Abstract
The effect of nonnutritive sweeteners (NNSs) on the body mass index [BMI (in kg/m2)] of children and adolescents remains unclear despite rising consumption. Detailed systematic evaluations are warranted. We aimed to summarize evidence on NNS consumption and BMI sex- and age-specific absolute changes (kg/m2) in pediatric populations, by NNS type, study design, duration, analysis type, conflicts of interest (COI), geographical region, age, sex, and baseline BMI. We searched randomized controlled trials (RCTs) and prospective cohort studies in children (2-9 y), adolescents (10-24 y), and young adults (20-24 y). Pooled estimates derived from random-effects meta-analysis for BMI changes, and the evidence quality was evaluated overall and by subgroup. From 2789 results, we included 4 RCTs [n = 1372; mean follow-up = 42.6 wk (standard deviation = 18.4); 2 (50%) with COI], and 8 prospective cohort studies [n = 35,340; median follow-up 2.5 y (interquartile range = 1.7-6.3), 2 (25%) with COI]. No identified studies evaluated NNS in food, NNS beverages compared with water, or participants aged 20-24 y. Random allocation to NNS beverages (25-2400 mg/d, from beverages) showed less BMI gain [mean difference = -0.114 kg/m2 (95% confidence interval [CI]: -0.207, -0.021); I2 = 87.02%] compared with sugar-sweetened beverages (SSBs). Stratified estimates resulted in less BMI gain in adolescents, participants with baseline obesity, consumers of mixed NNS, longer trials, and trials without COI. Pooled estimates from prospective cohorts showed a nonsignificant association between NNS beverages and BMI gain [0.05 kg/m2 (95% CI: -0.03, 0.13); I2 = 75.06%; per daily 355 mL serving]. Stratified estimates remained consistent. Removing studies with COI attenuated estimates. Evidence had low to moderate quality. In summary, pooled results from RCTs comparing NNS beverages compared with SSBs showed less BMI gain in adolescents with obesity. Meta-analyses of long-term cohort studies did not display a significant association between NNS beverages and BMI changes. This trial was registered at PROSPERO as CRD42022352284.
Summary
This systematic review and meta-analysis sought to assess the impact of low-and no-calorie sweeteners (LNCS) on sex- and age-specific BMI changes in children and adolescents, to help clarify conflicting recommendations, some discouraging LNCS use, others supporting it as a strategy to fight obesity and related conditions.
Following a systematic search of the literature following PRISMA guidelines, a total of four RCTs and eight prospective cohort studies were deemed eligible for inclusion.
Based on five comparisons derived from four RCTs involving a total of 1372 participants, results showed less BMI gain among participants who replaced sugar sweetened beverages (SSBs) with LNCS-sweetened beverages (LNCSBs) compared with those who continued consuming SSBs. The directionality of the effect remained consistent even after excluding studies with potential conflicts of interest. When stratifying the analysis by age categories, less BMI gain was only observed among adolescents; stratification also revealed that effect was greater for participants with obesity.
Subgroup analyses further showed that only longer interventions significantly reduced BMI gain.
In the meta-analysis of eight prospective cohort studies involving a total of 34,984 participants, the pooled estimate for the association between each serving of LNCSBs and changes in BMI during follow-up resulted non-significant. Like RCTs, estimates from industry-related studies did not indicate a benefit in BMI changes compared with their COI free counterparts.
Overall, the findings suggest that the potential benefits of LNCS on body weight are likely linked to reduced energy intake through sugar avoidance, an effect that appears more pronounced in overweight adolescents.