Reducing the Sugar Burden using Non-Nutritive Sweeteners: Review of Evidence and Recommendations

Review Article

Int J Nutr Sci. 2019; 4(1): 1029.

Reducing the Sugar Burden using Non-Nutritive Sweeteners: Review of Evidence and Recommendations

Hwalla N¹*, Al Dhaheri AS², Al-Madani K³, Ayesh WH4, El-Dien MM5, Cheikh Ismail L6 and Sadikot SM7

1Department of Nutrition and Food Sciences, American University of Beirut, Lebanon

2Department of Nutrition and Health, United Arab Emirates University, United Arab Emirates

3Department of Clinical Nutrition, Vice President of Saudi Society for Food and Nutrition, KSA

4Department of Clinical Nutrition in Clinical Support Services, Sector for the Dubai Health Authority, United Arab Emirates

5Department of Food Safety and Contamination, National Research Centre (NRC), Egypt

6Department of Clinical Nutrition and Dietetics, University of Sharjah, United Arab Emirates

7Department of International Diabetes Federation. President, India

*Corresponding author: Hwalla N, Department of Nutrition and Food Sciences, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon, Tel.: +961-370 6700, Email: [email protected]

Received: February 20, 2019; Accepted: March 19, 2019; Published: March 26, 2019

Abstract

Consumption of added sugars has been imnplicated in an increased risk of a variety of chronic diseases including obesity, cardiovascular diseases, diabetes as well as cognitive decline and some cancers. Middle East (ME) region suffers from high rates of nutrition-related non-communicable diseases (NR-NCDs), as well as a high intake of sugar, higher than the level recommended by the World Health Organization (WHO). FDA approved Non-Nutritive Sweeteners (NNS) are commonly used as sugar substitutes as they are sweeter than sugar and contribute negligible calories when added to food, making them a desirable substitute to sugar for dietary management of diabetes, obesity and the NCDs. Safety concerns have been raised in the ME region regarding the safety and efficacy of NNS and their efficient use in foods.

Data from animal and observational studies and evidence from systematic reviews and meta-analyses of Randomized Controlled Trials (RCTs) have shown the potential of NNS as a safe replacement for sugar but have, at times, reported caution for their use as harmful to health. This paper aims to review the available published data on the safety of NNS and provide evidence-based recommendations for their use in the Middle East region.

Keywords: Sugar; Sweetener; Non-nutritive sweetener; Low calorie sweetener; Artificial sweetener; High intensity sweetener; Safety

Abbreviations

ME: Middle East; NR-NCD: Nutrition-Related Non- Communicable Diseases; WHO: World Health Organization; NNS: Non-Nutritive Sweeteners; RCT: Randomized Controlled Trials; CVD: Cardiovascular Disease; NAFLD: Non-Alcoholic Fatty Liver Disease; NHANES: National Health and Nutrition Examination Survey; MENA: Middle East and North Africa Region; FDI: Federation Dentaire Internationale; FAO: Food and Agricultural Organization; BMI: Body Mass Index; UAE: United Arab Emirates; US: United States; FDA: Food and Drug Administration; GRAS: Generally Recognized as Safe; Ace-K: Acesulfame-Potassium; NTP: National Toxicology Program; NIH: National Institute of Health; EFSA: European Food Safety Authority; FSANZ: Food Standards Australia and New Zealand; HC: Health Canada; JECFA: Joint WHO/FAO Expert Committee of Food Additives; ADI: Acceptable Daily Intake; NOAEL: No Observed Adverse Effect Level; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta- Analyses; CINAHL: Cumulative Index to Nursing and Allied Health Literature; ADA: American Diabetes Association; NCI: National Cancer Institute

Introduction

Consumption of added sugars has been implicated in increased risk of a variety of chronic diseases including obesity, Cardiovascular Disease (CVD), diabetes and Non-Alcoholic Fatty Liver Disease (NAFLD) as well as cognitive decline and even some cancers [1-4]. Analysis of National Health and Nutrition Examination Surveys (NHANES, 1988-1994, 1999-2004, and 2005-2010) demonstrated a significant increase in cardiovascular mortality with increasing levels of sugar intake [5]. A systematic review, commissioned by the World Health Organization (WHO) in 2012, included a total of 68 trials, and concluded that reduced intake of dietary sugars was associated with a decrease in body weight [6]. A systematic review of 8 human epidemiologic studies on sugar and dental caries demonstrated a significant increase in the risk of dental caries with increasing level of sugar intake, especially above 10% of total calorie intake [7]. Further clinical trials have shown that excessive sugar consumption may be associated with an increased risk of cancer [8-10].

The Middle East and North Africa region (MENA) has very high intake of sugar, higher than the levels recommended by the WHO. Data on sugar consumption from the second edition of the Oral Health Atlas published by the Federation Dentaire Internationale (FDI) World Dental Federation in 2011 indicates that most countries in our region consume sugar at 15% of total energy intake i.e. approximately 75 g sugar per person per day (Table 1) [11]. WHO 2015 data indicates that calorie intake in the MENA region has escalated from 2290 Kcal per capita per day in the years 1964-1966, to 3090 Kcal per capita per day in the year 2015, and is estimated to reach 3170 Kcal per capita per day by the year 2030 [12]. The 2012 food-based dietary guidelines, promoted by Food and Agricultural Organization (FAO) and WHO, noted that overconsumption of foods rich in sugar leads to poor dental health and an increase in energy intake, which contributes to weight gain [13].