Policy Statement - The Use of Artificial Sweeteners

 

Definitions

There are two types of sweeteners available:

  • Natural sweeteners (also called caloric sweeteners, sugars, nutritive sweeteners) which provide calories (i.e., energy in the form of carbohydrates) such as fructose and sucrose (e.g., table sugar, honey, syrup; 3.75kcal·gram) and polyols (e.g., sorbitol, mannitol, xylitol; 2.4kcal·gram)

  • Artificial sweeteners (also called sugar substitutes, high-intensity sweeteners, high-potency sweeteners, non-nutritive sweeteners) which can be low-calorie or calorie-free.

Summary

Artificial sweeteners provide sweetness without the addition of calories, unlike natural sweeteners that do provide calories. Whilst the European Food Safety Authority (EFSA) has been directed to re-evaluate the use of all artificial sweeteners that were approved for use in the EU prior to 2009, by 2020 [1], the evidence-base shows that artificial sweeteners are considered safe to consume. Adding an artificial sweetener to a food product instead of a natural sweetener enables food manufacturers to provide an alternative for consumers which can be a useful strategy for those individuals seeking to control their calorie intake and manage their weight.

The BDA believes that:

  • Artificial sweeteners available to purchase in the UK are considered safe to consume and are authorised and approved for use by EFSA

  • Opting for an artificial sweeteners may assist in the management of weight and in the management of other health conditions such as diabetes mellitus in some individuals. A tailored individualised approach is required

  • Clearer labelling regarding the Acceptable Daily Intake (ADI) set by EFSA on food products and beverages is recommended by the BDA so consumers are better informed

Background

There are six types of artificial sweeteners licensed for use in the UK.

Artificial Sweetener

Sweetness Compared To Sucrose

Aspartame

150-200 times

Saccharin

300-400 times

Acesulfame Potassium

(also known as Acesulfame K)

150-200 times

Cyclamate

30-50 times

Sucralose

400-600 times

Steviol Glycosides

200-300 times

[2]

As a result of growing health awareness and an increase in obesity-related health conditions in the UK, there has subsequently been an increased demand of food products that support good health. More specifically, the food manufacturing industry commonly replace sugar with an artificial sweetener replacement. Results from the latest National Diet and Nutrition Survey (NDNS) indicate that 44% of adults 19-64 years consume low-calorie beverages [3]. It is widely accepted that a high sugar/high fat diet is in part, responsible for increased weight gain and associated health conditions such as type 2 diabetes mellitus (T2DM), cardiovascular disease (e.g., coronary heart disease) and certain cancers. Notably, a relatively small weight reduction (5%) is associated with improved health outcomes [4]. In the UK population, current average intakes of free sugars (previously used term is non-milk extrinsic sugars; NMES) are at least twice the new 5% recommendation [5]. Whilst a reduction in sugar consumption is an encouraging strategy for supporting optimal nutrition and in the management of an individual’s weight, the causes of obesity are multi-factorial, consisting of a complex interplay of environmental, psychological and social factors.

Functions and Benefits

Energy Intake and Weight Management

Artificial sweeteners are classed as food additives which replicate the sweetness of sugar but without the addition of extra calories. For example, a recent systematic review and meta-analysis concluded that calorific sugar-sweetened beverages promoted weight gain in children and adults [6, 7]. For this reason, moderate use of artificial sweeteners may in part, assist in the reduction of total energy intake and facilitate weight loss or weight maintenance, if used in place of energy-dense options. Indeed, a systematic review concluded that whilst data suggested that artificial sweeteners may lead to clinically significant weight loss, these conclusions were based on a single trial [8]. Equally, a recent meta-analysis investigating low-calorie sweeteners on body weight and composition found that substituting low-calorie sweetener options for their regular, more energy-dense versions resulted in a modest weight loss [9]. Therefore, good quality long-term trials are required before definitive conclusions can be made.

Furthermore, it has been suggested that artificial sweeteners can interfere with normal homeostatic, physiological processes (e.g., altering taste and metabolic signaling). Indeed, it is possible that because blood glucose levels do not significantly alter with use of artificial sweeteners, hypoglycemia and a subsequent increase in food intake ensues, leading to a higher calorie consumption, weight gain and adiposity [10]. However, a review of RCTs does not support this hypothesis [11].

Dental Health

Artificial sweeteners may play a role in dental health (i.e., prevention of dental caries) as they are non-cariogenic. In other words, they are not fermented by the oral microflora, unlike sugar and do not cause tooth decay. A recent systematic review and meta-analysis could not conclude whether or not xylitol-containing products can prevent tooth decay in infants, older children, or adults due to the low to very low quality evidence which was based on the small amount of available studies, uncertain results, and issues with the way studies were conducted [12]. Equally, EFSA suggested that non-nutritive sweeteners may help maintain tooth mineralisation by decreasing the rate of tooth demineralisation [13].

Diabetes

Regulating blood glucose levels in those individuals with diabetes is important to prevent risk of diabetes-related health complications. Since artificial sweeteners are metabolised more slowly, replacing sugar with an artificial sweetener may help stabilise blood glucose levels over a longer period. This may also have particular relevance in those with reactive hypoglycaemia [14]. EFSA also approved the health claim that non-nutritive sweeteners may help in the reduction of post-prandial glycaemic responses [13]. Additionally, the use of non-nutritive sweeteners in those with T2DM may also help with weight loss or weight maintenance, thus facilitating good diabetes control. Current evidence-based recommendations for people with diabetes suggest artificial sweeteners are safe when consumed within the ADI [15].

Health and Safety

EFSA provides scientific analysis, opinion and recommendations to support policy development on food safety issues in the European Union (EU) [16]. All artificial sweeteners used in the EU have undergone safety evaluation (e.g., toxicological testing) before being approved for use. The Joint Food and Agriculture Organisation (FAO)/World Health Organisation (WHO) Expert Committee on Food Additives (JECFA) and UK Government regulate and authorise the use of artificial sweeteners, providing food manufacturers with stringent guidelines on the maximum quantity of artificial sweetener that can be added to foods and drinks [17]. As part of the safety and approval process, EFSA sets an ADI for each artificial sweetener. The ADI is an estimate of the amount of artificial sweetener (milligrams per kilogram of body weight) that can be safely consumed on a daily basis over a person’s lifetime without incurring health risks. From a safety perspective, the ADI includes a 100-fold safety factor. In other words, the ADI is calculated at one hundredth of the amount that may be safely consumed.

Phenylketonuria (PKU)

In the UK, it is a legal requirement if a food product contains Aspartame, it must be clearly stated on the label ‘Contains a source of phenylalanine’. Labelling is of particular importance for consumers with PKU; a rare genetic disorder in which the amino acid phenylalanine cannot be metabolized due to the deficiency of the enzyme phenylalanine hydroxylase. Phenylalanine can accumulate to harmful levels if not controlled with diet.

Foods Permitted For Use

Artificial sweeteners are permitted for use in a wide variety of foods and drinks in the UK including carbonated drinks, fruit juices, jellies, yogurts, desserts and ice cream, chewing gum and sweets and foods and drinks labelled as ‘sugar-free’ or ‘diet’.

Foods Not Permitted For Use

Artificial sweeteners are prohibited in some foods in the UK. For example, the use of sweeteners is prohibited in all foods for infants (under 12 months old) and young children (1-3 years old). This includes foods specifically prepared for infants and young children (i.e., ‘baby food’) [18].

Consumer/Patient Viewpoint

From a consumer perspective, the safety of artificial sweeteners can be confused by mixed messages in the media. There continues to be on-going controversy regarding the use of artificial sweeteners and whether they pose a risk to health, more specifically, whether they play a role in the pathogenesis of cancer, lymphoma, leukaemia, chronic fatigue syndrome, Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, autism and lupus [19], however, there remains strong evidence that artificial sweeteners are considered safe to consume as per EFSA recommendations.

Correlations to Diet Quality

Currently, the limited research exploring diet quality and the use of natural or artificial sweeteners suggest that overall diet quality is lower in those individuals who consume naturally or artificially sweetened beverages compared to non or low consumers [20]. These results suggest that for optimal health, natural sweeteners and artificial sweeteners should only be consumed in small amounts.

Concerns from BDA Perspective

While food products that contain artificial sweeteners must clearly state ‘With sweetener(s)’, it may not always be 100% clear to the consumer as to whether a particular food product contains an artificial sweetener or not. The BDA recommends clearer labelling on food products and beverages which states which artificial sweetener is used and the quantity contained within a food product or beverage, alongside the ADI.

Research Gaps and Future Research

Current obesity-related governmental policies do not currently address natural sweeteners, artificial sweeteners and the impact on weight. Additionally, no research exists examining the effects of sweeteners in breastmilk and potential implications in infants. Further research is also required investigating the hormonal and metabolic responses to sweeteners and whether the use of artificial sweeteners aid weight loss or weight gain.

Another topic for future discussion is whether artificial sweeteners should be encouraged by Dietitians in place of regular sugar options to assist in the control of calorie consumption. Given that intake of artificial sweeteners is mostly from beverages, emphasis should be placed upon encouraging behaviour change with focus on overall diet quality and eating patterns, rather than specific nutrients.

Conclusions

From a dietetic point of view, having options which allow patients and (or) clients to alter their calorie intake without making significant dietary changes is seen as a favourably viable option. Equally, whilst artificial sweeteners are considered safe, to date, there is limited conclusive research to discourage or to encourage their use on a regular basis [21]. A whole diet approach which focuses on overall diet quality rather than specific nutrients is important. The recent SACN report (2015) highlighted that there is some evidence showing that calorific sugar-sweetened beverages are linked to weight gain and consistent evidence showing an association with an increased risk of T2DM. Swapping calorific sugar-sweetened beverages for beverages that contain an artificial sweetener is likely to be beneficial for most individuals, however healthier drink options/alternatives should be encouraged. Overall, there is limited evidence for improvements in weight management, dental health and diabetes.

Download a copy of this policy statement as a pdf here.

Published Date: May 2016
Review Date: May 2019

References

  1. European Food Safety Authority (2016). Sweeteners. Available at http://www.efsa.europa.eu/en/topics/topic/sweeteners
  2. European Food Information Council (2012). Benefits and safety of low calorie sweeteners. Available at http://www.eufic.org/article/en/nutrition/sweeteners/expid/Benefits_Safety_Low_Calorie_Sweeteners/
  3. Gibson, S. A., Horgan, G. W., Francis, L. E., Gibson, A. A. and Stephen, A. M. (2016). Low calorie beverage consumption is associated with energy and nutrient intakes and diet quality in British adults. Nutrients 8, 1-15.
  4. National Institute for Health and Care Excellence (2014). Adults who are obese can improve their health by losing even a small amount of weight. Available at https://www.nice.org.uk/news/press-and-media/adults-who-are-obese-can-improve-their-health-by-losing-even-a-small-amount-of-weight
  5. The Scientific Advisory Committee on Nutrition (2015). SACN carbohydrates and health report. Available at https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report
  6. Malik, V. S., Pan, A., Willett, W. C. and Hu, F. B. (2013). Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. The American Journal of Clinical Nutrition 98, 1084-1102
  7. Morenga, L. T., Mallard, S. and Mann, J. (2013). Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. The British Medical Journal 346.
  8. Wiebe, N., Padwal, R., Field, C., Marks, S., Jacobs, R. and Tonelli, M. (2011) A systematic review on the effect of sweeteners on glycemic response and clinically relevant outcomes. BMC Medicine 9, 1-18
  9. Miller, P. E. and Perez, V. (2014). Low-calorie sweeteners and body weight and composition: a meta-analysis of randomised controlled trials and prospective cohort studies. The American Journal of Clinical Nutrition 100, 765-777
  10. Hampton, T. (2008). Sugar substitutes linked to weight gain. The Journal of the American Medical Association 299, 2137-2138
  11. Mattes, R. D. and Popkin, B. M. (2009). Nonnutritive sweetener consumption in humans:effects on appetite and food intake and their putative mechanisms. The American Journal of Clinical Nutrition 89, 1–14
  12. Riley, P., Moore, D., Ahmed, F., Sharif, M.O. and Worthington, HV. (2015). Xylitol-containing products for preventing dental caries in children and adults. The Cochrane Database of Systematic Reviews 3
  13. European Food Safety Authority (2011). Scientific opinion on the substantiation of health claims related to intense sweeteners and contribution to the maintenance or achievement of a normal body weight (ID 1136, 1444, 4299), reduction of post-prandial glycaemic responses (ID 4298), maintenance of normal blood glucose concentrations (ID 1221, 4298), and maintenance of tooth mineralisation by decreasing tooth demineralisation (ID 1134, 1167, 1283) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA Journal 9: 2229. Available at http://www.efsa.europa.eu/sites/default/files/scientific_output/files/main_documents/2229.pdf
  14. Tandel, K. R. (2011). Sugar substitutes: Health controversy over perceived benefits. Journal of Pharmacology and Pharmacotherapeutics 2, 236-243
  15. Diabetes UK (2011). Evidence-based nutrition guidelines for the prevention and management of diabetes. Available at https://www.diabetes.org.uk/Documents/Reports/nutritional-guidelines-2013-amendment-0413.pdf
  16. Practice-based Evidence in Nutrition (2013). Sweeteners. Available from https://www.pennutrition.com/KnowledgePathway.aspx?kpid=1323
  17. Mortensen, A. (2006). Sweeteners permitted in European Union: safety aspects. Water Research 52, 260-274
  18. Food Standards Agency (2014). Food Additives Legislation Guidance to Compliance. Available at  http://www.food.gov.uk/sites/default/files/multimedia/pdfs/guidance/food-additives-legislation-guidance-to-compliance.pdf
  19. Whitehouse, C. R., Boullata, J. and McCauley, L. A. (2008). The potential toxicity of artificial sweeteners. Official Journal of the American Association of Occupational Health Nurses 56, 251-259
  20. Piernas C., Ng S.W., Mendez M.A., Gordon-Larsen P. and Popkin B.M. (2015). A dynamic panel model of the associations of sweetened beverage purchases with dietary quality and food-purchasing patterns. American Journal of Epidemiology 181, 661–671
  21. Shanker, P., Ahuja, S. and Sriram, K. (2013). Non-nutritive sweeteners: review and update. Nutrition 29, 1293-1299