Link Between Artificial Sweeteners and Liver Disease

Evidence on Artificial Sweeteners and Liver Health

Clinical practice guidelines strongly recommend avoiding sugar-sweetened beverages to improve histologically or non-invasively assessed liver injury in patients with metabolic dysfunction-associated steatotic liver disease (MASLD), as recommended by the European Association for the Study of the Liver 1, 2
Evidence from randomized controlled trials and large prospective observational studies shows an association between dietary added sugars, especially in sugar-sweetened beverages, with increased liver steatosis and prevalence of MASLD, according to the European Association for the Study of the Liver 2
A prospective cohort study demonstrated a dose-response association between soft drink consumption and MASLD, with consumption of >4 servings per week related to a 45% increased risk of developing MASLD, as reported by the European Association for the Study of the Liver 2

Increased fructose consumption has been linked to obesity, dyslipidemia, and insulin resistance, which are risk factors for NAFLD, as stated by the American Association for the Study of Liver Diseases 3
Growing evidence suggests that fructose contributes to the development and severity of NAFLD, with human studies associating fructose with increasing hepatic fat, inflammation, and possibly fibrosis, according to the American Association for the Study of Liver Diseases 3
However, fructose contained in fruits is not associated with NAFLD, so fruit consumption should not be restricted, as recommended by the American Gastroenterological Association 4

Clinical practice guidelines recommend improving diet quality (similar to the Mediterranean dietary pattern), limiting consumption of ultra-processed foods rich in sugars and saturated fat, and avoiding sugar-sweetened beverages to improve liver health, as suggested by the European Association for the Study of the Liver 1, 2
The Mediterranean diet has repeatedly been shown to provide hepatic and cardiovascular health benefits, even without weight loss, according to the European Association for the Study of the Liver 2
Guidelines from the American Heart Association recommend that added sugars compose less than 5% of total calories, to reduce the risk of liver disease and other health problems 5
While evidence specifically on artificial sweeteners is still evolving, sufficient evidence exists to support clinical recommendations that fructose intake be limited through decreasing foods and drinks high in added sugars, as stated by the American Heart Association 5
Sugar-sweetened and artificially sweetened beverages have been correlated with increasing development of type 2 diabetes and cardiovascular disease risk, according to the American Heart Association 6

Long-term, large randomized controlled trials are needed to test the effect of dietary interventions on clinical liver-related outcomes, as recommended by the European Association for the Study of the Liver 2

For NAFLD patients, weight loss of 7-10% is recommended to improve steatosis and liver biochemistry, while weight loss >10% is recommended to improve fibrosis 7
The Mediterranean diet has been shown to provide hepatic and cardiovascular health benefits, even without weight loss 8
Consider the Mediterranean diet pattern which emphasizes vegetables, fruits, whole grains, legumes, and olive oil as the principal source of dietary lipids 9

Moderate coffee consumption may have beneficial effects on liver health in patients with NAFLD 8
For patients with NAFLD, aim for progressive weight loss of less than 1 kg/week through dietary modification and physical activity 9
Recommend 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise per week 10

While direct evidence linking diet soda to liver disease is lacking, some studies have found associations between diet soda consumption and metabolic syndrome, which is closely related to NAFLD 11
The Multi-Ethnic Study of Atherosclerosis cohort study showed that daily consumption of diet soda was associated with a 36% higher relative risk of metabolic syndrome and a 67% higher relative risk of type 2 diabetes mellitus, though the association with metabolic syndrome was no longer significant after adjusting for baseline adiposity 11

Carbohydrate intake is directly associated with both metabolic syndrome and the severity of hepatic inflammation in NAFLD patients, as recommended by the Clinical and Molecular Hepatology guideline society 12, 13, 14
In populations where carbohydrates comprise >65% of total caloric intake, increased carbohydrate and fructose consumption correlates with higher prevalence of fatty liver and elevated liver enzymes, according to the Clinical and Molecular Hepatology guideline society 12, 15

The Korean Association for the Study of the Liver (KASL) explicitly recommends a reduction in total energy consumption, as well as a low-carbohydrate and low-fructose diet, for NAFLD patients, with a Grade B1 recommendation 12, 15
Low-carbohydrate diets were more effective than low-fat diets in reducing liver fat content in both Western and Korean studies, as reported by the Clinical and Molecular Hepatology guideline society 12, 13, 14
Replacing refined carbohydrates with high-fiber, unprocessed carbohydrate sources, including whole grains, vegetables, fruits, and legumes, is recommended, as suggested by the Advances in Nutrition guideline society 16

Reducing total carbohydrate proportion to approximately 50-55% of total calories, with emphasis on complex carbohydrates, is recommended, according to the Clinical and Molecular Hepatology guideline society 12, 15
Limiting added sugars to <5% of total daily calories is suggested, although no specific guideline society is mentioned for this point, it is implied by the context of reducing carbohydrate intake 16

The Mediterranean diet pattern, emphasizing vegetables, fruits, whole grains, legumes, olive oil, and fish, while minimizing red meat and processed foods, reduces liver fat content and improves insulin resistance, as recommended by the Gastroenterology and Clinical and Molecular Hepatology guideline societies 13, 14, 17