Recent epidemiological, clinical and laboratory findings question whether recommendations for the use of artificial sweeteners are indeed appropriate. A careful review of this literature by health professionals including physicians, epidemiologists, and dietitians is necessary to help consumers make well-informed decisions about their health. In this review, we have examined the existing evidence supporting or refuting a link between artificial sweetener use and weight change and other metabolic effects in children.
Epidemiologic studies of artificial sweetener use in children have generally shown a positive association between artificial sweetener intake (most commonly as diet soda) and weight gain. In interpreting such studies, it is critical to consider the conditions required to support causality in such studies, including the strength of the association, consistency in findings, temporality, biological gradient, plausibility, coherence between epidemiological and laboratory findings, and strength of the dose-response relationship (58
). Based on these criteria, causality is far from established with regard to artificial sweetener use and weight gain in children. It is particularly difficult to establish causality between artificial sweetener consumption, weight gain, and metabolic abnormalities, as artificial sweetener intake is likely to be an indicator for other variables. For example, the decision to consume artificial sweeteners is often made by individuals who are concerned about their weight in an effort to reduce their caloric intake. In the case of children, this decision is frequently made by parents who are concerned about their own weight and consequently the weight of their offspring, thus further confounding the choice to use artificial sweeteners with genetic and behavioral variables.
Studies of artificial sweeteners and food intake demonstrate that caloric compensation is more complete in children than in adults, in whom food intake is substantially influenced by social cues and learned behaviors. However, even in children the degree of caloric compensation depends on the timing of the preload relative to the ad libitum
meal, as well as the age of the child and other experimental circumstances. Although not all studies agree, the general trend is that artificial sweeteners may reduce total caloric intake when consumed between meals, but when consumed with meals, children may compensate for low-calorie snacks or drinks by increasing meal-associated calories. One study (49
) supported the hypothesis that training children to associate sweet taste with low caloric density may result in overeating. Such studies, while not realistically mimicking actual human behavior, may provide insight into underlying mechanisms.
The strongest evidence for causation between artificial sweetener use and either adverse or beneficial health effects comes from randomized controlled trials. The few small, randomized controlled trials conducted in children did not find an association between artificial sweetener consumption and weight change. However, these studies were not specifically designed to look for effects of artificial sweeteners on weight change, and were presumably underpowered to find such effects. Currently, several trials are in progress to study the effects of artificially-sweetened carbonated soft drinks on body weight and other metabolic parameters in both children and adults (59
), and studies of mechanisms underlying metabolic effects of artificial sweeteners are ongoing as well (61
). These studies, and other similar investigations, will be critical for advancing understanding of the role of artificial sweeteners in metabolic health.
At the current time, the jury remains out regarding a possible role of increased artificial sweetener use in the obesity and diabetes epidemics, whether adverse, beneficial or neutral. In particular, very little data exist regarding the role of artificial sweeteners in glucose metabolism in children. Our growing understanding of the active metabolic role played by such chemicals in animal models should spur further research into the effects of these common food additives in humans.