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About 85% of girls suffer painful bloating, cramps and abdominal pain during their monthly periods — and for some the problems can last for years.
“Since menstrual pain is a leading cause of school absenteeism for adolescent girls, it’s important to explore options that can minimize the pain,” said Dr. Stephanie Faubion, director of the Mayo Clinic’s Center for Women’s Health in Jacksonville, Florida, in a statement. She was not involved in the study.
But there are behavioral adjustments girls and young women can make to reduce pain, according to a new analysis of studies. “Diet modification could be a relatively simple solution that could provide substantial relief for them,” said Faubion, who is also the medical director for The North American Menopausal Society, of the research findings.
The abstract, presented Wednesday at the annual meeting of NAMS, explored the connection between diet and dysmenorrhea, the medical term for painful periods. The lead author, Serah Sannoh, told CNN she became interested in the topic due to her own menstrual pain, which has plagued her since adolescence.
“I found diets high in inflammatory foods such as animal meats, oil, sugars, salts, and coffee contribute to an increased risk of pain during a woman’s period,” said Sannoh, who conducted the research as an intern at Rutgers University’s Robert Wood Johnson Medical School in New Jersey. She is currently a medical student at Temple University’s Lewis Katz School of Medicine in Philadelphia.
“A lot of the things that young people like to eat are are highly inflammatory … lunch meats, foods full of sugars and trans fats. But if you go on an anti-inflammatory diet — fruit, vegetables, olive oil, like the Mediterranean diet — you’ll get less cramping,” said NAMS board member Dr. Monica Christmas, an associate professor of obstetrics and gynecology at the University of Chicago, who was not involved in the study.
The scientific evidence has shown eating a healthy diet, getting good sleep and exercising are effective measures in curtailing the duration and severity of cramps, Christmas said. But she noted it’s important women see a health care provider: “Make sure that there’s not some other medical condition that might also be contributing to the symptoms.”
As your body prepares to menstruate, endometrial cells that built a lining in the uterus to welcome a fertilized egg begin to break down. As they do, those cells release large amounts of fatty acids calledprostaglandins to make the uterine layer contract and expel the unused tissue. The body also releases prostaglandins naturally during labor to open the cervix for birth.
Prostaglandins act like hormones, causing blood vessels and smooth muscles to constrict, resulting in cramping and pain. Researchers have found prostaglandin levels are higher and uterine contractions are stronger and more frequent in women with menstrual pain than women who have little or no pain, according to American Association of Family Physicians.
Eating inflammatory foods only adds to the discomfort, studies have found. Highly processed and high-sugar foods and fatty, greasy foods are common culprits — a 2018 study found college students who ate more snacks had more pain during their periods.
Another 2018 study of Spanish college students found women who drank cola and ate meat were more likely to suffer pain during their cycle than women who ate more vegetables and fruits. In fact, a 2020 study found women who ate fewer than two servings of fruit a day were more likely to suffer pain during their menstrual cycle.
Part of the problem is an imbalance between omega-3 and omega-6 fatty acids, Sannoh found. Omega-3 fatty acids — found in foods such as salmon, tuna, sardines, oysters, walnuts, chia and flaxseeds — are anti-inflammatory. Studies have linked them to a reduction in risk for many chronic diseases triggered by inflammation.
Omega-6 fatty acids keep skin, hair and bones healthy and help regulate metabolism, in addition to their role in the reproductive system. But too many of these fatty acids can cause inflammation when the body ultimately breaks them down into arachidonic acid, which lowers the body’s pain threshold.
“From my research, I found out that people with diets high inomega-6 fatty acids, especifically those derived from animal-based products, have a higher presence of arachidonic acid in the body, which increases the amount of pro-inflammatory prostaglandins that help the uterus contract,” Sannoh said.
“When you have a diet that balances omega-3 and omega-6 fatty acids, and you decrease the amount of inflammatory foods that you ingest, that will decrease the painful menstrual experience,” she added.
Two separate studies from2011 and 2012 revealed women who took omega-3 fatty acid supplements reduced the intensity of menstrual discomfort enough to lower their use of ibuprofen for pain relief. And a 1996 study found a highly significant relationship between omega-3 fatty acids and milder menstrual symptoms in teens.
Changing your diet is not the only way to fight menstrual pain. Nonsteroidal anti-inflammatory drugs, or NSAIDs, reduce the production of prostaglandins, which is why they are a mainstay of treatment for cramps, Christmas said.
However, these pain medications also have side effects. According to a 2015 Cochrane Library review of evidence, NSAIDs are linked to bloating, diarrhea, dizziness, indigestion, headaches, heartburn, high blood pressure, nausea, vomiting and on rare occasions, raised liver enzymes.
Certain oral birth control pills also lower the production of prostaglandins in the uterine lining, which then reduces both blood flow and cramping. Doses of less than 35 micrograms were “effective and should be the preparation of choice,” according to a 2009 Cochrane Library review.
But if you are not interested in using these methods — or want extra relief — give an anti-inflammatory diet a try. Sannoh put her research into practice by decreasing her intake of red meat and other inflammatory foods such as sugar and coffee, and told CNN that it did decrease her menstrual pain.
There’s an added benefit to adopting an anti-inflammatory lifestyle, Christmas said.
“These diets are also associated with less high blood pressure, less cardiovascular disease, less diabetes, less arthritic issues, decreased morbidity and mortality, especially after menopause,” Christmas said.
“So if you can get people who are young to eat better, exercise, and live a healthier lifestyle, they’re going fare better as they age.”
A new study has found a link between artificial sweeteners and an increased risk of cardiovascular disease. (Photo via Getty Images)
This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. Contact a qualified medical professional before engaging in any physical activity, or making any changes to your diet, medication or lifestyle.
A new study has found artificial sweeteners may be linked to heart disease and the risk of stroke.
The study, which was published in the British Medical Journal, involved more than 100,000 adults in France, 80 per cent of whom were women. In the web-based study, the average age of participants was 42.
Researchers found that participants who consumed a lot of aspartame, which is found in sweeteners such as NutraSweet and Equal, as well as in food like diet sodas, chewing gum, desserts and yogurt, were at an increased risk of stroke compared to people who didn’t consume any.
Participants who consumed sucralose, which is found in Splenda, baked goods, beverages and dairy desserts, as well as acesulfame potassium, which is used in sugar-free pop, had a higher risk of coronary artery disease.
Launched in 2009, the study had participants complete five online questionnaires about their diet, health, lifestyle and physical activity. They were also asked about sociodemographic data like education and occupation.
Over time, participants completed dietary assessments every six months. During these assessments, they had to report every food and drink they had over a 24-hour period. They were also asked to report any new medical conditions and treatments that came up.
Overall, 37 per cent of participants consumed artificial sweeteners. The study found participants consumed about 42 milligrams per day, which is about one individual packet of tabletop sweetener or 100 millilitres of diet soda.
The study found participants who consumed a lot of aspartame were at an increased risk of stroke compared to people who didn’t consume any. (Photo via Getty Images)
What are artificial sweeteners?
Artificial sweeteners are an alternative to sugar to sweeten foods and drinks. They are made from chemicals and natural substances, and have fewer calories compared to sugar.
Many people use artificial sweeteners to lose weight, control blood sugar and limit sugar intake.
According to theBritish Medical Journal‘s study, more than 23,000 products worldwide contain artificial sweeteners.
However, Health Canada regulates the use of sugar substitutes and has deemed them safe for most people.
What Canadian experts say about the study
Dr. Marc Ruel, president of the Canadian Cardiovascular Society, tells Yahoo Canada that while the study broaches a very important public health question, the conclusions are not supported by the data.
“I think the conclusions are overstated. This is an observational study, meaning researchers are looking at the links. They’re correlations, they’re not causation,” he explains. “If someone’s going to drink Pepsi versus Diet Pepsi or vice-versa, I don’t think this study changes much. This does not provide sufficiently scientifically supported conclusions to change.”
Ruel also points to a limitation of the study: The fact that pre-existing diabetics were excluded.
According to the cardiovascular expert, many participants at the age of 42 may have “silent diabetes,” meaning they have not been diagnosed with the disease yet and will be later in life.
“You see a population at risk that has not been accounted for,” he adds. “We know diabetic or pre-diabetic people are at a hugely increased risk of cardiovascular disease. They may have changed their behaviour, including taking artificial sweeteners, based on their knowledge of that risk.”
A Canadian cardiovascular expert recommends eating a Mediterranean diet to decrease your risk of heart disease. (Photo via Getty Images)
Improving cardiovascular health
Participants of the British Medical Journal study who consumed high amounts of artificial sweetener were younger, had a higher body mass index, were more likely to smoke and were less physically active. They also consumed high amounts of sodium, red and processed meat as well as dairy products, and consumed fewer fruits and vegetables.
When it comes to cardiovascular health, Ruel says there are lifestyle changes he would recommend to lower a person’s risk of heart disease.
The recommendations include eating a Mediterranean-type diet, which includes fruits and vegetables, beans, nuts, whole grains, lean poultry and fish. He also advises minimizing alcohol consumption, avoiding smoking and being physically active.
“All sweets should be curtailed as much as possible, whether they are artificial sweeteners or non-artificial sweeteners,” Ruel shares. “That being said, if you’re in an area where there’s a huge level of consumption of sweetened drinks, well, then I don’t think this discloses the small impact that artificial sweeteners might have in decreasing obesity and cardiovascular complications in the long run.”
The Canadian Heart and Stroke Foundation’s heart-healthy tips also suggest maintaining a healthy weight and managing stress to prevent premature heart disease.
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Naturally sweet fruit is the ideal substitute for foods high in sugar, according to Dr. Katie Page, an associate professor of medicine at USC.
Fake sweeteners might not be a suitable substitute for sugar and could even have harmful effects on a person’s health.
According to NBC News, a study by Mathilde Touvier, research director at the French National Institute for Health and Medical Research, may have discovered a connection between the use of artificial sweeteners and heart disease.
Another study published last month found that ingesting sugar replacements with few calories or nutrients, or so-called “non-nutritive sweeteners,” may affect a person’s gut microbes and perhaps increase blood sugar levels.
A study recently published in the medical journal BMJ may have found a connection between artificial sweeteners and heart disease, as well as diabetes. (Photo Credit: Adobe Stock)
Prior to that, it was discovered that artificial sweeteners caused gut bacteria to enter cells in the bowel wall, increasing one’s risk of infection or organ failure. Artificial sweeteners have also been connected to an increased risk of obesity, high blood pressure, diabetes, stroke and heart disease as well as cancer.
“The more data that comes out showing these adverse health effects, the less we’re going to want to encourage people to switch from added sugars to non-nutritive sweeteners,” said Dr. Katie Page, an associate professor of medicine at the University of Southern California, according to NBC.
Touvier asserted that her study, which encompassed more than 100,000 adults in France and was published Wednesday in the BMJ, is the first to directly examine how a person’s overall dietary intake of artificial sweeteners affects the risk of developing heart disease. Prior research mostly focused on the link between artificially sweetened beverages and the disease.
The findings of her study indicated that consumption of aspartame, which is present in foods including cereal, candy and diet drinks, as well as the tabletop sweeteners Equal and NutraSweet, increased the risk of stroke in individuals.
Similar to sucralose – which Page said is the most widely used artificial sweetener in the world – acesulfame potassium is frequently used in “sugar-free” soda. Touvier’s study revealed that those who consumed large amounts of either have a higher risk of coronary heart disease. Sucralose can be found in Splenda as well as baked goods, ice cream, canned fruit and syrups.
Touvier’s team established the daily average for a large amount of sweetener at 77 milligrams, or around two packets of tabletop sweetener. Soft drinks accounted for more than half of the participants’ artificial sweetener usage, while tabletop sweeteners made up 30%. Another 8% came from dairy products with added sugar, such as fruit-topped cottage cheese or yogurt.
Naturally sweet fruit is the ideal substitute for foods high in sugar, according to Page. Choosing table sugar or even sweeteners seen as natural, like agave, is not the healthiest option.
“We really need to encourage people to eat sugar in more moderation and try to decrease sugar consumption,” said Page, according to NBC. “And the way to do that isn’t to consume more non-nutritive sweeteners.”
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A new study has uncovered a potential direct association between higher artificial sweetener consumption and increased cardiovascular disease risk.
These food additives “should not be considered a healthy and safe alternative to sugar,” argue researchers.
A potential direct association between higher artificial sweetener consumption and increased cardiovascular disease risk, including heart attack and stroke has been uncovered by a large study of French adults published on September 7 by The BMJ.
These food additives are consumed daily by millions of people and are present in thousands of foods and drinks. The findings indicate that these artificial sweeteners should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies.
Artificial sweeteners are widely used as no or low-calorie alternatives to sugar. They represent a $7.2 billion (£5.9 billion; €7.0 billion) global market and are found in thousands of products worldwide. They are particularly common in ultra-processed foods such as artificially sweetened drinks, some snacks, and low-calorie ready meals.
Several studies have already linked the consumption of artificial sweeteners or artificially sweetened beverages (ASB) to weight gain, high blood pressure, and inflammation. However, findings remain mixed about the role of artificial sweeteners in the cause of various diseases, including cardiovascular disease (CVD). Moreover, several observational studies have used ASB consumption as a proxy to explore CVD risk, but none have measured artificial sweetener intake from the overall diet.
To investigate this further, a team of researchers at the French National Institute for Health and Medical Research (Inserm) and colleagues, drew on data from 103,388 participants (average age 42 years; 80% female) of the web-based NutriNet-Santé study. Launched in France in 2009, this ongoing study investigates relations between nutrition and health.
Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24-hour dietary records. A wide range of potentially influential health, lifestyle, and sociodemographic factors were taken into account.
Artificial sweeteners from all dietary sources (beverages, dairy products, tabletop sweeteners, etc.) and by type (aspartame, sucralose, and acesulfame potassium) were included in the analysis.
A total of 37% of participants consumed artificial sweeteners, with an average intake of 42.46 mg/day. This corresponds to approximately one individual packet of tabletop sweetener or 100 mL (3.4 ounces) of diet soda.
Among participants who consumed artificial sweeteners, mean intakes for lower and higher consumer categories were 7.46 and 77.62 mg/ day, respectively.
Compared with non-consumers, higher consumers tended to be younger, be less physically active, have a higher body mass index (BMI), were more likely to smoke, and to follow a weight loss diet. They also had lower total energy intake, and lower alcohol, carbohydrate, saturated and polyunsaturated fats, fiber, fruit, and vegetable intakes, and higher intakes of sodium, red and processed meat, dairy products, and beverages with no added sugar. However, the investigators took these differences into account in their analyses.
During an average follow-up period of nine years, 1,502 cardiovascular events occurred. They included heart attack, angioplasty (a procedure to widen blocked or narrowed arteries to the heart), angina, transient ischemic attack, and stroke.
The scientists found that total artificial sweetener intake was associated with an increased risk of cardiovascular disease (absolute rate 346 per 100,000 person-years in higher consumers and 314 per 100,000 person-years in non-consumers).
Artificial sweeteners were more particularly associated with cerebrovascular disease risk (absolute rates 195 and 150 per 100,000 person-years in higher and non-consumers, respectively).
Aspartame intake was associated with an increased risk of cerebrovascular events (186 and 151 per 100,000 person-years in higher and non-consumers, respectively), while acesulfame potassium and sucralose were associated with increased coronary heart disease risk (acesulfame potassium: 167 and 164 per 100,000 person-years; sucralose: 271 and 161 per 100,000 person-years in higher and non-consumers, respectively).
Because this is an observational study, it can’t establish cause. Additionally, the researchers cannot rule out the possibility that other unknown (confounding) factors might have affected their results.
Nevertheless, this was a large study that evaluated individuals’ artificial sweetener intake using precise, high-quality dietary data. Furthermore, the findings are in line with other studies linking exposure to artificial sweeteners with several markers of poor health.
Therefore, the researchers say their results suggest that there is no benefit from substituting artificial sweeteners for added sugar on CVD outcomes.
Further prospective cohort studies need to confirm these results and experimental studies are required to clarify biological pathways, they add.
In the meantime, they suggest this study provides key insights into the context of artificial sweetener re-evaluation currently being carried out by the European Food Safety Authority, the World Health Organization (WHO), and other health agencies.
Reference: “Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort” by Charlotte Debras, Eloi Chazelas, Laury Sellem, Raphaël Porcher, Nathalie Druesne-Pecollo, Younes Esseddik, Fabien Szabo de Edelenyi, Cédric Agaësse, Alexandre De Sa, Rebecca Lutchia, Léopold K Fezeu, Chantal Julia, Emmanuelle Kesse-Guyot, Benjamin Allès, Pilar Galan, Serge Hercberg, Mélanie Deschasaux-Tanguy, Inge Huybrechts, Bernard Srour and Mathilde Touvier, 7 September 2022, The BMJ. DOI: 10.1136/bmj-2022-071204
Share on PinterestConsuming artificial sweeteners was associated with an increased risk of cardiovascular disease, study finds. Mirror Images/Getty Images
A new study found consuming artificial sweeteners was associated with an increased risk of cardiovascular disease.
People who ate more artificial sweetener had an 18% higher risk of stroke or another type of cerebrovascular disease compared to non-consumers.
Researchers looked at a detailed estimate of people’s consumption of artificial sweeteners from all sources, as well as their intake of fruits, vegetables, dairy products, red meat and other types of foods.
Millions of Americans consume artificial sweeteners — not just in soft drinks and other beverages, but also in snack foods, dairy products, ready-to-go meals, and as those little packets you find at restaurants.
While some people use these to avoid the health-related risks of added (real) sugars, artificial sweeteners may also negatively impact your health, especially when consumed in higher amounts.
This includes heart-related risks, suggests a recent large observational study by French researchers.
They found that people who consumed higher amounts of artificial sweeteners had an increased risk of cardiovascular disease overall, and also stroke and other types of cerebrovascular disease.
The study, published Sept. 7 in The BMJ journal, included over 103,000 French adults who participated in a web-based nutrition study. The average age of participants at the start was 42 years and almost 80% were female.
At the start of the study, people filled out questionnaires about their diet, health, physical activity, and personal information such as education, smoking status, and occupation.
They also completed multiple dietary assessments at the beginning of the study and every 6 months afterward. During these dietary recalls, they were asked to report every food and beverage they consumed over a 24-hour period.
This provided researchers with a detailed estimate of people’s consumption of artificial sweeteners from all sources, as well as their intake of fruits, vegetables, dairy products, red meat, and other types of foods or nutrients.
People also reported on new health events, medical treatments, and examinations — including ones related to cardiovascular diseases, such as heart disease, heart attack, and stroke.
Overall, 37% of participants consumed artificial sweeteners in some form. On average, these people consumed about 42 milligrams per day, equivalent to one individual packet of tabletop sweetener or 3.4 ounces (100 milliliters) of diet soda.
The average intake of artificial sweeteners for “high consumers” was around 78 milligrams per day; for “low consumers” it was around 8 milligrams per day. There was also a group of people who didn’t consume any artificial sweeteners.
People who consumed higher amounts of artificial sweeteners tended to be younger, have a higher body mass index (BMI), and were more likely to smoke, be less physically active and follow a weight-loss diet.
They also consumed fewer calories overall, and less alcohol, saturated and polyunsaturated fats, fiber, carbohydrates and fruits and vegetables; and consumed higher amounts of sodium, red and processed meats and dairy products.
Researchers took into account these differences, as well as other factors such as age, sex, physical activity, education, smoking status, and family history of cardiovascular disease.
“After the adjustment [for these], there is still a signal that there appears to be increased cardiovascular events in those reporting increased use of artificial sweeteners,” said Dr. Elizabeth H. Dineen, a cardiologist at the Susan Samueli Integrative Institute at UCI Health in Orange County, Calif. Dineen was not part of the research.
After following people for 9 years on average, researchers found that intake of artificial sweeteners was associated with an increased risk of cardiovascular disease overall.
In particular, people who consumed higher amounts of artificial sweeteners had a 9% higher risk of cardiovascular disease compared to people who didn’t consume any artificial sweeteners.
People who ate the most artificial sugar also had an 18% higher risk of stroke or another type of cerebrovascular disease compared to non-consumers.
In addition, higher consumers of aspartame had an increased risk of cerebrovascular disease; and higher consumers of acesulfame potassium and sucralose had a higher risk of coronary heart disease.
The dietary assessments recorded people’s intake of other types of artificial sweeteners — including plant-based stevia — but participants consumed too little of these for researchers to include them in their analysis.
Researchers also looked at whether substituting artificial sweeteners for added sugar would reduce the risk of cardiovascular disease overall, cerebrovascular disease, or coronary heart disease. Their analysis “did not suggest a benefit,” they wrote.
Given the results of the study, artificial sweeteners “should not be considered a healthy and safe alternative to sugar,” they wrote, especially with the “extensive use of these substances in products on the global market.”
Dineen said the study was well-done, but there are certain limitations. One is that it’s an observational study, so the researchers can’t prove a causal link between artificial sweeteners and cardiovascular disease.
However, other research has found that people who consume higher amounts of artificially sweetened beverages have a higher risk of cardiovascular disease overall and stroke.
Most previous research on the risk of cardiovascular disease has focused on the consumption of artificial sweeteners in beverages. This study, though, included all food sources.
“Beverages are, of course, a significant source of artificial sweeteners, but these sweeteners seem to be showing up in foods you wouldn’t think of, such as crackers and bread,” said Lori Chong, RDN, LD, a registered dietitian at The Ohio State University Wexner Medical Center in Columbus, Ohio.
In the new study, soft drinks with no added sugars accounted for 53% of artificial sweetener consumption, but people also consumed artificial sweeteners in tabletop sweeteners (30%) and yogurts and cottage cheese (8%).
Heart-related risks are only one concern that comes with consuming artificial sweeteners.
Another study by the authors of the new study, published March 2022 in PLoS ONE, found an increased risk of cancer with higher consumption of artificial sweeteners, especially aspartame and acesulfame-K.
“Based on other studies and this one, it appears wise to limit artificial sweeteners,” said Dineen, also an assistant professor of medicine, cardiovascular diseases, at UCI School of Medicine in Irvine, Calif.
In addition, “it is important for all individuals to minimize their risk of cardiovascular disease by following preventive strategies — such as dietary interventions,” she said, “and certainly if cardiovascular disease is already diagnosed, then these preventive efforts are of utmost importance.”
Chong said even before this study, she recommended that people minimize their intake of artificial sweeteners — but “minimize doesn’t mean avoid at all cost.”
Of course, limiting the intake of artificial sweeteners will mean different things to different to people.
So “a practical approach could be to assess which foods and beverages you are regularly consuming that contain artificial sweeteners, and then consider alternatives to these products or [ways to] reduce them,” said Chong.
This doesn’t mean just going back to added sugars — “real [added] sugars in any of its forms still needs to be limited,” said Chong.
A good rule of thumb, she said, is the World Health Organization’s recommendation of consuming no more than 10% of your daily calories as added sugars — or no more than 5% for additional health benefits.
She also suggests that people look at the ingredient lists on food packages.
“Short and simple is best versus long and complicated,” she said. “And be sure to buy enough whole foods — like fresh fruit and vegetables — that do not need an ingredient label.”
While studies like this new one and others can help guide people toward healthier eating, Dineen said healthy eating is often intuitive.
“Most people know what is generally healthy versus not,” she said. “But we are all creatures of habit, and [sometimes] it becomes difficult to break those habits.”
Some people who have trouble shifting their eating patterns may benefit from dietary counseling with a dietitian, individually or in a group, she said.
She also recommends the Mediterranean diet, which “has been a staple in the world of prevention, when it comes to heart disease.”
This diet is rich in fruits, vegetables, whole grains, and healthy fats. While traditionally, the Mediterranean diet includes fish and seafood, Dineen said the diet should be tailored to a person’s health factors and personal preferences.
In general, “the more natural and less processed, the better,” she said. “So avoiding added artificial sugars would make sense, and this [new] study helps to support that.”
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Key Takeaways
High intake of artificial sweeteners was linked to increased risks for cardiovascular, cerebrovascular and coronary heart disease.
Researchers found no benefits to substituting added sugars for artificial sweeteners regarding CVD risk.
Greater consumption of artificial sweeteners was associated with a higher risk for cardiovascular, cerebrovascular and coronary heart disease, a study published in the BMJ found.
Acknowledging the known health risks that sugar poses to consumers, Charlotte Debras, a PhD candidate at Sorbonne Paris Nord University, and colleagues wrote that its healthier-in-theory alternative has been shown in previous studies to affect cardiovascular signals, including weight status, hypertension, inflammation, vascular dysfunction and gut microbiota.
Data derived from: Debras C, et al. BMJ. 2022;doi:10.1136/bmj-2022-071204.
“Most of these studies suggested adverse effects, and few suggested neutral or beneficial properties. Although the results were mixed, this literature generally supports a potential involvement of artificial sweeteners in cardiovascular health, with plausible mechanisms,” they wrote.
The potential association of artificial sweeteners and adverse cardiovascular effects are particularly relevant in the United States, where heart disease was the leading cause of death in 2020, accounting for 696,962 mortalities, according to the CDC. Stroke was the fifth-leading cause of death, with 160,264 mortalities.
Drawing data from 2009 to 2021, Debras and colleagues examined 103,388 participants —79.8% women with a median age of 42 years at baseline — from the French web-based cohort NutriNet-Santé. Participants were divided into three groups based on artificial sweetener intake:
higher consumers (19,139, 18.51%), who consumed 77.62 mg daily;
lower consumers (19,221, 18.59%), who consumed 7.46 mg daily; and
non-consumers (65,028, 62.9%), who consumed 0 mg daily.
The participants provided 24-hour dietary recalls for 3 nonconsecutive days during the baseline period and then every 6 months thereafter. In addition to overall artificial sweetener intake, the researchers analyzed specific sweeteners (aspartame, acesulfame potassium and sucralose) and dietary sources.
Overall, 37.1% of participants reported consuming artificial sweeteners, with a daily intake of 42.46 mg. During a median follow-up period of 9 years, 1,502 total CVD incident events occurred.
Debras and colleagues found that total artificial sweetener intake was associated with a higher risk for CVDs, with an HR of 1.09 (95% CI, 1.01-1.18), while absolute incident rates per 100,000 person years were 346 and 314 for higher consumers and lower consumers, respectively.
Higher artificial sweetener consumers had a significantly greater risk for developing cerebrovascular disease than non-consumers (HR = 1.18; 95% CI, 1.06 to 1.31), according to the researchers. Cerebrovascular disease was also linked to higher intake of aspartame (HR = 1.17; 95% CI, 1.03-1.33), while higher intakes of acesulfame potassium (HR = 1.4; 95% CI, 1.06-1.84) and sucralose (HR = 1.31; 95% CI, 1-1.71) were associated with an increased coronary heart disease risk.
The researchers additionally found no benefits for substituting artificial sweeteners for added sugar for cardiovascular, cerebrovascular or coronary heart disease risk.
While further studies are needed to confirm the results and examine biological pathways, Debras and colleagues wrote that these sweeteners “consumed daily by millions of people and present in thousands of foods and beverages, should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies.”
A new study has found a link between artificial sweetener intake and heart disease and stroke.
Artificial sweeteners were more particularly associated with cerebrovascular disease risk, such as stroke-related events, compared to coronary heart disease.
Despite this new information, doctors do not recommend switching back to added sugar in beverages or food as an alternative to artificial sweeteners.
Artificial sweeteners could be doing you a lot more harm than good, especially when it comes to your heart health.
A new study published in The BMJ investigated the relationship between artificial sweetener consumption and the risk of heart disease. The research, led by experts from the Sorbonne Paris Nord University, looked at the consumption of sweeteners from all dietary sources, including drinks, tabletop sweeteners, and dairy products, and compared it with participants’ risk of coronary heart disease and cerebrovascular disease (a group of conditions that affect blood flow to the brain).
Researchers looked at the artificial sweeteners on a molecular level, too, taking into account aspartame, acesulfame potassium, and sucralose.
It’s no secret that many people use artificial sweeteners and sugar substitutes as no- or low-calorie alternatives to sugar. They are found in thousands of products worldwide, particularly ultra-processed foods such as artificially sweetened drinks (like diet sodas), some snacks, and low-calorie ready meals.
Researchers looked at data from 103,388 French participants of which the average age was 42 and 80% were female. Dietary intake and consumption of artificial sweeteners were assessed by self-reported repeated 24-hour dietary records.
The study found that total artificial sweetener intake was associated with an increased risk of cardiovascular diseases. Artificial sweeteners were more particularly associated with cerebrovascular disease risk, compared to coronary heart disease.
The intake of aspartame, a specific kind of artificial sweetener, was associated with an increased risk of cerebrovascular events, such as stroke. On the other hand, acesulfame potassium and sucralose, both different kinds of artificial sweeteners, were associated with increased coronary heart disease risk.
Researchers concluded that there is a potential direct association between consuming a high amount of artificial sweeteners (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk.
While there are many strengths to this study, there are some limitations to consider. It’s important to remember that no causal relation can be established with results from an observational study, so we can only confidently say that there is a strong association and potential direct relationship between higher artificial sweetener consumption and a higher risk of heart disease. Also, given that the research was conducted in a population of mostly women with higher education levels, this data is likely not generalizable to the entire French population, as well as the global population. Lastly, given that the participants’ data was self-reported, there is a chance that the information collected is not truly representative of the entire health profiles of the individuals.
It’s also important to note that if any of the participants had a history of obesity or any other health conditions that would have predisposed them to a higher risk of heart disease, the increased risk found in this study may not be only attributed to higher artificial sweetener intake, explains Karen Aspry, M.D., co-chair of the American College of Cardiology Prevention of Cardiovascular Disease Section and Nutrition and Lifestyle Work Group.
The team of researchers added that more studies need to be done to confirm these results. In the meantime, international health agencies, such as the European Food Safety Authority and the World Health Organization, should consider the key insights this study provides and re-evaluate how they look at artificial sweeteners in various food products.
Several studies have linked the intake of artificial sweeteners or artificially sweetened beverages to weight gain, high blood pressure, and inflammation in the past. But findings remain mixed about the role of artificial sweeteners in the cause of various diseases, including heart disease.
The bottom line
The harm from these artificially sweetened drinks and foods have relatively low harm to your health alone. However, drinking fewer of these beverages as well as processed foods is better for your health overall, says Dr. Aspry.
And for those of us with sweet tooths, try to get your sweetness ratio from naturally sweet foods, such as fruit, when you can. Sugary drinks can be a hard thing to drop in one day, but limit your use where you can, and your heart will thank you for it!
Madeleine, Prevention’s assistant editor, has a history with health writing from her experience as an editorial assistant at WebMD, and from her personal research at university. She graduated from the University of Michigan with a degree in biopsychology, cognition, and neuroscience—and she helps strategize for success across Prevention’s social media platforms.
You know the feeling. You slurp that diet soda relishing the sweet taste without the guilt or calories associated with sugar. But a new study suggests that these artificial sweeteners may not be as harmless as once thought; they may even increase the risk of diabetes or weight gain.
Scientists have long suspected a link between artificial sweeteners and obesity in humans, but until now that connection had only been shown in lab mice. Now, in a first of its kind trial, scientists in Israel have tested these chemicals in humans. Their results show that artificial sweeteners not only disturb the microbes living in the guts of humans—which are critical for supplying essential nutrients, synthesizing vitamin K, and digesting dietary fibers among other things—but some may impact how quickly the body removes sugar from the blood after a meal. The longer glucose stays in the blood, the greater the risk of diabetes, cardiovascular disease, and chronic kidney disease.
“They are used with the hope of giving us the sweet taste without having to pay the caloric price,” says Eran Elinav an immunologist at Weizmann Institute of Science in Israel, who led the latest study. “But non-nutritive sweeteners are not inert in humans.”
Every human hosts a unique bouquet of microbes—bacteria, viruses, and fungi—that live naturally in and on our bodies; in the intestine, nose, mouth and on the skin and eye. The number of cells that make up this vast microbial community is approximately equal the number of cells in human body. This community, called microbiome, is seeded at birth, and not only helps digestion but also protects against pathogens and supports the immune system.
The disruption to the microbiome occurs because non-nutritional sweeteners, although zero or low calorie for humans, serve as nutrients for some microbes, which then proliferate. This causes an imbalance in microbial populations that can cause chronic intestinal inflammation or colon cancer.
“They’re designed to be calorie free for us, but not for our gut microbes, which can still thrive on them,” says Michael Goran, a professor of pediatrics and program director for Nutrition and Obesity at Children’s Hospital Los Angeles.
The Israeli study confirms that non-nutrition sweeteners can disrupt the gut microbiome within two weeks of exposure and suggest their effects on sugar metabolism can vary from person to person.
“It’s a convincing study to show how these sweeteners really are affecting the human body. And, also, they have similar effects, despite being different types of compounds,” Goran says.
David Katz, a nutrition specialist, and the founder of Yale University’s Yale-Griffin Prevention Research Center, agrees. “This is an elegant, elaborate, and powerful study which establishes decisively that non-nutritional sweeteners impair glucose metabolism by causing specific damage to the microbiome.”
Bitter history of artificial sweeteners
Our innate taste for sweet edibles, and avoidance of bitter substances, is an evolutionary adaptation that drove us to high-energy foods at a time when nutritious foods were scarce. Natural sugars, such as glucose, fructose, cane, or milk sugars, are digested to produce energy—measured in calories—that helps our organs function. Non-nutritional sweeteners, which can be hundreds to thousands of times sweeter than cane sugar, are generally not metabolized by the human body, which is why they provide no or few calories.
Saccharin, the first commercialized non-nutritive sweetener, was discovered serendipitously in 1879 in coal-tar derivatives at Johns Hopkins University. Thanks to President Theodore Roosevelt, who thought that this artificial sugar was a guilt-free way to lose weight, saccharin dodged a ban by the nascent U.S. Food and Drug Administration. In 1977, when the FDA tried again to ban saccharin because of the suspected risk of causing cancer in rats, Americans fought back. They sent millions of letters to Congress, the FDA, and President Jimmy Carter protesting the proposed ban.
Ultimately, only a cancer warning label was required on products containing saccharin. But this was dropped too in 2000 when scientists found that humans metabolize saccharin differently from rats, and it didn’t pose a cancer risk for humans.
Low or zero calorie sugar substitutes are in thousands of beverages and foods worldwide and generated $21.3 billion in 2021. This number is expected to rise as demand for these sweeteners—particularly in low- and middle-income countries—continues to expand. In the United States, a 2017 nationwide nutritional survey found 80 percent of children and more than half of adults consumed low-calorie sweeteners once daily. Obese adults used low-calorie sweeteners more frequently.
Artificial sweeteners, from mice to humans
For more than a decade, Elinav has been interested in uncovering the links between nutrition, gut microbes, and the risk of developing common diseases, such as obesity and diabetes, with the hope of devising microbiome-based personalized medicine.
In 2014, Elinav and colleagues found that saccharin, sucralose, and aspartame each raised blood glucose of mice to levels that were significantly higher than those of mice that were fed sugar.
When gut microbes collected from mice fed with artificial sweeteners were administered to mice that had no gut bacteria of their own and had never been given artificial sweeteners, their blood-glucose levels shot-up as if they were consuming artificial sweeteners themselves.
“In mice, some of these non-nutritive sweeteners are sensed, and they impact the gut microbes, which have an amazing capacity to metabolize many of these compounds,” Elinav says. He decided to test whether the same held true in humans: Could altered gut microbes disturb the glucose metabolism?
Elinav’s team first screened 1,375 volunteers for any consumption of zero-calorie sweeteners in their daily lives. They identified 120 adults not previously exposed and gave them one of the four commonly used sweeteners—saccharin, sucralose, aspartame, and stevia for two weeks. The volunteers were then monitored for a third week. Scientists compared their blood-glucose responses against those who were not given artificial sweeteners.
Within 14 days after beginning any of the four tested artificial sweeteners, scientists observed significant differences in the populations of gut bacteria among volunteers. “We identified very distinct changes in the composition and function of gut microbes, and the molecules they secret in blood,” Elinav says. This suggests that gut microbes rapidly respond to artificial sweeteners.
To test how artificial sweeteners affect the body’s ability to control the surges in blood sugar after consuming sugar as part of meals, volunteers were monitored for blood glucose levels after a test glucose drink. Normally, blood glucose levels should peak in 15 to 30 minutes and then return to normal within two to three hours. If the glucose levels remain elevated, it signals that the body isn’t processing and storing excess glucose properly, a phenomenon known as glucose intolerance.
In the Israeli study, sucralose and saccharin pushed the body towards glucose intolerance, which if sustained can cause weight gain and diabetes. Aspartame and stevia did not affect the glucose tolerance at the tested ingested levels.
“The glycemic responses that are induced by saccharin and sucralose, possibly by the gut microbiome, may be more pronounced,” Elinav says.
To confirm that disturbance in microbial populations disrupted blood glucose levels, scientists administered fecal microbes from stool of human participants to germ-free mice. The study found that microbes from the volunteers with elevated blood sugar levels also suppressed glucose control in the mice.
“The gut microbes, and the molecules they secrete into our bloodstream, are very altered in all four non-nutritive sweetener consumers,” Elinav says. “Each of the groups responded in a unique way.”
Although, the study didn’t follow the volunteers long term, the study is the first to show that the human microbiome responds to non-nutritive sweeteners in a highly individual manner. This can disrupt sugar metabolism in some, if not all consumers, depending on their microbes and the sweeteners they consume. “This study is very comprehensive in terms of the microbiome,” Goran says.
“But this study creates new questions, more than it answered,” says Dylan Mackay, a human nutrition specialist at University of Manitoba in Canada and a diabetic. Since volunteers were screened to be free of prior exposure to non-nutritional sweeteners, it is unclear whether similar glucose dysregulation would be seen in people who routinely consume such sweeteners or whether there might be some degree of adaptation, Katz says. It is also unclear whether differences observed among individuals could be due to genetic, epigenetic, or lifestyle factors.
Should we switch to eating more sugar?
Some scientists think that changes in the gut microbiome after a short exposure to non-nutritional sweeteners are not sufficient to cause alarm. “It is reasonable to consider the variety of non-nutritional sugars of having some sort of impact physiologically,” says Karl Nadolsky, an endocrinologist at Michigan State University. “But projecting that to clinical outcomes and concerns is a very big jump.”
“We don’t know anything about the durability of these results yet,” says Mackay. “Could this be something that happens when you are first exposed to these non-nutritiional sweeteners? Does it continue forever?”
The study authors themselves caution that studying long term exposure to different artificial sweeteners might be required to fully assess the potential health effects due to altered microbiomes. But the scientists also stress that their results should not be interpreted as a call to consume more sugar as an alternative to non-nutritional sweeteners.
“On one hand, sugar consumption still constitutes a very bad and well-proven health risk for obesity, diabetes, and other health implications, and our findings do not support or promote the consumption of sugar,” Elinav says. “But on the other hand, these impacts from sweeteners that we show means a healthy caution should be advised.”
This study provides fairly decisive evidence of both short-term harmful effects and of mechanisms that might cause the same adverse effects in the long term, Katz says. “That does not mean non-nutritional sweeteners should be replaced with sugar, but rather that alternative approaches to reducing sugar intake should be prioritized.”
“We need better solutions to our sweet-tooth craving,” Elinav says. “To me personally, drinking only water is the best.”
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Objectives To study the associations between artificial sweeteners from all dietary sources (beverages, but also table top sweeteners, dairy products, etc), overall and by molecule (aspartame, acesulfame potassium, and sucralose), and risk of cardiovascular diseases (overall, coronary heart disease, and cerebrovascular disease).
Design Population based prospective cohort study (2009-21).
Setting France, primary prevention research.
Participants 103 388 participants of the web based NutriNet-Santé cohort (mean age 42.2±14.4, 79.8% female, 904 206 person years). Dietary intakes and consumption of artificial sweeteners were assessed by repeated 24 h dietary records, including brand names of industrial products.
Main outcomes measures Associations between sweeteners (coded as a continuous variable, log10 transformed) and cardiovascular disease risk, assessed by multivariable adjusted Cox hazard models.
Results Total artificial sweetener intake was associated with increased risk of cardiovascular diseases (1502 events, hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03); absolute incidence rate in higher consumers (above the sex specific median) and non-consumers was 346 and 314 per 100 000 person years, respectively. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (777 events, 1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150 per 100 000 person years in higher and non-consumers, respectively). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151 per 100 000 person years in higher and non-consumers, respectively), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (730 events; acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161).
Conclusions The findings from this large scale prospective cohort study suggest a potential direct association between higher artificial sweetener consumption (especially aspartame, acesulfame potassium, and sucralose) and increased cardiovascular disease risk. Artificial sweeteners are present in thousands of food and beverage brands worldwide, however they remain a controversial topic and are currently being re-evaluated by the European Food Safety Authority, the World Health Organization, and other health agencies.
Introduction
The harmful effects of added sugars on various health outcomes including cardiometabolic disorders have been extensively studied, meta-analysed12 and are currently recognised as major risk factors by public health authorities. In particular, the World Health Organization recommends that less than 5% daily energy intake should come from free sugar.3 Artificial sweeteners emerged as an alternative to added sugar that enabled the sweet taste to be reproduced without using sugar and therefore reduced calorie content from free sugar, which was highly appreciated by consumers.4 Artificial sweeteners currently represent a $7200m (£5900m; €7000m) market globally, with a 5% annual growth projected to attain $9700m by 2028.5 An extensive number of brands worldwide contain these food additives, especially ultra-processed foods such as artificially sweetened beverages, some snacks, and low calorie ready-to-go meals or dairy products; overall more than 23 000 products worldwide contain artificial sweeteners.6 Artificial sweeteners are also directly used by consumers as table top sweeteners instead of sugar. Acceptable daily intakes for each artificial sweetener have been set by the European Food Safety Authority (EFSA), the United States Food and Drug Administration, or the Joint Expert Committee on Food Additives. Nonetheless, they remain a topic of controversy and are currently undergoing a re-evaluation by several health authorities, including the EFSA7 and WHO.8
Some experimental in vivo and in vitro studies, observational studies, and human randomised controlled trials investigated early markers of cardiovascular health, for example, weight status,9101112 hypertension,13 inflammation,14 vascular dysfunction,1516 or gut microbiota perturbation17181920 in association with consumption of artificial sweeteners or artificially sweetened beverages. Most of these studies suggested adverse effects,11121314151617181920 and few suggested neutral or beneficial properties.910 Although the results were mixed, this literature generally supports a potential involvement of artificial sweeteners in cardiovascular health, with plausible mechanisms.212223
Cardiovascular diseases (CVDs) are the leading cause of death worldwide.24 Randomised controlled trials have not directly assessed the impact of artificial sweetener intake on hard endpoints such as CVD risk for ethical reasons. Similarly, observational prospective studies have not directly investigated the association between artificial sweetener intake (mg/day) and CVD risk, but several have used artificially sweetened beverage consumption (millilitres or servings/day) as a proxy to explore these associations with conflicting results.222325262728293031323334 One of these studies was performed in the NutriNet-Santé cohort28 and found that sugary drinks and artificially sweetened beverages were associated with increased CVD risk. Systematic reviews and meta-analyses3536 have suggested direct associations between artificially sweetened beverages and CVD risk. The WHO 2022 report on the health effects of artificial sweeteners notably observed associations between consumption of beverages with artificial sweeteners (used as a proxy) and some intermediate markers of CVD,8 including a modest increase in the unfavourable total cholesterol to HDL cholesterol ratio (meta-analysis of four randomised control trials), and an increased risk of hypertension (meta-analysis of four prospective studies). The international health authority also identified an increase in CVD mortality, and in the incidence of cardiovascular events and strokes associated with greater intake of soft drinks containing artificial sweeteners (meta-analysis of four randomised control trials). However, prospective studies remain limited and the level of evidence for these associations is still considered low by WHO.8 Additionally, because artificially sweetened beverages only represent part of the total artificial sweetener intake, it is crucial to consider all dietary sources in causal studies.
In this context, our objective was to conduct a large scale prospective study using quantitative data to investigate the associations between consumption of artificial sweeteners (mg/day) from all dietary sources (beverages but also table top sweeteners, dairy products, etc), overall and by type (aspartame, acesulfame potassium, and sucralose), and risk of CVD (overall, coronary, and cerebrovascular). Our study was performed within the population based NutriNet-Santé cohort, which includes detailed information on commercial names and brands of industrial food consumed.
Methods
Study population and data collection
This study was based on the prospective NutriNet-Santé e-cohort, launched in France in May 2009, with an open ongoing enrolment of volunteers. The main objective was to investigate the relations between nutrition and health.37 Participants are French adults, aged 18 years or older, with internet access, recruited from the general population by means of multimedia campaigns. They are followed through their personal account created at inclusion on the study website (https://etude-nutrinet-sante.fr/). Immediately after enrolment, each person completes five online questionnaires about diet (24 h dietary records, detailed below), health (eg, personal and familial history, prescription drug use), anthropometric data (height and weight3839), lifestyle and sociodemographic data (eg, date of birth, sex, education level, professional occupation, smoking status, number of children40), and physical activity. Physical activity levels were defined based on the validated seven day assessment International Physical Activity Questionnaire (IPAQ).41 All activities declared by participants were converted into metabolic equivalent of task (MET) minutes per week according to the compendium of physical activities.42 Three levels of physical activity were defined: low (<600 MET-min/week), moderate (600-1500 MET-min/week), and high (>1500 MET-min/week) using standardised IPAQ processing guidelines.41 For instance, 600 MET-min/week is equivalent to 150 min/week of moderate intensity (4 METs) physical activity or 75 min/week of high intensity (8 METs) physical activity.
Each person included in the NutriNet-Santé cohort provides informed consent electronically. The study is registered at ClinicalTrials.gov (NCT03335644), conducted according to the Declaration of Helsinki guidelines, and approved by the Institutional Review Board of the French Institute for Health and Medical Research (IRB-Inserm) and the Commission Nationale de l’Informatique et des Libertés (CNIL No 908450/909216).
Dietary assessment
Three non-consecutive days of 24 h dietary records were randomly assigned over a two week period, at baseline, and every six months thereafter. During those recording days (two weekdays and one weekend day) participants indicated all foods and beverages consumed during the three main meals and any other eating occasions, and in what quantities, using validated photographs and standard serving containers43 or by directly entering the amount (in grams or millilitres). All 24 h dietary records provided during the first two years of each person’s follow-up were averaged to obtain baseline diet. This represents a reliable estimate of consumption habits, while respecting the prospective design and guaranteeing sufficient delay between consumption and CVD outcomes. Intakes of energy, alcohol, and nutrients were assessed using the NutriNet-Santé food composition table (≈3500 food/beverage items44). Nutritional contributions of mixed dishes were estimated by standard French recipes defined by nutrition professionals. Dietary assessment through these 24 h dietary records were validated against interviews by a trained dietitian45 and against blood and urinary biomarkers.4647 The basal metabolic rate and the Goldberg cut-off method enabled any under reporting to be identified484950; participants who under reported were excluded from the analyses. Supplementary method 1 gives details of methods used to identify under reporting.
Artificial sweetener intakes
Chazelas and colleagues described the quantitative evaluation of food additive consumption in participants of the NutriNet-Santé cohort.51 Briefly, food additive intakes, including artificial sweeteners, were assessed through the interactive online 24 h dietary record tool, in which commercial names and brands of industrial products consumed could be recorded. The presence of food additives was first determined for each food and beverage using ingredients lists available from three large scale food composition databases: Open Food Facts (https://world.openfoodfacts.org/)6; the French food safety agency database Oqali (https://www.oqali.fr/oqali_eng/)52; and Mintel’s Global New Products Database.53 Doses of additives were determined by around 2700 assays performed by accredited laboratories, requested by the Nutritional Epidemiology Research Team or by a consumer association (UFC Que Choisir). These quantitative data were completed by average doses per food group provided by EFSA and the Joint FAO/WHO Expert Committee on Food Additives.54 Food additive composition data were matched by date to account for possible industrial reformulations and changes in additive composition (date of consumption was considered to match the product to the closest consumption data). Supplementary method 2 gives additional information on food additive and artificial sweetener intake assessment.
For this study, we were able to estimate intakes of aspartame (European food additive identification number E951), acesulfame potassium (E950), sucralose (E955), cyclamates (E952), saccharin (E954), thaumatin (E957), neohesperidine dihydrochalcone (E959), steviol glycosides (E960), and salt of aspartame-acesulfame potassium (E962) and to create a sum variable labelled total artificial sweeteners.
Cardiovascular disease determination
Throughout follow-up, biannual health questionnaires and a permanently open personal health interface on the study account allowed participants to report any new health events, medical treatments, and examinations. For each incident CVD event declared, participants were contacted by a physician of the team and asked to provide any relevant medical records (eg, radiological reports, electrocardiogram, angioplasty). When necessary, the study physicians contacted the patient’s physician or any hospitals providing treatment to collect additional information. These medical data were reviewed by physician experts. An investigation was also conducted by the physicians of the NutriNet-Santé study by contacting the participant’s family or their physician when no connection to the study website was made for more than a year. Beyond this proactive health follow-up, data were paired with the medico-administrative databases of the national health insurance system database (SNIIRAM) and the national mortality registry (CépiDC), thereby limiting potential bias due to people with CVD not reporting their disease to the study investigators (further information available in supplementary method 3). International classification of diseases clinical modification, 10th revision, was used to classify CVD.55 For this study, first incidence of CVD, coronary heart disease (myocardial infarction, code I21; acute coronary syndrome, code I21.4; angioplasty, code Z95.8; angina pectoris, code I20.0), or cerebrovascular disease (stroke, code I64; transient ischaemic attack, codes G45.8 and G45.9) diagnosed between inclusion and 5 October 2021 were considered as events and investigated in the analyses.
Statistical analyses
Participants with at least two valid dietary records during the first two years of follow-up were included in the analysis. Those with prevalent CVD or pre-existing diabetes were excluded. To limit reverse causality bias (particularly sensitive when sugar was substituted by artificial sweeteners), participants with CVD diagnosed during the first two years of follow-up were also excluded. Supplementary figure 1 presents a flowchart showing detailed selection of the study population.
We classified participants into three categories of artificial sweetener consumption: non-consumers, lower consumers (participants with artificial sweetener intake below the sex specific median among consumers), and higher consumers. Baseline characteristics (sociodemographic, health, lifestyle, dietary intakes) were assessed for each category and compared using χ2 tests for categorical variables and analysis of variance tests for continuous variables (table 1).
Table 1
Baseline characteristics of the study population, NutriNet-Santé cohort, France, 2009-21 (n=103 388)
Associations between artificial sweeteners, overall and the most represented (aspartame, acesulfame potassium, and sucralose, consumed by more than 5% of participants), and CVD (overall, coronary heart disease, and cerebrovascular disease) were investigated using multivariable adjusted Cox proportional hazard models (table 2). Participants contributed person time from their inclusion in the cohort until the date of CVD, date of last follow-up, date of death, or 5 October 2021, whichever occurred first. We first tested dose-response analyses using the restricted cubic spline (RCS) functions with the SAS macro developed by Desquilbet and Mariotti.56 Given the logarithmic profile of the associations suggested by the RCS curves (supplementary fig 2) and to account for the large proportion of non-consumers (especially for each specific artificial sweetener), artificial sweetener intakes were log transformed (log10 of sweetener consumption in mg/g+1) to compute continuous models (+1 was uniformly added to all consumptions because log(0) is not allowed). The continuous model was used as the primary analyses to obtain hazard ratios and 95% confidence intervals. Supplementary tables 1 and 2 presentmodels using three categories (non-consumers, lower consumers, and higher consumers, separated by the sex specific median) and four categories (non-consumers and sex specific consumers in thirds) of sweetener consumption.
Table 2
Associations between intake of total artificial sweeteners, aspartame, acesulfame potassium, and sucralose and overall cardiovascular diseases, coronary heart diseases and cerebrovascular diseases, NutriNet-Santé cohort, France, 2009-21 (n=103 388)
The main models were adjusted for several variables suspected or known to be associated with diet and with CVD risk: sociodemographic (age, sex, educational level), lifestyle (smoking status, number of smoked cigarettes, physical activity), and health (family history of CVD) factors, and food groups and nutrients for which a role in CVD cause has been strongly suggested575859606162636465: energy intake without alcohol, alcohol, sugar, sodium, saturated fatty acids, polyunsaturated fatty acids, fibre, fruit and vegetables, and red and processed meat. We added a table showing the rationale for selection of each covariate and information on how they were collected and measured (supplementary method 4). Analyses by specific artificial sweeteners (aspartame, acesulfame potassium, and sucralose) were additionally adjusted for other artificial sweetener intakes. Multiple imputation by chained equations66 was applied to handle any missing values for covariates (15 imputed datasets; supplementary method 5). Cox proportional hazard assumption was verified using the rescaled Schoenfeld type residual method (supplementary fig 3). Competing risks were accounted for in all analyses using cause specific Cox models,67 with death considered a competing risk for CVDs, coronary heart diseases, and cerebrovascular diseases. Additionally, cerebrovascular events were considered competing risks for coronary heart diseases and vice versa. Supplementary table 3 presents results from competing events. Cumulative incidence graphs were also plotted using the Fine and Gray model (presented in supplementary fig 4).
Associations were computed separately for each type of cerebrovascular or coronary disease event: myocardial infarction, acute coronary syndrome, angioplasty, angina pectoris, stroke and transient ischaemic event (supplementary table 4), and for all CVDs except transient ischaemic events. We also investigated associations between CVD risk and artificial sweeteners from beverages and from solid food (supplementary table 5). Substitution analyses were performed by entering added sugars and artificial sweeteners into the model. Hazard ratios and 95% confidence intervals for substituting artificial sweeteners for added sugars were estimated using the difference in coefficients obtained from this model. Supplementary method 6 presents these analyses. Formal interactions between body mass index (<25 or ≥25) and artificial sweeteners were tested for each outcome by entering the product of the two variables into Cox models.
We performed a sensitivity analysis in which we doubled the requested minimal number of 24 h dietary records (excluding participants with less than four records; supplementary table 6). Additionally, we computed models with artificial sweetener intakes coded as time dependent variables across the whole follow-up period (supplementary table 6). Other sensitivity analyses were also performed, with further adjustments for prevalent dyslipidaemia, for healthy and western dietary patterns (derived by principal components analysis) instead of food groups, added sugar intakes instead of sugar, proportion of ultra-processed foods in the diet, weight loss or calorie restricted diet, weight variation during follow-up, number of 24 h dietary records, body mass index, and social desirability score68; and analyses without excluding prevalent diabetes (details presented in supplementary table 6). All tests were two sided, and P<0.05 was considered statistically significant. We used the statistical analysis software SAS, version 9.4 for analyses.
Patient and public involvement
The research question developed in this article corresponds to a concern expressed by some participants involved in the NutriNet-Santé cohort, and by the public in general. Participants in the study are thanked in the Acknowledgments section.
Results
Descriptive characteristics
Overall, 103 388 participants were selected from the NutriNet-Santé cohort. Mean age at baseline was 42.2 years (standard deviation 14.4), 79.8% were women, and the mean number of 24 h dietary records during the first two years of follow-up was 5.6 (standard deviation 3.1). Supplementary figure 5 shows the distribution of the number of 24 h dietary records per person. Among the overall cohort, 0.94% (n=1639) participants have died since their inclusion (981 in the present population study) and 9.4% (n=16 306) dropped out because they did not want to receive any more questionnaires. A total of 37.1% of participants consumed artificial sweeteners. The average intake of artificial sweeteners was 15.76 mg/day among all participants and 42.46 mg/day among consumers only, which corresponds to approximately one individual packet of table top sweetener or 100 mL of diet soda.6970 Among participants who consumed artificial sweeteners, mean intakes for lower and higher consumer categories were 7.46 and 77.62 mg/day, respectively. Compared with non-consumers, higher consumers (unadjusted comparisons) tended to be younger, have a higher body mass index, were more likely to smoke, be less physically active, and to follow a weight loss diet; they had lower total energy intake, and lower alcohol, lipid (saturated and polyunsaturated), fibre, carbohydrate, fruit and vegetable intakes, and higher intakes of sodium, red and processed meat, dairy products, and beverages with no added sugar (table 1). Aspartame, acesulfame potassium, and sucralose contributed to 58%, 29%, and 10% of total artificial sweetener intakes, respectively (fig 1). Soft drinks with no added sugar accounted for 53% of artificial sweeteners; table top sweeteners were also an important vector (30%), as well as artificially sweetened flavoured dairy products (eg, yoghurts, cottage cheese, 8%; fig 2). As shown in supplementary figure 6, food group contributions varied for each artificial sweetener; for example, table top sweeteners contributed to 48% of aspartame intake, followed by soft drinks with no added sugar (41%), whereas acesulfame potassium and sucralose were both mainly provided by the consumption of soft drinks with no added sugar (76% and 78%, respectively). Participants who consumed artificial sweeteners tended to consume more than one type of the main artificial sweeteners, and 7.23% of the total participants consumed all three of the main types (supplementary fig 7).
Fig 1
Relative contribution of each specific artificial sweetener to the total intake of artificial sweeteners (%), NutriNet-Santé cohort, France, 2009-21 (n=103 388). *Cyclamates (E952), saccharin (E954), thaumatin (E957), neohesperidine dihydrochalcone (E959), steviol glycoside (E960), aspartame-acesulfame salt (E962)
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Fig 1
Relative contribution of each specific artificial sweetener to the total intake of artificial sweeteners (%), NutriNet-Santé cohort, France, 2009-21 (n=103 388). *Cyclamates (E952), saccharin (E954), thaumatin (E957), neohesperidine dihydrochalcone (E959), steviol glycoside (E960), aspartame-acesulfame salt (E962)
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Fig 2
Relative contribution of each food group to the total intake of artificial sweeteners (%), NutriNet-Santé cohort, France, 2009-21 (n=103 388). *Used as tablets, liquid, or powder, added by the participants in yoghurts, hot drinks and so on, or for cooking. †High protein food substitutes, sugary foods, cookies, biscuits, cakes, pastries, breakfast cereals, sauces, savoury foods, ultra-processed fish products
Associations between artificial sweetener intakes and cardiovascular diseases
During follow-up (904 206 person years; median follow-up duration 9.0 years, interquartile range 7.5-10.1 years), 1502 incident cardiovascular events occurred, among which there were 730 coronary heart disease events (143 myocardial infarction, 75 acute coronary syndrome, 477 angioplasty, and 277 angina pectoris events) and 777 cerebrovascular disease events (203 strokes and 598 transient ischaemic events). Mean age at CVD event was 62.7 years (standard deviation 12.9). The RCS analyses suggested a log shaped association (increased risk followed by a plateau; P for non-linearity=0.067, 0.494, 0.016, and 0.021 for total artificial sweetener, aspartame, acesulfame potassium, and sucralose, respectively, for the overall CVD model; supplementary fig 2).
Total artificial sweetener intake was associated with increased risk of CVD (hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03; table 2); absolute incidence rate in higher consumers (above the sex specific median) was 346 per 100 000 person years, and in non-consumers it was 314 per 100 000 person years. Artificial sweeteners were more particularly associated with cerebrovascular disease risk (1.18, 1.06 to 1.31, P=0.002; incidence rates 195 and 150). Aspartame intake was associated with increased risk of cerebrovascular events (1.17, 1.03 to 1.33, P=0.02; incidence rates 186 and 151), and acesulfame potassium and sucralose were associated with increased coronary heart disease risk (acesulfame potassium: 1.40, 1.06 to 1.84, P=0.02; incidence rates 167 and 164; sucralose: 1.31, 1.00 to 1.71, P=0.05; incidence rates 271 and 161). Results were similar when artificial sweetener intakes were coded as time dependent variables (supplementary table 6). For each type of cerebrovascular disease or coronary heart disease, direct associations were observed between sucralose and risk of angioplasties (n=477; 1.60, 1.17 to 2.21, P=0.004) and between total artificial sweeteners and transient ischaemic events (n=598; 1.18, 1.05 to 1.33, P=0.006). For artificial sweeteners from beverages or solid food, associations were statistically significant between sweeteners from beverages and CVD risk (P=0.02) and between aspartame from beverages and coronary heart disease risk (P=0.03). Associations were borderline between acesulfame potassium and sucralose from beverages and coronary heart diseases (P=0.06 and P=0.08, respectively), and between aspartame, acesulfame potassium, and sucralose from solid food sources and cerebrovascular diseases (P=0.006, P=0.01, and P=0.002, respectively; supplementary table 5). Substitution analyses did not suggest a benefit for substituting artificial sweeteners for added sugars for CVD risk (hazard ratio 1.00, 95% confidence interval 0.99 to 1.01, P=0.28), cerebrovascular disease risk (1.00, 0.99 to 1.01, P=0.89), or coronary heart disease risk (1.00, 0.99 to 1.01, P=0.13; supplementary method 6). The results were stable across all sensitivity analyses tested (supplementary table 6). The artificial sweetener by body mass index variable was not statistically significant for overall cardiovascular disease, coronary heart disease, and cerebrovascular disease (all P>0.05), suggesting no interaction on the multiplicative scale.
Discussion
Principal findings
In the NutriNet-Santé cohort, total artificial sweetener intake was associated with increased risk of overall CVD and cerebrovascular disease. Aspartame intake was associated with increased risk of cerebrovascular events, and acesulfame potassium and sucralose were associated with increased coronary heart disease risk. Our results suggest no benefit from substituting artificial sweeteners for added sugar on CVD outcomes.
Strengths and limitations of this study
This study was based on a large sample size (n=103 388) and prospectively investigated the associations between artificial sweetener intake from all dietary sources and CVD risk. There is no perfect measure of dietary consumption, therefore classification bias cannot be ruled out. However, the assessment of artificial sweetener consumption performed in this study was a comprehensive assessment at the individual level in a large scale population based cohort. The NutriNet-Santé study is an epidemiological cohort with precise and high quality dietary data. Dietary records have previously been validated by interviews with a trained dietitian33 and against blood and urinary biomarkers for energy and nutrient intakes.3435 Epidemiological studies worldwide generally use food frequency questionnaires (known to be less precise than repeated 24 h dietary records71) or a limited number of records or recalls at baseline.
The main vectors of artificial sweeteners are products that are generally consumed on a regular basis as part of daily dietary habits, including artificially sweetened beverages, table top sweeteners, and dairy products. Occasional artificial sweetener consumption is not likely to have a strong impact on CVD risk, and so even if some consumption might have been missed, it would probably have had a low impact on the study results. If there was a classification bias, it was non-differential due to the prospective design. Additionally, a sensitivity analysis was performed in the subgroup of participants with at least four records (mean 7.8, standard deviation 2.4, n=57 668), which doubled the minimal number of 24 h dietary records needed to be included in the analysis, and the results remained similar. Twenty four hour dietary recording days were decided in advance, which might have influenced the behaviour of participants on these days; however, adjustment for social desirability bias did not modify the findings, and the comprehensive recording enabled memory bias to be limited. In contrast to previous observational studies, artificially sweetened beverages were not used as a proxy to estimate artificial sweetener intakes. Detailed information on the brands of food or beverage consumed are collected as part of the NutriNet-Santé study. The dynamic date-to-date matching performed between the interactive web based 24 h dietary records and specific ingredient lists allowed the additive composition of industrial products to be identified, accounting for potential reformulations.51
Some limitations should be discussed. Residual confounding cannot be totally excluded and no causal relation can be established with results from a unique observational study. However, models were adjusted for a wide range of potential sociodemographic, anthropometric, dietary, and lifestyle confounders. Further adjustment for the proportion of ultra-processed food in the diet was conducted, ensuring that the associations observed were not entirely driven by following an ultra-processed diet in general.72 Additionally, reverse causality could lead to higher artificially sweetened food and beverage consumption among participants who were overweight or obese, and already had poorer cardiovascular health at baseline before CVD diagnosis.7374 However, this factor probably does not entirely explain the observed associations because we excluded CVD events occurring during the first two years of follow-up and we also tested models adjusted for baseline body mass index, weight loss diet, and weight change during follow-up, which did not substantially change the results.
Caution is needed to generalise these results to the whole French population. As generally observed in volunteer based cohorts, participants from the NutriNet-Santé study were more often women, with higher educational and socio-professional levels, and they were more likely to have a health conscious lifestyle and good dietary behaviours.75 Therefore, artificial sweetener intake among NutriNet-Santé participants could be lower compared with French adults in general. Mean intakes of aspartame and acesulfame potassium for consumers in the cohort were 0.49 and 0.22 mg/kg body weight/day, respectively versus 1.29 and 0.73 mg/kg body weight/day, respectively estimated in the French population.76 These intakes suggest that the associations found in our study between artificial sweetener consumption and risk of CVD might be underestimated. However, our assessment was more accurate than the one previously performed for the general French population,76 which was based on three days of dietary records by participants at most, and brand specific composition was not accounted for.
The order of magnitude obtained for the associations in this study is in line with the one traditionally observed in nutritional epidemiology studies for commonly consumed dietary factors,727778 and with the findings of WHO in its recent report,8 which was based on meta-analyses of prospective cohort studies investigating intake of beverages containing artificial sweeteners.2526272829303132 Furthermore, in terms of public health perspectives, the opportunity of preventing even a moderate proportion of CVD events through reduced artificial sweetener intake is of high interest given the extensive use of these substances in products on the global market. Associations were consistent across the many sensitivity analyses we performed; they were also consistent with previous epidemiological literature on proxies of sweetener intakes (eg, artificially sweetened beverages) and in line with mechanistic insights from experimental studies. All observed associations between sweetener intakes and CVD events went in the same (positive) direction, which is not in favour of random findings observed by chance.
The two complementary methods (self-reporting and medico-administrative databases) ensured good identification of CVD outcomes. However, the possibility of missing some events cannot be entirely ruled out. Additionally, despite efforts to identify transient ischaemic attacks as objectively as possible (based on medical or hospital reports, if possible a specialised neurological diagnosis, computed tomography or magnetic resonance imaging scan, or symptoms precisely described by the participant or a person close to them), these CVD events could not be diagnosed with the same certainty as for strokes or myocardial infarctions because they generally do not reveal sequelae on brain imaging. Finally, limited statistical power might have prevented us from detecting some associations for specific CVD pathologies.
Comparison with other studies
Observational prospective studies on the associations between artificial sweeteners, assessed from the whole diet (in mg/day), and CVD risk are lacking; therefore, no direct comparison was possible. However, several studies have been conducted25262728293031323334 and meta-analysed82235367379 using artificially sweetened beverage consumption as a proxy (in mL or serving/day) and CVD risk. In line with recent results from the NutriNet-Santé study,28 multiple cohorts found associations between artificially sweetened beverages and CVD. Higher artificially sweetened beverage consumption was associated with increased risks of stroke and cardiovascular events in the Women’s Health Initiative,2629 which is consistent with prospective investigations from the Nurses’ Health Study, the Health Professional Follow-up Study (HPFS),2530 the Framingham Offspring cohort,31 and the Northern Manhattan Study.27 Similarly, meta-analyses reported increased risks of stroke, vascular events, coronary heart diseases, CVDs, and CVD mortality.35367379 Consistent with our findings, no association was observed for coronary heart diseases in the HPFS.33 These studies mostly took place in the United States35 and have not been as extensively explored in European populations. In line with our results, the recent WHO meta-analyses8 reported positive associations between the intake of beverages containing artificial sweeteners and cardiovascular events overall (hazard ratio 1.32, 95% confidence interval 1.17 to 1.50, three prospective studies262728) and more specifically for the incidence of stroke (1.19, 1.09 to 1.29, five prospective studies2527293132), but not for coronary heart disease (1.16, 0.97 to 1.39, four prospective studies27293380).
Meta-analyses performed by Azad and colleagues22 also suggested associations between high intake of drinks with non-nutritive sweeteners and higher risk of strokes25 and cardiovascular events,2627 but no significant associations were found for coronary heart diseases.3380 However, other studies suggested associations between artificially sweetened beverages and stroke but also coronary heart diseases.29 Differences between results for coronary heart and cerebrovascular diseases could be because these pathologies have different causes and therefore, although they might share common nutritional determinants, others might play a different role in the development of these diseases. Each type of artificial sweetener might not have the same metabolic effect.14 For instance, after ingestion, acesulfame potassium is absorbed from the small intestine and distributed to the blood and tissues through the systemic circulation and then excreted in urine. However, sucralose passes through digestion and is almost entirely excreted in the stools; only a small part is absorbed from the gastrointestinal tract. The aspartame molecule is broken down in different amino acids: aspartic acid and phenylalanine are sent to the systemic circulation while methanol is metabolised by the liver.14 Because this study quantified the intake of each specific sweetener and investigated the association with CVD risk, overall and by type, future epidemiological studies and experimental data will be needed to further investigate a potential differential effect of artificial sweeteners according to cerebrovascular or coronary CVD types.
Furthermore, according to WHO8 and as mentioned in the systematic reviews by Toews and colleagues and Zhang and colleagues,2373 randomised controlled trials investigating the long term effects of artificial sweeteners on the risk of hard endpoints such as CVD are lacking. However, some have studied early markers of cardiovascular health, such as weight variations, hypertension, or blood glucose level.8182 Most of these studies were conducted among participants with particular conditions (eg, people who were overweight or those with prevalent hypertension)22 and were of short duration (follow-up around six months), with a level of evidence ranging from very low to moderate.2383 Additionally, it should be noted that many studies investigating the health effects of artificial sweeteners are funded by the industry, notably several randomised control trials included in reviews and meta-analyses. Azad and colleagues reported that industry sponsored randomised controlled trials suggest greater weight loss results compared with studies not financed by industry.22 For instance, a systematic review has specifically studied the issue of conflict of interest in this field84 and revealed that reviews sponsored by the artificial sweetener industry were more inclined to show beneficial weight loss effects. Therefore, no firm conclusion could be drawn from randomised controlled trials about the cardiometabolic impact of artificial sweeteners. However, several of these randomised controlled trials observed increased associations with several cardiometabolic outcomes, suggesting mechanistic plausibility for an impact of artificial sweeteners on cause of CVD.
Mechanistic plausibility from experimental studies
In some prospective cohort studies, associations have been reported between artificially sweetened beverage consumption and increased risk of obesity or weight gain.8228586 Low calorie sweeteners (from beverages, table top sweeteners, and foods) were associated with obesity in the National Health and Nutrition Examination Survey87 and abdominal obesity in the Baltimore Longitudinal Study of Ageing.88 A cross-sectional study also found that consumers of diet soft drinks had greater waist circumference.89 In the PREDIMED study (multicentre randomised trial) there was a positive association between artificially sweetened beverages and abdominal obesity.90 Therefore, part of the associations between artificial sweeteners and CVD risk observed in our study might be because of weight gain. However, the associations observed here are probably not entirely driven by increased body weight. The impact of artificial sweeteners on weight gain is debated.892223 Some randomised controlled trials found no effect on body weight when replacing sugar sweetened beverages with artificially sweetened versions,91 and others suggested decreased body weight, body mass index, fat mass, and waist circumference.8385 Adjustment for baseline body mass index and weight gain during follow-up did not modify the findings.
Other underlying mechanisms could be causally involved.9293 Meta-analyses suggest associations between artificially sweetened beverages and metabolic syndrome,9495 a cardiometabolic risk factor defined by dyslipidaemia, abdominal obesity, high blood glucose, insulin resistance, and hypertension.96 Artificially sweetened beverages were associated with increased risk of metabolic syndrome899097 in a cohort study,97 a cross-sectional study,89 and a multicentre randomised trial.90 More specifically, associations were observed with increased hypertension,89899 type 2 diabetes,887100 and hypertriglyceridemia.890 Another potential pathway could involve the interaction of artificial sweeteners with intestinal sweet taste receptors,92 which play a part in insulin secretion and glucose absorption. Experimental studies (rodent models) suggest that glucose and energy homoeostasis could be altered by artificial sweeteners.11101 Ingestion of sugar by animals accustomed to artificial sweeteners could lead to low glucagon like peptide 1 levels (which normally stimulate insulin secretion) and induce hyperglycaemia,101 which could also be observed in humans.92 Additionally, the alteration of gut microbiota by some artificial sweeteners could increase glucose intolerance,17 but the results remain conflicting.20 Vascular dysfunction, which contributes to CVD onset and development, after the ingestion of artificial sweeteners, has been observed in experimental studies (rodent models)15 and in vitro (human cellular model),16 and could also play a part in the risk of CVD. Finally, Basson and colleagues14 suggest that artificial sweetener consumption might be associated with increased inflammation, a risk factor for CVD.96
Policy implications and conclusions
In conclusion, these findings suggest that higher artificial sweetener consumption might be associated with increased risk of CVDs. Further well designed, large scale prospective studies need to confirm these results and experimental studies should be conducted to clarify biological pathways. In the meantime, this study provides key insights into the context of artificial sweetener re-evaluation by the EFSA, WHO, and other health agencies worldwide. Our results indicate that these food additives, consumed daily by millions of people and present in thousands of foods and beverages, should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies.23102
What is already known on this topic
The harmful effects of added sugars have been established for several chronic diseases, leading food industries to use artificial sweeteners as alternatives in a wide range of foods and beverages
The safety of artificial sweeteners is debated and study findings remain divided about their role in the cause of various diseases
The negative influence of these food additives on cardiovascular disease has been suggested in experimental studies, but data from human studies remain limited and previous observational studies have focused solely on artificially sweetened beverages used as a proxy
What this study adds
In this large scale, prospective cohort of French adults, artificial sweeteners (especially aspartame, acesulfame potassium, and sucralose) were associated with increased risk of cardiovascular, cerebrovascular, and coronary heart diseases
The results suggest that artificial sweeteners might represent a modifiable risk factor for cardiovascular disease prevention
The findings indicate that these food additives, consumed daily by millions of people and present in thousands of foods and beverages, should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies
Artificial sweeteners are linked to an increased risk of heart disease and “should not be considered a healthy and safe alternative to sugar”, according to researchers.
The harmful effects of added sugars have been long established for multiple chronic diseases, leading food companies to use artificial sweeteners instead in a wide range of food and drinks consumed daily by millions of people worldwide.
However, their use has come under increased scrutiny in recent years, although study findings have been divided about their part in various diseases.
Their role in cardiovascular disease has previously been suggested in experimental studies, but data from human studies was limited and previous observational studies focused solely on artificially sweetened drinks used as a proxy.
Now the findings from a large-scale prospective cohort study suggest a potential direct association between higher consumption of artificial sweetener and an increased risk of cardiovascular disease.
“Our results indicate that these food additives, consumed daily by millions of people and present in thousands of foods and beverages, should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies,” the researchers wrote in the BMJ.
In the study, of 103,000 French adults, artificial sweeteners were associated with increased risk of cardiovascular, cerebrovascular, and coronary heart diseases. “The results suggest that artificial sweeteners might represent a modifiable risk factor for cardiovascular disease prevention,” they wrote.
The research, led by experts from the Sorbonne Paris Nord University, examined intake of sweeteners from all dietary sources, including drinks, tabletop sweeteners and dairy products, and compared it with their risk of heart or circulatory diseases.
Participants had an average age of 42, and four in five were women. Sweetener intake was tracked using diet records.
The participants noted everything they ate, including which brand, for 24 hours, with their diet diary repeated three times at six-month intervals – twice on weekdays and once on a weekend day. Some 37% of them consumed artificial sweeteners.
During an average follow-up period of about a decade, 1,502 cardiovascular events were recorded, including heart attacks, stokes, mini strokes and angina.
Artificial sweetener consumption was linked to a 9% higher risk of cardiovascular disease, the BMJ reported. When researchers looked at specific types of illness, they found artificial sweetener consumption was linked to an 18% higher risk of cerebrovascular disease – conditions that affect the blood flow to the brain.
A specific type of sweetener – aspartame – was associated with a 17% increased risk of cerebrovascular events, while acesulfame potassium and sucralose were linked to increased risk of coronary heart disease.
The study was observational, so cannot establish cause, nor rule out the possibility that other unknown factors may have affected the results. Nevertheless, the researchers said, it was a large study that assessed artificial sweetener intake using precise, high-quality dietary data, and the findings were in line with other studies linking artificial sweeteners with markers of poor health. Further studies were needed, they said.
