Review of Recommendations for the Use of Caloric Sweeteners by Adults and Children

Alejandro Gabriel González-Garay¹, Alonso Romo-Romo² and Aurora Elizabeth Serralde-Zúñiga^3,

¹Methodology Research Unit, Instituto Nacional de Pediatría, Mexico City, Mexico

²Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias, Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

³Clinical Nutrition Unit, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Mexico City, Mexico

Cite this paper:
Alejandro Gabriel González-Garay, Alonso Romo-Romo and Aurora Elizabeth Serralde-Zúñiga. Review of Recommendations for the Use of Caloric Sweeteners by Adults and Children. Journal of Food and Nutrition Research. 2018; 6(5):313-319. doi: 10.12691/jfnr-6-5-6

Abstract

Sweeteners are natural or artificial substances that give food or a product a sweet flavour, and are divide by their nutritional value to caloric and non-caloric. Although they have been reported as safe, this review analyses the findings of various studies to obtain recommendations for their use based on their effect on energy consumption, weight, glucose and blood lipids. In addition to the compensation in energy intake, effects on appetite, hydration, preference for sweet flavours and cardiovascular function were reviewed. We searched MEDLINE, EMBASE, LILACS, and WHO ICTRP Search Portal without language restrictions. We included systematic reviews, controlled trials and observational studies comparing the administration of caloric and non-caloric sweeteners in adults and children. Two authors used AMSTAR tool, Risk of bias tool of the Cochrane Collaboration or ROBINS-I instrument for screening the studies according to their methodological quality and were included those have a low risk of bias. A reduction in blood glucose was more effective when sweetening foods with fructose compared with the use of sucrose in non-diabetic patients (–4.81 mmol/L; 95% CI –6.34 to –3.29, p<0.05). The reduction in body mass index was greater with the use of non-caloric sweeteners compared with sucrose in patients regardless of their weight (–0.3 to –0.9 kg/m², 95% CI –1.5 to 5). Although there is interest in identifying the efficacy of non-caloric sweeteners in preventing obesity and its complications, there is not sufficient evidence because of significant heterogeneity between the different studies and the lack of evidence in children. Thus, designing studies that will provide more evidence in this regard is necessary.

Keywords:
sweeteners obesity diabetes cardiovascular diseases chronic degenerative diseases infection

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References:

[1]	American Dietetic Association. “Position of the American Dietetic Association: use of nutritive and nonnutritive sweeteners”, J Am Diet Assoc, 104(2): 255-275. Feb.2004.
[2]	Valdés, S., Ruiz, M. “Edulcorantes en alimentos: aplicaciones y normativas”, Alimentación online, 13: 38-44. May.2009. [Online] Available: http://www.alimentacion.enfasis.com/notas/13134-edulcorantes-alimentos-aplicaciones-y-normativas/. [Accessed Feb. 2, 2018].
[3]	Gardner, C., Wylie-Rosett, J., Gidding, S., Johnson, R.K., Reader, D., Lichtenstein, A.H., et al. “Nonnutritive Sweeteners: Current Use and Health Perspectives: A Scientific Statement from the American Heart Association and the American Diabetes Association”, Circulation, 126(4): 509-519. Jul.2012.
[4]	González A. “Posición de consenso sobre las bebidas con edulcorantes no calóricos y su relación con la salud”, Rev Mex Cardiol, 24(2): 55-68. Apr.2013.
[5]	Magnuson, B.A., Burdock, G.A., Doull, J., Kroes, R.M., Marsh, G.M., Pariza, M.W., et al. “Aspartame: a safety evaluation based on current use levels, regulations, and toxicological and epidemiological studies”, Crit Rev Toxicol, 37 (8): 629-727. Oct.2007.
[6]	Bloomgarden Z. “Nonnutritive sweeteners, fructose and other aspects of diet”, Diabetes Care, 34: e46-51. May.2011.
[7]	Anton, S.D., Martin, C.K., Han, H., Coulon, S., Cefalu, W.T., Geiselman, P., et al. “Effects of Stevia, aspartame, and sucrose on food intake, satiety, and postprandial glucose and insulin levels”, Appetite, 55: 37-43. Aug.2010.
[8]	US Food and Drug Administration. Food Additives & Ingredients - Additional Information about High-Intensity Sweeteners Permitted for use in Food in the United States [Online]. Center for Food Safety and Applied Nutrition. Available: http://www.fda.gov/Food/IngredientsPackagingLabeling/FoodAdditivesIngredients/ucm397725.htm [Accesed Mar.18, 2018].
[9]	Chattopadhyay, S., Raychaudhuri, U., Chakraborty, R. “Artificial sweeteners - a review”, J Food Sci Technol, 51(4): 611-621. Apr.2014.
[10]	Warrington, S., Lee, C., Otabe, A., Narita, T., Polnjak, O., Pirags, V., Krievins, D. “Acute and multiple-dose studies to determine the safety, tolerability, and pharmacokinetic profile of advantame in healthy volunteers”, Food Chem Toxicol, 49: S77-83. Nov.2011.
[11]	Li, X.E., Lopetcharat, K., Drake, M.A. “Parents' and children's acceptance of skim chocolate milks sweetened by monk fruit and stevia leaf extracts”, J Food Sci, 80(5): S1083-1092. May.2015.
[12]	Academy of Nutrition and Dietetics. “Position of the Academy of Nutrition and Dietetics: Use of Nutritive and Nonnutritive Sweeteners”, J Acad Nutr Diet, 112: 739-758. May.2012.
[13]	Butchko, H.H., Stargel, W.W., Comer, C.P, Mayhew, D.A., Benninger, C., Blackburn, G.L., et al. “Aspartame: review of safety”, Regul Toxicol Pharmacol, 35:S1-93. Apr.2002.
[14]	Pope, E., Koren, G., Bozzo, P. “Sugar substitutes during pregnancy”, Can Fam Physician, 60(11): 1003-1005. Nov.2014.
[15]	Romo-Romo, A., Aguilar-Salinas, C.A., Gómez-Díaz, R.A., Brito-Córdova, G.X., Gómez-Velasco, D.V., López-Rocha, M.J., et al. “Non-Nutritive Sweeteners: Evidence on their Association with Metabolic Diseases and Potential Effects on Glucose Metabolism and Appetite”, Rev Invest Clin, 69(3): 129-138. May-Jun.2017.
[16]	Pepino, M.Y., Tiemann, C.D., Patterson, B.W., Wice, B.M., Klein, S. “Sucralose affects glycemic and hormonal responses to an oral glucose load”, Diabetes Care, 36(9): 2530-5. Sep.2013.
[17]	Brown, R.J., Walter, M., Rother, K.I. “Effects of diet soda on gut hormones in youths with diabetes”, Diabetes Care, 35(5): 959-64. May.2012.
[18]	12/18Secretaría de Economía de México. Análisis de la situación económica, tecnológica y de política comercial del sector edulcorantes en México. [Online]. Available: http://www.economia.gob.mx/files/comunidad_negocios/industria_comercio/Analisis_Sectorial_Mercado_Edulcorantes.pdf [Accesed Mar. 18, 2018].
[19]	Mattes, R., Popkin, B. “Nonnutritive sweetener consumption in humans: effects on appetite and food intake and their putative mechanisms”, Am J Clin Nutr, 89: 1-14. Apr.2009.
[20]	Romo-Romo, A., Almeda-Valdés, P., Brito-Córdova, G.X., Gómez-Pérez, F.J. “[Prevalence of nonnutritive sweeteners consumption in a population of patients with diabetes in Mexico]”, Gac Med Mex, 153(1): 61-74. Jan.2017.
[21]	Wiebe, N., Padwal, R., Field, C., Marks, S., Jacobs, R., Tonelli, M. “A systematic review on the effect of sweeteners on glycemic response and clinically relevant outcomes”, BMC Medicine, 9: 123. Nov.2011.
[22]	Sievenpiper, J.L., Carleton, A.J., Chatha, S., Jiang, H.Y., de Souza, R.J., Beyene, J., et al. “Heterogeneous effects of fructose on blood lipids in individuals with type 2 diabetes: systematic review and meta-analysis of experimental trials in humans”, Diabetes Care, 32 (10): 1930-1937. Oct.2009.
[23]	Livesey, G., Taylor, R. “Fructose consumption and consequences for glycation, plasma triacylglycerol, and body weight: meta-analyses and meta-regression models of intervention studies”, Am J Clin Nutr, 88 (5): 1419-1437. Nov.2008.
[24]	De Koning, L., Malik, V.S., Rimm, E.B., Willett, W.C., Hu, F.B. “Sugar-sweetened and artificially sweetened beverage consumption and risk of type 2 diabetes in men”, Am J Clin Nutr, 93: 1321-1327. Jun.2011.
[25]	Franz, M.J., Powers, M.A., Leontos, C., Holzmeister, L.A., Kulkarni, K., Monk, A.W., et al. “The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults”, J Am Diet Assoc, 110: 1852-1889. Dec.2010.
[26]	Romo-Romo, A., Aguilar-Salinas, C.A., Brito-Córdova, G.X., Gómez Díaz, R.A., Vilchis-Valentín, D., Almeda-Valdes P. “Effects of the Non-Nutritive Sweeteners on Glucose Metabolism and Appetite Regulating Hormones: Systematic Review of Observational Prospective Studies and Clinical Trials”, PLoS One, 11(8): e0161264. Aug.2016.
[27]	Raben, A., Vasilaras, T.H., Møller, A.C., Astrup, A. “Sucrose compared with artificial sweeteners: different effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects”, Am J Clin Nutr, 76:721-729. Oct.2002.
[28]	Suez, J., Korem, T., Zeevi, D., Zilberman-Schapira, G., Thaiss, C.A., Maza, O., et al. “Artificial sweeteners induce glucose intolerance by altering the gut microbiota”, Nature, 514(7521): 181-186. Oct.2014.
[29]	Rogers, P.J., Hogenkamp, P.S., de Graaf, C., Higgs, S., Lluch, A., Ness, A.R., et al. “Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies”. Int J Obes (Lond), 40(3): 381-394. Mar.2016.
[30]	Kun, E., Horvath, I. “The influence of oral saccharin on blood sugar”, Proc Soc Exp Biol, 66: 175-179. 1947.
[31]	Yamazaki, M., Sakaguchi, T. “Effects of D-glucose anomers on sweetness taste and insulin release in man”, Brain Res Bull, 17: 271-274. Aug.1986.
[32]	Fitzsimons, T.J., Le Magnen, J. “Eating as a regulatory control of drinking in the rat”, J Comp Physiol Psychol, 67: 273-283. 1969.
[33]	McKinley, M.J., Johnson, A.K. “The physiological regulation of thirst and fluid intake”, News Physiol Sci, 19: 1-6. Feb.2004.
[34]	Miller, P.E., Perez, V. “Low-calorie sweeteners and body weight and composition: a meta-analysis of randomized controlled trials and prospective cohort studies”, Am J Clin Nutr, 100(3): 765-777. Sep.2014.
[35]	Sievenpiper, J.L., Souza, R.J., Mirrahimi, A., Yu, M.E., Carleton, A.J., Beyene, J., et al. “Effect of fructose on body weight in controlled feeding trials: a systematic review and meta-analysis”, Ann Intern Med, 156 (4): 291-304. Feb.2012.
[36]	Bodearmel, S.J., Wyatt, H.R., Stroebele, N., Smith, S.M., Ogden, L.G., Hill, J.O. “Small changes in dietary sugar and physical activity as an approach to preventing excessive weight gain: the America on the Move family study”, Pediatrics, 120: e869–79. Oct.2007.
[37]	Ebbeling, C.B., Feldman, H.A., Osganian, S.K., Chomitz, V.R., Ellenbogen, S.J., Ludwig, D.S. “Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study”, Pediatrics, 117: 673-680. Mar.2006.
[38]	Fung, T.T., Malik, V., Rexrode, K.M., Manson, J.E., Willett, W.C., Hu, F.B. “Sweetened beverage consumption and risk of coronary heart disease in women”, Am J Clin Nutr, 89: 1037-1042. Apr.2009.
[39]	Lin, J., Curhan, G.C. “Associations of sugar and artificially sweetened soda with albuminuria and kidney function decline in women”, Clin J Am Soc Nephrol, 6: 160-166. Jan.2011.
[40]	Azad, M.B., Abou-Setta, A.M., Chauhan, B.F., Rabbani, R., Lys, J., Copstein, L., et al. “Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies”, CMAJ, 189(28): E929-E939. Jul.2017.
[41]	Azarpazhooh, A., Limeback, H., Lawrence, H.P., Shah, P.S. “Xylitol for preventing acute otitis media in children up to 12 years of age”, Cochrane Database Syst Rev, 8: CD007095. Aug.2016.