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Guideline Summary
Guideline Title
Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association.
Bibliographic Source(s)
Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D, Lichtenstein AH, American Heart Association Nutrition Committee of the Council on Nutrition [trunc]. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2012 Jul 24;126(4):509-19. [58 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Cardiovascular disease
  • Cardiometabolic syndrome
  • Coronary heart disease
  • Diabetes mellitus type 2
  • Overweight and obesity
Guideline Category
Counseling
Prevention
Clinical Specialty
Cardiology
Endocrinology
Family Practice
Internal Medicine
Nutrition
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To address the potential role of nonnutritive sweeteners (NNS) in helping Americans to adhere to population-wide reductions in added sugars intake in the context of current usage and health perspectives
  • To review the literature to determine whether there were adequate data to provide guidance for the use of NNS
Target Population

Adults and children in the United States who desire to reduce added sugars intake for decreased total energy intake and weight loss/weight control or to promote beneficial effects on related metabolic parameters

Interventions and Practices Considered

Counseling on use of nonnutritive sweeteners in beverages and foods as a replacement for caloric sweeteners

Major Outcomes Considered
  • Prevalence of nonnutritive sweetened beverage and food intake among U.S. children and adults
  • Consumer attitudes towards nonnutritive sweeteners (NNS)
  • Effects of NNS on appetite, hunger, and energy intake
  • Effects of NNS on body weight, cardiometabolic variables, and diabetes mellitus/glycemic response

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The literature search was conducted by using the following search terms: nonnutritive sweetener(s), artificial sweetener(s), noncaloric sweetener(s), diet (beverages and soft drinks), and the names of each of the 6 nonnutritive sweeteners (NNS) available for use in the United States (including their brand names). The initial search by use of PubMed was limited to original research published after 2000, studies conducted in humans (primarily restricted to controlled trials and prospective cohort studies), and systematic reviews. Additional articles were identified by use of the literature cited in the original publications and review articles, and the Evidence Analysis Library of the American Dietetic Association (http://www.adaevidencelibrary.com/ External Web Site Policy), as well. A Google search was used to identify published marketing research related to consumer views of NNS.

The focus of the statement is on the 6 NNS that are described in Table 1 of the original guideline document. Aspartame, acesulfame-K, neotame, saccharin, and sucralose are regulated as food additives by the US Food and Drug Administration and therefore had to be approved as safe before being marketed. Regarding stevia, at this time, the US Food and Drug Administration has not made a determination as to the Generally Recognized As Safe status, but has issued no objection letters for a number of Generally Recognized As Safe notifications for stevia sweeteners (http://www.fda.gov/Food/FoodIngredientsPackaging/GenerallyRecognizedasSafeGRAS/GRASNotificationProgram/default.htm External Web Site Policy). Because all 6 of these NNS have current US Food and Drug Administration approval, issues related to safety of these compounds are not addressed. In addition, the review of the literature is primarily restricted to human studies in which noncaloric sweeteners are used as a replacement for caloric sweeteners.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Review of Published Meta-Analyses
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This document was approved by the American Heart Association (AHA) Science Advisory and Coordinating Committee on April 18, 2012, and by the American Diabetes Association Executive Committee on April 19, 2012.

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements External Web Site Policy and select the "Policies and Development" link.

Recommendations

Major Recommendations

Conclusions and Recommendations

At this time, there are insufficient data to determine conclusively whether the use of nonnutritive sweeteners (NNS) to displace caloric sweeteners in beverages and foods reduces added sugars or carbohydrate intakes, or benefits appetite, energy balance, body weight, or cardiometabolic risk factors. Limiting added sugars is an important strategy for supporting optimal nutrition and healthy weights, as concluded in the 2009 American Heart Association scientific statement "Dietary Sugars Intake and Cardiovascular Health" (Johnson et al., 2009). Monitoring carbohydrate intake, which includes limiting added sugars, is also a key strategy to achieve glycemic control as published in the American Diabetes Association (ADA) clinical practice recommendations (ADA, 2012). There are some data to suggest that NNS may be used in a structured diet to replace sources of added sugars and that this substitution may result in modest energy intake reductions and weight loss. Successful reduction in energy intake requires that there is incomplete compensation of energy reduction from the use of NNS-containing beverages and/or foods. The impact of incorporating NNS and NNS-containing beverages and foods on overall diet quality should be included in assessing the overall balance of benefits and risks. Apparent from the available literature is the paucity of data from well-designed human trials exploring the potential role of NNS in achieving and maintaining a healthy body weight and minimizing cardiometabolic risk factors.

The evidence reviewed suggests that when used judiciously, NNS could facilitate reductions in added sugars intake, thereby resulting in decreased total energy and weight loss/weight control, and promoting beneficial effects on related metabolic parameters. However, these potential benefits will not be fully realized if there is a compensatory increase in energy intake from other sources.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The evidence reviewed suggests that when used judiciously, nonnutritive sweeteners could facilitate reductions in added sugars intake, thereby resulting in decreased total energy and weight loss/weight control, and promoting beneficial effects on related metabolic parameters. However, these potential benefits will not be fully realized if there is a compensatory increase in energy intake from other sources.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

The literature search yielded relatively few research studies that focused on the specific objective of this scientific statement, the potential role of nonnutritive sweeteners (NNS) in facilitating reduction of added sugars intake in humans. This is likely attributable to inherent complexities involved in the design and implementation of these types of studies. In particular, experimental studies designed to test the effects of NNS on health outcomes in food are particularly challenging, because replacing added sugars with NNS alters dietary composition (i.e., assuming portion size is not reduced, the relative proportions of fat, protein, and carbohydrate may be changed or the nature of the carbohydrate alone may be changed) in ways that can add potential confounding to the simple comparison of added sugars versus NNS. The majority of the human data in prospective observational studies and randomized controlled trials on the use of NNS focus specifically on diet soft drinks as a replacement/displacement of regular soft drinks. Assessment in large prospective cohorts of the use of NNS from sources other than diet soft drinks has been limited methodologically by such factors as lack of specificity in intake data collected by food frequency questionnaires (FFQs) and lack of accurate NNS composition values in available databases. Much of the published literature on NNS addresses research conducted in animal models and evaluations of potential toxicity, neither of which were areas of focus for this statement. Hence, the review that follows is notably limited by the lack of an extensive evidence base.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Gardner C, Wylie-Rosett J, Gidding SS, Steffen LM, Johnson RK, Reader D, Lichtenstein AH, American Heart Association Nutrition Committee of the Council on Nutrition [trunc]. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2012 Jul 24;126(4):509-19. [58 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2012 Jul 24
Guideline Developer(s)
American Diabetes Association - Professional Association
American Heart Association - Professional Association
Source(s) of Funding

American Heart Association

Guideline Committee

American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Disease in the Young

Composition of Group That Authored the Guideline

Writing Group: Christopher Gardner, PhD (Chair); Judith Wylie-Rosett, EdD, RD (Co-Chair); Samuel S. Gidding, MD, FAHA; Lyn M. Steffen, PhD, MPH, RD, FAHA; Rachel K. Johnson, PhD, MPH, RD; Diane Reader, RD, CDE; Alice H. Lichtenstein, DSc, FAHA

Financial Disclosures/Conflicts of Interest

The American Heart Association and the American Diabetes Association make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

See the original guideline document for a complete list of writing group and reviewer disclosures.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Circulation Journal Web site External Web Site Policy and the Diabetes Care Journal Web site External Web Site Policy.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Availability of Companion Documents

The following are available:

  • Non-nutritive sweeteners: what do they offer to a heart healthy diet? Commentary. Electronic copies: Available from the American Heart Association (AHA) Web site External Web Site Policy.
  • Top ten things to know. Non-nutritive sweeteners (NNS). Electronic copies: Available in Portable Document Format (PDF) from the AHA Web site External Web Site Policy.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Patient Resources

The following are available:

  • Non-nutritive sweeteners (artificial sweeteners). Electronic copies: Available from the American Heart Association (AHA) Web site External Web Site Policy.
  • Frequently asked questions. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Electronic copies: Available in Portable Document Format (PDF) from the AHA Web site External Web Site Policy.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on October 31, 2012. The information was verified by the guideline developer on December 3, 2012.

Copyright Statement

Copyright to the original guideline is owned by the American Heart Association, Inc. (AHA). Reproduction of the AHA Guideline without permission is prohibited. A copy of the document is available at http://my.americanheart.org/statements External Web Site Policy by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp External Web Site Policy. A link to the "Copyright Permissions Request Form" appears on the right side of the page.

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