Study reveals surprising trends in non-diabetic adults' use of artificial sweeteners in Brazil

With the known disadvantages of simple sugar consumption among individuals with diabetes mellitus, non-nutritive sweeteners (NNS) initially appeared to provide an alternative that would allow such groups to enjoy the experience of sweetness without putting their metabolic health at risk.

The advent of NNS has seen a large proportion of non-diabetics jump on the bandwagon. A new study published in Nutrients examines the extent of NNS use among non-diabetic Brazilian adults.

Background

NNS are also called dietary sweeteners and provide a sugar-free alternative when sweetness needs to be added to food. They comprise both natural and artificial sweeteners and were initially considered medicines. In Brazil, they were classified as drugs registered under the Ministry of Health.

At present, they are registered as dietary foods and are available in a multitude of products, from beverages and foods to supplements and hygiene products. This has made them widely available to the population.

However, the World Health Organization (WHO) recently recommended that NNSs not be used to reduce weight, cardiovascular disease, or other metabolic disease risks.

This has put the onus on health authorities to identify NNS users and reduce their consumption. The current study aimed, therefore, to estimate the regular usage rate of NNS among the non-diabetic adult population in Brazil.

The study drew data from the Longitudinal Study of Adult Health (ELSA-Brasil). This is part of a multicenter cohort comprising over 15,000 public servants between the ages of 35 and 74 years. These are thus highly educated and financially well-off individuals, belonging to six institutes for higher education and research in Brazil.

There were over 9,000 individuals in the study, none of whom were diabetic at baseline. The question asked was whether NNS was used at least once a day. The data came from 2008-2010.

What did the study show?

About 55% of the participants were white, with 40% being between 45 and 54 years of age. Just over half the sample were females, of whom ~31% used NNS. Four out of ten participants were overweight, as classified by the body mass index (BMI).

Two-thirds of those with a high BMI did not have a family member with diabetes, and the same proportion had normal blood pressure. As expected, over 60% were highly educated, with 40% earning more than twice the minimum wage.

About eight in ten participants drank alcohol, while about 40% smoked. Almost 80% were sedentary.

The researchers found that over a quarter of the sample consumed NNS regularly, that is, once a day or more. The risk factors for increased odds of regular NNS usage included increasing age, higher income, higher education levels, and BMI.

Women were twice as likely to use NNS regularly compared to men. Those with a higher educational level were 80% more likely to use NNS regularly compared to those with an elementary education. The same increased odds applied to those with a higher income (two times the minimum wage vs up to one times the minimum wage).

White participants were 50% more likely to use these foods compared to black participants. Similarly, there was a 40% increase in use among those in the age group of 65-74 years. Those who drank or had high blood pressure, as well as those with a family history of hypertension, showed a 20% higher likelihood of regular NNS use.

The highest increase in risk came with BMI variation, however. Among obese individuals, the odds of use were seven-fold that observed among the normal-weight category.

These findings corroborate earlier studies showing that a sizable proportion of the non-diabetic population consumes NNS regularly, amounting to 37% in France and 20% in an earlier Brazilian study.

In France, the odds were higher among younger and more overweight individuals as well as those who were dieting to lose weight. In contrast, a study in Portugal showed that better education, as well as a higher BMI, posed a risk for regular NNS use.

Beverages containing NNS, mostly artificial sweeteners, were consumed up to once a day by almost one in four women in an American cohort. A multiethnic study including African-American, Caucasian, Hispanic, and Chinese-American people between 45 and 84 years old showed that almost one in seven had one or more diet sodas. However, the highest use was among white and Hispanic participants.

In the current study, the high usage rate of NNS could be due to its consumption within coffee, a beverage in widespread use in Brazil, the second-highest coffee consumer in the world. In this study, participants drank an average of 150 mL per day of coffee, with a fourth using artificial sweeteners in their coffee.

Women may be more prone to use NNS to improve their body image and maintain good health. Advertisers may exploit this tendency to promote NNS for weight loss and general health improvement.

The higher rate of use among those with a family history of diabetes may be due to either the exposure to NNS in the households of people with diabetes or, conversely, the choice to use these products rather than sugar to avert or reduce the future risk of diabetes.

What are the implications?

“The idea that consuming products with NNSs is a healthy practice is precisely the focus of marketing actions for these products.” Certain groups appear to be much more likely to use NNS regularly than others, especially those with higher education and income levels, who seem to choose these products for health-related or body image-related reasons.

The majority of NNS purchases and consumption is among white people, who are more likely to be wealthier and among the upper/upper-middle classes. The overall prevalence of use of these nutritional substitutes is relatively high.

The proliferation of products containing NSSs, notably those described as highly processed, raises concerns about the quality of a nation’s diet.

Moreira et al. 2023

This mandates the development of health policies in Brazil and other countries faced with similar issues of increased NNS consumption. These should promote clear food labeling and accurate education about these foods, targeting potential consumers and the public at large, in keeping with the WHO’s warning.

The study could also boost collaborative initiatives focused on NNS-free, low-sugar diets to promote health in various cultural and dietary settings. 

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.