Non-caloric sweeteners (NCS) are widely used in diets aimed at reducing calorie intake, particularly for individuals who are overweight or obese. These sweeteners are increasingly prevalent in Western diets, with some Latin American countries reporting NCS consumption in as high as 70% of the population. However, concerns are emerging about the potential adverse effects of NCS on health, particularly concerning functional gastrointestinal disorders (FGDs). This article explores the definition of NCS diets, their effects on FGDs, and the broader implications for gastroesophageal reflux disease (GERD).
What is an NCS Diet?
An NCS (non-caloric sweetener) diet refers to a dietary approach that incorporates non-caloric sweeteners as a substitute for sugar. The primary goal of an NCS diet is often to reduce overall calorie consumption while maintaining the sweetness and palatability of foods and beverages. These diets are popular among individuals looking to manage their weight, control blood sugar levels, or reduce their intake of added sugars.
NCS diets can vary in their composition and the specific types of non-caloric sweeteners used. Some common NCS found in these diets include:
- Sucralose
- Saccharin
- Aspartame
- Acesulfame-K
- Neotame
- Stevia
The level of NCS consumption in these diets can range from moderate to high, depending on individual preferences and dietary goals. For instance, a study might define a diet containing NCS (c-NCS) as one with 50-100 mg/day NCS, whereas an NCS-free diet (NCS-f) would have less than 10 mg/day NCS.
Non-Caloric Sweeteners (NCS) and Functional Gastrointestinal Disorders (FGDs)
Functional gastrointestinal disorders (FGDs) are a group of chronic conditions characterized by recurrent gastrointestinal symptoms without any identifiable structural or biochemical abnormalities. These disorders include irritable bowel syndrome (IBS), functional dyspepsia, functional constipation, diarrhea, and gastroesophageal reflux disease (GERD).
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Emerging research suggests a potential link between NCS consumption and the development or exacerbation of FGDs. The gut microbiota can metabolize unabsorbed sweeteners, leading to changes in intestinal habits. Additionally, NCS consumption may affect the secretion of hormones that regulate intestinal transit, such as glucagon-like peptide-1 (GLP-1), gastric inhibitory polypeptide (GIP), peptide YY (PYY), and cholecystokinin (CCK).
A randomized, controlled study aimed to compare the effects of consuming a diet containing NCS (c-NCS) versus a non-caloric sweetener-free diet (NCS-f) on FGDs in adult volunteers. The study found that participants on the c-NCS diet experienced an increase in FGDs, including:
- Diarrhea
- Post-prandial discomfort
- Constipation
- Burning or retrosternal pain
Conversely, those on the NCS-f diet saw a decrease in FGDs, such as:
- Abdominal pain
- Post-prandial discomfort
- Burning or retrosternal pain
- Early satiety
- Epigastric pain
These findings suggest that consuming a diet high in NCS may contribute to the development or worsening of FGD symptoms, while eliminating NCS from the diet may lead to symptom improvement.
NCS and Gastroesophageal Reflux Disease (GERD)
Gastroesophageal reflux disease (GERD) is a common digestive disorder characterized by the reflux of stomach contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. While dietary interventions are often recommended as part of GERD management, the specific role of NCS in GERD is not well-defined.
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Some evidence suggests that NCS may influence GERD symptoms through various mechanisms. For example, certain NCS have been shown to increase incretin secretion in the form of GLP-1, GIP, PYY, or CCK. These hormones can affect gastrointestinal motility and gastric emptying, potentially contributing to GERD symptoms.
GLP-1 decreases motility in the antro-duodeno-jejunal region and inhibits the migrating motility complex in healthy controls and IBS patients. CCK delays gastric emptying, and GIP can also slow gastric emptying. PYY causes delayed intestinal transit. Interestingly, acesulfame-K in combination with fructose might cause slow gastric emptying by increasing motilin secretion, promoting satiety just five minutes after NCS administration.
Dietary Assessment Methods
Accurately assessing dietary intake, including NCS consumption, is crucial for understanding the relationship between diet and health outcomes. Various methods are used to collect dietary data, each with its strengths and limitations. These methods include:
- Food Records: Recording food intake at the time of consumption over several days.
- Diet History Questionnaires (DHs): Retrospective assessment of "usual" food intake, including details about food preparation and portion sizes.
- 24-Hour Recall (24HR): Retrospective method where an interviewer prompts the respondent to recall all foods and beverages consumed in the preceding 24 hours.
- Food Frequency Questionnaires (FFQs): Retrospective method asking respondents to report their usual frequency of consumption of each food from a list of foods for a specific period.
- Doubly Labeled Water (DLW) Method: A method used to measure energy expenditure in free-living subjects.
Consistent Carbohydrate Diet (CCHO)
Another dietary approach often recommended for managing conditions like type 2 diabetes is the Consistent Carbohydrate Diet (CCHO). This diet involves eating the same amount of carbohydrates each day to help stabilize blood sugar levels. While not directly related to NCS, understanding the principles of a CCHO diet can provide insights into broader dietary management strategies.
The CCHO diet focuses on consuming consistent amounts of carbohydrates at each meal to maintain stable blood sugar levels. This can be particularly beneficial for individuals with diabetes, as it helps them manage their insulin levels and prevent drastic fluctuations in blood glucose.
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Dietary Interventions for GERD
Given the potential role of diet in GERD, various dietary interventions have been explored as treatment options. A systematic review and meta-analysis evaluated the efficacy of dietary interventions on GERD-related outcomes. The interventions were divided into low-carbohydrate diets, high-fat diets, speed of eating studies, low-FODMAP diets, and other interventions.
The review found that low-carbohydrate diets resulted in a significant reduction in esophageal acid exposure time. In contrast, a slow speed of eating did not lead to a lower percentage of reflux events compared to fast eating. The overall evidence regarding dietary interventions in GERD remains scarce, highlighting the need for further research in this area.
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