COMMENTARY

Are Low-Calorie Sweeteners Useful? Dangerous?

Boris Hansel, MD

Disclosures

February 10, 2015

High-intensity sweeteners are additives that are used to impart a sweet taste to foods while providing a negligible number of calories. In fact, sweeteners are very diverse substances from a chemical standpoint. Their common feature is that they have very high sweetening power. For example, only 30 mg of aspartame yields the sweet taste obtained with 5 g of sugar.

Diabetic patients thus frequently replace sugar with high-intensity sweeteners to avoid raising their blood sugar. Sometimes they use these products on the basis of advice from their doctor or dietitian. What is the evidence for this practice?

Conclusions From Recent European Studies

In recent years, some high-profile studies have caused concern, suggesting that pregnant women who use high-intensity sweeteners incur risks, including premature delivery.[1] Studies in mice have highlighted cancers related to ingestion of sweeteners in large quantities[2] and potential diabetogenic effects of artificial sweeteners through microbiota.[3] These latter findings have not been tested in humans, so conclusions are lacking.

To address these concerns, the European Food Safety Authority launched a sweetener reevaluation program. It is currently under way, and results for aspartame were obtained in 2013. The findings were clear: The report concluded that aspartame is safe if ingestion remains below 40 mg/kg per day. As an example, 40 mg/kg is the equivalent of drinking at least 12 cans of diet soda per day every day of the week.[4]

Alongside this European study, the Agency for Food, Environmental and Occupational Health & Safety (Agence Nationale de Sécurité Sanitaire [ANSES]) in France convened a working group to evaluate the benefits and nutritional risks of high-intensity sweeteners. The working group's findings were published in January 2015[5] and are summarized here:

There is no evidence to date that sweetener consumption causes eventual habituation to sweet tastes and an increased appetite for sugary products. The idea that children who consume sweeteners today will want to eat sweeter foods in the short or medium term is unfounded at the moment.

With regard to sweetener use for weight control, currently available data are contradictory. Some studies show that sweetener consumption is associated with weight gain; however, there are important confounding factors in these studies, and we cannot currently establish a causal relationship and thus cannot conclude that sweeteners are related to weight gain. Conversely, we also cannot conclude that substituting sugar with sweeteners leads to weight loss. Therefore, there may be no risk for weight gain, but also no benefit in terms of weight loss.

There is speculation that sweetener consumption causes insulin secretion, owing to an increase in blood glucose levels. However, the vast majority of studies show no effects of sweeteners on insulin or on blood glucose levels. In addition, in observational studies, sweeteners do not appear to increase the risk for diabetes.

With regard to pregnancy, data are insufficient to confirm a risk for premature birth or any health risk to the mother or child.

With regard to cancer, ANSES concluded that there is no evidence to link consumption of sweeteners and cancer risk. One study suggests a link between consumption of drinks containing sweeteners and the occurrence of lymphoma, but this does not provide evidence of the carcinogenic risk of sweeteners, and continuing research and obtaining complementary results are justified.

In summary, if the ANSES study offers reassurance regarding the risks of using high-intensity sweeteners, it also highlights the lack of demonstrated benefit from consuming them.

What Advice Should We Give Our Patients With Diabetes?

So what should we do in practice? In my view, we should not consider sweeteners as "healthy" foods, because there is no proven benefit. However, for people (especially diabetics) who regularly consume soft drinks or unsweetened fruit juice and who cannot replace these beverages with water, I think we should engage in a reassuring dialogue, and we must encourage the consumption of artificially sweetened beverages rather than sugary drinks.

Editor's Note: Six artificial sweeteners have been tested and approved by the US Food and Drug Administration: acesulfame potassium (also called "acesulfame K'), aspartame, saccharin, sucralose, neotame, and advantame.

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