Nonnutritive Sweeteners Scientific Statement - Diabetes Core Update

Summary

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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.

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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.

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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]

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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]

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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

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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.

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Transcript

[A]

Welcome to the American Diabetes Association Core Update. A new scientific statement from the American Heart association and the American Diabetes association was recently issued on non nutritive current use and health perspectives. Here with us today will be our usual host, Dr. Neal Skolnick, as well as one of the co chairs of the scientific statement committee, Dr. Judith Wiley Rosette. Dr. Skolnick.

[B]

Hello, I'm Dr. Neal Skolnick for the American Diabetes Association. Today we're going to be talking about non nutritive sweeteners, their current use in health Perspectives from a scientific statement from the American Heart association and the American Diabetes association that was published online the second week of July 2012 and is going to be published in both Diabetes Care and circulation. The context in which this scientific statement is occurring is a clear, straightforward one. Americans eat too many sugar sweetened foods and beverages. In fact, this was discussed in an American Heart association scientific statement in 2009 which concluded that Americans eat a good deal more added sugar as a part of their ordinary daily intake than is recommended for a healthy diet. Non nutritive sweeteners, also called very low calorie sweeteners or artificial sweeteners, have a higher intensity of sweetness per gram than caloric sweeteners such as sucrose, corn syrup, fruit juice concentrates or other sugars. The present statement from the American Heart association and the American Diabetes association addresses the potential role of these non nutritive sweeteners in helping Americans decrease their added sugar intake. Joining us today in our discussion is the co chair of the committee that developed the scientific statement, Dr. Judith Wiley Rosette. Dr. Wiley Rosett is professor and Division Head for Health Promotion and Nutrition Research in the Department of Epidemiology and Population Health at the Albert Einstein College of medicine. Welcome Dr. Wiley Rosette.

[C]

Thank you. It's a pleasure to be here.

[B]

We only have about 20 minutes to discuss the scientific statement, so we'll restrict our discussion to highlights of the guidelines and encourage listeners to go to the American Diabetes association [e-mail] to download and read the full statement. For Our first question, Dr. Wiley Rosette, could you define for us non nutritive sweeteners and specifically go over which sweeteners we're talking about?

[C]

Non nutritive sweeteners are characterized by being very low in calories and very intensely sweet, often several hundred times as sweet as regular sugar and other names for the category would be non nutritive sweeteners or non caloric sweeteners or artificial sweeteners. The six specific sweeteners that are Addressed in the statement are sulfame K, aspartame, neotame, saccharin, sucralose and stevia.

[B]

Thanks. I'm often asked about the safety of non nutritive sweeteners, and while I know that this wasn't the emphasis of the scientific statement, what was the position of the committee regarding safety of non nutritive sweeteners?

[C]

The committee took the position that the Federal Drug Administration had reviewed the safety of all six sweeteners. So we limited the statement to ones that had been approved by or had been reviewed by fda. And interestingly, a lot of consumers worry if the question is just asked about specific sweeteners, their concern and worry about safety is less. So it may be the word artificial.

[B]

Okay, that's interesting. Can you give us some more details about the importance of non nutritive sweeteners to the American public and their frequency of use?

[C]

Well, the intake has almost doubled since 1980 and that may be because at that time saccharin was the only product on the market and about 15% of the population uses non nutritive sweeteners daily. But one out of every four women over the age of 18 on a given day uses a diet soda product or a diet beverage product and about one out of every five men. But it's about one out of every 10 children. And the consumption of non nutritive sweeteners in solid foods is much less interesting.

[B]

So clearly very important. One of the important goals that people have in using non nutritive sweeteners is to reduce their caloric intake from the use of added sugars in foods and beverages. It seems intuitive that if every day you replace 100 calories of a regular sweetened beverage with a 0 calorie non nutritive sweetened beverage, you would decrease your caloric intake by 100 calories a day. And we know that over time, with about 3,500 calories per pound, that might equal a pound loss compared to what you'd otherwise have over every 35 days. But things are seldom this simple. Can you explain to our listeners the concept of compensatory energy intake and how that affects the calculation of calories saved with non nutritive beverages and foods?

[C]

I think the easiest way to think of it is make an analogy to money. If you when we see a sale item, we're saying we're saving X amount of dollars, but we're actually spending money. And when it comes to food, if we consume a diet product or a diet soda, we often feel that we can be freer about what else we consume. And a good example of that might be if somebody consumes cheesecake and then has coffee with non nutritive sweeteners to sweeten it, they have gotten many more calories than they would have if they used regular sugar in the coffee. So that it takes much more conscious effort. And whether this compensation is. It goes on a little bit more physiologically because we seem to compensate less for beverages than we do for solid foods. And it may be that the solid foods aren't as satisfying as they would have been if they had been the full. So it's an area that we don't know that much about, but we know it's happening.

[B]

Yeah. Is there an estimate of how much? So that is, if you take away 100 calories by using a non nutritive sweetener in a beverage instead of a sweetened beverage, do you tend to completely compensate, add 100 calories in that cheeseburger or do you end up saving something?

[C]

It looks like that we compensate for about a third of what we have saved. So that it's really hard to look at because the studies vary a bit. We compensate much more again with the solid food products.

[B]

Okay, interesting. So we do save some calories, but not the amount of calories that we would anticipate saving. So that leads to my next question, which is what is the effect of non nutritive sweeteners on body weight?

[C]

The research studies have been a little bit inconsistent, but it looks like there's a modest effect on weight such that 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 and that may be because they are more conscientiously using the artificial, the non nutritive sweeteners.

[B]

Okay, so the effect is more in people who are overweight.

[C]

It looks like again, there tend to be very few studies and trying to blind the studies or mask it so that people don't know what they're doing. The one study that was the most impressive was actually done in children and they got water or diet sodas so that they may have known that they were in the special study group, the experimental group, rather than in the comparison group.

[B]

Interesting. How about the effect of non nutritive sweeteners on traditional cardiovascular risk factors?

[C]

The non nutritive sweeteners, basically they're sensitivity. If you look cross sectionally, people who have metabolic syndrome tend to have higher intake or more likely to consume non nutritive sweeteners. And there are studies that suggest that people who consume nitrogen nutrient sweeteners may develop metabolic syndrome, which basically tends to be higher triglycerides, some insulin resistance or a little bit of elevation of glucose, higher blood pressure. But the people who are at risk for these may be the people who are consuming. So we can't consider this cause and effect. There have been no experimental studies where they've been used and somebody develops these. It's been more observational studies, but it gives us reason for caution not to say it's a blanket cure for worrying about these areas.

[B]

It's a hard area to study because any observational studies are always difficult because you don't know if the effect is that of a confounding variable as you described, that people who are overweight tend to, or who will develop metabolic syndrome will tend to try not to by having non nutritive sweeteners. So it's unclear where the cause and effect is.

[C]

Exactly.

[B]

How about effect on diabetes and glycemic.

[C]

Response in terms of immediate postprandial effects consuming a product, the immediate effect is lower. So if you consume a regular soda or a diet soda, any patient who has diabetes can tell you that there's much less of an effect on their blood glucose. However, in studies over time, the results have not been impressive in terms of improvement in glycemia. And that may again get back to the concept of compensating. And so again, it may take a very conscious effort to get better glucoses with using non nutritive sweetened products.

[B]

Okay, so in summary, after going over all of these details, and it seems like the evidence review is a challenging one because there's observational trials, there's some conflicting information out there. What did the committee conclude and recommend?

[C]

Well, interestingly, because there was so much conflicting information, the first recommendation is to get more research and focusing on particularly around energy compensation mechanisms of action and looking at the impact on body weight and glycemic control and better assessments of intake. However, there were recommendations in terms of intake which were basically monitoring food intake carefully when consuming non nutrient sweeteners. Just make sure that the intended benefit is.

[B]

Well, thank you, Dr. Wiley. Rosette. That was a wonderful overview of the scientific statement on non nutritive sweeteners for the American diabetes association. I'm Dr. Neal Skolnick and thank you for listening.