It’s official, India has become the Diabetes Capital of the World. A June 2023 Indian Council of Medical Research–India Diabetes (ICMR-INDIAB) study reveals that India is home to 101 million diabetics.
With the increase in diabetics, the demand and use of food products, beverages, and health supplements using non-sugar sweeteners (NSS) or sugar substitutes is equally flourishing in India and worldwide. However, the WHO’s guidelines on the use of NSS is worrying the F&B sector and prompting the latter to counter it. Let’s explore further.
According to Fortune Business Insights, the global sugar substitutes market was valued at $7.50 billion in 2021. The market is projected to grow from $7.91 billion in 2022 to $12.86 billion by 2029, at a CAGR of 7.20 per cent in the forecast period, 2022-2029.
This growth is not only driven by the diabetic population but increased demand for health-enhancing products including low-calorie, sugar-free, and nutritious food products have also been some of the leading drivers for the sugar substitute market. Sugar alternatives are commonly used in beverages, ice creams, powdered drink mixes, sauces, jellies, puddings, candies, dairy products, and many other F&B products that consumers are obsessed with. In such a scenario, where many big F&B brands strongly rely on NSS, the World Health Organisation (WHO) has come up with a guideline on NSS that might shake the F&B industry, quite adversely.
What does the guideline say?
In May 2023, WHO released a new guideline on NSS, which recommends against the use of NSS to control body weight or reduce the risk of noncommunicable diseases (NCDs). The recommendation is based on the findings of a systematic review of the available evidence which suggests that the use of NSS does not confer any long-term benefit in reducing body fat in adults or children. Results of the review also suggest that there may be potential undesirable effects from long-term use of NSS, such as an increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults.
“Replacing free sugars with NSS does not help with weight control in the long term. People need to consider other ways to reduce free sugars intake, such as consuming food with naturally occurring sugars, like fruit, or unsweetened food and beverages,” says Francesco Branca, WHO Director for Nutrition and Food Safety. “NSS are not essential dietary factors and have no nutritional value. People should reduce the sweetness of the diet altogether, starting early in life, to improve their health.”
The recommendation applies to all except individuals with pre-existing diabetes and includes all synthetic and naturally occurring or modified non-nutritive sweeteners that are not classified as sugars found in manufactured foods and beverages, or sold on their own to be added to foods and beverages by consumers. Common NSS include acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, sucralose, stevia and stevia derivatives.
With the issuance of the said guidelines, there exists a state of confusion and a number of concerns among F&B players, in India and globally.
End of Aspartame Era?
Aspartame, an artificial NSS, is widely used in various food and beverage products since the 1980s, including diet drinks, chewing gum, gelatin, ice cream, dairy products such as yoghurt, breakfast cereal, toothpaste, and medications such as cough drops and chewable vitamins. It has a huge market and is used by almost all the big and small players manufacturing these aforementioned F&B products. However, on July 14, 2023, the WHO’s cancer arm, International Agency for Research on Cancer (IARC) deemed aspartame a ‘possible carcinogen’. This declaration has been even more concerning for the F&B industry worldwide.
Controversies associated with sugar substitutes and contradictory opinions about the same have affected consumers’ perceptions for ages. However, looking at the market, there are no signs of reduced use of Aspartame among F&B products. Moreover, the willingness of consumers toward switching to unsweetened drinks is significantly low hence F&B players are even more reluctant toward letting go of Aspartame. In 2016, PepsiCo removed the aspartame-based diet cola products from the market. However, as the sales dropped markedly, the company had to bring back aspartame in its Diet Pepsi. Aspartame is one of the least-expensive sugar alternatives to use, its combination with various beverages and powder mixes has always been popular among consumers. Not only diet sodas but sugar-free gums, diet teas, diet lemonade drink mix, sugar-free energy drinks, and thousands of products have aspartame on their labels.
The Food and Drug Administration (FDA) disagrees with IARC’s conclusion that these studies support classifying aspartame as a possible carcinogen to humans. FDA scientists reviewed the scientific information included in IARC’s review in 2021 when it was first made available and identified significant shortcomings in the studies on which IARC relied.
Dr Robert M Califf, Commissioner of US FDA said, “We note that JECFA did not raise safety concerns for aspartame under the current levels of use and did not change the Acceptable Daily Intake (ADI). Aspartame is one of the most studied food additives in the human food supply. FDA scientists do not have safety concerns when aspartame is used under the approved conditions. The sweetener is approved in many countries. Regulatory and scientific authorities, such as Health Canada and the European Food Safety Authority have evaluated aspartame and also consider it safe at current permitted use levels. Some consumers may rely on products with aspartame and other sweeteners to help reduce their sugar consumption. We recognise that navigating different information from health organisations is challenging. We will continue to provide reliable, science-based information on aspartame and other sweeteners on the FDA’s website to help consumers make informed choices.”
In this scenario where two big names in global organisations have mixed opinions, the issue is becoming even more complex for F&B players.
The Indian counterview
The WHO’s guidelines on NSS are challenging for most of the countries worldwide and India is not an exception. However, India is looking for the reasoning behind these guidelines. Various health and nutrition experts and F&B players from India are emphasising the crucial role that low/no-calorie sweeteners play in decreasing sugar and calorie consumption, assisting in weight management, and enabling product reformulation in accordance with public health recommendations. In short, the experts and stakeholders are challenging the WHO’s precept.
While sharing her thoughts on the Diabetes scenario in India, Dr Jagmeet Madan, Principal, Professor, Director (Research and Consultancy), Sir Vithal Das Thackersey College of Home Science, SNDTWU, Mumbai, and National President, Indian Dietetic Association, said, “Prediabetes, Insulin resistance is striking sub-clinically across young adults today both in overweight and lean obese. It is evident that the key determinants are total empty calories and the quality of food in the diet. Priming the taste buds to get acquainted with less sweet tastes right from childhood is crucial. While following a healthy diet, these sugar swaps with sweeteners can be a stepping stone which can help in reducing the added sugar intake.”
A lot of health experts, mainly Diabetologists have been positive toward the moderate use of NSS and their need in the F&B products.
“Sweeteners can promote diet healthfulness by increasing the palatability of nutrient foods and beverages. NSS consumption may be a marker for other positive health behaviours and lifestyles. As far as the BMI is concerned, all the non-nutritional sweeteners are either weight neutral or sometimes help you to sustain lost weight. Evidence reveals that the use of NSS influences the microbial composition of the oral mucosa,” said Dr Mangesh Tiwaskar, Consultant Physician and Diabetologist at Shilpa Medical Research Centre, Mumbai.
He further added, “Numerous human studies and clinical reviews have unanimously concluded that low-calorie sweeteners (LCS) have no impact on appetite, hunger, or the desire for sweetness. It is now well-established that LCS consumption does not affect the normal physiological mechanisms related to hunger and appetite, as affirmed by scientific research.”
Dr V Mohan, Chairman and Chief of Diabetology – Dr. Mohan’s Diabetes Specialities Centre, Chennai, also shared his views on the moderate use of NSS in food products, “It is recommended to reduce the carbohydrate–sugar intake. Substituting added sugar in tea/ coffee with one to two tablets is just fine. What is not ok is excess consumption of products just because it doesn’t have sugar. We have just completed a study on replacing added sugar in daily tea/ coffee/ milk with sweeteners to understand its effect on health, and we are presenting the results in ADA. This is one of the largest randomised clinical studies on sweeteners done so far in India.”
On the same line, a Senior Diabetologist and Director, North Delhi Diabetes Centre, New Delhi, Dr Rajeev Chawla commented, “The alarming rise in type-II diabetes and the staggering number of individuals with pre-diabetes necessitates urgent action and awareness. There is a need to advocate for the use of non-nutritive sweeteners, approved by global regulatory bodies, to provide sweetness without compromising the management of diabetes.”
Decoding the NSS
The WHO guideline on NSS has a number of questions and gaps in the current evidence that should be addressed by future research were identified. There is no data available on the factors such as robust exposure assessment of NSS, more precise evaluations of NSS intake, patterns of NSS use, reverse causation, etc. Research and development efforts are also necessary in identifying potential differences in short-term and long-term responses to NSS based on sex, age, ethnicity, genotype, body weight status and risk for relevant NCDs, with sensitive methods to detect short-term changes, particularly in assessing insulin resistance.
Dr Pulkit Mathur, professor and the head of the Department of Food and Nutrition and Food Technology at Lady Irwin College, University of Delhi, emphasised, “There is a need for more data to understand the consumption of NSS and their effect on health. These studies need to have a well-defined study design, with a larger sample size, more homogenous samples, and monitoring the overall diet esp. mapping the total energy intake. The portion size intake is very crucial to manage the issues of overweight/ obesity today.”
While adding to Dr Mathur’s thoughts, Tarun Arora, CEO, Zydus Wellness Limited said, “The WHO guidelines say substantive discussions and country-specific policy is required. The discussion among the experts in India clearly indicates that the status quo on sweeteners is to be maintained, and long-term studies in the country are necessary. Further research and data generation to manage risks effectively is the need of the hour in such circumstances.”
Such expert views signal that policy decisions based on WHO’s recommendation may require substantive discussion in specific country contexts, linked for example, to the extent of consumption in different age groups. Hence, further studies might explain the NSS concerns in a constructive manner which will smoothen the policy-framing procedure for NSS. Till then, NSS are expected to enjoy its presence in the F&B industry, without impacting the F&B stakeholders.
Mansi Jamsudkar