artificial sweeteners

the boston globe today had an interesting article on artificial sweeteners (see http://www.bostonglobe.com/lifestyle/health-wellness/2014/01/27/are-calorie-sweeteners-safe/B56kqUuKVJwcEfcWx2PmhO/story.html?s_campaign=email_BG_TodaysHeadline). deborah kotz quotes some studies and interviews several people (including walt willett at harvard school of public health, who does lots of nutrition studies). their points:

--more than 12% of children now drink artificially-sweetened beverages (twice the rate of 15 yrs ago)

--manufacturers have changed: in 2007 16 of them agreed to decrease calories to stem the obesity epidemic -- by 2012 selling 6.4 trillion fewer calories

but,...

--johns hopkins study: dietary surveys of 12K americans found that overweight people drinking diet beverages (vs sugar-sweetened ones) consumed 88 more cal/day. obese americans consumed 194 additional calories.  ?? if these drinks using extremely sweet but artificial sweeteners (200-600x sweeter than sugar) reinforce cravings for sweets?

--Marion Nestle (NYU nutrition professor, and, hopefully not tied to the Nestle Corporation) suggests using sugar as sweetener, but in moderation

--Walt Willett thinks these sweeteners are so strong that they distort taste preferences, decreasing the sweet taste of natural foods, like apples and carrots

--recent study in Diabetes Care journal (see obesity sucralose inc insulin secretion diab care 2013 in dropbox, or DOI: 10.2337/dc12-2221) looked at 17 obese pts (BMI 42) who had not used non-nutritive sweeteners before and were insulin-sensitive, gave them a 5-h oral glucose tolerance test preceded by consuming sucralose or water (cross-over design), and found that pre-ingestion of sucralose led to a 14% increased peak glucose after the glucose load, a 20% increase in insulin area under the curve, a 22% increase in peak insulin, a 7% decrease in insulin clearance, and a 23% decrease in insulin sensitivity.

and, to boot, there are lingering concerns about the safety of these sweeteners: animals with tumors (leukemia and lymphoma in rats) assoc with high doses of aspartame, sucralose altering the gut flora. we don't have any longterm human data on the myriad of artificial sweeteners on the market, though the FDA states that they "have been well studies and have a reasonable certainty of no harm to consumers under their conditions of intended uses"

my sense (and practice) had been in the past to promote diet drinks as an alternative, but has evolved to "just say water", which has worked surprisingly well with my patients.  assuming that the water is not polluted.

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response from Jason Perry Block:

With regards to artificial sweeteners, which is an area of interest of mine (though not my direct line of research), the debate really turns on what we're comparing it to.  In most research, including some RCTs, drinks with artificial sweeteners are found to be better than sugar-sweetened drinks.  There were 2 RCTs published in NEJM in October 2012 demonstrating this (at least to some degree) when weight was the outcome -http://www.nejm.org/toc/nejm/367/15/.  But, there may be risks to artificial sweeteners, when compared to something like water. 

Walt Willett and I have written a few things regarding this, including for a agricultural journal a few years back - http://www.choicesmagazine.org/choices-magazine/policy-issues/can-taxing-sugary-soda-influence-consumption-and-avoid-unanticipated-consequences.  We cite a nice review of the research in this area -

Malik, V. S., Schulze, M. B., and Hu, F. B. (2006). Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition, 84(2), 274-288.  There were other articles in that Choices Magazine issue, written by public health researchers, that discuss this topic as well.

I typically talk to patients about a continuum from water (best) to high calorie sugar drinks (worst).  If they can't get all the way to water, then moving in that direction probably is beneficial, even if can't get all the way to water.  I have found some patients just simply won't drink water because they don't like drinking something without taste.

Anyway, just wanted to give my two cents.