Long-term Safety of Artificial Sweeteners in Kids Unclear, AAP Says

Veronica Hackethal, MD

November 05, 2019

A new statement from the American Academy of Pediatrics (AAP) says there is insufficient evidence about the long-term safety of artificial sweeteners in children and adolescents and calls on food manufacturers to be more transparent about the presence of these substances on food labels.

The statement, published online October 28 in Pediatrics, provides an overview of US Food and Drug Administration (FDA)–approved artificial sweeteners (also called nonnutritive sweeteners), describes research about their benefits and potential adverse effects in children and adolescents, and makes recommendations for researchers, policy makers, and healthcare providers.

"The prevalence of nonnutritive sweeteners (NNSs) in the food supply has increased over time. Not only are more children and adolescents consuming NNSs, but they are also consuming a larger quantity of NNSs in the absence of strong scientific evidence to refute or support the safety of these agents," write Carissa Baker-Smith, MD, MPH, FAAP, of the School of Medicine, University of Maryland, and colleagues with the AAP Committee on Nutrition, Section on Gastroenterology, Hepatology, and Nutrition.

The committee reviewed research articles on the use of artificial sweeteners by children and adolescents that were published in English within the past 10 years through August 20, 2018. Only six high-quality, randomized controlled trials about the use of artificial sweeteners by children were published during that period, they note.

Recent trends show an increase in consumption of artificial sweeteners by children. Most consumption of artificial sweeteners occurs through diet sodas; however, the number of foods that contain at least one artificial sweetener has quadrupled during the past several years. How much children are actually consuming remains unknown because manufacturers are not required to list the amount of artificial sweetener per serving on package labels.

"To better inform the public about consumption of NNSs, the FDA should require products marketed in the United States to include labels that list the type and quantity of any NNS contained per serving of a product," the committee writes.

The FDA has approved artificial sweeteners in some form since 1958. Currently, saccharin, aspartame, acesulfame potassium, sucralose, neotame, and advantame have received premarket approval from the FDA as food additives. Two other artificial sweeteners, stevia and monk fruit extract, have received the FDA designation of "generally recognized as safe" (GRAS); such products do not require premarket approval.

Despite this long history, lingering questions remain about the long-term safety of artificial sweeteners. Information about their health effects comes mainly from animal studies. Although studies in adult humans show no link between artificial sweeteners and cancer, the long-term safety of NNSs in children has not been studied.

"No advice can be provided on the use of NNS in children younger than 2 years old given the absence of data on this age group," the committee writes.

Artificial sweeteners are thought to increase weight loss by decreasing caloric intake. According to the AAP committee, some children — especially those with obesity and those with type 1 or 2 diabetes — may benefit from artificial sweeteners. But weight loss is likely to be small (only about 1 kg).

In fact, some evidence suggests that artificial sweeteners may actually promote weight gain. Artificial sweeteners are 180 to 20,000 times sweeter than table sugar, and they may increase preferences for sugary foods, though evidence is inconclusive. They may also leave people feeling less satisfied, resulting in their eating more in the long run. In animal studies, artificial sweeteners have been linked to glucose intolerance, insulin resistance, and diabetes. Long-term effects on weight management, metabolic function, dyslipidemia, and other cardiovascular diseases in humans remain unknown.

"[H]ealth care providers should be aware that NNS use in isolation is unlikely to result in important weight loss, that observational studies show that NNS intake is associated with higher rates of metabolic syndrome and diabetes, and that a better understanding is needed about whether NNS use has a causal and harmful effect on metabolism and the risk of diabetes mediated through the gut microbiome or other as-yet unidentified pathways," the authors write.

They do note, however, that artificial sweeteners may decrease dental cavities in children.

They add that no data support an association between artificial sweeteners and attention-deficit/hyperactivity disorder or autism. There are no absolute contraindications to their use in children except for aspartame and neotame, which are contraindicated in children with phenylketonuria.

The AAP committee further urges healthcare providers to stay up to date and remain sensitive to patient and family preferences. They recommend that healthcare providers discuss the following: FDA and GRAS approval ratings of artificial sweeteners; the link between short-term weight loss and artificial sweeteners; the need for long-term data on their use in children; the existence of high-quality evidence suggesting no link between artificial sweeteners and hyperactivity in children; and the lack of data about the impact of artificial sweeteners on appetite and taste preferences.

"Funding should be allocated to encourage researchers to conduct high-quality research on the use of NNSs in childhood, focusing on age of exposure and taste preferences, neurodevelopment, and effect on the microbiome and its relevance to obesity, metabolic syndrome, and diabetes," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 28, 2019. Full text

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