As demand for sugar substitutes continues to rise, the World Health Organization (WHO) warns against using these additives for weight control or managing noncommunicable illnesses. In fact, ongoing consumption may increase the risk of cardiovascular diseases, type 2 diabetes, and even death, According to this organization “Non-sugar sweeteners are not essential dietary factors and have no nutritional value. People should reduce the sweetness of the diet altogether, starting early in life, to improve their health.”

Why This Matters

Although focused on the risks of non-sugar sweeteners, the guideline acknowledges that consuming too much actual sugar is tied to obesity. Nearly 2 billion adults and more than 340 million children and adolescents are overweight or obese, according to the WHO’s most recent estimates. Obesity is linked with several noncommunicable diseases, the leading causes of death worldwide. This guideline is important because the use of non-sugar sweeteners in the food supply has become increasingly prevalent with continued efforts to lower intakes of added sugar.

While sugar substitutes are often touted for having fewer calories than sugar—or no calories at all—it’s unclear whether long-term use can aid weight loss or management. And accumulating evidence demonstrates that non-sugar sweeteners may have unfavorable effects on risk factors for chronic disease.

Last year, researchers in France connected artificial sweeteners with an increased risk of cardiovascular disease. A recent study additionally found that sucralose-6-acetate, a chemical formed when ingesting sucralose (Splenda) , can damage DNA and increase gene activity associated with inflammation and cancer. This guideline is relevant for children and adults without preexisting diabetes. It applies to artificial and natural sweeteners not classified as sugar—like aspartame, saccharin, stevia, and sucralose—but not sugar alcohols or low-calorie sugars. It also doesn’t apply to medications or hygiene and personal care products, which sometimes contain traces of sugar substitutes for palatability. Thus, non-sugar sweetener use or consumption means consuming foods and beverages containing sugar substitutes or adding them to such products.

To establish their recommendation, investigators reviewed 283 studies, including randomized trials, prospective cohort studies, and case-control studies.

Key Findings

In adults:

  • Consuming non-sugar sweeteners for short periods of time, about 3 months or less, was associated with lower weight and body mass index. Yet short-term use didn’t improve other indicators of cardio-metabolic health, such as glucose or insulin levels. Longer-term use between 6 months and 18 months didn’t appear to affect weight, but data from related trials were difficult to interpret because of differing methodologies.
  • Across prospective studies, including those that followed participants for a decade, higher use of non-sugar sweeteners correlated with an increased risk of obesity, type 2 diabetes, several cardiovascular diseases—including stroke—and death from any cause. Although using sugar substitutes wasn’t associated with an overall higher risk of cancer, saccharin was linked with bladder cancer in a small number of case-control studies.

In children:

  • Evidence for the health effects of sugar substitutes was limited. Even though children lost weight when sugar-sweetened beverages were replaced with beverages containing sugar substitutes, there was no observable difference in body mass index scores. Moreover, several studies found no significant connections between consuming non-sugar sweeteners and improved health outcomes.

In pregnant individuals:

  • Data were also limited. Whereas higher use of non-sugar sweeteners during pregnancy was associated with an increased risk of preterm birth, it’s unclear whether offspring’s weight at birth or later in life was affected. Sugar substitutes didn’t decrease the risk of gestational diabetes, but using such sweeteners during pregnancy may affect some offspring outcomes: maternal consumption was associated with an increased risk of asthma and allergies, as well as reduced cognitive function.

The guideline acknowledges that most findings don’t have strong evidence, and the effect size was often small. Another limitation is possible reverse causation, which could have contributed to observations of long-term non-sugar sweetener use associated with disease risk. Thus, the guideline is designated as a conditional recommendation, meaning the WHO isn’t sure whether the benefits of avoiding sugar substitutes outweigh the risks in most cases.

The reason why the guideline was conditional is because the evidence is not conclusive and more research is needed to fully elucidate the role of non-sugar sweeteners in weight management and chronic disease. However, the guideline is still important given that use of non-sugar sweeteners is increasing—especially in light of efforts to reduce added sugar intake—yet an accumulating body of evidence has raised concerns about their consumption. Moreover, establishing a correlation does not necessarily there is a causal relationship, that is, is it possible that those individuals requiring more non-sugar sweeteners were destined to develop the diseases for reasons beyond this consumption?

The Bottom Line

When possible, the guideline suggests opting for unsweetened foods and beverages. It also recommends that policy makers focus on reducing consumption of sugar and its substitutes in infants and young children still forming taste preferences.

It is encouraging that with the current boom of weight management medications, this guideline falls more towards diet recommendations, one of the arms that make up the bedrock for weight management. But this recommendation is a welcome addition to guide the general public about how they can modify their diets.


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