Low/no calorie sweetened beverages are safe and do not increase risk of mortality

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ISA statement in response to meta-analysis of observational studies by Li et al.

Brussels, 7th May 2021: Contrary to the claims reported in a new systematic review and meta-analysis of prospective cohort (observational) studies1, the International Sweeteners Association (ISA) points to the safety of all approved low/no calorie sweeteners and to the important limitations of this new study claiming that low/no calorie sweeteners would increase the risk of cardiovascular disease and mortality.2

Low/no calorie sweeteners are amongst the most thoroughly researched ingredients worldwide. Their safety has been repeatedly and consistently confirmed by regulatory authorities around the world such as the Joint Food and Agriculture Organization (FAO)/ World Health Organization (WHO) Expert Committee on Food Additives (JECFA), the US Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA).3,4,5 Prior to being approved for use on the market, the regulatory authorities thoroughly assess all kinds of studies examining potential side effects.

The current review by Li et al. examines observational studies that, as per their nature, cannot prove a cause-and-effect relationship.6 Only 4 studies with 5 cohorts were analysed for low/no calorie sweetened beverages and the authors acknowledged that these findings were more prone to bias due to confounding for its limited number of studies. Moreover, the reported association between the consumption of diet beverages and the risk of all-cause mortality and cardiovascular disease mortality might be due to reverse causality: in other words, people more likely to be overweight or with obesity, hypertensive, and hypercholesterolemic, or with diabetes might turn to sugar alternatives in their effort to reduce their calorie and sugar intake, not the other way around.

At a time when obesity and non-communicable diseases including diabetes and dental diseases remain major global health challenges, and in light of current public health recommendations to reduce overall sugar intake, low/no calorie sweeteners can be helpful in creating healthier food environments. They provide a wide choice of sweet-tasting options with low or no calories, and thus can be a useful tool, when used in place of sugar and as part of a balanced diet, in helping reduce overall sugar and calorie intake, as well as in managing blood glucose levels.7 Low/no calorie sweeteners are also not fermentable by oral bacteria, which means that they do not contribute to tooth demineralisation, which is one of the reasons for tooth decay.7 They can therefore contribute to good dental health, when used in place of sugar8 and as part of a tooth-friendly diet.

  1. Li H, Liang H, Yang H, et al. Association between intake of sweetened beverages with all-cause and cause-specific mortality: a systematic review and meta-analysis. J Public Health (Oxf) 2021 Apr 9;fdab069. doi: 10.1093/pubmed/fdab069.
  2. Pyrogianni V, La Vecchia C. Letter by Pyrogianni and La Vecchia Regarding Article, “Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women’s Health Initiative”. Stroke; 2019 Jun;50(6):e169. doi: 10.1161/STROKEAHA.119.025555
  3. http://www.fao.org/food/food-safety-quality/scientific-advice/jecfa/en/
  4. https://www.fda.gov/food/food-additives-petitions/high-intensity-sweeteners
  5. http://www.efsa.europa.eu/en/topics/topic/sweeteners
  6. Sievenpiper JL, Khan TA, Ha V, Viguiliouk E, Auyeung R. The importance of study design in the assessment of non-nutritive sweeteners and cardiometabolic health. A letter in response to Azad et al study in CMAJ. CMAJ November 20, 2017 189 (46) E1424-E1425
  7. EFSA Scientific opinion on the substantiation of health claims related to intense sweeteners. EFSA 2011 Journal 9(6): 2229, and 9(4): 2076.
  8. Sugar substitutes and their role in caries prevention, FDI World Dental Federation, September 2008