Explained | What is WHO’s advice on non-sugar sweeteners?

Why have NSS been linked to diabetes, cardiovascular diseases and other ailments? How did WHO arrive at this conclusion about artificial sweeteners? What is WHO’s recommendation on alternatives for natural sugars which are found in fruit and unsweetened foods? 

May 21, 2023 03:53 am | Updated 01:04 pm IST

Non-sugar sweeteners (NSS) are marketed as low or no-calorie alternatives to free sugars which aid in weight loss, and in controlling blood glucose in individuals with diabetes. File

Non-sugar sweeteners (NSS) are marketed as low or no-calorie alternatives to free sugars which aid in weight loss, and in controlling blood glucose in individuals with diabetes. File | Photo Credit: The Hindu

The story so far: The World Health Organization (WHO) issued new guidelines on May 15 advising against the use of non-sugar sweeteners (NSS) like aspartame, saccharin, stevia and other derivatives as a “healthy” alternative to sugar. In what WHO has called a ‘conditional’ guideline, it has suggested that non-sugar sweeteners should not be used as a means of achieving weight control or reducing risk of diet-related non-communicable diseases. The spotlight on NSS intensified after 2015, when WHO had said that high intake of free sugars is linked to weight gain and obesity, leading consumers to turn to NSS as an alternative.

What are non-sugar sweeteners?

Non-sugar sweeteners (NSS) are marketed as low or no-calorie alternatives to free sugars which aid in weight loss, and in controlling blood glucose in individuals with diabetes. NSS categories studied by WHO include acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, sucralose, stevia, and stevia derivatives.

Aspartame is popularly used to sweeten diet colas that claim to have ‘no sugar, no calories.’ Saccharin is used, for instance, to sweeten tea or coffee.

How did WHO conclude its findings?

The WHO analysed a total of 283 studies on the intake of NSS in adults and children. It included studies that compared NSS consumption with no or lower doses of NSS consumption as well as trials that compared the intervention with any type of sugar, placebo, plain water or no intervention. The paper, ‘Heath effects of the use of non-sugar sweeteners’, written by Magali Rios-Leyvraz and Jason Montez, states that it did not include studies that only compared one or more NSS to one another, without also comparing them with a sugar, placebo, plain water or no intervention. The outcome of the trials was that the WHO noted that ‘higher intake’ of NSS was associated with a 76% increase in risk of obesity and a 0.14 kg/m2 increase in BMI (Body Mass Index). In the final analysis, no evidence of long-term benefit on reducing body fat in adults and children was found. It warned that long-term use of NSS could lead to increased risk of Type 2 diabetes, cardiovascular diseases, chronic kidney disease and cancer.

Also read | ‘Artificial sweetener not for children, pregnant women’

Dr Ambrish Mithal, Chairman and Head, Endocrinology and Diabetes division of Max Healthcare Hospital, says we need more studies because currently the evidence studied by the WHO on NSS has been categorised into either moderate, low or very low certainty. Moderate certainty indicates that the WHO is moderately confident about the risks and that the true effect is likely to be close to the estimate, but there is a possibility that it is substantially different. The WHO has said the guideline does not apply to people with diabetes, and for dosages that are taken on prescription in small amounts. Dr. Mithal says the guidelines have been particularly issued “to prevent unfettered consumption of artificially sweetened products like chocolates and colas, as consumers tend to over-indulge in these with a perception that they may be better than sugary products.”

What are the concerns?

Health experts point out that India should take necessary steps to guide people on NSS because one in nine women and one in 25 men are obese, according to the National Family Health Survey’s fifth round conducted between 2019 and 2021. Obese people are more prone to suffer from diabetes. There are an estimated 25 million people living with pre-diabetes in India, according to WHO data.

Two or three decades ago, Dr. Mithal says he never diagnosed a 20-year-old or a 25-year-old with lifestyle-related Type 2 diabetes. “This has changed. Now for every three young patients who are Type 1 (diabetic at birth due to genetic factors), I have one patient under 25 years who has diabetes due to lifestyle and diet-related causes,” he explains. Those who are obese in their teenage years and diabetic in their twenties have a higher chance of getting heart attacks in their thirties and forties, he cautions.

A food industry player who adds artificial sweeteners to the ice-creams the company sells says: “For us, developing products that have no added sugar but taste as sweet with similar palatability is a priority.” Dr. Mithal points out that artificial sweeteners are known to have an effect on the gut and bones and that they cause bloating. “I know young patients who have at least six diet colas a day. This needs to be restricted,” he says.

What is WHO’s nutritional advice?

WHO says it is difficult to view the role of sweeteners in isolation when it comes to weight loss studies that were analysed, so it is important to note that the quality (nutritional profile) and quantity of diet are also crucial in this matrix. “Simply replacing free sugars in diet with NSS means that overall quality of the diet is largely unaffected, this is because free sugars are often found in highly processed foods and beverages with undesirable nutritional profiles,” WHO says. It instead recommends having alternative foods which are minimally processed, unsweetened foods and beverages. While analysing studies, WHO has found that weight loss in certain subjects cannot entirely be attributed to switching from sugars to NSS, as it also depended on having reduced portion size or energy intake of food.

What happens next?

Experts say WHO’s conditional guideline is such that it is less certain that desirable consequences of implementing this recommendation outweigh the undesirable consequences. This means that the Ministry of Health will have to initiate discussions among policy-makers before it decides to adopt this ‘conditional’ recommendation as a national policy.

The WHO recommends that with the help of this guidance efforts should be made, with a focus on youngsters, to tweak taste preferences and eating behaviours. It also said that potable water as a preferred replacement for beverages that are sweetened with NSS and as a mode of hydration should be incorporated.

“The guidance is useful for doctors to direct our patients to reduce consumption of NSS beverages as foodstuffs and control portion sizes. We can now be more confident in our messaging,” says Dr. Mithal.

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