Curr Gastroenterol Rep (2015) 17:1 DOI 10.1007/s11894-014-0423-z
NUTRITION AND OBESITY (S MCCLAVE, SECTION EDITOR)
The Paradox of Artificial Sweeteners in Managing Obesity Jason R. Roberts
# Springer Science+Business Media New York 2015
Abstract The role of artificial sweeteners in the management of obesity is controversial. Observational data have suggested that nonnutritive sweeteners (NNSs) may promote weight gain through poorly understood mechanisms of cravings, reward phenomenon, and addictive behavior via opioid receptors. Interventional studies suggest the opposite that substitution of NNS for sugar-sweetened beverages (SSBs) results in reduced caloric intake and modest degrees of weight loss. Whether the use of NNS provides benefit toward weight reduction in the individual patient may depend on the characteristics of their baseline diet, associated changes, or dietary compensation involved with ingestion of NNS, and the degree of compliance with a more complete weight loss program. Keywords Artificial sweeteners . Obesity . Sugar substitutes
Introduction The obesity epidemic affects diverse parts of the globe and is linked to a “Westernized lifestyle,” which includes a caloriedense diet and a relative lack of exercise resulting in a net positive-energy balance. The long-term-associated health outcomes include type 2 diabetes mellitus (DM), dyslipidemia, coronary artery disease (CAD), insulin resistance, hypertension, hepatic steatosis, and cerebral vascular disease. There are numerous factors at the individual and societal levels This article is part of the Topical Collection on Nutrition and Obesity J. R. Roberts Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA J. R. Roberts (*) Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY 40202, USA e-mail: [email protected]
contributing to this epidemic, making a single solution to the problem unrealistic. Our diets are dense in calories, largely from added sugars, leading to an imbalance in energy intake and expenditure. Sugar-sweetened beverages (SSBs) are the greatest source of added dietary sugars and are the single largest source of calories in the diets of Americans [1, 2]. These drinks are consumed with meals and as snacks and are void of much nutritional value. The regular consumption of SSB has been linked with the onset of obesity, insulin resistance, dental caries, type 2 DM, and CAD [3–8]. The consumption of SSB by children is especially alarming given the marketing of fruit juices, sports drinks, vitamin waters, and soft drinks to this demographic and the life-long implications of establishing poor dietary choices at a young age. Nonnutritive sweeteners (NNSs) have been used as food additives for decades, and six (saccharine, aspartame, acesulfame-K, sucralose, tagatose, and steviol glycoside) are approved by the FDA under the category of generally regarded as safe (GRAS) for consumption. It is logical to conclude that replacing SSB with NNS beverages would lead to a reduction in calories and less weight gain or even weight loss. The key is whether energy compensation occurs, which is to say, there is consumption of additional calories exceeding the calorie savings from the NNS. The National Health and Nutrition Examination Survey (NHANES) concluded that on any given day, 15 % of Americans consumed a NNS during 2003 compared to just 3 % in 1965 and this trend is growing [9]. The International Food Information Council Foundation surveyed American adults in 2012 about why they chose NNS over nutritive sweeteners [10]. Seventy-three percent of respondents indicated that they used NNS to reduce their caloric intake. It is clear that more and more people are drinking NNS beverages to at least reduce total calorie intake and in some cases to achieve weight loss. The literature however contains conflicting data concerning the role of NNS as a weight management tool,
1
Page 2 of 3
Curr Gastroenterol Rep (2015) 17:1
Longitudinal and cross sectional studies have shown an overall association of NNS consumption and obesity, whereas others have not [11]. To infer causality from these observed associations would be incorrect. These early studies have been criticized for not meeting the Bradford-Hill criteria for causal inference, and more recent studies have largely contradicted these earlier findings [12]. Reverse causality likely contributes to these observed associations, where consumption of NNS is higher in obese individuals. In these cases, NNS are more likely being used as a weight loss tool by obese individuals and not the cause of their obesity. This is supported by the responses from a 2012 survey where 40 % of people consuming NNS did so to achieve weight loss and 41 % did so for calorie reduction [12]. A perception of NNS is that they don’t satiate and that they may have the opposite effect of increasing hunger, leading to immediate or delayed energy compensation. While the results of small, short-term studies are mixed on the appetite effect of NNS, Mattes and Popkin concluded from these studies that NNS substituted for SSB results in incomplete energy compensation [9]. This is particularly true when NNS beverages are consumed in combination with energy-yielding foods. The short-term effects of NNS on appetite regulation by Maersk compared energy intake from an ad libitum meal following ingestion of either a SSB, NNS, or water [13]. The total energy intake was higher in the SSB group, and gastric inhibitory peptide, Ghrelin concentrations, GLP-1, and appetite scores were similar in the NNS and water groups. At 10 weeks, the NNS effects on postprandial glucose, insulin, lactate, triglyceride, leptin, glucagons, and GLP-1 were significantly lower in subjects randomized to NNS and the ad libitum diet compared to a SSB group [14]. Although these short-term data are interesting, there is a need for long-term studies demonstrating the effect of habitual consumption of NNS and the role they play in satiety and metabolism.
2006 evaluated changes in diet and lifestyle and the impact on weight gain in men and women [15]. In the multivariate analysis, diet soda consumption was associated with weight loss of −0.11 (−0.21 to −0.02; p=0.02), whereas SSB were associated with weight gain of 1.00 (0.83 to 1.17; p=
NUTRITION AND OBESITY (S MCCLAVE, SECTION EDITOR)
The Paradox of Artificial Sweeteners in Managing Obesity Jason R. Roberts
# Springer Science+Business Media New York 2015
Abstract The role of artificial sweeteners in the management of obesity is controversial. Observational data have suggested that nonnutritive sweeteners (NNSs) may promote weight gain through poorly understood mechanisms of cravings, reward phenomenon, and addictive behavior via opioid receptors. Interventional studies suggest the opposite that substitution of NNS for sugar-sweetened beverages (SSBs) results in reduced caloric intake and modest degrees of weight loss. Whether the use of NNS provides benefit toward weight reduction in the individual patient may depend on the characteristics of their baseline diet, associated changes, or dietary compensation involved with ingestion of NNS, and the degree of compliance with a more complete weight loss program. Keywords Artificial sweeteners . Obesity . Sugar substitutes
Introduction The obesity epidemic affects diverse parts of the globe and is linked to a “Westernized lifestyle,” which includes a caloriedense diet and a relative lack of exercise resulting in a net positive-energy balance. The long-term-associated health outcomes include type 2 diabetes mellitus (DM), dyslipidemia, coronary artery disease (CAD), insulin resistance, hypertension, hepatic steatosis, and cerebral vascular disease. There are numerous factors at the individual and societal levels This article is part of the Topical Collection on Nutrition and Obesity J. R. Roberts Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA J. R. Roberts (*) Division of Gastroenterology, Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY 40202, USA e-mail: [email protected]
contributing to this epidemic, making a single solution to the problem unrealistic. Our diets are dense in calories, largely from added sugars, leading to an imbalance in energy intake and expenditure. Sugar-sweetened beverages (SSBs) are the greatest source of added dietary sugars and are the single largest source of calories in the diets of Americans [1, 2]. These drinks are consumed with meals and as snacks and are void of much nutritional value. The regular consumption of SSB has been linked with the onset of obesity, insulin resistance, dental caries, type 2 DM, and CAD [3–8]. The consumption of SSB by children is especially alarming given the marketing of fruit juices, sports drinks, vitamin waters, and soft drinks to this demographic and the life-long implications of establishing poor dietary choices at a young age. Nonnutritive sweeteners (NNSs) have been used as food additives for decades, and six (saccharine, aspartame, acesulfame-K, sucralose, tagatose, and steviol glycoside) are approved by the FDA under the category of generally regarded as safe (GRAS) for consumption. It is logical to conclude that replacing SSB with NNS beverages would lead to a reduction in calories and less weight gain or even weight loss. The key is whether energy compensation occurs, which is to say, there is consumption of additional calories exceeding the calorie savings from the NNS. The National Health and Nutrition Examination Survey (NHANES) concluded that on any given day, 15 % of Americans consumed a NNS during 2003 compared to just 3 % in 1965 and this trend is growing [9]. The International Food Information Council Foundation surveyed American adults in 2012 about why they chose NNS over nutritive sweeteners [10]. Seventy-three percent of respondents indicated that they used NNS to reduce their caloric intake. It is clear that more and more people are drinking NNS beverages to at least reduce total calorie intake and in some cases to achieve weight loss. The literature however contains conflicting data concerning the role of NNS as a weight management tool,
1
Page 2 of 3
Curr Gastroenterol Rep (2015) 17:1
Longitudinal and cross sectional studies have shown an overall association of NNS consumption and obesity, whereas others have not [11]. To infer causality from these observed associations would be incorrect. These early studies have been criticized for not meeting the Bradford-Hill criteria for causal inference, and more recent studies have largely contradicted these earlier findings [12]. Reverse causality likely contributes to these observed associations, where consumption of NNS is higher in obese individuals. In these cases, NNS are more likely being used as a weight loss tool by obese individuals and not the cause of their obesity. This is supported by the responses from a 2012 survey where 40 % of people consuming NNS did so to achieve weight loss and 41 % did so for calorie reduction [12]. A perception of NNS is that they don’t satiate and that they may have the opposite effect of increasing hunger, leading to immediate or delayed energy compensation. While the results of small, short-term studies are mixed on the appetite effect of NNS, Mattes and Popkin concluded from these studies that NNS substituted for SSB results in incomplete energy compensation [9]. This is particularly true when NNS beverages are consumed in combination with energy-yielding foods. The short-term effects of NNS on appetite regulation by Maersk compared energy intake from an ad libitum meal following ingestion of either a SSB, NNS, or water [13]. The total energy intake was higher in the SSB group, and gastric inhibitory peptide, Ghrelin concentrations, GLP-1, and appetite scores were similar in the NNS and water groups. At 10 weeks, the NNS effects on postprandial glucose, insulin, lactate, triglyceride, leptin, glucagons, and GLP-1 were significantly lower in subjects randomized to NNS and the ad libitum diet compared to a SSB group [14]. Although these short-term data are interesting, there is a need for long-term studies demonstrating the effect of habitual consumption of NNS and the role they play in satiety and metabolism.
2006 evaluated changes in diet and lifestyle and the impact on weight gain in men and women [15]. In the multivariate analysis, diet soda consumption was associated with weight loss of −0.11 (−0.21 to −0.02; p=0.02), whereas SSB were associated with weight gain of 1.00 (0.83 to 1.17; p=
