A sweetener review reporting 3.6 million participants used a diabetes estimate from before the original study adjusted for dieting and body weight.
Kim and colleagues' May 2026 meta-analysis reported associations with diabetes, hypertension, heart failure, stroke and mortality. The supplied headline numbers match the paper. The harder question is what those numbers can establish.
1. One input represents a different adjustment level.
The diabetes forest plot uses de Koning's hazard ratio of 1.91, adjusted only for age. That study followed 40,389 men and recorded 2,680 diabetes cases over 20 years.
After fuller adjustment, including health status, dieting, weight change and body mass index, its estimate was 1.09, with a 95% confidence interval of 0.98–1.21. Yet the meta-analysis lists those broader adjustments alongside the study while plotting the age-only result. [Original study](
pmc.ncbi.nlm.nih.gov/article…)
The audit reconstructed the pooled diabetes estimate from the 16 printed rows: HR 1.26, interval 1.14–1.40. Replacing only that input produced about 1.20, interval 1.11–1.30.
This is a sensitivity check, not a corrected meta-analysis. Other inputs still need checking, and several rows reuse participants from the same cohorts. Separate estimates of caffeinated and caffeine-free drinks do not create independent groups of people. Neither do estimates of consumption frequency and duration from the same women.
2. The two reviews ask different questions.
The cautious January 2026 review explicitly excluded studies focused on artificially sweetened beverages. It found 11 articles, split between dietary consumption and blood measurements, and described the dietary evidence as limited and mixed.
That is a different evidence set from the larger review. Its conclusion is not proof that the same association was tested and disproved. The audit could verify its abstract, but not obtain its full paper. [January review](
doi.org/10.1093/nutrit/nuaf2…)
3. Replacing sugar differs from replacing water.
A randomized-trial review found that replacing sugary drinks with low/no-calorie alternatives reduced body weight by about 1.06 kg, with a 95% interval of 0.41–1.71 kg lower weight. The relevant direct comparisons involved 601 adults. Median follow-up across the review's trials was 12 weeks. This supports a modest weight benefit, not a claim about lifelong cardiovascular safety. [Trial review](
pmc.ncbi.nlm.nih.gov/article…)
Water comparisons are less uniform. In SODAS, 181 adults with established diabetes who habitually drank diet drinks were randomized to continue them or replace them with water. Over 24 weeks, HbA1c, a measure of blood-sugar control, changed less favourably in the water group by 0.29 percentage points (standard error 0.12).
That result concerns existing users with diabetes. It does not establish that healthy water drinkers should start consuming sweeteners. [SODAS](
pmc.ncbi.nlm.nih.gov/article…)
4. Confounding does not explain away every concern.
NutriNet-Santé reported cardiovascular associations that persisted after several attempts to address health-related switching. Modeled substitution studies also remain observational, even when their comparisons better match a real dietary decision. [NutriNet-Santé](
bmj.com/content/378/bmj-2022…)
Erythritol and xylitol experiments provide evidence about clotting mechanisms. But blood levels can reflect the body's own production, and small, acute experiments do not establish long-term clinical harm. Findings about these sugar alcohols cannot automatically be assigned to aspartame or sucralose. [Erythritol](
pmc.ncbi.nlm.nih.gov/article…), [xylitol](
pmc.ncbi.nlm.nih.gov/article…)
The six scores for Kim's review are:
- Design fit: 3/5. Observational synthesis suits an association question, but the pooled studies use different designs and comparisons.
- Measurement quality: 2/5. Verified adjustment and study-description errors weaken confidence in the extracted inputs.
- Analysis and robustness: 2/5. Repeated cohort contributions and a consequential adjustment mismatch limit trust in the pooled estimates.
- Transparency and reproducibility: 3/5. Printed estimates permit a diabetes-pool reconstruction, but the authors' analysis inputs were unavailable for checking.
- Claim discipline: 4/5. The authors acknowledge confounding, contrasting trial findings and the inability to establish causality.
- Generalizability: 3/5. The broad evidence base combines populations and sweetener measurements that limit product-specific conclusions.
Rebuilding the inputs by cohort, adjustment level, sweetener and comparator could change this rating if the revised estimates remain stable. A reliable answer must specify what is being replaced, in whom, and which outcome is measured.
Paper:
doi.org/10.4162/nrp.2026.20.…