Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies

Abstract

Background: Nonnutritive sweeteners, such as aspartame, sucralose and stevioside, are widely consumed, yet their long-term health impact is uncertain. We synthesized evidence from prospective studies to determine whether routine consumption of non-nutritive sweeteners was associated with long-term adverse cardiometabolic effects.

Methods: We searched MEDLINE, Embase and Cochrane Library (inception to January 2016) for randomized controlled trials (RCTs) that evaluated interventions for nonnutritive sweeteners and prospective cohort studies that reported on consumption of non-nutritive sweeteners among adults and adolescents. The primary outcome was body mass index (BMI). Secondary outcomes included weight, obesity and other cardiometabolic end points.

Results: From 11 774 citations, we included 7 trials (1003 participants; median follow-up 6 mo) and 30 cohort studies (405 907 participants; median follow-up 10 yr). In the included RCTs, nonnutritive sweeteners had no significant effect on BMI (mean difference -0.37 kg/m²; 95% confidence interval [CI] -1.10 to 0.36; I² 9%; 242 participants). In the included cohort studies, consumption of nonnutritive sweeteners was associated with a modest increase in BMI (mean correlation 0.05, 95% CI 0.03 to 0.06; I² 0%; 21 256 participants). Data from RCTs showed no consistent effects of nonnutritive sweeteners on other measures of body composition and reported no further secondary outcomes. In the cohort studies, consumption of nonnutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. Publication bias was indicated for studies with diabetes as an outcome.

Interpretation: Evidence from RCTs does not clearly support the intended benefits of nonnutritive sweeteners for weight management, and observational data suggest that routine intake of nonnutritive sweeteners may be associated with increased BMI and cardiometabolic risk. Further research is needed to fully characterize the long-term risks and benefits of nonnutritive sweeteners. Protocol registration: PROSPERO-CRD42015019749.

Figure 1:

RISMA flow diagram. NNS = nonnutritive sweetener, RCT = randomized controlled trial. *Companion studies included abstracts, trial registrations and earlier reports from included studies.

Figure 2:

Forest plots of consumption of NNS and selected cardiometabolic health outcomes. (A) Differences in mean BMI between NNS consumption and control groups for RCTs. A value less than 0 represents reduced BMI with NNS consumption. (B) Correlaton of BMI change per unit of NNS intake for cohort studies. A value less than 0 represents a reduced BMI. (C) Standard mean differences in weight between NNS consumption and control groups for RCTs. A value less than 0.0 represents weight loss. (D) Correlation of weight change per unit NNS intake for cohort studies. A value less than 0 favours weight loss. (E) Incidence of type 2 diabetes for highest versus lowest quantiles of NNS intake in cohort studies. A value less than 1.0 represents a lower risk of type 2 diabetes. Additional outcomes are shown in Table 3, and Appendix 1, Figures S1–4. Squares represent effect estimates within each study, with 95% CIs represented by horizontal lines. Square size is proportional to the weight of each study. Diamonds represent the weighted mean effect estimates. Cohort acronyms are defined in Table 2. Note: BMI = body mass index, CI = confidence interval, MD = mean difference, NNS = nonnutritive sweetener, RCT = randomized controlled trial, RR = risk ratio, SD = standard deviation, SE = standard error, SMD = standardized mean difference.