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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

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k4718 (Published 02 January 2019) Cite this as: BMJ 2019;364:k4718

Linked editorial

Non-sugar sweeteners and health

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Non-sugar sweeteners: lack of evidence that they help to control weight

Selective Research Makes Bad Policy

The World Health Organization commissioned this review of sweeteners (1) . But the health of the world would suffer if they acted on its conclusions.

It covers only a small proportion of the vast research evidence on sweeteners, but judges them ineffective. The review omits or disregards many studies showing benefits from sweeteners -- described in companion letters by Bellisle and Rogers. Such selectivity is no basis for universal dietary recommendations.

This is not just methodological nit-picking. If translated into policy, this study would have grave practical consequences.

Increasingly, reformulation of mass-market sweet products is the principal strategy for sugar reduction, in developing and developed countries alike. If manufacturers attempt reformulation without sweeteners, they are left with simply using less sugar, trying to lower people's liking for sweetness and sweet products: the "de-habituation strategy".

Reformulation without sweeteners will not suffice. It demands that whole societies reduce their liking for sweetness voluntarily. Even if they did, de-habituation would take a long time. But we do not have time. The rapid global rise in diabetes, with earlier onset in children, threatens a financial as well as health catastrophe. Sugar reduction is urgent.

The review agrees with most other authorities that sweeteners are safe. But the simultaneous conclusion that they are ineffective will nonetheless fuel the controversy still simmering around sweeteners, despite their widespread and growing success in soft drinks, the vague sense among non-specialist consumers that there is something not quite right about them.

Such attitudes, reflected in market research, frighten food manufacturers. They worry that using sweeteners in reformulated products might have consequences for their sales, brands and corporate reputation. So they tip-toe towards the technical changes that are necessary.

Hence, this review may make matters worse rather than better. No global WHO nutrition policy should rest on such crumbly foundations.

(1) Toews I, Lohner S, Kullenberg de Gaudry D, et al. 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. BMJ 2018;363:k4718

Competing interests: No competing interests

15 March 2019
Jack T Winkler
Emeritus Professor of Nutrition Policy
London Metropolitan University
London UK