In July 2021, during one of the leading conferences for doctors on Diabetes, Dr. Mangesh Tiwaskar a leading diabetologist from Mumbai, was delivering a comprehensive talk on the safety and regulatory status of non-nutritive sweeteners (NNS) or sugar substitutes as they are commonly referred to.
Towards the end of the hour long session, he reached his last slide inspired from the cult Hollywood movie – The Good, the Bad, and the Ugly. He explained to an erudite and keen audience comprising of health care professionals that the Good news is that all the approved NNS are safe in pregnancy, lactation, children, diabetes etc.
The bad news is that the academic & medical fraternity has failed to create adequate awareness about NNS, to develop guidelines for the uses of NNS, to address effectively safety concerns, to generate safety data through RCTs and to provide scientific forums to discuss these and disseminate proper scientific information and evidence around NNS.
The ugly truth is that we continue to grow as “Westoxified TOFI (Thin Outside Fat Inside) Sarcopenic” community with love for energy dense nutrient poor junk food and poor emphasis on physical activity & healthy lifestyle which inflicts more damage than the sweeteners.
Thus, person with diabetes and calorie conscious people who are the primary beneficiaries of these sweeteners are plagued with utter confusion regarding their safety and regulatory status. Primary reason being the scenario of blind men and the elephant plays out amongst their primary sources of information – doctors, nutritionists & information resources.
Hence, when last week, world went into a tizzy over the widely covered, allegedly leaked, WHO report on carcinogenicity involving Aspartame - one of the oldest and widely used sweeteners, we decided to keep calm and reach out to the research & development professionals associated with popular formulations using sweeteners, leading diabetologists whose patients have been using these sweeteners to manage their sweet cravings after being sentenced by diabetes to forego sugar completely, and eminent persons associated with public health institutions to decipher the implications of the report in an unambiguous manner to help patients and calorie conscious consumers step clear of the confusion and panic.
Dr. V Mohan Chairman & Chief of Diabetology, Dr Mohan’s Diabetes Specialities Centre, Chennai, said that media & influencers’’ are drumming up the so-called initial findings of the WHO report and the possibility of aspartame being labelled carcinogen as a big catastrophic event for the consumers and diabetic community as if they have accessed the complete report and have interpreted it in the Indian context with the required scientific and academic rigour before arriving at the conclusions.
He advised the larger community of the people with diabetes, diabetologists and nutritionists to wait for the release of the report on July 14 and not get perturbed and stressed by the fear mongering social media posts and the media hype around conjectures of what the report might contain.
On being asked why do we need to consider Indian context, he averred that while an average American might consume 10 to 15 cans of diet coke per day, the majority of the Indian population’s diet coke consumption would not be of that level. Hence, it needs to be considered in the Indian context as well.
He further stressed that till the time he does not see the complete report and the evidence that it offers, he would stick to the fact that sweeteners are safe to be consumed in the recommended doses which are way below the adverse effects causing limit prescribed the national and international regulatory bodies.
In fact, Dr Mohan was the first Indian doctor to do comprehensive videos giving a scientific lowdown on sweeteners, usage, dosage, safety and regulatory status on his YouTube channel in response to large number of queries that he received on the topic.
Dr. Mangesh Tiwaskar said, “I happened to go through plethora of published scientific literature on sweeteners for the last couple of years and after reviewing the same in its totality, have arrived at the conclusion that NNS are safe and there is an urgent need to disseminate this evidence based knowledge to a larger audience. Only after one has gone through the complete report and looked at the new evidence, if any, one can hope to reach a conclusion regarding the carcinogenicity of Aspartame and Sucralose. Before that, any hue and cry on the presumed carcinogen status in media both offline & online is doing a great disservice to diabetic patients who have been consuming these products to manage the blood glucose levels in the absence of a strong will power to give up the sugar completely. These alarmist conclusions drawn basis sections of report interpreted out of context are only going to add to the confusion for the patient who might either not have the access to scientific evidence based knowledge or lacks the knack to make a sense of these confusing often diametrically opposite pieces of information regarding sweeteners.”
Dr B Sesikaran, Former Director, National Institute of Nutrition, ICMR Hyderabad, contends that WHO, USFDA, FSSAI and other leading regulatory bodies would not have recommended NNS even if there was a remote possibility of their causing harm in the first place, not even for people with diabetes. But they did recommend these.
He observes that of late, there has been a rising trend of creating social media posts with alarmist conclusions based on spliced sentences picked up from recently published scientific articles from reputed universities and journals which helps in getting the stamp of authentication since they are from reliable sources.
But the viewer is oblivious to the fact that these conclusions are picked up without really looking into the discussions, design and the data in the paper. To make his point, he quotes the example of the recent news about the negative effects of Non-Nutritive Sweeteners (NNS). WHO did say that they have no benefits on weight loss, but the social media posts went beyond and created panic.
There was another paper on sucralose causing DNA damage. These were only in vitro or test tube methods. And we do know that when you add anything to the cells in vitro they could cause DNA damage but that doesn’t mean it happens in the body as well. The safety of any additive or for that matter any chemical is dependent on dose or the quantity in which it is consumed, and there is a recommended dose for all the approved additives which is way lower than the adverse effect causation level.
He recommends that it will be good if the social media were to see the reports of the Joint (WHO & FAO) Expert Committee on Food Additives (JECFA) which reviews several hundreds of published articles on a single additive that includes mechanistic, bioavailability, in vitro studies, animal data as well as human exposure levels and published adverse events to ensure that the levels of any permitted additive approved for human use is no less than a hundred times lower than any adverse effect level. Many times even at higher levels also the adverse effects are not seen.
For instance, it was said that NNS caused “Leaky Gut”. The levels at which such a thing happens is many times more than even the highest consumer levels. He concludes, “While it is impossible to prevent either social media craze or even the media hype, dissemination of the right kind of knowledge based on systematic and evidence based reviews should be attempted wherever possible.”
Few of the senior R&D experts with decades of experience of working on the formulations involving the use of these sweeteners, emphasised the importance of NOAEL as a guiding principle for the R&D fraternity while working on any of the approved additive formulations. NOAEL is the acronym for No Observed Adverse Effect Level which is the highest dose fed to the animals in the long term studies with no adverse toxicological effect. This is taken as the basis of working out the average daily intake or (ADI) which is maximum quantity of a given additive that can be consumed in a day.
Recommended dosage and usually the actual consumed quantity per day, is at least a hundred times lower than even this safe limit. Thus, people need to understand & consider these two terms – NOAEL & ADI before jumping the gun and joining the carcinogen bandwagon even before the report is out.
Therefore, the doctors, food scientists and R&D experts see no reason to panic and be stressed over a remote possibility of carcinogenicity that has yet not been presented to public scrutiny and reference. People with diabetes and other calorie conscious consumers would do well not to get carried away with the media blitz – social or otherwise, keep calm and trust their doctors, scientific academic community and regulatory authorities of the country!
