MADRID — A scientific review by researchers in Spain confirms the negative influence of artificial sweeteners on several primary cardiovascular risk factors. It also shows evidence that these products are not beneficial for controlling excess weight.
Francisco Gómez-Delgado, MD, PhD, and Pablo Pérez-Martínez, MD, PhD, are members of the Spanish Society of Arteriosclerosis and of the Spanish Society of Internal Medicine. They have coordinated an updated review of the leading scientific evidence surrounding artificial sweeteners: evidence showing that far from positively affecting our health, they have "negative effects for the cardiometabolic system."
The paper, published in Current Opinion in Cardiology, delves into the consumption of these sweeteners and their negative influence on the development of obesity and of several of the most important cardiometabolic risk factors (hypertension, dyslipidemia, and diabetes).
Globalization and the increase in consumption of ultraprocessed foods have led to a need for greater knowledge on the health impacts of certain nutrients such as artificial sweeteners (nutritive and nonnutritive). This review aims to analyze their role and their effect on cardiometabolic and cardiovascular disease risk.
Cardiovascular Risk
The detrimental effects of a high-calorie, high-sugar diet have been well established. For this reason, health authorities recommend limiting sugar consumption. The recommendation has led the food industry to develop different artificial sweeteners with specific properties, such as flavor and stability (nutritive artificial sweeteners), and others aimed at limiting sugar in the diet (nonnutritive artificial sweeteners). Recent evidence explores the influence of these two types of artificial sweeteners on cardiovascular disease risk through risk factors such as obesity and type 2 diabetes, among others.
Initially, the consumption of artificial sweeteners was presented as an alternative for reducing calorie intake in the diet as an option for people with excess weight and obesity. However, as this paper explains, the consumption of these artificial sweeteners favors weight gain because of neuroendocrine mechanisms related to satiety that are abnormally activated when artificial sweeteners are consumed.
Weight Gain
On the other hand, evidence shows that consuming artificial sweeteners does not encourage weight loss. "Quite the contrary," Pérez-Martínez, scientific director at the Maimonides Biomedical Research Institute in Córdoba and internist at the University Hospital Reina Sofia in Córdoba, told Medscape Spanish Edition. "There is evidence showing weight gain resulting from the effect that artificial sweetener consumption has at the neurohormonal level by altering the mechanisms involved in regulating the feeling of satiety."
However, on the basis of current evidence, sugar cannot be claimed to be less harmful. "What we do know is that in both cases, we should reduce or remove them from our diets and replace them with other healthier alternatives for weight management, such as eating plant-based products or being physically active."
Confronting Ignorance
Nonetheless, these recommendations are conditional, "because the weight of the evidence is not extremely high, since there have not been a whole lot of studies. All nutritional studies must be viewed with caution," Manuel Anguita, MD, PhD, told Medscape Spanish Edition. Anguita is department head of Clinical Cardiology at the University Hospital Reina Sofia in Córdoba and past president of the Spanish Society of Cardiology.
"It's something that should be included within the medical record when you're assessing cardiovascular risk. In addition to identifying patients who use artificial sweeteners, it's especially important to emphasize that it's not an appropriate recommendation for weight management." There are other much healthier measures, like moderate exercise and following diets like the Mediterranean diet.
Explaining why this research is valuable, he said, "It's generally useful because there's ignorance not only in the population but among physicians as well [about] these negative effects of sweeteners."
Diabetes and Metabolic Syndrome
Artificial sweeteners cause significant disruptions in the endocrine system, leading our metabolism to function abnormally. The review revealed that consuming artificial sweeteners raises the risk for type 2 diabetes by between 18% and 24% and raises the risk for metabolic syndrome by up to 44%.
Gómez-Delgado, who is an internal medicine specialist at the University Hospital of Jaen and first author of the study, discussed the deleterious effects of sweeteners on metabolism with Medscape Spanish Edition. "On one hand, neurohormonal disorders impact appetite, and the feeling of satiety is abnormally delayed." On the other hand, "they induce excessive insulin secretion in the pancreas," which in the long run, encourages metabolic disorders that lead to diabetes. Ultimately, this process produces what we know as "dysbiosis, since our microbiota is unable to process these artificial sweeteners." Dysbiosis triggers specific pathophysiologic processes that negatively affect cardiometabolic and cardiovascular systems.
No Differences
Regarding the type of sweetener, Gómez-Delgado noted that currently available studies assess the consumption of special dietary products that, in most cases, include various types of artificial sweeteners. "So, it's not possible to define specific differences between them as to how they impact our health." Additional studies are needed to confirm this effect at the cardiometabolic level and to analyze the different types of artificial sweeteners individually.
"There's enough evidence to confirm that consuming artificial sweeteners negatively interferes with our metabolism — especially glucose metabolism — and increases the risk of developing diabetes," said Gómez-Delgado.
High-Sodium Drinks
When it comes to the influence of artificial sweeteners on hypertension, "there is no single explanation. The World Health Organization already discussed this issue 4-5 years ago, not only due to their carcinogenic risk, but also due to this cardiovascular risk in terms of a lack of control of obesity, diabetes, and hypertension," said Anguita.
Another important point "is that this is not in reference to the sweeteners themselves, but to soft drinks containing those components, which is where we have more studies," he added. There are two factors explaining this increase in hypertension, which poses a problem at the population level, with medium- to long-term follow-up. "The sugary beverages that we mentioned have a higher sodium content. That is, the sweeteners add this element, which is a factor that's directly linked to the increase in blood pressure levels." Another factor that can also influence blood pressure is "the increase in insulin secretion that has been described as resulting from sweeteners. In the medium- and long-term, this is associated with increased blood pressure levels."
Cardiovascular Risk Factor?
Are artificial sweeteners considered to be a new cardiovascular risk factor? "What they really do is increase the incidence of the other classic risk factors," including obesity, said Anguita. It has been shown that artificial sweeteners don't reduce obesity when used continuously. Nonetheless, "there is still not enough evidence to view it in the same light as the classic risk factors," added Anguita. However, it is a factor that can clearly worsen the control of the other factors. Therefore, "it's appropriate to sound an alarm and explain that it's not the best way to lose weight; there are many other healthier choices."
"We need more robust evidence to take a clear position on the use of this type of sweetener and its detrimental effect on health. Meanwhile, it would be ideal to limit their consumption or even avoid adding artificial sweeteners to coffee or teas," added Pérez-Martínez.
Regulate Consumption
Pérez-Martínez mentioned that the measures proposed to regulate the consumption of artificial sweeteners and to modify the current legislation must involve "minimizing the consumption of these special dietary products as much as possible and even avoiding adding these artificial sweeteners to the foods that we consume; for example, to coffee and tea." On the other hand, "we must provide consumers with information that is as clear and simple as possible regarding the composition of the food they consume and how it impacts their health."
However, "we need more evidence to be able to take a clear position on what type of sweeteners we can consume in our diet and also to what extent we should limit their presence in the foods we consume," said Pérez-Martínez.
Last, "most of the evidence is from short-term observational studies that assess frequencies and patterns of consumption of foods containing these artificial sweeteners." Of course, "we need studies that specifically analyze their effects at the metabolic level as well as longer-term studies where the nutritional follow-up of participants is more accurate and rigorous, especially when it comes to the consumption of this type of food," concluded Gómez-Delgado.
Follow Javier Cotelo, MD, of Medscape Spanish Edition on Twitter @Drjavico.
This article was translated from the Medscape Spanish Edition.