I can’t keep up with emails from my readers asking about a highly publicized new guidance that the World Health Organization released on May 15, 2023, regarding the use of [what they call] “non-sugar sweeteners” to help with weight loss.
Before I go into details and answer the FAQs, let me sum it up for you.
There is currently no definitive consensus on the effectiveness of zero-calorie sweeteners for long-term weight loss. In order to address this issue, the World Health Organization (WHO) conducted a comprehensive evaluation of 283 studies done to date.
The findings of the WHO evaluation showed that the available evidence is of low certainty, indicating a low quality of the studies' results. Consequently, it's hard to draw definitive conclusions as the studies do little to help us understand the science in this area.
Even though the agency knew about the studies' problem, it published guidelines. But it emphasized that the strength of the recommendations regarding non-sugar sweeteners is "conditional," and not strong. It means they have a lack of confidence or certainty that the desirable consequences of implementing the advice outweigh the undesirable consequences.
If you’re interested in learning more, keep reading as I dig deeper into the 2023 WHO guideline on non-sugar sweeteners.
THE ESSENTIAL DETAILS OF THE GUIDELINE
WHO advises not to use non-sugar (NS) sweeteners for long-term weight loss or to reduce the risk of chronic diseases—such as cardiovascular diseases (heart attacks and stroke) and type 2 diabetes.
As stated by WHO, this guideline is NOT intended to provide updates about these sweeteners’ safety. They remain safe and are approved in numerous countries.
What’s a non-sugar sweetener in WHO’s view?
WHO defines “non-sugar sweeteners” as zero-calorie sweeteners that are NOT classified as sugar.
Wondering what exactly is sugar?
I have a page on my website that lists all the sweeteners classified as sugar HERE.
WHO uses the term “free sugar” instead of simply “sugar” and defines it HERE as mono- and di-saccharides added to foods & beverages such as table sugar, honey, and maple syrup.
So, what sweeteners are considered non-sugars?
Non-sugar sweeteners refer to a group of sweet compounds — each one with different chemical structures, sweetness levels, properties, and metabolism in the body.
Non-sugar sweeteners include stevia, sucralose, aspartame, saccharin, and acesulfame, among other not-so-common sweeteners. All of them are way sweeter than table sugar, and so, known as high-intensity sweeteners and used in very small amounts.
Take sucralose, for example.
It’s about 600x sweeter than sugar, so you need just 3/4 of a teaspoon to sub for 1 cup of table sugar. To swap one teaspoon of sugar, you need 1/64 tsp (0.01 grams) of sucralose.
Because it’s kind of a hassle having to measure tiny amounts, you often find high-intensity sweeteners blended with bulk sweeteners such as erythritol, allulose, or maltodextrin, so they have an overall resemblance to table sugar. Therefore, bulk sweeteners make it easier for you to measure sugar substitutes at home. Instead of having to measure or weigh minuscule amounts of product, you can use the measuring tools you have in your kitchen.
All that to say, most people use these non-sugar sweeteners in small amounts because they’re super sweet.
Which sweeteners were excluded from the 2023 guideline?
The 2023 recommendation does not mention three of the top zero-calorie sweeteners sold in America—monk fruit, allulose, and erythritol.
Monk fruit is way sweeter than table sugar, but allulose and erythritol are less sweet. So, allulose and erythritol are not high-intensity sweeteners. Instead, they have a mild sweetness of about 70% that of table sugar, which means you need to use more to get the same sweetness level.
Most sugar alternatives in America are made up of erythritol as the predominant ingredient, so this guideline does not apply to the most common sugar alternatives you buy in stores.
Here’s why they were excluded:
Monk fruit is not on the list of sweeteners from WHO because it’s relatively new on the market, so there’s less research on its long-term effects. But that does not mean it’s off the hook, as it most likely acts the same way as the other included high-intensity sweeteners.
Allulose is not on the list because it provides calories—despite the fact that here in the U.S., by law, it can be labeled as zero-calorie. Another reason allulose was excluded is that it’s technically a sugar. Plus, being new on the market, there’s less research on its long-term effects.
Erythritol and other sugar alcohols were also excluded because they provide calories. In WHO’s view, erythritol does not qualify as a “non-sugar sweetener.” But the truth is that, technically, it is, in fact, a non-sugar sweetener because it’s NOT a sugar. Also, here in the U.S., by law, it can be labeled as a zero-calorie sweetener.
WHO's new guideline does not apply to honey, maple syrup, and other refined & unrefined sugars. They already wrote a guideline for these sweeteners in 2015, and you can read it HERE or HERE. They advise limiting sugars to 10% of daily calories, which is twelve teaspoons a day on average. Furthermore, they recommend it’s best to keep it below 5% of daily calories, meaning no more than six teaspoons a day.
What is WHO's new recommendation?
WHO gives two recommendations.
It advises not to use non-sugar sweeteners for weight loss. That’s because there’s a lack of evidence showing they’re effective in helping people lose weight in the LONG TERM (over 6 to 18 months), even though studies have shown small weight loss in the short term (3 months or less).
WHO also recommends not to use non-sugar sweeteners to reduce the risk of diet-related chronic diseases. That’s because studies showed a CORRELATION between NS sweetener use and increased risk of chronic diseases.
Note that diet-related chronic diseases, also known as noncommunicable diseases, or NCDs, are the leading cause of premature death globally. They include mainly cardiovascular diseases but also type 2 diabetes.
Why is the evidence evaluated by WHO of low quality?
Put simply, the available evidence is of low certainty (low quality) because the impacts of diet and the cause-and-effect of real-life dietary decisions are difficult to study.
WHO’s guidance was based on 283 studies conducted in two ways:
Randomized-control trials (RCT) Of all the many ways research can be conducted, the gold standard in nutrition and clinical study is RCT. In an RCT, people are randomly assigned with the goal of determining if the sweetener actually makes a positive difference. The problem is that randomized trials involving the use of sweeteners are often small short-term studies. Their findings do not apply to long-term effects, which is important because weight loss and maintenance of a healthy weight have to be sustained over the long term to have a meaningful impact on health. Another problem is that most RCTs have participants consume sugar and NS sweeteners in their existing diets rather than measure the effects of replacing sugar with sweeteners. Aside from the problems, RCTs have shown that higher NS sweetener use actually led to weight loss—when compared with not using NS sweeteners at all or consuming low amounts. But that’s not the findings in long-term observational studies, as I discuss next.
Observational studies Observational studies are long-term studies that observe people over time, following both their sweetener use and their health outcomes, like rates of diabetes or heart attacks. The problem observational studies show an association, not cause and effect. Here are two pieces of evidence from these studies: • Correlation: There’s a link between the high use of NS sweeteners and a higher risk of chronic diseases, such as type 2 diabetes and cardiovascular disease. • Not causation: A link does NOT mean sweeteners cause chronic diseases such as diabetes and CVD. • Correlation: There’s a link between a high intake of NS sweeteners and the incidence of obesity. • Not causation: A link does NOT mean sweeteners cause people to become obese. The problem with observational studies results from what is known as “reverse causality.” Reverse causality is the association of two variables differently than expected. For example, an association between the high use of non-sugar sweeteners and higher body weight may be the consequence of and not the reason for overweight and obesity. Instead of the sweeteners actually causing people to be overweight or obese, it might be that those who use high amounts of sweeteners are more likely to be obese. Or it might be that people who use a lot of sweetener are also more likely to be obese because of their unhealthy lifestyle & diet in the first place. And that’s why observational studies tend to show that sweeteners cause diseases rather than the diseases leading them to use a lot of sweetener. So, you might be thinking, what’s the benefit of conducting observational studies? When the findings of observational studies show a correlation, it indicates a need for further studies examining the long-term effects of non-sugar sweeteners.
FAQ AND MY RECOMMENDATIONS
1– Can zero-calorie sweeteners help people lose weight?
Yes, non-sugar sweeteners can help you lose weight.
Here's how:
You can eat healthier and lose weight because they help you eat less sugar or even go sugar-free. Weight loss results because there’s a reduction in energy intake when you substitute NS sweeteners for sugar.
However, sweeteners alone are not a guarantee of weight loss, as people tend to think that NS sweeteners give them a free pass to overeat other high-calorie foods.
They work well as a tool for weight loss when they're part of a healthy balanced diet.
[Be aware that the main source of sugars in the American diet is not added to foods by consumers. Instead, it's added by manufacturers and found in highly processed foods and beverages. So, simply replacing sugars with zero-calorie sweeteners means that the overall quality of the diet is not going to change much.]
2– Does this guideline say that it’s better to use sugar instead of NS sweeteners?
No, it does not. Do not react to this WHO guideline by swapping sweeteners with sugar. In fact, WHO has already issued a guideline to cut back on sugar in 2015. They recommend limiting the amount of sugar we eat to no more than 10% of daily calories, which is twelve teaspoons a day on average. They go even further, saying it’s best to keep below 5% of daily calories, meaning no more than six teaspoons a day.
3– What’s your advice on the best way to reduce the use of sugar & sweeteners?
There’s no doubt that everybody would be healthier eating less sugar. But we all know that cutting out sugar cold turkey isn’t easy and not even recommended. The key, regardless of the sweetener, is not to go overboard.
The best way to reduce your sugar or sweetener intake is by adjusting your palate to foods that are not super sweet. Choose where it might be easiest to modify. You can start cutting 10% of the sugar/sweetener in your coffee, for example. Once you get accustomed, keep cutting back. You’ll find that you come to prefer less sweet coffee.
That’s the ultimate goal: gradually eat less sugar/sweetener by training your palate.
Of course, NS sweeteners are not the only way to help people eat less sugar. Healthy alternatives include foods that are naturally sweet, such as fruits. Plus, including more minimally-processed or whole foods with protein and fiber in your diet can help you crave less sugar.
4– What are the long-term health concerns about using non-sugar sweeteners?
There is still no clear consensus on whether zero-calorie sweeteners are effective for long-term weight loss. So, further studies are needed to understand the long-term effects of NS sweeteners.
5– What’s the point of publishing guidelines if WHO is not confident they are true?
The point was to evaluate the available evidence—a total of 283 studies—and provide clear, concise information [even if it shows the low quality of the studies' results].
That’s how science advances.
This guideline is not directly intended for individuals. Instead, it’s a recommendation for policy-makers and health professionals to address non-sugar sweetener use in their populations of adults, children, and pregnant and lactating women. [WHO did not evaluate any studies that included people with diabetes, so the guideline does not apply to such individuals].
I view this guideline as a suggestion for those stakeholders not to promote the use of NS sweeteners as a tool to solve obesity and other chronic diseases. But, for individuals, substituting sweeteners for sugar remains a tool that can help them eat healthier and lose or maintain their weight.
CONCLUSION
In conclusion, the World Health Organization's new guideline on non-sugar sweeteners brings attention to the lack of definitive evidence regarding their effectiveness in weight loss and reducing the risk of chronic diseases. While the WHO acknowledges the limitations of the existing research, they still offer conditional recommendations against using these sweeteners for long-term weight loss or preventing conditions like cardiovascular diseases and type 2 diabetes.
It's important to note that the guideline does not question the safety of non-sugar sweeteners, as they remain approved and considered safe in many countries.