a period of 14 weeks. All groups achieved good alcohol intakes of 5-6 g/kg/day. Only one rat, in the aspartame group, became cirrhotic; all the others had varying degrees of fibrosis which did not differ significantly among the treatments. Although it was not effective in reliably achieving cirrhosis, sweetening the alcohol solution with artificial sweeteners led to reasonable alcohol intakes with resultant hepatic fibrosis, and without the high carbohydrate intake which occurs when sucrose is used.

[Abuse of artificial sweetener as differential diagnosis of lactose intolerance]

A two year old dystrophic boy with chronic diarrhea was described. At the age of 6 month the boy developed a severe gastroenteritis with a secundary lactase deficiency. Dietary treatment was however not successful and consequently the boy became dystrophic. At last, an abuse of sweetener was diagnosed.

Bladder cancer and the consumption of alcoholic beverages in Spain

The relationship between bladder cancer and alcohol consumption was investigated in a case-control study conducted in 506 patients (453 males and 53 females) with diagnoses of papillary urothelial carcinoma during 1978-1982 at "La Paz" hospital (Madrid), and an equal number of controls matched for age, sex and date of admission to the hospital. The results showed that the risk of bladder cancer does not increase with the intake of beer, wine and spirit beverages. However, a high risk of bladder cancer was associated with consumption of wine mixed with "gaseosa" (a refreshment beverage consisting of carbonated water plus artificial sweeteners).

[Etiology of bladder cancer]

Multiple agents have been suggested as urinary bladder carcinogens. Of these, certain aromatic amines and some tryptophan metabolites (Anthranilic acid, 3 hydroxy Anthranilic acid) have been proved to be carcinogenic. Others are suggested but are not conclusively proved as carcinogenic agents. Various animal species have been used as experimental models for the study of induction of cancer of the bladder and substantial progress has been made in the search for etiologic factors and pathogenesis of bladder tumors. A carcinogenic model of cancer bladder induction is proposed. However, knowledge of the tumorigenesis of cancer of the bladder is still limited and fragmentary. It appears, however, that Tryptophan dysmetabolism play a major role in this field and future experimental and epidemiologic studies should take this fact into consideration.

Artificial sweeteners and cancer of the lower urinary tract

We evaluated the relation between cancer of the lower urinary tract and the use of artificial sweeteners in a case-control study of 592 patients with lower-urinary-tract cancer (94 per cent of whom had a bladder tumor) and 536 controls chosen from the general population of the study area. A history of use or artificial sweeteners and exposure to other known or suspected risk factors was determined by interview. In those who had used dietetic beverages and in those who had used sugar substitutes, the relative risk of lower-urinary-tract cancer was estimated as 0.9 (0.7 to 1.2, 95 per cent confidence interval), as compared with 1 in nonusers of artificial sweeteners. Among men, the relative risk was 0.8 (0.6 to 1.1) in those who had used dietetic beverages and 0.8 (0.5 to 1.1) in those who had used sugar substitutes. Among women, the corresponding relative risks were 1.6 (0.9 to 2.7) and 1.5 (0.9 to 2.6). Increasing frequency of duration of use of artificial sweeteners was not consistently associated with increasing relative risk. This study suggests that, as a group, users of artificial sweeteners have little or no excess risks of cancer of the lower urinary tract.

Saccharin, cyclamate, and human bladder cancer. No evidence of an association

An epidemiologic study designed to elucidate the possible roles of the artificial sweeteners saccharin and cyclamate in human urinary bladder cancer was recently completed. The previous intake of each of these substances among 519 patients with histopathologically confirmed bladder cancer and an equal number of matching controls in metropolitan Baltimore did not differ significantly in frequency, quantity, or duration. These normal findings persisted after simultaneous adjustment for the effects of smoking, occupation, age, diabetes mellitus, and a number of other potentially confounding factors. They are substantiated by the failure of the relative risk of bladder cancer to increase with increasing exposure to artificial sweeteners. It is concluded that neither saccharin nor cyclamate is likely to be carcinogenic in man, at least at the moderate dietary ingestion levels reported by the patient sample.

Artificial sweeteners and human bladder cancer

A positive association between the use of artificial sweetners, particularly saccharin, and risk of bladder cancer in males has been observed in a case-control study of 480 men and 152 women in three Provinces in Canada. The risk ratio for ever versus never used is 1-6 for males (P=0-009, one-tailed test), and a significant dose-response relationship was obtained for both duration and frequency of use. The population attributable risk for males is estimated at 7%, though for diabetics, who have a similar risk ratio for artificial sweetner use as non-diabetics, the attributable risk is 33%.

Three cases of human bladder cancer following high dose cyclamate ingestion

Vesical implantation and oral feeding studies in animals raised sufficient suspicion of the carcinogenic propensity of cyclamates to result in their withdrawal from sale throughout the world. The structural similarity to known carcinogens, an effect on human chromosomes in tissue culture and a high carcinogenic potential when combined with non-injurious co-carcinogens gave further support to this ban. On the other hand, numerous epidemiological studies failed to support any statistical relationship between cyclamate ingestion and vesical carcinoma in man. Three patients are described in whom vesical carcinoma developed after a prolonged period of ingestion of an unusually high amount of cyclamate sweetener. Moreover, the severity of the disease appeared to be proportional to the dose ingested. Although this is not a conclusive indictment of the role of cyclamates we believe that patients with bladder cancer should be questioned about intake of cyclamates either directly or in diet soft drinks.

Effects of cyclamate calcium on the immune response in rabbits

To determine the effect of cyclamate calcium on the humoral immune response in rabbits, one group was fed a 3% and another a 5% water solution of cyclamate calcium. A third group served as controls. After 150 days, the animals were tested for their ability to respond immunologically to bovine serum albumin (BSA). Other aspects of immunity investigated were the presence or absence of neoplasia of the urinary bladder, spleen, thymus, and lymph nodes, the number of white and red blood cells, and cyclamate conversion and excretion in the urine. The results indicated that the 5% group had a delayed and suppressed response to BSA. No neoplasia was detected. This group had fewer red cells and excreted increased concentrations of cyclohexylamine in the urine.

Coffee drinking and cancer of the lower urinary tract

The relationship between coffee drinking and cancer of the lower urinary tract (LUT) was investigated by a case-control study of white women identified from hospitals in urban areas of Massachusetts and Rhode Island. Data on coffee drinking, tea drinking, use of coffee additives, and cigarette smoking were obtained by mail questionnaire. Information was available for 135 women with LUT cancer and 390 controls. For women who usually drank 1+ cups of coffee per day, the risk ratio of having LUT cancer was 2.1 (95 percent confidence limits, 1.1-4.3), compared to a risk of 1 for women who drank less or not at all. However, no dose-response relationship was demonstrated between LUT cancer and usual daily coffee consumption or "cup-years" of coffee drinking. The association of coffee with disease was no different, whether decaffeinated, nondecaffeinated, regular, or instant coffee had been drunk, or whether the coffee was brewed strong or weak. Use of nondairy creamers, saccharin, or cyclamates was not associated with increased risk of disease. The risk of LUT cancer for cigarette smokers relative to nonsmokers was 1.6 (1.0-2.4). The attendant dose-response relationship was statistically significant. The absence of a dose-response relationship between coffee drinking and LUT cancer suggested that the association observed was noncasual.

Cyclamates: a review of the current position

Cyclamates were prohibited for use as food additives in the U.S.A. and other parts of the world during 1970 because of the fears of carcinogenicity. The author reviews the evidence leading to this ban and discusses the appeal made against the decision which led to the lifting of the cyclamate restrictions in Australia in November 1974.

Bladder cancer mortality in England and Wales in relation to cigarette smoking and saccharin consumption

Cohort analyses of bladder cancer mortality rates in men and women in England and Wales have been compared with figures for the per caput consumption of saccharin and cigarette tobacco and with similar analyses of cigarette smoking habits. The increase in bladder cancer mortality rates in male cohorts born since 1870 can be attributed to cigarette smoking, and there is no evidence of any break in the continuity of the trends in either men or women which corresponds to the introduction of saccharin.