The Pan American Health Organization (PAHO) Nutrient Profile model was published in 2016 and proposed new criteria to define “excessive” levels of sugar, salt, and fat in processed food and drinks. The purpose of this model is to provide a tool that can be used in the design and implementation of policies related to the prevention and control of obesity/overweight, including restriction in the marketing of unhealthy foods and beverages to children, the regulation of school food environments (feeding programs and food and beverages sold in schools), the use of front-of-package (FOP) warning labels, the definition of taxation policies to limit consumption of unhealthy food and the identification of foods to be provided by social programs to vulnerable groups.
Regarding sugar, PAHO claims “the best scientific evidence available” was reviewed in order to classify processed and ultra-processed foods and beverages as having “excessive” amounts of sugar if the amount of added sugars is 10% or more of total calories. Additionally, the model specifies that products whose ingredients include artificial or natural non-caloric or caloric sweeteners should be defined as “containing other sweeteners”, which should be limited or avoided.
The recommendation to limit or avoid non-nutritive sweeteners (NNS) as part of the WHO/PAHO sugar reduction recommendations is problematic, as this disregards the established benefits and safety of these ingredients and discourages the use of products that can be an important tool in weight management and addressing certain diseases.
The PAHO Nutrient Profile Model cites literature reporting a proportional increase in sugar-sweetened beverage sales and the general population’s average body mass index (BMI) in Latin America. This claim not only highlights just one component of the total diet, it fails to address the large of body of evidence suggesting the role of NNS in reducing energy intake and body weight. Following a thorough analysis and review of available evidence, the 2018 Ibero-American Consensus concluded that the use of NNS in weight reduction programs involving the replacement of caloric sweeteners with NNS in the context of structured diet plans may favor sustainable weight reduction.
Further, a 2019 systematic review and meta-analysis of randomized controlled trials found no significant differences in change in body weight between adults receiving NSSs compared with those receiving different sugars or placebo. This finding suggests that there are other elements of the diet or lifestyle factors that may attribute the weight gain. Furthermore, studies have also shown that the effect of consuming beverages sweetened with NNS on weight loss is similar to that of drinking water. Suggesting products containing NNS have the same impact on BMI as sugar-sweetened products is not supported by the totality of available scientific evidence and ultimately deprives consumers of a useful and science-supported tool to help manage weight.
When substituted for sugar, not only do NNS have the potential to aid in achieving and maintaining a healthy weight, they can also be used to manage blood glucose levels by those with diabetes. A 2017 review of current research on sucralose upheld the findings of previous reviews and reported that, given that sucralose is not digested or metabolized for energy, it provides no calories and does not affect blood glucose levels. Therefore, foods and beverages that contain sucralose are suitable for persons with diabetes or those aiming to reduce calorie or carbohydrate intake.
From an international standpoint, following a thorough review of available scientific literature, the European Food Safety Authority (EFSA) Panel on Dietetic Products Nutrition and Allergies concluded that replacing sugar-containing foods with those containing NNS induces a lower blood glucose rise following consumption. The 2018 Ibero-American Consensus concluded that the use of NNS in diabetes management programs may contribute to a better glycemic control in patients. Lastly, the European Commission based their authorization of a health claim regarding NNS and post-prandial glucose on this finding.
International scientific organizations and regulatory agencies, including the Joint FAO/WHO Expert Committee of Food Additives (JECFA), US Food and Drug Administration (FDA), and European Food Safety Authority (EFSA) have extensively reviewed NNS and have recognized their safety. A 2017 scoping review of the safety and association of NNS and certain health outcomes found no conclusive evidence of the harmful effect of NNS use.
The WHO/PAHO position to limit or avoid NNS or non-nutritive sweeteners as part of their sugar reduction recommendations implies that these sweeteners contribute to obesity and diabetes when, in fact, the beneficial effects are largely due to the replacement of sugar in diet. As a result, NNS should be recognized as a tool in weight and diabetes management, not a hindrance. Recommending the reduction of ingredients with substantial evidence to support their safety and health benefits may actually result in unintended consequences, such as consumer confusion and the reduced availability of products important for the management of common diet-related diseases. As the current recommendations and subsequent national legislation may prove too restrictive to some consumers, they may opt to disregard the guidelines altogether and continue their consumption habits. We encourage WHO and PAHO to thoroughly review the scientific literature regarding NNS, reconsider their recommendations and ultimately promote the incorporation of these ingredients that can be used to help reduce caloric intake and manage body weight and blood glucose levels.
References:
Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D and Lichtenstein AH. Nonnutritive Sweeteners: Current Use and Health Perspectives. Circulation. 2012; CIR.0b013e31825c42ee
Commission, European. (2012). Commission Regulation (EU) No 432/2012 of 16 May 2012. Official Journal of the European Union. 1-40.
Lohner S, Toews I, Meerpohl JJ. Health outcomes of non-nutritive sweeteners: analysis of the research landscape. Nutr J 2017; 16: 55.
Magnuson BA, Roberts A, and Nestmann ER. Critical review of the current literature on the safety of sucralose. Food Chem Toxicol 2017 Aug;106 (Pt A):324-355. doi: 10.1016/j.fct.2017.05.047
Nichol AD, Maxwell JH & Ruopeng A. (2018). Glycemic impact of non-nutritive sweeteners: a systematic review and meta-analysis of randomized controlled trials. Eur J of Clin Nutr 2018; 72. 10.1038/s41430-018-0170-6.
Pan American Health Organization (PAHO) (2016) Pan American Health Organization Nutrient Profile Model. Washington, D.C.
Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC, Vander Veur SS et al. The effects of water and non-nutritive sweetened beverages on weight loss during a 12-week weight loss treatment program. Obesity 2014; 22: 1415–1421.
Rogers PJ, Hogenkamp PS, de Graaf C, Higgs S, Lluch A, Ness AR, Penfold C, Perry R, Putz P, Yeomans MR, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies. Int J Obes (Lond) 2016; 40:381–94.
Serra-Majem L, Raposo A, Aranceta-Bartrina J, Varela-Moreiras G, Logue C, Laviada H, Socolovsky S, Pérez-Rodrigo C, Aldrete-Velasco J, Meneses Sierra E, et al. Ibero–American Consensus on Low- and No-Calorie Sweeteners: Safety, Nutritional Aspects and Benefits in Food and Beverages. Nutrients 2018;10: 81
Tate DF, Turner-McGrievy G, Lyons E, Stevens J, Erickson K, Polzien K et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr 2012; 95: 555-563
Toews I, Lohner S, Küllenberg de Gaudry D, et al. Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies. BMJ. 2019 Jan 2; 364:k4718. doi: 10.1136/bmj.k4718.
Ultra-processed food and drink products in Latin America: Trends, impact on obesity, policy implications. Washington D.C.: Pan American Health Organization, 2015
Do you have questions about low-calorie sweeteners? Want to learn more about maintaining a healthy lifestyle? You asked and we listened. Our resident Registered Dietitians answered the most popular questions about low-calorie sweeteners.
