Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies

Caloric labels do not influence taste pleasantness and neural responses to erythritol and sucrose

INTRODUCTION

The beneficial effects of substituting sugar with non-caloric sweeteners (NCSs) remain uncertain due to the mismatch between their rewarding sweet taste and lack of energy content. Functional magnetic resonance imaging (fMRI) studies indicate an influence of cognitive processes (e.g., beliefs, expectations) on reward system responses to NCSs, thereby changing their rewarding properties. We measured the impact of cognitive influences about the caloric content on brain responses and liking ratings to erythritol, a natural NCS with satiating properties, versus sugar (i.e., sucrose).

METHODS

We performed a within-subject, single-blind, counterbalanced fMRI study in 30 healthy males (mean ± SD: age 23 ± 0.6 years, BMI 22.5 ± 0.3 kg/m²). Concentrations of erythritol were individually titrated to match the perceived sweetness intensity of a 16% sucrose solution. During the scan, sucrose and equisweet erythritol solutions were delivered as 1 mL sips with either correct or purposefully incorrect "low-calorie" or "high-calorie" labels. After each sip, participants rated sweetness liking. Water with a "water" label was used as the control condition.

RESULTS

A 2 × 2 ANOVA revealed lower liking ratings for erythritol than sucrose (p<0.0001), but no main effect of the label, nor label-by-sweetener interaction. General Linear Model (GLM) analysis of brain responses at FDR q<0.05 showed no main effect of sweetener nor label, nor a label-by-sweetener interaction. However, several patterns of brain activity mediated the differences in subjective liking ratings between the sweeteners. Moreover, different neural responses were found for sucrose vs. water in parcel-wise, SVM, and ROI-based analyses, whereas for erythritol vs. water, only the latter two showed differences. Lastly, sucrose induced a stronger craving signature response compared to erythritol, driven by the pattern specific to drug craving.

CONCLUSION

Liking ratings were lower for erythritol than sucrose, and they were unaffected by the caloric label. There were no differences in neural responses between the sweeteners and labels, except in comparisons with water.

Sugar-sweetened or artificially sweetened beverage consumption, physical activity and risk of type 2 diabetes in US adults

AIMS/HYPOTHESIS

A positive association between sugar-sweetened beverages (SSBs) and diabetes risk has been shown, with inconsistent evidence between artificially sweetened beverages (ASBs) and diabetes. Moreover, it is uncertain if physical activity can mitigate the negative effects of these beverages on diabetes development. Therefore, we aimed to evaluate the independent and joint associations between SSB or ASB consumption and physical activity on the risk of type 2 diabetes.

METHODS

We followed 64,029 women in the Nurses' Health Study (1980-2016), 88,340 women in the Nurses' Health Study II (1991-2017) and 39,436 men in the Health Professionals Follow-up Study (1986-2016). SSB and ASB consumption was calculated from food-frequency questionnaires administered every 4 years, while physical activity data were collected biennially. A validated supplementary questionnaire on diabetes symptoms, diagnostic tests and treatment confirmed type 2 diabetes cases. Multivariable Cox proportional hazards regression models were used to calculate HRs and 95% CIs for developing type 2 diabetes.

RESULTS

During 5,105,351 person-years of follow-up, we recorded 19,940 new cases of type 2 diabetes. Compared with those who never or rarely consumed SSBs or ASBs, those who consumed ≥2 servings/day had a 41% (HR 1.41 [95% CI 1.33, 1.50]) and 11% (HR 1.11 [95% CI 1.07, 1.16]) higher risk of type 2 diabetes, respectively. For participants meeting physical activity guidelines (≥7.5 metabolic equivalent of task [MET] h/week) and consuming ≥2 servings/week of SSBs or ASBs, the risk was 22% (HR 1.22 [95% CI 1.15, 1.29]) and 7% (HR 1.07 [95% CI 1.02, 1.12]) higher, respectively, compared with those who met physical activity guidelines and never or rarely (<1 serving/month) consumed these beverages. For participants meeting the physical activity guidelines and consuming 1-4 servings/month of SSBs, there was a 9% (HR 1.09 [95% CI 1.02, 1.15]) higher risk of type 2 diabetes. Compared with the reference group (those who met physical activity guidelines and consumed <1 SSB serving/month), adults who did not meet physical activity guidelines (<7.5 MET h/week) and who never or rarely (<1 serving/month) consumed SSBs, had 1-4 SSB servings/month, or had ≥2 SSB servings/week, the HRs (95% CIs) were 1.22 (1.13, 1.31), 1.28 (1.20, 1.37), and 1.51 (1.43, 1.61), respectively. Similarly, for ASB consumption, adults who did not meet physical activity guidelines and who never or rarely (<1 serving/month) consumed ASBs, had 1-4 servings/month, or had ≥2 servings/week, the HRs (95% CIs) were 1.21 (1.14, 1.28), 1.21 (1.13, 1.30), and 1.30 (1.23, 1.37) compared with the reference group (who met physical activity guidelines and consumed <1 ASB serving/month).

CONCLUSIONS/INTERPRETATION

Even when individuals were physically active, a higher consumption of SSBs or ASBs was associated with a higher risk of type 2 diabetes. Meeting physical activity guidelines reduced the impact of SSB and ASB consumption on diabetes risk, underscoring the need to promote physical activity as part of lifestyle modifications to lower diabetes incidence.

Research Progress on the Relationship Between Artificial Sweeteners and Breast Cancer

Artificial sweeteners, as low-calorie sugar substitutes, have attracted much attention in recent years, especially in terms of their potential health effects. Although they add almost no calories, studies have shown that artificial sweeteners may affect metabolism by stimulating insulin secretion and changing the intestinal microbiota, increasing the risk of metabolic syndrome and type 2 diabetes. Breast cancer, as the most common cancer in the world, is related to multiple factors such as genetics and hormone levels. The results of studies on artificial sweeteners and breast cancer risk are conflicting, with some showing a positive correlation between the two and others failing to confirm it. Differences in study design, participant characteristics, and the types of sweeteners have led to this ambiguity. Although some studies have focused on mechanisms such as hormone disorders, insulin response, and changes in the intestinal microbiota, further exploration is needed to establish a causal relationship. Our review aims to comprehensively analyze the potential association between artificial sweeteners and breast cancer and its mechanisms, as well as encourage future studies to reveal its long-term health effects.

Association of coffee consumption with cardiometabolic multimorbidity: A prospective cohort study in the UK biobank

BACKGROUND AND AIMS

Previous observational studies have investigated the association between coffee consumption and single cardiometabolic disease. Yet, the extent to which coffee might confer health advantages to individuals with a singular cardiometabolic disease remains unclear. This study aimed to further investigate the association of coffee consumption and the onset and progression from single cardiometabolic disease to cardiometabolic multimorbidity (CMM).

METHODS AND RESULTS

This prospective cohort study included 185,112 participants from the UK Biobank who were enrolled between 2006 and 2010 and followed up until 2020. Coffee consumption was collected using a 24-h dietary questionnaire. CMM was defined as the coexistence of at least two cardiometabolic diseases, including type 2 diabetes (T2D), coronary heart disease (CHD) and stroke. Cox proportional hazards and multi-state models estimated the associations between coffee consumption and CMM. During a median follow-up of 11.4 years, 1585 participants developed CMM. Compared with nonconsumers, coffee consumers had lower risks for the transitions from baseline to single cardiometabolic disease, with the respective lowest hazard ratios and 95% confidence intervals (CIs) for the transitions from baseline to T2D, CHD and stroke after multivariable adjustment being 0.79 (CI, 0.72-0.87), 0.91 (CI, 0.86-0.97) and 0.87 (CI, 0.78-0.96). Coffee consumption resulted in a significant reduction in the risk of the transitions from CHD and stroke to CMM, with the lowest estimates were 0.56 (CI, 0.43-0.73) and 0.60 (CI, 0.43-0.83). Similar associations were observed in unsweetened coffee. Sugar-sweetened coffee was associated with some transitions at low levels of consumption. The associations between artificially sweetened coffee and CMM were less consistent.

CONCLUSIONS

Coffee consumption was associated with lower risk for almost all transition phases of CMM development and consistent findings were observed with unsweetened coffee.

The impact of non-nutritive sweeteners on fertility, maternal and child health outcomes: a review of human and animal studies

There is significant evidence that an unhealthy diet greatly increases the risk of complications during pregnancy and predisposes offspring to metabolic dysfunction and obesity. While fat intake is typically associated with the onset of obesity and its comorbidities, there is increasing evidence linking sugar, particularly high fructose corn syrup, to the global rise in obesity rates. Furthermore, the detrimental effects of added sugar intake during pregnancy on mother and child have been clearly outlined. Guidelines advising pregnant women to avoid food and beverages with high fat and sugar have led to an increase in consumption of 'diet' or 'light' options. Examination of some human birth cohort studies shows that heavy consumption (at least one beverage a day) of non-nutritive sweetener (NNS) containing beverages has been associated with increased risk of preterm birth and increased weight/BMI in male offspring independent of maternal weight, which appears to be offset by breastfeeding for 6 months. Rodent models have shown that NNS exposure during pregnancy can impact maternal metabolic health, adipose tissue function, gut microbiome profiles and taste preference. However, the mechanisms underlying these effects are multifaceted and further research, particularly in a translational setting is required to fully understand the effects of NNS on maternal and infant health during pregnancy. Therefore, this review examines maternal sweetener intakes and their influence on fertility, maternal health outcomes and offspring outcomes in human cohort studies and rodent models.

Novel gnd_v2 Fusion Tag and Engineered TEV Protease Enable Efficient Production of Brazzein

Protein solubility and purification challenges often hinder the large-scale production of valuable proteins like brazzein, a potent sweet protein with significant health benefits and commercial potential. This study introduces two novel tools to overcome protein expression and purification bottlenecks: a gnd_v2 fusion tag and an engineered Tobacco Etch Virus (TEV) protease. The gnd_v2 tag, derived from 6-phosphogluconate dehydrogenase, was engineered to improve the soluble expression of brazzein. This tag increased brazzein's solubility by four times compared to the wild-type gnd tag, marking a significant advancement in efficient brazzein production. To address the challenge of cleaving the fusion tag, we engineered a TEV protease variant with high efficiency, particularly at the glutamine residue at brazzein's P1' site - a known difficulty for wild-type TEV proteases. We achieved streamlined production of pure, functional brazzein by integrating this tailored protease cleavage with an ultrafiltration-based purification protocol. Notably, the purified brazzein demonstrated a sweetness potency approximately 2500 times that of sucrose, highlighting its potential as a high-intensity natural sweetener. While this study focused on brazzein, the gnd_v2 tag shows promise for enhancing the solubility of other challenging proteins. More broadly, this work presents a versatile toolset for the scalable production of diverse functional proteins, with significant implications for industrial applications in food and pharmaceutical domains.

The effects of non-nutritive sweeteners on energy and macronutrients intake in adults: a grade-assessed systematic review and meta-analyses of randomized controlled trials

Objectives

The effect of non-nutritive sweeteners (NNSs) on long-term satiety is not well understood. This systematic review and meta-analysis were performed to investigate the effect of NNSs on long-term total energy and macronutrients intake.

Methods

Online databases including Scopus, PubMed, ISI Web of Science, and Google Scholar were searched up to September 2024 to find relevant randomized control trials (RCTs). A random effects model was used for estimating the overall effects.

Results

The results showed a reducing effect of NNSs consumption vs. sugar on total energy intake [total energy intake change = -175.26 kcal/day, 95% confidence interval (CI): -296.47 to -54.06, I2 = 61.19%] and carbohydrate intake [Hedges' g = -0.35, 95% CI: -0.63 to -0.06, I2 = 58.99%]. While, NNSs intake vs. water was not associated with significant change in total energy intake [total energy intake change = 29.94 kcal/day, 95% CI: -70.37 to 130.24, I2 = 34.98%] and carbohydrate intake [Hedges' g = 0.28, 95% CI: -0.02 to 0.58, I2 = 65.26%]. The Consumption of NNSs compared to the either sugar or water did not have a significant effect on fat intake [Hedges' g sugar = 0.08, 95% CI: -0.10 to 0.26, I2 = 8.73%/ fat intake change water = 0.20 g/day, 95% CI: -3.48 to 3.88, I2 = 0%] and Protein intake [Hedges' g sugar = 0.16, 95% CI: -0.11 to 0.42, I 2  = 50.83%/Hedges' g water = 0.00, 95% CI: -0.15 to 0.16, I2 = 0%].

Conclusion

In summary, our findings suggest that NNSs consumption may be effective in reducing total energy and carbohydrate intake compared to sugar.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=432816, CRD42023432816.

Early-Life Gut Microbiota: A Possible Link Between Maternal Exposure to Non-Nutritive Sweeteners and Metabolic Syndrome in Offspring

Metabolic syndrome (MetS) is recognized as a group of metabolic abnormalities, characterized by clustered interconnected traits that elevate the risks of obesity, cardiovascular and atherosclerotic diseases, hyperlipidemia, and type 2 diabetes mellitus. Non-nutritive sweeteners (NNS) are commonly consumed by those with imbalanced calorie intake, especially in the perinatal period. In the past, accumulating evidence showed the transgenerational and mediated roles of human microbiota in the development of early-life MetS. Maternal exposure to NNS has been recognized as a risk factor for filial metabolic disturbance through various mechanisms, among which gut microbiota and derived metabolites function as nodes linking NNS and MetS in early life. Despite the widespread consumption of NNS, there remain growing concerns about their transgenerational impact on metabolic health. There is growing evidence of NNS being implicated in the development of metabolic abnormalities. Intricate complexities exist and a comprehensive understanding of how the gut microbiota interacts with mechanisms related to maternal NNS intake and disrupts metabolic homeostasis of offspring is critical to realize its full potential in preventing early-life MetS. This review aims to elucidate the effects of early-life gut microbiota and links to maternal NNS exposure and imbalanced offspring metabolic homeostasis and discusses potential perspectives and challenges, which may provide enlightenment and understanding into optimal perinatal nutritional management.

Chronic Use of Artificial Sweeteners: Pros and Cons

Over the past few decades, the scientific community has been highly concerned about the obesity epidemic. Artificial sweeteners are compounds that mimic the sweet taste of sugar but have no calories or carbohydrates; hence, they are very popular among patients suffering from diabetes or obesity, aiming to achieve glycemic and/or weight control. There are four different types of sweeteners: artificial, natural, rare sugars, and polyols. Artificial and natural sweeteners are characterized as non-nutritional sweeteners (NNSs) since they do not contain calories. The extended use of sweeteners has been reported to have a favorable impact on body weight and glycemic control in patients with type 2 diabetes (T2DM) and on tooth decay prevention. However, there is concern regarding their side effects. Several studies have associated artificial sweeteners' consumption with the development of insulin resistance, nonalcoholic fatty liver disease (NAFLD), gastrointestinal symptoms, and certain types of cancer. The present review focuses on the description of different types of sweeteners and the benefits and possible deleterious effects of the chronic consumption of NNSs on children's health. Additionally, possible underlying mechanisms of the unfavorable effects of NNSs on human health are described.

Serum Erythritol and Risk of Overall and Cause-Specific Mortality in a Cohort of Men

Erythritol occurs naturally in some fruits and fermented foods, and has also been used as an artificial sweetener since the 1990s. Although there have been questions and some studies regarding its potential adverse health effects, the association between serum erythritol and long-term mortality has not been evaluated. To examine the association between serum erythritol's biochemical status and risk of overall and cause-specific mortality, a prospective cohort analysis was conducted using participants in the ATBC Study (1985-1993) previously selected for metabolomic sub-studies. The analysis included 4468 participants, among whom 3377 deaths occurred during an average of 19.1 years of follow-up. Serum erythritol was assayed using an untargeted, global, high-resolution, accurate-mass platform of ultra-high-performance liquid and gas chromatography. Cause-specific deaths were identified through Statistics Finland and defined by the International Classification of Diseases. After adjustment for potential confounders, serum erythritol was associated with increased risk of overall mortality (HR = 1.50 [95% CI = 1.17-1.92]). We found a positive association between serum erythritol and cardiovascular disease mortality risk (HR = 1.86 [95% CI = 1.18-2.94]), which was stronger for heart disease mortality than for stroke mortality risk (HR = 3.03 [95% CI = 1.00-9.17] and HR = 2.06 [95% CI = 0.72-5.90], respectively). Cancer mortality risk was also positively associated with erythritol (HR = 1.54 [95% CI = 1.09-2.19]). The serum erythritol-overall mortality risk association was stronger in men ≥ 55 years of age and those with diastolic blood pressure ≥ 88 mm Hg (p for interactions 0.045 and 0.01, respectively). Our study suggests that elevated serum erythritol is associated with increased risk of overall, cardiovascular disease, and cancer mortality. Additional studies clarifying the role of endogenous production and dietary/beverage intake of erythritol in human health and mortality are warranted.

Plasma Levels of Polyols Erythritol, Mannitol, and Sorbitol and Incident Coronary Heart Disease Among Women

BACKGROUND AND AIMS

Erythritol, a sugar alcohol (polyol), has recently been linked to the risks of major adverse cardiovascular events. We investigated whether plasma erythritol and other polyols (mannitol/sorbitol) were associated with the risk of incident coronary heart disease (CHD).

METHODS

This prospective nested case-control study included 762 incident cases of CHD and 762 controls from the Nurses' Health Study. Plasma concentrations of polyols were measured at baseline (1989-90 or 2000-02). Associations of erythritol with cardiometabolic risk factors were also analyzed in the Women's Lifestyle Validation Study (n=728; blood collected in 2010-12).

RESULTS

Higher erythritol levels were related to more adverse cardiometabolic risk factor status. The relative risk (RR) for CHD per 1-SD increment was 1.15 [95% CI: 1.04, 1.28] for erythritol and 1.16 [1.05, 1.28] for mannitol/sorbitol, after adjusting for diet quality, lifestyles, and adiposity. Compared with women in the lowest quartile, those in the highest quartile (Q4) of erythritol had a RR 1.55 [1.13, 2.14] for CHD. The RR in Q4 of erythritol was 1.61 [1.15, 2.24; p=0.006] when hypertension and dyslipidemia were further added to the model; the RR was 1.21 [0.86, 1.70] after adjustment for diabetes. For mannitol/sorbitol, the RR in the Q4 was 1.42 [1.05, 1.91; p=0.022] for CHD in the multivariable-adjusted model including diabetes.

CONCLUSIONS

Higher plasma erythritol and mannitol/sorbitol were related to elevated risks of CHD even after adjustment for diet, lifestyles, adiposity, and other risk factors. The unfavorable association of mannitol/sorbitol, but not erythritol, with CHD risk remained significant independently of diabetes/hyperglycemia.

Evaluation of Conflicts of Financial Interest in Publications on the Consumption of High-Intensity Sweeteners and Body-Weight Changes: A Systematic Review

CONTEXT

Diseases related to excessive sugar consumption have become a public health concern. However, there may be a direct association between the consumption of artificial sweeteners and changes in body weight.

OBJECTIVE

The aim was to evaluate potential industry financial conflicts of interest in publications on the relationship between high-intensity sweetener consumption and changes in body weight in observational and intervention studies.

DATA SOURCES

The systematic review used the Medline, Embase, Cochrane, Scopus, and the VHL (Virtual Health Library) Regional Portal, including the LILACS databases. The PICOS strategy were used in the search strategy for intervention studies and for observational studies used the exposure factor as the criterion.

DATA EXTRACTION

Inclusion criteria were observational and intervention studies in adults, without population or health status restrictions, without restriction on the year of publication, but restricted to full articles in Portuguese, English, and Spanish. Exclusion criteria were humans younger than 18 years, cross-sectional studies, and animal and in vitro studies.

DATA ANALYSIS

There were extracted effect estimates, odds ratios, and linear associations, quantifying the effects per unit of intake of high-intensity sweeteners. The risk of bias in the intervention studies was assessed using the Cochrane Collaboration Risk of Bias tool (RoB). The Newcastle Ottawa Scale was used for observational studies (case-control and cohort).

CONCLUSION

Most clinical trials favor using artificial sweeteners and receive contributions from the food industry. Observational studies, for the most part, show that the use of artificial sweeteners is unfavorable. In these studies, there was no sponsorship from the food industry, only from regulatory bodies. This result suggests that studies that had the support of the food industry had their influence on their outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42016036204.

Neural responses to oral administration of erythritol vs. sucrose and sucralose explain differences in subjective liking ratings

INTRODUCTION

High sugar intake is associated with many chronic diseases. However, non-caloric sweeteners (NCSs) might fail to successfully replace sucrose due to the mismatch between their rewarding sweet taste and lack of caloric content. The natural NCS erythritol has been proposed as a sugar substitute due to its satiating properties despite being non-caloric. We aimed to compare brain responses to erythritol vs. sucrose and the artificial NCS sucralose in a priori taste, homeostatic, and reward brain regions of interest (ROIs).

METHODS

We performed a within-subject, single-blind, counterbalanced fMRI study in 30 healthy men (mean ± SEM age:24.3 ± 0.8 years, BMI:22.3 ± 0.3 kg/m2). Before scanning, we individually matched the concentrations of both NCSs to the perceived sweetness intensity of a 10% sucrose solution. During scanning, participants received 1 mL sips of the individually titrated equisweet solutions of sucrose, erythritol, and sucralose, as well as water. After each sip, they rated subjective sweetness liking.

RESULTS

Liking ratings were significantly higher for sucrose and sucralose vs. erythritol (both pHolm = 0.0037); water ratings were neutral. General Linear Model (GLM) analyses of brain blood oxygen level-depended (BOLD) responses at qFDR<0.05 showed no differences between any of the sweeteners in a priori ROIs, but distinct differences were found between the individual sweeteners and water. These results were confirmed by Bayesian GLM and machine learning-based models. However, several brain response patterns mediating the differences in liking ratings between the sweeteners were found in whole-brain multivariate mediation analyses. Both subjective and neural responses showed large inter-subject variability.

CONCLUSION

We found lower liking ratings in response to oral administration of erythritol vs. sucrose and sucralose, but no differences in neural responses between any of the sweeteners in a priori ROIs. However, differences in liking ratings between erythritol vs. sucrose or sucralose are mediated by multiple whole-brain response patterns.

A review of the state of sweeteners science: the natural versus artificial non-caloric sweeteners debate. Stevia rebaudiana and Siraitia grosvenorii into the spotlight

The rapid increase in the worldwide prevalence of obesity and certain non-communicable diseases (NCDs), such as: cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, has been mainly attributed to an excess of sugar consumption. Although the potential benefits of the synergetic use of sweeteners have been known for many years, recent development based on synthesis strategies to produce sucrose-like taste profiles is emerging where biocatalyst approaches may be preferred to produce and supply specific sweetener compounds. From a nutritional standpoint, high-intensity sweeteners have fewer calories than sugars while providing a major sweet potency, placing them in the spotlight as valuable alternatives to sugar. Due to the modern world awareness and incidence of metabolic diseases, both food research and growing markets have focused on two generally regarded as safe (GRAS) groups of compounds: the sweet diterpenoid glycosides present on the leaves of Stevia rebaudiana and, more recently, on the cucurbitane triterpene glycosides present on the fruits of Siraitia grosvenorii. In spite of their flavor advantages, biological benefits, including: antidiabetic, anticancer, and cardiovascular properties, have been elucidated. The present bibliographical review dips into the state-of-the-art of sweeteners and their role in human health as sugar replacements, as well as the biotransformation methods for steviol gylcosides and mogrosides apropos of enzymatic technology to update and locate the discoveries to date in the scientific literature to help boost the continuity of research efforts of the ongoing sweeteners.

Artificially sweetened beverage consumption and all-cause and cause-specific mortality: an updated systematic review and dose-response meta-analysis of prospective cohort studies

BACKGROUND

Artificially sweetened beverages (ASB) are consumed globally, but their impact on overall health remains uncertain. We summarized published associations between ASB intake with all-cause and cause-specific mortality.

METHODS

We searched Medline, Embase, Web of Science, and Cochrane CENTRAL databases until August 2023. Random effect meta-analysis was conducted to calculate pooled risk ratios (RRs) and 95% confidence intervals (95%CIs) for highest versus lowest categories of ASB consumption in relation to all-cause and cause-specific mortality. Linear and non-linear dose-response analyses were also performed.

RESULTS

Our systematic review and meta-analysis included 11 prospective cohort studies. During a median/mean follow-up period of 7.0 to 28.9 years, 235,609 deaths occurred among 2,196,503 participants. Intake of ASB was associated with higher risk of all-cause and CVD mortality with pooled RRs (95%CIs) of highest vs. lowest intake categories of 1.13 (1.06, 1.21) (I2 = 66.3%) for all-cause mortality and 1.26 (1.10, 1.44) (I2 = 52.0%) for CVD mortality. Dose-response analysis revealed a non-linear association of ASB with all-cause mortality (pnon-linearity = 0.01), but a linear positive association with CVD mortality (pnon-linearity = 0.54). No significant association was observed for ASB intake and cancer mortality. Moreover, a secondary meta-analysis demonstrated that replacing 1 serving/day of sugary sweetened beverages (SSB) with ASB was associated with 4-6% lower risk of all-cause and CVD mortality. Per NutriGrade, the evidence quality for associations between ASB intake with all-cause and CVD mortality was moderate.

CONCLUSIONS

Higher intake of ASB was associated with higher risk of all-cause and CVD mortality, albeit a lower risk than for SSB.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022365701.

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.

Investigating the Sociodemographic and Health Characteristics of Non-Sugar Sweeteners Consumption in Greek School-Aged Children: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

The childhood consumption of non-sugar-sweetened (NSS) soft drinks is a growing concern due to its potential health implications. This study investigated demographic, anthropometric, and lifestyle factors influencing NSS soft drink consumption among children.

METHODS

A sample of 1304 children and their parents were surveyed.

RESULTS

Analysis revealed that nearly 60% reported consuming NSS soft drinks at least once a week. Also, positive associations were found between NSS soft drink consumption and lower socioeconomic status, increased total beverage consumption, higher maternal BMI, and parental soft drink habits. However, upon employing multivariable models, only the association between total and NSS soft drinks consumption remained statistically significant (OR = 18.925, p < 0.05 for children; OR = 3.801, p < 0.05 for parents), highlighting the pivotal role of parental behavior in shaping children's consumption patterns.

CONCLUSIONS

These findings emphasize the importance of tracking parental habits, revealing a strong correlation between parental behavior and children's soft drink consumption patterns. Understanding these factors is crucial for developing effective public health strategies for children, which should prioritize not only individual behaviors but also parental modeling and household dynamics.

Could Insulin Be a Better Regulator of Appetite/Satiety Balance and Body Weight Maintenance in Response to Glucose Exposure Compared to Sucrose Substitutes? Unraveling Current Knowledge and Searching for More Appropriate Choices

BACKGROUND

Insulin exerts a crucial impact on glucose control, cellular growing, function, and metabolism. It is partially modulated by nutrients, especially as a response to the intake of foods, including carbohydrates. Moreover, insulin can exert an anorexigenic effect when inserted into the hypothalamus of the brain, in which a complex network of an appetite/hunger control system occurs. The current literature review aims at thoroughly summarizing and scrutinizing whether insulin release in response to glucose exposure may be a better choice to control body weight gain and related diseases compared to the use of sucrose substitutes (SSs) in combination with a long-term, well-balanced diet.

METHODS

This is a comprehensive literature review, which was performed through searching in-depth for the most accurate scientific databases and applying effective and relevant keywords.

RESULTS

The insulin action can be inserted into the hypothalamic orexigenic/anorexigenic complex system, activating several anorexigenic peptides, increasing the hedonic aspect of food intake, and effectively controlling the human body weight. In contrast, SSs appear not to affect the orexigenic/anorexigenic complex system, resulting in more cases of uncontrolled body weight maintenance while also increasing the risk of developing related diseases.

CONCLUSIONS

Most evidence, mainly derived from in vitro and in vivo animal studies, has reinforced the insulin anorexigenic action in the hypothalamus of the brain. Simultaneously, most available clinical studies showed that SSs during a well-balanced diet either maintain or even increase body weight, which may indirectly be ascribed to the fact that they cannot cover the hedonic aspect of food intake. However, there is a strong demand for long-term longitudinal surveys to effectively specify the impact of SSs on human metabolic health.

Association between consumption of sweeteners and endometrial cancer risk: a systematic review and meta-analysis of observational studies

The purpose of this study is to further investigate the relationship between sweetener exposure and the risk of endometrial cancer (EC). Up until December 2022, a literature search in an electronic database was carried out utilizing PubMed, Web of Science, Ovid, and Scopus. The odds ratio (OR) and 95 % confidence interval (CI) were used to evaluate the results. Sweeteners were divided into nutritional sweeteners (generally refers to sugar, such as sucrose and glucose) and non-nutritional sweeteners (generally refers to artificial sweeteners, such saccharin and aspartame). Ten cohort studies and two case-control studies were eventually included. The study found that in 12 studies, compared with the non-exposed group, the incidence rate of EC in the sweetener exposed group was higher (OR = 1·15, 95 % CI = [1·07, 1·24]). Subgroup analysis showed that in 11 studies, the incidence rate of EC in the nutritional sweetener exposed group was higher than that in the non-exposed group (OR = 1·25, 95 % CI = [1·14, 1·38]). In 4 studies, there was no difference in the incidence rate of EC between individuals exposed to non-nutritional sweeteners and those who were not exposed to non-nutritional sweeteners (OR = 0·90, 95 % CI = [0·81, 1·01]). This study reported that the consumption of nutritional sweeteners may increase the risk of EC, whereas there was no significant relationship between the exposure of non-nutritional sweeteners and the incidence of EC. Based on the results of this study, it is recommended to reduce the intake of nutritional sweeteners, but it is uncertain whether use of on-nutritional sweeteners instead of nutritional sweetener.

Investigating the use and awareness of artificial sweeteners among diabetic patients in Bangladesh

BACKGROUND

As with many countries around the world, the incidence of diabetes in Bangladesh is increasing significantly. Whilst there is controversy in the field regarding the health impact of artificial sweeteners in Western communities, the link between sweetener consumption and awareness in Bangladesh has not been established.

METHODS

In the present study, 260 diabetic patients completed a questionnaire survey to investigate the use and awareness of sweeteners and how this links to demographics and potential co-morbidities.

RESULTS

Findings show that daily artificial sweetener consumption is significantly associated with hypertension but not other co-morbidities such as kidney disease or obesity. We further demonstrate that there is limited checking of artificial sweeteners in food or drink products by participants. the rurality of diabetic participants was found to significantly correlates with lower awareness of any health impact of artificial sweeteners.

CONCLUSIONS

The findings from this study demonstrate that there is a need to increase the awareness of artificial sweetener use in diabetic patients in Bangladesh. Combined with a more robust understanding of the health impact of artificial sweeteners, these findings suggest that there is potential to improve outcomes for diabetic patients by improving this awareness.

The role of study quality in aspartame and cancer epidemiology study reviews

Toews et al. [1] and the World Health Organization (WHO) [2] reviewed observational epidemiology studies of non-sugar sweeteners (NSSs) and various health effects. The former used the Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool and the latter used both the ROBINS-I tool and the Newcastle-Ottawa Scale to evaluate study quality. Both reviews concluded that there were no associations between NSS or aspartame consumption and cancer (except possibly between saccharin and bladder cancer) but indicated that the certainty of the evidence for all cancer types was "very low." While we agree with this conclusion, the support for the confidence in the evidence generally was not transparently documented, as the results of the study quality assessment were only provided in scores or ratings. An examination of illustrative case studies shows that some important aspects of study quality domains specific for NSSs generally or aspartame specifically (i.e., issues with the exposure and outcome assessments, the consideration of confounding/covariates, and selection bias) may have been overlooked or not given appropriate consideration, while other aspects that were less likely to have a large impact on overall study quality dominated the results in the two assessments. Our review of other studies published after the WHO [2] review further demonstrates this point. While this may not seem important given the overall lack of associations, it impacts the degree to which evidence supports a lack of effects as opposed to not being adequate to evaluate associations. In the future, aspartame and cancer outcome reviews should focus on those study quality domains that are most likely to impact the interpretation of results and discuss them in a transparent, systematic manner. If there is very low certainty in the evidence as a result of low study quality, reviewers should conclude the evidence is inadequate for making a causal determination.

Effects of front-of-package caffeine and sweetener disclaimers in Mexico: cross-sectional results from the 2020 International Food Policy Study

OBJECTIVE

Front-of-package warning labels introduced in Mexico in 2020 included disclaimers that caution against allowing children to consume products with non-sugary sweeteners and caffeine. We examined the awareness and use of the disclaimers among Mexican adults and youth 1 month after the regulation was implemented. We also investigated their impact on the perceived healthfulness of industrialised beverages designed for children.

DESIGN

Data on the awareness and use of the disclaimers were analysed. Two between-subjects experiments examined the effect of a sweetener disclaimer (Experiment 1, youth and adults) or a caffeine disclaimer (Experiment 2, only adults) on the perceived healthfulness of industrialised beverages. Interactions between experimental conditions and demographic characteristics were tested.

SETTING

Online survey in 2020.

PARTICIPANTS

Mexican adults (≥18 years, n 2108) and youth (10-17 years, n 1790).

RESULTS

Most participants (>80 %) had seen the disclaimers at least rarely, and over 60 % used them sometimes or frequently. The sweetener disclaimer led to a lower perceived healthfulness of a fruit drink (adults: 2·74 ± 1·44; youth: 2·04 ± 0·96) compared with the no-disclaimer condition (adults: 3·17 ± 1·54; youth: 2·32 ± 0·96) (t's: >4·0, P values: <0·001). This effect was larger among older adults and male youth. The caffeine disclaimer did not affect adult's perceived healthfulness of a caffeinated drink (t = 0·861, P value = 0·3894).

CONCLUSIONS

There were high awareness and use of the sweeteners and caffeine disclaimers shortly after the warning labels were implemented. The sweetener disclaimer appears to be helping consumers modify their perceptions regarding industrialised beverages for children. Findings may help decision-makers improve the regulation and better target communication strategies.

A Narrative Review on Strategies for the Reversion of Prediabetes to Normoglycemia: Food Pyramid, Physical Activity, and Self-Monitoring Innovative Glucose Devices

In 2019, "Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report" was published. This consensus report, however, did not provide an easy way to illustrate to subjects with prediabetes (SwPs) how to follow a correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of SwPs and to provide a food pyramid for this population. The pyramid built shows that everyday consumption should consist of: whole-grain bread or potatoes eaten with their skins (for fiber and magnesium) and low glycemic index carbohydrates (GI < 55%) (three portions); fruit and vegetables (5 portions), in particular, green leafy vegetables (for fiber, magnesium, and polyphenols); EVO oil (almost 8 g); nuts (30 g, in particular, pistachios and almonds); three portions of dairy products (milk/yogurt: 300-400 g/day); mineral water (almost 1, 5 L/day for calcium intake); one glass of wine (125 mL); and three cups of coffee. Weekly portions should include fish (four portions), white meat (two portions), protein plant-based food (four portions), eggs (egg portions), and red/processed meats (once/week). At the top of the pyramid, there are two pennants: a green one means that SwPs need some personalized supplementation (if daily requirements cannot be satisfied through diet, vitamin D, omega-3, and vitamin B supplements), and a red one means there are some foods and factors that are banned (simple sugar, refined carbohydrates, and a sedentary lifestyle). Three to four times a week of aerobic and resistance exercises must be performed for 30-40 min. Finally, self-monitoring innovative salivary glucose devices could contribute to the reversion of prediabetes to normoglycemia.

Maternal Consumption of Non-Nutritive Sweeteners during Pregnancy Is Associated with Alterations in the Colostrum Microbiota

Non-nutritive sweeteners (NNSs) provide a sweet taste to foods and beverages without significantly adding calories. Still, their consumption has been linked to modifications in adult's and children's gut microbiota and the disruption of blood glucose control. Human milk microbiota are paramount in establishing infants' gut microbiota, but very little is known about whether the consumption of sweeteners can alter it. To address this question, we sequenced DNA extracted colostrum samples from a group of mothers, who had different levels of NNS consumption, using the Ion Torrent Platform. Our results show that the "core" of colostrum microbiota, composed of the genera Bifidobacterium, Blautia, Cutibacteium, Staphylococcus, and Streptococcus, remains practically unchanged with the consumption of NNS during pregnancy, but specific genera display significant alterations, such as Staphylococcus and Streptococcus. A significant increase in the unclassified archaea Methanobrevibacter spp. was observed as the consumption frequency of NNS increased. The increase in the abundance of this archaea has been previously linked to obesity in Mexican children. NNS consumption during pregnancy could be related to changes in colostrum microbiota and may affect infants' gut microbiota seeding and their future health.

[Low and non-calorie sweeteners as a tool for reducing the energy density at foodstuffs. An alternative for helping to control and reduce overweight and obesity]

Introduction

Introduction: there is more and more scientific data on sweeteners but at the same time there is more dissemination of information and it is sometimes contradictory Methods: observational field study with analysis of data referring to current legislation, approvals by European Union authorities and systematic reviews. Results: the European Union has one of the best systems in the world for the evaluation, approval and authorization of sweeteners and those approved have been immersed since 2010 in a revaluation process, such as that of the other additives. Conclusions: sweeteners are a tool for the reduction and elimination of sugar at foodstuffs. The total diet is the one that must have as a whole a reduction in calories to be effective in the control and reduction of overweight and obesity.

Sugar and low/no-calorie-sweetened beverage consumption and associations with body weight and waist circumference changes in five European cohort studies: the SWEET project

PURPOSE

Results of prospective studies investigating associations between low/no-calorie sweeteners (LNCS) and body weight-related outcomes are inconclusive. We conducted dose-response and theoretical replacement individual patient data meta-analyses using harmonised prospective data to evaluate associations between sugar-sweetened beverage (SSB) consumption, low/no-calorie sweetened beverage (LNCB) consumption, and changes in body weight and waist circumference.

METHODS

Individual participant data were obtained from five European studies, i.e., Lifelines Cohort Study, NQplus study, Alpha Omega Cohort, Predimed-Plus study, and Feel4diabetes study, including 82,719 adults aged 18-89 with follow-up between 1 and 9 years. Consumption of SSB and LNCB was assessed using food-frequency questionnaires. Multiple regression analyses adjusting for major confounders and including substitution models were conducted to quantify associations in individual cohorts; random-effects meta-analyses were performed to pool individual estimates.

RESULTS

Overall, pooled results showed weak adverse associations between SSB consumption and changes in body weight (+ 0.02 kg/y, 95%CI 0.00; 0.04) and waist circumference (+ 0.03 cm/y, 95%CI 0.01; 0.05). LNCB consumption was associated with higher weight gain (+ 0.06 kg/y, 95%CI 0.04; 0.08) but not with waist circumference. No clear associations were observed for any theoretical replacements, i.e., LNCB or water for SSB or water for LNCB.

CONCLUSION

In conclusion, this analysis of five European studies found a weak positive association between SSB consumption and weight and waist change, whilst LNCB consumption was associated with weight change only. Theoretical substitutions did not show any clear association. Thus, the benefit of LNCBs as an alternative to SSBs remains unclear.

Sugar-Sweetened and Artificially Sweetened Beverages and Risk of Liver Cancer and Chronic Liver Disease Mortality

Importance

Approximately 65% of adults in the US consume sugar-sweetened beverages daily.

Objective

To study the associations between intake of sugar-sweetened beverages, artificially sweetened beverages, and incidence of liver cancer and chronic liver disease mortality.

Design, Setting, and Participants

A prospective cohort with 98 786 postmenopausal women aged 50 to 79 years enrolled in the Women's Health Initiative from 1993 to 1998 at 40 clinical centers in the US and were followed up to March 1, 2020.

Exposures

Sugar-sweetened beverage intake was assessed based on a food frequency questionnaire administered at baseline and defined as the sum of regular soft drinks and fruit drinks (not including fruit juice); artificially sweetened beverage intake was measured at 3-year follow-up.

Main Outcomes and Measures

The primary outcomes were (1) liver cancer incidence, and (2) mortality due to chronic liver disease, defined as death from nonalcoholic fatty liver disease, liver fibrosis, cirrhosis, alcoholic liver diseases, and chronic hepatitis. Cox proportional hazards regression models were used to estimate multivariable hazard ratios (HRs) and 95% CIs for liver cancer incidence and for chronic liver disease mortality, adjusting for potential confounders including demographics and lifestyle factors.

Results

During a median follow-up of 20.9 years, 207 women developed liver cancer and 148 died from chronic liver disease. At baseline, 6.8% of women consumed 1 or more sugar-sweetened beverage servings per day, and 13.1% consumed 1 or more artificially sweetened beverage servings per day at 3-year follow-up. Compared with intake of 3 or fewer servings of sugar-sweetened beverages per month, those who consumed 1 or more servings per day had a significantly higher risk of liver cancer (18.0 vs 10.3 per 100 000 person-years [P value for trend = .02]; adjusted HR, 1.85 [95% CI, 1.16-2.96]; P = .01) and chronic liver disease mortality (17.7 vs 7.1 per 100 000 person-years [P value for trend <.001]; adjusted HR, 1.68 [95% CI, 1.03-2.75]; P = .04). Compared with intake of 3 or fewer artificially sweetened beverages per month, individuals who consumed 1 or more artificially sweetened beverages per day did not have significantly increased incidence of liver cancer (11.8 vs 10.2 per 100 000 person-years [P value for trend = .70]; adjusted HR, 1.17 [95% CI, 0.70-1.94]; P = .55) or chronic liver disease mortality (7.1 vs 5.3 per 100 000 person-years [P value for trend = .32]; adjusted HR, 0.95 [95% CI, 0.49-1.84]; P = .88).

Conclusions and Relevance

In postmenopausal women, compared with consuming 3 or fewer servings of sugar-sweetened beverages per month, those who consumed 1 or more sugar-sweetened beverages per day had a higher incidence of liver cancer and death from chronic liver disease. Future studies should confirm these findings and identify the biological pathways of these associations.

Non-sugar sweeteners and health outcomes in adults without diabetes: deciphering the WHO recommendations in the Indian context

BACKGROUND AND AIMS

A systematic review and meta-analysis conducted by the World Health Organization (WHO) assessed the health outcomes of non-sugar sweeteners (NSS) in randomized controlled trials (RCTs) and prospective cohort studies (PCSs) and reported conflicting findings. We aim to decipher these conflicting findings in RCTs and PCSs by critically reviewing their results, comparing them with previous meta-analyses, and providing a simplified interpretation including the Indian perspective.

METHODS

We critically reviewed the 210-page dossier of WHO including the full text of most of the key studies of NSS included in this meta-analysis and subsequently compared it with previous meta-analyses to identify similarities and differences to address a few key questions pertaining to health outcomes associated with NSS use in adults.

RESULTS

Poor health outcomes are often associated with excess sugar intake. While NSS are typically consumed as a sugar replacement, benefits are conflicting. While RCTs found some benefits in the short term, PCSs found harm associated with NSS use in the long term.

CONCLUSION

The 2022 WHO meta-analysis that assessed the health outcomes of NSS is the most robust and critically analyzed document available to date. Despite the absence of any strong conclusion that suggests NSS consumption increases the risk of cardio-metabolic disorders, no firm evidence also rejects this statement. NSS could be an attractive replacement for sugar in overweight/obese people in the short term, but long-term harm cannot be fully ruled out. We suggest avoiding consuming sugar and restricting NSS intake wherever possible until long-term studies confirm or refute these findings.

Effects of non-nutritive sweetened beverages versus water after a 12-week weight-loss program: A randomized controlled trial

OBJECTIVE

The aim of this study was to compare non-nutritive sweetened (NNS) beverages versus water for weight loss after a 12-week behavioral weight-management program.

METHODS

This is an ongoing, 2-year, parallel-group, open-label, controlled equivalence trial; week-12 data are reported. Adults with BMI of 27 to 35 kg/m2 who regularly drank cold beverages were randomized 1:1 to intention-to-treat water or NNS beverages while undergoing a weekly 12-week group behavioral weight-management program. Weight change to week 12 was the primary end point (equivalence: two-sided p > 0.05); changes in waist and hip circumference, blood pressure, glycemic control markers, fasting lipid profiles, liver function tests, hunger (visual analog scale), sugar and sweetener consumption, and activity levels were secondary end points.

RESULTS

Overall, 493 participants were randomized (water: n = 246; NNS beverages: n = 247); 24.1% were NNS beverage naïve. Weight change was equivalent with water versus NNS beverages (-5.6 vs. -5.8 kg; difference [90% CI]: -0.2 kg [-0.7 to 0.4]). There were no significant differences between groups for secondary end points except reductions in waist circumference (greater with NNS beverages vs. water), glycated hemoglobin, and consumption of any type of sweetener (both greater with water vs. NNS beverages).

CONCLUSIONS

Weight loss was equivalent with NNS beverages and water following a 12-week behavioral weight-management program.

Artificial sweeteners and cardiovascular risk

PURPOSE OF REVIEW

Globalization and the increase in consumption of ultra-processed foods have led to a need for greater knowledge on the health impacts of certain nutrients such as artificial sweeteners. This review aims to analyse the role of artificial sweeteners (nutritive and nonnutritive) and their impact on cardiometabolic and cardiovascular disease (CVD) risk.

RECENT FINDINGS

The detrimental effects of a high-calorie, high-sugar diet have been well established. In light of this, health authorities recommend limiting sugar consumption. This has led the food industry to develop different artificial sweeteners with specific properties, such as flavour and stability (nutritive artificial sweeteners: NAS), and others aimed at limiting sugar in the diet (nonnutritive artificial sweeteners: nNAS). Likewise, recent evidence explores the influence of artificial sweeteners (NAS and nNAS) on CVD risk through risk factors such as obesity and type 2 diabetes mellitus, among others.

SUMMARY

This review aims to provide an updated overview of the impact of NAS and nNAS on cardiovascular health and provide recommendations regarding their consumption.

Food Network Analysis in Non-Obese Patients with or without Steatosis

BACKGROUND

Steatosis is the most common liver disease worldwide and the leading cause of liver-associated morbidity and mortality. The aim of this study was to explore the differences in blood parameters and dietary habits in non-obese patients with and without steatosis.

METHODS

The present study included 987 participants with BMI < 30, assessed in the fourth recall of the MICOL study. Patients were divided by steatosis grade, and a validated food frequency questionnaire (FFQ) with 28 food groups was administered.

RESULTS

The prevalence of non-obese participants with steatosis was 42.86%. Overall, the results indicated many statistically significant blood parameters and dietary habits. Analysis of dietary habits revealed that non-obese people with or without steatosis had similar dietary habits, although higher daily amounts of red meat, processed meat, ready meals, and alcohol were recorded in participants with liver disease (p < 0.05).

CONCLUSIONS

Many differences were found in non-obese people with and without steatosis, but in light of a network analysis, the two groups demonstrated similar dietary habits, proving that pathophysiological, genetic, and hormonal patterns are probably the basis of their liver status, regardless of weight. Future genetic analyses will be performed to analyze the expression of genes involved in the development of steatosis in our cohort.

Position statement on nutrition therapy for overweight and obesity: nutrition department of the Brazilian association for the study of obesity and metabolic syndrome (ABESO-2022)

Obesity is a chronic disease resulting from multifactorial causes mainly related to lifestyle (sedentary lifestyle, inadequate eating habits) and to other conditions such as genetic, hereditary, psychological, cultural, and ethnic factors. The weight loss process is slow and complex, and involves lifestyle changes with an emphasis on nutritional therapy, physical activity practice, psychological interventions, and pharmacological or surgical treatment. Because the management of obesity is a long-term process, it is essential that the nutritional treatment contributes to the maintenance of the individual's global health. The main diet-related causes associated with excess weight are the high consumption of ultraprocessed foods, which are high in fats, sugars, and have high energy density; increased portion sizes; and low intake of fruits, vegetables, and grains. In addition, some situations negatively interfere with the weight loss process, such as fad diets that involve the belief in superfoods, the use of teas and phytotherapics, or even the avoidance of certain food groups, as has currently been the case for foods that are sources of carbohydrates. Individuals with obesity are often exposed to fad diets and, on a recurring basis, adhere to proposals with promises of quick solutions, which are not supported by the scientific literature. The adoption of a dietary pattern combining foods such as grains, lean meats, low-fat dairy, fruits, and vegetables, associated with an energy deficit, is the nutritional treatment recommended by the main international guidelines. Moreover, an emphasis on behavioral aspects including motivational interviewing and the encouragement for the individual to develop skills will contribute to achieve and maintain a healthy weight. Therefore, this Position Statement was prepared based on the analysis of the main randomized controlled studies and meta-analyses that tested different nutrition interventions for weight loss. Topics in the frontier of knowledge such as gut microbiota, inflammation, and nutritional genomics, as well as the processes involved in weight regain, were included in this document. This Position Statement was prepared by the Nutrition Department of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO), with the collaboration of dietitians from research and clinical fields with an emphasis on strategies for weight loss.

Global trends in added sugars and non-nutritive sweetener use in the packaged food supply: drivers and implications for public health

OBJECTIVE

The health implications of excessive added sugar intakes have led to national policy actions to limit their consumption. Subsequently, non-nutritive sweeteners (NNS) may be used to maintain product sweetness. We aimed to assess trends in quantities of added sugars and NNS sold in packaged food and beverages worldwide, and the association between these trends and the number of national policy actions across regions to reduce added sugar consumption.

DESIGN

(i) Longitudinal analysis of Euromonitor sales data (2007-2019) to assess the quantity of added sugars (kg) and NNS (g) sold in packaged foods and beverages globally, across regions, and across country income categories; (ii) policy-mapping of policy actions targeting added sugar consumption globally from the NOURISHING database; and (iii) Spearman's correlations to assess the association between national policy actions across regions and changes in added sugar/NNS sales.

SETTING

Worldwide.

PARTICIPANTS

Not applicable.

RESULTS

Per capita volumes of NNS from beverage sales increased globally (36 %). Added sugars from beverage sales decreased in high-income countries (22 %) but increased in upper-middle-income countries (UMIC) and lower-middle-income countries (LMIC) (13-40 %). Added sugars from packaged food sales increased globally (9 %). Regions with more policy actions had a significant increase in NNS quantities from beverage sales (r = 0·68, P = 0·04). The sweetness of the packaged food supply (the sweetness of each NNS and added sugar, relative to sucrose, multiplied by sales volume) increased over time.

CONCLUSIONS

The increasing use of NNS to sweeten beverages globally, and in packaged food in UMIC and LMIC, may have health and dietary implications in the future. Their use as a substitute for added sugar should be considered in public health nutrition policymaking.

Sugar- or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in US adults

Background

The extent to which physical activity attenuates the detrimental effects of sugar (SSBs)- or artificially-sweetened beverages (ASBs) on the risk of cardiovascular disease is unknown.

Methods

We used Cox proportional-hazards models to calculate hazard ratios and 95% confidence interval [HR (CI)] between SSB or ASB intake and physical activity with cardiovascular disease risk among 65,730 women in the Nurses' Health Study (1980-2016) and 39,418 men in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-years and physical activity biannually.

Results

A total of 13,269 cardiovascular events were ascertained during 3,001,213 person-years of follow-up. Compared with those that never/rarely consumed SSBs or ASBs, HR and 95% CI for cardiovascular disease for participants consuming ≥2 servings/day were 1.21 (95% CI,1.12 to 1.32; P-trend<0.001) and 1.03 (95% CI, 0.97 to 1.09; P-trend=0.06), respectively. In the joint analyses, for participants meeting and not meeting physical activity guidelines (<7.5 vs ≥7.5 MET-h/week) as well as consuming ≥2 servings/day of SSBs or ASBs, the HRs for cardiovascular disease were 1.15 (95% CI, 1.08 to 1.23) and 0.96 (95% CI, 0.91 to 1.02), and 1.47 (95% CI, 1.37 to 1.57) and 1.29 (95% CI, 1.22 to 1.37) respectively, compared with participants who met physical activity guidelines and never/rarely consumed these beverages. Similar patterns were observed when coronary heart disease and stroke were analyzed.

Conclusions

Our findings suggest that among physically active participants, higher SSB intake, but not ASBs, is associated with a higher cardiovascular risk. Our results support current recommendations to limit the intake of SSB and maintain adequate physical activity levels.

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.

Rationale, Design and Participants Baseline Characteristics of a Crossover Randomized Controlled Trial of the Effect of Replacing SSBs with NSBs versus Water on Glucose Tolerance, Gut Microbiome and Cardiometabolic Risk in Overweight or Obese Adult SSB Consumer: Strategies to Oppose SUGARS with Non-Nutritive Sweeteners or Water (STOP Sugars NOW) Trial and Ectopic Fat Sub-Study

BACKGROUND

Health authorities are near universal in their recommendation to replace sugar-sweetened beverages (SSBs) with water. Non-nutritive sweetened beverages (NSBs) are not as widely recommended as a replacement strategy due to a lack of established benefits and concerns they may induce glucose intolerance through changes in the gut microbiome. The STOP Sugars NOW trial aims to assess the effect of the substitution of NSBs (the "intended substitution") versus water (the "standard of care substitution") for SSBs on glucose tolerance and microbiota diversity.

DESIGN AND METHODS

The STOP Sugars NOW trial (NCT03543644) is a pragmatic, "head-to-head", open-label, crossover, randomized controlled trial conducted in an outpatient setting. Participants were overweight or obese adults with a high waist circumference who regularly consumed ≥1 SSBs daily. Each participant completed three 4-week treatment phases (usual SSBs, matched NSBs, or water) in random order, which were separated by ≥4-week washout. Blocked randomization was performed centrally by computer with allocation concealment. Outcome assessment was blinded; however, blinding of participants and trial personnel was not possible. The two primary outcomes are oral glucose tolerance (incremental area under the curve) and gut microbiota beta-diversity (weighted UniFrac distance). Secondary outcomes include related markers of adiposity and glucose and insulin regulation. Adherence was assessed by objective biomarkers of added sugars and non-nutritive sweeteners and self-report intake. A subset of participants was included in an Ectopic Fat sub-study in which the primary outcome is intrahepatocellular lipid (IHCL) by 1H-MRS. Analyses will be according to the intention to treat principle.

BASELINE RESULTS

Recruitment began on 1 June 2018, and the last participant completed the trial on 15 October 2020. We screened 1086 participants, of whom 80 were enrolled and randomized in the main trial and 32 of these were enrolled and randomized in the Ectopic Fat sub-study. The participants were predominantly middle-aged (mean age 41.8 ± SD 13.0 y) and had obesity (BMI of 33.7 ± 6.8 kg/m2) with a near equal ratio of female: male (51%:49%). The average baseline SSB intake was 1.9 servings/day. SSBs were replaced with matched NSB brands, sweetened with either a blend of aspartame and acesulfame-potassium (95%) or sucralose (5%).

CONCLUSIONS

Baseline characteristics for both the main and Ectopic Fat sub-study meet our inclusion criteria and represent a group with overweight or obesity, with characteristics putting them at risk for type 2 diabetes. Findings will be published in peer-reviewed open-access medical journals and provide high-level evidence to inform clinical practice guidelines and public health policy for the use NSBs in sugars reduction strategies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03543644.

Sweetener Purchases in Chile before and after Implementing a Policy for Food Labeling, Marketing, and Sales in Schools

Background

Chile's landmark food labeling and advertising policy led to major reductions in sugar purchases. However, it is unclear whether this led to increases in the purchases of nonnutritive sweeteners (NNS).

Objectives

The objective of this study was to assess the changes in NNS and caloric-sweetened (CS) products purchased after the law's first phase.

Methods

Longitudinal data on food and beverage purchases from 2,381 households collected from January 1, 2015 to December 31, 2017, were linked to nutritional information and categorized into added sweetener groups (unsweetened, NNS-only, CS-only, or NNS with CS). Logistic random-effects models and fixed-effects models were used to compare the percentage of households purchasing products and the mean volume purchased by sweetener category to a counterfactual based on pre-regulation trends.

Results

Compared with the counterfactual, the percentage of households purchasing any NNS beverages (NNS-only or NNS with CS) increased by 4.2 percentage points (pp) (95% CI: 2.8, 5.7; P < 0.01). This increase was driven by households purchasing NNS-only beverages (12.1 pp, 95% CI: 10.0, 14.2; P < 0.01). The purchased volume of beverages with any NNS increased by 25.4 mL/person/d (95% CI: 20.1, 30.7; P < 0.01) or 26.5%. Relative to the counterfactual, there were declines of -5.9 pp in households purchasing CS-only beverages (95% CI: -7.0, -4.7; P < 0.01). Regarding the types of sweeteners purchased, we found significant increases in the amounts of sucralose, aspartame, acesulfame K, and steviol glycosides purchased from beverages. Among foods, differences were minimal.

Conclusions

The first phase of Chile's law was associated with an increase in the purchases of beverages containing NNS and decreases in beverages containing CS, but virtually no changes in foods.

The effect of regular consumption of four low- or no-calorie sweeteners on glycemic response in healthy women: A randomized controlled trial

OBJECTIVES

The aim of this study was to determine the effects of regular exposure to certain low- or no-calorie sweeteners (LNCS) on glucose tolerance and glucagon-like peptide 1 (GLP-1) release in healthy individuals.

METHODS

It was designed as a randomized, single-blinded, controlled study. Healthy and normoglycemic adults who did not have regular consumption of LNCS were recruited. Participants underwent a 75-g oral glucose tolerance test (OGTT) at baseline and were randomly assigned to consume 330 mL water sweetened with saccharine, sucralose, or aspartame + acesulfame-K (Asp+Ace-K), or plain water for the control group, daily for 4 wk. Fasting plasma glucose, insulin, GLP-1, and glycated hemoglobin A_1c (HbA_1c) levels and 1-h, 2-h, and 3-h plasma glucose and insulin levels during OGTT were obtained at baseline. The change in insulin sensitivity was assessed by both the Homeostatic Model Assessment Insulin Resistance (HOMA-IR) Index and the Matsuda Index. Anthropometric measurements and dietary intakes were determined at baseline. Baseline measurements were repeated at week 4.

RESULTS

Of the participants enrolled in the study, 42 (age, 21.24 ± 2.26 y; body mass index, 20.65 ± 2.88 kg/m²) completed the 4-wk intervention period. There were no differences for glucose, insulin, GLP-1, or HbA_1c levels or HOMA-IR scores at baseline or at week 4 when compared with the control group. The area under the curve of mean glucose and insulin values during OGTT were also found to be similar between groups at baseline and week 4. There were also no effects of LNCS intake on body weight, body composition, and waist circumference.

CONCLUSIONS

These results suggest that regular consumption of LNCS-sweetened water similar to doses consumed in daily life over 4 wk had no significant effect on glycemic response, insulin sensitivity, GLP-1 release, and body weight in healthy individuals. This trial was registered at www.

CLINICALTRIALS

gov as NCT04904133.

Can habitual tea drinking be an effective approach against age-related neurodegenerative cognitive disorders: A systematic review and meta-analysis of epidemiological evidence

Our present knowledge about the efficacy of tea consumption in improving age-related cognitive disorders is incomplete since previous epidemiological studies provide inconsistent evidence. This unified systematic review and meta-analysis based on updated epidemiological cohort studies and randomized controlled trials (RCTs) evidence aimed to overcome the limitations of previous reviews by examining the efficacy of distinct types of tea consumption. PubMed, Embase, and MEDLINE were searched up to May 20, 2022, and 23 cohorts and 12 cross-sectional studies were included. Random-effects meta-analyses were conducted to obtain pooled RRs or mean differences with 95% CIs. The pooled RRs of the highest versus lowest tea consumption categories were 0.81 (95% CIs: 0.75-0.88) and 0.69 (95% CIs: 0.61-0.77), respectively. The pooled mean difference of four included RCTs revealed a beneficial effect of tea on cognitive dysfunction (MMSE ES: 1.03; 95% CI, 0.14-1.92). Subgroup analyses further demonstrated that green and black tea intake was associated with a lower risk of cognitive disorders in eastern countries, especially in women. The evidence quality was generally low to moderate. The present review provides insight into whether habitual tea consumption can be an effective approach against age-related neurodegenerative cognitive disorders and summarizes potential mechanisms based on currently published literature.

Perception and knowledge of low- and no-calorie sweeteners in multidisciplinary stakeholders from Spain

Low- and no-calorie sweeteners (LNCS) as a category are one of the most thoroughly evaluated additives, and thus their safety has been largely recognised. However, their potential risks and benefits generate great controversy and discussion within countries' food policies and public debate. The goal of this study was to evaluate the degree of knowledge and the perception of key Spanish stakeholders about the role of LNCS in diet, their safety, regulatory issues and their impact on health and wellness, as well as to complete a SWOT analysis of the Strengths, Weaknesses, Opportunities and Threats regarding this topic from their perspective. Participants (n = 45 stakeholders) completed an anonymous survey about their knowledge and perception of LNCS, their role in the diet, safety and legislation, as well as health issues and completed a SWOT analysis. Most of them agreed with aspects related to safety guarantees and authorisation procedure of LNCS; however, certain disparity in their opinion in relation to several of the topics was observed, especially regarding the possible role of LNCS in diet quality and health. Effective communication strategies to inform professionals and the general population, as well as new research that deepens our knowledge of the role of LNCS in weight management and other health outcomes seem to be urgently needed.

Using GRADE Evidence to Decision frameworks to support the process of health policy-making: an example application regarding taxation of sugar-sweetened beverages

BACKGROUND

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks are well-known tools that enable guideline panels to structure the process of developing recommendations and making decisions in healthcare and public health. To date, they have not regularly been used for health policy-making. This article aims to illustrate the application of the GRADE EtD frameworks in the process of nutrition-related policy-making for a European country.

METHODS

Based on methodological guidance by the GRADE Working Group and the findings of our recently published scoping review, we illustrate the process of moving from evidence to recommendations, by applying the EtD frameworks to a fictitious example. Sugar-sweetened beverage (SSB) taxation based on energy density was chosen as an example application.

RESULTS

A fictitious guideline panel was convened by a national nutrition association to develop a population-level recommendation on SSB taxation aiming to reduce the burden of overweight and obesity. Exemplary evidence was summarized for each EtD criterion and conclusions were drawn based on all judgements made in relation to each criterion. As a result of the high priority to reduce the burden of obesity and because of the moderate desirable effects on health outcomes, but considering scarce or varying research evidence for other EtD criteria, the panel made a conditional recommendation for SSB taxation. Decision-makers may opt for conducting a pilot study prior to implementing the policy on a national level.

CONCLUSIONS

GRADE EtD frameworks can be used by guideline panels to make the process of developing recommendations in the field of health policy more systematic, transparent and comprehensible.

No Association between Low-Calorie Sweetener (LCS) Use and Overall Cancer Risk in the Nationally Representative Database in the US: Analyses of NHANES 1988-2018 Data and 2019 Public-Use Linked Mortality Files

Low-calorie sweeteners (LCS) serve to replace added sugars in beverages and foods. The present goal was to explore any potential links between LCS use and cancer risk using the nationally representative National Health and Nutrition Examination Surveys 1988-2018 linked to 2019 Public-Use Linked Mortality Files. Analyses were based on dietary intakes from 1988-1994 NHANES (n = 15,948) and 1999-2018 NHANES (n = 48,754) linked to mortality data. The 1988-1994 NHANES separated aspartame from saccharin consumption; later data did not. LCS consumers were more likely to be older, female, non-Hispanic White, and with higher education and incomes compared to nonconsumers. LCS consumers were less likely to smoke and had higher HEI-2015 scores indicating higher-quality diets. In the cross-sectional NHANES data, LCS use was associated with higher BMI and higher prevalence of obesity and diabetes. There was no indication that aspartame, saccharin, or all LCS had any impact on overall cancer mortality. By using nonconsumers as the reference group, the hazard ratio (95th confidence interval, CI) group trend for tertiles of LCS use for 1988-1994 for aspartame was 1.00 (0.89-1.12), for saccharin 0.96 (0.79-1.10), and for 1988-2018 for all LCS was 0.92 (0.88-1.101). The null group trend effects were seen for analyses stratified by age/gender. The present analyses confirm past US-based reports that LCS use was associated with higher socioeconomic status, lower prevalence of smoking, and generally higher-quality diets. No association with cancer mortality was observed.

Association between soft drink consumption types and risk of lung cancer and all-cancer: A prospective study of PLCO data

Diet/sugar-free soft drinks are considered to be healthier than regular soft drinks. However, few studies have examined the relationship between the types of soft drinks (regular and diet/sugar-free) and lung cancer (LC)/all-cancer (AC) risk. In this study, we comprehensively assessed the influence of the type of soft drink consumption on LC/AC risk based on the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Multivariable Cox proportional hazards and competing risks Fine-Gray regression models adjusted for relevant confounders were used to estimate hazard ratios (HRs) and subdistribution HRs for different types of soft drink consumption. In the PLCO population, female subgroup, and the ever/current smoker subgroup, consumption of both regular and diet soft drinks was associated with a significantly reduced risk of LC compared with no soft drinks at all. For the non-lung cancer (NLC) risk, consumption of only diet soft drinks had a significant positive association for the total population and female subgroup. Based on our findings, it was suggested that partial replacement of regular soft drinks with diet soft drinks might be beneficial to LC prevention, especially for females and ever/current smokers. Additionally, completely replacing regular soft drinks with diet soft drinks might be detrimental to NLC prevention, especially for females.

Sugar-Sweetened Beverage, Diet Soda, and Nonalcoholic Fatty Liver Disease Over 6 Years: The Framingham Heart Study

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) is associated with sugar-sweetened beverage (SSB) consumption in cross-sectional studies. In a prospective cohort, we examined the association of beverage consumption (SSB and diet soda) with incident NAFLD and changes in hepatic fat in the Framingham Heart Study (FHS).

METHODS

We conducted a prospective observational study of participants from the FHS Third Generation and Offspring cohorts who participated in computed tomography sub-studies. Participants were classified according to their average SSB or diet soda consumption, which was derived from baseline and follow-up food frequency questionnaires: non-consumers (0-<1/month), occasional consumers (1/month-<1/week), and frequent consumers (≥1/week-≥1/day). Hepatic fat was quantified by the liver fat attenuation measurements on computed tomography scan. The primary dependent variable was incident NAFLD; secondarily, we investigated change in liver fat.

RESULTS

The cohorts included 691 Offspring (mean age, 62.8 ± 8.2 years; 57.7% women) and 945 Third Generation participants (mean age, 48.4 ± 6.3 years; 46.6% women). In the Offspring cohort, there was a dose-response relationship with SSB consumption and incident NAFLD. Frequent SSB consumers had 2.53 times increased odds of incident NAFLD compared with non-consumers (95% confidence interval, 1.36-4.7) after multivariable analysis. For Offspring cohort participants, occasional and frequent consumers of SSB had a more adverse increase in liver fat compared with non-consumers.

CONCLUSIONS

Higher average SSB intake is associated with increase in liver fat over 6 years of follow-up and increased odds of incident NAFLD especially among the older cohort, whereas no consistent association was observed for the younger Third Generation cohort.

Protocol for a multicentre, parallel, randomised, controlled trial on the effect of sweeteners and sweetness enhancers on health, obesity and safety in overweight adults and children: the SWEET project

INTRODUCTION

The aim of this randomised controlled trial (RCT) is to investigate whether prolonged consumption of sweeteners and sweetness enhancers (S&SEs) within a healthy diet will improve weight loss maintenance and obesity-related risk factors and affect safety markers compared with sugar.

METHODS AND ANALYSIS

SWEET (S&SEs: prolonged effects on health, obesity and safety) is a 1-year multicentre RCT including at least 330 adults with overweight (18-65 years, body mass index (BMI) >25 kg/m²) and 40 children (6-12 years, BMI-for-age >85th percentile). In an initial 2-month period, adults will consume a low-energy diet with the aim to achieve ≥5% weight loss. Children are advised to consume a generally healthy diet to maintain body weight, thus reducing their BMI-for-age z-score. In the following 10 months, participants will be randomised to follow a healthy ad libitum diet with or without S&SE products. Clinical investigations are scheduled at baseline, after 2, 6 and 12 months. The primary outcomes are body weight for efficacy and gut microbiota composition (in relation to metabolic health) for safety, both in adults. Secondary outcomes include anthropometry, risk markers for type-2 diabetes and cardiovascular diseases, questionnaires including, for example, food preferences, craving and appetite and tests for allergenicity.

ETHICS AND DISSEMINATION

The trial protocol has been approved by the following national ethical committees; The research ethics committees of the capital region (Denmark), approval code: H-19040679, The medical ethics committee of the University Hospital Maastricht and Maastricht University (the Netherlands), approval code: NL70977.068.19/METC19-056s, Research Ethics Committee of the University of Navarra (Spain), approval code: 2019.146 mod1, Research Ethics Committee of Harokopio University (Greece), approval code: 1810/18-06-2019. The trial will be conducted in accordance with the Declaration of Helsinki. Results will be published in international peer-reviewed scientific journals regardless of whether the findings are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

NCT04226911 (Clinicaltrials.gov).

Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort

OBJECTIVES

To study the associations between artificial sweeteners from all dietary sources (beverages, but also table top sweeteners, dairy products, etc), overall and by molecule (aspartame, acesulfame potassium, and sucralose), and risk of cardiovascular diseases (overall, coronary heart disease, and cerebrovascular disease).

DESIGN

Population based prospective cohort study (2009-21).

SETTING

France, primary prevention research.

PARTICIPANTS

103 388 participants of the web based NutriNet-Santé cohort (mean age 42.2±14.4, 79.8% female, 904 206 person years). Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24 h dietary records, including brand names of industrial products.

MAIN OUTCOMES MEASURES

Associations between sweeteners (coded as a continuous variable, log10 transformed) and cardiovascular disease risk, assessed by multivariable adjusted Cox hazard models.

RESULTS

Total artificial sweetener intake was associated with increased risk of cardiovascular diseases (1502 events, hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03); absolute incidence rate in higher consumers (above the sex specific median) and non-consumers was 346 and 314 per 100 000 person years, respectively. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (777 events, 1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150 per 100 000 person years in higher and non-consumers, respectively). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151 per 100 000 person years in higher and non-consumers, respectively), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (730 events; acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161).

CONCLUSIONS

The findings from this large scale prospective cohort study suggest a potential direct association between higher artificial sweetener consumption (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk. Artificial sweeteners are present in thousands of food and beverage brands worldwide, however they remain a controversial topic and are currently being re-evaluated by the European Food Safety Authority, the World Health Organization, and other health agencies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03335644.

The EAT-Lancet reference diet and cognitive function across the life course

The EAT-Lancet Commission devised a sustainable reference diet with the aim of reducing the incidence of non-communicable diseases and mortality globally while improving food system sustainability. The extent to which the reference diet supports cognitive function across the life course, however, has not yet been evaluated. This Review assesses the evidence for diet supporting cognitive function from childhood into old age. A comprehensive but non-exhaustive literature search was done, synthesising studies that investigated the effect of whole foods on cognition in healthy, community-dwelling human participants. We found that the current evidence base is weak with mixed conclusions and multiple methodological caveats, which precludes strong conclusions pertaining to the suitability of dietary recommendations for each food group per age group. Long-term intervention and prospective cohort studies are needed to reduce this knowledge deficit. Revising dietary recommendations with the aim of maintaining an adequate nutrient intake to sustain healthy cognitive function across the life course could be worthwhile. This Review outlines recommendations for future work to help improve the current knowledge deficit regarding dietary intake and cognitive function across the life course and its implications for dietary guidelines such as the EAT-Lancet Commission.

Personalized microbiome-driven effects of non-nutritive sweeteners on human glucose tolerance

Non-nutritive sweeteners (NNS) are commonly integrated into human diet and presumed to be inert; however, animal studies suggest that they may impact the microbiome and downstream glycemic responses. We causally assessed NNS impacts in humans and their microbiomes in a randomized-controlled trial encompassing 120 healthy adults, administered saccharin, sucralose, aspartame, and stevia sachets for 2 weeks in doses lower than the acceptable daily intake, compared with controls receiving sachet-contained vehicle glucose or no supplement. As groups, each administered NNS distinctly altered stool and oral microbiome and plasma metabolome, whereas saccharin and sucralose significantly impaired glycemic responses. Importantly, gnotobiotic mice conventionalized with microbiomes from multiple top and bottom responders of each of the four NNS-supplemented groups featured glycemic responses largely reflecting those noted in respective human donors, which were preempted by distinct microbial signals, as exemplified by sucralose. Collectively, human NNS consumption may induce person-specific, microbiome-dependent glycemic alterations, necessitating future assessment of clinical implications.