Session : Impact of Sugars, Non-Nutritive and Natural Sweeteners on Cardiometabolic Health

We are confronted with a rapidly increasing pandemic of obesity, diabetes, and their downstream complications. Dietary guidelines and clinical practice guidelines for obesity and diabetes have responded with universal recommendations to reduce sources of added and free sugars to <5-10% of energy with a particular focus on sugar-sweetened beverages. Non-nutritive sweeteners represent an important strategy to achieve these public health targets. There is, however, an emerging concern that non-nutritive sweeteners (NNS) may not have the intended benefits and may even have unintended adverse effects increasing the risk of obesity and its downstream cardiometabolic complications through changes in the microbiome. As a result, both the WHO and Health Canada have diverged from the diabetes guidelines consensus recommending against the use of NNS for sugars reduction. A growing number of commentaries, editorials, letters to the editor, and an expert consensus have argued that the evidence on which these concerns are based is at high risk of bias for failure to account for the nature of the comparator (caloric versus non-caloric comparators) in randomized controlled trials and important sources of residual confounding and reverse causality in prospective cohort studies. To address these sources of bias, A series of systematic reviews and meta-analyses were commissioned the for the update of the European Association or the Study of diabetes (EASD) Clinical Practice Guidelines for Nutrition Therapy (ClinicalTrials.gov identifiers, NCT02879500 and NCT04245826). These syntheses focussed on 3 prespecified substitutions of clinical and public health concern involving the most important source of NNS in the diet and a single matrix, non-nutritive sweetened beverages (NNSBs): NNSBs for SSBs (intended substitution with caloric displacement), water for SSBs (“standard of care” substitution with caloric displacement), and NSBs for water (reference substitution without caloric displacement). The intended substitution of NNSBs for SSBs was found to improve body weight and cardiometabolic risk factors in randomized controlled trials and was associated with reductions in incident obesity and coronary heart disease and total mortality in prospective cohort studies, with similar benefits to those observed with the standard of care, water. The best available evidence supports the intended benefits of NNSBs. More research will be important for improving the certainty of the estimates, including our Strategies To OPpose Sugars with Non-nutritive sweeteners Or Water trial (STOP Sugars NOW), a randomized controlled trial of the effect of replacements of SSBs with NNSBs versus water on changes in glucose tolerance and gut microbiome (ClinicalTrials.gov identifier, NCT03543644).

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