Eating Artificial Sweeteners May Increase Risk of Heart Disease

The study, published Sept. 7 in The BMJ journal, included over 103,000 French adults who participated in a web-based nutrition study. The average age of participants at the start was 42 years and almost 80% were female.

At the start of the study, people filled out questionnaires about their diet, health, physical activity, and personal information such as education, smoking status, and occupation.

They also completed multiple dietary assessments at the beginning of the study and every 6 months afterward. During these dietary recalls, they were asked to report every food and beverage they consumed over a 24-hour period.

This provided researchers with a detailed estimate of people’s consumption of artificial sweeteners from all sources, as well as their intake of fruits, vegetables, dairy products, red meat, and other types of foods or nutrients.

People also reported on new health events, medical treatments, and examinations — including ones related to cardiovascular diseases, such as heart disease, heart attack, and stroke.

Overall, 37% of participants consumed artificial sweeteners in some form. On average, these people consumed about 42 milligrams per day, equivalent to one individual packet of tabletop sweetener or 3.4 ounces (100 milliliters) of diet soda.

The average intake of artificial sweeteners for “high consumers” was around 78 milligrams per day; for “low consumers” it was around 8 milligrams per day. There was also a group of people who didn’t consume any artificial sweeteners.

People who consumed higher amounts of artificial sweeteners tended to be younger, have a higher body mass index (BMI), and were more likely to smoke, be less physically active and follow a weight-loss diet.

They also consumed fewer calories overall, and less alcohol, saturated and polyunsaturated fats, fiber, carbohydrates and fruits and vegetables; and consumed higher amounts of sodium, red and processed meats and dairy products.

Researchers took into account these differences, as well as other factors such as age, sex, physical activity, education, smoking status, and family history of cardiovascular disease.

“After the adjustment [for these], there is still a signal that there appears to be increased cardiovascular events in those reporting increased use of artificial sweeteners,” said Dr. Elizabeth H. Dineen, a cardiologist at the Susan Samueli Integrative Institute at UCI Health in Orange County, Calif. Dineen was not part of the research.

After following people for 9 years on average, researchers found that intake of artificial sweeteners was associated with an increased risk of cardiovascular disease overall.

In particular, people who consumed higher amounts of artificial sweeteners had a 9% higher risk of cardiovascular disease compared to people who didn’t consume any artificial sweeteners.

People who ate the most artificial sugar also had an 18% higher risk of stroke or another type of cerebrovascular disease compared to non-consumers.

In addition, higher consumers of aspartame had an increased risk of cerebrovascular disease; and higher consumers of acesulfame potassium and sucralose had a higher risk of coronary heart disease.

The dietary assessments recorded people’s intake of other types of artificial sweeteners — including plant-based stevia — but participants consumed too little of these for researchers to include them in their analysis.

Researchers also looked at whether substituting artificial sweeteners for added sugar would reduce the risk of cardiovascular disease overall, cerebrovascular disease, or coronary heart disease. Their analysis “did not suggest a benefit,” they wrote.

Given the results of the study, artificial sweeteners “should not be considered a healthy and safe alternative to sugar,” they wrote, especially with the “extensive use of these substances in products on the global market.”

Dineen said the study was well-done, but there are certain limitations. One is that it’s an observational study, so the researchers can’t prove a causal link between artificial sweeteners and cardiovascular disease.

However, other research has found that people who consume higher amounts of artificially sweetened beverages have a higher risk of cardiovascular disease overall and stroke.

Most previous research on the risk of cardiovascular disease has focused on the consumption of artificial sweeteners in beverages. This study, though, included all food sources.

“Beverages are, of course, a significant source of artificial sweeteners, but these sweeteners seem to be showing up in foods you wouldn’t think of, such as crackers and bread,” said Lori Chong, RDN, LD, a registered dietitian at The Ohio State University Wexner Medical Center in Columbus, Ohio.

In the new study, soft drinks with no added sugars accounted for 53% of artificial sweetener consumption, but people also consumed artificial sweeteners in tabletop sweeteners (30%) and yogurts and cottage cheese (8%).

Heart-related risks are only one concern that comes with consuming artificial sweeteners.

Another study by the authors of the new study, published March 2022 in PLoS ONE, found an increased risk of cancer with higher consumption of artificial sweeteners, especially aspartame and acesulfame-K.

“Based on other studies and this one, it appears wise to limit artificial sweeteners,” said Dineen, also an assistant professor of medicine, cardiovascular diseases, at UCI School of Medicine in Irvine, Calif.

In addition, “it is important for all individuals to minimize their risk of cardiovascular disease by following preventive strategies — such as dietary interventions,” she said, “and certainly if cardiovascular disease is already diagnosed, then these preventive efforts are of utmost importance.”

Chong said even before this study, she recommended that people minimize their intake of artificial sweeteners — but “minimize doesn’t mean avoid at all cost.”

Of course, limiting the intake of artificial sweeteners will mean different things to different to people.

So “a practical approach could be to assess which foods and beverages you are regularly consuming that contain artificial sweeteners, and then consider alternatives to these products or [ways to] reduce them,” said Chong.

This doesn’t mean just going back to added sugars — “real [added] sugars in any of its forms still needs to be limited,” said Chong.

A good rule of thumb, she said, is the World Health Organization’s recommendation of consuming no more than 10% of your daily calories as added sugars — or no more than 5% for additional health benefits.

She also suggests that people look at the ingredient lists on food packages.

“Short and simple is best versus long and complicated,” she said. “And be sure to buy enough whole foods — like fresh fruit and vegetables — that do not need an ingredient label.”

While studies like this new one and others can help guide people toward healthier eating, Dineen said healthy eating is often intuitive.

“Most people know what is generally healthy versus not,” she said. “But we are all creatures of habit, and [sometimes] it becomes difficult to break those habits.”

Some people who have trouble shifting their eating patterns may benefit from dietary counseling with a dietitian, individually or in a group, she said.

She also recommends the Mediterranean diet, which “has been a staple in the world of prevention, when it comes to heart disease.”

This diet is rich in fruits, vegetables, whole grains, and healthy fats. While traditionally, the Mediterranean diet includes fish and seafood, Dineen said the diet should be tailored to a person’s health factors and personal preferences.

In general, “the more natural and less processed, the better,” she said. “So avoiding added artificial sugars would make sense, and this [new] study helps to support that.”