Observational Data Presented by Chazelas et al. Fails to Show Causation with Diet Drinks and Cardiovascular Disease

A letter to the editors of the Journal of the American College of Cardiology was published, entitled “Sugary Drinks, Artificially-Sweetened Beverages, and Cardiovascular Disease in the NutriNet-Santé Cohort”. ¹This letter references the findings of an observational study conducted by the authors, which was published previously in the European Journal of Public Health, and reports that both sugar and low-and no-calorie sweetened (LNCS) beverages are associated with an increased risk of cardiovascular disease (CVD).² Not only is there no evidence of a causal relationship between the use of LNCS and CVD risk, the Calorie Control Council maintains its longstanding position that, when consumed as part of a healthy and balanced diet, the consumption of LNCS may serve as a tool for managing body weight, blood glucose control and sugar intake.

Research Limited by Several Factors

The Calorie Control Council strongly cautions that its findings should be interpreted carefully due to several limitations in the study methodology:

1. Epidemiological studies, even those built on large sample sizes, are subject to potential pitfalls including reverse causality, in which participants who were already at increased risk for CVD chose LNCS to help manage their caloric and sugar intake.
2. Confounding is another important limitation of these types of studies, which refers to the inability to control for lifestyle and other factors that influence health outcomes, such as exercise and smoking.
3. Observational studies such as the one conducted by Chazelas et al. cannot prove cause-and-effect relationships.
4. Self-reported data is subject to inaccurate and/or underreporting. The use of 24-hour dietary recall records, which were collected every six months throughout the study duration may not be an accurate reflection of actual intake and any changes in consumption over time.

Studies Show Low- and No- Calorie Sweeteners Help Reduce Body Weight

Given the call for a reduction in sugar intake in the recent Dietary Guidelines Advisory Council Scientific Report,³ it is important to recognize the a large body of evidence suggests that LNCS can help in reducing energy intake and body weight.⁴ A meta-analysis reviewing 35 years of independent studies on the relationship between LNCS and weight status, conducted by Drs. Vanessa Perez and Paige Miller,⁵ found that randomized control trials “resulted in statistically significant reductions in body weight, BMI, fat mass, and waist circumference.” Further, in her 2019 editorial published in the British Medical Journal, Dr. Vasanti Malik referenced a comprehensive systematic review and meta-analysis on non-sugar sweeteners (NSS) conducted by Toews, et al.,⁶ and noted, “Based on existing evidence including long term cohort studies with repeated measurements and high quality trials with caloric comparators, use of NSS as a replacement for free sugars (particularly in sugar sweetened beverages) could be a helpful strategy to reduce cardiometabolic risk among heavy consumers, with the ultimate goal of switching to water or other healthy drinks.”⁷

In conclusion, the highest quality science supports that LNCS can be consumed as part of a balanced diet and can assist with the reduction of cardiometabolic risk through the management of body weight and reduced caloric intake. There is no credible evidence suggesting a link between LNCS consumption and CVD risk.

References

1. Chazelas et al. Sugary Drinks, Artificially-Sweetened Beverages, and Cardiovascular Disease in the NutriNet-Santé Cohort. J Am Coll Cardiol 2020; 76(18):2175-6.
2. Chazelas, et al. Sugary drinks, artificially sweetened beverages and cardiovascular disease in NutriNet-Santé cohort, European Journal of Public Health, Volume 30, Issue Supplement_5, September 2020, ckaa165.573, https://doi.org/10.1093/eurpub/ckaa165.573
3. Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.
4. Rogers PJ, Hogenkamp PS, De Graaf C, 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. 2016. doi:10.1038/ijo.2015.177
5. Miller PE, Perez V. Low-calorie sweeteners and body weight and composition: a meta-analysis of randomized controlled trials and prospective cohort studies. Am J Clin Nutr. 2014. doi:10.3945/ajcn.113.082826
6. Toews I, Lohner S, Gaudry DK De, Sommer H, Meerpohl JJ. 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. 2018. doi:10.1136/bmj.k4718
7. Malik VS. Non-sugar sweeteners and health. Bmj. 2019;364:k5005. doi:10.1136/BMJ.K5005