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Artificial sweeteners – not sweet for your heart

Comment by Martin Bahls, Population Science and Public Health Section

Risk Factors and Prevention
Heart Failure

Heart failure (HF) is a major public health threat, which poses one of the greatest healthcare challenges in the coming years for ageing Western societies. Albeit significant advances in prevention and therapy, HF related mortality and morbidity are still high. On a personal level, patients with heart failure suffer from a very poor quality of life. The previous decade has already identified lifestyle factors for the prevention and treatment of heart failure. For example, exercise training has shown to be beneficial irrespective of heart failure entity and exercise modality (e.g. HF-ACTION, SMART-EX, EX-DHF and OptimEX).

In addition to exercise and physical activity, nutrition may also play a significant role for preventing heart failure. For example, the Dietary Approach to Stop Hypertension (DASH) diet, which includes lower intake of sugar-sweetened beverages (SSBs) was associated with lower risk of HF. The biological reason underlying this association is most likely related to the fact that the consumption of SSBs is positively associated with several cardiovascular risk factors like obesity, hypertension, and Type 2 diabetes. Some individuals may try to reduce their sugar intake by consuming beverages with artificial sweeteners like aspartame, sucralose, and erythritol. Whether a substitution of sugar with these artificial sweeteners is a viable option was assessed in a recent publication in the European Journal of Preventive Cardiology.

In “Sweetened beverages and incident heart failure” data from the UK Biobank was used to investigate the association of the consumption of SSB, artificial sweetened beverages (ASBs) and, fruit juice (pure juice; PJ) with incident heart failure in 209,829 participants. Going in line with previous publications fizzy drinks and squash were defined as SSBs, whereas low-calorie drinks were defined as ASBs. Pure orange juice, grapefruit juice, and other pure fruit or vegetable juices were defined as PJs. An interesting aspect of the analysis was that the consumption was stratified into non-consumers, study participants who drank between 0 and 1 L per week, or between 1 and 2 L per week, or more than 2 L per week.

In this large prospective cohort, Zhang et al. report that the consumption of ASBs of more than 2 L per week was associated with a 30 % greater risk for heart failure after adjusting for relevant confounders1 . Interestingly, consuming more than 2 L of SSB per week “only” resulted in 22 % higher risk for heart failure. Drinking up to one liter of juice per week was related to a 10 % lower risk of heart failure. These findings have significant implications for recommendations with regards to the consumption of sweet beverages.
The observed association of SSBs with a higher risk for heart failure may partially be explained by the adverse outcome of sugar on the lipid metabolism. The consumption of artificial sweeteners deteriorates glucose tolerance via alterations of the gut microbiota. With regards to juice, one should note that while a consumption of pure juice up to 1 L per week was related to a lower risk of heart failure, drinking more than 1 L of juice had no beneficial effects.

There are several practical recommendations based on the findings, which should be highlighted. A prime example may be for individuals with Type 2 diabetes mellitus. These patients already have an increased risk for heart failure and may try to improve their health by replacing SSBs with ASBs. However, in patients with type 2 diabetes mellitus the consumption of more than 2 L of ASBs per week was related with a 62 % greater risk for heart failure. Therefore, artificial sweeteners may not be a safe alternative to sugar for diabetic patients. Yet, recommendations not just for patients but also for the general population may be derived from this research article. Given that ASBs and SSBs are the beverage of choice for some individuals during their lunch time even a relatively small bottle (i.e. 0.5 L) per lunch will accumulate to 2.5 l per week, which would be related with a greater risk for heart failure. Hence, one should consider exchanging this daily treat with a bottle of water.

Even though this large data set cannot differentiate between different heart failure subtypes, the work still highlights the detrimental effects of not just SSB but also artificial sweeteners on cardiovascular disease health. The adverse effects of artificial sweeteners on cardiovascular disease risk in general and not just related to beverages was recently highlighted in a systematic review and meta-analysis by the World Health Organization2. Overall, sweet beverages should probably be avoided to reduce cardiovascular risk.


Martin Bahls commented on:

1. Ziteng Zhang, Kun Zhang, Ying Sun, Bowei Yu, Xiao Tan, Yingli Lu, Yu Wang, Fangzhen Xia, Ningjian Wang, Sweetened beverages and incident heart failure, European Journal of Preventive Cardiology, Volume 30, Issue 13, September 2023, Pages 1361–1370,

Additional references:

2. Rios-Leyvraz, Magali, Jason Montez, and World Health Organization. "Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis." (2022).


Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.