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A recent large cohort study (n=102,865 adults) examined artificial sweetener intake and cancer risk and concluded that artificial sweeteners were associated with increased cancer risk (1). This has important implications for practice given the wide range use of sweeteners in foods and beverages and the frequency that these foods and beverages are consumed, particularly for people living with chronic diseases, including diabetes. The PEN Team took a closer look at this study to see if the findings were consistent with current practice recommendations.

The 2022 study by Debras et al. looked at dietary intakes and the consumption of sweeteners through repeated 24-hour dietary records from a NutriNet-Santé (2009-2021) cohort (1). Cox proportional hazards models were used to assess associations between sweeteners and cancer incidence, which were adjusted for many factors that could influence the study outcomes. Participants enrolled in the study were primarily women (79%) with an average age of 42 years and a BMI of 24.  Dietary information identified that most participants (63%) did not consume artificial sweeteners. For those who did consume artificial sweeteners (37%, classified as low or high consumers), aspartame (58% of intake) and acesulfame-K (29%) were the most common, primarily from soft drinks and as table-top sweeteners. After a median follow up of seven years, a higher risk of overall cancer (n=3,358 cases, hazard ratio (HR) 1.13, 95%CI 1.03 to 1.25, P-trend = 0.002) was found in higher consumers of total artificial sweeteners (i.e. above the median exposure in consumers) when compared to consumers who did not use sweeteners. In particular, aspartame (HR 1.15, 95%CI 1.03 to 1.28, P=0.002) and acesulfame-K (HR 1.13, 95%CI 1.01 to 1.26, P=0.007) were associated with increased cancer risk. Putting this into context, a 13-15% increase in cancer risk was observed with high artificial sweetener consumption (1), which is a small magnitude of effect compared to an effect size >2, which is the cut-off used to enhance the certainty of evidence for observational studies (2).  

Other observations related to total artificial sweetener intake included higher risks for breast cancer (n=979 cases, HR 1.22, 95%CI 1.01 to 1.48, P=0.036, for aspartame) and obesity-related cancers (n=2,023 cases, HR 1.13, 95%CI 1.00 to 1.28, P=0.036 for total artificial sweeteners and HR 1.15, 95%CI 1.01 to 1.32, P=0.026 for aspartame).

The authors noted several limitations based on the observational design, including selection bias of study participants, residual confounding despite efforts to control for confounding variables and some reverse causality that limits confidence in the study’s outcomes (1). Reverse causality can occur because high consumers of artificial sweeteners may be consuming these to encourage weight loss rather than these sweeteners causing obesity-related cancers. The study’s conclusion, therefore, warrants  further investigation when suggesting an individual’s cancer risk may be elevated with intake of artificial sweeteners. Thus, the current findings cannot be used to justify avoiding artificial sweeteners to reduce cancer risk.

General practice guidance continues to be moderation in artificial sweetener consumption and their related products. Daily use should be at or below their Acceptable Daily Intake. To learn about the evidence on the safety of sweeteners, including the Acceptable Daily Intake, refer to the PEN Practice Question: What is the evidence on the safety of sweeteners (e.g. nonnutritive, artificial, intense, low calorie, sugar substitutes)?

For more information on sweeteners, see Additional Content: Sweeteners Knowledge Pathway.