Artificial Sweeteners: Experts Weigh In On Regulation, Reducing Dependence
The fate of non-sugar sweeteners (NSS) or popularly known as sugar-free substitutes might just be changing as the scientific evidence gathering against them suggests that the artificial sweeteners may not be efficacious for many health benefits that they were previously lauded for or which led to their fame.
Earlier this week on 15 May 2023, the World Health Organisation (WHO) warned people about the use of artificial sweeteners and advised against using them for controlling body weight or reducing the risk of noncommunicable diseases (NCDs). The WHO stated that there may be potential undesirable effects from long-term use of NSS, such as an increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults. However, the WHO said that these guidelines do not apply to people with preexisting diabetes.
The WHO's recommendation includes all synthetic and naturally occurring or modified non-nutritive sweeteners that are not classified as sugars found in manufactured foods and beverages, or sold on their own to be added to foods and beverages by consumers. “Common NSS include acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, sucralose, stevia and stevia derivatives," the WHO stated.
The clinical experts in India have lauded and welcomed the WHO guidelines but among the many questions that arise, one is could these guidelines have come earlier, “The guidelines by the WHO are quite pertinent and well-directed. Although they should have come in earlier as patients have been misled into believing that this is a healthier option,” stated Dr Shuchin Bajaj, Founder Director, Ujala Cygnus Group of Hospitals.
Dr Subhash Kumar Wangnoo, Senior Consultant Endocrinologist and Diabetologist, Apollo Hospitals, said that by highlighting the lack of long-term benefits and potential risks associated with NSS, the WHO has promoted healthier alternatives and encouraged people to adopt balanced diets that limit the consumption of artificial sweeteners.
“WHO conducted a comprehensive analysis of 283 studies, which included both randomized trials and observational studies. Despite this comprehensive review, the findings indicate only a minimal amount of weight loss, if any. Therefore, it is reasonable to conclude that the impact of non-sugar sweeteners on weight loss is not significant,” said Dr Ambrish Mithal, Chairman and Head - Endocrinology and Diabetes, Max Super Speciality Hospital.
The Piling Scientific Evidence
A 2022 study published in the US journal National Centre For Biotechnology Information stated that multiple scientific studies in humans suggest that artificial sweeteners have “no effect on body weight or glycemic control” while the early intake of NSS was also shown to suppress the taste response to sugar.
“Notably, the effects of artificial sweeteners depend on individual differences, including the gut bacteria, and may increase blood glucose levels, promote atherosclerosis, and increase cardiovascular risk and total mortality,” the author of the study stated.
The study further pointed out that the use of NSS in treatment of diabetes and obesity should be reconsidered, “The replacement of sugar with artificial sweeteners in patients will require long-term tracking of not only intake but also changes in blood glucose and weight as well as future guidance based on gut bacteria data.”
Another study published in 2020 in the same journal stated that there is mechanistic evidence that artificial sweeteners may induce gut microbiota dysbiosis, by altering the gut microbiota composition and function. The gut microbiome or microbiota are microorganisms that exist in the human digestive system helping in energy harvesting, digestion and immune defense.
Dr Edwina Raj, Head of Clinical Nutrition and Dietetics, Aster CMI Hospital delineated that according to recent evidence replacing free sugars with NSS does not benefit weight control in the long term and its regular consumption disturbs your gut health which increases the risk of obesity, diabetes, heart disease, stroke, hypertension, and preterm delivery among pregnant women.
“The disruption of microbiota function by NSS is a topic of ongoing research, and the specific effects on individuals with diabetes and obesity are still being investigated. However, it is believed that the gut microbiota plays a significant role in metabolic health, including glucose regulation and weight management. Disruptions to the microbiota can potentially impact these processes,” said Dr Wangnoo.
Dr Mithal further added that there are also suggestions that the intense sweetness of artificial sweeteners can condition the brain to prefer excessively sweet tastes, making naturally sweet foods like fruits seem less appealing.
People With Diabetes, Obesity
The WHO’s new guidelines exclude people with pre-existing diabetes, this clinical experts say could be due to the help rendered by artificial sweeteners to people who have diabetes, “It is acknowledged that artificial sweeteners can help reduce the spike in blood sugar levels when substituted for sugar. This aspect is well-established and there is no doubt about its efficacy. Considering this perspective, artificial sweeteners can be viewed as a suitable option for occasional use when one has a craving for sugar but wants to avoid the associated spike in blood sugar levels.”
Dr Bajaj stated that the WHO guidelines may not apply directly to people with pre-existing diabetes, as they often have specific dietary considerations and need personalised guidance from healthcare professionals or registered dietitians. “It is important for people with pre-existing diabetes to work closely with healthcare professionals or registered dietitians to understand how non-sugar sweeteners fit into their overall dietary plan and provide recommendations tailored to their unique circumstances,” he enumerated.
Nonetheless, Dr Mithal warns that the artificial sweeteners should not be used as a constant substitute and should be used sparingly, “It is important to note that artificial sweeteners should not be considered a comprehensive solution for managing diabetes.”
Dr Wangnoo pointed out that for individuals with diabetes, alterations in the gut microbiota could potentially affect glycemic control adding that a healthy and diverse gut microbiota composition is generally associated with improved glucose metabolism. “Therefore, any changes caused by NSS consumption that negatively impact the microbiota could potentially have implications for blood sugar regulation in people with diabetes,” he added.
For obesity, Dr Wangnoo said that studies have suggested a potential link between alterations in the gut microbiota and weight gain or difficulty losing weight and disruptions caused by NSS could potentially influence energy metabolism and fat storage, which might impact obesity management. However, medical experts added that more research is needed to fully understand the extent of these effects and how they may differ among individuals.
Regulating The Artificial Sweetener Industry
Today, the artificial sweeteners industry is booming with its offerings present in sugar-free sachets, beverages, snacks, bakery products and other processed foods available in the market which are hailed and branded as “healthy” and “safe”.
According to a 2022 report by Market Data Forecast, the global artificial sweeteners industry is valued at USD 7.2 billion and is presently growing at a CAGR of 5.05 per cent expected to reach USD 9.7 billion by 2028. While in India another report by Mordor Intelligence suggests that the industry is expected to grow at a CAGR of 3.2 per cent going forward.
Major players to the likes of Zydus Wellness, Sunwin Stevia International, and PureCircle among many others have dug deep into the industry offering a wide range of sugar-free products under their brand names while also collaborating with other major players selling food and beverages products. The question is will the new guidelines or emerging scientific evidence change the fate of the industry? And if yes, how should the food regulators look at this developing transition?
Experts weigh heavily on a comprehensive approach that the Indian food regulators should adopt to evaluate and regulate sugar-free products to protect the health of the consumers. “The Indian food regulators should ensure that sugar-free products are clearly labelled with accurate and transparent information about the type and amount of non-sugar sweeteners used. This will help consumers make informed choices based on their individual needs and preferences,” stated Dr Wangnoo.
Agreeing to this Dr Mithal said that the issue of non-labelled foods containing artificial sweeteners, where individuals may unknowingly consume them without checking the label or due to unclear labelling, should be addressed. Highlighting the presence of artificial sweeteners on food labels would serve as a useful warning for consumers, he said.
Dr Raj said that people should educate themselves and refrain from promotional advertisements, and brand endorsement that carries NSS in their food products.
Dr Mithal explained that another concern regarding artificial sweeteners is that people often consume them in larger quantities due to the belief that they contain few to no calories. This increased portion size, he said, offsets the advantage of lower calorie content. “A prime example is diet cola, where people may exercise caution with regular cola but become more liberal in their consumption of diet cola, thereby exposing themselves to various chemicals that may not be beneficial for their health,” Dr Mithal added.
Dr Mithal further said that like with most things in life, moderation is key, and occasional use is unlikely to have detrimental effects. “However, relying on them excessively and consuming them with every cup of tea or coffee may not be advisable,” he stated.
Medical experts concluded that while it is possible that some individuals may choose to completely avoid artificial sweeteners and opt for sugar instead, it would be unwise and potentially disastrous to encourage a widespread shift back to sugar consumption. Instead, it is advisable to gradually reduce reliance on sweeteners and work towards developing a preference for less intense sweetness.
