Sweeteners include nutritive and non-nutritive, meaning those with calories and those without. Within the nutritive sweeteners, there are sugars, modified sugars, sugar alcohols, and natural caloric sweeteners. These may be listed under ingredients as sucrose, barley malt, dextrose, maltose, and rice syrup, in addition to others.
Under the non-nutritive sweetener umbrella there are artificial sweeteners, such as aspartame and saccharine, and natural non-caloric sweeteners, such as stevia. The world of these non-sugar sweeteners is a controversial one, leading to much confusion on the topic, with research showing both positive and negative outcomes with artificial sweetener intake. The study below explores non-sugar sweeteners and health outcomes through systematic review and meta-analyses.
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
This systematic review and meta-analyses used Cochrane review methodology to study the relationship between non-sugar sweeteners (NSSs) and health outcomes. Inclusion criteria were studies with general, healthy populations of adults or children, including those with overweight or obesity. Studies with pregnant women, diseased populations, in vitro, and animals were excluded.
Fifty-six studies were included in this systematic review and meta-analysis. The interventions were NSS intake compared to alternative intake such as another type of caloric or non-caloric sweetener, sugar, placebo, or plain water. Primary outcome measures were body weight, oral health, diabetes incidence, and eating behavior. Secondary outcomes included preference for sweet taste, cancer, cardiovascular disease, and chronic kidney disease incidences. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to categorize the certainty of the evidence of the studies into high, moderate, low, and very low certainty.
The authors found that:
1. Very low and low certainty of evidence from 2 studies (n=174) showed a small beneficial effect of NSSs and BMI
2. Very low and low certainty of evidence from 2 studies (n=52) demonstrated a small beneficial effect of NSSs and fasting blood glucose
3. Very low certainty of evidence from 1 study (n=17,934) found lower doses of NSSs were associated with lower weight gain compared with higher doses of NSSs
4. Moderate certainty of evidence from 2 studies (n=528) in children found a smaller increase in BMI z-score with NSSs compared with sugar intake
5. All other outcomes did not show differences between the use and non-use of NSSs or between dosages of NSSs
6. There is room for improvement regarding reporting sufficient information about the sweetener used, intervention, comparison group, and outcomes, as well as a need for longer term studies to determine influence of real-life pattern consumption of NSSs on chronic diseases
For the Patient and Caregiver
Humans are faced with innumerable food and drink choices each day, one of which may include what to use as a sweetener in a coffee–white sugar, sugar in the raw, sweet ‘n low, equal, or stevia. These decisions become overwhelming, and because there is so much information out there that provides contradicting answers, evidence-based research coming from large systematic reviews and meta-analyses are the best recommendations to rely on. Because we still do not have enough long-term research for a definitive answer regarding the health benefits or risks of artificial sweeteners, the “right” decision remains cloudy. The most important idea to keep in mind is the foundation of a nutritious diet associated with decreased risk of chronic diseases does not include added sugars or added artificial sugars, but rather is structured around a plant-based or Mediterranean-based diet high in vegetables, fruits, whole grains, legumes, and healthy fats.
For the Healthcare Team
Oftentimes patients will ask which sugar or artificial sugar to choose. First, educate patients that added sugars come in many forms, including honey and agave, and even if they are natural or organic, they still lead to spikes in blood sugar and may make up a food that is low in protein and fiber. Next, explain that the current research is inconclusive, so it is a personal choice. Using small amounts of natural sugar, occasionally using artificial sweeteners, or trying stevia or monk fruit may all be options. Most importantly, suggest obtaining the sweet taste from non-processed foods such as whole fruits that are high in fiber including berries, pears, apples, and oranges.
[i] Toews I, Lohner S, Kullenberg de Gaudry D, Sommer H, Meerpohl JJ. (2019). 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. BMJ;364:k4718. doi: 10.1136/bmj.k4718