WHO’s Sweetener Guidelines: Urgent Call for Re-Evaluation
In a recent publication featured in the European Journal of Clinical Nutrition, researchers have raised significant concerns regarding the World Health Organization’s (WHO) guidelines concerning the use of non-sugar sweeteners (NSS) and have called for an immediate re-evaluation.
Background:
The WHO’s Nutrition and Food Safety Department recently issued guidelines on the use of NSS, drawing from a systematic review and meta-analysis (SRMA). This guideline addressed a crucial matter: the contrasting outcomes observed in randomized controlled trials (RCTs) and prospective cohort studies concerning NSS usage.
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The Divergent Findings:
The WHO guideline explicitly acknowledged that RCTs indicated positive outcomes, such as reduced adiposity, following NSS consumption. In contrast, prospective cohort studies hinted at an association between NSS use and increased risks of chronic diseases and adiposity. The WHO recommendations characterized NSS as ineffective for weight management and the prevention of non-infectious diseases, although the latter was conditionally recommended.
Critical Concerns Raised:
Researchers expressed two primary concerns. Firstly, they questioned the WHO’s reliance on findings from observational studies rather than RCTs. Secondly, they scrutinized the methodologies employed in these observational studies, particularly the baseline (or prevalent) analysis, which introduced a higher risk of bias.
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Weight of Evidence:
The WHO’s SRMA indicated that NSS led to reduced energy intake when compared to calorie-equivalent sources, a promising sign for weight loss and BMI management. However, prospective cohort studies included in the SRMA painted a different picture, revealing both positive and negative associations between NSS usage and BMI, obesity, type 2 diabetes (T2D), cardiovascular disease (CVD), and mortality.
Bias and Certainty in Evidence:
The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework assigns higher certainty to RCTs due to their inherent protection against bias. Prospective cohort studies, on the other hand, start with low certainty in GRADE as they are more susceptible to bias and struggle to establish causality.
Addressing Bias and Advancements:
The WHO SRMA acknowledged the limitations of prospective cohort studies but considered the negative associations linked to NSS consumption as valid. Recent advancements in analytical methodologies have addressed some of these limitations, including the use of sequential assessments and substitution analysis, modeling NSS as a substitute for caloric sugars.
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Supporting Evidence:
A recent SRMA conducted by Lee et al. analyzed 14 prospective cohort studies of NSS intake, utilizing sequential assessments and substitution analysis while accounting for initial adiposity. This comprehensive study indicated that increased NSS intake correlated with reduced body weight and waist circumference, without adverse effects on T2D. Furthermore, it highlighted the benefits of substituting NSS beverages for sugar-sweetened ones, reducing the risk of obesity, coronary heart disease, and mortality without detrimental effects on T2D.
Conclusions:
The researchers assert that the WHO’s dismissal of change and substitution analysis, as well as RCT data, deviates from established norms in nutrition research. By relying heavily on biased prospective cohort studies, the WHO’s approach lacks biological rationale. Concurrently, the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes recommends NSS usage as a strategy for reducing cardiometabolic risks. The emerging consensus suggests that NSS may not be a causative factor but a response to increased disease risk. Consequently, there is an urgent call to re-evaluate the WHO’s evidence base and guidelines concerning NSS usage.
