The safety and regulatory process for low calorie sweeteners in the United States

Xylitol is prothrombotic and associated with cardiovascular risk

BACKGROUND AND AIMS

The pathways and metabolites that contribute to residual cardiovascular disease risks are unclear. Low-calorie sweeteners are widely used sugar substitutes in processed foods with presumed health benefits. Many low-calorie sweeteners are sugar alcohols that also are produced endogenously, albeit at levels over 1000-fold lower than observed following consumption as a sugar substitute.

METHODS

Untargeted metabolomics studies were performed on overnight fasting plasma samples in a discovery cohort (n = 1157) of sequential stable subjects undergoing elective diagnostic cardiac evaluations; subsequent stable isotope dilution liquid chromatography tandem mass spectrometry (LC-MS/MS) analyses were performed on an independent, non-overlapping validation cohort (n = 2149). Complementary isolated human platelet, platelet-rich plasma, whole blood, and animal model studies examined the effect of xylitol on platelet responsiveness and thrombus formation in vivo. Finally, an intervention study was performed to assess the effects of xylitol consumption on platelet function in healthy volunteers (n = 10).

RESULTS

In initial untargeted metabolomics studies (discovery cohort), circulating levels of a polyol tentatively assigned as xylitol were associated with incident (3-year) major adverse cardiovascular event (MACE) risk. Subsequent stable isotope dilution LC-MS/MS analyses (validation cohort) specific for xylitol (and not its structural isomers) confirmed its association with incident MACE risk [third vs. first tertile adjusted hazard ratio (95% confidence interval), 1.57 (1.12-2.21), P < .01]. Complementary mechanistic studies showed xylitol-enhanced multiple indices of platelet reactivity and in vivo thrombosis formation at levels observed in fasting plasma. In interventional studies, consumption of a xylitol-sweetened drink markedly raised plasma levels and enhanced multiple functional measures of platelet responsiveness in all subjects.

CONCLUSIONS

Xylitol is associated with incident MACE risk. Moreover, xylitol both enhanced platelet reactivity and thrombosis potential in vivo. Further studies examining the cardiovascular safety of xylitol are warranted.

Pathologists' perspective on the study design, analysis, and interpretation of proliferative lesions in a lifetime rodent carcinogenicity bioassay of sucralose

Sucralose, a sugar substitute first approved for use in 1991, is a non-caloric sweetener regulated globally as a food additive. Based on numerous experimental animal studies (dating to the 1980s) and human epidemiology studies, international health agencies have determined that sucralose is safe when consumed as intended. A single lifetime rodent carcinogenicity bioassay conducted by the Ramazzini Institute (RI) reported that mice fed diets containing sucralose develop hematopoietic neoplasia, but controversy continues regarding the validity and relevance of these data for predicting health effects in humans. The present paper addresses the controversy by providing the perspective of experienced pathologists on sucralose-related animal toxicity and carcinogenicity data generally, and the RI carcinogenicity bioassay findings specifically, using results from publicly available papers and international regulatory authority decisions. In the authors' view, flaws in the design, methodology, data evaluation, and reporting of the RI carcinogenicity bioassay for sucralose diminish the value of the data as evidence that this agent represents a carcinogenic hazard to humans. This limitation will remain until the RI bioassay is repeated under Good Laboratory Practices and the design, data, and accuracy of the pathology diagnoses and interpretations are reviewed by qualified pathologists with experience in evaluating potential chemically-induced carcinogenic hazards.

The MILK study: Investigating intergenerational transmission of low-calorie sweeteners in breast milk

Introduction

Forty-four percent of lactating women in the United States consume beverages containing low calorie sweeteners (LCS), and the presence of LCS in the food supply has continued to increase in recent years. While LCS are approved by the United States Food and Drug Administration (FDA) and are believed to be safe for human consumption, intergenerational LCS transmission and the health impacts of early life LCS exposure are severely understudied.

Methods and analysis

In a tightly controlled, single site, prospective interventional study, mothers' plasma and breast milk, and infants' plasma will be collected from 40 mother-infant dyads over the course of 72 h, with rich sampling following maternal ingestion of a LCS sweetened beverage containing sucralose and acesulfame potassium (ace-K). Concentration-time data will be used to build maternal and infant pharmacokinetic models for future simulations and analysis.

Conclusion

This study aims to measure LCS concentrations in breast milk, maternal plasma, and infant plasma, to gain insight into infant exposure and inform recommendations for LCS consumption during breastfeeding.

Sweeteners and the Gut Microbiome: Effects on Gastrointestinal Cancers

Worldwide, the demand for natural and synthetic sweeteners in the food industry as an alternative to refined sugar is increasing. This has prompted more research to be conducted to estimate its safety and effects on health. The gut microbiome is critical in metabolizing selected sweeteners which might affect overall health. Recently, more studies have evaluated the relationship between sweeteners and the gut microbiome. This review summarizes the current knowledge regarding the role played by the gut microbiome in metabolizing selected sweeteners. It also addresses the influence of the five selected sweeteners and their metabolites on GI cancer-related pathways. Overall, the observed positive effects of sweetener consumption on GI cancer pathways, such as apoptosis and cell cycle arrest, require further investigation in order to understand the underlying mechanism.

Sweet Taste Receptor T1R3 Expressed in Leydig Cells Is Closely Related to Homeostasis of the Steroid Hormone Metabolism Profile

Taste receptor type 1 subunit 3 (T1R3) is initially expressed in mammal tongue for recognition and response of sweet/umami tastants and is critical to nutrient absorption, even endocrine. In this study, down-regulation of related steroidogenic enzymes such as StAR, 3β-HSD, CYP17A1, and 17β-HSD with the decrease of T1R3 expression was found in Leydig cells treated by a T1R3 inhibitor (lactisole). The abundances of progesterone, 17a-hydroxyprogesterone, androstenedione, testosterone, and deoxycorticosterone were down-regulated by 2.3, 3.5, 1.4, 1.6, and 2.2 times, respectively, after T1R3 inhibition. In addition, opposite results were found in saccharin sodium treatment. T1R3 activation contributed to intracellular cyclic adenosine monophosphate (cAMP) accumulation (14.41 ± 0.58 vs 20.21 ± 0.65) and increased testosterone (20.31 ± 3.49 vs 50.01 ± 7.44) and steroidogenic metabolite levels. Coadministration of human chorionic gonadotropin and saccharin sodium resulted in elevating the testosterone and cAMP levels and enhancing the expression levels of steroidogenic-related factors. Similarly, intratesticular injection of lactisole and saccharin sodium further confirmed that T1R3 inhibition/activation affected the expression of related steroidogenic enzymes and the testosterone levels in mice. The above findings suggest that T1R3 plays a role in testicular steroidogenesis.

The artificial sweetener erythritol and cardiovascular event risk

Artificial sweeteners are widely used sugar substitutes, but little is known about their long-term effects on cardiometabolic disease risks. Here we examined the commonly used sugar substitute erythritol and atherothrombotic disease risk. In initial untargeted metabolomics studies in patients undergoing cardiac risk assessment (n = 1,157; discovery cohort, NCT00590200 ), circulating levels of multiple polyol sweeteners, especially erythritol, were associated with incident (3 year) risk for major adverse cardiovascular events (MACE; includes death or nonfatal myocardial infarction or stroke). Subsequent targeted metabolomics analyses in independent US (n = 2,149, NCT00590200 ) and European (n = 833, DRKS00020915 ) validation cohorts of stable patients undergoing elective cardiac evaluation confirmed this association (fourth versus first quartile adjusted hazard ratio (95% confidence interval), 1.80 (1.18-2.77) and 2.21 (1.20-4.07), respectively). At physiological levels, erythritol enhanced platelet reactivity in vitro and thrombosis formation in vivo. Finally, in a prospective pilot intervention study ( NCT04731363 ), erythritol ingestion in healthy volunteers (n = 8) induced marked and sustained (>2 d) increases in plasma erythritol levels well above thresholds associated with heightened platelet reactivity and thrombosis potential in in vitro and in vivo studies. Our findings reveal that erythritol is both associated with incident MACE risk and fosters enhanced thrombosis. Studies assessing the long-term safety of erythritol are warranted.

Enzyme kinetics by real-time quantitative NMR (qNMR) spectroscopy with progress curve analysis

This review article summarizes how the experimental data obtained using quantitative nuclear magnetic resonance (qNMR) spectroscopy can be combined with progress curve analysis to determine enzyme kinetic parameters. The qNMR approach enables following the enzymatic conversion of the substrate to the product in real-time by a continuous collection of spectra. The Lambert-W function, a closed-form solution to the time-dependent substrate/product kinetics of the rate equation, can estimate the Michaelis-Menten constant (K_M.) and the maximum velocity (V_max) from a single experiment. This article highlights how the qNMR data is well suited for analysis using the Lambert-W function with three different applications. Results from studies on acetylcholinesterase (acetylcholine to acetic acid and choline), β-Galactosidase (lactose to glucose and galactose), and invertase (sucrose to glucose and fructose) are presented. Furthermore, an additional example of how the progress curve analysis is applied to understand the inhibitory role of the artificial sweetener sucralose on sucrose's enzymatic conversion by invertase is discussed. With the wide availability of NMR spectrometers in academia and industries, including bench-top systems with permanent magnets, and the potential to enhance sensitivity using dynamic nuclear polarization in combination with ultrafast methods, the NMR-based enzyme kinetics could be considered a valuable tool for broader applications in the field of enzyme kinetics.

Non-nutritive sweeteners and their impacts on the gut microbiome and host physiology

Non-nutritive sweeteners (NNS) are broadly incorporated into foods, especially those representing a growing share of the beverage market. NNS are viewed as a noncaloric and desirable alternative to sugar-based sweeteners and are thought to contribute to reducing overall caloric intake. While these compounds have been studied extensively and have long been considered inert, new research has presented a different view and raises new questions about the effects of NNS on human physiology. Namely, the influence on glucose responses, the gastrointestinal epithelium, and the gut microbiome. As the gut microbiome is now recognized as a major mediator of human health and perturbations to this community are generally associated with negative health trajectories or overt disease, interactions between NNS and the gut microbiome are of increasing interest to clinicians and researchers. Several NNS compounds are now hypothesized to affect human physiology by modulating the gut microbiome, though the mechanism for this action remains unclear. The purpose of this review is to discuss the history and current knowledge of NNS, their reported utility and effects on host physiology and the gut microbiome, and describes a model for investigating the underlying mechanism behind reported effects of NNS on the gut microbiome.

Low-calorie sweeteners and human health: a rapid review of systematic reviews

INTRODUCTION

Low-calorie sweeteners are increasingly prevalent in the food supply and their consumption has increased in recent decades. Although low-calorie sweeteners approved for use are considered safe from a toxicological perspective, their short- and long-term impacts on chronic disease risk remain uncertain. The aim of this review was to summarize the evidence from systematic reviews on low-calorie sweetener use and chronic conditions and risk factors in children and adults.

METHODS

MEDLINE and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews of randomized and nonrandomized studies that considered low-calorie sweeteners in relation to type 2 diabetes, cardiovascular disease, cancer, anthropometric measures, hypertension, hyperglycemia, hyperlipidemia, insulin resistance, and dental caries. Data were extracted from 9 reviews deemed of moderate or high quality on the basis of AMSTAR-2.

RESULTS

Narrative synthesis suggested inconsistent evidence on low-calorie sweetener use in relation to chronic conditions and associated risk factors, with nonrandomized studies suggesting positive associations and randomized studies suggesting negative or no associations.

CONCLUSION

Continued research on the long-term health impacts of low-calorie sweeteners across all life stages is warranted.

Gastrointestinal microbiome, what is behind faecal microbiota transplantation?

The intestinal microbiota is made up of billions of microorganisms that coexist in an organised ecosystem, where strict and facultative anaerobic bacteria predominate. The alteration or imbalance of these microorganisms, known as dysbiosis, can be associated with both gastrointestinal and extraintestinal diseases. Based on a review of the literature, the intestinal microbiota is described in its state of health, the changes associated with some gastrointestinal diseases and the potential role that faecal microbiota transplantation has in the reestablishment of an altered ecosystem. Undoubtedly, the information revealed makes us reflect on the indication of faecal microbiota transplantation in various pathologies of intestinal origin. However, to ensure the efficacy and safety of this therapy, more studies are needed to obtain more evidence.

Use of sucralose in foods heated during manufacturing does not pose a risk to human health

Regulatory agencies around the world have found sucralose to be a safe ingredient for use in food. A recent review by the German Federal Institute for Risk Assessment (BfR) hypothesized that sucralose use in foods heated during their manufacture might pose a health risk, by resulting in the formation of certain chlorinated compounds; specifically, polychlorinated dibenzodioxins (PCDDs), polychlorinateddibenzofurans (PCDFs) and/or free or bound 3-monochloropropanediol (3-MCPD), some of which are considered potential carcinogens. The BfR further encouraged the European Food Safety Authority (EFSA), which is in the process of conducting a staged re-evaluation of a range of food additives, including sucralose, to specifically address their hypothesis. This paper reports the results of new studies requested by EFSA to analyze for the presence of PCDDs, PCDFs and 3-MCPDs in a range of foods. As requested, foods were prepared with typical sucralose use levels and thermally processed under typical food processing conditions. The presence of the compounds of interest were analyzed using validated and accepted analytical methods (e.g. US Environmental Protection Agency (EPA); American Oil Chemists Society (AOCS)). The results of these new analytical studies show no evidence for the formation of these compounds due to sucralose presence. This paper also reports a critical analysis of the studies cited in the BfR review as the basis for its hypothesis. This analysis shows that the cited studies do not represent food manufacturing conditions and are thus not reliable for predicting the fate of sucralose in foods. This work reaffirms that sucralose is safe for use in food manufacture, including when heating is required.

An Overview of Current Knowledge of the Gut Microbiota and Low-Calorie Sweeteners

This review provides an overview of the interrelationships among the diet, gut microbiota and health status, and then focuses specifically on published research assessing the relationship of low/no-calorie sweeteners (LNCS) to selected aspects of the gut microbiota. Microbiome research is expanding as new data on its role in health and disease vulnerability emerge. The gut microbiome affects health, digestion, and susceptibility to disease. In the last 10 years, investigations of LNCS effects on the gut microbiota have proliferated, though results are conflicting and are often confounded by differences in study design such as study diet, the form of the test article, dosage, and study population. Staying current on microbiome research and the role of dietary inputs, like LNCS, will allow healthcare and nutrition practitioners to provide evidenced-based guidance to the individuals they serve.

Soft drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners?

The rapid increase in obesity, metabolic syndrome, and cardiovascular diseases (CVDs) has been related to the rise in sugar-added foods and sweetened beverages consumption. An interesting approach has been to replace sugar with alternative sweeteners (AS), due to their impact on public health. Preclinical and clinical studies, which analyze the safety of AS intake, are still limited. Major pathogenic mechanisms of these substances include ROS and AGEs formation. Indeed, endothelial dysfunction involving in the pathogenesis of micro- and macro-vascular diseases is mitochondrial dysfunction dependent. Hyperglycemia and endoplasmic reticulum stress together produce ROS, contributing to the development and progression of cardiovascular complications during type 2 diabetes (T2D), thus causing oxidative changes and direct damage of lipids, proteins, and DNA. Epidemiological studies in healthy subjects have suggested that the consumption of artificial AS can promote CV complications, such as glucose intolerance and predisposition to the onset of T2D, whereas natural AS could reduce hyperglycemia, improve lipid metabolism and have antioxidant effects. Long-term prospective clinical randomized studies are needed to evaluate precisely whether exposure to alternative sugars can have clinical implications on natural history and clinical outcomes, especially in children or during the gestational period through breast milk.

Tiered intake assessment for low- and no-calorie sweeteners in beverages

A tiered intake assessment approach is presented and applied to derive the maximum potential global low- and no-calorie sweeteners (LNCS) intake estimates. The US and Uk markets served as representative for the world and the EU region, respectively, to determine the maximum potential exposure for acesulfame potassium (AceK), aspartame, saccharin, steviol glycosides, and sucralose in various subpopulations, including brand-loyal consumers. Conservative intake estimates for LNCS used in non-alcoholic beverages were calculated for the general population 2 + y, toddlers (12-35 months (US) or 18-35 months (UK)), young children 3-9 y, adolescents 10-17 y, adults 18-64 y, elderly 65-74 y, and very elderly 75 + y based on assumed uses in high beverage consumption markets, leveraging either the 2-day food consumption data from the 2013-2016 US National Health and Nutrition Examination Survey or the 4-day food consumption data from the 2008-2017 UK National Diet and Nutrition Survey Rolling Programme. Strong concordance between the refined budget method and the brand-loyal deterministic approach was shown, the latter assumes the maximum industry-reported global LNCS use level is present in 100% of non-alcoholic beverages. This study shows that safety of LNCS in beverages at proposed use levels can be supported for any geography, with all intake estimates falling below the acceptable daily intake in refined assessments. Importantly, this study shows the refined budget method to be a valid first-tier screening assessment in prioritising those LNCS that may benefit from more refined intake assessments when warranted.

Practical Strategies to Help Reduce Added Sugars Consumption to Support Glycemic and Weight Management Goals

Overconsumption of added sugars is a key contributor to the growing obesity, prediabetes, and type 2 diabetes pandemics. The nutrition therapy guidance of the American Diabetes Association recognizes that using low- and no-calorie sweeteners (LNCS) to reduce consumption of added sugars can reduce low-nutrient-density sources of calories and carbohydrate to beneficially affect glycemia, weight, and cardiometabolic health. This article provides information for primary care providers, diabetes care and education specialists, and other diabetes clinicians on the safety of LNCS and summarizes research evidence on the role of LNCS in glycemic and weight management. It also provides practical strategies for counseling individuals about how to integrate LNCS into their healthy eating pattern.

Transgenerational transmission of behavioral phenotypes produced by exposure of male mice to saccharin and nicotine

The use of non-nutritive sweeteners such as saccharin is widely prevalent. Although saccharin is considered safe for human consumption, it produces behavioral changes in experimental animals. We report that saccharin’s behavioral effects are much more pervasive than currently recognized. In a mouse model, saccharin exposure produced motor impulsivity not only in the saccharin-exposed males but also in their offspring. In addition, the offspring showed locomotor hyperactivity and working memory deficit not observed in fathers. Spermatazoal DNA was hypermethylated in the saccharin-exposed fathers, especially at dopamine receptor promoter regions, suggesting that epigenetic modification of germ cell DNA may mediate transgenerational transmission of behavioral phenotypes. Dopamine’s role in hyperactivity was further highlighted by the finding that the stimulant drug methylphenidate mitigated the hyperactivity. Nicotine is another substance that is widely used. Its use via smokeless tobacco products, some of which contain saccharin, is on the rise contributing to concerns about adverse outcomes of co-exposure to saccharin and nicotine. We found that co-exposure of male mice to saccharin and nicotine produced significant behavioral impairment in their offspring. Thus, our data point to potential adverse neurobehavioral consequences of exposure to saccharin alone or saccharin and nicotine for the exposed individuals and their descendants.

Neuroendocrine and Metabolic Effects of Low-Calorie and Non-Calorie Sweeteners

Since excessive sugar consumption has been related to the development of chronic metabolic diseases prevalent in the western world, the use of sweeteners has gradually increased worldwide over the last few years. Although low- and non-calorie sweeteners may represent a valuable tool to reduce calorie intake and prevent weight gain, studies investigating the safety and efficacy of these compounds in the short- and long-term period are scarce and controversial. Therefore, future studies will need to elucidate the potential beneficial and/or detrimental effects of different types of sweeteners on metabolic health (energy balance, appetite, body weight, cardiometabolic risk factors) in healthy subjects and patients with diabetes, obesity and metabolic syndrome. In this regard, the impact of different sweeteners on central nervous system, gut hormones and gut microbiota is important, given the strong implications that changes in such systems may have for human health. The aim of this narrative review is to summarize the current evidence for the neuroendocrine and metabolic effects of sweeteners, as well as their impact on gut microbiota. Finally, we briefly discuss the advantages of the use of sweeteners in the context of very-low calorie ketogenic diets.

Older US adults like sweetened colas, but not other chemesthetic beverages

Many older adults suffer from difficulty swallowing thin beverages like water or coffee. To improve swallowing safety, beverages are typically thickened. This creates a new problem: the thickened beverages can be disgusting. New research suggests chemesthesis, particularly spiciness, carbonation, or intense sourness, could improve swallowing without the need for thickeners. Yet, whether such beverages would be liked by older adults is unknown. We thus conducted this experiment to establish older adults' sensory perception and liking/disliking of commercially available chemesthetic beverages. We recruited participants to rate sweetness, sourness, fizziness, stinging, and liking/disliking of unsweetened carbonated waters (1 plain, 5 flavored), sour orange juice, spicy ginger beer, and colas (sugar or aspartame-sweetened). Initial tests (N = 30 older adults) indicated sour orange juice, spicy ginger beer, and two of the flavored waters were not well-liked, so other beverages were selected for a second test (N = 94, 30 younger adults, 64 older adults). Sweetened, carbonated colas were the best-liked of the beverages. The unsweetened, flavored carbonated waters were in general not liked. Regarding comparisons of sensory ratings between older and younger adults, only sweetness differed between age groups. In particular, intensity ratings for the chemesthetic aspects of the beverages (stinging/burning/spiciness, fizziness) and the sour taste did not differ by age. As the chemesthetic properties are the most likely reason the beverages could aid in swallowing safety, observing no suppression of these sensations in older adults is encouraging for the potential of these products as a treatment option.

Perspective: Standards for Research and Reporting on Low-Energy ("Artificial") Sweeteners

Widely differing views exist among experts, policy makers, and the general public with regard to the potential risks and benefits of reduced- or low-energy sweeteners (LES) in the diet. These views are informed and influenced by different types of research in LES, with differing hypotheses, designs, interpretation, and communication. Given the high level of interest in LES, and the public health relevance of the research evidence base, it is important that all aspects of the research process are framed and reported in an appropriate and balanced manner. In this Perspective, we identify and give examples of a number of issues relating to research and reviews on LES, which may contribute toward apparent inconsistencies in the content and understanding of the totality of evidence. We conclude with a set of recommendations for authors, reviewers and journal editors, as general guidance to improve and better standardize the quality of LES research design, interpretation, and reporting. These focus on clarity of underlying hypotheses, characterization of exposures, and the placement and weighting of new research within the wider context of related prior work.

Nonalcoholic fatty liver disease, insulin resistance, and sweeteners: a literature review

Introduction: Sweeteners are substances used to replace sugar. They can either be chemically produced (artificial sweeteners) or extracted from plants (natural sweeteners). In the last two decades, there is an increased popularity in their role as sugar substitutes in individuals to promote weight loss or maintain glycemic control. However, despite their favorable effects, there is concern regarding their side effects and especially their influence in the development of nonalcoholic fatty liver disease (NAFLD).Areas covered: A comprehensive literature search was conducted on Medline including systematic reviews, longitudinal controlled studies, and retrospective cohort studies. We present an up-to-date systematic review of the current literature regarding the safety in artificial and natural sweeteners use as a means of weight loss or diabetes control.Expert opinion: Natural sweeteners have not been associated directly with NAFLD, and on the contrary, some, such as stevia, and trehalose, may have a protective effect. Rare sugars and polyols can be used safely and have significant benefits that include anti-oxidant effect and optimal glycemic control. Artificial sweeteners, due to their effect on NAFLD development and insulin resistance, are not indicated in patients with obesity or diabetes. Further studies in human subjects are required to verify the above findings.

“Sweet” ionic liquids comprising the acesulfame anion – synthesis, physicochemical properties and antifeedant activity towards stored product insects

The synthesized “sweet” ionic liquids comprising acesulfame anion proved to be effective antifeedants with designer physicochemical properties.

When the beverage is sweet, how does the liver feel?

Purpose of review

The purpose of this paper is to both review the available data and also highlight the gaps in knowledge, regarding the link between pediatric NASH and different type of sweeteners including caloric sweeteners (CS) and non-caloric sweeteners (NCS).

Recent findings

Studies have demonstrated that patients with NASH generally have had an unhealthy diet, characterized by on overconsumption of carbohydrates especially fructose. Mechanistically, a high-fructose diet reduces hepatic lipid oxidation, increases proinflammatory response, increases intestinal permeability and decreases microbiome diversity. Consumption and availability of NCS has therefore been increasing dramatically. Most NCS are not considered to be metabolized in the body and therefore thought to be safe for consumption. It was reported that pharmacological properties of rebaudioside, a type of NCS, as a potential hepatoprotector are through anti-inflammatory and antifibrotic mechanisms, associated with enhancing glucose-induced insulin secretion and inducing the difference of microbiome diversity.

Summary

Diet is an important factor in the pathogenesis of NAFLD and popular dietary patterns are contributing to the increased replacement of natural sweeteners with NCS. Screening for NAFLD by pediatricians and counseling on the avoidance of sugar-sweetened beverages are recommended. We feel that the various NCS available to the consumer today merit further investigation, and may potentially have hitherto unknown effects on hepatic metabolic function.

Low Calorie Sweeteners Differ in Their Physiological Effects in Humans

Low calorie sweeteners (LCS) are prevalent in the food supply for their primary functional property of providing sweetness with little or no energy. Though tested for safety individually, there has been extremely limited work on the efficacy of each LCS. It is commonly assumed all LCS act similarly in their behavioral and physiological effects. However, each LCS has its own chemical structure that influences its metabolism, making each LCS unique in its potential effects on body weight, energy intake, and appetite. LCS may have different behavioral and physiological effects mediated at the sweet taste receptor, in brain activation, with gut hormones, at the microbiota and on appetitive responses. Further elucidation of the unique effects of the different commercially available LCS may hold important implications for recommendations about their use for different health outcomes.

Changes in nutrient and calorie intake, adipose mass, triglycerides and TNF-α concentrations after non-caloric sweetener intake: A pilot study

Establishing the safety of non-caloric sweetener consumption in humans is a difficult task, since many contradictory results have been reported. The objective of this study was to compare the effect of frequent intake of sucrose, sucralose or steviol glycosides, on selected anthropometric, biochemical and immunological parameters in healthy, young adults. 38 individuals with normal body mass index were recruited and randomly divided into three experimental groups. After a washout week (where food with added sweeteners was restricted), each group was supplemented with sucrose (8 × 5 g packets/day), sucralose or steviol glycosides (4 × 1 g packets/day each) for 6 weeks. Selected variables were measured before and after treatment in each group and differences within and among groups were assessed. Our results showed that, compared to baseline, there was a modest but significant increase in weight (p = 0.0293) in the sucralose group, while the steviol glycosides group reduced their fat mass (p = 0.0390). No differences were observed in glycaemia; however, there was a significant increase in serum triglycerides (77.8-110.8 mg/dL) and cholesterol (162.0-172.3 mg/dL) in the sucrose group, whereas the steviol glycosides group presented lower triglycerides (104.7-92.8 mg/dL) and TNF-α concentrations (51.1-47.5 pg/mL). Comparison among groups showed differences in serum triglycerides (p = 0.0226), TNF-α (p = 0.0460) and IL-β (p = 0.0008). Our results suggest that, even in a short time span, frequent intake of steviol glycosides may have positive effects on metabolic parameters that may be relevant for human health.

Evolving regulatory policies regarding food enzymes produced by recombinant microorganisms

Bio-based industries rely extensively on the use of enzymatic biocatalysts. The global market for industrial enzymes, of which approximately half is used for food applications, is estimated at $5.5 billion. Most enzymes used in food production worldwide are produced by recombinant DNA techniques. Production and use of food enzymes are regulated by three main bodies: the Joint Food and Agriculture Organization of the United Nations/World Health Organization Expert Committee on Food Additives; the European Food Safety Authority; and the U.S. Food and Drug Administration. Regulation in the U.S. follows a largely product-oriented approach while the EU emphasizes production processes. Both systems have, or are developing, lists of approved enzymes to facilitate trade while protecting consumer health and welfare. This paper compares regulatory policies, and presents the growing food industry in Turkey as a case study of a national system responding to the food enzyme production and regulatory landscape.

Glycyrrhetic acid monoglucuronide: sweetness concentration-response and molecular mechanism as a naturally high-potency sweetener

Glycyrrhetic acid monoglucuronide (GAM) is obtained from the natural sweetener glycyrrhizin through enzymolysis. Its sweetness concentration-response (C-R) behavior in room-temperature in water was determined using two-alternative forced choice discrimination tests. The C-R equation of resultant hyperbolic curve relating sucrose equivalent (SE, %) to GAM concentration ([GAM], mg/L) was SE = 19.6 × [GAM]/(194.8 + [GAM]). From the C-R function, Pw (2) of GAM, relative to a 2% (w/v) sucrose reference, is more than 900, which has much higher potency than its precursor glycyrrhizin. Molecular modeling showed that GAM is finely bound into protein 1EWK through conventional hydrogen bonds, π-Alkyl interactions and Van der Waals bonds, which exhibited better protein inclusion than Glycyrrhizin. Thus, GAM could be developed as a new zero-calorie, naturally high-potency sweetener.

Consumption of low-calorie sweetened beverages and water is associated with lower intake of carbohydrates and sugars and not associated with glycemic response in U.S. non-diabetic adolescents: Results from the 2001-2014 National Health and Nutrition Examination Surveys

OBJECTIVES

Consumption of no- and low-calorie sweetened beverages (LCSBs) in the United States appears to be on the rise. To our knowledge, the relationships between LCSB consumption and dietary intake and metabolic outcomes in adolescents have not been thoroughly investigated. The aim of this study was to evaluate possible associations between LCSB and water consumption with nutrient intake and prediabetes criteria among adolescents who were free of diabetes.

METHODS

This cross-sectional study evaluated possible associations between LCSB consumption and water consumption using a 24-h diet recall from the National Health and Nutrition Examination Survey (NHANES) 2001-2014 in 8868 adolescents 12 to 18 y of age who were free of diabetes.

RESULTS

Compared with consuming <1 serving/d, consuming ≥1 serving/d of either LCSB or water was significantly associated with lower consumption of carbohydrates (LCSB: -22 g; water: -15 g), total sugars (LCSB: -29 g; water: -20 g), and added sugars (LCSB: -5.7 tsp eq; water: -6 tsp eq). Neither LCSB nor water intake were associated with any measures of glycemic response.

CONCLUSIONS

These findings suggest that consuming ≥1 serving/d of either LCSB or water is not associated with an increased risk for prediabetes. Confirmation of these findings with a larger sample within the context of a randomized clinical trial would further suggest that LCSBs may represent an additional beverage option other than water for adolescents to help moderate overall dietary sugar intake.

How Non-nutritive Sweeteners Influence Hormones and Health

Non-nutritive sweeteners (NNSs) elicit a multitude of endocrine effects in vitro, in animal models, and in humans. The best-characterized consequences of NNS exposure are metabolic changes, which may be mediated by activation of sweet taste receptors in oral and extraoral tissues (e.g., intestine, pancreatic β cells, and brain), and alterations of the gut microbiome. These mechanisms are likely synergistic and may differ across species and chemically distinct NNSs. However, the extent to which these hormonal effects are clinically relevant in the context of human consumption is unclear. Further investigation following prolonged exposure is required to better understand the role of NNSs in human health, with careful consideration of genetic, dietary, anthropometric, and other interindividual differences.

Stevia Leaf to Stevia Sweetener: Exploring Its Science, Benefits, and Future Potential

Steviol glycoside sweeteners are extracted and purified from the Stevia rebaudiana Bertoni plant, a member of the Asteraceae (Compositae) family that is native to South America, where it has been used for its sweet properties for hundreds of years. With continued increasing rates of obesity, diabetes, and other related comorbidities, in conjunction with global public policies calling for reductions in sugar intake as a means to help curb these issues, low- and no-calorie sweeteners (LNCSs, also known as high-potency sweeteners) such as stevia are gaining interest among consumers and food manufacturers. This appeal is related to stevia being plant-based, zero calorie and with a sweet taste that is 50-350 times sweeter than sugar, making it an excellent choice for use in sugar- and calorie-reduced food and beverage products. Despite the fact that the safety of stevia has been affirmed by several food regulatory and safety authorities around the world, insufficient education about stevia's safety and benefits, including continuing concern with regard to the safety of LNCSs in general, deters health professionals and consumers from recommending or using stevia. Therefore, the aim of this review and the stevia symposium that preceded this review at the ASN's annual conference in 2017 was to examine, in a comprehensive manner, the state of the science for stevia, its safety and potential health benefits, and future research and application. Topics covered included metabolism, safety and acceptable intake, dietary exposure, impact on blood glucose and insulin concentrations, energy intake and weight management, blood pressure, dental caries, naturality and processing, taste and sensory properties, regulatory status, consumer insights, and market trends. Data for stevia are limited in the case of energy intake and weight management as well as for the gut microbiome; therefore, the broader literature on LNCSs was reviewed at the symposium and therefore is also included in this review.

Ibero⁻American Consensus on Low- and No-Calorie Sweeteners: Safety, Nutritional Aspects and Benefits in Food and Beverages

International scientific experts in food, nutrition, dietetics, endocrinology, physical activity, paediatrics, nursing, toxicology and public health met in Lisbon on 2⁻4 July 2017 to develop a Consensus on the use of low- and no-calorie sweeteners (LNCS) as substitutes for sugars and other caloric sweeteners. LNCS are food additives that are broadly used as sugar substitutes to sweeten foods and beverages with the addition of fewer or no calories. They are also used in medicines, health-care products, such as toothpaste, and food supplements. The goal of this Consensus was to provide a useful, evidence-based, point of reference to assist in efforts to reduce free sugars consumption in line with current international public health recommendations. Participating experts in the Lisbon Consensus analysed and evaluated the evidence in relation to the role of LNCS in food safety, their regulation and the nutritional and dietary aspects of their use in foods and beverages. The conclusions of this Consensus were: (1) LNCS are some of the most extensively evaluated dietary constituents, and their safety has been reviewed and confirmed by regulatory bodies globally including the World Health Organisation, the US Food and Drug Administration and the European Food Safety Authority; (2) Consumer education, which is based on the most robust scientific evidence and regulatory processes, on the use of products containing LNCS should be strengthened in a comprehensive and objective way; (3) The use of LNCS in weight reduction programmes that involve replacing caloric sweeteners with LNCS in the context of structured diet plans may favour sustainable weight reduction. Furthermore, their use in diabetes management programmes may contribute to a better glycaemic control in patients, albeit with modest results. LNCS also provide dental health benefits when used in place of free sugars; (4) It is proposed that foods and beverages with LNCS could be included in dietary guidelines as alternative options to products sweetened with free sugars; (5) Continued education of health professionals is required, since they are a key source of information on issues related to food and health for both the general population and patients. With this in mind, the publication of position statements and consensus documents in the academic literature are extremely desirable.

Aspartame Consumption for 12 Weeks Does Not Affect Glycemia, Appetite, or Body Weight of Healthy, Lean Adults in a Randomized Controlled Trial

Background

Low-calorie sweeteners are often used to moderate energy intake and postprandial glycemia, but some evidence indicates that they may exacerbate these aims.

Objective

The trial's primary aim was to assess the effect of daily aspartame ingestion for 12 wk on glycemia. Effects on appetite and body weight were secondary aims.

Methods

One hundred lean [body mass index (kg/m2): 18-25] adults aged 18-60 y were randomly assigned to consume 0, 350, or 1050 mg aspartame/d (ASP groups) in a beverage for 12 wk in a parallel-arm design. At baseline, body weight and composition were determined, a 240-min oral-glucose-tolerance test (OGTT) was administered, and measurements were made of appetite and selected hormones. Participants also collected a 24-h urine sample. During the intervention, the 0-mg/d ASP group consumed capsules containing 680 mg dextrose and 80 mg para-amino benzoic acid. For the 350-mg/d ASP group, the beverage contained 350 mg aspartame and the 1050-mg/d ASP group consumed the same beverage plus capsules containing 680 mg dextrose and 700 mg aspartame. Body weight, blood pressure, heart rate, and waist circumference were measured weekly. At weeks 4, 8, and 12, participants collected 24-h urine samples and kept appetite logs. Baseline measurements were repeated at week 12.

Results

With the exception of the baseline OGTT glucose concentration at 60 min (and resulting area under the curve value), there were no group differences for glucose, insulin, resting leptin, glucagon-like peptide 1, or gastric inhibitory peptide at baseline or week 12. There also were no effects of aspartame ingestion on appetite, body weight, or body composition. Compliance with the beverage intervention was ∼95%.

Conclusions

Aspartame ingested at 2 doses for 12 wk had no effect on glycemia, appetite, or body weight among healthy, lean adults. These data do not support the view that aspartame is problematic for the management of glycemia, appetite, or body weight. This trial was registered at www.clinicaltrials.gov as NCT02999321.

Noncaloric Sweeteners in Children: A Controversial Theme

Noncaloric sweeteners (NCS) are food additives used to provide sweetness without adding calories. Their consumption has become more widespread around the world in all age groups, including children. The aim of this study is to show the state of the art about the intake of noncaloric sweeteners in children, as well as their benefits and consumption risk. Scientific searchers were used (PUBMED, Scopus, and Scielo) to analyze articles that included keywords (noncaloric sweeteners/saccharin/cyclamate/acesulfame potassium/aspartame/sucralose/stevia/children) in English, Spanish, and Portuguese. Authors conclude that it is imperative that health professionals judiciously and individually evaluate the overall benefits and risks of NCS use in consumers before recommending their use. Different subgroups of the population incorporate products containing NCS in their diet with different objectives, which should be considered when recommending a diet plan for the consumer. In childhood, in earlier age groups, this type of additives should be used as a dietary alternative when other forms of prevention in obesity are not sufficient.

The role of low-calorie sweeteners in the prevention and management of overweight and obesity: evidence v. conjecture

By virtue of reducing dietary energy density, low-calorie sweeteners (LCS) can be expected to decrease overall energy intake and thereby decrease body weight. Such effects will be limited by the amount of sugar replaced by LCS, and the dynamics of appetite and weight control (e.g., acute compensatory eating, and an increase in appetite and decrease in energy expenditure accompanying weight loss). Consistent with these predictions, short-term intervention studies show incomplete compensation for the consumption of LCS v. sugar, and longer-term intervention studies (from 4 weeks to 40 months duration) show small decreases in energy intake and body weight with LCS v. sugar. Despite this evidence, there are claims that LCS undermine weight management. Three claims are that: (1) LCS disrupt the learned control of energy intake (sweet taste confusion hypothesis); (2) exposure to sweetness increases desire for sweetness (sweet tooth hypothesis); (3) consumers might consciously overcompensate for 'calories saved' when they know they are consuming LCS (conscious overcompensation hypothesis). None of these claims stands up to close examination. In any case, the results of the intervention studies comparing LCS v. sugar indicate that the effect of energy dilution outweighs any tendency LCS might conceivably have to increase energy intake.

Health outcomes of non-nutritive sweeteners: analysis of the research landscape

BACKGROUND

Food products containing non-nutritive sweeteners (NNSs) instead of sugar have become increasingly popular in the last decades. Their appeal is obviously related to their calorie-free sweet taste. However, with the dramatic increase in their consumption, it is reasonable and timely to evaluate their potential health benefits and, more importantly, potential adverse effects. The main aim of this scoping review was to map the evidence about health outcomes possibly associated with regular NNS consumption by examining the extent, range, and nature of research activity in this area.

METHODS

We systematically searched Ovid MEDLINE, EMBASE and the Cochrane CENTRAL databases for studies on NNSs (artificial sweeteners or natural, non-caloric sweeteners, either used individually or in combination) using text terms with appropriate truncation and relevant indexing terms. All human studies investigating any health outcomes of a NNS intervention or exposure were eligible for inclusion. No studies were excluded based on language, study design or methodological quality. Data for each health outcome were summarized in tabular form and were discussed narratively.

RESULTS

Finally, we included 372 studies in our scoping review, comprising 15 systematic reviews, 155 randomized controlled trials (RCTs), 23 non-randomized controlled trials, 57 cohort studies, 52 case-control studies, 28 cross sectional studies and 42 case series/case reports. In healthy subjects, appetite and short term food intake, risk of cancer, risk of diabetes, risk of dental caries, weight gain and risk of obesity are the most investigated health outcomes. Overall there is no conclusive evidence for beneficial and harmful effects on those outcomes. Numerous health outcomes including headaches, depression, behavioral and cognitive effects, neurological effects, risk of preterm delivery, cardiovascular effects or risk of chronic kidney disease were investigated in fewer studies and further research is needed. In subjects with diabetes and hypertension, the evidence regarding health outcomes of NNS use is also inconsistent.

CONCLUSIONS

This scoping review identifies the needs for future research to address the numerous evidence gaps related to health effects of NNSs use.It also specifies the research questions and areas where a systematic review with meta-analyses is required for the proper evaluation of health outcomes associated to regular NNSs consumption.

Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: a significant public health hazard

Caffeinated energy drinks (EDs) are increasingly popular among adolescents despite growing evidence of their negative health effects. The consumption of EDs has seen a substantial increase during the past few decades, especially in the Western and Asian countries. EDs contain high levels of caffeine, sugar, and novel ingredients, and are often marketed through youth-oriented media and venues. The known and unknown pharmacology of the constituents of EDs poses a risk of caffeine toxicity and other ill effects when consumed by young people. Caffeine intoxication may result in tachycardia, vomiting, cardiac arrhythmias, seizures, and even death. Other health concerns related to consumption of EDs include obesity and dental enamel erosion resulting from the acidity of EDs. Coingestion of caffeine and ethanol has been associated with increased risk-taking behaviors in adolescent users, impaired driving, and increased use of other illicit substances. Several researchers have demonstrated that consuming alcohol mixed with energy drinks leads to altered subjective states including decreased perceived intoxication, enhanced stimulation, and increased desire to drink/increased drinking compared to consuming alcohol alone. Caffeine’s effect on intoxication may be most pronounced when mixers are artificially sweetened, that is, lack sucrose which slows the rate of gastric emptying of alcohol. In conclusion: 1) health care providers should educate youth and their parents about the risks of caffeinated drinks; 2) emergency department clinicians should consider asking patients about ED and traditional caffeine usage and substance use when assessing patient symptoms; 3) policy makers should increase their attention on introducing regulatory policies on television food advertising to which youth are exposed; 4) failure to comply with standards for efficacious product labelling, and absence of broader education regarding guidelines, need to be addressed and 5) further studies must be done to improve our understanding of potential negative consequences of caffeinated energy drinks on health. (www.actabiomedica.it)