Abstract
BackgroundThe major metabolic complications of obesity and type 2 diabetes may be prevented and managed with dietary modification. The use of sweeteners that provide little or no calories may help to achieve this objective.MethodsWe did a systematic review and network meta-analysis of the comparative effectiveness of sweetener additives using Bayesian techniques. MEDLINE, EMBASE, CENTRAL and CAB Global were searched to January 2011. Randomized trials comparing sweeteners in obese, diabetic, and healthy populations were selected. Outcomes of interest included weight change, energy intake, lipids, glycated hemoglobin, markers of insulin resistance and glycemic response. Evidence-based items potentially indicating risk of bias were assessed.ResultsOf 3,666 citations, we identified 53 eligible randomized controlled trials with 1,126 participants. In diabetic participants, fructose reduced 2-hour blood glucose concentrations by 4.81 mmol/L (95% CI 3.29, 6.34) compared to glucose. Two-hour blood glucose concentration data comparing hypocaloric sweeteners to sucrose or high fructose corn syrup were inconclusive. Based on two ≤10-week trials, we found that non-caloric sweeteners reduced energy intake compared to the sucrose groups by approximately 250-500 kcal/day (95% CI 153, 806). One trial found that participants in the non-caloric sweetener group had a decrease in body mass index compared to an increase in body mass index in the sucrose group (-0.40 vs 0.50 kg/m2, and -1.00 vs 1.60 kg/m2, respectively). No randomized controlled trials showed that high fructose corn syrup or fructose increased levels of cholesterol relative to other sweeteners.ConclusionsConsidering the public health importance of obesity and its consequences; the clearly relevant role of diet in the pathogenesis and maintenance of obesity; and the billions of dollars spent on non-caloric sweeteners, little high-quality clinical research has been done. Studies are needed to determine the role of hypocaloric sweeteners in a wider population health strategy to prevent, reduce and manage obesity and its consequences.
Highlights
The major metabolic complications of obesity and type 2 diabetes may be prevented and managed with dietary modification
Primary articles included in the systematic review (n=51) Trials included in the systematic review (n=53)
Initial screening, 491 articles were retrieved for detailed evaluation (Figure 1) and of these 440 articles were excluded resulting in 53 trials that met the selection criteria
Summary
The major metabolic complications of obesity and type 2 diabetes may be prevented and managed with dietary modification. The use of sweeteners that provide little or no calories may help to achieve this objective. Non-caloric sweeteners have been available commercially since the late 1800s [1] and their use in food products and as table-top sweeteners is increasing perhaps due in part to aggressive marketing promoting their capacity to induce weight loss and weight maintenance [2,3]. Sugar alcohols can be used as sweetener additives and provide less calories per gram than saccharides (sugars). A variety of different saccharides is commonly used to sweeten foods, such as sucrose, fructose, glucose, maltose, isomaltulose, and fructooligosaccharide (FOS). FOS has half the calories per gram than sucrose, fructose, or glucose. Fructose (a highly commercially used sweetener used in combination with glucose as high fructose corn syrup (HFCS)) has been controversially linked with hypertriglyceridemia [6]
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