Low/no calorie sweetened beverages do not increase the risk of cardiovascular disease

ISA statement in response to the letter published by Chazelas et al.

Brussels, 27th October 2020: The International Sweeteners Association (ISA) responds to a letter published this week by Chazelas et al. about low/no calorie sweetened beverages. Contrary to the claims made in this publication, there is actually no evidence that low/no calorie sweeteners would increase the risk of cardiovascular disease, nor a plausible mechanism by which they could cause heart disease in humans.1

Firstly and importantly, the safety of all approved low/no calorie sweeteners 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).2,3,4 Low/no calorie sweeteners are amongst the most thoroughly researched ingredients worldwide. It goes without saying that in order to be approved for use, the regulatory authorities thoroughly assess all kinds of studies examining potential side effects.

This letter by Chazelas et al.5 describes briefly the results of an analysis of data from the NutriNet-Santé Cohort, an observational study which has the known limitations of this type of study design: observed association does not mean a cause-and-effect relationship.6 In fact, the reported association between the consumption of diet beverages and the risk of cardiovascular disease in this study might be due to reverse causality: in other words, people at risk of developing cardiovascular disease might have turned to sugar alternatives in their effort to reduce their calorie and sugar intake, not the other way around. Furthermore, and as also acknowledged by the authors, all confounding factors which may affect the results of the study can never be eliminated in observational studies.

In addition, while the publication includes only limited information about the actual data analysis, the presented results raise questions about the authors’ conclusions: the claimed effect of consumption of low/no calorie sweetened drinks is practically based only on less than 155 heart disease cases out of 14,875 consumers, out of a total cohort of 104,760 participants in this study.

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. 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
  2. http://www.fao.org/food/food-safety-quality/scientific-advice/jecfa/en/
  3. https://www.fda.gov/food/food-additives-petitions/high-intensity-sweeteners
  4. http://www.efsa.europa.eu/en/topics/topic/sweeteners
  5. Chazelas et al. Sugary Drinks, Artificially-Sweetened Beverages, and Cardiovascular Disease in the NutriNet-Santé Cohort. J Am Coll Cardiol 2020; 76(18):2175-6.
  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. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2012:136:0001:0040:en:PDF
  8. Sugar substitutes and their role in caries prevention, FDI World Dental Federation, September 2008