How “sweet” is using sweeteners?

Sweeteners can be classified into two main categories: 

• nutritive sweeteners, which provide calories and include sugars such as sucrose, fructose, and glucose, 
• non-nutritive sweeteners, which do not provide significant calories and include substances such as aspartame, saccharin, and stevia.

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The Good, The Bad, and The Science

There are both positive and negative aspects associated with the use of sweeteners in food and beverages. 

Some potentially negative aspects are associated with the use of sweeteners.

 There have been several studies that have suggested a possible link between consuming large amounts of certain artificial sweeteners and an increased risk of metabolic disorders such as type 2 diabetes and obesity. 

• A study published in the journal Obesity (Fowler SP, 2012) found that consuming high amounts of artificial sweeteners was associated with an increased risk of obesity and metabolic syndrome in adults.

• A study published in Nature (Suez J, 2014) found that consumption of saccharin, sucralose, and aspartame can alter the composition of gut bacteria in mice and humans. This, in turn, can lead to glucose intolerance, a condition associated with diabetes.

• Another study published in Diabetes Care (Peppino MY, 2013) found that daily consumption of diet soda (which often contains artificial sweeteners) was associated with an increased risk of type 2 diabetes in women.

• Consumption of artificial sweeteners could alter taste preferences and increase the preference for sweet taste, which could lead to the overconsumption of sugar-sweetened beverages. (Wilk K, 2022)

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• There have been some studies investigating the potential link between sweeteners and dementia, but the evidence is limited and conflicting.

One study published in 2018 in the journal Stroke examined the association between artificially sweetened beverage consumption and stroke and dementia. The study found that higher consumption of artificially sweetened beverages was associated with an increased risk of stroke, but there was no significant association with dementia.

A 2020 review of the evidence published in the journal Nutrients concluded that there is currently insufficient evidence to draw firm conclusions about the link between sweeteners and dementia. The review noted that some studies have suggested a potential association, while others have not found any significant effects.

Overall, more research is needed to better understand the potential link between sweeteners and dementia. 

It is important to note that excessive consumption of any type of sweetened beverage, whether sugar-sweetened or artificially sweetened, is generally not recommended for overall health and may contribute to other health problems

• The evidence for a link between sweeteners and cancer is mixed and inconclusive. Some studies have found no association between sweeteners and cancer, while others have suggested a possible link. 

A populational study investigated the associations between artificial sweetener intakes (total from all dietary sources, and most frequently consumed ones: aspartame [E951], acesulfame-K [E950], and sucralose [E955] and cancer risk. 102,865 adults from the French population-based cohort NutriNet-Santé(2009-2021) were included (median follow-up time = 7.8 years). 

Compared to non-consumers, higher consumers of total artificial sweeteners had a higher risk of overall cancer (n = 3,358 cases, hazard ratio [HR]= 1.13 [95% CI 1.03 to 1.25], P-trend = 0.002). 

In particular, aspartame (HR = 1.15 [95% CI 1.03 to 1.28], P = 0.002) and acesulfame-K (HR = 1.13 [95% CI 1.01 to 1.26], P = 0.007) were associated with increased cancer risk. 

This study has some limitations including potential selection bias, residual confounding, and reverse causality. 

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These negative effects are still being researched, and the extent of their impact on health is still unclear.

The safety of sweeteners is a topic of ongoing discussion

A recently published study (Witkowski, 2023) concludes that erythritol (a commonly user sugar substitute) increases the risk of major adverse cardiovascular events - MACE (including death or nonfatal myocardial infarction or stroke). The authors did not provide information regarding erythritol concentrations in the study population. The group with the highest plasma erythritol concentration exhibited a higher risk of cardiovascular events, but the association became much smaller when adjusted for participant age (this group has also the oldest participants). The origin of plasma erythritol is unclear. Moreover, erythritol is used in other products such as toothpaste and drugs.

On the other hand, evidence shows that erythritol has potential as a beneficial replacement for sugar in healthy and diabetic subjects as it exerts no effects on glucose or insulin and induces gut hormone secretions that modulate satiety to promote weight loss.

It is important to note that more research is needed to fully understand the potential risks associated with consuming artificial sweeteners and that moderation is key when it comes to any type of sweetener, whether artificial or natural.

The benefits of sweeteners

• The primary benefit of sweeteners is their ability to reduce calorie intake. This is especially important for people who are trying to manage their weight or control their blood sugar levels.

• Replacing high-calorie sweeteners with lower-calorie or zero-calorie alternatives has been suggested as a way to support weight loss or weight management by reducing overall calorie intake.
• Low-calorie sweeteners (LCSs) have the potential to enhance compliance with weight loss or weight maintenance goals by maintaining the delicious taste of foods and drinks with lower calorie content compared to sugar.
• ‍Sweeteners can also reduce the risk of dental caries. Tooth decay is a widespread disease that affects as many as 90% of children and the majority of adults across the globe. It is easily preventable and treatable by adopting good oral health habits such as brushing the teeth regularly and reducing the intake of sugary foods and beverages. The harmful bacteria in the mouth, responsible for causing decay, multiply and adhere to the tooth surfaces producing a sticky film when left undisturbed. Consequently, consuming sugar allows these bacteria to make acid, leading to tooth decay.

It's also worth noting that while sweeteners may be helpful for reducing sugar intake in some cases, they are not a magic pill for managing health. For example, if someone consumes large amounts of diet soda or other artificially sweetened foods and beverages, they may still be consuming a diet that is high in processed foods and low in nutrient-dense whole foods.

The acceptable daily intake (ADI)

ADI is the amount of a sweetener that can be consumed daily over a person's lifetime without appreciable health risks. The ADI is determined by regulatory agencies based on toxicological studies and is expressed in milligrams (mg) of sweetener per kilogram (kg) of body weight.

The ADI varies depending on the type of sweetener. Here are the ADI values for some common sweeteners as established by the European Food Safety Authority (EFSA):

• Aspartame (E951): 40 mg/kg body weight/day
• Acesulfame-K (E950): 9 mg/kg body weight/day
• Saccharin (E954): 5 mg/kg body weight/day
• Sucralose (E955): 15 mg/kg body weight/day
• Erythritol (E968): 1 g/kg body weight/day, but max 40 g
• Steviol glycosides (from Stevia): 4 mg/kg body weight/day

It's important to note that the ADI is set well below the level at which health effects might occur, and it is intended to be a conservative estimate of safe intake.

However, it's still recommended to consume sweeteners in moderation and as part of a balanced diet. Additionally, it's important to note that the ADI is not a recommended daily intake, but rather a guideline for a maximum amount that is considered safe to consume.

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