Indian govt calls for clear communication amid WHO’s artificial sweetener carcinogen warning

The Indian government has called for clear communication between regulators and the industry to avoid confusion in healthcare-related matters, as the World Health Organization’s (WHO’s) cancer research arm, the International Agency for Research on Cancer (IARC), is considering officially announcing artificial sweeteners as potential carcinogens.

WHO red flag

The row over terming artificial sweeteners causative agents of cancer has been continuing for over a month. The apex global public health agency, in its guidelines on the “use of non-sugar sweeteners” released on May 15, warned that the use of non-sugar sweeteners (NSS), predominantly saccharin, was associated with an increased risk of bladder cancer as assessed in case-control studies (very low certainty evidence). The WHO guideline stated that long-term NSS use was associated with an increased risk of type 2 diabetes, cardiovascular diseases (CVDs), and mortality in prospective cohort studies conducted in adults. The WHO also added that a meta-analysis of three prospective observational studies found an increased risk of preterm birth with higher NSS use during pregnancy, but the associations observed between birth weight or weight of offspring later in life and NSS use during pregnancy were inconsistent.

“While the IARC ruling is based on evidence, it doesn’t consider safe consumption levels determined separately. Past IARC rulings have impacted the industry and consumer behaviour but have also caused confusion. Clear communication between regulators and the industry is vital to help consumers make informed choices,” Dr. K Madan Gopal, Advisor-Public Health Administration, National Health Systems Resource Centre, Union Health Ministry, told BT.

“It will be interesting to see how the IARC’s ruling aligns with or differs from the Joint Food and Agriculture Organization (FAO)-WHO Expert Committee on Food Additives (JECFA) findings. The focus should be on promoting public health by providing accurate information based on comprehensive scientific assessments,” he added.

A study published in the PLOS medicine journal in March 2022, conducted on a large group of people, found a link between higher consumption of artificial sweeteners, specifically aspartame and acesulfame-K, and an increased risk of cancer. The study included 102,865 adults from the French population-based cohort NutriNet-Santé from 2009 to 2021. The participants' dietary intakes and sweetener consumption were recorded using repeated 24-hour dietary records, which also included information about brand names of commercial products.

Aspartame is an artificial sweetener commonly used to replace sugar in various food and drink products such as diet sodas, sugar-free gum, low-calorie desserts, and processed foods labelled as “sugar-free” or “diet”.

“Over the past several years, Diet Coke has significantly increased its presence among the younger generation. It is perceived as a healthier alternative, as it does not lead to weight gain while still providing the pleasure of drinking Coke in its original form,” said Dr. Rahul Bhargava, Director and Head of Hematology and Bone Marrow Transplant at Fortis Memorial Research Institute, Gurugram.

“Artificial sweeteners can potentially cause cancer if used in the long term. The debate is not about the exact quantity of usage but rather the fact that they have been found to be carcinogenic. It is a sufficient reason for people to avoid these practices and opt for traditional drinks instead,” he added.

What are the regulations? 

Different countries have implemented regulations and policies regarding the use of aspartame. In the United States, the Food and Drug Administration (FDA) oversees the regulation of aspartame as a food additive. The FDA has established an Acceptable Daily Intake (ADI) limit for aspartame, which is set at 50 milligrams per kilogram of body weight. This means that on a daily basis, the average adult can safely consume up to this amount of aspartame without experiencing any harmful effects.

Similarly, the European Union has also put forth regulations for aspartame. The European Food Safety Authority (EFSA) has recommended a slightly lower ADI for aspartame, specifically 40 milligrams per kilogram of body weight per day.

These ADI values have been determined through extensive scientific research and studies that assess the safety of consuming aspartame. The regulations aim to ensure that the use of aspartame in food and beverages remains within safe limits for the general population.

“To consider aspartame as a potential carcinogen, we need to consider the amount of aspartame we consume in a day. It becomes carcinogenic only if the amount consumed reaches the ADI of 40 to 50 mg per kg per day. To reach this level, a 60 kg adult would have to consume at least 12 cans of diet soft drink every day,” said Dr Pooja Babbar, Consultant in Medical Oncology at CK Birla Hospital, Gurugram.

Babbar further clarified that aspartame is primarily linked to a specific problem, particularly in individuals with phenylketonuria, a genetic disorder that impairs the breakdown of phenylalanine, an amino acid found in aspartame. Therefore, people with this disorder should exercise caution and avoid products containing aspartame, as they are labelled with a warning about phenylketonuria and phenylalanine content.

“Otherwise, for aspartame to be carcinogenic to the human body, consumption would need to be at least 40-50 mg per kg per day,” Babbar said.

Not so sweet

The WHO, in another publication released in April 2023 titled "Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis," indicated that while results of randomized controlled trials have generally suggested non-sugar sweeteners may have little impact on glucose metabolism and result in lower body weight when coupled with energy restriction in the short-term, there is no clear consensus on whether non-sugar sweeteners are effective for long-term weight loss or maintenance, or if they are linked to other long-term health effects at intakes within the ADI.

“The risk of cancer was initially suspected with the use of saccharin, but it was not ultimately confirmed. However, a study published in PLOS One in 2022 provided evidence that aspartame, an artificial sweetener, may indeed increase the risk of cancer, specifically breast cancer. Additionally, other artificial sweeteners have also come under suspicion regarding their potential cancer risk,” said Anoop Misra, Executive Chairman, Fortis C-DOC Hospital for Diabetes and Allied Sciences.

“Warnings about the association between artificial sweeteners and cancer risk have been issued based on the available data, which is moderately strong. However, it is important to note that further trials and studies are still needed to gain a deeper understanding of this relationship and to establish conclusive evidence,” said Misra, who is also the Director of the National Diabetes Obesity and Cholesterol Foundation (NDOC) and President of the Diabetes Foundation (India).

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