Non-sugar sweeteners and healthBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5005 (Published 03 January 2019) Cite this as: BMJ 2019;364:k5005
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While the meta-analysis by Toews et al. suggest that artificial sweeteners are safe to consume, their uses go beyond sugar substitution and calorie reduction. Artificial sweeteners allow the cheaper and more efficient production of highly processed foods with long product shelf life and enable the formulation of new sweet products. Sweeteners such as sucralose or aspartame are 200- 600-fold sweeter than sugar. Novel candy products and beverages often contain sugar and artificial sweeteners together, with different combinations of nutritive and hedonic effects. The consumption of artificial sweeteners, and of products combining sugars and artificial sweeteners, has strongly increased 1. Since children are known to seek out more highly sweetened products the effects of early exposure on future consumption of processed foods and their health effects need to be investigated 2.
Artificial sweeteners are added to products that traditionally have not been sweetened or were sweetened at much lower levels. One example are tobacco products. In a recent study we identified that newly introduced snus products, a form of smokeless tobacco, contain much higher levels of artificial sweeteners than confectionary products and older smokeless products 3. In some cases, these products are so strongly sweetened they are significantly sweeter than their weight in sugar. We also found artificial sweeteners in the mouthpieces and wrappers of flavored little cigars strongly preferred by adolescents 4. Sweetness is known to suppress bitter taste perception and irritation associated with tobacco use 5, suggesting that artificial sweeteners are added by tobacco manufacturers to facilitate use initiation and transition to tobacco addiction. These examples demonstrate that artificial sweeteners are not always used for calorie reduction but are added strategically to modify consumer behavior.
1. Sylvetsky AC, Jin Y, Clark EJ, et al. Consumption of Low-Calorie Sweeteners among Children and Adults in the United States. Journal of the Academy of Nutrition and Dietetics 2017;117(3):441-48.e2. doi: 10.1016/j.jand.2016.11.004 [published Online First: 2017/01/15]
2. Bobowski N, Mennella JA. Personal Variation in Preference for Sweetness: Effects of Age and Obesity. Childhood obesity (Print) 2017;13(5):369-76. doi: 10.1089/chi.2017.0023 [published Online First: 2017/05/13]
3. Miao S, Beach ES, Sommer TJ, et al. High-Intensity Sweeteners in Alternative Tobacco Products. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco 2016;18(11):2169-73. doi: 10.1093/ntr/ntw141 [published Online First: 2016/05/25]
4. Erythropel HC, Kong G, deWinter TM, et al. Presence of High-Intensity Sweeteners in Popular Cigarillos of Varying Flavor Profiles. Jama 2018;320(13):1380-83. doi: 10.1001/jama.2018.11187 [published Online First: 2018/10/05]
5. Mennella JA, Bobowski NK. The sweetness and bitterness of childhood: Insights from basic research on taste preferences. Physiology & behavior 2015;152(Pt B):502-7. doi: 10.1016/j.physbeh.2015.05.015 [published Online First: 2015/05/24]
Competing interests: Dr. Jordt receives research grants from the National Institute on Drug Abuse (NIDA) and the National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH). He received research reagents from GlaxoSmithkline Pharmaceuticals and provided consulting services to Hydra Biosciences and Sanofi Pharmaceuticals, for studies unrelated to this response.
After intense arbitrary persecution of fats, and profiting from the introduction of expensive "low fat" products, industrial Companies targeted profits from new products containing non-sugar sweeteners (NSS).
In both cases, consequent systematic reviews and meta-analyses of randomised controlled trials demonstrated no clinical health benefits.
I hope the lesson is finally learned, and future radical industrial trends in nutrition will not be followed, despite aggressive marketing.
Competing interests: No competing interests
Non-sugar sweeteners (NSSs) are frequently in use as a sugar substitute. People consider them healthy and beneficial in weight control, and NSSs do contribute to the reduction of daily calorie intake1 but the health effects have limited evidence and the decision is quite debatable. The study conducted by Toews and colleagues gave a very good comprehensive insight about various health outcomes like bodyweight, body mass index (BMI), eating behaviour, cardiovascular disease, cancer, kidney disease, mood and neurocognition, revealing that there is no certain evidence of harmful effects of NSSs. A previous study showed that there is limited evidence may increase the risk of certain cancers2.
Diabetes and obesity is a worldwide menace. The prevalence of obesity and diabetes is increasing at a rapid rate in India also 3. In 2000, India (31.7 million) topped the world with the highest number of people with diabetes mellitus4, and the increasing rates have promoted the use of NSSs. Therefore, more studies are needed to provide compelling evidence regarding the effects of NSSs.
We agree with the authors that we can use NSS as replacement for free sugars but up to a certain level among overweight, obese and heavy consumers of sugar sweetened beverages. A healthy lifestyle with a limited sugar intake can reduce the requirement of NSSs.
1. Toews I, Lohner S, Küllenberg 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. BMJ2018;363:k4718.
2. Mishra, A., Ahmed, K., Froghi, S., & Dasgupta, P. (2015). Systematic review of the relationship between artificial sweetener consumption and cancer in humans: analysis of 599,741 participants. International journal of clinical practice, 69(12), 1418-1426.
3. Gulati, S., & Misra, A. (2014). Sugar intake, obesity, and diabetes in India. Nutrients, 6(12), 5955-5974.
4. Kaveeshwar, S. A., & Cornwall, J. (2014). The current state of diabetes mellitus in India. The Australasian medical journal, 7(1), 45.
Competing interests: No competing interests