1. Total artificial sweetener intake was associated with increased risk of cardiovascular diseases in a large cohort of French participants.
2. Artificial sweeteners may not be a safe and healthy sugar alternative and may represent a modifiable risk factor for cardiovascular disease.
Evidence Rating Level: 2 (Good)
Study Rundown: The harmful effects of added sugars on various health outcomes, including cardiometabolic disorders, have been well studied and documented. The World Health Organization recommends that less than 5% daily energy intake should come from free sugar. Artificial sweeteners that produce a sweet taste but have less calorie content than free sugar have emerged as an alternative to added sugar. A number of food safety authorities worldwide have established acceptable daily intakes for different artificial sweeteners and they currently represent a $7200 million market globally. Nevertheless, they remain a controversial topic consistently underdoing discussion and reevaluation. Prior studies have found that consumption of artificial sweeteners is associated with early markers of cardiovascular disease, such as increased weight gain, hypertension, inflammation, and vascular dysfunction. Prospective studies remain limited and the level of evidence for these associations is still considered to be low. Consequently, this study investigated the associations between artificial sweeteners from all dietary sources and risk of cardiovascular diseases. The study was performed within the population-based NutriNet-Santé cohort, which was conducted between 2009 and 2021 in France and explored the relation between nutrition and health. Participants’ dietary intakes and artificial sweetener consumption were assessed using repeated 24-hour dietary records. Throughout follow-up, biannual health questionnaires and a permanently open personal health interface allowed participants to report any new health diagnoses and treatments. Associations between sweeteners and cardiovascular disease risk were assessed by multivariable-adjusted Cox hazard models. It was found that total artificial sweetener intake was associated with increased risk of cardiovascular diseases. These results suggest that artificial sweeteners, consumed daily by millions of individuals, should not be considered a safe and healthy alternative to sugar, and may represent a modifiable risk factor for cardiovascular disease prevention.
In-Depth [Prospective Cohort Study]: This study was based on the prospective NutriNet-Santé cohort, launched in France in May 2009. It aimed to investigate associations between nutrition and health. French adults, aged 18 and older, were enrolled and followed via a personal account created on the study website. Each participant completed five online questionnaires about diet, health, anthropometric data, lifestyle and sociodemographic data, and physical activity. The diet questionnaire consisted of three non-consecutive days of 24-hour dietary records that were randomly assigned over a two-week period at baseline and every six months thereafter. Participants were asked to indicate all foods and beverages consumed during their three main meals and at any other eating occasions, alongside quantities. All 24-hour dietary records provided during the first two years of each participant’s follow-up were averaged to obtain a baseline diet. The presence of food additives, including artificial sweeteners, was determined for each food and beverage using ingredient lists available from three food composition databases. For cardiovascular disease determination, participants completed a health questionnaire biannually. They also had access to an open health interface on their personal study accounts. For each cardiovascular disease event declared, participants were contacted by a team physician and asked to provide relevant details and records. Associations were investigated using multivariable-adjusted Cox proportional hazard models. Overall, 103,388 participants were selected from the NutriNet-Santé cohort (mean age 42.2 years, 79.8% women). 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. 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, have a higher body mass index, were more likely to smoke, be less physically active, and to follow a weight loss diet. 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 ischemic events). Total artificial sweetener intake was associated with an increased risk of CVD (hazard ratio 1.09, 95% confidence interval 1.01 to 1.18, P=0.03). 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). The findings from this study suggest a potential direct association between higher artificial sweetener consumption and increased cardiovascular risk.
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