CONFERENCE REPORT
Consensus statement on benefits of
low-calorie sweeteners
S. Gibson*, A. Drewnowski†
, J. Hill‡
, A. B. Raben§
, H. Tuorila¶
, E. Widström**
*Sig-Nurture, Ltd., Guildford, Surrey, UK;
†
University of Washington Center for Obesity Research, Washington, DC, USA;
‡
Anschutz Health and Wellness Center, University of Colorado, Boulder, CO, USA;
§
Department of Human Nutrition, University of Copenhagen, Denmark;
¶
Department of Food and Environmental Sciences, University of Helsinki, Finland;
**National Institute for Health and Welfare, Helsinki, Finland
International Sweeteners Association
Conference,Why low calories count:The
effective use of low calorie sweeteners
in today’s diet and lifestyle choices
(1–2 April 2014), Brussels, Belgium
Preference for sweetness is innate and universal, and
probably represents a biological response to safe sources
of energy such as mother’s milk and fruit (Ventura &
Mennella 2011). There is some evidence that sweetness
preference declines with age, is partly heritable
and varies among cultures (Keskitalo et al. 2007;
Drewnowski et al. 2012). Given current concerns about
overweight and obesity, low-calorie sweeteners (LCS)
are increasingly used to replace sugar and supply sweetness
without calories, helping people to moderate their
energy intake (Anderson et al. 2012). However, some
people are confused about the effects of LCS on nutrition
and well-being, despite positive statements about
safety from regulatory authorities worldwide. This consensus
paper summarises current evidence on the benefits
of LCS, as reviewed by a panel of independent
experts at the International Sweeteners Association
Conference in Brussels, in April 2014. The panel
included the following scientific experts.
• Prof Adam Drewnowski, Professor of Epidemiology,
Director of the University of Washington Center for
Obesity Research, University of Washington, USA;
• Prof James Hill, Professor of Pediatrics and Medicine,
Executive Director, Anschutz Health and Wellness
Center, University of Colorado School of Medicine, USA;
• Prof Anne Birgitte Raben, Department of Nutrition,
Exercise and Sports, University of Copenhagen,
Denmark;
• Prof Eeva Widstrom, Chief Dental Officer, CDO Professor
at the National Institute for Health and Welfare,
Finland;
• Prof Hely Tuorila, Chair of Sensory Food Science,
University of Helsinki, Finland.
Definitions
LCS are intensely sweet compounds that contain virtually
no calories, and which can be used to replace sugar
in food and drinks. Examples are aspartame, acesulfame
K, saccharin, sucralose and steviol glycosides.
Hunger, appetite and satiety
Recent studies suggest that LCS neither promote nor
suppress appetite (Bellisle & Drewnowski 2007;
Renwick & Molinary 2010). Because of their volume,
low- and no-calorie beverages may suppress appetite for
about an hour, but do not appear to affect food intake at
the next meal. By contrast, a caloric beverage will suppress
appetite and may or may not reduce energy intake
at the next meal. Satiety (fullness after consumption)
was similar for children given LCS-containing beverages
or sugar-sweetened beverages (SSB) in an 18-month
intervention trial (de Ruyter et al. 2013), and similar
effects have been found among adults (Rolls 1991; Holt
et al. 2000). For example, in a crossover study, adults
given foods sweetened with LCS (290 kcal) or sucrose
(490 kcal) before lunch and dinner reported similar
hunger and satiety ratings and ate similar amounts at
the next meal (Anton et al. 2010). A recent meal test
study (Maersk et al. 2012) showed that after drinking
Correspondence: International Sweeteners Association (ISA), Avenue
des Gaulois 9; B-1040 Brussels, Belgium.
E-mail: isa@ecco-eu.com
[Corrections made after online publication: The following text ‘and
on behalf of the International Sweeteners Association’ was removed
from the author listing as the article represents the views of the
independent panel members. Author’s affiliation for Tuorila H. was
changed to ‘Department of Food and Environmental Sciences,
University of Helsinki, Finland’.]
bs_bs_banner
DOI: 10.1111/nbu.12116
386 © 2014 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 39, 386–389
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
500 ml of an SSB total energy intake (from the drink
and the following ad libitum meal) was higher compared
with a diet soft drink or water. It was concluded
that the energy provided by SSB was not fully compensated
by decreased energy intake at the following meal,
emphasizing the risk of generating a positive energy
balance by frequent consumption of energy-containing
beverages. Furthermore, there were no indications that
the artificial sweetener used in this study (aspartame)
increased appetite or energy intake, compared with
water. More research is needed into possible habituation
to the effects of LCS on appetite, satiety and food
intake. There is also concern about the generalisability
of blinded experimental studies, when cognitive and
social factors may have more influence on consumption
in real life (Anderson et al. 2012).
Energy intake
Studies suggest that food and beverages sweetened with
LCS may help reduce energy intake if used in place
of more energy-dense food and drinks (Mattes &
Popkin 2009). Hence, the benefit of LCS will tend
to be greater for drinks (where sugar is the main or
only energy source) than for foods (where other
macronutrients may be needed to replace sugar and
provide bulk). Reviews of randomised controlled trials
in which LCS were used in place of sugar or SSB over
several days or weeks conclude that ad libitum energy
intakes are lower with LCS because people only partly
compensate for the missing calories (de la Hunty et al.
2006; Mattes & Popkin 2009). The degree of compensation
of the food or drink is likely to vary depending on
the physical form, composition, amount, timescale and
individual factors. Variation in design may explain why
some studies find a larger energy deficit than others.
Such differences may include the type of LCS used, its
physical form (food or beverage), the choice of control
(e.g. SSB, water), the amounts consumed and the caloric
context (ad libitum, hypercaloric, weight-reducing diet).
Although more data from longer-term interventions are
needed, it appears that LCS, especially in beverages, can
be a useful aid to maintain reduced energy intake
(Raben & Richelsen 2012).
Weight management
Several reviews of epidemiological and clinical studies
have concluded that reducing or replacing SSB with lowor
no-calorie alternatives has beneficial effects on
bodyweight (Dennis et al. 2009; Malik et al. 2013;
Ebbeling 2014), but evidence that using LCS results in
weight loss has been limited (Shankar et al. 2013). In
2011, the European Food Safety Authority (EFSA)
rejected a claim for non-nutritive sweeteners in weight
loss, partly on the grounds that a cause and effect relationship
between sugar intake and obesity had not been
proven and partly because some of the evidence cited
related to beverages rather than LCS-containing products
in general (EFSA NDA 2011). However, evidence is
steadily accruing from randomized controlled trials, and
recent reviews have concluded that using LCS to replace
sugars results in (modest) weight loss (<1 kg over several
weeks) (Te Morenga et al. 2013) and a reduction in fat
mass and waist circumference (Miller & Perez 2014).
However, many studies included large amounts of
sugars or SSB as the control, while others found significant
effects only in subgroups, for example, overweight
subjects or Hispanics. Such data indicate that additional
research is needed to understand variation in response
and mechanisms (Kaiser et al. 2013; Ebbeling 2014). In
general, evidence supports the conclusion that substituting
energy-free beverages or water in place of SSB
facilitates weight management (Dennis et al. 2009).
However, few studies have compared the impact of consuming
LCS-containing beverages versus water, which
would address whether LCS-containing beverages facilitate
dietary adherence and weight loss because of their
sweet taste and palatability, as opposed to merely substituting
for sugar calories. This question was investigated
in a recently published randomized controlled
trial from the United States, which has indicated that
LCS-containing beverages produce greater weight loss
over 3 months compared with water (Peters et al. 2014).
In this study, subjects were randomly assigned to
consume either LCS-containing beverages or water (at
least 710 ml/day) while participating in a 12-week
behavioural weight loss programme, comprising weekly
group sessions covering topics such as weight loss strategies,
food labels, portion control and physical activity.
Those assigned to the LCS group lost 5.95 kg, which
was significantly greater than the average of 4.09 kg lost
by those in the water-only group (P < 0.0001).
Prevention of weight gain is also important for public
health and it has been hypothesised that an energy
deficit of 100 kcal/day may be sufficient to prevent progressive
weight gain in 90% of the adult population
(Hill et al. 2003). A 100 kcal/day reduction in liquid
calories was associated with a small weight loss
(0.25 kg) over 6 months in the PREMIER prospective
study (Chen et al. 2009); this deficit is equivalent to the
energy in a 250-ml SSB or six teaspoons of sugar added
to tea or coffee during the day. A high proportion of
American adults who are trying to maintain their weight
Benefits of low-calorie sweeteners 387
© 2014 The Authors. Nutrition Bulletin published by John Wiley & Sons Ltd on behalf of British Nutrition Foundation Nutrition Bulletin, 39, 386–389
use LCS as part of that strategy and also follow other
healthy eating and lifestyle behaviours (Drewnowski
2013). Phelan et al. (2009) found that weight loss
maintainers consumed more artificially sweetened soft
drinks and used more fat- and sugar-modified foods
than normal weight controls (Phelan et al. 2009). Similarly,
participants in the US National Weight Control
Registry consume three times as much LCS as normal
weight controls. The other behaviours associated with
successful weight loss maintenance in this cohort
include calorie counting, consistent dietary restraint,
self-weighing, eating breakfast and taking exercise
(Wing & Hill 2001).
Diabetes and insulin
Diabetes has different forms, but all feature abnormal
glucose metabolism because of insulin deficiency and/or
impaired insulin effects. People with diabetes are
encouraged to follow a healthy diet, with around 50%
of energy from carbohydrates, which can include a small
amount of added sugar. There is evidence that LCS can
provide sweetness without raising blood sugar or affecting
insulin or gut peptide release in any way (Grotz et al.
2003; Ma et al. 2009, 2010), in contrast to high sucrose/
high-energy diets, which normally tend to increase postprandial
glycaemia, insulinaemia and lipidaemia (Raben
et al. 2011). Equally, when consumed with glucose, LCS
do not appear to modulate the glycaemic response
(Bryant et al. 2014). LCS have been declared safe for
people with diabetes, and EFSA has recently approved
the health claim that LCS help reduce post-prandial
glycaemic response (EFSA NDA 2011). Maintaining a
healthy bodyweight is central to good control of diabetes,
so LCS may also benefit people with diabetes by
facilitating weight control, if consumed in the context of
a calorie-controlled diet and healthy lifestyle. More
research is needed into their role in long-term blood
glucose control.
Oral and dental health
LCS are non-cariogenic, which means that they are not
fermented by oral bacteria and do not cause tooth decay
(Grenby 1991). However, LCS-containing foods are not
necessarily ‘tooth-friendly’ if they contain fermentable
carbohydrates or food acids with an erosive effect.
Hence, the tooth-friendly property depends upon the
food’s overall composition and characteristics. EFSA has
published a positive opinion on the claim that sweeteners
may decrease the rate of tooth demineralization (EFSA
NDA 2011).
Conclusions
(1). LCS do not increase appetite and have no discernible
effect on satiety.
(2). LCS help to reduce energy when used in place of
higher energy ingredients.
(3). LCS can enhance weight loss under real-life conditions
when used as part of a behavioural weight loss
programme.
(4). LCS may have a beneficial effect on post-prandial
glucose and insulin in healthy individuals and in people
with diabetes.
(5). LCS have dental benefits when used in food, beverages,
toothpaste and medications, provided other constituents
are also non-cariogenic and non-erosive.
Acknowledgement
This work was funded by an unrestricted educational
grant from the International Sweeteners Association.
Conflict of interest
Consensus panel experts were: Prof Adam Drewnowski,
Prof James Hill, Prof Anne Raben, Prof Hely Tuorila,
Prof Eeva Widstrom. An independent nutritionist
(Sigrid Gibson) was responsible for literature research,
drafting the preliminary document and revising for publication.
All authors agreed the final version.
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