Sweeteners
in different countries varies. In the US, for example, the Food and Drug Administration has approved six NSSs for consumption, whereas the range of currently approved NSSs in the European Union is wider – for example, including cyclamate. In general, current evidence supports the safety of several NSSs to be used in foods. Recognised regulatory bodies have established acceptable daily intakes based on various safety studies. Other NSSs are currently declared as unsafe or have not yet been assessed. Although many of the NSSs currently being used in foods have been declared safe for consumption at levels below the respective acceptable daily intakes, less is known regarding potential benefits and harms of NSSs within this range of intake; evidence from studies and reviews is often limited and conflicting. The WHO is developing guidance on the use of NSSs by adults and children based on the evidence generated by a systematic review.
Following the guidance of the WHO Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health, a comprehensive assessment of the association between commonly consumed NSSs and health requires answers to many different questions. One being what, in the general adult population, the effects of NSS consumption versus no consumption on relevant health outcomes might be. What the effects are of higher versus lower NSS doses and more frequent versus less frequent NSS consumption on relevant health outcomes. Another being, in an overweight or obese adult population with explicit intentional weight loss, what are the effects of NSS consumption versus no consumption on relevant health outcomes. The same can be asked regarding the general child population, and in overweight and obese children with intentional weight loss plans.
Assessment of risk of bias Two review authors independently assessed the risk of bias for each study. For the risk of bias assessment of randomised controlled trials, the report used the Cochrane risk of bias tool. For non-randomised controlled trials, it used the ROBINS-I tool (risk of bias in non-randomised studies of interventions); planning to create funnel plots when data of ten or more studies were available to assess the likelihood of dissemination bias. Since none of the meta-analyses included ten studies or more, a thorough assessment of dissemination bias was not feasible. The risk ratios were calculated and their respective 95% confidence intervals for randomised controlled trials, controlled clinical trials, and cohort studies, as well as odds ratios and their respective 95% confidence intervals for case-control studies. Mean differences or standardised mean differences with 95% confidence intervals were calculated for continuous outcomes. Meta-analyses,
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using the random effects model, was also conducted where comparable outcome data from two or more studies were available. When baseline and final values were given, changes were computed from the baseline and any missing standard deviation values using an imputed correlation coefficient were added.
Sensitivity analyses
As for the robustness of the results, they were tested using sensitivity analyses. In forest plots, the reported results of analyses with the random effects model was the primary effect estimate. In most sensitivity analyses with the fixed effect model, the effects were more precise – narrower 95% confidence intervals – and consequently statistically significant at times, compared with analyses using the random effects model. However, given the clinical heterogeneity of the included studies, these were judged to not be appropriate, and therefore the results are not reported in detail. Only one study was found with low risk of bias; thus, an analysis of studies with a low risk of bias only was not feasible. Study populations were divided into participants age 18 years and older and those younger than 18 years in sensitivity analyses so that the effect of NSSs on children only and adults only could be analysed.
Assessment of the certainty of the evidence
Using the GRADE approach (grading of recommendations assessment, development, and evaluation) the certainty of the evidence for the most relevant, available measures of all critical and important outcomes was assessed. According to this approach, the study classified the certainty of evidence in four categories: high, moderate, low, and very low certainty of evidence. The certainty assessment per outcome was documented in GRADE evidence profiles, together with the pooled effects for the interventions – using GRADEpro GDT online software to compile the
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The US FDA has approved six NSSs as safe for consumption.
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