Diabetes Core Update – Nonnutritive Sweeteners Scientific Statement

Podcast: Diabetes Core Update
Date: August 7, 2012
Presented by: Dr. Neil Skolnik (Host); Dr. Judith Wiley Rosett (Guest, Co-Chair of the Scientific Statement Committee)
Episode Theme: Review and discussion of the new scientific statement on nonnutritive sweeteners issued by the American Heart Association (AHA) and the American Diabetes Association (ADA), focusing on current use, safety, efficacy, and implications for clinical practice.

Episode Overview

This episode centers on a recent joint scientific statement from the AHA and ADA regarding nonnutritive sweeteners (NNS), also known as artificial or low-/non-caloric sweeteners. Dr. Neil Skolnik hosts a conversation with Dr. Judith Wiley Rosett, who co-chaired the committee behind the statement. They discuss key findings, address common clinical questions about safety and efficacy, and provide guidance for healthcare professionals advising patients on the use of NNS for managing sugar intake, weight, and cardiometabolic risk.

Key Discussion Points and Insights

1. Definition and Scope of Nonnutritive Sweeteners

• What are NNS?
  • “Non nutritive sweeteners are characterized by being very low in calories and very intensely sweet, often several hundred times as sweet as regular sugar.” – Dr. Judith Wiley Rosett [02:59]
  • Other terms: non-caloric sweeteners, artificial sweeteners.
• Which sweeteners are included?
  • Six sweeteners reviewed: acesulfame K, aspartame, neotame, saccharin, sucralose, stevia. [03:14]

2. Safety of Nonnutritive Sweeteners

• Regulatory review:
  • “The committee took the position that the Federal Drug Administration had reviewed the safety of all six sweeteners. … We limited the statement to ones that had been approved by or had been reviewed by the FDA.” – Dr. Judith Wiley Rosett [03:45]
• Public perception:
  • “A lot of consumers worry…their concern and worry about safety is less when asked about specific sweeteners. So it may be the word ‘artificial’ [that triggers concern].” – Dr. Judith Wiley Rosett [04:03]

3. Prevalence and Patterns of Use

• NNS usage has nearly doubled since 1980.
• Usage statistics:
  • Daily use: ~15% of the U.S. population uses NNS [04:24]
  • “One out of every four women over the age of 18 on a given day uses a diet soda product…about one out of every five men…about one out of every ten children.” – Dr. Judith Wiley Rosett [04:31]
  • Consumption in solid foods far less frequent than in beverages.

4. Intended Benefits: Reducing Added Sugar and Calories

• Replacement strategy: Replacing sugar-sweetened beverages with NNS-sweetened alternatives intuitively should decrease caloric intake.
• The “compensatory energy intake” phenomenon:
  • “If we consume a diet product or a diet soda, we often feel that we can be freer about what else we consume.” – Dr. Judith Wiley Rosett [05:59]
  • Example: Saving calories with a diet drink may lead to consuming more elsewhere (e.g., cheesecake with coffee).
  • “We compensate less for beverages than we do for solid foods.” [06:49]
• Net calorie reduction:
  • “It looks like that we compensate for about a third of what we have saved.” – Dr. Judith Wiley Rosett [07:20]
  • Calorie savings are partially offset by increased intake from other sources, especially with solid foods.

5. Effects on Body Weight

• Research findings are inconsistent, but overall:
  • “There is a meaningful weight loss, which is quite small, basically less than half a pound a week if you take the aggregate of all the different studies. But the effects seem to be better in people who are overweight.” – Dr. Judith Wiley Rosett [07:57]
• Study limitations:
  • More pronounced in overweight individuals, possibly due to more diligent use of NNS [08:30]
  • Blinding and study design challenges noted.

6. Cardiovascular Risk Factors

• Cross-sectional and observational association:
  • High NNS consumption is linked to higher prevalence of metabolic syndrome, but causality is unclear.
  • “There have been no experimental studies where [NNS have] been used and somebody develops [metabolic syndrome]. … It gives us reason for caution not to say it’s a blanket cure for worrying about these areas.” – Dr. Judith Wiley Rosett [09:05]
• Confounding by indication:
  • Often, people at higher risk for cardiometabolic disease are more likely to use NNS, complicating the interpretation. [09:57]

7. Impact on Glycemia and Diabetes

• Acute effects:
  • “In terms of immediate postprandial effects…there's much less of an effect on [blood] glucose [with diet soda vs. regular soda].” – Dr. Judith Wiley Rosett [10:25]
• Long-term studies:
  • No meaningful improvement in glycemic control found in available studies, likely again related to compensation behavior.
  • “It may take a very conscious effort to get better [blood] glucoses with using nonnutritive sweetened products.” [10:56]

8. Final Committee Recommendations

• Key takeaways:
  • The evidence is challenging and somewhat conflicting, particularly due to compensation effects and study limitations.
  • “The first recommendation is to get more research, focusing on…energy compensation, mechanisms of action, impact on body weight and glycemic control, and better assessments of intake.” – Dr. Judith Wiley Rosett [11:20]
• Practical advice:
  • “Monitor food intake carefully when consuming non-nutrient sweeteners—just make sure that the intended benefit is [achieved].” – Dr. Judith Wiley Rosett [11:49]

Notable Quotes & Memorable Moments

• On consumer compensation:
  • “If we consume a diet product or a diet soda, we often feel that we can be freer about what else we consume.” – Dr. Judith Wiley Rosett [05:59]
• Calorie savings reality check:
  • “We compensate for about a third of what we have saved.” – Dr. Judith Wiley Rosett [07:20]
• Summary of evidence:
  • “The effects seem to be better in people who are overweight and that may be because they are more conscientiously using the…nonnutritive sweeteners.” – Dr. Judith Wiley Rosett [08:30]
• Caution on observational data:
  • “It gives us reason for caution not to say it’s a blanket cure for worrying about these areas.” – Dr. Judith Wiley Rosett [09:49]
• Guidance for clinicians:
  • “Monitor food intake carefully…just make sure that the intended benefit is [achieved].” – Dr. Judith Wiley Rosett [11:49]

Timestamps of Major Segments

• [00:36] Episode introduction, background on NNS, introduction of guest
• [02:59] Definition and types of nonnutritive sweeteners
• [03:45] Safety and FDA review
• [04:24] Patterns and prevalence of use in the US
• [05:59] Compensatory eating and calorie savings
• [07:20] Actual impact on caloric intake
• [07:57] Research on body weight impact
• [09:05] Associations with metabolic syndrome and cardiovascular risk
• [10:25] Effect on glycemic response and diabetes outcomes
• [11:20] Committee conclusions and practical recommendations

Summary

This episode provides a clinician-focused overview of the current evidence on nonnutritive sweeteners, highlighting their FDA-reviewed safety, widespread use, and nuanced health impacts. While NNS can reduce sugar intake and potentially aid weight management, their net benefit is smaller than expected due to compensatory behaviors. The data show modest weight benefit, particularly in overweight individuals, but evidence for improving glycemia or cardio-metabolic risk is limited and inconclusive. The AHA/ADA statement encourages more research and emphasizes the need for careful dietary monitoring to ensure intended benefits are realized in real-world clinical practice.