Artificial Sweeteners and Patients with Eating Disorders

Reprinted from Eating Disorders Review
May/June 2006 Volume 17, Number 3
©2006 Gürze Books

Artificially sweetened foods, such as nonfat yogurt and soft drinks, are especially attractive to people with eating disorders. But how often are such foods consumed? Do they cause adverse effects? Do people with eating disorders consume more of these products than do the general public? These and other questions led a team at New York State Psychiatric Institute, New York, NY, to what is believed to be the first attempt to quantify the use of artificially sweetened, low-calorie products by women with anorexia nervosa (AN) and bulimia nervosa (BN) (Int J Eat Disord 2006; 39:341).

Diane A. Klein, MD and colleagues enrolled 78 women with eating disorders and 38 healthy women without histories of eating disorders in their study. Among the eating disorders patients, 18 had restricting subtype AN (AN-R), 12 had AN-binge-purge subtype AN (AN-B/P), and 48 had BN. The women were surveyed with a questionnaire assessing use of artificial sweeteners during the previous month, and for inpatients with AN, use of artificially sweeteners the month prior to their hospitalization. The survey was completed in written form by the participants or by telephone interview with a research assistant.

Some differences emerged among the groups

As expected, the body mass indexes of groups with AN were significantly lower than those of women in the other groups. And, although the women with AN-B/P and BN were somewhat more likely to report using of each of the product categories, the only areas where significant differences between groups appeared was for chewing gum and packets of sweeteners. Analysis showed that the difference in the use of sweetener packets was attributable to participants with AN-B/P, who were more likely to report use than were the other groups. The difference in use of artificially sweetened gum appeared to be attributable to lower use among the AN-R group. However, all three of the groups drank equal amounts of diet drinks.

In a second analysis, the researchers examined the amount of artificially sweetened food among the participants during the last month. Women with AN-B/P and BN used more diet drinks and chewing gum than did controls. Both AN patient groups used more packets of sweetener than did controls, and use among women with AN-R was greater than that among women with BN.

Amounts used were often striking

Although there was some suggestion that the proportion of women endorsing the use of artificially sweetened products differed by eating disorder, a much more striking finding, according to the authors, was the amounts of substances used by study participants. For example, one patient told of adding dozens of artificial sweetener packets to popped corn and another described eating “Equal® sandwiches.” Others reported that they ate sweetener directly from the packet, and often used as many as 100 packets a day.

The role of dietary restraint

Dr. Klein and her co-workers speculate that the excessive use of these products by persons with AN and BN is a manifestation of dietary restraint characteristic of these disorders. Dietary restriction stimulates appetite, which, coupled with the strong motivation to resist food intake, may lead individuals to choose foods that provide maximal orosensory stimulation with minimal calories.

The association between semistarvation and a heightened drive for orosensory stimulation has been described in other populations, such as the Minnesota men who voluntarily participated in a study of the effects of starvation during World War II. During that study, these previously healthy men developed several unusual food-related behaviors, such as chewing 40 or more packets of gum per day.

The authors also reported a distinct pattern of product use across subject groups. The greater use of diet beverages among women who purge is consistent with a higher tolerance for gastric distention and the use of fluids to facilitate vomiting. Diet beverages often contain caffeine, which appears to have a higher rate of abuse among women who binge and purge.

The lower overall use of artificially sweetened products among women with restricting type AN compared to those with AN-BP may reflect a higher degree of dietary restraint among the former group.

No clinical side effects were reported. Despite its small size, the study did show that consumption of artificial sweeteners among persons with eating disorders, especially those with AN, may be a sign of appetitive drive induced by semistarvation.

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