The Nonnutritive Sweetener Paradox

by Ashley Jordan Ferira, PhD, RDN

Nonnutritive sweeteners were designed to limit caloric intake and assist in weight and blood glucose management,¹ but recent findings linked nonnutritive sweetener use to higher adiposity and cardiometabolic risk.²

Nonnutritive sweeteners (NNS) including aspartame, sucralose and stevioside are zero- or low-calorie sugar substitutes commonly consumed in the US.³ Approximately 25% of children and 41% of adults consume low-calorie sweeteners, with increased consumption in adults with higher body weight.³ Although beverages are the top source of NNS, many foods contain these ingredients too. The long-term impact of widespread NNS use has not been established.

The goal of the study by Azad et al. was to quantify the impact of routine NNS consumption on obesity and cardiometabolic endpoints.² Seven randomized controlled trials (RCT) including 1,003 participants (median follow-up of 6 months) and 30 prospective cohort studies (405,907 participants; median follow of 10 years) were included in the meta-analysis. Major observations included:²

• In RCT interventions, NNS had no significant effect (in either direction) on BMI
• In cohort studies, NNS consumption was associated with a modest increase in weight and BMI
• In cohort studies, NNS was associated with an increase in waist circumference, hypertension, cardiovascular events, metabolic syndrome, and type 2 diabetes

The intended benefits of NNS for weight management were not supported by results from RCTs, and observational studies associated routine NNS consumption with increased abdominal adiposity and cardiometabolic risk.² Authors note limitations of relatively short RCT duration and potential for confounding bias in the observational studies.²

Why is this Clinically Relevant?

• NNS are widely consumed by children and adults in the US and are often recommended in a clinical context for weight management or glycemic control
• NNS may contribute to increased abdominal obesity and cardiometabolic dysfunction
• Until long-term risks and benefits of NNS are fully characterized, clinicians should practice caution when recommending routine NNS consumption

Reference

Link to Article

Citations

1. Fitch C, Keim KS. Position of the Academy of Nutrition and Dietetics: use of nutritive and nonnutritive sweeteners. J Acad Nutr Diet. 2012;112:739-758.
2. Azad MG, Abou-Setta AM, Chauhan BF, et al. Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies. CMAJ. 2017;189:E929-939.
3. Sylvetsky AC, Jin Y, Clark EJ, et al. Consumption of low-calorie sweeteners among children and adults in the United States. J Acad Nutr Diet. 2017;117(3):441-448.