Varied effects of sweeteners on pediatric hypertension: A multicenter study

Background & aims

The link between sugar-sweetened beverage consumption and metabolic syndrome has prompted the use of non-nutritive sweeteners(NNS). However, emerging evidence links NNS to elevated cardiovascular risk in children. This study examines the association between sweetener consumption and pediatric hypertension to guide cardiovascular health recommendations for children.

Methods

The Taiwan Pubertal Longitudinal Study, initiated in July 2018, is a multicenter, prospective cohort study involving 1696 patients aged 7–17 years. Baseline dietary exposures were collected using the validated NNS Food Frequency Questionnaire covering acesulfame potassium(AceK), aspartame, sucralose, glycyrrhizin, steviol glycosides, sorbitol, and added sugars. Spot urine samples were collected concurrently. Anthropometric and blood pressure measurements were recorded every 3 months. Pediatric hypertension was defined as systolic or diastolic blood pressure at or above 95th percentile for age, sex, and height, using the measurement closest to dietary assessment. Multivariate generalized linear mixed models were used to examine associations between sweetener exposure and pediatric hypertension, adjusting for age, sex, z-BMI, family history of hypertension, total calorie intake, sodium intake, physical activity, parental education, and household income. Participants were recruited on an ongoing basis, and data collected from July 2018 to September 2022 were analyzed.

Results

Aspartame and added sugars were dose-dependently associated with increased pediatric hypertension risk (aspartame: OR = 1.69, 95%CI:1.03–2.75; p = 0.04; added sugar: OR = 2.63, 95%CI:1.50–4.60; p < 0.001), while steviol glycosides showed borderline protective effects (p for trend = 0.05). AceK was negatively associated with hypertension in girls (OR = 0.30, 95%CI:0.09–0.98; p = 0.05), whereas aspartame was positively associated with hypertension risk in boys (OR = 3.13, 95%CI:1.30–7.54; p = 0.01). The association between added sugar intake and hypertension was stronger in overweight children. Substituting added sugars with NNS was associated with lower hypertension risk. Urinary biomarker analysis further supported the inverse association between AceK and hypertension, particularly in girls.

Conclusion

This study demonstrated that aspartame and added sugars were associated with a higher pediatric hypertension risk, while steviol glycosides were linked to lower hypertension risk. Replacing added sugar with NNS was associated with lower pediatric hypertension risk. These findings emphasize the need for tailored dietary guidelines and further investigation on sweetener use in children.