Category: Health

Source: United Kingdom – Executive Government & Departments

April 8, 2025

A study published in PLOS Medicine looks at food additives type 2 diabetes incidence. 

Dr Nerys Astbury, Associate Professor of Diet & Obesity, Nuffield Department of Primary Health Care Sciences, University of Oxford, said:

“This prospective study conducted in France explores the association between the amount of common mixtures of food additives and the risk of future development of type 2 diabetes.

“The study reports that there was no association between the consumption of three of the mixtures studies and type 2 diabetes.  There were positive associations between the consumption of two of the mixtures investigated including a mixture including emulsifiers/gelling agents including modified starches, pectin, guar gum, carrageenan and xantham gum which the authors show were linked with the consumption of dairy desserts and fats and sauces; as well as a mixture including artificial sweeteners and acidity regulators which were linked with consumption of low-energy/diet soft drink consumption.

“Previous studies have reported associations between some of these individual food additives and risk of type 2 diabetes, but additives are commonly included in foods in mixtures where they may have interactive effects.  Indeed the authors showed in their exploratory analysis that there were both synergistic and antagonist interactions between several food additives.

“One limitation of this study is that the mixtures of additives investigated include a range of different additives with different functional properties, with some additives included in more than one mixture group, meaning it is not possible to ascertain whether the effects observed can be attributed to groups of additives with similar functional properties.

“The authors controlled for typical type 2 diabetes risk factors including age, sex, body mass index, physical activity level, smoking status, educational level and profession.  But it is possible that other factors that were not controlled for may have influenced the relationship.

“Some of the findings may subject to reverse causality, where the outcome (in this case type 2 diabetes diagnosis) precedes, and therefore influences the presumed cause (in this case the consumption of the food additive mixtures).  For example, if a person knew they were at risk of developing type 2 diabetes, because they either had a family history of the condition, or that a doctor conducted tests to show they had pre-diabetes, they may decide to make lifestyle choices to reduce their risk of developing the condition.  One thing they might decide to do is replace sugar sweetened beverages for low-energy or diet versions.

“It is important to note that by design this study can only demonstrate association, it cannot say whether the consumption of these additives (or the foods that contain then) caused or contributed to the development of type 2 diabetes.  To determine causality large scale complex clinical trials are required.

“The growing interest in the effects of consuming ultra-processed foods, which contain additives to enhance taste, flavour, texture and improve shelf life of food products, means this study is important and timely and adds to the growing body of evidence of association between increased consumption of common food additives and adverse health outcomes.  Further research is needed to ascertain a causal link and establish the mechanisms.”

Prof Nita Forouhi, Professor of Population Health and Nutrition, and Programme Leader of the Nutritional Epidemiology programme, MRC Epidemiology Unit, University of Cambridge, said:

“The researchers in France once again tapped into the only existing research study that has the relevant data to investigate links between different types of food additives and risk of chronic diseases.  They have extended their previous findings on the links of individual additive emulsifiers and artificial sweeteners with risk of type 2 diabetes to now identifying food additive mixtures that are frequently consumed together, reporting that the associations were not strongly driven by a unique additive alone and suggesting that interactions between types of food additives may play a role.

“The authors identified 269 food additives consumed by over 100,000 study participants, quantifying additive intakes from repeated 24h recalls over a long time using multiple sources and they hence provide probably the most comprehensive additives database to-date.  Using 75 of these additives that were consumed by at least 5%of the study participants, they statistically derived five food additive mixture groups, of which two were associated modestly with the development of type 2 diabetes.  It is important to note that these associations are present at population level intake doses of additives in their usual diets.  However, it is unknown if additives consumed by a smaller proportion of the study population but in higher doses would have been related with the risk of type 2 diabetes.  A sensitivity analysis testing this would have been informative.

“This research helps to an extent with understanding mechanisms through which ultra-processed foods (UPFs), that typically contain mixtures of additives, may be related with disease risk.  This is an important research gap to fill because a lack of evidence on mechanisms by which UPFs may be related with health harms, over and above the links already established for foods high in (saturated) fat, sugar and salt, is part of the reason for withholding a specific government policy on UPF reduction in the UK.

“It is important to distinguish between additive mixtures by their food sources as we know from other research that not all UPFs are the same, with some being potentially harmful and others not.  Moreover, their analysis has not accounted for the proportion of UPF in the diet.  Also, the five food additive mixture groups the researchers identified were related with a limited set of food groups, largely cakes, biscuits, savoury snacks, broth, dairy desserts, fats and sauces and sugar sweetened or artificially sweetened drinks.  Thus, it is unclear if additives from other food groups not identified in this study population may be relevant in other populations.

“Several of the current analyses were appropriate, such as adjusting for a comprehensive range of factors (including accounting for saturated fat, salt and added sugar), doing sensitivity analyses, checking the stability of food additive mixture intakes over time, and testing whether the additive mixtures found associated with type 2 diabetes contributed to mediating the associations between the food groups most associated with these mixtures and incidence of type 2 diabetes.  But, there were also important limitations the authors did not or could not address.

“Exposure to food additives could not be validated against blood or urine biomarkers due to a lack of specific biomarkers.  Many tests for interaction were performed but it is unclear if there was adequate statistical power.  The data variables used in analysis, such as dietary intakes or health behaviours like physical activity or smoking and alcohol intake, are likely to vary over time but only baseline data, not time-varying data were used.  The authors showed several participant characteristics in the cohort at the study baseline but did not show these characteristics by total food additive or food additive mixture types, which is relevant to understanding the appropriateness of their analytical strategy.  This research included mostly women (80% of participants), so the findings in men remain under-studied.  The authors acknowledge that they could not collect data on ethnicity so the generalisability of findings to different population sub-groups is unclear but there seems no strong reason to expect that findings would vary in different ethnic groups.  Nonetheless, future studies in diverse populations should apply the current study methods to test the reported findings.  The authors appropriately acknowledged the limitations of observational research, but such research remains an important part of the evidence base.

“More investment in research is needed to replicate the findings of this currently sole resource of the NutriNet-Sante’ study that has generated relevant data for the study of food additives.  In the meantime, we should take these current findings seriously and build further upon them to help understand the mechanistic links between UPF-related additive mixtures and human health.”

Prof Tom Sanders, Professor emeritus of Nutrition and Dietetics, King’s College London, said:

“This new report from a French prospective study (NutriNet-Santé) is an analysis of food additive intake based on estimates of dietary intake based on recall, and subsequent risk of developing type 2 diabetes.  79% of the participants were female and the average age was 42.  After 7.7 years of follow up, they found 2 out of 5 mixtures of additives were associated with very small increases in risk of developing type 2 diabetes.  The first mixture was associated with an 8% increase in risk – this consisted mainly of food additives used to thicken foods and drinks (guar gum, carrageenan xanthan gum), polyphosphates (that help retain water), curcumin (a naturally occurring yellow food colour used mainly in margarine) and potassium sorbate (a preservative).  The second mixture was associated with a 13% increase in risk, this consisted of a diverse mixture of additives but included several that are used in soft drinks – citric acid, sodium citrates, phosphoric acid, sulphite ammonia caramel (used in cola drinks), acesulfame-K, aspartame, sucralose, arabic gum, malic acid, carnauba wax (a glazing agent), paprika extract, anthocyanins (purple natural colours), guar gum, and pectin.

Limitations

“This was an observational study and not a controlled trial and can only suggest associations.  A major limitation of this study is that the incidence of type 2 diabetes was low over the follow up period.  Over the follow-period only 1% of the 108,643 participants developed type 2 diabetes.  This may well be because the average body mass index (23 kg/m2) was close to the ideal level (22.5).  A potential strength claimed is that multiple estimates of dietary intake were made over the follow-up period (on average 5 occasions).  However, these estimates were based on what the participants remembered eating the previous day.  A daily recall only provides data for one day and is not a good measure of usual dietary intake which needs a longer period of recording (preferable taking into seasonal variations in account).  Dietary recalls also lack the granularity in terms of detail regarding portion size and brand which are important for estimating the intake of food additives.

“Dietary recalls are subject to reporting bias (over-reporting fruit and vegetable intake and under-reporting food and drink that regarded being less healthy, e.g. alcohol and confectionery).  The reported dietary intake of sugar is extremely high (198g, equivalent about 50 cubes of sugar per day).  This raises questions regarding the reliability of intake data.

“The statistical analyses involved creating mixtures of food additives by a form of statistical analysis by computer not by a prior hypothesis.  Associations of mixtures of food additives are likely to be reflective of overall dietary patterns or components (e.g. fizzy drinks).  While this type of exploratory statistical analyses can be used to create new hypotheses, the results should never be used as evidence of causality.

“There seems to be no scientific basis for relating the components of these mixtures of food additives to risk of type 2 diabetes.  For example, citric acid probably accounts for the bulk of food additives consumed.  The body makes enormous amounts in the citric acid cycle (the Krebs cycle) to generate metabolic energy.  It is also present in quite high amounts in fruit and vegetables.  Gums are used as thickeners in some foods like yogurt.  There is no reason to suspect that gums would have an adverse effect on risk of diabetes especially as studies have shown that gums slow glucose absorption and can improve blood glucose control in patients with type 2 diabetes.  The association of artificial sweetener intake with risk of diabetes is well known but not thought to be causal, as recently discussed by SACN (https://www.gov.uk/government/publications/sacn-statement-on-the-who-guideline-on-non-sugar-sweeteners/sacn-statement-on-the-who-guideline-on-non-sugar-sweeteners-summary).

Conclusion

“My concern is that a “toxic cocktail of food additives” narrative may detract from sensible dietary advice to maintain a healthy weight.”

Dr George Savva, Senior Research Scientist, Quadram Institute, said:

“This study adds to the evidence that people who consume more food additives associated with sugary and sweetened drinks have a higher risk of diabetes, after controlling for overall calories, sugar intake, saturated fats and other aspects of diet.  A smaller association was seen for a second group associated with dairy desserts, broths, fats and sauces.  Other major groups of additives, including those associated with cakes and biscuits, showed no association with incident diabetes.

“The study was large with a very detailed dietary assessment, but is limited by being non-randomised and being conducted in a volunteer cohort.  The authors did try to control for demographic and lifestyle factors like exercise and smoking but this is difficult to do well.  So, although the control for other aspects of diet was good, it is possible that other factors led to higher risk of diabetes in this group.  Showing no association between diabetes and additives linked to cakes, biscuits and snacks may suggest that residual confounding isn’t a huge problem in this study (because if other aspects of diet and lifestyle were really causing this association we might also expect to see a positive association between diabetes and the group of additives associated with cakes and biscuits).

“Considering mixtures of additives is interesting because they are rarely consumed in isolation; as the study shows many difficult additives are often used together.  The evidence was strong that consuming additives associated with sugary and sweetened drinks was particularly associated with getting diabetes later in life, but there was little evidence for any particular additive or combination of additives being the main driver of that risk.

“It is difficult to study the impact of food additives using randomised controlled trials, because they are highly prevalent in our diets and the effects are likely to take many years to manifest.  So it is important to attempt to study their effects in studies like this, and to combine with evidence from other kinds of studies to understand whether and how additives might harm metabolic health.”

Prof Alan Boobis, Emeritus Professor of Toxicology, Imperial College London, said:

“My takeaway from this is that it is an observational study and as acknowledged by the authors, association does not necessarily mean causation.  The findings are important in generating hypotheses, but further investigation would be necessary to inform advice to consumers.  It is unclear whether the mixtures themselves or key components are involved, or whether, despite adjustments for other components of the diet, the mixtures are indicative of some other characteristics of the subjects.”

Prof Oliver Jones, Professor of Chemistry, RMIT University, said:

“I can see this paper leading to more scary headlines about food additives, but although the work is based on a large dataset, we need to be careful about what conclusions are drawn from it.

“As the authors themselves clearly state, the study does not prove that food additives cause diabetes.  All that is reported are slight associations between certain mixtures of some additives and the likelihood of type 2 diabetes, and there are some large caveats to this.

“Firstly, an association between two factors does not mean one caused the other; it just means there appears to be an association between them.

“Secondly, the authors didn’t measure food additive intake directly.  They relied on self-reporting of food intake from study participants and then estimated the additive intake from this.  This is a reasonable approach, but self-reported data is often inaccurate.  This means great care must be taken in interpreting the results.

“It is also not clear from the main paper how the authors classified someone as having diabetes.  Diagnosis does not seem to have been done by a medical professional but rather estimated by self-reported health data and medication use from a linked database.  This is far from conclusive.

“So, whilst this is an interesting theoretical study, people should not worry.  In the end, all that can really be said is that, based on self-reported data and estimations of possible food additive consumption and health conditions, there is a possible, small association between two specific mixtures of additives and the likelihood of type 2 diabetes, and the error bars are pretty big on even this conclusion.”

Prof Kevin McConway, Emeritus Professor of Applied Statistics, Open University, said:

“This is a complicated study in terms of the statistical and computational methods it uses.  I think its results are pretty hard to interpret.  The meaning of the word ‘mixtures’ in the findings is, I’d say, so different from the everyday meaning of the word as to be potentially pretty confusing.  The researchers, rightly, warn that their study cannot establish whether consuming particular mixtures of food additives causes the associations with type 2 diabetes that they observed.  The associations that they observed are, as the press release indicates, not very strong anyway.  Also, there are questions, that might well be important, that just can’t be answered from this research.

“I take away two things from this study.  First, there are some more indications that it may be important to consider potential associations between food additives and health by looking at several additives at once, rather than investigating them separately.  Second, looking for such associations isn’t easy, and to do it convincingly would require other types of research than those used in this study.

“I’ll try to clarify what the researchers meant by a ‘food additive mixture’.  You might expect that to mean that a participant in the study consumes a certain amount of a given set of additives, maybe two or three of them, and researchers would look at how their health is associated with consumption of this specific mixture.

“But what’s meant in this research is something wider and more complicated.  The researchers collected data on how much each of the nearly 110,000 participants consumed of well over 200 different food additives.  They then used a statistical method (called nonnegative matrix factorization) to summarize all this data into a score, for each participant, on five different scales that they called ‘mixtures’.  And they then measured the statistical association between each of these five scores and the participants’ chance of being diagnosed with type 2 diabetes over time.  They found associations between two of the scores and the risk of type 2 diabetes – the other three scores were not found to be associated with diabetes.

“The associations with diabetes risk were not particularly strong for either of these scores, though it’s difficult to explain in simple terms exactly how large they were, because of the difficulty of explaining what the actual scores are measuring.

“What makes this hard to link to an everyday idea of a ‘mixture’ is that each of the scores depends on the amounts of consumption of, potentially, a large number of different additives.  Of the two ‘mixture’ scores that were found to be associated with diabetes risk, one mainly depends on the consumption of eight different additives, and the other on 14 additives, and in fact other additives than these 8 and 14 do come into the calculation as well.

“Also, two participants could get similar scores for one of these ‘mixtures’ by actually consuming different patterns of additives.  So one participant could get a moderately high score on the first of these ‘mixtures’ by consuming food and drink containing a lot of modified starches but little or none of the other additives, while another participant could get the same score by consuming quite a lot of food containing other additives that contribute to this mixture, but very little or no modified starch.  Others could also get the same score by a different pattern of consumption of additives that contribute to this ‘mixture’, possibly not overlapping much with the consumptions of the other two participants I’ve mentioned.  In technical terms, this is an acceptable use of the term ‘mixture’, but it’s probably not what a non-scientist would think of.

“The researchers do emphasise that this study cannot establish causality.  That is, although they found associations, that is, correlations, between the scores for two of their additive ‘mixtures’ and the risk of type 2 diabetes, they can’t say that it is the additive consumption that caused the differences in diabetes risk.

“That’s for several reasons. Mainly, it’s because the study is observational.  The participants weren’t made to consume different patterns of additives by the researchers – they just ate what they would have eaten anyway, and the researchers recorded that as best they could (and there are always potential limitations on the accuracy of such recordings).  So the observed associations could really be caused by some other factors that happen to be associated with food additive consumption, and also independently associated with diabetes risk.  There’s just no way of telling what causes what, with any level of certainty, in this kind of study.

“In some circumstances, if a lot of different observational studies are all pointing in the same direction, one might be a little more confident about what’s causing what.  But this is effectively the first study looking at data in this way on a major scale.  As the researchers themselves say, in order to get good evidence on whether particular groups of food additives, when consumed alongside one another, do actually cause ill health, one would need to carry out studies of different kinds – so-called mechanistic studies, to learn more about what might actually be happening inside the body.  This study might help a little in pointing to what further studies might be most useful, but it’s an observational study that did not itself measure anything going on inside the participants’ bodies or cells.  I’m not a nutritional scientist so am not in a position to comment on how these mechanistic studies would best be done.

“The researchers did make statistical adjustments for several possibly factors that might have accounted for what they observed, and might be getting in the way of interpretations of cause and effect.  But you can never adjust for everything potentially relevant, and data on some factors will simply not be available.

“In this study there’s an obvious question of whether the differences in diabetes risk could be due to the additives in people’s food and drink, or due to the non-additive parts of the food and drink that they consumed, or indeed due to other things entirely.  After all, consuming a food additive generally involves consuming the food or drink that it’s been added to, and so will go along with consuming fats, sugars, proteins, fibre, and whatever else is in that food or drink.

“The researchers did investigate some aspects of this question, and did find limited evidence that the associations with diabetes risk depend on additives as well as other aspects of what’s in the food and drink, though I don’t feel that they really sorted this out very far.  Anyway it would be very difficult to take account of all the possible food and drink components that are not classed as additives, as well as those that are, in a single statistical set of statistical analyses.

“Interestingly, among all the detailed results, the study found a limited amount of evidence that points to why it may be important to look at additives together rather than separately. In some cases, it appeared that consuming two additives, linked to diabetes risk, had a stronger association with the diabetes risk than you’d expect from looking at the additives separately; in other cases, it went the other way, with a lower risk from the combination of additives than you might expect from looking at them separately.”

Comments from our colleagues at the Australian SMC:

Professor Ian Rae is an expert on chemicals in the environment at the School of Chemistry at the University of Melbourne. He was also an advisor to the United Nations Environment Programme on chemicals in the environment and is former President of the Royal Australian Chemical Institute

“Type 2 diabetes arises when various parts of the body becoming resistant to the normal action of insulin, which is to pack sugar away in cells.

The result is elevated blood sugar levels that can cause damage to the eyes and to organs like the liver. The chance of developing type 2 diabetes increases with age, and it is associated with increased body weight, obesity and lack of physical activity, all of which track with age, too.

Exposure to chemical substances is not believed to be a cause of type 2 diabetes. The French researchers whose work is reported in this paper were testing not a single substance but instead they surveyed the effects of mixtures of additives that are commonly included in processed food, such as starch, pectin, vegetable gums, and citric acid which is also naturally present in some foods).

They identified two mixtures – of 8 and 15 constituents, respectively – that did correlate with slight effects. Only one of the mixtures included the kind of ‘chemical suspects’ that one expects to find in such studies, the two synthetic sweeteners, aspartame and sucralose. The associations between the mixtures and the condition were very weak, and similar mixtures that included many of the same constituents showed no association. Of course, association does not equal causation.

Testing a single substance for toxicity or the ability to damage our bodies in other ways is difficult enough. Only in a very few cases have pairs of substances or small groups of substances that are chemically closely related ever been tested. The results have been ambiguous, to say the least. Testing mixtures of 8 or 15 substances is just not good science. The authors themselves suggest that ‘the potential synergies and antagonisms may be of interest in future mechanistic investigations’ but that’s really just an admission that their own approach was overly optimistic in its search for a definite cause of type 2 diabetes.

Although it has involved a lot of work – not just by the 23 authors of this paper, but by the 100,000 people who were surveyed – the results are weak. I wondered why this was ever published.”

Ian has not declared any conflicts of interest.

Dr Alan Barclay is an Honorary Associate at the University of Sydney

“This French prospective cohort study identified small associations between certain mixtures of food additives and the risk of developing type 2 diabetes.

The mixtures of additives were identified using computer algorithms. Study participants were predominantly female (79.2%), relatively young (average age 41 years), well-educated, and within the healthy weight range (average BMI 23.6 kg/m2). Ethnic background was not reported (ethical reasons cited).

Australia’s food supply is different from France’s, and it is not known how common the additive mixtures identified would be consumed in this country, and by whom.

In Australia, type 2 diabetes occurs most commonly after the age of 45 years, in overweight or obese (BMI > 25 kg/m2) people (more frequently men than women), from lower socio-economic backgrounds, and incidence (new cases) has been decreasing over the past decade.

The observed associations are both less than 20%, so residual confounding is likely a significant problem within this study.

While novel, the generalisability of this French observational study to people at risk of type 2 diabetes living in Australia is unknown.

Our food supply is regulated by Food Standards Australia New Zealand and the types and amounts of additives permitted to be added to foods and drinks is carefully assessed and reviewed on a regular basis.”

Potential conflict of interest: I consult to the National Retail Association.

Emeritus Professor Jennie Brand-Miller AM is from the School of Life and Environmental Sciences and Charles Perkins Centre at the University of Sydney, and Director of both the Sydney University Glycemic Index Research Service and Glycemic Index Foundation

“I find these results surprising because both mixtures contain substances that occur naturally in food and are recognised forms of dietary fibre (xanthan gums, guar gums and carrageenan). This means they provide fuel for our large bowel microbiome. Guar gum is a highly viscous fibre known to slow down the rate of digestion and absorption of carbohydrates, more so than any other fibre. Citric acid is found in citrus fruits, and also slows down digestion and reduces glycaemia.

Both mechanisms would therefore be expected to REDUCE the risk of type 2 diabetes, not increase it. I suspect these findings are simply chance findings because the researchers looked at so many food additives.

At present, there is a bias towards finding fault with food additives and processed foods. In Australia, all food additives other than flavours are highly regulated with substantial data to back up their safety in the amounts used in food.”

Jennie’s conflict of interest declaration: I have no direct conflicts of interest. I receive royalties from popular books about nutrition, diabetes and health. I oversee a glycemic index testing company at the USYD. I consult to the China National Research Institute of Food and Fermentation Industries, the Novo Foundation and Zoe Global.

Dr Gideon Meyerowitz-Katz is an epidemiologist and Senior Research Fellow from the University of Wollongong

“The authors here looked at whether diabetes risks were impacted by different mixtures of food additives. They found a very small increased risk of diabetes associated with two mixtures of additives, and no increase for the other three mixtures that they tested – these mixtures included a wide range of additives such as aspartame, guar gum, curcumin, and more.

The study is reasonably strong, but suffers from weaknesses in the underlying cohort. These results are entirely based on self-report, which is to say that the only information that the authors had on how many food additives people ate was how much they said they were eating. This form of self-report is notoriously unreliable and impossible to correct for in large epidemiological studies of this nature.

It’s also unclear what meaning these results have. The biggest risk increase in the study was seen for Mixture 5, which contained 14 different food additives including citric acid and paprika extract. But due to the complex methodology the authors used to create these mixtures, it’s not clear how you could implement these findings in your daily life. The closest the authors come is saying that it might be a good idea to reduce your soft drink intake, but we didn’t really need this study to know that. It’s an interesting piece of research, but it’s hard to see how the results could be used outside of a strictly research setting.”

Gideon has not declared any conflicts of interest.

Dr Evangeline Mantzioris is an Accredited Practicing Dietitian and the Program Director of Nutrition and Food Sciences at the University of South Australia

“This study has looked at the impact of commonly used additives in ultra-processed foods in our food system and their association with Type 2 diabetes. This study was conducted on a large group of over 108,000 adults in France over a 7 ½ year time period. Dietary data was collected from dietary records every 6 months, and from this the intake of additives was calculated.

The researchers found that there were two groups of food additives that were linked with an increased risk of type 2 diabetes. In the statistical analyses the researchers took into account the participants’ weight, sociodemographic factors, lifestyle practice and their diet.

The first group of food additives included modified starches, pectin, guar gum, carrageenan, polyphosphates, potassium sorbates, curcumin, and xanthan gum. The other group included citric acid, sodium citrates, phosphoric acid, sulphite ammonia caramel, acesulfame-K, aspartame, sucralose, arabic gum, malic acid, carnauba wax, paprika extract, anthocyanins, guar gum, and pectin.

However, it must be remembered that this is an observational study and not an experimental study, and hence a cause-and-effect relationship cannot be drawn from it. Additionally, the intake of food additives in the diet of the participants could not be verified by any blood or urine tests.

There is a growing evidence base of the impact of UPF [ultra-processed foods] on both physical, cognitive and mental health. As well as containing low levels of nutrients, high levels of saturated and trans fats, sugar and salt, UPF also contain food additives to improve taste and shelf life of foods. This study adds to this evidence base of the health risks associated with a high intake of UPFs.”

Evangeline has not declared any conflicts of interest.

‘Food additive mixtures and type 2 diabetes incidence: Results from the NutriNet-Santé prospective cohort’ by Marie Payen de la Garanderie et al. was published in PLOS Medicine at 19:00 UK time on Tuesday 8 April 2025. 

DOI: 10.1371/journal.pmed.1004570

Declared interests

Dr Nerys Astbury: “No conflicts.”

Prof Nita Forouhi: “None.”

Prof Tom Sanders: “I have been retired for 10 years but during my career at King’s College London, I formerly acted as consultant for companies that made artificial sweeteners and sugar substitutes.

I am a member of the Programme Advisory Committee of the Malaysia Palm Oil Board which involves the review of research projects proposed by the Malaysia government.

I also used to be a member of the Scientific Advisory Committee of the Global Dairy Platform up until 2015.

I did do some consultancy work on GRAS affirmation of high oleic palm oil for Archer Daniel Midland more than ten years ago.

My research group received oils and fats free of charge from Unilever and Archer Daniel Midland for our Food Standards Agency Research.

Tom was a member of the FAO/WHO Joint Expert Committee that recommended that trans fatty acids be removed from the human food chain.

Member of the Science Committee British Nutrition Foundation.  Honorary Nutritional Director HEART UK.

Before my retirement from King’s College London in 2014, I acted as a consultant to many companies and organisations involved in the manufacture of what are now designated ultraprocessed foods.

I used to be a consultant to the Breakfast Cereals Advisory Board of the Food and Drink Federation.

I used to be a consultant for aspartame more than a decade ago.

When I was doing research at King’ College London, the following applied: Tom does not hold any grants or have any consultancies with companies involved in the production or marketing of sugar-sweetened drinks.  In reference to previous funding to Tom’s institution: £4.5 million was donated to King’s College London by Tate & Lyle in 2006; this funding finished in 2011. This money was given to the College and was in recognition of the discovery of the artificial sweetener sucralose by Prof Hough at the Queen Elizabeth College (QEC), which merged with King’s College London. The Tate & Lyle grant paid for the Clinical Research Centre at St Thomas’ that is run by the Guy’s & St Thomas’ Trust, it was not used to fund research on sugar. Tate & Lyle sold their sugar interests to American Sugar so the brand Tate & Lyle still exists but it is no longer linked to the company Tate & Lyle PLC, which gave the money to King’s College London in 2006.”

Dr George Savva: “I have no conflict of interest.”

Prof Alan Boobis: “My interests are: until recently, chair of the UK Committee on Toxicity (COT); member of the joint Scientific Advisory Committee on Nutrition (SACN)/COT working group on plant-based drinks; member of the External Advisory Committee, Michigan State University MSU Center for Research on Ingredient Safety (CRIS); member of the Board of Directors of ILSI (International Life Sciences Institute) Europe.”

Prof Oliver Jones: “I am a Professor of Chemistry at RMIT University in Melbourne, Australia.  I don’t have any conflicts of interest to declare.  However, many years ago, I worked on a project funded by the UK Food Standards Agency on the toxicity of pesticide mixtures.”

Prof Kevin McConway: “Previously a Trustee of the SMC and a member of its Advisory Committee.”