Low-Calorie Sweetened Beverages and Cardiometabolic Health: A Science Advisory From the American Heart Association

Abstract

In the United States, 32% of beverages consumed by adults and 19% of beverages consumed by children in 2007 to 2010 contained low-calorie sweeteners (LCSs). Among all foods and beverages containing LCSs, beverages represent the largest proportion of LCS consumption worldwide. The term LCS includes the 6 high-intensity sweeteners currently approved by the US Food and Drug Administration and 2 additional high-intensity sweeteners for which the US Food and Drug Administration has issued no objection letters. Because of a lack of data on specific LCSs, this advisory does not distinguish among these LCSs. Furthermore, the advisory does not address foods sweetened with LCSs. This advisory reviews evidence from observational studies and clinical trials assessing the cardiometabolic outcomes of LCS beverages. It summarizes the positions of government agencies and other health organizations on LCS beverages and identifies research needs on the effects of LCS beverages on energy balance and cardiometabolic health. The use of LCS beverages may be an effective strategy to help control energy intake and promote weight loss. Nonetheless, there is a dearth of evidence on the potential adverse effects of LCS beverages relative to potential benefits. On the basis of the available evidence, the writing group concluded that, at this time, it is prudent to advise against prolonged consumption of LCS beverages by children. (Although water is the optimal beverage choice, children with diabetes mellitus who consume a balanced diet and closely monitor their blood glucose may be able to prevent excessive glucose excursions by substituting LCS beverages for sugar-sweetened beverages [SSBs] when needed.) For adults who are habitually high consumers of SSBs, the writing group concluded that LCS beverages may be a useful replacement strategy to reduce intake of SSBs. This approach may be particularly helpful for persons who are habituated to a sweet-tasting beverage and for whom water, at least initially, is an undesirable option. Encouragingly, self-reported consumption of both SSBs and LCS beverages has been declining in the United States, suggesting that it is feasible to reduce SSB intake without necessarily substituting LCS beverages for SSBs. Thus, the use of other alternatives to SSBs, with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.

Effects of nonnutritive sweeteners on body weight and BMI in diverse clinical contexts: Systematic review and meta‐analysis

“…These contradictory results can possibly be attributed to differences in inclusion criteria, statistical methods, and adjustments used by different authors. Additionally, a review by Romo‐Romo et al, 39 which synthesized results from prospective cohort studies evaluating cardiometabolic outcomes, found that associations between NNS consumption and both obesity and metabolic diseases are attenuated when analyses include adjustments for confounding variables related to adiposity and also addressed the possibility of inverse causality 40 . Our meta‐analysis, composed exclusively of RCTs, showed overall weight reduction when NNS were used as an intervention.…”

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

“…A recent American Heart Association science advisory concluded that “at this time, it is prudent to advise against prolonged consumption of LCSB by children.” The authors further stated that “the use of other alternatives to sugar‐sweetened beverages, with a focus on water, should be encouraged.” Our results support this recommendation, as while cross‐sectional analyses cannot establish causality, LCSB consumption was associated with both higher energy intake and higher sugar intake in comparison with water, with energy intakes among LCSB consumers similar to SB consumers. Given that the highest intakes of energy, carbohydrates, and sugar were observed among combined consumers of LCSB + SB, these results suggest that LCSB may be used in addition to, rather than as a replacement for, SBs in the diet.…”

Non-sugar sweeteners and health

“…Most report positive associations between NSS intake (mostly from diet beverages), weight gain, and risk of cardiometabolic diseases 1. However, inherent biases such as residual confounding by related diet and lifestyle factors or reverse causation (whereby individuals use NSS as a strategy to control their weight or metabolic risk) complicate the interpretation of the results 1…”