Discussion and recommendations
The use and consumption of intense sweeteners have
risen sharply over the last twenty years, probably due to
concerns linked to the doubling of prevalence of overweight
and obesity. While the potential risks of each intense
sweetener are assessed before their authorisation,
no general assessment of the overall nutritional risks
and benefits of these products has been conducted at
the European level up to now [81–83].
After an analysis of all of the scientific literature, it appears
that, despite a large number of studies, the data
are insufficient to determine any long-term nutritional
benefits related to the consumption of products containing
IS as sugar substitutes. The available data do not
show any risks related to IS consumption. However, due
to the limited number of studies, it is not possible to
rule out potential long-term risks related to IS consumption
in specific populations, particularly adult daily consumers
and children. It is important to note that before
their authorization to be on the market, the potential
risks of each intense sweetener are assessed and an acceptable
Daily Intake (ADI) is set for each IS. Based on
several food surveys, an estimate of the dietary intakes
of the ISs currently used in various countries shows that
in all study populations (i.e. adults and children over the
age of three, pregnant women and young diabetics) and
irrespective of the IS taken into consideration, the mean
and 95th percentile intakes are lower than the ADIs.
The use of intense sweeteners as a substitute for sugar
in most cases engenders a short term reduction in caloric
intake due to the low calorie levels of these substances
and the lack of compensation. However, the
available data cover insufficient time periods for guaranteeing
that this effect is maintained in the long term.
Moreover, studies of weight control in adults and children
have reported conflicting associations. Certain observational
studies show that intense sweetener use is
paradoxically associated with weight gain, although the
causality of this relationship has not been established.
The consumption of intense sweeteners was not
shown to have any beneficial effects on prevention of
type 2 diabetes; similarly, their regular consumption as a
sugar substitute does not appear to have any beneficial
effect on regulating blood glucose concentrations. For
the risks of developing cancer, type 2 diabetes, or premature
births, the data available to date do not enable a
link to be established between onset of these risks and
the consumption of intense sweeteners.

A few studies do however highlight the need to obtain further knowledge
on the link between intense sweeteners and certain risks
and in specific populations, particularly adults daily consumers
and children.
This review of the scientific literature revealed some gaps
that should be filled and areas of research that should be
explored. There were differences between the results of
randomised controlled trials and the results of observational
studies. Furthermore, the studies assessing the effects
of replacing sugars with IS on eating behaviour or energy
intake were undertaken over the short term and should be
supplemented with long-term studies. Two types of additional
studies seem necessary to clear up these differences.
On the one hand, longer-term (at least one year) blind,
placebo-controlled intervention studies would shed further
light on the metabolic and physiological effects of IS. On
the other hand, intervention studies in which IS are consciously
consumed would help to understand potential
changes in eating behaviour related to the replacement of
sugars with IS in near-real-life conditions. There are also
very few data on the long-term impact of IS on food preferences.
Therefore, it appears necessary to study the effects
of IS consumption on dietary choices. In most of the cohort
studies, the consumption of artificially sweetened beverages
was reported only when the subjects were first
included, and subsequent consumption was not taken into
account. These studies assessed only the consumption of
artificially sweetened beverages, and not the total consumption
of artificial sweeteners. It is also difficult to distinguish
between the effects of the various IS consumed alone and
their effects when combined with other IS. Future cohort
studies should be capable of taking into account qualitative
and quantitative changes in the consumption of artificially
sweetened products and adapted dietary questionnaires, to
accurately and specifically assess IS consumption. Specific
populations such as pregnant women, children, diabetic
subjects and regular IS consumers have not been adequately
studied. It appears necessary to further study the
effects of IS in these populations. Likewise, it appears necessary
to determine the repercussions of IS consumption
during the peri-natal phase on offspring (under the ‘foetal
programming’ assumption). Some data suggested that the
potential effects of IS on changes in weight or the incidence
of diabetes may vary depending on initial corpulence. Due
to the increasing prevalence of obesity, it appears necessary
to study potential interactions between corpulence and IS
consumption in terms of the risk of weight gain or diabetes.
At last, the literature on steviol glycosides is still sparse and
should be enhanced, particularly given the recent growth in
their use in beverages and foods.
Conclusions
No beneficial effects have been shown that provide grounds
to recommend regular IS consumption for adults or
children. Moreover, the available data do not show
the occurrence of risk in occasional consumers. However,
based on the epidemiological data currently
available, it is not possible to completely rule out certain
risks in the event of regular, prolonged consumption.
Therefore, for the general population, the overall
assessment of potential risks and benefits does not
justify the long-term use of IS as sugar substitutes,
particularly in beverages, which are their main vector.
Lastly, in a nutritional policy context in which one of
the main objectives is the reduction of sugar intake
in the general public, as pointed out by the 2015
WHO guidelines on sugar intake, this review points
out that no meaningful data exist that justify encouraging
the substitution of sugars by intense sweeteners.
This objective of reduction of sugar intake levels
should be reached through a reduction in sweet tasting
foods in general at an early age. It should therefore
be recommended that artificially-sweetened and
sugar-sweetened soft drinks shall not be consumed as
a replacement for water.