Edulcorantes Artificiales en el Tratamiento

de la Obesidad:
Qué dice la evidencia??

Dra. Catalina Fuentes G

Nutrióloga Hospital Clínico FACh
Clínica las Lilas
Placer por lo dulce, azúcar y obesidad

Edulcorantes artificiales: no tan rápido!

Mecanismos propuestos para el “daño”

Evidencia actual

Conclusiones
El ser humano nace con una fuerte preferencia por
el sabor dulce….
Se estima que..
•  La ingesta promedio de azúcar agregada en USA,
corresponde a un 15.8% de las calorías totales.
•  47% de esas calorías viene dado por bebidas
azucaradas
•  El consumo de este tipo de bebidas aumentó 135%
entre 1977 y 2001
•  Si se agrega a la dieta 1 lata de bebida
azucarada=150 kcal (40-50g azúcar)por día (sin
modificar el resto)------ +6.75 kg/año
Am
 J
 Clin
 Nutr
 2006;84:274–88
 

Pro v Con Debate: Role of sugar sweetened beverages in obesity
Resolved: there is sufficient scientific evidence
F. B. Hu that
decreasing sugar-sweetened beverage consumption
will reduce the prevalence of obesity and
obesity-related diseases
F. B. Hu1,2
1
Departments of Nutrition and Epidemiology,
Harvard School of Public Health, Boston, MA,
USA; 2Channing Division of Network
Medicine, Department of Medicine, Brigham
and Women’s Hospital, Harvard Medical
School, Boston, MA, USA
Received 17 March 2013; revised 1 April
2013; accepted 1 April 2013
Address for correspondence: FB Hu,
Department of Nutrition, Harvard School of
Public Health, 665 Huntington Ave, Boston,
MA 02115, USA.
E-mail: frank.hu@channing.harvard.edu
will reduce the prevalence of obesity
obesity-related
diseases
1,2
1
Departments of Nutrition and Epidemiology, Summary
Sugar-sweetened beverages (SSBs) are the s
Harvard School of Public Health, Boston, MA,
USA; 2Channing Division of Network the top source of energy intake in the U.S. d
Medicine, Department of Medicine, Brigham
and Women’s Hospital, Harvard Medical
there is sufficient scientific evidence that de
the prevalence of obesity and its related
School, Boston, MA, USA studies address dietary determinants of lo
eases, whereas randomized clinical trials
Received 17 March 2013; revised 1 April effects of specific interventions on weigh
Summary 2013; accepted 1 April 2013 critical in evaluating causality. Findings fr
Sugar-sweetened beverages (SSBs) are the single largest source of added sugar and have consistently shown a significant ass
the top source of energy intake in the U.S. diet. In this review,
Address we evaluate FB
for correspondence: whether
Hu, demonstrated a direct dose–response relati
there is sufficient scientific evidence that decreasing SSB consumption will reduceof
Department of Nutrition, Harvard School long-term weight gain and risk of type 2
the prevalence of obesity and its related diseases. Public Health, 665 Huntington Ave, Boston,
Because prospective cohort meta-analysis of RCTs commissioned by t
studies address dietary determinants of long-termMAweight 02115, USA.
gain and chronic dis- that decreased intake of added sugars signi
E-mail: frank.hu@channing.harvard.edu
eases, whereas randomized clinical trials (RCTs) typically evaluate short-term 95% confidence interval [CI] 0.39–1.21;
intake led to a comparable weight increa
effects of specific interventions on weight change, both types of evidence are
parallel meta-analysis of cohort studies a
critical in evaluating causality. Findings from well-powered prospective cohorts
among children was associated with 55% (
have consistently shown a significant association, established temporality and
overweight or obese compared with tho
demonstrated a direct dose–response relationship between SSB consumption and analysis of eight prospective cohort studies
long-term weight gain and risk of type 2 diabetes (T2D). A recently published of SSB intake was associated with a 26%
meta-analysis of RCTs commissioned by the World Health Organization found developing T2D compared with occasion
that decreased intake of added sugars significantly reduced body weight (0.80 kg, month). Recently, two large RCTs with a
95% confidence interval [CI] 0.39–1.21; P < 0.001), whereas increased sugar convincing data that reducing consumption
intake led to a comparable weight increase (0.75 kg, 0.30–1.19; P = 0.001). A gain and adiposity in children and adolesc
parallel meta-analysis of cohort studies also found that higher intake of SSBs decreasing SSBs will decrease the risk of ob
among children was associated with 55% (95% CI 32–82%) higher risk of being is compelling. Several additional issues wa
overweight or obese compared with those with lower intake. Another meta- tion of long-term weight gain through diet
analysis of eight prospective cohort studies found that one to two servings per day tion of SSBs is more important than sh
of SSB intake was associated with a 26% (95% CI 12–41%) greater risk of prevalence of obesity in the population.
individual becomes obese, it is difficult to l
developing T2D compared with occasional intake (less than one serving per
should consider the totality of evidence r
month). Recently, two large RCTs with a high degree of compliance provided
(e.g. from short-term RCTs only). Finally,
convincing data that reducing consumption of SSBs significantly decreases weight
harm on health against SSBs is strong, we
gain and adiposity in children and adolescents. Taken together, the evidence that
absolute proof before allowing public hea
decreasing SSBs will decrease the risk of obesity and related diseases such as T2D
is compelling. Several additional issues warrant further discussion. First, preven- Keywords: Diabetes, nutrition, obesity, su
tion of long-term weight gain through dietary changes such as limiting consump-
obesity reviews (2013) 14, 606–619
tion of SSBs is more important than short-term weight loss in reducing the
Fácil: cambiemos las bebidas por agua!
 The negative impact of consuming sugar-sweetened
beverages on weight and other health outcomes has
•  Potencial valor de reemplazar la sacarosa de
been increasingly recognized; therefore, many people
have turned to high-intensity sweeteners like aspar-
tame, sucralose, and saccharin as a way to reduce the
risk of these consequences. However, accumulating evi-
bebidas y otros alimentos por endulzantes no
dence suggests that frequent consumers of these sugar
substitutes may also be at increased risk of excessive
weight gain, metabolic syndrome, type 2 diabetes, and
calóricos…
cardiovascular disease. This paper discusses these find-
ings and considers the hypothesis that consuming
sweet-tasting but noncaloric or reduced-calorie food
and beverages interferes with learned responses that
normally contribute to glucose and energy homeostasis.
Because of this interference, frequent consumption of
high-intensity sweeteners may have the counterintuitive
effect of inducing metabolic derangements.
Sweeteners and health
Consumption of sugar-sweetened beverages (SSB; see
Glossary) has been increasingly associated with negative
health outcomes such as being overweight, obesity, type 2
diabetes (T2D), and metabolic syndrome, for reviews, see
[1–5]. Based largely on these associations, many research-
ers and healthcare practitioners have proposed that non-
caloric, high-intensity sweeteners provide a beneficial
alternative in foods and beverages [6–10].There is no
doubt that replacing caloric with noncaloric sweeteners
reduces the energy density of foods and beverages. How-
ever, whether reducing energy density in this manner
always translates into reduced energy intake, lower body
weight, and improved metabolic health is much less cer-
tain. Recent reviews of studies spanning at least the past
40 years have concluded that high-intensity sweeteners
are potentially helpful [11], harmful [12], or have as yet
unclear effects [9,13–15] with regard to regulation of
energy balance or other metabolic consequences. One
purpose of this opinion paper is to summarize and evalu-
ate recent research that is consistent with the rather
counterintuitive claim that consuming high-intensity
sweeteners may promote excess energy intake, increased
Corresponding author: Swithers, S.E. (swithers@purdue.edu).
Keywords: obesity; diabetes; sweeteners.
1043-2760/$ – see front matter
! 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tem.2013.05.005
body weight, and other related co-morbidities. A secon
goal is to identify and examine the types of physiologic
mechanisms that could underlie such adverse health co
sequences. A third aim is to consider factors that can ma
studies into the effects of artificial sweeteners on ener
and body weight regulation difficult to interpret.
Glossary
Artificially sweetened beverages (ASB): also known as ‘diet’ soft drinks
beverages manufactured with one or more high-intensity sweeteners in plac
of energy-yielding sugars like sucrose or high-fructose corn syrup with th
purpose of reducing or eliminating calories.
Body mass index (BMI): used as an index of risk for weight-related healt
outcomes and is calculated as (kg/m2). In adults BMIs of 18.5–24.9 ar
considered to be within the normal range, whereas BMIs from 25 to 29.9 ar
classified as overweight and a BMI greater than 30 is classified as obese.
Hazard ratio (HR) and odds ratio (OR): statistical measures of how often a
event occurs in one group compared to another. A HR or OR of 1 means there i
no difference between the groups and an HR or OR >1 means there is a
increased likelihood that the event will occur in the group of interest relative t
the comparison group.
High-intensity sweeteners: also known as low-calorie sweeteners, artificia
sweeteners, non-nutritive sweeteners, or noncaloric sweeteners are chemical
that produce the perception of sweet taste at very low concentrations. High
intensity sweeteners currently used commonly in foods and beverages includ
sucralose, aspartame, saccharin, and acesulfame potassium, as well as newl
approved extracts from the plant Stevia rebaudiana. Although some high
intensity sweeteners can be metabolized by the body, foods and beverage
typically contain them in such small quantities that even those that can b
metabolized contribute minute amounts of energy to the diet.
Incretin hormones: hormones such as glucagon-like peptide-1 (GLP-1) an
glucose-dependent insulinotropic peptide (GIP) that are released from L cell
and K cells in the intestine, respectively, and serve to enhance the release o
insulin from beta cells, slow the rate of gastric emptying, and may contribute t
satiety.
Metabolic syndrome: a group of factors that occur together and contribute t
increased risk for coronary artery disease, stroke, and type 2 diabetes (T2D
Typical definitions require three or more of the following: blood pressure >130
85 mmHg; fasting blood glucose >100 mg/dl; large waist circumference (me
>102 cm, women >89 cm); low high-density lipoprotein (HDL) cholestero
(men <40 mg/dl; women <50 mg/dl); triglycerides >150 mg/dl.
Post-prandial glucose homeostasis: following meals (post-prandial) levels o
glucose in the blood are tightly regulated by the release of a variety o
hormones that contribute to clearance of glucose. For example, release o
insulin from the beta cells of the pancreas is required to move sugar from th
blood into cells.
Sugar-sweetened beverages (SSB): also known as ‘regular’ soft drinks
manufactured with one or more caloric sweeteners such as sucrose or high
fructose corn syrup.
Thermic effect of food: increase in metabolic rate after consumption of a mea
related to energy required to process and metabolize the consumed food.
Type 2 diabetes: chronic elevation of blood glucose due to insulin resistanc
that is also characterized by impaired incretin secretion.
Trends in Endocrinology and Metabolism, September 2013, Vol. 24, No. 9 4
 El valor de los endulzantes para disminuir el
aporte total de calorías es mayor en
productos líquidos Intense sweeteners, energy intake and the control of body weight
F Bellisle and A Drewnowski

Table 2 Comparison of sugar-reduced and regular foods and drinks

Type of food or drink Regular Sugar-reduced or sugar-free

CHO content (per 100 g) Energy content (kcal per 100 g) CHO content (per 100 g) Energy content (kcal per 100 g)

Cola drinks 10.2 40 0 2

Fruit drinks 14 56 1.9 11
Cocoa 10.9 50 4.4 25
Hard candies 100 375 93 253
Drinking yogurt 12.8 72 4.0 42
Yogurt nonfat 13.8 75 4.9 44
Fruit Pie 33.6 237 26 171
Gelatin 13.6 57 0 8
Pudding 21.2 131 8.6 64
RTE cereal 90 360 90 360
Muesli 68 380 69 344
Cookies 33 445 32.5 445
Chocolate syrup 61 261 32.9 140
Chocolate 59 513 49 510
Chewing gum 120 500 60 300

energy density of beverages; the reduction is smaller for
semi-liquid food products, and can be very small for solid
foods. The impact of intense sweeteners on energy intakes
may, therefore, largely depend on the energy density of the
1998b). Typically, preload volume is adjusted by the addition
of water preload and energy is adjusted by the addition of
non-caloric components (intense sweeteners or fat replace-
ments), whereas preload nutrient composition is determined
European Journal of Clinical Nutrition (2007) 61, 691–700
Placer por lo dulce, azúcar y obesidad

Edulcorantes artificiales: no tan rápido!

Mecanismos propuestos para el “daño”

Evidencia actual

Conclusiones
Aumento de la prevalencia de obesidad y
sobrepeso a pesar de la incorporación de
Opinion
edulcorantes no calóricos
Trends in Endocrinology an
[(Figure_1)TD$IG]
cross-sectionally, b

Per capita consump!on

150
Key: study, SSB intake

in 2000 (litres)
100
SSB males only in the
50
ASB were no increased
Overweight and obesity 0
ASB SSB
body fat percentag
30 100 ferences in outcom
Change in overweight and obesity

Fowler et al. stud

prevalence since 1962 (Percent)

availability since 1962 (litres)

Change in per capita soda
80 younger subjects, a
However, neither s
20
60 sumption was ass
weight gain or incr
40
10 Metabolic syndrom
20 A number of studie
ic syndrome for c
0 0 cohorts [6,20–22] (
1974 1980 1994 2000 increase in the risk
Year consuming ASB ra
TRENDS in Endocrinology & Metabolism ratios (HRs) and o
Figure 1. Beverage consumption and the prevalence of obesity. Line graph illustrates
(e.g., those consum
Trends  
changes in per capita consumption of artificially in  Endocrinology  
sweetened beverages and  M etabolism  
(ASB; red September  
bolic 2syndrome
013,  Vol.  24,  Ncom
o.  
Estudios de Cohorte Prospectivos/
observacionales
 Dietary Intake and the Development of the
Metabolic Syndrome
The Atherosclerosis Risk in Communities Study
Pamela L. Lutsey, MPH; Lyn M. Steffen, PhD, MPH, RD; June Stevens, PhD, MS, RD

•  “… Diet Soda también se asoció positivamente con la

ackground—The role of diet in the origin of metabolic syndrome (MetSyn) is not well understood; thus, we sough
evaluate the relationship between incident MetSyn and dietary intake using prospective data from 9514 participants (a
incidencia de SM. Aquellos en el tercil más alto de
45 to 64 years) enrolled in the Atherosclerosis Risk in Communities
ethods and Results—Dietary intake was assessed at baseline via a 66-item food
Dietary
(ARIC)Intake study. and the Development o
Metabolic
frequency Syndromequestionnaire. We u
principal-components analysis to derive “Western” and “prudent” dietary
consumo con 34% mayor riesgo que el tercil más bajo. La
10 food groups used in previous studies of the ARIC cohort.
patterns from 32Risk
The Atherosclerosis
MetSyn was defined by American Heart Associat
foodingroups
Pamela L. Lutsey, MPH; Lyn M. Steffen, PhD, MPH, RD; June Steven
and evalua
Communities St

guidelines. Proportional-hazards regression was used. Over 9 years of follow-up, 3782 incident cases of MetSyn w
fuerza de esta asociación es sorprendente. Sin embargo es
Background—The role of diet in the origin of metabolic syndrome (MetSyn) is not well un
identified. After adjustment for demographic factors, smoking, physical activity, and energy intake, consumption o
evaluate the relationship between incident MetSyn and dietary intake using prospective data
Western dietary pattern (Ptrend!0.03) was adversely associated
45 to 64with
years) incident MetSyn.
enrolled in the After
Atherosclerosis Riskfurther adjustment
in Communities for int
(ARIC) study.

consistente con datos recientes del Estudio Framingham,

Methods and Results—Dietary intake was assessed at baseline via a 66-item food freque
of meat, dairy, fruits and vegetables, refined grains, and whole grains, analysis
principal-components of individual
analysis to derive “Western” and food groups
“prudent” revealed
dietary patterns from 3
meat (Ptrend"0.001), fried foods (Ptrend!0.02), and diet soda (Ptrend!" 0.001) also were adversely associatedbyw
10 food groups used in previous studies of the ARIC cohort. MetSyn was defined

que encontró 56% aumento del riesgo de SM entre quienes

guidelines. Proportional-hazards regression was used. Over 9 years of follow-up, 3782 in
incident MetSyn, whereas dairy consumption (Ptrend!0.006) was
identified. Afterbeneficial. No associations
adjustment for demographic were
factors, smoking, observed
physical betw
activity, and ene
incident MetSyn and a prudent dietary pattern or intakesof of whole grains, refined grains, fruits and vegetables, n
Western dietary pattern (P !0.03) was adversely associated with incident MetSyn. After
trend
meat, dairy, fruits and vegetables, refined grains, and whole grains, analysis of individu

consumían una porción de diet soda por día…”

coffee, or sweetened beverages. meat (P "0.001), fried foods (P !0.02), and diet soda (P !" 0.001) also wer
onclusions—These prospective findings suggest that consumption
trend

ofanda aWestern dietary

trend trend
incident MetSyn, whereas dairy consumption (P !0.006) was beneficial. No associat
pattern orpattern, meat,grains,
andrefined
friedgrains
fo
trend
incident MetSyn prudent dietary intakes of whole
promotes the incidence of MetSyn, whereas dairy consumptioncoffee, orprovides some protection. The diet soda association w
sweetened beverages.
Conclusions—These prospective findings suggest that consumption of a Western dietary p
not hypothesized and deserves further study. (Circulation. 2008;117:754-761.)
promotes the incidence of MetSyn, whereas dairy consumption provides some protection. T
not hypothesized and deserves further study. (Circulation. 2008;117:754-761.)
Key Words: dairy products ! diet ! food habits Key
! meat
Words:! metabolic
dairy syndrome
products ! diet ! food habitsX! meat ! metabolic s
 O R I G I N A L A R T I C L E

Diet Soda Intake and Risk of Incident Cardiovascular and Metabolic Risk

Metabolic Syndrome and Type 2 Diabetes

O R I G I N A L A R T I C L E

in the Multi-Ethnic Study of Diet Atherosclerosis

Soda Intake and Risk of In
(MESA)* Metabolic Syndrome and Type
Nettleton and Associates
in the Multi-Ethnic Study of Ath
1 4
J A. N
ENNIFER ,
ETTLETON PHD J A. L , OÃO IMA PHD residual confounding by other dietary be-
2 4
PAMELAL. L ,
UTSEY PHD E D. M , RIN ICHOS MD haviors, lifestyle factors, or demographic
Table 2—Risk of incident metabolic syndrome and type 2 diabetes according to diet soda consumption categories in participants from MESA
(MESA)*
3 2,5
YOUFAW ,
ANG MD, PHD D R. J , J .,
AVID ACOBS characteristics (1,2). Biological mecha-
R PHD
nisms possibly explaining these associa-
tions are few and largely focus on artificial
# rare/never but !1 !1 serving/week to !1 increasing
OBJECTIVE — We determined associations between diet soda consumption and riskJENNIFER of sweeteners in beverages/foods
A. NETTLETON , PHD1 JOÃO A. LIMA, PHD4 re
Rare or never serving/week
incident metabolic syndrome, its components, and type 2 diabetes in the Multi-Ethnic Study of the
PAMELA serving/day
L. Ldesire
UTSEY, for
!1
PHD (and consumption E
2 of) serving/day 4
RIN D. MICHOS, MD
Ptrend* ha
Atherosclerosis. WANG, MD, PHD3 energy-dense beverag-
YOUFA sugar-sweetened, DAVID R. JACOBS, JR., PHD2,5 ch
Metabolic syndrome es/foods (3) or disrupting consumers’ ni
RESEARCH DESIGN AND METHODS
Los  sujetos  en  el  percen.l  más  alto  de  consumo  de  diet  
2,288 — Diet soda consumption367
n was assessed by food ability to accurately722 estimate energy in- 501
frequency questionnaire at baseline (2000 –2002). Incident type 2 diabetes was identified at
tio
Cases 478 95 take and remaining
169
OBJECTIVE — We determined energy needs (4).
associations between 129 diet soda consumption and risk of sw
three follow-up examinations (2002–2003, 2004 –2005, and 2005–2007) as fasting glucose
Thus, diet soda consumption may result th
soda  tenían  mayor  IMC  y  circunferencia  de  cintura  basales  
!126HRmg/dl,
(95%self-reported
CI) type 2 diabetes,1.00† 1.34 (1.07–1.67)
or use of diabetes medication. Metabolic syndrome incident metabolic syndrome,
1.20 (1.00–1.43) its components, and type 2 diabetes in the Multi-Ethnic
1.31 (1.07–1.60) 0.003Study of
(and components) was defined by National Cholesterol Education Program Adult Treatment in overconsumption, increased body
Atherosclerosis. su
1.00‡ 1.42 (1.14–1.78) 1.28 (1.06–1.53) 1.36 (1.11–1.66) !0.001
Panel III criteria. Hazard ratios (HRs) with 95% CI for type 2 diabetes, metabolic syndrome, and weight, and consequent metabolic dys- es
metabolic syndrome components were estimated, 1.00§ adjusting for1.31 (1.05–1.64)
demographic, RESEARCH
lifestyle, and function. DESIGN
1.13 (0.94–1.37) AND METHODS
If true, such relations 1.18 —have (0.96–1.44)
Diet soda consumption was 0.06 by food
assessed ab
frequency questionnaire
important at baseline (2000 –2002).
implications for dietary coun- Incident type 2 diabetes was identified at
dietary confounders. 1.00! 1.30 (1.04–1.62) 1.15examinations
three follow-up
(0.95–1.38) (2002–2003,
1.17
2004
(0.96–1.44) 0.06
–2005, and 2005–2007) as fasting glucose
ta
Type 2 diabetes seling, given the high frequency of diet Th
RESULTS — At least daily consumption of diet soda was associated with a 36% greater relative!126 mg/dl, self-reported type 2 diabetes, or use of diabetes medication. Metabolic syndrome
beverage consumption
(and components) was
by those at high in
risknof incident metabolic syndrome 2,961 455 type 2 diabetes
and a 67% greater relative risk of incident risk for 914defined
metabolic
by National Cholesterol
dysfunction (5). 681Education Program Adult Treatment
w
compared Panel III criteria. Hazard ratios (HRs) with 95% CI for type 2 diabetes, metabolic syndrome, and
Cases with nonconsumption (HR 1.36 221 [95% CI 1.11–1.66] for metabolic 33 syndrome metabolic
and
Replication
syndrome 84 of previously
components observedadjusting
were estimated, 75 for demographic, lifestyle, and fu
1.67 [1.27–2.20] for type 2 diabetes). Of metabolic syndrome components, only high waist
HR (95%(men
circumference CI) !102 cm and women !88 1.00† 1.06
cm) and high fasting (0.73–1.52)
glucose (!100 mg/dl) were dietary diet soda–metabolic
1.39
confounders.(1.07–1.80)syndrome associa- 1.63 (1.24–2.13) !0.001 im
1.00‡ Associations1.10
prospectively associated with diet soda consumption. (0.76–1.59)
between diet soda consump- tions in a distinct cohort would bolster
1.46 (1.12–1.89) 1.67 (1.27–2.20) !0.001 se
tion and type 2 diabetes were independent 1.00§
of baseline measures of1.00
adiposity or changes in RESULTS
these their—credibility
At least daily
andconsumption of diet soda
provide further in- was associated with a 36% greater relative be
(0.69–1.45) sight1.23
risk of incidentinto (0.94–1.60)
metabolic syndrome
the nature of theand a 67%1.40greater
relationship. (1.06–1.84) 0.01
relative risk of incident type 2 diabetes ri
measures, whereas associations between diet soda and metabolic syndrome were not indepen-
dent of these factors. 1.00! 0.98 (0.68–1.42) compared 1.25
with
Previous (0.96–1.62)
nonconsumption
studies have not(HR 1.36
addressed 1.38
[95%asso-CI (1.04–1.82)
1.11–1.66] for metabolic 0.01
syndrome and
1.67 [1.27–2.20] for type 2 diabetes). Of metabolic syndrome components, only high waist
n " 5,011. *Ptrend with categorical variable modeled continuously. †Model 1 adjusted forciations
study(men
circumference
between
site, !102
dietrace/ethnicity,
age, sex, soda and individual
cm and women !88and cm) energy
and highintake. ‡Model(!100
fasting glucose 2 adjusted
mg/dl) were di
CONCLUSIONS — Although these observational data cannot establish causality, consump-
for the variables in model 1 above plus education, physical activity, smoking status,prospectively metabolic syndrome
pack-years,associated
and weekly components
ordiet
more or risk
supplement use. §Adjustedbetween
for thediet
variables in tio
with soda
tion of diet soda at least daily was associated with significantly greater risks of select incident of type 2 diabetes nor have they fully ad-consumption. Associations soda consump-
model 2 above $ waist circumference (centimeters). !Adjusted for the variables in model
tion 2
and above
type 2 $ waist
diabetes circumference
were independent (centimeters)
of baseline and BMI
measures of (weight
adiposityin
orkilograms
changes in these th
metabolic syndrome components and type 2 diabetes. dressed potential longitudinal mediators si
divided by the square of height in meters). measures, whereas associations between diet soda and metabolic syndrome were not indepen-
Diabetes Care 32:688–694, 2009 dent of of these
these relationships, i.e., changes in ad-
factors. Pr
iposity status (body weight and or waist ci
CONCLUSIONS

T
circumference). Therefore,
2 — Although thesewe evaluated data cannot establish causality, consump-
observational m
If
wowe excludedcohort
longitudinal fromstudies
our analyses
have such par-as diet1.10
soda,–are
4.51] with consid-
commonly BMItion!25 diet kg/m
of associations and
soda at least daily was
between
Metabolic
diet associated
syndrome
with
soda consump- significantlycomponent
greater risks of select incident
2 of
ticipants with any metabolic syndrome
shown positive associations be- ered “benign” 1.48 [1.07–2.05]
because with
they contribute noBMI
metabolic !25
tion and kg/m
syndrome Compared
of )incidentand
riskcomponents with
syn- nonconsumers, individ-
type 2 diabetes.
metabolic dr
component
tween dietatsoda baseline (leaving
consumption and a energy
muchandand few nutrients
for typeto2the diet. Con-
diabetes (1.94 [0.87–
drome 4.35]
(and metabolicuals consuming
syndrome !1 daily serving of diet of
incident metabolic syndrome indepen- sequently, the previously observed diet
2 Diabetes Care 32:688–694, 2009
smaller sample of 1,078 participants and components) as well soda as incident
had atype 2
significantly greater risk of de- ip
Causalidad Reversa??
Confundentes Residuales??

•  Podría ser el consumo de diet soda un marcador de otros

estilos de vida poco saludables o a algún patrón
alimentario que derive en riesgo metabólico??
 REVIEW
Does low-energy sweetener consumption affect energy intake
and body weight? A systematic review, including meta-
analyses, of the evidence from human andLow-energy
animalsweeteners
studies systematic review
PJ Rogers et al
PJ Rogers1, PS Hogenkamp2, C de Graaf3, S Higgs4, A Lluch5, AR Ness6, C Penfold6, R Perry6, P Putz7, MR Yeomans8 and DJ Mela9

By reducing energy density, low-energy sweeteners (LES) might be expected to reduce energy intake (EI) and body weight (BW). To
assess the totality of the evidence testing the null hypothesis that LES exposure (versus sugars or unsweetened alternatives) has no
effect on EI or BW, we conducted a systematic review of relevant studies in animals and humans consuming LES with ad libitum
access to food energy. In 62 of 90 animal studies exposure to LES did not affect or decreased BW. Of 28 reporting increased BW, 19
compared LES with glucose exposure using a specific ‘learning’ paradigm. Twelve prospective cohort studies in humans reported
inconsistent associations between LES use and body mass index (−0.002 kg m−2 per year, 95% confidence interval (CI) −0.009 to
0.005). Meta-analysis of short-term randomized controlled trials (129 comparisons) showed reduced total EI for LES versus sugar-
sweetened food or beverage consumption before an ad libitum meal (−94 kcal, 95% CI −122 to −66), with no difference versus
water (−2 kcal, 95% CI −30 to 26). This was consistent with EI results from sustained intervention randomized controlled trials
(10 comparisons). Meta-analysis of sustained intervention randomized controlled trials (4 weeks to 40 months) showed that
consumption of LES versus sugar led to relatively reduced BW (nine comparisons; −1.35 kg, 95% CI –2.28 to −0.42), and a similar
relative reduction in BW versus water (three comparisons; −1.24 kg, 95% CI –2.22 to −0.26). Most animal studies did not mimic LES
consumption by humans, and reverse causation may influence the results of prospective cohort studies. The preponderance of
evidence from all human randomized controlled trials indicates that LES do not increase EI or BW, whether compared with caloric or
non-caloric (for example, water) control conditions. Overall, the balance of evidence indicates that use of LES in place of sugar, in
children and adults, leads to reduced EI and BW, and possibly also when compared with water.

International Journal of Obesity (2016) 40, 381–394; doi:10.1038/ijo.2015.177

INTRODUCTION Although the imprecise control of short-term energy balance

Low-energy sweeteners (LES), such as acesulfame-K, aspartame,
saccharin, stevia and sucralose are consumed throughout the
world.1 The history of their use has been accompanied by debate
and disagreements, not least about their potential nutritional
impact. The use of LES to replace or partially replace added sugar
in foods and beverages might well be expected to reduce energy
intake (EI),2–4 yet over recent years there has been widely reported
speculation that consumption of LES might increase the risk of
becoming overweight and obese.5–7
Studies covertly manipulating energy density show higher EI
after consumption of a reduced-energy food or beverage, but that
the degree of energy ‘compensation’ is variable.8 Crucially, energy
compensation is usually lower than the difference in energy
content of the comparison foods/beverages, seemingly being
lowest of all for liquids.8 This suggests that consuming LES in place
of sugar-sweetened products should reduce overall EI, and
orest plot showing individual and combined effect sizes for prospective cohort studies reporting the association betw
particularly so for consumption of beverages, the most popular
OPEN
n and change in BMI over the follow-up period. Effect sizes have been standardised to a 1 year follow-up period. Negativ
vehicles for LES.1 The question also arises whether the presence of
LES in beverages affects appetite and EI relative to plain water.1,9
predicts that LES consumption should help reduce EI and
therefore reduce risk of overweight and obesity,3,10 it is possible
that, as consumed in everyday life, other effects of LES balance or
even outweigh the energy dilution effect. For example, a low
calorie or ‘diet’ label may cause the consumer to eat a larger
portion of the product or eat more of accompanying foods in the
meal, or eat more later.11–14 More simply, adding sweetness to a
product may increase intake owing to increased palatability.15,16
Or, by ‘uncoupling’ the relationship between sweetness and
energy content, the consumption of LES may undermine the
usefulness of sweetness as a cue in the control of energy
balance.5,17–20
The effects of LES consumption on EI and body weight (BW)
have been the subject of many studies over the past 30 years;
nonetheless there is no clear consensus about this body of
evidence. Taken together, a number of narrative reviews1–4,21–25
and systematic reviews of some types of studies26–30 lead to the
International Journal of Obesity (2016) 40, 381–394
consistent but guarded conclusion that substitution of LES for © 2016 Macmillan Publishers Limited All rights reserved 0307-05
sugar, especially in beverages, can help reduce EI, but that fully
Placer por lo dulce, azúcar y obesidad

Edulcorantes artificiales: no tan rápido!

Buscando Causalidad: Plausibilidad Biológica

Evidencia actual

Conclusiones
–  El hecho de agregar sabor a un “vehículo” no calórico
podría aumentar el apetito posterior.
–  Estudios no han demostrado efectos en apetito cuando
edulcorantes se han administrado a través de SNG o en
cápsulas
 Am  J  Clin  Nutr  2009;89:1–14.  

Hambre, Apetito y Saciedad

Respuestas Digestivas Efectos Nutritivos y Osmóticos
Preabsortivas

El  sabor  dulce  de  la  sacarina  promovería   Bebidas  con  mayor  densidad  
una  aumento  del  hambre  e  ingesta  a   energéKca  u  osmolaridad  son  
través  de  esKmulación  de  secreción  de   vaciadas  más  lentamente  del  
insulina  (preabsorKva)   estómago  
Hambre, Apetito y Saciedad
Respuesta de Péptidos
Intestinales

•  Macronutrientes en la dieta
estimulan la liberación de
péptidos intestinales.
•  CH estimula secreción de
GLP-1, potente incretina y
factor de saciedad

Am  J  Clin  Nutr  2009;89:1–14.  

Aumento de ingesta y Balance
Uso informado produciría Disrupción del aprendizaje de
sobrecompensación asociación
Placer por lo dulce, azúcar y obesidad

Edulcorantes artificiales: no tan rápido!

Mecanismos propuestos para el “daño”

Evidencia actual

Conclusiones
 F Bellisle and A Drewnowski
694
Table 3 The impact of intense sweetener aspartame on hunger and energy intakes compared to the control conditions

Study Subjects Dose (mg) Volume Vehicle Control Delay Meal Hunger Consumption
(ml) condition(s) (min)

Blundell and Hill (1986) 95 162 200 Water Water — — Increased —

Rogers et al. (1988) 8M, 4F 162 200 Water Water 60 Lunch Higher No effect
Glucose No effect No effect
Birch et al. (1989) 24 (4–5 years) 140 205 Fruit drink Water 0–60 Snacks — No effect
Rodin (1990) 24 250 500 Water Water 38 Lunch — No effect
Fructose
Glucose
Estudios de “precarga”
Rolls et al. (1990) 42M 110 240 Lemonade Water 0,30, 60 Lunch Decreased No effect
220 480
Black et al. (1991) 20 M 160 280 Soft drink Water 60 Lunch No effect No effect
320 560
Canty and Chan (1991) 2M, 18F 112 200 Fruit drink Water 60 Lunch No effect No effect
Sucrose No effect No effect
Black et al. (1993) 18M 340 280 Capsule Water 65 Lunch No effect No effect
560 Water
Soft drink
DiSogra et al. (1990) 6M, 6F 234 Capsules Water 60 Lunch — Decreased
10M, 5F 235 Capsules Water 60 Lunch Decreased Decreased
470 Decreased Decreased
Tordoff and 60M, 60F 0.05–1% — Chewing gum Plain gum — — Higher —
Alleva (1990a) No gum Higher
Anderson et al. (1989) 20 (9–10 years) 10 mg/kg 300 Fruit drink Sucrose 90 Lunch No effect No effect
Rolls et al. (1989) 16M, 16F 211–391 Ad lib Pudding/ Sucrose 120 Lunch No effect No effect
Gelatin
Mattes (1990a) 12M, 12F 0.16% by 70g Cereal Plain 180 Lunch Decreased No effect
weight Sucrose Dinner Decreased No effect
Drewnowski et al. (1994b) 12M, 12F 500 500 Soft white Plain 3h Lunch No effect No effect
cheese Sucrose 6.5h Snack
Maltodextrin 9.5h Dinner
Drewnowski et al. (1994b) 24F 500 500 Soft white Plain 3h Lunch No effect No effect
cheese Sucrose 6.5h Snack
Maltodextrin 9.5h Dinner
Lavin et al. (1997) 14F Not 330 Lemonade Sucrose Variable Snack No effect Increased
reported Water Lunch No effect No effect
Dinner
Beridot-Therond et al. (1998) 12M, 12F 50 mg/l Ad lib Fruit drink Water B15 Lunch No effect No effect
Unsweetened B6.5hr Dinner No effect No effect
Sucrose No effect
Melanson et al. (1999b) 10M B100 350 Lemon Water Carbohydrate Variable Lunch — No effect
Fat
King et al. (1999) 16M Not 790 Fruit drink Water B15 Lunch No effect Increased
reported
Sucrose No effect Increased
Wilson (2000) 135 (2–5 years) Not Ad lib Milk Milk 0 Lunch — No effect
reported
Sucrose milk No effect
Van Wymelbeke 12M, 12F 40 2000 Fruit drink Sucrose Varibale Lunch No effect No effect
et al. (2004) Dinner
 and GIP, the so-called incretin hormones, from the gut in healthy Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia.
humans (3). In patients with type 2 diabetes, the incretin effect is E-mail: chris.rayner@adelaide.edu.au.
4
Abbreviations used: GIP, glucose-dependent insulinotropic polypeptide;
impaired (4). Incretin-based therapies for diabetes have focused
Effects of different sweet preloads on incretin hormone secretion,
on GLP-1 rather than on GIP, because the insulinotropic action
GLP-1, glucagon-like peptide 1; iAUC, incremental AUC; SGLT1, sodium-
glucose cotransporter-1; T50, half-emptying time;
1–3 TIM, tagatose/isomalt mix-
gastric emptying, and postprandial glycemia in healthy humans
of the latter is diminished in these patients (5). Other actions of ture; 3OMG, 3-O-methyglucose.
GLP-1 include slowing of gastric emptying (6) and reduction of Received June 11, 2011. Accepted for publication October 11, 2011.
Tongzhi Wu,appetite
Beiyi Rand energy
Zhao, intakeJ(7).
Michelle Bound, Helen L Checklin, Max Bellon, First published
Tanya online
J Little, December
Richard 7, 2011; doi: 10.3945/ajcn.111.021543.
L Young,
Karen L Jones, Michael Horowitz, and Christopher K Rayner
78 Am J Clin Nutr 2012;95:78–83. Printed in USA. ! 2012 American Society for Nutrition

ABSTRACT One promising strategy to stimulate endogenous GLP-1 is the

•  No  hubo  incremento  de  niveles  de  insulina  después  de  la  carga  de  sucralosa  ni  
Background: Macronutrient “preloads” can stimulate glucagon-
like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypep-
“preload” concept, in which a small load of macronutrient is given
a fixed interval before a meal, to induce the release of gut peptides
de  tagatosa  a  diferencia  de  glucosa  
tide (GIP), slow gastric emptying, and reduce postprandial glycemic
excursions. After sweet preloads, these effects may be signaled by
such as GLP-1 and GIP to slow gastric emptying and stimulate
insulin secretion in advance of the main nutrient load. We have

both.
•  No  hubo  incremento  de  los  niveles  de  GLP-­‐1  después  de  carga  de  sucralosa  
sodium-glucose cotransporter-1 (SGLT1), sweet taste receptors,Appetite or shown
55 (2010)that
37–43both fat and protein preloads markedly reduce post-
prandial glycemic excursions in patients with type 2 diabetes by
•  No  hubo  diferencia  significaKva  en  el  Kempo  de  vaciamiento  gástrico  después  

Downloaded from ajcn.nutrition.org by guest on May 3, 2016

Objective: We determined the effects of 4 sweet preloads on GIP these mechanisms (8, 9). However, a potential disadvantage is that
and GLP-1 release, gastric emptying, and postprandial Contents lists available at ScienceDirect
glycemia. the preload could increase overall energy intake; preloads that
de  la  carga  de  sucralosa  o  glucosa  
Design: Ten healthy subjects were studied on 4 separate occasions entail minimal additional energy would be advantageous.
each. A preload drink containing 40 g glucose, 40 g tagatose/iso- Appetite
•  La  sensación  de  saciedad  fue  mayor  después  de  la  carga  de  glucosa  que  
Incretin stimulation by carbohydrates may be signaled by
malt mixture (TIM), 40 g 3-O-methylglucose (3OMG; a nonmeta- sweet taste receptors and/or SGLT1. Data from in vitro, animal,
bolized substrate of SGLT1), or 60 mg sucralose was consumed 15
sucralosa,  sin  embargo  no  hubo  diferencias  en  apeKto  ni  en  ingesta  posterior  
min before a 13C-octanoic acid–labeled mashed j o u r n apotato
l h o mmeal.
e p a gBlood
and human studies in this area have been inconsistent. For example,
e: www.elsevier.com/locate/appet
stimulation of sweet taste receptors by sucralose (a noncaloric
glucose, plasma total GLP-1 and GIP, serum insulin, and gastric artificial sweetener) was reported to release GLP-1 from entero-
emptying were determined. endocrine L cells in vitro (10, 11) but has no effect on GLP-1
Research report
Results: Both glucose and 3OMG stimulated GLP-1 and GIP re- secretion and gastric emptying in humans (12). It has also been
lease in advance of the meal (each P , 0.05), whereas TIM and
Effects
sucralose did ofnot.stevia,
The overallaspartame,
postprandial GLP-1 and sucrose
response was on food
postulated that intake,
SGLT1 maysatiety,
be involved and postprandial
in incretin hormone se-
§ cretion (13). Monosaccharides that are substrates for SGLT1, in-
glucose
greater and3OMG,
after glucose, insulin and TIM levels
than after sucralose (P ,
cluding glucose, galactose, and 3OMG, stimulate GLP-1 release in
0.05), albeit later after TIM than the other preloads. The blood
a,b,d, a vitro anda in perfused ileum in aanimal studies (14–16), ana effect
glucose
Stephen and insulin responses in*the
D. Anton first 30 min
, Corby after the meal
K. Martin were
, Hongmei Han by , Sandra
a,cP , 0.05). Gastric emptying was aslower
inhibited phloridzin,Coulon , William
which blocks T. Cefalu
SGLT1 (13). Similarly, ,in ob/
greatest
Paulaafter glucose (each
Geiselman , Donald A. Williamson ob mice,
Appetite GIP is37–43
55 (2010) secreted in response to glucose, galactose, and
after both 3OMG and TIM than after sucralose (each P , 0.05).
a
Pennington Biomedical Research Center, Baton Rouge, LA, United States 3OMG (17), but not to fructose and mannose, which are not
Conclusions: In healthy humans, SGLT1 substrates stimulate GLP-1
b
and
Department of Aging and Geriatric Research, University of Florida, United States
GIP and slow gastric emptying, regardless of whether they
SGLT1 substrates (18, 19). 3OMG is a glucose analog that is ab-
are lists available at ScienceDirect
c
Department of Psychology, Louisiana State University, United States Contents
sorbed from the small intestine via SGLT1, but it is not metabo-
•  Menor  aumento  de  glucosa  post  carga  de  stevia  y  aspartame  en  relación  
metabolized, whereas the artificial sweetener sucralose does not.
d
Institute on Aging, University of Florida, 210 E Mowry Rd., Gainesville, FL 32611, United States
Poorly absorbed sweet tastants (TIM), which probably expose lized and makes no contribution to energy intake. Whether 3OMG
Appetite stimulates GIP and GLP-1 secretion in humans is unknown.
A RnotT Iin
a  sacarosa  
a greater length of gut to nutrients, result in delayed GLP-1 secretion
but C delayed
L E I N FGIP
O release. These observations A B have
S T Rthe
A Cpotential
T

•  Menor  aumento  de  insulina  post  carga  de  stevia  en  relación  a  aspartame  
1
to optimize the use of preloads for glycemic control. This trial was From the Discipline of Medicine, University of Adelaide, Royal Ade-
journal homepage: www.elsevier.com/locate/appet
registered at www.actr.org.au as ACTRN12611000775910.
Article history: Consumption of Am J laide Hospital,
sugar-sweetened Adelaide,
beverages may Australia
be one of(TW, BRZ, MJB,
the dietary HLC,
causes TJL, KLJ, MH,
of metabolic disorders,

y  sacarosa  
Received 30 September 2009 such as obesity. Therefore,and substituting
CKR), and sugar with low calorie
the Department sweeteners
of Nuclear may(MB)
Medicine be anand
efficacious weight
the Nerve
Clin Nutr 2012;95:78–83.
Received in revised form 1 December 2009 management strategy. We tested the effect of preloads containing stevia, aspartame, or sucrose on food
Gut Laboratory (RLY), Royal Adelaide Hospital, Adelaide, Australia.
Research report
Accepted 10 March 2010 2
intake, satiety, and postprandial glucose and insulin levels. Design: 19 healthy lean (BMI = 20.0–24.9)
Sin   d iferencias   e n   a peKto   n i   i ngesta   posterior  
Supported by a grant awarded by the National Health and Medical Re-
• 
INTRODUCTION
MajorEffects
Keywords:
determinantsofofstevia, aspartame,
postprandial
and 12 obese (BMI = 30.0–39.9) individuals 18–50 years old completed three separate food test days
blood glucose include
search
during which they received
Council (NHMRC)
preloads
of Australia (grant no. 627139). TJL was sup-
andthesucrose on food intake, satiety, and postprandial
containing stevia Clinical
(290 kcal), aspartame (290 kcal), or sucrose
Stevia
ported by an NHMRC Overseas Postdoctoral Training Fellowship
rate (493 kcal)
of gastric emptying (1, 2) and the postprandial before the
§insulin re-lunch(grant
and dinner meal. The preload order was balanced, and food intake (kcal) was
no. 519349).
Aspartame
sponse, glucose and insulin levels directly calculated. Hunger
Sucrose of which !50% is stimulated by the secretion of GLP-1
4 and
3 satiety
Address levels were reported
correspondence beforeDiscipline
to CK Rayner, and afterofmeals, and Royal
Medicine, every hour
FoodGIP,
intake throughout the afternoon. Participants provided
Adelaide Hospital, blood
North samples
Terrace, immediately
Adelaide, before and
South Australia 500020 min after the
Australia.
and the so-called incretin hormones,
a,b,d, from the gut in healthy
a
lunch preload. Despite a in preloads (290 kcal a
the caloric difference vs. 493 kcal), participants dida not
 RCT Largo Plazo Intense sweeteners, energy intake and the control of body weight
F Bellisle and A Drewnowski
69
Table 4 Long-term studies of the impact of intense sweetener aspartame on body weight

Study Subjects Design Period Weight loss diet Products Body weight loss

Tordoff and Alleva (1990b) 21M,9F Normal wt. Xover 3 ! 3 weeks No Soda, 1150 g reg. or 0.5 kg loss M, F
diet (aspartame)
Kanders et al. (1988) 13M,46F Obese 2arm 12 weeks Yes Aspartame vs not All lost, non-Asp F lost
least
Blackburn et al. (1997) 163F Obese 2arm 19 weeks þ 1 year Yes Aspartame vs not Both lost B10%, Asp
regained less

Raben et al. (2002) 6M,35F 2arm 10 weeks No Sucrose vs Aspartame Aspartame lost,
sucrose gained
Overwt.
Porikos et al. (1977) 6F, 2M Obese Xover 3 ! 6 ! 6 days No Sucrose vs Aspartame No change

Asp ¼ Aspartame.

reduction in sugar intake. On the other hand, Bellisle et al. 1977, 1982; Tordoff and Alleva, 1990b; Kanders et al., 1990;
Tate   J F   / 2012)   318   a dultos   2  
(2001) found, in a cohort of 4278 French adults, aged 45–60 b razos   +   6  meses   No     and
Naismith Cambio  
Rhodes, de  b1995; ebidas  Blackburn
regulares   et al.,
Sin   diferencias  
1997; Gatenby
sobrepeso   y  
years, that about 30% of women and 22% of men were at control   por   d iet   o   a gua  
et al., 1997; Reid and Hammersley, 1998; Raben et al., -­‐2%   d el   p eso  
2002).
obesos  
least occasional users of intense sweeteners. As expected, These RCTs showed considerable variations in their design,
higher body mass index (BMI) values and higher waist/hip study population, duration and type of control. In addition,
Peters  JC  (2014)   303  adultos   2  brazos   12+40  semanas   Si     24  onzas  de  diet  soda/24  onzas   -­‐5.95  kg  asp,  
ratios were associated with more frequent use, suggesting certain studies compared dietary conditions that did not
sobrepeso  y   de  agua  por  día   menos  hambre  
that overweight persons were using intense sweeteners as a only differ by the presence or absence of intense sweeteners.
obesos   -­‐4.09  kg  agua  
strategy for weight control. Users had lower energy intakes For example the Foltin et al. (1988, 1992) studies did not
(significant difference in men only) and consumed less focus specifically on intense sweeteners but compared diets
carbohydrate than did nonusers. In a Spanish study of 2450 varying in fat as well as carbohydrate contents, thereby
persons (Serra-Majem et al., 1996), about 18% of the making it impossible to single out the contribution of
population used cyclamate. Within the user group, higher sweeteners in the reported effects. The meta-analysis re-
Wing examined the use of NNS beveragesduring by thosea 12-week
in the behavioral
National weight loss treatment
a function program. treatment but was not significantly dif-
of the behavioral
Methods: An equivalence trial design with water or NNS beverages as the main factor in a prospective
Weight Control Registry and found that successful weight losers ferent between groups. Sedentary behavior actually decreased signif-
randomized trial among 303 men and women was employed. All participants participated in a behavioral
drank three times the NNS beverages compared to those who had icantly in the Waterweight grouploss overphase
time (12 but weeks)
not theofNNS group. The
The Effects
never lost weight (24).
of Water and Non-Nutritive
weight loss treatment program. Sweetened
The results of theBeverages
changes
an ongoing trial (1
year) that is also evaluating the effectsover time two
of these weretreatments
not significant
on weight between groups. Taken
loss maintenance were
on Weight Loss During areported. 12-week Weight Loss Treatment together, changes in physical activity and sedentary behaviors cannot
We chose 12 weeks as the weight loss phase Results:because
The two mosttreatments
studies were account for the difference
not equivalent with the in weight
NNS loss observed.
beverage treatment group losing signifi-
Program
show that weight loss slows considerablycantly after more
6 months weightofcomparedtreat- to the water group (5.95 kg versus 4.09 kg; P < 0.0001) after 12 weeks.
ment with
John C. more
Peters 1 thanR.half
, Holly of1,the
Wyatt weight
Gary Participants
2 occurring in
loss
D. Foster , Zhaoxing Pan inthe
1theNNS firstC.
, Alexis beverage
12Wojtanowski
Based group 2on reported
the design
, Stephanie S.significantly
of thisVeur
Vander greater
study
2
, wereductions
are unablein to subjective
say, what feelings
is theof
weeks (25,26), 2
probably 1
owing to difficulty
Sharon J. Herring , Carrie Brill and James O. Hill hunger
1
with than
longer those
term in the
adher-water group
mechanism during 12
for weeks.
the greater weight loss in the NNS group compared
ence to a hypocaloric regimen. Furthermore, Conclusion:
it is now These results show
recognized that water
to the water group.
is not superior
Weekly tohunger NNS beverages
scores were for significantly
weight loss duringlower a
comprehensive behavioral weight loss program.
that weight loss is a different process from weight maintenance, among the NNS group than the water group although the absolute
both
•  Objetivo: comparar la eficacia de ENC o agua para la pérdida de peso
Objective: To compare
behaviorally and the efficacy of non-nutritive
physiologically, soObesity
during a 12-week behavioral weight loss treatment program.
sweetened
it is(2014)
important
22, 1415–1421.tobeverages
study (NNS) changes
doi:10.1002/oby.20737
or water for weight
were small.
treatment effects on these two processes separately (27). The benefit were more likely to adhere to the dietary recommendations due to
Whilelossit is plausible that the NNS participants

durante un programa de tratamiento de obesidad

Methods: An equivalence trial design with water or NNS beverages as the main factor in a prospective
of the current 1 year trial is that we will be able to compare both less hunger than the Watera beneficial
randomized trial among 303 men and women Introduction
was employed. All participants participated in a behavioral
group we cannot
effect conclude
or no effect of NNSthis based and
on appetite on energy

•  303 adultos obesos de ambos sexos, todos participaron del programa de

weight
weight loss
participants.
and weight
loss treatment
The trial was
loss maintenance
program.
designed to
within
of the the
The results Beverage
allow
year) that is also evaluating the effects ofgold-standard
weight
preplanned
same
consumption
these twobeverage
lossgroupphaseof(12 this
recommendations
analysis
treatments of
weeks)
may
on weight
study. of an
(1) suggest
increase
Someongoing
water
lossUSmaintenance
authors
as the
appetite
Dietary Guide- werefor
(3,5,6)Other
trial (7-11).
(1
with
havestudies
consumption
sweet foods
suggested
ofand
NNS disrupt
that use
have reported
(11) but generally
of of
findings
regulation
NNS
increased
withoutofan acco

manejo conductual.
for optimal health. The ing increase in caloric intake.
the treatment effects after just the 12-week
reported. weight
lines (2) suggestloss phasebeverages
that while as energy balance.sweeteners
with non-nutritive Weight loss results for the present study suggest
well as after (NNS) are preferable to those with caloric
that sweeteners, there is still a did not increase energy intake from other
Results: The 9two months of weight
treatments weremaintenance
not equivalent (still
withunderway)
the NNS which
beverage NNSgroup
treatment consumption
losing signifi-
will•  Al grupo ENC se le pidió consumir al menos 24 onzas de bebidas con ENC
bemore
cantly reported
weight separately.
compared to the water group
question about whether they are beneficial for weight management. Several observational studies have reported a positive asso
(5.95 kg versus 4.09 kg;foods
P < compared
0.0001)
While numerous clinical trials have examined the effects of nutritive after to12water.
weeks. This isNNS
between consistent
consumption with
and other
greater studies
body weight thatand weig

por día+ consumo libre de agua

Participants in the NNS beverage group reported significantly greater have
reductions
sugar sweetened beverages (NS) compared to NNS beverages on not
in found
subjective increased
feelings over
of time (4,12).
consumption Determining
of sweet causality
or high is not possible
energy wit
studies but it is possible that they represent “reverse ca
hunger than those in the water group during 12
weightweeks.
loss, few studies
While most secondary outcomes were not different between the foods while using NNS (28,29). have directly compared water and NNS Further studies will be needed to
design.loss duringwhereby obesity may cause people to seek diet beverages (10
•  Al grupo agua, se le pidió consumir al menos 24 onzas de agua por día y no
waterbeverages
Conclusion: These groupresults showed
show that is on weight to
not superior lossNNSusingbeverages
an equivalence fortrial
weight
groups, the NNS greater reductions in total- and ascertain the mechanism(s)athat may be responsible for the weight
comprehensive behavioral
LDL-cholesterol. This may weight
be duelosstoprogram.
the NNS
greaterwereweight lossintointhethefood loss
supplyresults.
consumir ni agregar are
ENC enin hundreds
cualquier producto líquido. Sí podían consumir
introduced over 50 years ago and The largest and most recent randomized trial (14) to compare
being used
Obesity (2014) 22, 1415–1421. doi:10.1002/oby.20737 of different food and beverage products. diet beverages and an attention control for their effects on

otros alimentos con controversy

ENC. concerning their role in the diet, particularly whether beverage treatment, but not water, significantly increased the
Despite the long history of usage there continues to be considerable loss used a superiority trial design. The authors found that

they are a useful tool as an aid in weight loss and weight loss main- bility of losing 5% of body weight over the 6-month study d
Introduction
TABLE 3 Absolute weight loss (kg) for completers
a beneficial effect or no effect of NNS on appetite and energy intake
tenance (3-6). NNS provide sweetness equivalent to NS but contrib- compared to a standard weight loss education and monitori
(7-11). Other studies have reported findings of increased hunger
Beverage consumption recommendations (1) suggestute essentially
water as the zero energy. Since the 1980s a number of short-term gram. Subjects in both treatment groups lost a significant am
with consumption of NNS (11) but generally without an accompany-
gold-standard beverage for optimal health. The US Dietaryexperimental
Guide-studies have compared NNS to NS and several com- weight but the amount of weight lost compared to the cont
Baseline
lines (2) suggest that while beverages with non-nutritiveprehensive Week
reviews 12
sweeteners haveclinic
ing increase in caloric intake.
concluded that the evidence supports either not different 90% CL mean
between treatment groups. P value
Group
(NNS) are preferable to those withweight (kg)
caloric sweeteners, there is still weight
a (kg) Change for change for change
question about whether they are beneficial for weight management.
1 Several observational studies have reported a positive association
Anschutz Health and Wellness Center, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA. Correspondence: John C. Peters
NNS
While(nnumerous
5 142)clinical trials have93.56 (13.23)
examined between
of nutritive87.11
the effects(john.c.peters@ucdenver.edu) NNS
(12.85)2 consumption
Temple and greater
26.45
University, Center body weight
(3.68)*
for Obesity andand
Research weight gain Department
25.94,
Education, 26.96 of Medicine, Philadelphia,
<0.0001 PA, USA
sugar sweetened beverages (NS) compared to NNS beverages on over time (4,12). Determining causality is not possible with these
Water (n 5 134) 93.88 (12.99) Funding Agencies: 89.33 (13.07)
studies but fully
it funded
is possible 24.55 (3.67)*
that theyBeverage
represent 24.03, 25.08
“reverse causality” <0.0001
weight loss, few studies have directly compared water and NNS The study was by The American Association.
NNS—water
beverages on weight loss using an20.32 (13.12)
equivalence 22.22
Disclosure: JCP,
trial design. JOH (12.96)
whereby
received obesity may
consulting fees from 21.90
causeThe
people to(3.67)*
Coca-Cola seek diet beverages
Company 21.16,work.
outside of the(10,13).
submitted 22.63 <0.0001
The remaining co-authors declared no conflict of in
Author contributions: JP, HW, GF, ZP, JH, were involved in study design, data analysis and data interpretation; CB, SH, SV, AW were involved in data collection
authors were involved in writing the manuscript and approved the final submission.
NNS were introduced into the food supply over 50 Received:
years ago16and The largest and 7most recent randomized trial27(14) to compare water,
Analysis including participants who completed 12 weeks of theJanuary 2014;
trial. Although Accepted:
equivalenceMarch 2014;
cannot Published online
be established May 2014. doi:10.1002/oby.20737
participants lost more weight in the NNS group as com-
are being used in hundreds of different food and beverage
This is products.
an open accessdiet beverages
article under the and
termsan
of attention
the Creative control
Commons for their effects on weight
Attribution-NonCommercial-NoDerivs License, whichStatistically
permits use and distribution in any
pared to the water group. All analyses were completed using a Satterthwaite two sample t test. All values are Mean (SD) unless otherwise noted. significant
Despite the long history of usage there continues to beprovided
considerable loss isused
the original work a superiority
properly cited, the usetrial
values (P < 0.05) are shown by an asterisk (*) and statistically significant P values are shown in bold. design. The and
is non-commercial authors found that
no modifications the diet are made.
or adaptations
controversy concerning their role in the diet, particularly whether beverage treatment, but not water, significantly increased the proba-
www.obesityjournal.org Obesity | VOLUME 22 | NUMBER 6 | JUNE 2014
they are a useful tool as an aid in weight loss and weight loss main- bility of losing 5% of body weight over the 6-month study duration
 REVIEW
Does low-energy sweetener consumption affect energy intake
and body weight? A systematic review, including meta-
analyses, of the evidence
Low-energy sweeteners from human and animal studies
systematic review
PJ Rogers et al
PJ Rogers1, PS Hogenkamp2, C de Graaf3, S Higgs4, A Lluch5, AR Ness6, C Penfold6, R Perry6, P Putz7, MR Yeomans8 and DJ Mela9

By reducing energy density, low-energy sweeteners (LES) might be expected to reduce energy intake (EI) and body weight (BW). To
OPEN Internation
assess the totality of the evidence testing the null hypothesis that LES exposure (versus sugars or unsweetened alternatives) has no © 2016 Mac
effect on EI or BW, we conducted a systematic review of relevant studies in animals and humans consuming LES with ad libitum www.natu
access to food energy. In 62 of 90 animal studies exposure to LES did not affect or decreased BW. Of 28 reporting increased BW, 19
compared LES with glucose exposure using a specific ‘learning’ paradigm. Twelve prospective cohort studies in humans reported
−2
inconsistent associations between LES use and body mass index (−0.002 kg m per year, 95% confidence interval (CI) −0.009 to
REVIEW
0.005). Meta-analysis of short-term randomized controlled trials (129 comparisons) showed reduced total EI for LES versus sugar-
Does low-energy sweetener consump
sweetened food or beverage consumption before an ad libitum meal (−94 kcal, 95% CI −122 to −66), with no difference versus
water (−2 kcal, 95% CI −30 to 26). This was consistent with EI results from sustained intervention randomized controlled trials
and body weight? A systematic revie
(10 comparisons). Meta-analysis of sustained intervention randomized controlled trials (4 weeks to 40 months) showed that
consumption of LES versus sugar led to relatively reduced BW (nine comparisons; −1.35 kg, 95% CI –2.28 to −0.42), and a similar
analyses, of the evidence from huma
relative reduction in BW versus water (three comparisons; −1.24 kg, 95% CI –2.22 to −0.26). Most animal studies did not mimic LES
consumption by humans, and reverse causation may influence the results of prospective cohort studies. The preponderance of
PJ Rogers1, PS Hogenkamp2, C de Graaf3, S Higgs4, A Lluch5, AR Ness6, C Pen
evidence from all human randomized controlled trials indicates that LES do not increase EI or BW, whether compared with caloric or
non-caloric (for example, water) control conditions. Overall, the balance of evidence indicates that use of LES in place of sugar, in
children and adults, leads to reduced EI and BW, and possibly also when compared By reducing energy density, low-energy sweeteners (LES) might be expected t
with water.
assess the totality of the evidence testing the null hypothesis that LES exposu
effect on EI or BW, we conducted a systematic review of relevant studies in
International Journal of Obesity (2016) 40, 381–394; doi:10.1038/ijo.2015.177
access to food energy. In 62 of 90 animal studies exposure to LES did not affe
compared LES with glucose exposure using a specific ‘learning’ paradigm. Tw
inconsistent associations between LES use and body mass index (−0.002 kg
0.005). Meta-analysis of short-term randomized controlled trials (129 compar
sweetened food or beverage consumption before an ad libitum meal (−94 k
INTRODUCTION Although thewater
imprecise
(−2 kcal, control
95% CI −30 of toshort-term
26). This wasenergy balance
consistent with EI results from su
Low-energy sweeteners (LES), such as acesulfame-K, aspartame, predicts that(10LES consumption should help reduce
comparisons). Meta-analysis of sustained intervention EI and randomized contro
3,10
saccharin, stevia and sucralose are consumed throughout the therefore reduce risk of overweight
consumption of LES versus andsugarobesity, it is reduced
led to relatively possibleBW (nine compar
world.1 The history of their use has been accompanied by debate that, as consumed
relativein everyday
reduction life,versus
in BW otherwater
effects of LES
(three balance −1.24
comparisons; or kg, 95% CI –2
and disagreements, not least about their potential nutritional even outweigh the energy
consumption dilutionandeffect.
by humans, reverseFor example,
causation may ainfluence
low the results o
impact. The use of LES to replace or partially replace added sugar calorie or ‘diet’ labelfrom
evidence mayall cause the consumer
human randomized to eat
controlled a indicates
trials larger that LES do no
in foods and beverages might well be expected to reduce energy portion of the product or eat more of accompanying foods in thethe balance of ev
non-caloric (for example, water) control conditions. Overall,
Efecto  en  el  peso:  edulcorantes  v/s  azúcar  
2–4
intake (EI), yet over recent years there has been widely reported meal, or eat children
more later.and11–14
adults, leadssimply,
More to reduced EI and
adding BW, and possibly
sweetness to a also when co
speculation that consumption of LES might increase the risk of product may increase intake owing to increased palatability.15,16
5–7 International
Or, by ‘uncoupling’ theJournal
relationship (2016) 40, 381–394;
of Obesity between sweetnessdoi:10.1038/ijo.2015.177
and
Placer por lo dulce, azúcar y obesidad

Edulcorantes artificiales: no tan rápido!

Mecanismos propuestos para el “daño”

Evidencia actual

Conclusiones
Conclusiones
•  Se ha establecido una relación de causalidad entre el
consumo de azúcar y bebidas azucaradas con el
aumento de la prevalencia de sobrepeso y obesidad a
nivel mundial
•  Los edulcorantes artificiales no calóricos representan
una alternativa de valor al disminuir el aporte de azúcar
de alimentos y sobre todo bebidas
•  Estudios observacionales han reportado asociación
entre el uso de edulcorantes no calóricos y riesgo de
obesidad
•  No se ha encontrado causalidad para esta relación
•  De la gran cantidad de estudios, de diferente diseño,
publicados, se puede desprender que el uso de
edulcorantes no tendría efectos adversos en baja de
peso ni su mantención.

•  No se ha demostrado beneficio significativo en la baja

de peso con el uso de edulcorantes artificiales.

•  Por qué habría de esperarse que sólo por el hecho de

consumir edulcorantes no calóricos alguien pudiera
perder peso??...

•  Los edulcorantes no calóricos podrían promover la baja

de peso en el contexto de una “dieta” o cambios activos
en la conducta alimentaria.