This review summarizes the literature pertaining to the epidemiology and current recommendations for pediatric artificial sweetener use and presents the results of studies investigating metabolic responses to artificial sweeteners among children. An understanding of the research previously conducted and the gaps that remain will inform future clinical and translational research, to develop evidence-based recommendations for artificial sweetener use in the prevention and treatment of pediatric obesity.
Artificial sweeteners and obesity
Childhood obesity is associated with many unfavorable consequences, including type 2 diabetes mellitus, nonalcoholic fatty liver disease, hypertension, and psychosocial problems, and often results in obesity during adulthood. Consumption of added sugars is positively associated with higher energy intakes and is thought to be a significant contributor to the rapid rise in obesity worldwide. Because the majority of added sugars are obtained from consumption of soft drinks, artificially sweetened beverages have emerged as an alternative, providing the desired sweetness and palatability without contributing to caloric intake. In addition to their use in “diet” and “light” beverages, artificial sweeteners are often used to replace added sugars in various foods, including yogurts, puddings, baked goods, and ice cream, among many other items frequently consumed by children and adolescents. Despite their widespread and increasing use, the effects of artificial sweeteners in children have not been well studied.
The purpose of this review is to summarize the existing literature pertaining to the epidemiology and current recommendations for artificial sweetener use in children and to present the results of studies investigating metabolic responses to artificial sweeteners among children. In addition, this review touches on the growing body of literature about taste, craving, and addiction to sweet taste. Artificial sweeteners have also been studied in relation to dental cavities, fetal outcomes, and carcinogenesis, but these issues are not addressed in this review. In presenting and analyzing the current scientific evidence on the metabolic safety of artificial sweeteners and their potential effectiveness in promoting weight loss and weight management, this review aims to provide clinicians with a comprehensive understanding of current knowledge about artificial sweetener usage in children.
Regulatory status of artificial sweeteners
There are currently 5 artificial sweeteners approved by the Food and Drug Administration (FDA) for use in the United States ( Table 1 ). These include aspartame, acesulfame potassium, saccharin, sucralose, and neotame. In addition, stevia, a natural sweetener made from extracts of the intensely sweet Stevia rebaudiana Bertoni plant has been approved for limited use. For each sweetener, the FDA establishes an acceptable daily intake (ADI), in mg per kg body weight, which is the amount of sweetener thought to be safe to consume every day for a lifetime. The ADI is typically 100 times lower than the dose of the sweetener that caused toxicity in animal studies. To determine if a sweetener should be approved for use, the FDA then must establish that typical human intake of the sweetener (estimated daily intake [EDI]) is below the ADI. If the EDI is below the ADI, then the sweetener is considered safe for human use. Aspartame, saccharin, sucralose, and neotame are classified as food additives by the FDA, whereas stevia is classified as generally recognized as safe (GRAS), meaning that similar data consistent with its safety exist as for food additives.
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There are 5 artificial sweeteners currently approved for use in the United States as well as stevia, a natural noncaloric sweetener.
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For each sweetener, the FDA establishes an ADI, which is the amount of sweetener thought to be safe to consume every day for a lifetime.
| Sweetener | FDA Status | ADI | Sweetness Relative to Sucrose |
|---|---|---|---|
| Acesulfame potassium | NNS, REG | 15 mg/kg (∼30 cans of diet soda) | 200× |
| Aspartame | NUTRS, REG, GMP | 50 mg/kg (∼18 cans of diet soda) | 160–220× |
| Neotame | NNS, REG, GMP | 2 mg/kg | 7000×–13,000× |
| Saccharin | NNS, REG/ITEM | 5 mg/kg | 300× |
| Stevia | GRAS | 5 mg/kg | 300× |
| Sucralose | NNS, REG, GMP | 5 mg/kg (∼6 cans of diet soda) | 600× |
Regulatory status of artificial sweeteners
There are currently 5 artificial sweeteners approved by the Food and Drug Administration (FDA) for use in the United States ( Table 1 ). These include aspartame, acesulfame potassium, saccharin, sucralose, and neotame. In addition, stevia, a natural sweetener made from extracts of the intensely sweet Stevia rebaudiana Bertoni plant has been approved for limited use. For each sweetener, the FDA establishes an acceptable daily intake (ADI), in mg per kg body weight, which is the amount of sweetener thought to be safe to consume every day for a lifetime. The ADI is typically 100 times lower than the dose of the sweetener that caused toxicity in animal studies. To determine if a sweetener should be approved for use, the FDA then must establish that typical human intake of the sweetener (estimated daily intake [EDI]) is below the ADI. If the EDI is below the ADI, then the sweetener is considered safe for human use. Aspartame, saccharin, sucralose, and neotame are classified as food additives by the FDA, whereas stevia is classified as generally recognized as safe (GRAS), meaning that similar data consistent with its safety exist as for food additives.
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There are 5 artificial sweeteners currently approved for use in the United States as well as stevia, a natural noncaloric sweetener.
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For each sweetener, the FDA establishes an ADI, which is the amount of sweetener thought to be safe to consume every day for a lifetime.
| Sweetener | FDA Status | ADI | Sweetness Relative to Sucrose |
|---|---|---|---|
| Acesulfame potassium | NNS, REG | 15 mg/kg (∼30 cans of diet soda) | 200× |
| Aspartame | NUTRS, REG, GMP | 50 mg/kg (∼18 cans of diet soda) | 160–220× |
| Neotame | NNS, REG, GMP | 2 mg/kg | 7000×–13,000× |
| Saccharin | NNS, REG/ITEM | 5 mg/kg | 300× |
| Stevia | GRAS | 5 mg/kg | 300× |
| Sucralose | NNS, REG, GMP | 5 mg/kg (∼6 cans of diet soda) | 600× |
Artificial sweetener consumption among children
Apparent consumption of artificial sweeteners (based on servings of foods and beverages containing these sweeteners) has increased with time across all age groups. Because the FDA does not require manufacturers to report the actual amounts of sweeteners contained in foods and beverages, quantification of the precise amount of sweeteners present in the food supply is difficult. Hence, information about the total quantity of sweeteners in use is extracted from intake information for the various foods that contain them, using food composition tables and validated food databases. The sweetening power of the artificial sweeteners (listed previously) is hundreds of times greater than that of sucrose (see Table 1 ). Therefore, it takes a much smaller amount of an artificial sweetener relative to caloric sugars to produce the same level of sweetness in a product.
Because of their smaller size and high intake of beverages, children consume the highest amount of artificial sweeteners relative to their body weight per day. A recent systematic review estimated that between 4% and 18% of total carbonated beverage intake among children is from artificially sweetened beverages. A second review determined that approximately 15% of the total US population above the age of 2 years uses artificial sweeteners. A third study, comparing NHANES data from 1999–2000 to 2007–2008, and a recent study (Jean Welsh, PhD, unpublished data, 2011) showed that consumption of artificially sweetened beverages has increased in the general population and doubled among children during those years. Artificial sweetener consumption in foods has increased to a greater extent than in beverages. Furthermore, of those who already consume artificially sweetened products, the amount of these products being consumed has increased. Given the extent to which consumption of artificially sweetened products is rising, it is important that more intervention studies testing the effects are conducted, to develop evidence-based recommendations for artificial sweetener usage in the prevention and treatment of childhood obesity.
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Artificial sweetener consumption is increasing in all age groups, particularly in children.
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Because the FDA does not require manufacturers to report the actual amounts of sweeteners contained in foods and beverages, quantification of the precise amount of sweeteners in food is difficult.
Current recommendations
There are few explicit recommendations regarding consumption of artificially sweetened foods and beverages in children; however, the American Dietetic Association (ADA) states that both nutritive and artificial sweeteners may comprise part of a diet that follows the Dietary Guidelines for Americans. Specifically, a position statement from the ADA stated that artificial sweeteners can allow consumers to enjoy sweetness while continuing to manage weight, diabetes, and other chronic illnesses. With regard to children specifically, the ADA stated that artificial sweeteners are safe to use within the range of the ADI, which varies for each of the 5 FDA-approved artificial sweeteners. Current intake levels of artificial sweeteners among children are believed well below the ADI but range from approximately 10% of the ADI for current levels of aspartame consumption to as high as 60% of the ADI for acesulfame potassium. In contrast, the Institute of Medicine does not support artificial sweetener use in children because artificially sweetened beverages have been shown to displace milk and 100% juice at mealtimes. In addition, the Institute of Medicine stated that more research is needed on the effectiveness of artificial sweeteners for weight management and that more studies are needed on safety effects when artificial sweeteners are consumed for many years starting in childhood or adolescence. Similarly, the American Academy for Pediatrics stated that artificial sweeteners have been inadequately studied for use in children and that they should not form a significant part of a child’s diet. Other medical societies have stated their positions on the use of artificial sweeteners, which are outlined in Table 2 . These statements are not sweetener specific, however, and many do not make recommendations for the use of these sweeteners in a pediatric population.
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There are few explicit recommendations for artificial sweetener consumption in children.
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Recommendations from medical societies are conflicting.
| Scientific Organization | Year | Position Statement | Population Considered |
|---|---|---|---|
| American Dietetic Association | 2004, 2009 | Consumers can safely use artificial sweeteners when consumed in a diet guided by current federal nutrition recommendations. The wide range of artificial sweeteners available in food supply should keep artificial sweetener intake in children well below the acceptable daily intakes | Children and adults |
| American Academy of Pediatrics | 2010 | The use of artificial sweeteners to provide health benefits for children and adolescents has been inadequately studied. As such, they should not form a significant part of a child’s diet | Specific to children |
| American Heart Association | 2010 | People with diabetes can use artificial sweeteners, as can people on a weight loss diet | General population |
| American Diabetes Association | 2010 | Foods and drinks that contain artificial sweeteners are an option for those with diabetes to consume fewer calories and carbohydrates when replaced for a food or drink containing sugar | General population |
| Institute of Medicine | 2007 | No recommendations are made regarding foods containing artificial sweeteners because (1) artificially sweetened beverages have been shown to displace milk and 100% juice at mealtimes, (2) more research is needed on the effectiveness of artificial sweeteners in foods for weight management, and (3) more studies are needed on safety effects when artificial sweeteners are consumed for many years starting in childhood or adolescence | Specific to children |
Artificial sweeteners and the control of body weight
Although artificial sweeteners do not contribute significantly to energy intake, their effectiveness in promoting weight loss and weight control has been questioned. To date, 8 observational studies have explored the relationship between consumption of artificial sweeteners and weight in children. Of the 3 cross-sectional studies, including between 385 and 3311 children, the 2 conducted in school-age and adolescent children showed positive associations between artificial sweetener consumption and body mass index (BMI), whereas the study in 2-year-old to 5-year-old children did not find an association. Similarly, 4 of the 5 longitudinal cohort studies, including between 166 and 11,654 children, showed positive associations between artificially sweetened beverage consumption and weight related outcomes, including BMI change (in boys but not girls), BMI z score, energy intake (but not BMI), and fat mass (no longer significant after adjustment for covariates). A single study showed no association between artificially sweetened beverage intake and BMI but an inverse correlation with incident obesity, meaning that children who consumed fewer artificially sweetened beverages were less likely to become obese. Given the observational nature of these studies, these data cannot establish that consumption of artificially sweetened beverages was the cause of increased body weight or food intake. There are likely to be many differences, both genetic and cultural, between families that do or do not offer their children artificially sweetened beverages. Children consuming artificial sweeteners may be those who are at risk of weight gain, thus reversing the direction of the causal relationship.
One proposed explanation for the association between artificial sweetener consumption and weight gain in epidemiologic studies is that knowledge of consuming a substance lower in energy could drive people to eat more ; this phenomenon has been best described in the context of low-fat foods, in which people overeat foods after receiving a food labeled as low fat. In addition, studies in animals (who have no cognitive awareness of the energy content of foods) have shown that the disconnect between sweetness and caloric content from use of artificial sweeteners may impair energy regulation and lead to positive energy balance. It has also been suggested that the observed paradoxic relationship between artificial sweetener intake and body weight may be due to alteration of gut microbiota. Although these hypotheses are intriguing, few data exist to support them, especially in children, and future human studies are greatly needed.
Although it is expected that substituting artificially sweetened beverages for sugar-sweetened beverages would lead to weight loss due the lower caloric intake, experimental studies have shown that the assumed calorie deficit is not maintained. One reason for this is that people tend to compensate for the “missing calories” in an artificially sweetened food or drink by subsequently eating more. Compensation involves the ability to account for excess calorie consumption by reducing intake later or, in the case of an artificially sweetened beverage, to account for the missing calories, by subsequently consuming more. Seven studies have evaluated how children compensate for changes in calorie density due to use of caloric versus artificial sweeteners. These studies involved between 14 and 262 participants, ages 2 to 14 years. The results of these studies are complex and vary significantly based on study design. In general, younger children seemed to compensate better for missing calories in artificially sweetened foods and drinks by increasing subsequent food intake, thus raising questions about the efficacy of these products for weight control in young children. This study design, however, only provides insight into effects that occur within hours, whereas changes in body weight occur over much longer time frames. In addition, these studies generally take place in laboratory settings and it may not be accurate to generalize their findings to “real life.” It is, therefore, of great interest to evaluate changes in food intake and body weight that occur with chronic consumption of artificial sweeteners over the course of weeks, months, or years.
There are few randomized controlled trials evaluating the effects of artificial sweeteners on weight change in children. One study randomized 103 adolescents of varying BMI to either consume only noncaloric beverages (including both water and artificially sweetened beverages) or to maintain their normal beverage consumption habits. At the end of the 25-week intervention, no difference in BMI was found between groups; however, a post hoc subgroup analysis including only overweight participants did show lower BMI in the treatment group. The effect of increased water versus artificially sweetened beverages, however, cannot be determined. A confirmatory study enrolling only overweight adolescents is currently in progress. A second trial randomized overweight adolescent girls to a restricted, 1500 kcal per day diet that either permitted sugar-sweetened soda (within the 1500-kcal limit), or permitted only water or artificially sweetened beverages. Both diets led to a modest amount of weight loss, but there were no significant differences between groups in this small pilot study. In a third study designed to prevent excess weight gain, children in the intervention group were assigned to replace sugar with artificial sweeteners and increase physical activity. As in other studies, the primary outcome of change in BMI z score was not different between groups, but fewer children in the intervention group increased their BMI z score. The effect of the artificial sweetener and the physical activity intervention, however, cannot be separated. Finally, a study conducted shortly after the approval of aspartame randomized 55 children and young adults to consume an aspartame capsule 3 times daily or a placebo while on a calorie-restricted diet. No significant difference in weight loss was observed at the end of the 13-week intervention.
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The majority of observational studies show a positive association between artificial sweetener consumption and body weight.
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The results of short-term satiety studies are complex and vary significantly based on study design. In general, younger children seem to compensate better for lower calories in artificially sweetened drinks by increasing subsequent food intake.
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Unlike observational studies, randomized controlled trials of artificial sweeteners in children have not shown that artificial sweeteners cause weight gain. The current studies are not sufficient, however, to show that these sweeteners aid in weight loss, either.
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