Judith Wylie-Rosett 2018 Transcript

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In this Exclusive Interview transcript, Judith Wylie-Rosett talks with Diabetes in Control publisher Steve Freed during the ADA 2018 convention in Orlando about non-nutritive sweetener safety and uses, and the effect of low-calorie, sweetened beverages on cardiometabolic health.

Freed: This is Steve Freed and we’re here at the American Diabetes Association, 78th Scientific Sessions. And we have with us today a very special guest, Judith Wylie-Rosett. Is that correct?

Wylie-Rosett: That is correct.

Freed: And she’s doing a presentation here. And maybe we can just start out with telling us a little bit about yourself and what you do.

Wylie-Rosett: I’m New York based at Albert Einstein College of Medicine and Co-Director of the Center for Diabetes Translation Research, which basically the purpose is to try to do research that translates current evidence into care, and basically just dissemination and implementation of research related to that, so that diabetes care improves as advances in knowledge improves.

Freed: So, the title of your presentation, if I’m correct, is Evidence for Effective Non-nutritive Sweeteners on Cardiometabolic Health in Adults.

Wylie-Rosett: Yes. And the reason I was asked to do this talk is I’m the American Diabetes Association liaison to the Heart Association Nutrition Committee. And there is a draft of a paper, a scientific advisory on the use of low calorie sweetened beverages in relation to cardiometabolic health. The statement is not yet out, but because I was a member of the writing committee they asked me to do this presentation.

Freed: Well, I’ve got to ask the question that I keep seeing popping on the internet. The non-nutritive sweeteners, are they dangerous in any shape or form in the amounts that normal people use them?

Wylie-Rosett: The FDA has determined that, the ones that are in the market in the US, that they have done safety checks and consider them to be safe. Maybe there are some questions that have been raised about health, but they may be more about how people use them rather than whether they use them or not. Maybe people who use them may have other unhealthy lifestyle issues as well.

Freed: Is it just people that want to lose weight that use them, or who uses them?

Wylie-Rosett: Interestingly enough if you take the national sample in the US from the National Health and Nutrition Examination Survey, basically the users tend to be — as weight goes up, people who are obese, about half of the people use non-nutritive sweeteners, whereas about a third of people who are normal weight. Women use it at a higher rate, about 10% higher than men. College educated, higher income people use more and people with diabetes — 2/3rds of people with diabetes use it. Only about 40% of people who don’t have diabetes use it. So, it’s basically people who are probably concerned about weight and concerned about diabetes are probably the biggest users.

Freed: So, what are the most commonly consumed sources of low calorie sweeteners?

Wylie-Rosett: By far and large the biggest use is in diet beverages. About three quarters of what’s consumed by adults is in diet beverages, very small amounts in food.

Freed: And what is the evidence regarding using low calorie sweeteners for weight loss from randomized clinical trials and control trials?

Wylie-Rosett: There have been several randomized clinical trials. And they — when there’s a behavioral program — now, most of these trials have compared nonnutritive sweeteners to water. So, you’re not comparing it to if they consumed the equal amount of beverage as a sugar sweetened beverage. There’s a weight loss but there have been a couple of studies that didn’t find weight loss, so it’s not as dramatic as one might think. But it is pretty strong evidence that it can be effective if carefully planned in weight loss. But most of the trials are fairly short, they’re like three-month trials. What we don’t know is what happens over a longer period of time, because there are no 10-year trials, there are no five-year trials, I think there are virtually no one-year trials.

Freed: So, how does the evidence from observational studies regarding the relationship between low caloric sweeteners differ from the randomized trials?

Wylie-Rosett: Interestingly, if you asked people what their weight history has been for the past 10 years and people who consumed no diet products, no low calorie sweetened products, are more likely to be weight neutral. And if you go out with greater consumption, there’s a greater likelihood that somebody may have either gained 50 pounds or lost 50 pounds both directions, but the spread is enormous. So, we know that people — and I would interpret that to mean that people who want to lose weight — some people have lost weight and use them to lose weight. And people who have gained weight, maybe used them for trying to lose weight, because it’s not a homogeneous population needless to say. So, it’s sort of a mixed picture in terms of the observational studies.

Freed: So, do we know if a person who’s overweight switches from the sweet drinks to the artificial sweeteners, can they actually lose weight or — obviously it depends on –?

Wylie-Rosett: The clinical trials say absolutely yes that that somebody can lose. The typical weight loss is probably five to ten pounds but that’s within the first three months. And that’s assuming they were consuming two cans of regular soda before they started the trial that showed that. So, if they were a low consumer of sugar sweetened beverages the switch would probably — but if you take somebody who’s consuming 250 calories of sugar sweetened beverages or 500 calories which is very commonly done, you just take that out of the diet and switch to a low calorie sweetened beverage then you’re cutting out 500 calories. They should be able to lose a pound a week. And the studies tend to be fairly consistent with that.

Freed: What’s the evidence regarding the effects of low calorie sweeteners on cardiometabolic health?

Wylie-Rosett: Interestingly, there had been a review that looks at 28 trials; 13 of the trials look at people with diabetes. But only — of the 13, only five looked at Glycated Hemoglobin A1C. And of the five Glycated Hemoglobin A1C, none showed improvement in the Hemoglobin A1C. So, that raises a question of what it does. And there had been very few studies that have looked cardiometabolic risk factors like the lipid profile, the triglycerides. So, that we really don’t know as much as we wish, we think we might know. We assume since sweeteners have been around for over a 100 — the low calorie sweeteners have been around for over a 100 years, we would think that research would have been done but it’s not there in the literature.

Freed: Well, you’re an expert in the low calorie sweeteners which one would you recommend or do you ever recommend?

Wylie-Rosett: Actually we’ve now had a proliferation of using fruit essence in water and the water infusers. And I personally don’t like the diet soda or any soda. I don’t like the sweetened carbonated beverages. So, I’m very happy with the fruit essence and I think it’s going to probably increase in popularity.

Freed: Yeah, but would you put that in your coffee?

Wylie-Rosett: I actually have never — I always thought if I would ever want sweet coffee it’s as iced coffee. I am not a sweetened coffee or sweetened tea [fan]. Somebody said that’s my Scottish background.

Freed: So, what should we tell patients that have diabetes? To start using them if they’re not using them or just not even mention it?

Wylie-Rosett: Actually there was a survey done in — or interviews with 75 dietitians in the EU. And about half of them prohibited their patients from using them and about a quarter recommended them. And some were in between. And the way I like to look at is looking at, if somebody is consuming sugar sweetened beverages, what are the options? How do they feel about water? How do they feel about using a diet beverage? And really work it out on an individual basis. And interestingly, if you look at people who were — 100 people were surveyed who were going for bariatric surgery and the people who use a lot of the low calorie sweeteners in that population tend to be more unhealthy. So, looking at the total person and what their goals are, because I’m not in the driver’s seat for the people with diabetes, they are.

Freed: So, you had a presentation. How was the turnout for your presentation?

Wylie-Rosett: Standing-room only.

Freed: I would think so because it’s a very common topic. So, maybe you can just go through some of the high points, what you would like medical professionals to take away from your presentation.

Wylie-Rosett: Okay. First, I’d like to have health professionals evaluate their patients for how much they may be consuming sugar sweetened beverages and then to look at what the alternatives are. And to really have a dialogue with the patients in terms of if they want to use a diet beverage, how they’re going to go about using it. If they sort of refuse using a diet beverage, would they consider it if — actually I probably would first mention that water is a wonderful beverage. Traditionally water was the beverage we drank for thirst. We now feel that we have to have something that’s special for our thirst. And so, I would really work it out on an individual basis. And I think there’s concern that people with type 1 diabetes, if they are consuming sugar sweetened beverages the glucose excursion afterwards, and what I hope in the future with the proliferation of continuous glucose monitoring research, we’ll know a lot more about what the effects of sugar sweetened beverages, non-caloric beverages are on the postprandial glucose because the A1C is a little bit more removed from that.

Freed: So, for my last question, we hear a lot about obesity and how it’s increasing especially with children. Children probably drink more sugary drinks than adults do. What are your thoughts as far as how important it is for children to basically stay away from sugary drinks and even some of the fruit drinks, you must have an opinion from your –?

Wylie-Rosett: In fact, actually implicit in that question is what about switching to diet. Based on New York City, it prohibits the use of non-caloric sweeteners in any product serving our city schools, which is more conservative than a lot of other school districts. Kids with diabetes who consume non-diet beverages — a higher quantity of non-diet beverages tend to have more unhealthy habits, which may not be true with adults. So, I think what we really need to do is to look at the total dietary pattern of kids and trying to get them to eat fruits, vegetables, and eating a healthy pattern. And sugar sweetened beverages may have a very small role, but the amount of recommended — the limits that we should put on our sugar intake from the calorie perspective is very — a sugar sweetened beverage would take care of that, unless somebody were extremely athletic.