Should patients substitute sugar for artificial sweetener?

In May 2023, the World Health Organisation (WHO) released a statement that “non-sugar sweeteners should not be used as a means of achieving weight control or reducing the risk of noncommunicable diseases” (1). Here’s what you need to know about the evidence and what patients can do to make the healthiest choice for themselves.

Learn more about this topic in the HealthCert Professional Diploma program in Medical Nutrition Management – online nutrition training for GPs.

What are artificial sweeteners?

Artificial sweeteners encompass either natural or synthesised compounds that are up to 400 times sweeter than sugar by weight but contain no or negligible energy. Common types of artificial sweeteners include acesulfame K, aspartame, sucralose, and stevia. Artificial sweeteners are often used as an alternative to sugar and have become increasingly popular as people look for ways to satisfy their sweet tooth without the extra kilojoules associated with regular sugar, which contains 17kJ per gram. They can be found in a range of different products available in the supermarket, such as cordials, soft drinks, or lollies and are often labelled as ‘no sugar’ or ‘diet’ products.

Why does the WHO advise against artificial sweeteners?

The WHO’s advice is based on the findings of a 2022 systematic review that suggests artificial sweeteners do not confer any long-term benefit in reducing body fat, and that they may have undesirable effects from their long-term use (2). The review included 283 studies, in which 50 were randomised control trials. Outcomes that were measured included adiposity, prediabetes, type 2 diabetes, cardiovascular diseases, cancer, dental caries, and chronic kidney disease. It should be noted that the guidelines are not based on toxicological assessments.

What did the review find?

Artificial sweeteners were previously thought to be a good substitute for sugar due to their negligible energy and were promoted as a product that may lead to weight loss. However, the review found that they do not help with weight control in the long-term (2).

The review also found that higher intakes of artificial sweeteners were associated with an increased risk of type 2 diabetes, cardiovascular disease, and mortality in the long-term prospective studies which followed participants for an average of 13 years (2). The WHO noted that baseline characteristics of participants may confound the results of the review, and as such the recommendation is conditional. This advice also does not apply to people with pre-existing diabetes.

Additional research has found that higher intakes of artificial sweeteners were associated with increased risk of chronic diseases even when other lifestyle risk factors were considered (3). It’s been proposed that artificial sweeteners may contribute to weight gain by reducing feelings of fullness, affecting appetite which can lead to overeating, and may impair blood sugar responses and increase the risk of developing type two diabetes (4,5). One large scale study of over 100,000 adults also found that a high intake was associated with an increased risk of developing cancer (6). They may also impair health by altering the gut microbiota and reducing beneficial bacteria (7).

Should patients have sugar instead of artificial sweeteners?

It is well established that high consumption of added sugars are harmful to health and can lead to increased risk of chronic disease, obesity, and mortality (8). Added sugars can be found in ultra-processed foods such as soft drinks, chocolate, baked goods, and other confectionary foods. Patients should aim to have less than 10% of their total energy intake from added sugars.

General practitioners can advise patients to reduce the added sugars in their diet and replace them with naturally occurring sugars found in fruit rather than opting for artificial sweeteners. The natural sugars found in fruit are accompanied with important nutrients like fibre, vitamins, and minerals which are important components of a healthy and balanced diet.

Learn more with the online HealthCert Professional Diploma program in Medical Nutrition Management.

– Sarah Marko, Accredited Practising Dietitian

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References

(1)    WHO. Use of non-sugar sweeteners: WHO guideline. 2023 May. Available from: https://www.who.int/publications/i/item/9789240073616
(2)    WHO. Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis. 2022 Apr. Available from: https://www.who.int/publications/i/item/9789240046429
(3)    Debras C, Chazelas E, Sellem L, Porcher R, Druesne-Pecollo N, Esseddik Y, et al. Artificial sweeteners and risk of cardiovascular diseases: Results from the prospective NutriNet-Santé cohort. BMJ 2022. https://doi.org/10.1136/bmj-2022-071204.
(4)    Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP. Fueling the obesity epidemic? Artificially sweetened beverage use and long-term weight gain. Obesity 2008. https://doi.org/10.1038/oby.2008.284.
(5)    Pepino MY, Tiemann CD, Patterson BW, Wice BM, Klein S. Sucralose affects glycemic and hormonal responses to an oral glucose load. Diabetes Care 2013. https://doi.org/10.2337/dc12-2221.
(6)    Suez J, Korem T, Zilberman-Schapira G, Segal E, Elinav E. Non-caloric artificial sweeteners and the microbiome: Findings and challenges. Gut Microbes 2015. https://doi.org/10.1080/19490976.2015.1017700.
(7)    Debras C, Chazelas E, Srour B, Druesne-Pecollo N, Esseddik Y, de Edelenyi FS, et al. Artificial sweeteners and cancer risk: Results from the NutriNet-Santé population-based cohort study. PLoS Med 2022. https://doi.org/10.1371/journal.pmed.1003950.
(8)    Huang Y, Chen Z, Chen B, Li J, Yuan X, Li J, Wang W, Dai T, Chen H, Wang Y, Wang R, Wang P, Guo J, Dong Q, Liu C, Wei Q, Cao D, Liu L. Dietary sugar consumption and health: umbrella review. BMJ. 2023 Apr 5;381:e071609. doi: 10.1136/bmj-2022-071609. PMID: 37019448; PMCID: PMC10074550.