However, given the potential risk of confusion, one expert believes that it is impossible to draw strong conclusions from the data.
Artificial sweeteners used as sugar substitutes in foods and drinks may be associated with an increased risk of cardiovascular events and strokes, data from the large NutriNet-Santé study of French adults suggest.
The analysis, conducted by doctoral student Charlotte Debras (University Sorbonne Paris Nord, France) and published in the BMJassessed dietary intake of artificial sweeteners (from beverages to a variety of food products and table-top sweeteners) and measures of individual sweetener consumption (aspartame, acesulfame potassium, and sucralose).
“In the NutriNet-Sante cohort, total consumption of artificial sweeteners was associated with an increased risk of overall cardiovascular and cerebrovascular disease,” the researchers write. “Aspartame consumption was associated with an increased risk of cerebrovascular events, and acesulfame potassium and sucralose were associated with an increased risk of coronary heart disease.”
As for how artificial sweeteners might lead to adverse cardiovascular and cerebrovascular events, Debras and colleagues say part of the association might be related to body weight, noting that some prospective cohort studies have reported links between consumption of artificially sweetened beverages and an increased risk of obesity or weight gain.
However, John L. Sievenpiper, MD, PhD (St. Michael’s Hospital, Toronto, Canada), who was not involved in the study but did research on artificial sweeteners and health, said that one problems with the interpretation of epidemiological observations is that the data presents a high risk of reverse causation.
“Basically, that means people can take artificial sweeteners as a way to mitigate risk: to lose weight, for example, or to maintain a healthier body weight, and they do so because they’re at risk. This background risk is usually what you see with the higher event rates in people consuming sweeteners,” he said.
People may take artificial sweeteners as a way to mitigate risk: to lose weight, for example, or to maintain a healthier body weight. John L. Sievenpiper
The researchers acknowledge that while they cannot rule out reverse causation, they do not believe it can fully explain the observed associations. Their analysis excluded cardiovascular events occurring during the first 2 years of follow-up and adjusted for baseline body mass index (BMI), dieting, and weight change during follow-up, “which does not ‘did not significantly change the results,’ they said. write.
In a recent systematic review and meta-analysis, Sievenpiper and colleagues addressed sources of bias in studies of artificial sweeteners and came to a different conclusion than the NutriNet-Santé researchers. There, after adjusting for confounders, people drinking diet, low-calorie, or no-calorie beverages had a lower risk of cardiometabolic outcomes, including lower weight, body fat, cardiovascular events, and total mortality when they consumed them as substitutes for sugary drinks. Additionally, no impact on cardiovascular events was observed when beverages were replaced with plain water.
Most common aspartame
For the new study, Debras and colleagues analyzed data from 103,388 participants (mean age 42; 80% female) recruited from the general French population and enrolled in NutriNet-Santé, which examines nutrition and health more broadly. . Upon registration, participants complete detailed online questionnaires about their diet (including 24-hour food records), personal and family medical history, height and weight, lifestyle, and socio-demographics. , as well as their physical activity levels (including minutes of activity per week). All information from the questionnaires was used to assess dietary intakes and consumption of artificial sweeteners.
Consumption of sugar substitutes was reported by 37% of all participants, with an average daily intake of 42.46 mg (range 7.46 to 77.62 mg/day), which according to the authors is equivalent to an individual sachet of sweetener or to 100 mL of a carbonated diet drink. The most commonly consumed sweetener was aspartame (58%), followed by acesulfame potassium (29%) and sucralose (10%), with other artificial sweeteners such as saccharin and steviol glycoside , extracts from the stevia plant, representing the remaining 3. %.
Daily intake ranged from a minimum of 7.46 mg/day to a maximum of 77.62 mg/day. Compared to participants who reported not using sugar substitutes, those with the highest consumption were younger, had a higher BMI, were more likely to smoke, were less physically active, and were more likely to diet for losing weight. Heavy users of artificial sweeteners also had lower total calorie intake, drank less alcohol, and ate fewer saturated and polyunsaturated fats, fiber, carbohydrates, fruits, and vegetables. They also had higher intakes of sodium, red and processed meat, dairy products and drinks with no added sugar.
Over 9 years of follow-up, there were 730 CV events and 777 TIAs and strokes among the participants. CV events occurred at a rate of 314 per 100,000 person-years in non-consumers of artificial sweeteners and 346 per 100,000 in those with the highest daily consumption levels.
Compared to non-consumers, those who consumed a lot of aspartame had an increased risk of cerebrovascular events (P = 0.02). Similarly, people with high intakes of acesulfame potassium and sucralose had an increased risk of CVD compared to nonusers (P = 0.02 and P = 0.05, respectively).
Debras and his colleagues say other underlying mechanisms could explain their findings, including metabolic syndrome, which has been linked to drinking artificially sweetened beverages in several studies. It is also possible, they add, that glucose and energy homeostasis are impaired by artificial sweeteners and that the gut microbiota is also affected, leading to increased glucose intolerance.
“Vascular dysfunction, which contributes to the appearance and development of CVD, after the ingestion of artificial sweeteners, has been observed in experimental (rodent models) and in vitro (human cell model) studies, and could also play a role in CVD risk,” the researchers write. They also note that one study has suggested that the consumption of artificial sweeteners may be associated with increased inflammation.
Sievenpiper said that while the researchers adjusted for many important known confounders, there are likely many more unknown confounders at play.
This study has an advantage [over some others] because they have people reporting what they are consuming. They recorded the actual food and the amount based on a 24-hour recall to get individual sweetener usage, which I think was helpful,” he said. “But you still have the problem that most sweeteners aren’t used in isolation. They’re in food, they’re in drinks, . . . so looking at sweeteners individually may not get us important interactions needed for causation.
Finally, he cautioned that communicating to the general public about epidemiological studies can be tricky.
“If the message people are getting is to go back to sugary drinks, it’s pretty clear that that wouldn’t be a good thing,” Sievenpiper said. “Ideally, you wouldn’t want people to drink sugary or artificially sweetened beverages. We prefer that they drink water and unsweetened beverages like tea or coffee. But many people will want a sweet substitute, and that’s probably better [based on the totality of evidence] that they drink the low-calorie, zero-calorie artificially sweetened beverage compared to the sugary beverage.