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JNS JOURNAL OF NUTRITIONAL SCIENCE REVIEW ARTICLE https://doi.org/10.1017/jns.2020.59 . Low-calorie sweeteners in the human diet: scientific evidence, recommendations, challenges and future needs. A symposium report from the FENS 2019 conference Alison M. Gallagher1* , Margaret Ashwell2 , Jason C. G. Halford3, Charlotte A. Hardman4, Niamh G. Maloney4 and Anne Raben5 1Nutrition Innovation Centre for Food and Health (NICHE), Biomedical Sciences Research Institute, Ulster University, Coleraine BT52 1SA, https://www.cambridge.org/core/terms Northern Ireland, UK 2Ashwell Associates, Ashwell, Hertfordshire, UK 3School of Psychology, University of Leeds, Leeds, UK 4Department of Psychology, University of Liverpool, Liverpool, UK 5Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, Frederiksberg DK-1958, Denmark (Received 9 December 2020 – Accepted 15 December 2020) Journal of Nutritional Science (2021), vol. 10, e7, page 1 of 10 doi:10.1017/jns.2020.59 Abstract Overconsumption of free sugars, particularly from sugar-sweetened beverages (SSB), has potential negative health impacts. Implementation of a range of public health strategies is needed to reduce intakes of free sugars, including reducing portion sizes, promoting healthier dietary choices and reformulating foods and beverages. Although low-calorie sweeteners (LCS) are a useful tool for reducing energy intake and control glucose response when consuming sweet foods and drinks, several opinions persist about the adverse health effects of LCS, many of which are based , subject to the Cambridge Core terms of use, available at on poor, little or no scientific evidence. This symposium report summarises key messages of the presentations and related discussions delivered at a scientific symposium at the 13th European Nutrition Conference (FENS 2019). These presentations considered the scientific evidence and current recommendations about the use and potential benefits of LCS for human health, with a particular focus on current evidence in relation to body weight and glycaemic control. Many of the studies to date on LCS have focused on low-calorie sweetened beverages (LCSB); however, the psychological and behavioural factors influencing consumer beliefs and consumption of LCSB need to be further explored. Current recommen- dations for LCS use are described, including the conclusions from a recent expert consensus report identifying the challenges that remain with 24 Sep 2021 at 10:50:12 LCS research. Finally, existing knowledge gaps and future actions are described, as well as two large ongoing research projects: SWITCH and , on SWEET. Key words: Low-energy sweeteners: Intense sweeteners: Non-nutritive sweeteners: Weight management: Glycaemic control: Nutrition policy 170.106.40.219 Introduction potential negative impact of overconsumption of free sugars, Free sugars, which encompass all monosaccharides and disac- particularly from sugar-sweetened beverages (SSB), in relation . IP address: charides added to foods by the manufacturer, cook or con- to weight gain, increased risk of type II diabetes mellitus and sumer, and sugars that are naturally present in honey, tooth decay is well recognised and has informed dietary syrups, fruit juices and fruit juice concentrates(1,2) have recently recommendations to reduce population intakes of free sugars drawn particular attention in relation to public health. The to 10 or sometimes 5 % of the total energy intake(1,2). * Corresponding author: Alison Gallagher, fax +44(0) 28 7012 4965, email [email protected] https://www.cambridge.org/core © The Author(s), 2021. Published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribu- tion, and reproduction in any medium, provided the original work is properly cited. 1 Downloaded from journals.cambridge.org/jns However, given the current high intakes of free sugars, achiev- swaps’ in SSB consumers. However, under EU Regulation ing such reductions is challenging and will require implemen- 1333/2008, the permitted use of LCS depends on the food cat- tation of a range of public health strategies, including reducing egory/categories into which the product falls, and, currently, portion sizes, promoting healthier dietary choices and refor- LCS cannot be incorporated into most of the fine baked pro- mulating foods and beverages(3). ducts (e.g. biscuits or cakes), thus potentially limiting the oppor- Non-nutritive sweeteners provide a desired sweet taste with- tunities for food reformulation(7). Furthermore, whilst LCS may out the addition of appreciable energy and can help maintain be a useful tool for reducing energy intake and control glucose the palatability of reformulated products. They can be broadly response when consuming sweet foods and drinks, several the- categorised as bulk sweeteners or intense sweeteners. This ories persist about the adverse health effects of LCS acutely or symposium report will focus on intense sweeteners, commonly in the long term, many of which are based on poor, little or no fi (3) https://doi.org/10.1017/jns.2020.59 referred to as low-calorie sweeteners (LCS), and it will consider scienti cevidence . the scientific evidence for the use and potential benefits of LCS. Recommendations from health-related organisations In 2011, the EFSA(8) concluded that there is sufficient scien- Safety evaluation tific information to support the claims that intense sweeteners, Prior to approval for use, all LCS undergo extensive safety as all sugar replacers, lead to a lower postprandial rise in blood sugar levels, if consumed in place of sugars. Public Health evaluation; the responsibility for these evaluations lies with (9) ‘ ’ regulatory bodies such as the European Food Safety England recommends sugar-swaps , replacing sugary soft drinks for diet, sugar-free or no added sugar varieties to https://www.cambridge.org/core/terms Authority (EFSA), the FAO/WHO Joint Expert Committee reduce free sugar intakes. This position has also been endorsed on Food Additives (JEFCA) and the US Food and Drug (10) Administration (FDA). These evaluations usually result in by those at the British Dietetic Association, who highlight that swapping SSB for low-calorie sweetened beverages the establishment of the Acceptable Daily Intake (ADI) for fi each LCS. The ADI is typically calculated following the appli- (LCSB) is likely to be bene cial for most individuals from a cation of large safety factors (often a factor of 100 times lower weight management, dental and diabetes perspective; however, than the ‘no observed adverse effect level’ (NOAEL) to give a they highlight that healthier drink options/alternatives should be actively encouraged (e.g. milk-based drinks) as these pro- large margin of safety for even the most susceptible and sen- fi sitive individuals in the population, including children and vide additional nutritional bene ts that LCSB do not. Given pregnant women (Fig. 1). The ADI is often misinterpreted; that weight management is key to managing (and preventing) it does not represent a threshold between safe and unsafe, type II diabetes, the BDA also advocates the use of LCS in but it refers to a lifetime exposure situation, not a single occa- adults and children, where this is in place of free sugars, noting that in such cases LCS may be a useful means of reducing sion, and, therefore, infrequent consumption of levels higher (10) (5) energy intake and can help maintain a healthy body weight . than the ADI is not a health concern . (11) , subject to the Cambridge Core terms of use, available at At present within the EU, a total of eleven LCS are approved In 2018, Diabetes UK launched a Position Statement , for use (Table 1) in accordance with the EU Regulation 1333/ which concluded that low or non-caloric sweeteners are 2008(6) on food additives; the use of LCS in most of the cases is shown to be safe and that they can be used as part of a strategy authorised in beverage or food categories with a reduction of at for adults and children in the management of weight and least 30 % of beverage/food product energy or with no added diabetes. sugars. Replacing free sugars in SSBs with LCS is relatively More recently, the American Diabetes Association (ADA) 24 Sep 2021 at 10:50:12 (12) straightforward and as such offers the potential for ‘sugar- also issued a new Consensus Report in 2019 . Some of , on the conclusions were that replacing added sugars with sugar substitutes (LCS) could decrease the daily intake of carbohy- drates and calories. These dietary changes could beneficially affect glycaemic, body weight and cardiometabolic control. 170.106.40.219 The ADA also stated that using sugar substitutes does not make an unhealthy choice healthy; rather, it makes such a choice less unhealthy(12). Finally, if sugar substitutes are used . IP address: to replace caloric sweeteners, without caloric compensation, they may be useful in reducing caloric and carbohydrate intake, although further research is needed to confirm these concepts(12). The American Academy of Pediatrics has recently released a policy statement(13) on the use of LCS in children, noting in their key findings and recommendations that when substituted https://www.cambridge.org/core for sugar-sweetened foods or beverages, LCS can reduce Fig. 1. Safety factors applied to establish the ADI.

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