Experts reach consensus over the role of low/no calorie sweeteners in public health

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Highlights:

  • Reduction in the excessive intake of sugars is being recommended globally to lower the risk and prevalence of obesity. Low/no calorie sweeteners are one of the strategies to consider.
  • Experts agreed that, when used in place of sugars to reduce energy density of foods and drinks, low/no calorie sweeteners can help reduce net energy (calorie) intake and assist in weight and diabetes management.
  • The safety of low/no calorie sweeteners is demonstrated by a substantial body of evidence, reviewed and evaluated by independent regulatory agencies worldwide.
  • There is a need to research and develop evidence-based strategies to communicate facts to consumers, health professionals and policy makers.
  • Efforts should be made to understand and, where possible, reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede product development and reformulation designed to reduce sugars and/or calories.

A new study published in the peer-reviewed scientific journal Nutrition Research Reviews presents the reliable facts, the knowledge gaps and the suggested actions in relation to the role of low/no calorie sweeteners in public health and nutrition policy, as agreed by seventeen academic and scientific experts who participated in a workshop in London on 7 November 2018. A key strength of this workshop is the varied and years-long expertise of the participants in different areas of low/no calorie sweeteners’ science. Via consensus-forming techniques, the panel of experts discussed and reached consensus on statements relating to facts, gaps and actions about three themes:

  1. Role of low/no calorie sweeteners in weight management and glucose control
  2. Consumption and safety of low/no calorie sweeteners and consumer perception
  3. Role of low/no calorie sweeteners in relation to nutrition policy

The background

Public health experts globally suggest that reduction in the intake of sugars is required to help lower the risk and prevalence of obesity, which is a major public health concern. The use of low/no calorie sweeteners is one of the strategies to help achieve sugar reduction, and has helped already for decades the food industry to offer reduced-sugar and low-calorie products. However, despite the confirmed safety of low/no calorie sweeteners and efforts to lower intake of sugars, there is still some distrust of low/no calorie sweeteners among health professionals and policy makers, and misperceptions exist among consumers. Therefore, the aim of this workshop of experts was to review the current evidence and to establish clear and simple statements on low/no calorie sweeteners (facts), to highlight the areas where more research is required (gaps) and to propose how progress might be achieved (actions) relating to science and policy around sweeteners.

Main workshop outcomes: An overview of the consensus statements

The panel of experts discussed and agreed to 37 statements about what we know (15 statements – facts), what we still need to know (11 statements – gaps) and what we should do (11 statements – actions) as regards the science and nutrition policy related to low/no calorie sweeteners. The most important consensus statements that came out of the expert workshop are summarised below.

Facts:

  1. The safety of low/no calorie sweeteners is demonstrated by a substantial body of evidence, which is reviewed and evaluated by independent regulatory bodies worldwide. The safety of approved low/no calorie sweeteners is thoroughly and repetitively assessed and confirmed by these regulatory food safety bodies. Continual monitoring and modelling of low/no calorie sweeteners exposures is undertaken, and this demonstrates that intakes are within the Acceptable Daily Intakes (ADIs).
  2. When substituted for sugars to reduce energy density of foods and drinks, low/no calorie sweeteners reduce net energy intake and assist weight management. Low/no calorie sweeteners have no adverse effect on blood glucose and insulin regulation (HbA1c, fasting and post-prandial glucose and insulin levels) in people with, and without, diabetes. The potential value of low/no calorie sweeteners in the dietary management of diabetes derives from their role as substitutes for sugars, and hence carbohydrates.
  3. Reduction in the intake of sugars is being recommended globally to reduce the risk and prevalence of obesity. In achieving this, the use of low/no calorie sweeteners is one of the strategies to consider. Low/no calorie sweeteners can be used to reduce the sugar and energy content of beverages and some foods whilst maintaining a similar sensory profile. The potential for energy reduction depends on the options for reformulation and what replaces the bulk of sugar.

Gaps:

  1. Which factors (including knowledge, attitudes and behaviours) influence perception of risks and benefits of low/no calorie sweeteners’ consumption? What are the best strategies to communicate low/no calorie sweeteners’ safety and efficacy to health professionals and the general public?
  2. What are the longer-term benefits and effects of low/no calorie sweeteners on weight and diabetes management, and other health outcomes? Do these effects alter according to personal factors (age, sex, socio-economic status, health status, diet and lifestyle), or according to dietary context (ad libitum vs. weight-control diet), form of low/no calorie sweetened product (in liquids or solids), and type of sweeteners?
  3. How can low/no calorie sweeteners help individuals meet the population level dietary recommendations for reduction of sugars intake?

Actions:

  1. There is a need to research and develop evidence-based strategies to communicate facts to consumers, health professionals and policy makers. The extensive body of scientific evidence that backs regulatory approval and the on-going safety assessment of low/no calorie sweeteners can then encourage better informed public health decisions.
  2. There is a need for more high-quality human studies:
    • Well-designed RCTs (with appropriate time frame of a year or more) with different comparators and different carriers of low/no calorie sweeteners (food and beverage matrices) that will evaluate multiple endpoints (diet quality, gut microbiota function and metabolomics, and wider health and quality of life measures);
    • Population cohort studies to model changes in weight/ cardiometabolic risk in the context of changes in low/no calorie sweeteners’ consumption, not baseline values and to include substitution analysis (e.g. low/no calorie sweetened beverages for caloric beverages, water, etc.) and adjustment for adiposity.
  3. To help reconcile policy discrepancies, policy makers, scientists and regulatory affairs experts should agree on their understanding of the role of low/no calorie sweeteners in the diet. Modelling sweeteners’ intake trends and the ability to help meet sugar reduction targets is also needed to help inform policies.

Please watch this video presenting the main outcomes of the experts’ workshop and interviews with the main authors of the published paper, Dr Margaret Ashwell, OBE, DSc, PhD, FAfN, RNutr(Public Health), and Mrs Sigrid Gibson, MA, MSc, FAfN, RNutr(Public Health).

Take home message

Efforts should be made to understand and, where possible, reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede product development and reformulation designed to reduce sugars and/or calories. However, despite repeated and consistent reassurances from food safety authorities about low/no calorie sweeteners’ safety, there is still some distrust of low/no calorie sweeteners among consumers, health professionals and policy makers. Therefore, the panel considered that the substantial body of evidence concerning their safety should be communicated in a consistent manner. In addition, there is a need to develop communications to foster more informed public attitudes towards low/no calorie sweeteners, for example by emphasizing the potential health gains associated with sugar (and energy) intake reduction and the role of low/no calorie sweeteners in achieving this. It is important to explain that the overall impact of low/no calorie sweeteners will depend on the amount of sugars replaced in the diet and the overall reduction in calorie (energy) intake that ensues. Use of low/no calorie sweeteners alone cannot be expected to act as a ‘silver bullet’ for weight loss. Benefits will depend on how foods and beverages containing low/no calorie sweeteners are used and substituted, as well as on the overall quality of the diet and the total energy provision.

For more information, you may review the full list of consensus statements in the paper entitled “Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions” (Ashwell et al., 2020), published online in the peer-reviewed journal Nutrition Research Reviews.

  1. Ashwell MA, Gibson S, Bellisle F, Buttriss J, Drewnowski A, Fantino M, Gallagher AM, de Graaf K, Goscinny S, Hardman CA, Laviada-Molina H, López-García R, Magnuson B, Mellor D, Rogers P, Rowland I, Russell W, Sievenpiper J, la Vecchia C. Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions. Nutr Res Rev. 2020;33(1):145-154. doi: 10.1017/S0954422419000283. [Epub ahead of print]