Low calorie/no calorie sweeteners do not increase the risk of

BRUSSELS, Belgium, Sept. 08, 2022 (GLOBE NEWSWIRE) — The International Sweeteners Association (ISA) responds to new research by Debras, Chazelas et al.1 on low calorie sweeteners and cardiovascular disease pointing out that, contrary to claims made in this study, there is no causal evidence that low-calorie or no-calorie sweeteners may increase the risk of cardiovascular disease (CVD).

Indeed, while the study by Debras, Chazelas et al purports to show an association between consumption of low/calorie-free sweeteners and CVD risk, there is no evidence for a plausible mechanism to support the potential effects of low-calorie or no-calorie sweeteners on cardiometabolic health.2 The safety of all approved low calorie sweeteners has been confirmed by food safety organizations around the world including the Joint Expert Committee on Food Additives of the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO)3the European Food Safety Authority (EFSA)4and the United States Food and Drug Administration (FDA)5.

In fact, consumption of low-calorie/no-calorie sweeteners in the NutriNet-Santé cohort was extremely low, even for the highest consumers (defined in the study as participants whose sweetener intake was above the specific median gender among consumers). Importantly, experts have questioned the ability to detect an association between low or no calorie sweeteners at such low intake levels and any health outcomes and have pointed out that under such circumstances, confounding factors become more influential.6 By design, observational studies cannot establish a causal relationship due to their observational nature and their inability to rule out residual confounding or, importantly, to mitigate the effects of reverse causation.seven

Unlike the study by Debras, Chazelas et al, a systematic review and meta-analysis of prospective cohort studies including change and substitution analyzes that mitigate the influence of reverse causation providing more consistent and robust associations revealed that low-calorie or no-calorie sugary drinks are associated with lower risk of coronary heart disease and CVD mortality in planned replacement of sugary drinks.8 These results are consistent with evidence from randomized controlled trials that support the lack of adverse effects of calorie-restricted or calorie-free sweeteners on cardiometabolic risk factors, including blood pressure, lipid levels, blood sugar, and body weight, and in fact some benefits when used to replace sugars in the diet. 9,ten

At a time when non-communicable diseases, including diabetes and dental disease, remain major global health challenges, and in light of current public health recommendations to reduce overall sugar intake, low-calorie or no-calorie sweeteners may be helpful in creating healthier food environments. They offer people a wide choice of sweet tasting options with little or no calories, and can therefore be a useful tool, when used in place of sugar and as part of a balanced diet, in help reduce overall sugar and calorie intake, as well as manage blood sugar.11 Low-calorie or no-calorie sweeteners are also not fermentable by oral bacteria, which means they do not contribute to tooth demineralization, which is one of the causes of tooth decay.12

1 Debras C, Chazelas E, Sellem L, et al. Artificial sweeteners and risk of cardiovascular disease: results of the NutriNet-Santé prospective cohort. BMJ 2022;378:e071204.
2 Pyrogianni V, La Vecchia C. Letter from Pyrogianni and La Vecchia regarding the article, “Artificially sweetened beverages and stroke, coronary heart disease, and all-cause mortality in the women’s health initiative.” Stroke. 2019 Jun;50(6):e169
3 http://www.fao.org/food/food-safety-quality/scientific-advice/jecfa/en/
4 http://www.efsa.europa.eu/en/topics/topic/sweeteners
5 https://www.fda.gov/food/food-additives-petitions/high-intensity-sweeteners
6 Magnuson B. Comments in response to the article by Debras et al “Artificial sweeteners and cancer risk: results from the NutriNet-Santé population-based cohort study”. Available at: https://journals.plos.org/plosmedicine/article/comment?id=10.1371/annotation/edab6e54-e06a-4e33-ba10-f1a96bc43152
seven La Vecchia C. Comments in response to the article by Debras et al “Artificial sweeteners and cancer risk: results from the NutriNet-Santé population-based cohort study”. Available at: https://journals.plos.org/plosmedicine/article/comment?id=10.1371/annotation/e28d577e-cd1c-42eb-85aa-7ea0cf0d5ccd
8 Lee JJ, Khan TA, McGlynn et al. Relationship of switching or substituting low-calorie and no-calorie sugar-sweetened beverages with cardiometabolic outcomes: a systematic review and meta-analysis of prospective cohort studies. Diabetic treatments. 2022 Aug 1;45(8):1917-1930
9 McGlynn ND, Khan TA, Wang L, et al. Association of low-calorie, sugar-sweetened beverage replacements for sugary beverages with body weight and cardiometabolic risk: a systematic review and meta-analysis. JAMA Network Open 2022 Mar 1;5(3):e222092
ten Rios-Leyvraz M, Montez J (World Health Organization)‎. Health effects of the use of sugar-free sweeteners: a systematic review and meta-analysis. World Health Organization (WHO) 2022. https://apps.who.int/iris/handle/10665/353064. License: CC BY-NC-SA 3.0 IGO
11 Diabetes UK. The use of low or no calorie sweeteners. Position statement (updated December 2018). Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/food-nutrition-lifestyle/use-of-low-or-no-calorie-sweetners
12 EFSA scientific opinion on the substantiation of health claims related to intense sweeteners. EFSA 2011 Journal 9(6): 2229 and 9(4): 2076

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