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INTRODUCTION
The non-nutritive sweeteners (NNS) are a class of food additives that are used to sweeten foods and beverages without providing energy, including saccharin, aspartame, acesulfame potassium, sucralose, stevia, neotame, advantame, and monk fruit (1). The consumption of NNS has increased over time since today they are present in many products to reduce their calories and sugar content due to the global pandemic of obesity and diabetes (2,3). However, the use of these substances has been controversial because they have been linked to different effects on health, including an increase in insulin resistance and changes in gut microbiota and in appetite regulating hormones (4,5). The consumption of NNS has been evaluated around the world in different populations, including children, teenagers, adults, pregnant women and people living with diabetes (6-14). Nevertheless, little is known regarding the perception and beliefs that the population has regarding the NNS. In recent years, new scientific evidence has emerged reporting that some NNS such as sucralose and saccharin could promote insulin resistance by different pathways, suggesting that they are not metabolically inert (15-19). Thus, the perception of the population about the NNS may have changed recently and it is relevant to evaluate the opinion towards different aspects of NNS such as safety, taste, side effects, information, and price, discerning between consumers and non-consumers. Also, the perception of health professionals about the NNS could influence their patients’ preference for using these substances. A qualitative study made in 75 dietitians of five different European countries described their perception and concerns about the use of NNS, concluding that there are four main approaches regarding the advice given about NNS: a) they should not be used; b) they are permissible only as a transitional product; c) client’s informed preferences should determine its use; and d) they should be allowed or recommended (20). Therefore, the aim of this study is to describe and compare the beliefs concerning NNS consumption in consumers, non-consumers, and health professionals. In addition, a secondary objective was to identify the most common opinions of health professionals (dietitians and physicians) to recommend or not the use of NNS and the associated reasons.
MATERIAL AND METHODS
DESCRIPTION OF PARTICIPANTS AND ETHICS
The study was evaluated and approved by the ethics and research committees of the National Institute of Medical Sciences and Nutrition “Salvador Zubirán” in Mexico City (registration number 3282), and followed the principles established in the Declaration of Helsinki. All the participants received a full explanation of the study procedures and informed consent was obtained before enrollment. The selection criteria for each group were: a) consumers: people living with any type of diabetes, over 18 years old, who attended the nutrition consultation for the first time, and that reported a consumption of ≥ 3 products containing NNS in the last month; b) non-consumers: people without any diagnosed disease, over 18 years old, excluding health professionals, and that reported consumption of < 3 products containing NNS in the last month; and c) health professionals: registered dietitians or physicians who had no relationship with the researchers of this study. Exclusion criteria for all groups was inability to answer the questionnaire (e.g., illiteracy, mental health diseases, etc.) and elimination criteria was incomplete questionaries. The recruitment for the group of consumers was performed in the Diabetes Clinic of our institute; for the group of non-consumers, an invitation to participate in the study was made through social media, and relatives of patients and administrative personnel of our institute were also invited. Finally, for the group of health professionals, the participants were recruited through social media ads and in universities where registered dietitians and physicians were studying a postgraduate degree.
STUDY DESIGN
This is a comparative cross-sectional study. The participation of the volunteers included in the study consisted in one visit to collect general data (sex, age, education level, presence of diseases, profession, working information, etc.), to apply a questionnaire regarding the beliefs concerning NNS consumption, and a food frequency questionnaire (FFQ) of products containing NNS.
To evaluate the beliefs regarding NNS consumption, five questions were asked:
Do you think you have enough information about NNS?
Do you believe that the consumption of NNS is safe for your health?
Do you think that NNS are expensive?
Do you believe that the consumption of NNS causes discomfort such as headache, nausea, abdominal bloating and/or other?
Do you think that NNS have a pleasant taste?
Participants answered these items according to a Likert rating scale, which is used to evaluate a positive, negative, or neutral attitude to an idea, considering the following options: a) agree; b) neither agree nor disagree; and c) disagree. The FFQ to evaluate NNS consumption consisted in asking the regularity of consumption (daily, weekly, or monthly) of eight different categories of products (sugar substitute sachets, beverages, dairy, gelatins, gums and mints, water flavoring enhancers powders, cereals, and desserts) according to a questionnaire previously elaborated by our group including products in the Mexican market. This instrument has face validity and a good reliability, with an intraclass correlation coefficient (ICC) of 0.94 (95 % CI: 0.88-0.97, p < 0.001) for the inter-subject concordance and with an ICC of 0.82 (95 % CI: 0.56-0.93, p < 0.001) for the intra-subject test-retest reliability (8). In addition, health professionals were questioned about their opinion for recommending the use of NNS in four different approaches according to the study described in the introduction. Also, the main reasons for recommending or not recommending NNS consumption were asked in the health professional’s group and if their perception of NNS has changed in recent years.
STATISTICAL ANALYSIS
Variables distribution was evaluated with the Kolmogorov-Smirnov normality test for each group and they are presented as means ± standard deviations or as medians (interquartile range), as appropriate. Qualitative variables are described as frequencies and percentages. Differences in the proportions of the answers in the questions of the beliefs between groups were evaluated with the Chi-squared test for trend. Data were collected and analyzed using IBM SPSS Statistics version 25.0 software and a p value < 0.05 was considered as significant.
RESULTS
The general characteristics of the participants in the three groups are shown in table I. The proportion of women was higher in the three groups, being 52 %, 63 % and 72 % in the groups of consumers, non-consumers and health professionals, respectively. The consumers group showed higher age, with a mean of 52.1 ± 14.2; and the group of non-consumers was the youngest, with a mean age of 25.5 ± 5.6. Half of the health professionals were dietitians and half physicians. In addition, type 2 diabetes mellitus was the most common type (71 %) in the consumers’ group.
Table I. General characteristics of the participants by group (consumers, non-consumers and health professionals).
NNS: non-nutritive sweeteners; T1DM: type 1 diabetes mellitus; T2DM: type 2 diabetes mellitus. Values are means ± standard deviations, medians (interquartile ranges) or frequencies (percentages).
Among the main characteristics of the group of health professionals described in table II, most of the participants did not have postgraduate studies (78 %). Sixty-five health professionals had only one job and 14 % were unemployed. A significant proportion of the health professionals worked in private practice (49 %) or in a public health institution (39 %), and the most common work field was clinical (77 %).
Table II. Description of the working characteristics in the group of health professionals.
Values are medians (interquartile ranges) or frequencies (percentages).
The frequency of consumption of the different categories of products containing NNS is described in table III, finding that the most common categories consumed in the consumers group were beverages (80 %), sugar substitute sachets (77 %) and gelatins (61 %). In the non-consumers group, 24 % of the participants did not consume any product and the most common category of products consumed was gums and mints (41 %). The prevalence of NNS consumption in the health professionals group was 76 % and the most common categories consumed were beverages (53 %), sugar substitute sachets (53 %), gums and mints (51 %) and desserts (50 %).
Table III. Frequency of consumption of the different categories of products with NNS by group (consumers, non-consumers and health professionals).
NNS: non-nutritive sweeteners. Data are presented as frequencies and percentages.
In the evaluation of the beliefs concerning NNS consumption, showed in table IV, no significant difference was found between groups regarding the information they think they have about NNS (p = 0.53). However, a higher proportion of consumers (46 %) believed having enough information in contrast with the proportion of health professionals (36 %). The questions related to safety, side effects and taste showed significant differences between groups (p < 0.01), observing that most consumers (54 %) agreed that NNS are safe for health compared to health professionals, where the majority (48 %) disagreed with this idea. Seventy-three consumers disagreed that NNS cause side effects such as headache, nausea, abdominal bloating and/or others, while 51 % of health professionals agreed and 40 % of the non-consumers neither agreed nor disagreed regarding this belief. Most of the consumers agreed that NNS have a pleasant taste (62 %), in comparison with 52 % of the non-consumers and 42 % of the health professionals, who disagreed with this idea. Finally, no differences were found between groups regarding the idea that NNS are expensive (p = 0.93), observing that 61 % of the consumers and 55 % of the health professionals agreed, while 43 % of the non-consumers neither agreed nor agreed.
Table IV. Description and comparison of the beliefs concerning NNS consumption by group (consumers, non-consumers and health professionals).
NNS: non-nutritive sweeteners. Data are presented as frequencies and percentages.
*Differences were evaluated with Chi-squared test for trend.
†Question 1: Do you think you have enough information about the NNS?
‡Question 2: Do you believe that the consumption of NNS is safe for your health?
§Question 3: Do you think that the NNS are expensive?
¶Question 4: Do you believe that the consumption of NNS causes discomforts such as headache, nausea, abdominal bloating and/or others?
ǁQuestion 5: Do you think that the NNS have a pleasant tasté
Table V shows the different opinions concerning the use and recommendation of NNS in the health professionals group. Forty-eight health professionals agreed that NNS should be limited, used only as a transition and in certain patients, while the least common opinion (7 %) was that NNS can be recommended or at least allowed. The main reasons for recommending the use of NNS were replacement of carbohydrates or sugars (46 %), glycemic and/or lipid control (31 %) and weight loss (27 %), while the main reasons for not recommending the use of NNS were that they are not a healthy habit (36 %), encourage the preference for sweet taste (30 %) and are harmful to health (22 %). Seventy-seven health professionals agreed that their perception regarding the use and recommendation of NNS changed in recent years, while only 8 % disagreed and 15 % neither agreed nor disagreed. No significant differences were found in the opinion about the use of NNS and the reasons for recommending or not the use of NNS between dieticians and physicians or between consumers and non-consumers of the group of health professionals.
DISCUSSION
The consumption of NNS has increased worldwide, especially in adults, but still the knowledge about NNS among the population is low (3,21). A study conducted in 741 Irish adults showed that 73.5 % of the participants knew NNS, however, they were able to identify on average only two of all the NNS approved for use in Europe and 89.2 % reported being unaware of the acceptable daily intake (ADI) of NNS (22). Interestingly, in our study, health professionals had the lowest proportion that answered having enough information about NSS. It is important that both dietitians and physicians are well informed about NNS, since their recommendation regarding these products will influence the consumption of the population. A study in Mexican patients with diabetes reported that 53.3 % of the participants consumed NNS based on the recommendation of a relative, friend or by their own decision, which means that the opinion of a health professional is not always taken into consideration (8).
Both consumers and health professionals showed a high prevalence of consumption of different categories of products with NNS (at least four categories in each group were consumed in ≥ 50 % of the participants); however, it has been mentioned in the literature that Mexico has a higher percentage of packaged products with NNS compared to other countries like the United States, New Zealand and Australia (23).
Regarding the safety of NNS, most of the consumers (54 %) agreed that the consumption of NNS was safe in comparison to the health professionals group, where 48 % disagreed with this idea. A study conducted in Italian adolescents showed that 24.5 % of the participants stated that a frequent consumption of tabletop sweeteners could be very dangerous for health, similarly to white sugar (25.5 %). Only 9.1 % considered that the consumption of tabletop sweeteners does not cause health damage at all, in comparison to other sweeteners like honey (34.5 %) and brown sugar (22.7 %). In the same study, 14.5 % of the participants though that sugar-free drinks can cause a lot of damage to health and 17.3 % that these beverages are not harmful at all (24). A recent study in Canadian adults reported that most of the participants perceived the high-fructose corn syrup and aspartame as less healthy than table sugar (63.9 % and 52.4 %, respectively), while raw sugar was considered to be healthier than table sugar by 47.8 % of the population (25).
In reference to the other beliefs, the consumers were more prone to consider that NNS do not cause side effects and have a pleasant taste; however, the majority considered that they are expensive. The non-consumers were more neutral in their answers, except that this group disagreed that NNS taste pleasant, which may be one of the main reasons why they avoid these products. The health professionals revealed a tendency to have a more negative attitude towards NNS, since most agreed that NNS cause side effects and are expensive, while disagreed that they are tasty. A recently published study conducted in UK adult population showed that the main reasons for consuming NNS were that they are healthier than sugars, are low in calories, satisfy sweet cravings or simply are ingredients in foods and products that the population consumed; nevertheless, 44.9 % of the participants neither agreed nor disagreed that NNS are tasty (26).
The previously mentioned study in Mexican patients with diabetes reported that the consumption of NNS correlated with the belief that they are safe for health, do not cause discomfort and have a pleasant taste (p < 0.01) (8). The study conducted in Italian adolescents concluded that most of participants strongly disagreed that eating sugar-free products caused them to spend more, to have stomachache or to eat worse tasting products (24). We can conclude that consumers have a more positive opinion about NNS, although there are differences in the perception of the products price that could depend mainly on the socioeconomic level.
Finally, the main approach (48 %) for the use and recommendation of NNS in the health professionals was that NNS should be limited, used only as a transition and in certain patients. Lowest proportions of health professionals recommended (7 %) or not recommended (16 %) NNS. This is in agreement with the current position of the American Diabetes Association (ADA) guidelines, where it is established that beverages sweetened with NNS may serve as a short-term replacement strategy but health professionals should promote a lower consumption of both caloric and non-caloric sweeteners, preferring the natural flavor of food (27). The main reasons for recommending the use of NNS observed in our study were replacement of carbohydrates or sugars, glycemic and/or lipid control and weight loss; while the main reasons for not recommending the use of NNS were that they are not a healthy habit, encourage the preference for sweet taste and are harmful to health. The study carried out in an Irish population mentioned that 34.3 % of the participants opined that NNS should not be used, 20.9 % considered that NNS should be used and 44.8 % declared no opinion regarding this (22). Also, the qualitative study in European dietitians noted that there is a lack of reliable and consistent information sources regarding NNS, that there is uncertainty surrounding sweeteners and how to use them in dietetic practice, and that health professionals worry about their safety (20).
The limitations of the study include the sample size and that other beliefs and perceptions regarding the use of NNS could also be explored, such as which are considered to be the safest or the most harmful, in which life stages is safer to consume them or to analyze the association of NNS consumption with diet quality and other sociodemographic variables. However, this is a motivation to make a bigger study in general population with a higher number of participants and including other interesting outcomes to evaluate the current perceptions of the NNS at different ages, socioeconomic levels, schooling, health status, etc. This topic is relevant due to the fact that apparently the population perceive the healthiest sweeteners based on a natural origin rather than on energy content or associated metabolic effects (25). Nowadays, it has been reported that some NNS like sucralose may not be inert and potentially could cause certain negative health effects (28).
The strength of the study is that this information has not been reported in the Mexican population and that the approaches of health professionals towards the use and recommendation of NNS have been barely explored. Also, it is important to recognize the differences between the beliefs of consumers, non-consumers, and health professionals to understand the main reasons for consuming/recommending them and to identify the principal needs to empower consumers to make informed decisions, as well as that health professionals have sufficient and reliable information to correctly guide the population.
