AHA Advises Low-Calorie Sweeteners May Be Useful in Adults

Nancy A. Melville

August 15, 2018

With evidence lacking on the long-term effects of low-calorie sweetened beverages, the American Heart Association (AHA) is advising against the long-term consumption of the drinks by children but says the drinks may be useful for adults as an alternative to the regular consumption of sugar-sweetened beverages, in a new science advisory.

"On the basis of the available evidence, the [AHA] writing group concluded that, at this time, it is prudent to advise against prolonged consumption of low-calorie sweetened beverages by children," said the authors of the AHA science advisory.

"For adults who are habitually high consumers of sugar-sweetened beverages, the AHA writing group concluded that low calorie sweetened beverages may be a useful replacement strategy to reduce intake of sugar-sweetened beverages."

The report, published online July 30 in Circulation, is the first of its kind from the AHA to address the issue of low-calorie sweeteners. The document notes that the American Diabetes Association "supports this AHA Science Advisory and considers the clinical document to be of educational value."

An important exception to the recommendation for children is for those with diabetes mellitus; in those who follow a balanced diet and closely monitor their blood glucose, low-calorie beverages may represent a useful substitution in preventing excessive glucose excursions, the advisory concludes.

And in terms of the use of the drinks among adults, any benefits would likely be undermined if there is a compensatory increase in energy intake from other sources, the authors emphasized.

Harms of Sugar Avoided With Sweeteners?

In a 2012 expert review, the AHA teamed with the American Diabetes Association to address the issue of substitution of sugars with low-calorie sweeteners, recommending that, when used judiciously, the sweeteners could help to reduce sugar intake, allow for maintenance of a healthy body weight, and reduce cardiovascular disease (CVD) as well as type 2 diabetes.

But with low-calorie sweetened beverages representing 19% of all beverages consumed by children and 32% consumed by adults, the AHA noted the need for the new science advisory to further clarify the existing science on the relationship between the beverages and cardiometabolic health.

The advisory does not address the pros or cons of any particular low-calorie sweetener because of a lack of data on specific beverages. The recommendations refer to the six high-intensity sweeteners currently approved by the US Food and Drug Administration (FDA) — saccharin, aspartame, acesulfame-K, sucralose, neotame, and advantame — and the two additional high-intensity sweeteners to which the FDA has issued no objection letters — steviol glycosides, obtained from the leaves of the stevia plant (Stevia rebaudiana), and extracts obtained from Siraitia grosvenorii swingle fruit, also known as luo han guo or monk fruit.

The review of evidence on the long-term effects of low-calorie sweeteners for the advisory showed that most data are observational and largely inconclusive, the authors point out. For instance, the data suggest a link between long-term consumption of the beverages and a risk for type 2 diabetes and cardiovascular disease; however, the role of reverse causality and adiposity could not be ruled out.

In addition, observational studies appear to show a consistent link between low-calorie sweetened beverages and an increased stroke risk, but the AHA urged cautious interpretation because of numerous potential confounders, methodologic concerns, and the possibility of reverse causation.

Two notably large prospective studies with decades of follow-up showed similar conclusions regarding low-calorie sweeteners: One study looked at more than 42,000 men in the Health Professionals Follow-Up study and showed that during 22 years of follow-up,  the regular consumption of sugar-sweetened beverages was associated with increased risk for coronary heart disease and some adverse changes in lipids, inflammatory factors, and leptin, while no similar risks were associated with the regular intake of artificially sweetened beverages.

The other study, looking at more than 88,000 women in the Nurses' Health Study, showed that during a 24-year follow-up, the regular consumption of sugar-sweetened beverages was also associated with a significantly higher risk for coronary heart disease, even after adjustment for unhealthy lifestyle or dietary factors, while no increased risk was seen with the regular consumption of low-calorie sweeteners in beverages.

Meanwhile, few randomized controlled trials have evaluated low-calorie sweetened beverages and CVD, and none had sufficient sample size or patient characteristics to determine CVD endpoints, the AHA said.

In terms of outcomes other than CVD, some short-term evidence shows potential benefits of low-calorie sweetened beverages over sugar-sweetened beverages in the management of overweight and obesity, particularly in people with a high risk for obesity.

Recommendations From Other Groups

Guidelines from other medical groups on the consumption of low-calorie sweeteners generally follow the recommendations from the AHA, acknowledging some potential benefits as an aid for weight loss but noting the lack of evidence and concerns of effects on eating behaviors.

A 2012 review from the American Medical Association (AMA) Council on Science and Public Health, for instance, concludes that the beverages could have modest benefits for weight loss and regulation but notes the drinks can give the perception that more calories can be consumed from other foods and also foster a preference for sweet foods.

And the American Academy of Pediatrics (AAP), in a 2015 policy statement, noted that several low-calorie sweetened beverages approved by the FDA could be useful in lowering caloric intake and replacing added sugars.

Another clinical report from the AAP's Committee on Nutrition, however, echoes some of the AMA's concerns of the drinks leading to taste preferences for habitual consumption of sweetened beverages and a reduced awareness of caloric intake, as well as possibly substituting for healthier beverages and altering gut microbiota or increasing glucose intolerance.

Trends Show Reductions in Sweet Drink Consumption

In an encouraging sign, consumption of both sugar-sweetened as well as low-calorie sweetened beverages has been on the decline in the United States in recent years, possibly indicating increased consumer awareness about the healthier alternative of simply water, Rachel Johnson, PhD, who is chair of the AHA's Nutrition Committee, told theheart.org | Medscape Cardiology

"There have been numerous public health campaigns urging consumers to lower their consumption of sugary drinks," explained Johnson, who is the former associate provost of the University of Vermont and dean of the College of Agriculture and Life Sciences, in Burlington, Vermont.

"Furthermore, consumers seem to be becoming wary of many types of sweeteners, including low-calorie sweeteners."

Key messages that may have been resonant in the public include a 2016 AHA scientific statement  warning about the adverse effects of high intakes of added sugars in children's diets and advising that children and teens consume no more than 8 ounces of sugary beverages a week.

"There is very little room for sugary drinks in children's diets," Johnson said. The new report underscores the alternatives, she concluded.

"For children who drink sugary drinks on a regular basis, low-calorie drinks may be a useful tool to help them reduce their intakes of sugary drinks," Johnson said. "But there are healthier alternatives to low calorie drinks such as water, low-fat and fat-free milk."  

"We encourage parents to help their children transition to these healthier beverages," she said.

Evidence consistently shows that diets high in added sugars are linked to a host of risk factors for CVD, including obesity, dyslipidemia, elevated blood pressure, and chronic inflammation, and AHA recommendations therefore call for restricting the intake of added sugars to the equivalent of 100 calories per day in women, 150 calories in men, and less than 100 calories per day in children and adolescents 2 to 18; for children under 2, added sugars should not be included in the diet.

Johnson has disclosed no relevant financial relationships.

Circulation. Published July 30, 2018. Abstract

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