Sugar reduction and low/no calorie sweeteners: policies, evidence and dietary practice

Key remarks of a webinar by the European Federation of Associations of Dietitians (EFAD)


  • As a result of public health concerns about excess sugar consumption, European countries are implementing a range of policies to lower population sugars intake.
  • Food and drink reformulation and portion size reduction by the food industry are some of the recommended policies aiming at enabling a healthier food environment.
  • Low/no calorie sweeteners can support reformulation efforts by maintaining the palatability of products while reducing sugars and energy content; greater calorie reduction can be achieved in beverages.
  • New collective data show that low/no calorie sweetened beverages lead to lower body weight and improvements in cardiometabolic risk factors when used to displace excess calories from sugary drinks, i.e. the intended substitution.
  • Low/no calorie sweeteners have a place in different dietary patterns for diabetes by helping control blood glucose levels and by assisting in body weight regulation. This is supported by major diabetes associations in Europe, the US and Canada.

The new normal in online education offers health professionals a great opportunity to get updated on important nutrition topics by the best scientific experts worldwide. Online scientific events like the webinar on sugar reduction and low/no calorie sweeteners that was organised by the European Federation of Associations of Dietitians (EFAD), and supported by the International Sweeteners Association ISA), enable top international academics to come together to share their research and to discuss the latest best evidence on a subject.

Latest recommendations on sugars and sweeteners intake

Prof Maria Hassapidou from the International Hellenic University, Greece, recalled the guideline by the World Health Organisation (WHO) recommending that adults and children should reduce their free sugars intake to less than 10% of total daily energy intake, and if possible, further to below 5% of energy intake.1 Prof Hassapidou presented data supporting the assertion that low/no calorie sweeteners can help in meeting sugar reduction recommendations2, in reducing overall calorie intake, and in turn, in assisting in weight loss3,4, likely by improving compliance to a higher diet quality5.

Sugar reduction policies in Europe: a review of effective strategies

Prof Alison Gallagher from Ulster University, Northern Ireland, presented a summary of policy recommendations that are aimed at reducing sugars intake, including from the WHO6, the European Union7, Public Health England8 and the French Agency for Food, Environmental and Occupational Health & Safety (ANSES)9.

Food and drink reformulation as well as portion size reduction are actions recommended to the food industry to support a healthier food environment. Certainly, there is a place for low/no calorie sweeteners in food reformulation efforts as they help to maintain products’ palatability while reducing sugars and calorie content. Reformulation of products can help to provide healthier alternatives, although the path for reformulation outside beverages is not as straightforward. This is evident from the progress report of the UK sugar reduction programme between 2015-2018, where sugar reduction in some food categories (e.g. yogurts and breakfast cereals) was more successful than in others.10 With regard to beverages, a levy on sugar-sweetened beverages that was introduced since April 2018 as part of the sugar reduction policy in the UK, led to a voluntary reduction of sugar content in 50% of drinks, already ahead of the levy.

Prof Gallagher concluded that, in general, approaches that focus on the whole diet rather than on single food categories are preferable strategies to reduce population sugar intake, and that monitoring intakes of sugars and sweeteners with accurate methods, in addition to monitoring sugar content of products, is necessary to evaluate the effectiveness of different policies.

Do low/no calorie sweeteners have a place in different dietary patterns for diabetes?

Prof Anne Raben, University of Copenhagen, Denmark, discussed the conclusions of recent systematic reviews looking at the impact of low/no calorie sweeteners on glucose control. A meta-analysis of 24 clinical trials found that the ingestion of low/no calorie sweeteners has no acute effects on postprandial glycaemic or insulinemic responses compared with a control intervention, while a small beneficial effect on postprandial glucose was found in patients with type 2 diabetes.11 Prof Raben reminded that major diabetes associations such as the American Diabetes Association (ADA)12, Diabetes UK13 and Diabetes Canada14 are generally supportive of low/no calorie sweeteners use as a replacement of sugars. In her concluding remarks, Prof Raben stated that low/no calorie sweeteners have a place in different dietary patterns for diabetes by helping control blood glucose levels and by assisting in body weight regulation.

Does substituting sugar with LNCS improve cardiometabolic risk?

Dr John Sievenpiper from University of Toronto, Canada, presented a series of systematic reviews and meta-analysis work aiming to support the development of guidelines by the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD). The reviews aim to bridge the evidence gaps and have been submitted for publication.

A network meta-analysis of randomised controlled trials found that the intended substitution of sugar-sweetened beverages with low/no calorie sweetened alternative improves cardiometabolic risk factors (reduction of body weight, body fat, triglycerides and liver fat.15 Furthermore, a substitution analysis of prospective cohort studies found that replacing sugary drinks with diet alternatives was associated with a reduction in body weight, risk of diabetes, cardiovascular and all-cause mortality.16This evidence supports the use of low/no calorie sweetened beverages as an alternative replacement strategy for sugar-sweetened beverages.

Dr Sievenpiper finally called for a shift in the approach to sweeteners research and to the interpretation of scientific studies to confront the discrepancy in different recommendations regarding the use of low/no calorie sweeteners.17 The current literature on low/no calorie sweeteners and cardiometabolic risk has important methodological issues that should be considered when evaluating these studies. For example, systematic reviews that are pooling and analysing studies comparing sugars with sweeteners together with those comparing sweeteners to water likely lead to an underestimation of the true effect of low/no calorie sweeteners in their intended displacement of calories and sugars. The potential benefits and effects of low/no calorie sweeteners should be examined in the right context: by assessing the intended substitution of sugars with low/no calorie sweeteners.

For all those who missed the live broadcast but are interested to get all the latest scientific information on this topic, you may still watch the webinar by clicking here.

  1. Guideline: Sugars intake for adults and children. Geneva: World Health Organization; 2015. Available at:
  2. Patel L, Alicandron G, La Vecchia C. Low-calorie beverage consumption, diet quality and cardiometabolic risk factor in British adults. Nutrients 2018; 10: 1261
  3. Miller P, Perez V. Low-calorie sweeteners and body weight and composition: a meta-analysis of randomized controlled trials and prospective cohorts (391.1). FASEB J 2014; 28: 391
  4. Rogers PJ, Hogenkamp PS, de Graaf K, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. Int J Obes 2016; 40(3): 381-94
  5. Drewnowski A, Rehm CD. Consumption of low-calorie sweeteners among U.S. adults is associated with higher Healthy Eating Index (HEI 2005) scores and more physical activity. Nutrients. 2014; 6(10): 4389-403
  6. WHO 2015. World Health Organization Technical Report, Fiscal Policies for Diet and Prevention of Noncommunicable Diseases. Available at:
  7. EU Framework for National Initiatives on Selected Nutrients. Annex II: Added Sugars. Available at:
  8. Public Health England. Sugar Reduction: Achieving the 20%. 2017 Available at:…
  9. ANSES 2016. Opinion of the French agency for food, environmental and occupational health and safety on the establishment of recommendations on sugar intake. Available at:
  10. Public Health England. Guidance. Sugar reduction: progress between 2015-2018. Available at:…
  11. Greyling A, Appleton KM, Raben A, Mela DJ. Acute glycemic and insulinemic effects of low-energy sweeteners: a systematic review and meta-analysis of randomized controlled trials. American Journal of Clinical Nutrition 2020; 112(4): 1002-1014.
  12. Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KHK, MacLeod J, Mitri J, Pereira RF, Rawlings K, Robinson S, Saslow L, Uelmen A, Urbanski PB, Yancy Jr. WS. Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report. Diabetes Care. 2019 May;42(5):731-754
  13. Diabetes UK. The use of low or no calorie sweeteners. Position Statement (Updated December 2018). Available at:…
  14. Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes. 2018;42(Suppl 1):S1-S325
  15. McGlynn et al. Effect of Non-Nutritive Sweetened Beverages (NSBs) on Cardiometabolic Risk: A Network Meta-Analysis of Randomized Controlled Trials. Abstract presented at ASN Nutrition Live 2020
  16. Lee et al. Relation of Change or Substitution of Low Calorie Sweetened Beverages with Cardiometabolic Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies. Abstract presented at ASN Nutrition Live 2020
  17. Khan TA and Sievenpiper JL. Low-energy sweeteners and cardiometabolic health: is there method in the madness? Am J Clin Nutr. 2020 Sep 16;nqaa260. doi: 10.1093/ajcn/nqaa260