Sugar consumption has been found to be associated with weight gain, and a variety of associated diseases are attributed to it such as cardiovascular diseases, hypertension, type 2 diabetes, fatty liver, dental caries, and more. As a result, already in 2015, the dietary recommendations for the public on behalf of many government bodies and health organizations included a significant reduction in sugar consumption. These recommendations led the manufactures to produce drinks and foods with sugar substitutes that give the sweet taste but are not sugar itself.
The manufactures produce a product with almost the same taste and the customers are "satisfied", as they are sure that they got the drinks and foods they like without the calories and without the harm of sugar. It seemed like a perfect solution was found and that you could consume diet drinks without any concern. Over the years, accumulated data has proven it wrong. Here are a few things that disprove some of these beliefs.
In a survey carried out before the campaign on sweet drinks in 2022, it was found that about 32% of adults in the general population and the Haredi sector and about 24% of the Arab sector consume "diet" drinks at least once a week. Among children 3-18 years old, about 20% of the general population and the Arab sector and 12% from the Haredi sector consume diet drinks. Stornext data indicated that in 2018-2020, there was a decrease in the quantitative sales of sweetened beverages, though there was a significant increase in the quantitative and NIS sales of diet drinks.
The World Health Organization: sugar substitutes ("diet") has are associated with health damages
Sugar substitutes are a variety of natural or artificial substances with no or little calories, which stimulate a sweet taste. They were developed as an alternative to sugar for the purpose of sweetening. Although they are approved for use in the food industry, the effect of long-term use of them in high quantities and among different populations (children, pregnant women) is evaluated only several years later.
A broad literature review and meta-analysis performed by researchers of the World Health Organization recently (April 2022) sought to assess the relationship between the consumption of sugar substitutes and obesity, chronic morbidity (heart disease, diabetes, cancer) and mortality. The review included 370 studies that compared the use of sugar substitutes to the use of sugar, the use of placebo or the use of water.
So, what do we know today about sugar substitutes and their effect on health:
Do they help with weight loss and prevent diabetes?
After following large populations over a long period of time (studies of up to 30 years!) it was found that the consumption of sugar substitutes was associated with weight gain and a 76% increase in the risk of overweight.
In addition, the consumption of sugar substitutes was associated with an increased risk of developing type 2 diabetes – a 23% increase in risk following the consumption of sugar substitutes in beverages and a 34% increase in risk following the use of sugar substitutes as an addition to drinks and food.
Studies comparing the effect of sugar-sweetened beverages to drinks with sugar substitutes showed a decrease in calorie consumption (approximately 136 Kcal less per day when sugar-sweetened beverages were replaced with sugar substitutes). Finally, a negligible weight loss of less than 1 kg was observed over a period of several weeks, a decrease that was observed mainly among overweight people and was related, according to researchers, to their extensive efforts made to reduce calorie intake. Compared to the intervention group that drank only water, sugar substitutes had no advantage.
Are diet drinks recommended for preventing other chronic diseases?
High consumption of sugar substitutes was associated with a 21% increase in the risk of higher fasting sugar levels. Studies also found a 32% increase in cardiac events (stroke, heart attack, heart failure, coronary artery catheterization, coronary artery disease, and cardiovascular failure), a 13% increase in the risk of developing bladder cancer, and a 12% increase in the risk of mortality.
The researchers' conclusion: in the short term, using sugar substitutes instead of sugar can lead to a caloric reduction that helps losing weight, especially when the use of sugar substitutes is combined with additional efforts to lose weight. On the other hand, long term use of sugar substitutes leads to an increased risk of weight gain and associated morbidity, such as type 2 diabetes, heart disease, and mortality.
The preferred drink is water and not sweetened beverages or sugar substitutes of any kind.
The American Diabetes Association (ADA 2022) states that people with diabetes are recommended to replace juices and sweetened beverages with water. The use of sugar substitutes instead of sugar-sweetened products may reduce the total consumption of calories and carbohydrates, as long as there is no compensatory increase in energy consumption from other sources.
They also point out that for those consuming sweetened beverages regularly, diet drinks can be a temporary substitute as one of the strategies to reduce the consumption of sweetened beverages, as long as there is no compensatory increase in energy consumption from other sources. However, they emphasize that in general it is recommended that diabetics reduce their consumption of sweetened beverages and substitutes and consume water instead.
What are the mechanisms of the possible harms of sugar substitutes?
The need to taste sweets is innate. When we eat food and drink beverages with sweetness that does not provide glucose, a compensatory mechanism is activated. Consumption of beverages with sugar substitutes that do not contain glucose or calories apparently disrupts the mechanism of hunger and satiety and increases insulin resistance. It is assumed that due to the sweet taste resulting from their binding to receptors in the mouth and along the digestive tract, insulin is released from the pancreas, high levels of which lead to insulin resistance (i.e., more insulin is required to remove glucose from blood). It is also possible that the mechanism is carried out by the intestinal bacteria (the microbiome).
Another mechanism is related to the interaction with the intestinal bacteria and the secretion of metabolic hormones involved in the appetite mechanism, energy consumption and influence on the glucose (sugar) levels in the blood. The sugar substitutes encourage and preserve the habit of sweet intake and the need for caloric supplementation and therefore encourage the consumption of additional foods.
Are the sugar substitutes themselves harmful even though they are approved for use?
The approval process for sweeteners in Israel and around the world is established in dedicated international legislation. The sugar substitutes are tested for their level of toxicity and approved for use in the industry. The fact that they are regulatorily approved for use does not indicate that they are healthy for us. There is a growing concern among many professionals about the direct effect of the substitutes in case of long-term use, of the impact of the cumulative exposure, and of the interaction between the different sugar substitutes. It is important to understand that in order to ban a certain supplement or component, many studies are conducted and sometimes it takes years, from the publication of the first evidence of damage until it is decided to remove the supplement or component.
The environmental aspects of diet drink consumption
Beverages with sugar substitutes, like other beverages, are often sold in single-use plastic containers that ultimately increase the volume of landfilled waste and pollute the environment. Studies have suggested that the use of water and carbon emissions are lower when using substitutes that when sugar is used, but on the other hand, additional studies have shown that some sugar substitutes that reach the water are resistant to the processes that occur in wastewater treatment plants. Furthermore, there are other substances in these drinks such as flavoring agents (vanilla, caffeine etc.) that cause contamination of natural water sources because of the extensive use of fertilizers and pesticides.
What are the recommendations regarding diet drinks among children and adolescents?
Following the widespread use and increase in consumption of artificial sweeteners and sugar substitutes, extreme caution is required until the long-term risks and benefits of these products are fully evaluated. Drinking sweetened beverages is harmful at any age. Among children and adolescents it is especially important to develop healthy habits for life, and drinking water only all day from a young age is a key.
Leave sweetened beverages behind and drink water
The national nutrition recommendations, which take into account the health, environmental, social and economic aspects, highlight the need to consume raw food and drinks, according to Mediterranean diet. The green food bow indicates that it is recommended to consume water (tap water), while ultra-processed foods and drinks are found in the red bow, which we recommend to be avoid or reduce significantly. Snacks that contain sugar substitutes are classified as ultra-processed food. Note that diet drinks sometimes contain, in addition to the sugar substitutes, caffeine, flavor agents and various acids.
It seems that sweet moments in life will not be made of sugar-sweetened beverages or sugar substitutes.
Video: diet drinks? get used to drinking water! (with Hebrew captions)
Further reading
Rios-Leyvraz, M., Montez, J., & World Health Organization. (2022). Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis.
Draznin, B., Aroda, V. R., Bakris, G., Benson, G., Brown, F. M., Freeman, R., ... & Kosiborod, M. (2022). 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022. Diabetes Care, 45 (Supplement_1), S60-S82.
Suez J, et all Personalized microbiome-driven effects of non-nutritive sweeteners on human glucose tolerance, 2022 Cell 185, 1-22 September 1.
Kroger M, Meister K, Kava R. Low-calorie Sweeteners and Other Sugar Substitutes: A Review of the Safety Issues. Compr Rev Food Sc Food Safe 2006;5:35–47.