Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies

Abstract

ObjectiveTo assess the association between intake of non-sugar sweeteners (NSS) and important health outcomes in generally healthy or overweight/obese adults and children.DesignSystematic review following standard Cochrane review methodology.Data sourcesMedline (Ovid), Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and reference lists of relevant publications.Eligibility criteria for selecting studiesStudies including generally healthy adults or children with or without overweight or obesity were eligible. Included study designs allowed for a direct comparison of no intake or lower intake of NSS with higher NSS intake. NSSs had to be clearly named, the dose had to be within the acceptable daily intake, and the intervention duration had to be at least seven days.Main outcome measuresBody weight or body mass index, glycaemic control, oral health, eating behaviour, preference for sweet taste, cancer, cardiovascular disease, kidney disease, mood, behaviour, neurocognition, and adverse effects.ResultsThe search resulted in 13 941 unique records. Of 56 individual studies that provided data for this review, 35 were observational studies. In adults, evidence of very low and low certainty from a limited number of small studies indicated a small beneficial effect of NSSs on body mass index (mean difference −0.6, 95% confidence interval −1.19 to −0.01; two studies, n=174) and fasting blood glucose (−0.16 mmol/L, −0.26 to −0.06; two, n=52). Lower doses of NSSs were associated with lower weight gain (−0.09 kg, −0.13 to −0.05; one, n=17 934) compared with higher doses of NSSs (very low certainty of evidence). For all other outcomes, no differences were detected between the use and non-use of NSSs, or between different doses of NSSs. No evidence of any effect of NSSs was seen on overweight or obese adults or children actively trying to lose weight (very low to moderate certainty). In children, a smaller increase in body mass index z score was observed with NSS intake compared with sugar intake (−0.15, −0.17 to −0.12; two, n=528, moderate certainty of evidence), but no significant differences were observed in body weight (−0.60 kg, −1.33 to 0.14; two, n=467, low certainty of evidence), or between different doses of NSSs (very low to moderate certainty).ConclusionsMost health outcomes did not seem to have differences between the NSS exposed and unexposed groups. Of the few studies identified for each outcome, most had few participants, were of short duration, and their methodological and reporting quality was limited; therefore, confidence in the reported results is limited. Future studies should assess the effects of NSSs with an appropriate intervention duration. Detailed descriptions of interventions, comparators, and outcomes should be included in all reports.Systematic review registrationProspero CRD42017047668.

Non-sugar sweeteners and health

“…2 They included 56 interventional and observational studies, making this review the most comprehensive on this topic so far.…”

Letter by Pyrogianni and La Vecchia Regarding Article, “Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women’s Health Initiative”

“…3 Randomized controlled trials showed that systolic and diastolic blood pressure, the major risk factor for stroke, were either lower or unaffected with LCS intake, compared with sugar or placebo. 2 In addition, other randomized controlled trials that have investigated higher intakes of ASBs of 1 L/d or more for 6 months found favorable effects on liver and vascular fat, and no material impact on glycemia, blood cholesterol, and triglyceride levels. 4 Thus, the current evidence supports no plausible mechanism of how ASBs could increase the risk of stroke, coronary heart disease, or other cardiovascular disease in humans.…”

Non-nutritive sweetener consumption during pregnancy affects adiposity in mouse and human offspring

“…Almost 30% of mothers in the Canadian CHILD cohort consumed NNS during pregnancy (14), and similar rates have been reported in the USA (24% (15)) and Denmark (45% (16)). Contrary to their intended benefits, NNS have been inconsistently associated with metabolic derangements and adverse effects on cardiometabolic health in adults (17-19) and children (20); however, few studies have investigated the metabolic effects of NNS exposure in utero . In the CHILD cohort, we found that daily NNS beverage consumption during pregnancy was associated with a 2-fold higher risk of infant overweight at 1 year of age, compared to no maternal NNS beverage consumption (14).…”