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Do artificial sweeteners increase the risk of cardiovascular disease?

Health authorities recognize excessive consumption of added sugar as one of the main risk factors. The World Health Organization (WHO), for example, recommends that less than 5% of daily energy intake come from free sugars.

Artificial sweeteners have proven to be a popular alternative. According to Market Data Forecast, the market for artificial sweeteners is currently valued at €7 billion and is expected to grow to €9.7 billion by 2028.

Perhaps it’s no surprise then to learn that more than 23,000 products worldwide contain artificial sweeteners. Low-calorie and no-calorie sugar alternatives found in ultra-processed foods, such as artificially sweetened beverages, are also used directly by consumers as tabletop sweeteners.

At the same time, cardiovascular disease (CVD) continues to pose a serious health threat. CVD is the leading cause of death worldwide.

Past studies have attempted to identify a link between cardiovascular disease risk and consumption of artificial sweeteners, mostly focusing on consumption of artificially sweetened soft drinks. But researchers from France want to get a clearer picture of all artificial sweeteners in all areas of use, not just in drinks.

In a new study published in BMJResearchers examined the association between consumption of artificial sweeteners from all food sources (from beverages to table sweeteners and dairy products), by type (aspartame, acesulfame potassium, and sucralose) and CVD risk (total, coronary, and cerebrovascular).

Who uses artificial sweeteners? And how much?

The new study was conducted in the NutriNet-Santé population cohort. A total of 102,228 French adult participants who submitted their dietary records online were selected. Follow-up biennial health questionnaires and a personal health interface allowed participants to report any new health events, including CVD.

Results showed that 37.1% of participants consumed artificial sweeteners, and the average consumption of artificial sweeteners was 42.46% among consumers, corresponding to either one individual packet of table sweetener or 100 ml of diet soda.

Heavy users tended to be younger with a higher body mass index, more likely to smoke, and less physically active. They also had higher intakes of sodium, red and processed meats, dairy products and drinks without added sugar.

Soft drinks with no added sugar accounted for 53% of artificial sweeteners, but tabletop sweeteners also accounted for a significant percentage at 30%. Dairy products with artificial sugar, such as yogurts and cottage cheese, make up 8%.

Association of artificial sweeteners with CVD risk

A link between the use of artificial sweeteners and the risk of CVD has been found. “In the NutriNet-Santé cohort, total consumption of artificial sweeteners was associated with an increased risk of total CVD and cerebrovascular disease,”noted the authors of the study.

Aspartame consumption was associated with an increased risk of cerebrovascular events, and acesulfame potassium and sucralose were associated with an increased risk of coronary heart disease.

“Our results suggest no benefit of replacing added sugar with artificial sweeteners on CVD outcomes.”

The industry, however, disagrees. The International Sweeteners Association (ISA), whose members include Mars Wrigley and PepsiCo Inc., disputed the findings, arguing that, contrary to its claims, there “There is no evidence that low-calorie/no-calorie sweeteners can increase CVD risk.”

“Observational studies cannot establish cause and effect”

While the study claims to demonstrate an association between low-calorie/no-calorie sweeteners and cardiovascular disease risk, the ISA stressed that there is no evidence of a “plausible mechanism” supporting the potential effects of low-calorie/no-calorie sweeteners on cardiometabolic health.

“The safety of all approved low-calorie/no-calorie sweeteners has been validated by food safety authorities worldwide, including the UN/WHO Joint Expert Committee on Food Additives, EFSA and the US FDA.”

The ISA is particularly interested in the amount of sweeteners consumed by the French cohort, which they described as “extremely low”, even for “heavy consumers”.

“Importantly, experts questioned the ability to detect an association between low-calorie sweeteners/lack of them at such low levels of consumption and any health outcome and emphasized that confounding factors become more influential in such circumstances.

“By design, observational studies cannot establish causality due to their observational nature and inability to rule out residual confounding or, importantly, to attenuate reverse causality effects.”

The industry also questioned the researchers’ conclusion that replacing artificial sweeteners with added sugars would not provide any benefit to CVOD outcomes.

“At a time when non-communicable diseases, including diabetes and dental disease, remain major global health problems, and in light of current public health recommendations to reduce total sugar intake, low-calorie/no-calorie sweeteners may be useful for creating a healthier food environment, » noted the ISA spokesperson.

“They give people a wide choice of low- or no-calorie sweet options and can therefore be a useful tool when used in place of sugar and as part of a balanced diet to help reduce overall sugar and calorie intake and to manage the level of glucose in the blood.”

WHO: New guidelines question value of low-calorie/no-calorie sweeteners

This latest study isn’t the first time sugar-free sweeteners have been linked to health problems this year.

In July new WHO recommendations​ questioned the value of low-calorie/no-calorie sweeteners such as stevia, sucralose, aspartame, stevia, and monk fruit in a healthy diet.

According to the draft guidelines, WHO recommended against the use of sugar-free sweeteners as a means of achieving weight control or reducing the risk of non-communicable diseases.

The guidelines do not apply to people living with diabetes.

“The lack of evidence to suggest that consumption of non-sugar sweeteners has a beneficial effect on body weight or other measures of adiposity in the long term, together with the potential long-term adverse effects of increased risk of death and disease, outweighs any potential short-term health effects resulting from relatively small reductions in body weight and BMI observed in randomized controlled trials,” noted in WHO.

The ISA also weighed in at the time: “Failure to recognize the role of low-calorie/no-calorie sweeteners in reducing sugar and energy, and ultimately in weight management, is a disservice to public health.”

ISA Chairman Robert Peterson added: “Governments around the world are trying to solve the serious problem of rising obesity and diabetes. Not to mention dental disease… It’s a shame that the widely recognized benefits of non-sugar sweeteners used for dental health have not been recognised.’

Source: BMJ
“Artificial Sweeteners and Risk of Cardiovascular Disease: Results from the NutriNet-Santé Prospective Cohort
Published on September 7, 2022
DOI: https://doi.org/10.1136/bmj-2022-071204
Authors: Charlotte Debra, Eloi Chazelas, Lori Sellem, et al.

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