Artificial sweeteners and risk of cardiometabolic outcomes and mortality: a systematic review and meta-analysis.

BACKGROUND

Artificial sweeteners are widely used as sugar substitutes to reduce sugar intake and mitigate health risks. However, their potential long-term health effects remain uncertain as existing studies have reported inconsistent findings.

OBJECTIVE

This systematic review and meta-analysis aimed to examine the association between artificial sweetener intake and the risk of cardiometabolic outcomes and mortality.

METHODS

Studies were identified through comprehensive searches of PubMed and Embase up to October 8, 2025. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) comparing the highest and lowest artificial sweetener consumption categories were calculated using a random-effects model. Heterogeneity was assessed using the I2 statistic. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa Scale.

RESULTS

In total, 3,625,613 participants from 37 studies were included. Higher artificial sweetener intake was associated with an increased risk of type 2 diabetes (HR, 1.26; 95% CI, 1.14-1.40), hypertension (HR, 1.13; 95% CI, 1.09-1.18), heart failure (HR, 1.26; 95% CI, 1.14-1.39), stroke (HR, 1.12; 95% CI, 1.05-1.19), coronary artery disease (HR, 1.11; 95% CI, 1.00-1.23), cardiovascular mortality (HR, 1.18; 95% CI, 1.03-1.35), and all-cause mortality (HR, 1.09; 95% CI, 1.01-1.17). The association with atrial fibrillation was not significant (HR, 1.13; 95% CI, 0.94-1.37). Significant heterogeneity was observed for all endpoints except for stroke and heart failure.

CONCLUSIONS

This meta-analysis demonstrates that a higher intake of artificial sweeteners is associated with an increased risk of several cardiometabolic outcomes and mortality. These findings underscore the need for cautious consumption and further research into their cardiometabolic effects.

TRIAL REGISTRATION: International Prospective Registration of Systematic Reviews (PROSPERO) Identifier: CRD420251020488.