Artificial sweeteners and their implications for patients with diabetes: a systematic review and meta-analysis

Since their discovery in the 18^th century, artificial sweeteners have been an important part of modern-day nutrition. The same applies to sugar consumption, which has increased massively in the last few decades. That is why the World Health Organization (WHO) recommends limiting free sugar intake to less than 10% of total daily energy intake, with additional benefits likely at levels below 5% per day. This high consumption led to the fact that diabetes is now one of the most frequent comorbidities in the world, with around 529 million people suffering from this disease. Patients need to be careful with their diet, which raises the question of whether artificial sweeteners should be mandatory in a diabetic nutrition plan. To answer this question, a systematic review following PRISMA guidelines and a meta-analysis were conducted. Overall, 22 studies were included in this review. The results of the studies were ambivalent, and no general statement could thus be made. We found the same results in the meta-analysis, where Hedges' g was used as an effect size. Artificial sweeteners were associated with higher insulin (g = 0.50, 95% CI, 0.19-0.82) and higher HbA1c (g = 0.30, 95% CI, 0.06-0.54) in common-effects models; however, these associations were not relevant in random-effects models, and heterogeneity was substantial. No consistent effects were observed for other outcomes. Based on current evidence, the routine use of artificial sweeteners in diabetic diets cannot be recommended.