May 2021 Issue

Ask the Expert: Artificial Sweeteners and CVD — Do They Increase Risk?
By Toby Amidor, MS, RD, CDN, FAND
Today’s Dietitian
Vol. 23, No. 5, P. 10

Q: Is there any scientific evidence linking artificially sweetened beverages to increased risk of CVD?

A: A 10-year study published in September 2020 concluded that drinking artificially sweetened beverages may be just as unhealthful as drinking soft drinks, syrups, or fruit drinks, suggesting that consuming any amount of sugary or artificially sweetened beverages may be associated with CVD compared with not consuming any sugary or artificially sweetened beverages.1 As a result, some consumers and RDs have expressed concerns about this potential relationship.

Overall, studies have been somewhat mixed on a connection; valid concerns may exist, but it can be difficult to parse the nuances of findings, so more research is needed. Where there are established considerations of consuming these beverages, RDs can educate clients on the best ways to avoid negative health outcomes.

The Research and Its Context
The September 2020 study followed 104,761 participants from 2009 to 2019, using questionnaires to classify subjects as nonconsumers, low consumers, or high consumers of sugary or artificially sweetened beverages. Compared with nonconsumers, authors found that high consumers of both sugar-sweetened and artificially sweetened beverages had a greater risk of incident stroke, transient ischemic attack, myocardial infarction, acute coronary syndrome, and angioplasty. Researchers concluded that artificially sweetened beverages may not be a healthful substitute for sugary drinks.1

According to Karen Collins, MS, RDN, CDN, FAND, a consultant specializing in helping RDs address cardiovascular health and cancer prevention, several long-term prospective cohort studies have linked high consumption of added sugars (13% of calories or more) with increased incidence of CVD mortality, and intake of sugar-sweetened beverages specifically with greater weight gain and higher risk of type 2 diabetes, coronary heart disease, and stroke.2 The 2020–2025 Dietary Guidelines for Americans state that the largest source of added sugars in the typical US diet is sugar-sweetened beverages.3

However, Collins does say that some “prospective cohort studies also have linked routine (often the equivalent of about two cans/day) intake of artificially sweetened beverages with higher BMI and greater risk of diabetes and CVD.” For example, in the Women’s Health Initiative, artificially sweetened beverages increased risk of stroke with consumption of more than two servings per day.4

Yet, as with any observational study, these studies can’t establish causality. Collins emphasizes that the potential of reverse causality is of particular concern with studies on artificially sweetened beverages: “It is equally plausible that people who have overweight or obesity, diabetes, or prediabetes, for example, choose artificially sweetened beverages in an effort to control their condition. These people may even have previously been drinking sugar-sweetened beverages and switched to artificially sweetened beverages only recently.”

A 2019 report summarizing randomized controlled trials and observational studies found no clear benefit for use of artificial sweeteners for weight loss or CVD prevention.5 Collins counters these findings, saying that “research shows that when artificially-sweetened soft drinks displace added sugars in the diet, they do tend to decrease total calories and support weight loss.” She explains that there’s some limited recent evidence that specifically focuses on artificially sweetened soft drinks as a replacement for sugar-sweetened beverages in randomized controlled trials; these studies suggest that artificially sweetened soft drinks can help with weight loss, lower serum triglycerides, and lower A1c levels—all risk factors for CVD.6,7

Some experts have questioned whether consuming artificially sweetened beverages has secondary negative health effects rather than a direct effect on CVD risk. One concern is that those who use artificial sweeteners may replace the calories lost in their diets by consuming other high-calorie foods such as cake that would offset the health benefits of a lower-sugar or no-sugar drink. Another possible issue is that regular consumption of artificial sweeteners may overstimulate sugar receptors. This may limit tolerance for more complex tastes and cause people to find less intensely sweet foods, such as fruits, less palatable.8 Lastly, research suggests that artificial sweeteners may prevent individuals from associating sweetness with caloric intake, leading them to crave and choose calorie-dense sweets.9 All of these choices have the potential to increase CVD risk.

Recommendations for Clients
Prospective studies on artificially sweetened beverage consumption are underway. There isn’t enough evidence to steer clients away from artificially sweetened beverages altogether, but RDs can help those interested in using them maximize their potential benefits.

If clients inquire about the use of artificial sweeteners, Collins recommends first asking them why they’re choosing artificial sweeteners and how much they’re consuming, and then evaluating their current CVD risk factors. RDs should address any misconceptions clients have, such as they needn’t pay attention to the rest of their diet and habits if they consume artificial sweeteners. “[Clients] need to be replacing excess calories and added sugars to provide a benefit,” Collins says. For example, if a client is choosing artificially sweetened beverages and then consuming high-caloric foods such as cake or ice cream, this wouldn’t be consuming these beverages in a healthful manner.

— Toby Amidor, MS, RD, CDN, FAND, is the founder of Toby Amidor Nutrition ( and a Wall Street Journal best-selling author. Her cookbooks include The Best 3-Ingredient Cookbook, The Best Rotisserie Chicken Cookbook, The Create-Your-Plate Diabetes Cookbook, Smart Meal Prep for Beginners, The Easy 5-Ingredient Healthy Cookbook, The Healthy Meal Prep Cookbook, and The Greek Yogurt Kitchen. She’s a nutrition expert for and a contributor to U.S. News Eat + Run and other national outlets.


1. Chazelas E, Debras C, Srour B, et al. Sugary drinks, artificially sweetened beverages and cardiovascular disease in NutriNet-Santé cohort. J Am Coll Cardiol. 2020;76(18):2175-2177.

2. Khan TA, Tayyiba M, Agarwal A, et al. Relation of total sugars, sucrose, fructose, and added sugars with the risk of cardiovascular disease: a systematic review and dose-response meta-analysis of prospective cohort studies. Mayo Clin Proc. 2019;94(12):2399-2414.

3. US Department of Agriculture; Health and Human Services. Dietary Guidelines for Americans 2020–2025. Published December 2020.

4. Mossavar-Rahmani Y, Kamensky V, Manson JE, et al. Artificially sweetened beverages and stroke, coronary heart disease, and all-cause mortality in the Women’s Health Initiative. Stroke. 2019;50(3):555-562.

5. Toews I, Lohner S, Küllenberg de Gaudry D, Sommer H, Meerpohl JJ. Association between intake of non-sugar sweeteners and health outcomes: systematic review and meta-analyses of randomised and non-randomised controlled trials and observational studies. BMJ. 2019;364:k4718.

6. McGlynn N, Khan T, Zhang R. Effect of non-nutritive sweetened beverages (NSBs) on cardiometabolic risk: a network meta-analysis of randomized controlled trials. Curr Dev Nutr. 2020;4(Suppl 2):1659.

7. Rogers PJ, Hogenkamp PS, de Graaf C, et al. Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analysis, of the evidence from human and animal studies. Int J Obes (Lond). 2016;40(3):381-394.

8. Strawbridge H. Artificial sweeteners: sugar-free, but at what cost? Harvard Health Publishing website. Updated January 29, 2020.

9. Davidson TL, Martin AA, Clark K, Swithers SE. Intake of high-intensity sweeteners alters the ability of sweet taste to signal caloric consequences: implications for the learned control of energy and body weight regulation. Q J Exp Psychol (Hove). 2011;64(7):1430-1441.