A review of the policy statement by the American Academy of Pediatrics
Highlights:
- All approved low/no-calorie sweeteners have undergone a stringent safety evaluation by food safety authorities around the world who consistently confirm their safety.
- Clinical studies show that substituting sugary products with low/no calorie sweetened alternatives may help reduce weight gain or promote small amounts of weight loss in children and adolescents.
- Children need a balanced diet with adequate calories and a variety of foods and nutrients for proper growth and development into a healthy weight. For children who require calorie and/or sugar reduction in order to control excess weight gain, low/no calorie sweeteners can be safely consumed to replace part of sugars in their diet.
With childhood obesity being associated with non-communicable diseases in adult life and still on the rise in many parts of the world, public health authorities in several countries have shown a growing interest in policies encouraging food reformulation and the development of foods and drinks with lower calories and less sugar, saturated fat and salt (OECD, 2019). Over the last decades, low/no calorie sweeteners, used as sugar alternatives in foods and drinks, have helped in the development of such products that have less sugar and fewer calories (Gibson et al, 2017). In light of the increased interest in the use of low/no calorie sweeteners, the American Academy of Pediatrics (AAP) issued a policy statement in October 2019, which reviews current evidence on the use of low/no calorie sweeteners in children and suggests gaps in existing knowledge and potential areas of future research (Baker-Smith et al, 2019).
The AAP report states that, “It can be reasonably argued that certain subpopulations of children might benefit from the use of NNSs [non-nutritive sweeteners]. For example, children and adolescents who have obesity might benefit from lower total caloric intake. Children who have type 1 or 2 diabetes mellitus might also benefit from the lack of a glycemic response while enjoying the sweet taste of NNSs.” However, it also states that there is an “absence of strong scientific evidence to refute or support the safety of these agents”, despite the consistent confirmation from regulatory authorities globally that low/no calorie sweeteners are of no safety concern and the fact that they are amongst the most thoroughly researched ingredients worldwide.
The current article aims to provide a brief analysis of the scientific literature which sometimes includes conflicting information about the benefits of low/no calorie sweeteners and to discuss the strength and quality of the current evidence.
Low/no calorie sweeteners are safe for both adults and children
All approved low/no-calorie sweeteners have undergone a stringent safety assessment by food safety agencies around the world such as the Joint Expert Scientific Committee on Food Additives (JECFA) of the United Nations Food & Agriculture Organization (FAO) and the World Health Organization (WHO), the US Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA). These bodies have extensively evaluated all kinds of studies examining potential acute, sub-chronic and long-term effects in animals and humans, and on the basis of the totality of available science, they have consistently confirmed that low/no calorie sweeteners are safe for all population groups including children, when consumed within the established limits.
Research at global level confirms that low/no calorie sweeteners’ intake is well below the individual sweetener Acceptable Daily Intake (ADI) among the general population, in both children and adults (Martyn et al, 2018). The ADI represents the amount of each sweetener that can be ingested daily over a lifetime by person of all age groups including children without appreciable health risk.
You may also read the ISA statement in response to the AAP policy statement by clicking here.
Can low/no calorie sweeteners be part of children’s diet?
Children need adequate energy (calories) and a variety of foods and nutrients as part of an overall balanced diet to support growth and development, and in order to reach or maintain a healthy weight for height (Gidding et al, 2006). In general, caloric restriction should not be promoted during growth unless a child or adolescent needs to control excess weight gain. In managing overweight and obesity in children and adolescents, lifestyle modifications including dietary changes aimed at decreasing total caloric intake, increasing physical activity and reducing sedentary time are critical for weight control.
Rates of overweight and obesity in childhood and adolescence increased worldwide over the last four decades (NCD Risk Factor Collaboration, 2017). At the same time, limiting excess consumption of sugars, saturated fats, and salt is recommended for overall health including for weight management and obesity prevention. For example, the World Health Organization’s guideline on free sugars intake for adults and children recommends the reduction of free sugars to less than 10% of daily energy intake across the life course (WHO, 2015).
However, we also know that we are born with a natural preference for sweetness and that children have a heightened liking for sweet taste, which decreases into adulthood (Mennella, 2014). Therefore, trying to get children to reduce sweetness in their diet is challenging. One, among a pool of dietary strategies that can be used to help bring down calorie and sugar intake -when required-, while helping to manage our innate liking for sweet taste, is the use of low/ no calorie sweeteners to replace part of sugars in the diet (Bellisle, 2015).
The “sweet tooth” hypothesis in children
The AAP report states that, “Data suggest but do not conclusively demonstrate that NNS [non-nutritive sweeteners] use may promote the intake of sugary food and drink by affecting taste preferences.” However, the authors missed to review important data from studies in children and adolescents showing that the intake of low/ no calorie sweeteners in place of sugars can help manage intake of sweet-tasting foods.
Current evidence of effects of low/no calorie sweeteners’ consumption on appetite and food intake in children indicates that low/no calorie sweeteners have no impact on feelings of hunger, appetite or satiety, nor result in overeating, increased calorie intake and weight gain (Rodearmel et al, 2007; Ebbeling et al, 2012; de Ruyter et al, 2013). In fact, several reviews support the notion that low/no calorie sweeteners’ intake neither promotes nor suppresses appetite in humans (Bellisle, 2015; PHE, 2015; Rogers, 2017; Towes et al, 2019). Interestingly, in an 18-month intervention study in 641 children by de Ruyter et al., low calorie sweetened beverage consumption tended to reduce rather than increase the intake of sugar containing foods, and their use was associated with a lower intake of sweet tasting foods (de Ruyter et al, 2013). This suggests that low/no calorie sweeteners may help to satisfy a desire for sweetness and that low/no calorie sweeteners do not encourage a “sweet tooth” (Bellisle, 2015).
Overall, current evidence does not support an association between low/no calorie sweeteners’ use (or exposure to sweetness in general) and a heightened appetite for sugar or sweet products, or a change in taste preferences (Appleton et al, 2018).
Clinical research on low/no calorie sweeteners and body weight in children and adolescents indicates potential benefit
Some of the largest and most rigorously conducted randomised controlled trials (RCTs) so far studying the impact of replacing sugar-sweetened beverages with low calorie alternatives have shown beneficial effects of such replacement in children adiposity (Ebbeling et al, 2006; Rodearmel et al, 2007; Ebbeling et al, 2012; de Ruyter et al, 2012; Katan et al, 2016). This effect was found to be greater in children with a higher initial BMI suggesting that reducing the intake of sugar-sweetened drinks through replacement with low calorie options may benefit a large proportion of children, especially those at risk of or with overweight or obesity (Katan et al, 2016).
According to the policy statement by the American Academy of Pediatrics, short- and medium-term studies show that, “When substituted for caloric sweetened foods or beverages, NNSs can reduce weight gain or promote small amounts of weight loss (+-1 kg) in children (and adults); however, data are limited.”. Randomised controlled trials in children and adolescents have examined the role of low/no calorie sweeteners in weight control in studies lasting up to 18 months, which is a sufficient period of time to evaluate effects of interventions on body weight outcomes. These studies provide strong evidence that the replacement of sugar sweetened beverages with diet alternatives reduces weight and fat gain in children and adolescents after one year of follow-up, as recognised by independent experts (Malik et al, 2019).
Similarly, in a recent analysis of the scientific evidence on low/ no calorie sweeteners in childhood by a group of experts from the Mexican Society of Pediatrics, it is stated that current evidence shows that replacing sugar with low/no calorie sweeteners can lead to lower weight gain in children and that a few studies in adolescents have shown that this substitution can have moderate beneficial effects in overweight and obese teenagers. The group of experts concluded that in children with obesity, metabolic syndrome or diabetes, low/no calorie sweeteners can be an additional tool to be included within a healthy lifestyle that integrates a balanced diet and physical activity (Wakida-Kuzunoki et al, 2017).
Conflicting outcomes about effects on body weight: The importance of evaluating the quality of evidence
Contrary to findings of RCTs, which, by their design, provide higher quality of evidence, some research of observational study design has reported conflicting positive associations between low/no calorie sweeteners’ consumption and weight gain (Baker-Smith et al, 2019). However, observational studies, by their nature, are not studies of, and cannot prove, cause and effect, as selection bias, residual confounding and reverse causation may affect the observed associations (Sievenpiper et al, 2017). Evidence from epidemiological data is rated as being of low quality and is therefore considered “weak”. (WHO Handbook, 2014).
Future research about low/no calorie sweeteners in children
The AAP report concludes that current evidence in children is limited and recommends more research into how low/no calorie sweeteners affect children’s weight, taste preferences, blood sugar levels, insulin sensitivity and the risk of diabetes or metabolic syndrome. Evidence to date does not support any adverse effect of low/no calorie sweeteners on taste preferences and food intake, body weight or glycemic control. The collective evidence from controlled animal and human studies in both adults and children, including in children with type 1 diabetes, does not support any causal link or impact of low/no calorie sweeteners on insulin resistance and glucose control, diabetes or metabolic syndrome via effects on the gut microbiome or another mechanism (Tucker and Tan, 2017; Nichol et al, 2018; Lobach et al, 2019).
Future well-designed clinical research can help scientists, policy makers and consumers have a better understanding of the potential benefits of low/no calorie sweeteners.
Take-home message
The safety of all approved low/no calorie sweeteners is consistently confirmed by international regulatory authorities, such as JECFA, FDA and EFSA, for both adults and children.
The benefits of low/no calorie sweeteners are related to the reduction of sugars and calorie intake within a balanced diet. There should be no expectation that low/no calorie sweeteners, by themselves, can cause weight loss or decrease blood glucose levels; as food additives, they cannot act as magic bullets. Collectively, scientific evidence to date supports the notion that, when used to replace caloric sweetened foods or beverages, low/no calorie sweetened alternatives can have potential benefits in weight and glycaemic control. Also, the use of low/no calorie sweeteners has been associated with a reduced presence of dental caries.
