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Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj-2022-071204 (Published 07 September 2022) Cite this as: BMJ 2022;378:e071204
  1. Charlotte Debras, doctoral student12,
  2. Eloi Chazelas, doctoral student12,
  3. Laury Sellem, post-doctoral researcher in epidemiology12,
  4. Raphaël Porcher, professor of biostatistics34,
  5. Nathalie Druesne-Pecollo, doctor and operational coordinator12,
  6. Younes Esseddik, senior IT manager1,
  7. Fabien Szabo de Edelenyi, data manager1,
  8. Cédric Agaësse, dietitian (manager)1,
  9. Alexandre De Sa, dietitian1,
  10. Rebecca Lutchia, dietitian1,
  11. Léopold K Fezeu, doctor and senior researcher in nutritional epidemiology12,
  12. Chantal Julia, doctor and professor in nutrition15,
  13. Emmanuelle Kesse-Guyot, doctor and senior researcher in nutritional epidemiology12,
  14. Benjamin Allès, researcher in nutritional epidemiology1,
  15. Pilar Galan, doctor and senior researcher in nutritional epidemiology12,
  16. Serge Hercberg, professor of nutrition and hospital practitioner in public health125,
  17. Mélanie Deschasaux-Tanguy, doctor and researcher in nutritional epidemiology12,
  18. Inge Huybrechts, doctor, senior researcher in nutritional epidemiology26,
  19. Bernard Srour, doctor and post-doctoral researcher in epidemiology12,
  20. Mathilde Touvier, doctor and senior researcher in nutritional epidemiology12
  1. 1Sorbonne Paris Nord University, INSERM U1153, INRAE U1125, CNAM, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Centre, University of Paris (CRESS), Bobigny, France
  2. 2French network for Nutrition and Cancer Research (NACRe network), Jouy-en-Josas, France
  3. 3Université de Paris, CRESS UMR1153, INSERM, INRA, Paris, France
  4. 4Centre d’Épidémiologie Clinique, AP-HP, Hôtel-Dieu, Paris, France
  5. 5Public Health Department, Avicenne Hospital, AP-HP, Bobigny, France
  6. 6International Agency for Research on Cancer, World Health Organization, Lyon, France
  1. Correspondence to C Debras c.debras{at}eren.smbh.univ-paris13.fr (or @NutriNetSante on Twitter)
  • Accepted 1 July 2022

Abstract

Objectives To study the associations between artificial sweeteners from all dietary sources (beverages, but also table top sweeteners, dairy products, etc), overall and by molecule (aspartame, acesulfame potassium, and sucralose), and risk of cardiovascular diseases (overall, coronary heart disease, and cerebrovascular disease).

Design Population based prospective cohort study (2009-21).

Setting France, primary prevention research.

Participants 103 388 participants of the web based NutriNet-Santé cohort (mean age 42.2±14.4, 79.8% female, 904 206 person years). Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24 h dietary records, including brand names of industrial products.

Main outcomes measures Associations between sweeteners (coded as a continuous variable, log10 transformed) and cardiovascular disease risk, assessed by multivariable adjusted Cox hazard models.

Results Total artificial sweetener intake was associated with increased risk of cardiovascular diseases (1502 events, hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03); absolute incidence rate in higher consumers (above the sex specific median) and non-consumers was 346 and 314 per 100 000 person years, respectively. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (777 events, 1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150 per 100 000 person years in higher and non-consumers, respectively). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151 per 100 000 person years in higher and non-consumers, respectively), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (730 events; acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161).

Conclusions The findings from this large scale prospective cohort study suggest a potential direct association between higher artificial sweetener consumption (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk. Artificial sweeteners are present in thousands of food and beverage brands worldwide, however they remain a controversial topic and are currently being re-evaluated by the European Food Safety Authority, the World Health Organization, and other health agencies.

Trial registration ClinicalTrials.gov NCT03335644

Footnotes

  • Contributors: CD, EC, MDT, BS, MT: designed the study; EC, NDP, YE, FSdE, CA, ADS, RL, SH: developed the additives composition database and matched consumption/composition data; CA: coordinated dietitian work; FSdE: data management work; NDP, YE: global technical work; NDP, YE, EC, MT: supervised this technical work; CD: performed statistical analysis; EC, MDT, BS, MT: supervised statistical analysis; CD: drafted the manuscript; MT: supervised the writing. All authors contributed to the data interpretation and revised each draft for important intellectual content. All authors read and approved the final manuscript. CD and MT had full access to all the data in the study, MT takes responsibility for the integrity of the data and the accuracy of the data analysis; she is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: The NutriNet-Santé study was supported by the following public institutions: Ministère de la Santé, Santé Publique France, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut national de recherche pour l’agriculture, l’alimentation et l’environnement (INRAE), Conservatoire National des Arts et Métiers (CNAM) and Université Sorbonne Paris Nord. CD was supported by a grant from the French National Cancer Institute (INCa, grant No 2019-158). EC was supported by a doctoral fellowship from Université Sorbonne Paris Nord to Galilée Doctoral School. This project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program (consolidator grant agreement No 864219), the French National Cancer Institute (INCa_14059), the French Ministry of Health (arrêté 29.11.19) and the IdEx Université Paris Cité (ANR-18-IDEX-0001). This project was awarded the NACRe (French network for Nutrition and Cancer Research) Partnership Label and was awarded the Bettencourt Schueller foundation prize Coup d’élan pour la recherche française 2021. Researchers were independent from funders. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. Where authors are identified as personnel of the International Agency for Research on Cancer/World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the International Agency for Research on Cancer/World Health Organization.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from Ministère de la Santé, Santé Publique France, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut national de recherche pour l’agriculture, l’alimentation et l’environnement (INRAE), Conservatoire National des Arts et Métiers (CNAM) and Université Sorbonne Paris Nord, European Research Council, the French National Cancer Institute, the French Ministry of Health, and the IdEx Université Paris Cité for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Dissemination to participants and related patient and public communities: The results of the present study will be disseminated to the NutriNet-Santé participants through the cohort website, where lay summaries of all publications are posted (https://etude-nutrinet-sante.fr/link/zone/43-Publications). Additionally, results will be disseminated in public seminars and by a press release from the Journal or the French Medical Institute for Health and Medical Research, in association with Inrae, Cnam and Sorbonne Paris Nord communication and direction boards. This press release will be posted on their website and sent to their journalist contact book in France, Europe, and abroad (translated in English) as well as through their social medias Facebook and Twitter.

  • Provenance and peer review: Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Researchers from public institutions can submit a collaboration request including information on the institution and a brief description of the project to collaboration@etude-nutrinet-sante.fr. All requests will be reviewed by the steering committee of the NutriNet-Santé study. If the collaboration is accepted, a data access agreement will be necessary and appropriate authorisations from the competent administrative authorities might be needed. In accordance with existing regulations, no personal data will be accessible.

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