Sugar Substitutes and Type 2 Diabetes

A new study looks at the growing use of sugar substitutes and type 2 diabetes: can non-nutritive sweeteners cause, or help prevent, type 2?

Non-nutritive sweeteners are commonly referred to as “healthy” sugar substitutes. There are many different sugar substitutes that are used in many products. These sugars are popular in diet sodas and as a result, have resulted in high demand for these drinks. Some of the non-nutritive sweeteners that are approved by the FDA include aspartame, which is also known as NutraSweet; saccharin, which many people know as Sweet N’ Low; sucralose, which many people know as Splenda. There are also other non-nutritive sweeteners like Stevia and other less popular ones. As their popularity skyrocketed, many people began to wonder about what the long-term effects of these sugar substitutes could be, and whether they are bad for you.

One of the most important things a person could do when being diagnosed with type 2 diabetes is to make lifestyle changes to promote healthy behaviors. Many people who drink lots of sugary beverages typically switch to diet sodas because they have no sugar and are supposed to be “healthier,” but new evidence is showing that diet soda can contribute to a person’s diabetes.  In this study, previous studies were searched on three different databases: PubMed, Science Direct, and Scopus. Certain keywords were included in the search such as “artificial sweeteners,” “type 2 diabetes,” “prediabetes,” and “non-nutritive sweeteners.” Studies conducted on adolescents, pregnant women, children, or patients with diabetes were excluded from this study. Studies that were conducted between 2004 and October 2018 were considered for this meta-analysis.

In one study, the authors stated that artificially sweetened beverages were associated with fewer instances of prediabetes, therefore, lowering the risk of type 2 diabetes. On the other hand, another author from another study found that aspartame increased blood glucose in patients with obesity but not in lean patients, so the relationship between these low-calorie beverages and type 2 diabetes was still unclear. In many of the studies that were included, non-nutritional sweeteners were associated with type 2 diabetes after adjustments were made for BMI and other factors. In two other prospective studies, diet sodas did not appear to cause an increased risk of type 2 diabetes, but caffeinated beverages that contained artificial sweeteners were shown to have an increased risk of type 2 diabetes. This association was lost, however, once adjustments were made for body mass index and energy consumption. There were, however, studies that did show an association between artificial sweeteners and an increased risk of type 2 diabetes, even after adjusting for BMI and other confounding variables. One study found that drinking diet sodas daily had a positive correlation with an increased risk of type 2 diabetes after adjusting for BMI and other factors. Many other studies also concluded that daily artificial sweetener intake showed a strong relationship with the risk of type 2 diabetes.

After analyzing the many trials that tried to better understand the association between non-nutritive sweeteners and type 2 diabetes risk, it is unclear whether there is a true association between the two. Many of the studies had confounding variables that made it hard to determine if there was a significant change in risk between the control and intervention groups after adjusting for variables. Obesity was one of biggest confounding variables. A firm conclusion cannot be made due to the differences in study type and design.

Practice Pearls

• After analyzing many different studies, there is no strong evidence that can claim that these artificial sweeteners can help or cause type 2 diabetes
• Many trials showed a strong relationship between the two variables until they had to adjust for other factors, when the data for many of the studies became insignificant
• Due to the popularity of these sugar-free beverages, there is an urgent need for a study that clearly explains the role that artificial sweeteners play in type 2 diabetes after looking at all potential confounding variables

Daher, Mira I. “Non-Nutritive Sweeteners and Type 2 Diabetes: Should We Ring the Bell?” Diabetes Research and Clinical Practice, Elsevier B.V., 19 July 2019, https://doi.org/10.1016/j.diabres.2019.107786.

Joel John, Pharm.D. Candidate, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences