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This article comes from Weixin Official Accounts: Fanpu (ID: fanpu2019), by Li Changqing, Wang Chenguang

The evidence tends to suggest that sugar substitutes not only fail to help you lose weight, but may also pose other health risks. To be healthy, stay away from sugar substitutes.

wrote an article| Changqing Li (Doctor of Medicine, Medical Practitioner in the United States), Chenguang Wang (Doctor of Biology, Professor of Former Union Medical College)

On May 15, the World Health Organization (WHO) issued important health guidelines on sugar substitutes, making it clear that sugar substitutes are not recommended for weight control or other health care measures.

The WHO's move was seen by some in the health community as a death sentence for sugar substitutes. Echoing Ronaldo's push aside of carbonated drinks at a press conference two years ago, the incident has once again drawn widespread attention to the relationship between sugar substitutes and human health.

Sugar substitutes are non-sugar sweeteners that contain almost no calories. Its products include various beverages including diet cola, and various non-staple foods with sugar substitutes as additives. It has a huge market.

Although manufacturers are rarely seen publicly touting sugar substitutes for weight loss and disease prevention, they do a lot of things both in front of and behind the scenes: advertising and sponsoring sports events to link sugar substitutes to health (which is already routine in the commercial world); behind the scenes, they fund research to support their health benefits and cover up research reports that are harmful to their products.

All of these actions are undoubtedly aimed at selling more products. To a certain extent, their strategy is successful. The US sugar substitute market is increasing by about 100 million US dollars every year. Many domestic capitals are also eager to promote this upward trend.

This WHO guideline is likely to affect the pockets and jobs of many people. As the general public, most people don't care about, and can't care about, the pockets and jobs of the rich. They care more about their own health. So what is the effect of sugar substitutes on human health? Faced with this WHO recommendation, what should those who have loved sugar substitutes for many years and have developed the habit of using sugar substitutes do?

Sweeter foods tend to contain more free sugars, including fructose, sucrose, glucose, etc. Sweet taste not only means that food contains more calories, but sweet taste also stimulates most people's appetite, making people eat more to get more calories. This is becoming a health problem in modern, food-rich societies, where diseases associated with excessive calorie intake become a heavy burden on individuals, families and society.

As a substitute for free sugar, sugar substitutes are endowed with the desire to satisfy taste and reduce health risks, and are popular among people trying to lose weight.

Such good wishes are based on people's linear thinking, and the actual effect needs to be scientifically evaluated. One fact is that sales of sugar substitutes are rising year by year, as are obesity rates and the incidence of diet-related diseases. The WHO guidelines are based largely on a systematic review published last April that included the world's leading findings on the health effects of sugar substitutes to date.

Analyzing these studies, at least two expectations about sugar substitutes have been disappointed: one is to reduce health risks by replacing caloric sugar with sugar substitutes, which many studies have shown does not work, and the other is to satisfy sweet desires without increasing health risks. Studies have shown that long-term intake of sugar substitutes also increases health risks such as obesity and diabetes, and increases all-cause mortality.

If you're at high risk for diabetes, such as obesity, don't expect sugar substitutes to reduce your risk of developing diabetes, some studies suggest, and if you're not at high risk, don't try to prevent it, either, because they don't work and may increase your risk of cardiovascular disease and stroke, the new WHO guidelines conclude. If you want to be healthy, you should try to eat unsweet food and drink unsweet drinks, such as white water.

At first glance, it seems that eating calorie-free sugar substitutes should actually help you lose weight more than caloric sugar. But the reality is much more complicated than that.

Whether you can lose weight ultimately depends on the body's energy intake and consumption, that is, total control: intake is greater than consumption, body weight gain; otherwise, weight loss. The fact that sugar substitutes themselves contain no calories does not mean that they will reduce energy intake more than a calorie-rich free-sugar diet, just as for those who drink alcohol, the increased intake of two drinks per meal does not simply count the calories in those two drinks alone, and meals eaten more or less because of alcohol must also be counted.

There are many studies showing that sugar substitutes for most people not only do not reduce energy intake, but also increase appetite, so that people's appetite is wide open, thus increasing energy intake.

Small-scale human-based trials have evaluated whether the sweetener aspartame increases hunger, with subjects given different amounts of aspartame compared to chewing gum without the sweetener. The results showed that chewing gum containing sugar substitutes increased hunger in the subjects. Another study of young people drinking aspartame-containing drinks showed that sweetener drinks generally had an appetite stimulating effect.

Evolution has shaped our taste for sweetness. Over the course of evolution, the human brain has evolved a dependence on sugar, which activates regions of the brain associated with reward and appetite, leading to increased appetite. Even if a food or drink contains sugar substitutes, the brain associates them with high-calorie foods through sweetness, because high-sugar foods are usually high-energy foods. After ingesting sugar substitutes, the brain may expect more energy, which increases appetite.

However, not all people respond equally to sugar substitutes, and individual (and certain groups) lifestyle habits, dietary patterns, and psychological factors may also affect the association between sugar substitutes and appetite. Perhaps related to this, some studies have not found that sugar replacement intake leads to increased appetite. Therefore, if we use more stringent criteria, then the effect of sugar substitutes on appetite can be said to have no clear conclusion. The truth is that for some people, sugar substitutes increase appetite, while for others, they may not have a significant effect.

But overall, this does not affect the conclusion that sugar substitutes do not help weight loss. Even if appetite enhancement is not taken into account, there is another problem with sugar substitutes, which is that their "calorie-free" effects have psychological and behavioral effects: if a person believes in the health effects of sugar substitutes, they may relax their vigilance against other unhealthy foods and lifestyles, providing excuses for eating high-calorie foods, sitting for long periods of time and not exercising.

More directly: sugar substitutes themselves aren't necessarily safe not only do sugar substitutes fail to do what you'd expect when it comes to weight loss, many small-scale studies have pointed to potential health risks, including cancer, kidney disease and cardiovascular disease.

A large study has found a potential link between artificial sweeteners and an increased risk of stroke, heart attack and related cardiovascular problems. This large-scale epidemiological study, conducted in France, aims to shed light on the relationship between sugar replacement and heart health. Long-term follow-up of more than 100,000 people, mostly women, showed that sugar replacement increased the risk of heart disease by 9 percent and stroke by 18 percent.

In recent years, there has also been a so-called healthy eating trend in sweetener choices. That means eating naturally occurring, low-calorie or non-calorie sweeteners such as xylitol and erythritol. This trend caters to those who believe in "nature." Does this trend stand up to scientific scrutiny?

In February 2023, a study published in the journal Nature Medicine revealed a link between erythritol and cardiovascular disease. Erythritol occurs naturally, in some fruits and vegetables, but in relatively low amounts, and can be synthesized by the body itself. But when added to foods and drinks as a sweetener, erythrol is often present in thousands of times higher amounts than naturally occurring in foods. Drinking beverages containing erythrol, erythrol content in the blood will increase thousands of times, and can maintain a high concentration for a long time.

The study looked at the link between erythritol and heart attacks and strokes. Erythritol intake was associated with cardiovascular disease risk in more than 4000 people who were followed for three years. The team further investigated the reasons for the increased health risks of erythritol and found that erythritol increased the incidence of fatal and non-fatal cardiovascular and cerebrovascular events by increasing the sensitivity of platelets to blood coagulation and accelerating blood clot formation and artery occlusion in experimental animals.

In addition, studies have found that sugar replacement intake is associated with metabolic problems. Some studies have found that long-term intake of large amounts of sugar substitutes may interfere with the body's metabolic processes, leading to insulin resistance, increased risk of diabetes, and problems associated with metabolic syndrome. Other studies have found that long-term intake of certain sugar substitutes may have adverse effects on the gut microbiota, interfering with normal gut flora balance and thus negatively affecting health.

So far the conclusion has been clear: want to be healthy, stay away from sugar substitutes.

To interpret the backlash, it needs to be clear that the WHO conclusions are not new to the profession, and the guidelines do not provide new facts, but rather summarize existing data. Many systematic reviews have come to similar conclusions.

As with any scientific conclusion, every study on sugar substitutes is published with both support and opposition. Comparing the articles of both sides can distinguish right from wrong. In general, the data and logic stand on the side of sugar substitution harmful theory, and the relevant researchers are more independent; and the scientists who support sugar substitution are more difficult to justify themselves. For example, an endocrinologist in Michigan has written that all studies on sugar substitution are not conducive to weight loss and diabetes prevention are unreliable, but at the same time he supports the conclusion that sugar substitution is harmful to cardiovascular and cerebrovascular diseases.

Some of the researchers who wrote to the journal refuting the adverse cardiovascular effects of sugar substitutes were found to have received funding from manufacturers involved in sugar substitutes.

Business has worse behavior. According to a report published in the British Journal of Public Health Policy in 2019, researchers at Cambridge University found that Coca-Cola had signed agreements with a number of research institutions and universities, including Louisiana State University, the University of Southern California, the University of Toronto and the University of Washington, allowing Coca-Cola to review unpublished research in advance and hide certain data that was not conducive to the sale of its products.

After the WHO guidelines were released, the Calorie Control Committee, a joint spokesman for sugar substitutes, quickly expressed strong opposition. The group's official statement cited a scientific recommendation issued by the American Heart Association in 2018 for a sugar substitute drink platform. However, in that advice, the experts stated that for those who are used to drinking sugary drinks, if it is not easy to stick to drinking water at first, they can consider choosing sugary drinks, but they also suggested that they should try to encourage drinking water instead of relying on sugary drinks continuously.

The official statement also cited a systematic review published in JAMA Network Open. The review concluded that replacing sugary drinks with sugar substitutes helped to reduce weight; the same article also analyzed the effect of replacing sugary drinks with white water, and the results showed that the effect of replacing sugary drinks with sugar substitutes was more significant than that of white water. What do you think of this unusual result? Readers may get a hint from the long list of author interest statements at the end of the paper: most of the authors receive funding from sugar companies and organizations, including the calorie control committee.

Will the new guidelines spell doom for the sugar substitute industry? It can be expected that, based on the authority of WHO, this guide is bound to have a certain impact on the sugar substitute industry; however, the capital strength of sugar substitute should not be underestimated. They are familiar with how to deal with such professional guidelines and how to eliminate the negative impact of media reports. They also have professional response teams and experience. The dullness of scientific manuals and the obscurity of technical papers often keep the general public away; and the objective reporting of mass media is often confused by the sound of muddy water, which makes it difficult for the confused public to see clearly and retain memories for a long time. As such, the expansion and climb of the sugar substitute market is likely to continue and continue to have a negative impact on public health.

Only a small number of individuals who listened carefully to scientific voices and disciplined themselves accordingly probably benefited.

references

1. Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis. April 2022 (https://www.who.int/publications/i/item/9789240046429)

2. Pang MD, et al. The Impact of Artificial Sweeteners on Body Weight Control and Glucose Homeostasis. Front Nutr. 2021 Jan 7;7:598340.

3. Tordoff MG and Alleva AM. Oral stimulation with aspartame increases hunger. Physiol Behav. 1990 Mar;47(3):555-9.

4. Witkowski M., et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med. 2023 Mar;29(3):710-718.

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