Systematic reviewindependent cross-checkabstract checked★ key study I-SOD-101 in-depth review
Diet drinks linked to several diseases in observational data
Artificially Sweetened Beverages and Health Outcomes: An Umbrella Review.
Overview
Diaz C et al.. Adv Nutr 2023 · PMID 37187453 · DOI 10.1016/j.advnut.2023.05.010
Across many studies, regular diet-drink consumers had more obesity, diabetes, hypertension, heart disease and deaths; stroke and heart-death links were weak.
Does the study support the specific claim? Partly · Methodological quality: moderate
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Grade the credibility of links between diet drinks and health.
- How was the study done?
Umbrella review of meta-analyses.
- How many people, animals or samples were studied?
55 underlying studies.
- What was actually found?
Several associations highly suggestive; stroke and cardiovascular mortality weak.
- How large was the observed effect?
Credibility classes, not single effect sizes.
- What do the results mean in everyday life?
Diet drinks are not proven healthy; causation unclear.
- What are the study's limitations?
Observational; reverse causation likely.
- What does it say about Elawady's specific claim?
Partly supports 'diet soda is not a safe alternative'; does not support strong stroke effects.
- Do the results apply to Germany and Europe?
Applicable.
- What can explicitly not be concluded from this study?
Cannot show that sweeteners cause these diseases.
Scientific in-depth review
1. Full reference
- Authors
- Diaz C et al.
- Journal
- Adv Nutr
- Year
- 2023
- Identifier
- PMID 37187453 DOI 10.1016/j.advnut.2023.05.010
- Verification
- verified – PubMed efetch 2026-10-26 + Crossref 2026-10-26
- Retracted
- no
- Corrections
- none
- Extent checked
- abstract only
- Conflicts of interest and funding
Not stated in abstract record
2. Research question
How credible are claimed observational associations between ASB and health outcomes?
3. Study design and population
- Study design
- Systematic review – Umbrella review of meta-analyses of observational studies (Web of Science, Embase, PubMed to 25 May 2022); credibility grading; AMSTAR-2
- Population
Adults in cohort and case-control studies
- Country
International
- Period
to 25 May 2022
- Sample size
11 meta-analyses from 7 systematic reviews (51 cohort and 4 case-control studies)
- Inclusion and exclusion criteria
Systematic reviews with meta-analysis of ASB and any health outcome
4. Methods and endpoints
- Exposure / intervention
Artificially sweetened beverages (habitual vs low/no)
- Comparator
Low or no ASB consumption
- Endpoints
Obesity, T2D, mortality, hypertension, CVD, cancers, CKD, stroke and others
- Statistical methods
Umbrella-review credibility criteria (highly suggestive, suggestive, weak)
5. Actual results
- Results
ASB associated with higher risk of obesity, type 2 diabetes, all-cause mortality, hypertension and CVD incidence (highly suggestive evidence). Evidence for colorectal, pancreatic and gastrointestinal cancer, cancer mortality, cardiovascular mortality, CKD, coronary artery disease and stroke was weak. AMSTAR-2 showed deficiencies (unclear funding of primary studies; lack of protocols).
- Absolute risks
not reported
- Authors' conclusion
ASB consumption was associated with higher risk of obesity, T2D, all-cause mortality, hypertension and CVD incidence; further cohorts and trials are needed.
6. Strengths
- Systematic credibility grading
- Covers many outcomes
7. Weaknesses
- Observational associations only; reverse causation not addressed by grading
- Underlying reviews of limited quality
8. Risk of bias
- Orienting tool
- ROBIS
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- some concerns
- Rationale
Grading is statistical and cannot remove confounding by indication.
9. Assessment of the statistical interpretation
'Highly suggestive' is a statistical credibility label, not proof of causation; people at metabolic risk preferentially choose diet drinks.
10. Relevance to the specific claim
Supports the association part of C-SOD-10 (ASB and all-cause mortality) but rates cardiovascular mortality and stroke evidence as weak, which limits C-SOD-10 ('especially circulatory deaths') and C-SOD-06 (stroke).
11. Independent contrary findings
RCTs substituting ASB for SSB show small benefits (I-SOD-103).
12. Transferability to Germany and Europe
Applicable.
13. Overall methodological judgement
Best overview of ASB associations; association real, causality uncertain.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | moderate |
| Risk of bias | some concerns |
| Precision of results | moderate |
| Directness | direct |
| Reproducibility | replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | high |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
Causal effects of specific sweeteners.
15. Linked fact checks
- Diet soda is not a safe alternative to sugary soda: artificially sweetened drinks are linked to higher mortality, especially circulatory deaths. – Studies supporting the claim
- One diet soda per day nearly triples the risk of ischaemic stroke and of Alzheimer's dementia. – Studies contradicting or limiting the claim