A review of epidemiological studies on artificial sweeteners and bladder cancer

The Impact of Artificial Sweeteners on Human Health and Cancer Association: A Comprehensive Clinical Review

Artificial sweeteners are sugar substitutes that provide high sweetening power associated with low accompanied calories. In this study, we aim to review the data on the use, benefits, side effects, and cancer risks of artificial sweeteners. We reviewed data in the PubMed, MEDLINE, Google Scholar, Embase, and Scopus databases to search for studies about artificial sweeteners from the inception of the database to July 20, 2023, published in the English language. We discuss systematic reviews and meta-analyses, randomized clinical trials, and observational cohort studies that address the use of artificial sweeteners and their effect on health. In our review, we show that artificial sweeteners have been shown to impact various functions of the gastrointestinal system. Other studies have demonstrated an association with neurologic symptoms such as headache and taste alteration. Moreover, recent studies have established an association between artificial sweeteners and cardiovascular risk and diabetes. Importantly, the majority of research data show no link between the use of artificial sweeteners and cancer risk. Although most studies show that there is no established link between these products and cancer risk, artificial sweeteners are associated with multiple diseases. Hence, more studies are needed to better characterize the effect of artificial sweeteners on human health.

The Use of Nonnutritive Sweeteners in Children

The prevalence of nonnutritive sweeteners (NNSs) in the food supply has increased over time. Not only are more children and adolescents consuming NNSs, but they are also consuming a larger quantity of NNSs in the absence of strong scientific evidence to refute or support the safety of these agents. This policy statement from the American Academy of Pediatrics is intended to provide the pediatric provider with a review of (1) previous steps taken for approved use of NNSs, (2) existing data regarding the safety of NNS use in the general pediatric population, (3) what is known regarding the potential benefits and/or adverse effects of NNS use in children and adolescents, (4) identified gaps in existing knowledge and potential areas of future research, and (5) suggested talking points that pediatricians may use when discussing NNS use with families.

Safety assessment of 16 sweeteners for the Korean population using dietary intake monitoring and poundage method

A sweetener is a food additive that imparts a sweet taste to food products. Sweeteners have been increasingly used in Korea since the approval of sodium saccharin and d-sorbitol in 1962. Unlike food contaminants, humans are exposed to food additives only through the consumption of processed food products. For exposure assessments of sweeteners, the dietary intakes of food products containing acesulfame-K, aspartame, saccharin-Na, and sucralose were determined, and the resulting calculated estimated daily intake (EDI) values were compared directly with each additive's ADI. The poundage method was used to calculate the daily intake per capita for 12 additional sweeteners, such as lactitol, for which appropriate analytical methods for food products do not exist. The risk, as evaluated by comparing the EDI with the ADI, was determined to be 2.9% for acesulfame-K, 0.8% for aspartame, 3.6% for saccharin-Na, 4.3% for steviol glycosides, and 2.1% for sucralose. No hazardous effect was predicted for the other 11 sweeteners, including lactitol.

Effects of xylitol as a sugar substitute on diabetes-related parameters in nondiabetic rats

Abstract The present study was examined the effects of xylitol feeding on diabetes-associated parameters in nondiabetic rats. Seven-week-old male Sprague-Dawley rats were randomly divided into three groups: control (five rats), sucrose (six rats), and xylitol (six rats). Animal had free access to a commercial rat pellet diet, and ad libitum water, 10% sucrose solution, and 10% xylitol solution were supplied to the control, sucrose, and xylitol groups, respectively. After 3 weeks of feeding of experimental diets, food intakes were significantly (P<.05) lower in the sucrose and xylitol groups compared with the control group. Drink intake was significantly higher in the sucrose group but significantly lower in the xylitol group compared with the control group. Body weight gain was significantly lower in the xylitol group compared with the sucrose group. Weekly nonfasting blood glucose was significantly increased, but fasting blood glucose was significantly decreased, in the sucrose group compared with the control and xylitol groups. Significantly better glucose tolerance was observed in the xylitol group compared with the control and sucrose groups. Serum insulin and fructosamine concentrations were not significantly influenced by the feeding of xylitol or sucrose. Relative liver weight and liver glycogen were significantly increased in the xylitol group compared with the sucrose group, whereas no difference was observed between the xylitol and control groups. Serum total cholesterol and low-density lipoprotein-cholesterol were significantly decreased in the sucrose and xylitol groups, and serum triglyceride of the xylitol group, but not the sucrose group, was significantly increased compared with the control group. Data of this study suggest that xylitol can be a better sweetener than sucrose to maintain diabetes-related parameters at a physiologically safer and stable condition.

Impact of substituting added sugar in carbonated soft drinks by intense sweeteners in young adults in the Netherlands: example of a benefit-risk approach

PURPOSE

Substituting added sugar in carbonated soft drinks with intense sweeteners may have potential beneficial, but also adverse health effects. This study assessed the benefits and risks associated with substituting added sugar in carbonated soft drinks with intense sweeteners in young adults in the Netherlands.

METHODS

A tiered approach was used analogous to the risk assessment paradigm, consisting of benefit and hazard identification, exposure assessment and finally benefit and risk characterization and comparison. Two extreme scenarios were compared in which all carbonated soft drinks were sweetened with either intense sweeteners or added sugar. National food consumption survey data were used, and intake of added sugar and intense sweeteners was calculated using the food composition table or analytical data for sweetener content.

RESULTS

Reduction in dental caries and body weight were identified as benefits of substituting sugar. The mean difference in total energy intake between the scenarios was 542 kJ per day in men and 357 kJ per day in women, under the assumption that no compensation takes place. In the 100% sweetener scenario, the average BMI decreased 1.7 kg/m(2) in men and 1.3 kg/m(2) in women when compared to the 100% sugar scenario. Risks are negligible, as the intake of intense sweeteners remains below the ADI in the substitution scenario.

CONCLUSIONS

Substitution of added sugar by intense sweeteners in carbonated soft drinks has beneficial effects on BMI and the reduction in dental caries, and does not seem to have adverse health effects in young adults, given the available knowledge and assumptions made.

Application of meta-analysis in reviewing occupational cohort studies

Meta-analysis has been used increasingly in reviewing and summarising epidemiological studies. Reviews incorporating meta-analyses have appeared in medical journals in increasing numbers. Although there are several methodology papers on meta-analysis, most of these papers have been written primarily for discussion among epidemiologists. The present paper considers some of the basic methodological issues, the more practical aspects of meta-analysis, and targets an audience of mainly non-epidemiologists. Thus, the main objective of this paper is to provide some basic guidelines for non-epidemiologists to evaluate meta-analysis in occupational cohort studies. In this methodology paper, the limitations and problems of traditional qualitative reviews are pointed out. Some of these problems can be dealt with by quantitative meta-analysis. The potential limitations and benefits of quantitative meta-analysis are discussed. Rather than replacing traditional qualitative review, quantitative meta-analysis should be made part of the overall assessment. The term "meta-review" is proposed to emphasise the importance of both qualitative and quantitative components in a comprehensive review process. The basic steps in a meta-review are outlined, with a discussion on how to recognise and avoid some of the problems which are likely to occur at each step. A meta-review is useful in selecting studies, and in organising, presenting, and summarising results from individual studies. A meta-review can also be used to detect heterogeneity among studies. Major benefits of conducting a meta-analysis (the quantitative component in a meta-review) include the increase in statistical power and the estimate of a properly weighted summary risk estimate.

Cell proliferation in the bladder and implications for cancer risk assessment

Chemicals can increase carcinogenic risk by either directly damaging DNA or increasing cell replication or they can do both. These effects have different implications for a biologically-based extrapolation from rodent bioassays to humans. 2-Acetylaminofluorene (2-AAF) administered at low doses to mice for a lifetime has a different dose-response for the liver (approximately linear) compared to the urinary bladder (apparent no effect dose of 45 ppm with a sigmoidal dose response at 60-150 ppm), which can be explained if carcinogen metabolism, DNA adduct formation and cell proliferation effects are considered. In contrast to 2-AAF and other genotoxic chemicals, chemicals which form calculi in the urine do not generally damage DNA directly but increase cell proliferation dramatically by eroding the bladder surface, leading to regenerative hyperplasia. This occurs only at doses at which calculi form; lower doses do not produce calculi and, therefore, do not increase cell proliferation or cause tumors. Extrapolation to humans from the rodent bioassay should be dependent on dose requirements for formation of calculi rather than any type of statistical extrapolation to lower doses. Saccharin and other sodium salts administered at high doses to rats also produce bladder cancer by increasing cell proliferation. These salts do not affect mice, hamsters, guinea pig or monkeys. Based on dose and mechanistic considerations, saccharin and these other sodium salts are unlikely to be human carcinogens. Extrapolation to possible human cancer risk requires biological determinations rather than simply using statistical formulations.

The etiology of bladder cancer--are there any new clues or predictors of behavior?

It is well documented that the etiology of bladder cancer involves environmental factors. Most chemical carcinogens probably affect the urothelial cells via their presence in the urine. As an important cofactor, cell proliferative activity may be increased by urinary bladder infection, irritation by bladder stones or through the action of a variety of endogenously produced direct acting chemicals or agents. Among the known causative factors, avoidable major ones are occupational exposure to certain chemicals such as benzidine and 4-aminobiphenyl, cigarette smoking and bilharzial infection, which could be eradicated by a combination of praziquantel, antihelminth therapy, education and improvements in social welfare. An anticarcinogenic drug, cyclophosphamide, used as an immunosuppressive agent also seems to be associated with a high risk of idiopathic induction of bladder cancer and physicians should therefore pay particular attention to its diverse effects when considering its prescription. In contrast to the above, the consumption of coffee and tea including artificial sweeteners is now thought unlikely to be major risk. So far there is no good biochemical tool to predict individual exposure to bladder carcinogens/or relative risk of bladder cancer development. However, acetylation capacity can be applied to assess susceptibility to carcinogenic amines in people exposed in their working environment. Progress in molecular biological analysis will hopefully bring to light etiology-specific DNA damage in the bladder tumors and prove useful for prediction of tumor behavior in the near future.

A data-derived safety (uncertainty) factor for the intense sweetener, saccharin

An increased incidence of bladder cancer is found when male rats are fed high dietary concentrations of sodium saccharin (3% or more) from birth. This toxicity has been used as the basis for the development of a data-derived safety factor. Such an effect would attract an extra factor (10-fold) for nature of toxicity and in the absence of other data would result in a high overall safety factor. However the extensive mechanistic database on sodium saccharin allows an assessment of the potential relevance of the effect for humans. In addition the effect is only seen under specific conditions in rats, i.e. largely with the sodium salt and with a commercial rat diet. The effect is not related to the concentration of saccharin in the rat urine or bladder so that toxicokinetic considerations are simplified. The extensive animal database allows the determination of data-derived factors for inter-species differences in both toxicokinetics and toxicodynamics. Based on this analysis an overall safety factor of 50 (which includes the factor of 10 for severity of effect) would appear appropriate at the present time. This factor, and the ADI which would result from its application, are consistent with the absence of an association between the consumption of artificial sweeteners and bladder cancer in humans.

A review and biological risk assessment of sodium saccharin

Dietary sodium saccharin is associated with bladder tumors when fed at high levels to the male rat. Under these conditions urinary pH, sodium concentration, and volume are elevated and proliferative changes are present in the urothelium. Extensive epidemiological studies have shown that saccharin does not increase the risk of bladder cancer in humans and laboratory investigations have shown that sodium saccharin is not mutagenic and does not bind to DNA. Recent research indicates that the urothelium in male rats is damaged under conditions of high urinary pH and sodium levels by a mechanism that involves alpha 2u-globulin and possibly silicate crystalluria. These studies and their implications for human health risk are reviewed.

Cell proliferation in carcinogenesis

Chemicals that induce cancer at high doses in animal bioassays often fail to fit the traditional characterization of genotoxins. Many of these nongenotoxic compounds (such as sodium saccharin) have in common the property that they increase cell proliferation in the target organ. A biologically based, computerized description of carcinogenesis was used to show that the increase in cell proliferation can account for the carcinogenicity of nongenotoxic compounds. The carcinogenic dose-response relationship for genotoxic chemicals (such as 2-acetylaminofluorene) was also due in part to increased cell proliferation. Mechanistic information is required for determination of the existence of a threshold for the proliferative (and carcinogenic) response of nongenotoxic chemicals and the estimation of risk for human exposure.

Acceptable daily intake and the regulation of intense sweeteners

At the present time there are four intense sweeteners that are available in a number of countries: acesulfame-K, aspartame, cyclamate and saccharin. Extensive toxicity databases are available on each sweetener and these have been assessed by both national and international regulatory authorities. This review considers briefly the critical toxicity of each sweetener that is the basis for establishing the no adverse effect level in animal studies. The calculation of an acceptable daily intake (ADI) for human intake employs a large safety factor applied to the no-effect level. The magnitude of the safety factor for each sweetener is discussed in relation to the ADI values recommended by the Scientific Committee for Food in 1985.

The health risks of saccharin revisited

Almost from its discovery in 1879, the use of saccharin as an artificial, non-nutritive sweetener has been the center of several controversies regarding potential toxic effects, most recently focusing on the urinary bladder carcinogenicity of sodium saccharin in rats when fed at high doses in two-generation studies. No carcinogenic effect has been observed in mice, hamsters, or monkeys, and numerous epidemiological studies provide no clear or consistent evidence to support the assertion that sodium saccharin increases the risk of bladder cancer in the human population. Mechanism of action studies in the one susceptible species, the rat, continue to provide information useful in assessing potential risk to the human from saccharin consumption. Unlike typical carcinogens which interact with DNA, sodium saccharin is not genotoxic, but leads to an increase in cell proliferation of the urothelium, the only target tissue. It also appears that the effect of saccharin is modified by the salt form in which it is administered, despite equivalent concentrations of saccharin in the urine. The chemical form of saccharin in the urine is unaffected, and there is no evidence for a specific cell receptor for the saccharin molecule. Changes in several urinary parameters, such as pH, sodium, protein, silicates, volume, and others, appear to influence the reaction of the urothelium to sodium saccharin administration. Silicon-containing precipitate and/or crystals appear to be generated in the urine under specific circumstances, acting as microabrasive, cytotoxic material. Using a mathematical model of carcinogenesis, which encompasses the temporal dynamics and complexity of the process at a cellular level, including spontaneous genetic transitions, it has been shown that the effects of sodium saccharin can be explained entirely in terms of its non-genotoxic influence on cell proliferation. In interpreting these analytical studies in the human context, particularly as they pertain to the urinary milieu which appears to be pivotal in the effect of sodium saccharin, we are led to the conclusion that there is a threshold effect in male rats and that an effect on the human urothelium is unlikely at even the highest levels of human consumption.

Important recent advances in the practice of health risk assessment: implications for the 1990s

Health risk assessments have been so widely adopted in the United States that their conclusions are a major factor in many environmental decisions. The procedure by which these assessments are conducted is one which has evolved over the past 10-15 years and a number of short-comings have been widely recognized. Unfortunately, improvements in the process have often occurred more slowly than advancements in technology or scientific knowledge. Recent significant advances for more accurately estimating the risks posed by environmental chemicals are likely to have a dramatic effect on the regulation of many substances. Each of the four portions of risk assessment (hazard identification, dose-response assessment, exposure assessment, and risk characterization) has undergone significant refinement since 1985. This paper reviews some of the specific changes and explains the likely benefits as well as the implications. Emphasis is placed on the improved techniques for (a) identifying those chemicals which may pose a human cancer or developmental hazard, (b) using statistical approaches which account for the distribution of interindividual biological differences, (c) using lognormal statistics when interpreting environmental data, (d) using physiologically based pharmacokinetic models for estimating delivered dose and for scaling up rodent data, (e) using biologically based cancer models to account for the seven or more apparently different mechanisms of chemical carcinogenesis, (f) describing the severity of the public health risks by considering those portions of the population exposed to various concentrations of a contaminant, and (g) reviewing how criteria for acceptable risk have been influenced by the number of exposed persons. The net benefit of these improvements should be a reduction in the uncertainty inherent in current estimates of the health risks posed by low level exposure to carcinogens and developmental toxicants.

Nongenotoxic carcinogens in the regulatory environment

The biological activity of many carcinogens is to directly induce mutational events, thereby altering the information encoded in the DNA. Short-term tests for potential carcinogens and risk assessment models generally rely on the assumption that the agent in question will operate through a genotoxic mechanism. However, carcinogenesis is a multistep process, and it is increasingly clear that the primary biological effect for many carcinogenic chemicals involves events other than direct DNA reactivity. For many experimental rodent models as well as human cancers, nongenotoxic mechanisms appear to be the driving force in the formation of tumors. Many of these nongenotoxic mechanisms are highly species-specific. Thus, it is increasingly important to ask if the rodent model applies to the human situation at all, in addition to the examination of appropriate, hypothetical, mathematical risk assessment models. More research is now being focused to better define the mechanisms by which the many distinctly different classes of nongenotoxic carcinogens are acting. This understanding will become the basis for new predictive assays and more realistic risk assessment models. If specific conditions are met, then a no observed effect level with a safety factor may be the most appropriate risk model for some carcinogens.

Critical review of cancer epidemiology in petroleum industry employees, with a quantitative meta-analysis by cancer site

A critical review of close to 100 published and unpublished but otherwise available epidemiologic reports of petroleum industry employees from the United States, United Kingdom, Canada, Europe, Australia, and Japan was conducted. Analyses by duration of employment and latency are discussed, and summary standardized mortality ratios (SMRs) or meta-SMRs are developed for selected cancer sites. Findings indicate that the industry experienced a significantly lower cancer mortality than the general population for all cancer sites combined, digestive system, stomach, and lung. For the industry as a whole, SMRs similar to the general population were observed for skin, brain, pancreatic, prostatic, and kidney cancers. However, some data indicate that certain small groups within the industry might have elevated prostatic and kidney cancer risk. This review supports the conclusion that some refinery employees, particularly those employed before the 1940s, may have been at increased risk of leukemia. There is some indication that cancer of other lymphatic tissue may also be elevated. Unresolved issues affecting these conclusions are discussed, and specific directions for future research are offered.

Cell growth dynamics in long-term bladder carcinogenesis

A biologically based probabilistic model of the carcinogenic process has been developed based on a two-stage theory of carcinogenesis. The model has been validated utilizing experimental urinary bladder carcinogenesis studies in the rat, with an emphasis on quantification of cell dynamics. Critical parameters tracked through this process include mitotic rates, cell loss and birth rates, and irreversible cellular transitions from normal to initiated to transformed states. Analyses demonstrate the sensitivity of tumor incidence to the timing and magnitude of changes to these cellular variables. Modeling has been applied to genotoxic compounds, such as N-[4-(5-nitro-2-furyl)-2-thiazolyl]formamide, and non-genotoxic compounds, such as sodium saccharin. For the latter compounds, complex administration regimens have been studied, including two-generation experiments, initiation-promotion experiments, and sodium saccharin administration following ulceration and regenerative hyperplasia. Modeling indicates that the effects of such compounds can be explained entirely on the basis of cytotoxicity and consequent hyperplasia. Quantitative modeling based on biological processes has the potential for direct application to carcinogenic risk assessment.

Microbial amino acid metabolites and bladder cancer: no evidence of promoting activity in man

1. Indole, p-cresol and phenol are microbial amino acid metabolites which show co-carcinogenic or promoting activity in animal studies. Their involvement in the development of human bladder cancer has been determined by measuring the urinary excretion of indican (indoxyl sulphate) and conjugated phenols. 2. Thirty-two patients (22 males, 10 females) with histologically confirmed carcinoma of the urinary bladder and a similar number of age and sex matched controls took part in the study. The excretion of indican, p-cresol and phenol showed wide interindividual variability, but did not differ significantly between the two groups. 3. The findings indicate that these endogenous metabolites do not contribute significantly to the development of human bladder cancer.

The effect of saccharin ingestion on the excretion of microbial amino acid metabolites in rat and man

Low dietary levels of sodium saccharin (0-2%) fed to male rats for 6 weeks produced a dose-related increase in the urinary excretion of p-cresol, a major microbial metabolite of tyrosine. Some animals fed higher levels of saccharin (5-7.5%) for 6 weeks excreted increased amounts of p-cresol, but many excreted negligible amounts so that the overall dose-response relationship was bell shaped. After 20 weeks of exposure, all rats in the higher dose groups showed increased p-cresol excretion and by 26 weeks the 7.5% saccharin group showed a 36-fold increase over animals fed the 0% saccharin diet. The urinary excretion of phenol, another microbial amino acid metabolite, was constant in animals fed dietary levels of saccharin below 2% for 6 weeks, but was virtually abolished at higher levels. The excretion of indican (formed from indole, a microbial metabolite of tryptophan) was increased by saccharin in a dose-related fashion at all time points, but showed only a 3-fold increase at 7.5% compared with the 0% group. p-Cresol may therefore prove more sensitive than indican as an indicator of altered microbial metabolism due to saccharin. In a separate study the effect of 7.5% saccharin on p-cresol and indican excretion was shown to be largely reversible and the excretion of phenol increased rapidly when saccharin was withdrawn from the diet. Chronic saccharin administration to man at high doses (1 g/day for 4 weeks) had no perceptible effect on the excretion of these three metabolites.

Contribution of toxicology towards risk assessment of carcinogens

In the last decade many tests have been designed to detect possible carcinogenicity of compounds. Presently, many more or less simple and convenient systems are available to detect mutations, effects on chromosomes, DNA binding and damage and malignant transformation. These systems, which have been extensively refined during the last years, often show reasonably good relevance to carcinogenicity. Although inconsistencies in the patterns of response do indicate that their role as predictive indicators of carcinogenicity remains still uncertain, the use of such short-term tests in carcinogen risk assessment does seem feasible. Factors other than these tests should also be taken into consideration, since other characteristics like chemical structure, biotransformation, toxicokinetics, qualitative and quantitative physiological and/or morphological effects, species, strains, organ specificity, dose-response relation and information on studies in man, if available, are of importance too. In conjunction with the results of adequately performed carcinogenicity tests in mammals, one may attempt to classify carcinogens. Current knowledge does not permit a rigid classification, but may warrant a subclassification into carcinogens acting via a genetic or a non-genetic mechanism. It is emphasized that on theoretical and practical grounds a different extrapolation system should be used for the different types of carcinogens in risk assessment procedures. Evaluations on individual compounds should be made to decide whether such genotoxic or non-genotoxic compounds should be permitted in the human environment.

Carcinogens and mutagens that may occur in foods

The principal carcinogens and mutagens that have been identified in human foods are reviewed. These agents may occur in foods as naturally occurring components (e.g., metabolites made by plant or fungal cells), components of contaminating plants or microorganisms, food additives (usually unintentional), or products that arise during processing or cooking. In the mixed diets of developed countries the levels of the known carcinogens and mutagens are very low. However, serious contamination of foods by the potent hepatocarcinogen aflatoxin B1 has occurred in some parts of the world; contamination by N-nitroso compounds or their precursors is another important concern. Extrapolation of the data on the carcinogenicity and mutagenicity of chemicals that can occur in foods to an accurate estimation of the potential hazard to human populations is not yet possible.

The metabolism of intense sweeteners

Three organic acids (saccharin, acesulfame-K and cyclamate) are used or have been used extensively as intense sweeteners. Once absorbed from the gut they are eliminated, largely in the urine, without undergoing metabolism. Early studies using radiolabelled saccharin indicated the existence of limited metabolism, but this was not confirmed by later more extensive studies using highly purified compound. Metabolism could not be induced by a variety of pretreatments. Following an initial report of the presence of traces of cyclohexylamine in the urines of subjects given cyclamate, it was shown that chronic administration of the sweetener caused the induction of extensive metabolism. The metabolism, which showed wide inter- and intra-individual variability was performed the gut microflora. The peptide sweeteners (aspartame and thaumatin) are metabolized to their constituent amino acids in the gastro intestinal tract, prior to absorption. As such they are incorporated into normal intermediary metabolism and their low-calorie applications derive from their intense sweetness.