The WHO advises consumers to limit added sugar consumption to less than 10% of energy intakes (50g/day), and ideally to below 5% (25g/day).
However, it does not believe we should try and have our cake and eat it by using non-nutritive (zero or very low calorie) sweeteners such as aspartame, stevia or monk fruit as a means to reduce our added sugar consumption, according to a draft guideline issued on Friday "suggesting non-sugar sweeteners not be used as a means of achieving weight control or reducing risk of noncommunicable diseases.”
Non-sugar sweeteners are defined as “all synthetic and naturally occurring or modified non-nutritive sweeteners that are not classified as sugars."
The WHO does not provide a definitive list of non-sugar sweeteners, although it cites non-caloric sweeteners such as monk fruit, stevia, sucralose, aspartame, ace-K, saccharin, neotame, and advantame as examples. A systematic review and meta analysis of the health effects of non-sugar sweeteners published by the WHO in April also included studies on very-low-calorie sweeteners such as allulose (which has 0.4 calories per gram).
“Sugar alcohols and low-calorie sugars are not considered,” added the WHO, which said its new guideline - which is classified as a 'conditional recommendation' - does not apply to people living with diabetes.
WHO: Low/no cal sweeteners don't encourage healthy eating habits
While the new WHO guideline does not state that non-nutritive sweeteners are unsafe, it claims they are frequently used to make 'highly processed' low sugar or sugar-free junk foods, rather than encouraging fundamental shifts towards a healthier dietary pattern rich in whole foods.
"Because free [ie. added] sugars are often found in highly processed foods and beverages with undesirable nutritional profiles, simply replacing free sugars with non sugar sweeteners results in a food or beverage in which any other unhealthy elements are mostly retained, and as a result, the overall quality of the diet remains largely unaffected."
WHO: Short-term benefits do not outweigh ‘possible long-term undesirable effects in the form of increased risk of death and disease’
According to the WHO, any short term benefits in the form of weight loss from using non-nutritive sweeteners are outweighed by the "possible long-term undesirable effects."
It added: “The lack of evidence to suggest that non-sugar sweetener use is beneficial for body weight or other measures of body fatness over the long term together with possible long-term undesirable effects in the form of increased risk of death and disease, outweighed any potential short-term health effects resulting from the relatively small reductions in body weight and BMI observed in randomized controlled trials.”
The recommendation is “based on evidence of low certainty overall, from a systematic review that assessed the health effects of higher compared to lower intake of non-sugar sweeteners and found no evidence of long-term benefit on measures of body fatness in adults or children, and potential undesirable effects from long-term use in the form of increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults," added the WHO.
“Limited evidence suggests potential undesirable effects in the form of increased risk of preterm birth with non sugar sweeteners use during pregnancy.”
"Evidence from a systematic review and meta-analyses of randomized controlled trials and prospective observational studies found that higher NSS [non sugar sweeteners] consumption by adults led to lower body weight and BMI than not consuming NSS or consuming lower amounts of NSS when assessed in short-term randomized controlled trials, but was associated with increased BMI and risk of incident obesity in long-term prospective observational studies..."
In prospective observational studies (ie. correlation, not causation) with up to 10 years of follow-up, said the WHO, higher intakes of NSS were associated with higher BMI and increased risk of incident obesity, type 2 diabetes, and cardiovascular diseases.
Because weight loss and maintenance of a healthy weight must be sustained over the long-term to have a meaningful impact on health, added the WHO, "evidence of minor weight loss or reduced BMI over several months or less as observed in the randomized controlled trials without additional evidence of long-term impact, does not represent a health benefit."
It added: "Because free [ie. added] sugars are often found in highly processed foods and beverages with undesirable nutritional profiles, simply replacing free sugars with non sugar sweeteners results in a food or beverage in which any other unhealthy elements are mostly retained, and as a result, the overall quality of the diet remains largely unaffected."
WHO draft guideline: use of non-sugar sweeteners, July 15, 2022
Calorie Control Council: Guideline has ‘potential to negatively impact public health’
The Calorie Control Council - which counts sweetener suppliers such as Cargill and Tate & Lyle, and sweetener users such as Coca-Cola and PepsiCo among its members - said it was “disappointed” by the recommendation, adding that low and no calorie sweeteners “have been proven to assist in body weight and blood glucose level management, as well as calorie and sugar intake reduction.”
The CCC added: “It should be noted that the draft guideline is classified as ‘conditional’ and most of the evidence used to form this recommendation was graded as ‘very low’ to ‘moderate.’
“Further, noting the evidence regarding reductions in key outcomes such as body weight and BMI with low and no calorie sweetener use, only to issue a guideline against their use does not provide the full picture regarding the efficacy of these ingredients, does not take into account the important role of low and no calorie sweeteners, and has the potential to negatively impact public health.”
International Sweeteners Association: ‘A disservice to public health’
The International Sweeteners Association (ISA) - which counts Ajinomoto and Cargill as members, among others - echoed these comments, noting that high intensity sweeteners do not impact blood sugar levels and stimulate insulin production, are non-carcinogenic, and can help adults and children reduce their calorie intake: “Failing to recognize the role of low/no calorie sweeteners in sugar and energy reduction, and ultimately in weight management is a disservice to public health.”
ISA chairman Robert Peterson added: “The benefit of replacing added sugars with low/no calorie sweeteners in reducing calorie intake and aiding in weight management is supported by evidence reviewed by WHO, the US Dietary Guideline Advisory Committee of the Dietary Guidelines for Americans, 2020-2025, and numerous published systematic reviews and meta-analyses.
“Governments around the world are trying to tackle the serious problem of rising rates of obesity and diabetes. Not to mention dental diseases …. It is a pity that the well-established benefit of non-sugar sweeteners use in dental health has not been recognized.”
'This doesn't mean consumers should necessarily try to completely avoid non-sugar sweeteners in their diet'
Dr Rachel Cheatham, founder of food and nutrition consultancy FoodScape Group, told FoodNavigator-USA that, “What is most striking is that even after a systematic review and meta-analysis covering 283 studies, there is a lack of scientific consensus on the benefits of non-sugar sweeteners.
“One issue is analyzing all artificial and natural sweeteners with no to low calories as a monolith. Beyond the basics of safety and not raising blood sugar, there may be metabolic differences among them involving the gut microbiome for instance that are not yet fully understood.”
She added: “The net of the current scientific review suggests that non-sugar sweeteners offer short-term benefits; however, in the long-term, it appears there may be the potential for increased risk of obesity, diabetes, heart disease, and even mortality. Given this, the draft guidance to not use non-sugar sweeteners for weight control or to reduce risk of noncommunicable diseases is prudent.
That said, she noted, “This doesn't mean consumers should necessarily try to completely avoid non-sugar sweeteners in their diet. Rather, there should be no expectation that regular consumption of non-sugar sweeteners will aid in weight management or disease prevention.”
Consultant: 'This seems to be a case of using valid data to make spurious recommendations'
Renee Flesch, managing partner at food and ingredient consultancy TFG Consulting, said that while the guideline stresses that it is not applicable to diabetics, they could be indirectly impacted if firms pull back on using high intensity sweeteners in general. She added:
"We all know the 'Diet Coke with a candy bar' conundrum that is a common eating pattern for those that consume products with high intensity sweeteners. But what if these beverages (in this instance) were not around, would BMI increases be even larger over time?
"This seems to be a case of using valid data to make spurious recommendations that are irresponsible given the role that processed food plays to the global population (processed not as NOVA defines it, but rather the traditional term). Perhaps WHO could clarify by stating that while long term weight loss is not a likely goal of using HIS, reducing sugar consumption is still a good thing and viable through HIS. Instead they are judging consumers for eating processed foods."
More to follow...
*The deadline for public comments on the new guidelines is August 14. Click HERE to comment. In the interim period, the draft guideline will also undergo peer-review by an external expert group. Once the peer-review and public consultation are complete, the guideline will be finalized and reviewed by the WHO Guidelines Review Committee for final clearance prior to its official release.