Awareness, consumption patterns, and perceived health risks of non-sugar sweeteners among healthcare students in southern India: A cross-sectional study

Awareness, consumption patterns, and perceived health risks of non-sugar sweeteners among healthcare students in southern India: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Awareness, consumption patterns, and perceived health risks of non-sugar sweeteners among healthcare students in southern India: A cross-sectional study Jithin Surendran, Karthika Suresh, Rajath Rao, Prasanna Mithra, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8681082/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The widespread use of non-sugar sweeteners (NSS) is a major public health concern, given the potential risks to metabolic and cardiovascular health. This study aims to assess the awareness, perceptions, and consumption patterns of NSS while exploring their potential health effects among healthcare students. Methods This cross-sectional study was conducted among 387 adult health care students. The study tool captured details regarding awareness and perception levels, consumption patterns, side effects and health-seeking behavior toward NSS. The proportions of awareness, perception, consumption patterns and side effects of NSSs were reported with 95% CI. Univariate and multivariable analysis were performed, and the adjusted odds ratio was reported. Results Out of the 387 students, 73.6% (95% CI: 69.1–77.8) were aware of the NSS by name; only 59 [15.2%, 95% CI: 12.1–19.2] knew the FDA’s acceptable daily intake limits and recognised side effects such as abdominal discomfort (61%). Diet sodas (62.8%), health bars/jellies (62.8%), and jams/preserves (41.3%) were the most consumed NSS products. Around 14.5% discussed NSS consumption with consulting physicians. Conclusion This study reveals a significant awareness gap among healthcare students regarding NSS and their long-term health effects, emphasising the need for targeted education on the health risks of NSS consumption within this population. Sugar substitutes Non-communicable diseases Obesity Nutrition Artificial sweeteners Health behavior Plain English Summary Many health-conscious individuals use non-sugar sweeteners (NSS) like stevia, aspartame to avoid calories, but their long-term consequences on metabolic health remain debated. This study surveyed 387 healthcare students in southern coastal India to evaluate their awareness and habits related to NSS/sugar substitutes. While 74% of students knew of NSS products, largely through social media, most lacked deep technical knowledge regarding the same. Only 15% were aware of official safety limits for daily intake. Despite nearly half believing NSS and sugar are equally harmful, nearly two-thirds of the participants still consumed products like diet soda, health bars. Only a small proportion of these participants discussed this with their doctors. The findings suggest a significant knowledge gap even among future medical professionals, highlighting the need for a better education on nutrition and clear product labelling to help consumers make truly informed health choices. Introduction The global prevalence of non-communicable diseases (NCDs) has emerged as a significant public health concern and thus imposes a substantial burden on healthcare systems.[ 1 ] Excessive consumption of added or free sugar, particularly from sugar-sweetened beverages (SSBs), is strongly associated with these noncommunicable diseases, such as obesity, type 2 diabetes, and downstream complications of hypertension and coronary heart disease.[ 2 , 3 ] Consequently, international health authorities, including the World Health Organization (WHO), recommend limiting total sugar intake to less than 10% of daily caloric consumption.[ 4 ] In response to this public health imperative and a desire for sweet flavors, non-sugar sweeteners (NSS), also known as artificial sweeteners (ASs), nonnutritive sweeteners (NNS) or low-calorie sweeteners (LCS), have become increasingly popular as sugar substitutes.[ 5 ] These food additives offer an intense sweet taste with minimal or no calories and are widely incorporated into an extensive range of processed foods, beverages, and even nonfood products such as toothpaste and medicines.[ 6 , 7 ] The FDA-approved, widely recognized NSSs include saccharine, sucralose, aspartame, neotame, acesulfame-K, and stevia for use in humans and are generally recognized as safe (GRAS).[ 7 ] The consumption of these NSS has substantially increased globally, with notable increases in usage among both children and adults in countries such as the United States, and beverages frequently represent a primary source of intake.[ 8 ] While NSSs were initially accepted as beneficial strategies for weight management, glycemic control, and dental health, their long-term health implications have become a subject of intense scientific and public debate.[ 9 – 11 ] Emerging research paradoxically links high NSS consumption to increased risks of metabolic disorders, including weight gain, and a higher incidence of type 2 diabetes and cardiovascular diseases, as well as overall mortality.[ 12 , 13 ] The proposed mechanisms for these potential adverse effects often involve disruption of the gut microbiota, causing dysbiosis, impaired glucose tolerance, insulin resistance, and systemic inflammation.[ 14 , 15 ] Furthermore, concerns regarding potential neurotoxicity and carcinogenicity have been raised for certain artificial sweeteners, such as aspartame, with the WHO's International Agency for Research on Cancer (IARC) classifying it as "possibly carcinogenic to humans" on the basis of minimal evidence from animal studies and human observational research.[ 16 , 17 ] Additionally, adverse pregnancy outcomes, including preterm delivery and impacts on offspring metabolism, have been associated with NSS consumption on the basis of the speculation that younger fetuses are more susceptible to interleukins that cause inflammation.[ 18 ] Despite the widespread availability and consumption of NSS, studies indicate that the general population often possesses poor knowledge, holds pessimistic attitudes, and exhibits suboptimal practices toward nonnutritive sweeteners.[ 19 ] Findings from the United Kingdom revealed that many consumers express significant concerns about potential health impacts, harbor high-risk perceptions, and demonstrate limited awareness of regulations governing NSS use.[ 20 ] This scepticism is frequently fuelled by miscommunication, the perceived "artificial" nature of some sweeteners (with natural alternatives such as stevia often perceived as safer), and conflicting scientific information.[ 21 ] However, the extensive use of NSS and research on awareness and views among university students, including those in health and science fields in India, is limited. Given these ongoing debates and the critical role healthcare students will play as future providers of health advice, it is essential to assess their awareness, consumption patterns, and perceived health risks of NSS. Their understanding needs to be robust and evidence-based to effectively guide patients, particularly those with metabolic conditions, who often rely on the NSS as a dietary tool. Additionally, Sustainable Development Goal (SDG) 3, Target 3.4 aims to reduce premature mortality from NCDs by one-third by 2030.[ 22 ] Reducing dietary sugar and NSS intake is a crucial preventive measure to achieve this target. Additionally, SDGs 2 (zero hunger) and 12 (responsible consumption and production) are indirectly related to this, which promotes healthy eating choices and policies to create a more nutritious food environment by reducing the degree of marketing of the NSS and is critical.[ 23 , 24 ] With this background, this study aimed to assess the awareness, perceptions, and consumption patterns of non-sugar sweeteners (NSS) and the perceived potential side effects and health-seeking behavior toward the use of NSS among healthcare students. Materials and methods Study design and duration This facility-based cross-sectional study was conducted over a period of six months (July to December 2024). Study setting The study was conducted in the city of Mangalore, a coastal city in the South Indian state of Karnataka. There are approximately six medical colleges and seven dental colleges in the city. The study was performed under the supervision of the Department of Community Medicine of a medical college hospital in this region and included undergraduate students enrolled in Bachelor of Medicine and Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS), and Allied Health Sciences (AHS) courses at the same university. Study population The study included all undergraduates from the 1st to 4th years of their courses, as well as interns, who were aged 18 years or older and who provided informed written consent to participate. Sample size and sampling techniques The sample size was calculated on the basis of the assumption that 50% of the subjects in the population were aware of the side effects associated with the consumption of NSS, which was used as our anticipated proportion, 5% absolute precision, and 95% confidence interval. The minimum sample size calculated was 385 students on the basis of the following formula: N= Zα2(𝑝 × 𝑞)/𝑑2 (Z = 1.96, 95% confidence interval; p = 0.50; q = 1-p = 0.50, and d is 5% absolute precision) The population proportion to the sample size was applied to 385 participants. A total of 270 were MBBS (70%) students, 75 were BDS (20%) students, and 40 were AHS (10%) students. A convenient sampling method was employed for the three distinct streams of study participants. The study protocol was approved by the Institutional Ethics Committee, followed by obtaining permission from the Heads of the Institute. Study tool and procedure The study tool was written in Google Forms in English. The data collection tool was a validated questionnaire containing open- and closed-ended questions, which included details such as sociodemographic data such as age, gender, and course; awareness level of the NSS, such as the type of NSS, side effects, and ADI of the NSS; long-term side effects, such as gastrointestinal disturbance, sugar craving, and risk of diabetes mellitus; and perceptions, such as switching to healthier alternatives; self-satisfaction with taste preferences; consumption patterns, such as the consumption of diet beverages; sugar-free food items; and health-seeking behavior; and experienced side visits. The study tool was face validated by three experts from public health and nutrition and underwent a content validity assessment from six experts from community medicine, public health, and nutrition backgrounds. The content validity index (CVI) was 0.89, which is acceptable. The tool was then pretested among 30 participants who were not a part of this study. The tool was found to have good internal reliability. The study subjects were approached through the Google form and administered via an online mode to the students, and the nature and purpose of the study were explained to them in detail at the beginning of the form. Consent from participants ≥ 18 years of age was obtained, and participants < 18 years of age were excluded. The standard definition for non-sugar sweeteners was ‘a food additive that provides a sweetness like that of sugar while containing significantly less food energy than sugar-based sweeteners, making it a zero-caloric or low-caloric sweetener’.[ 25 ] Statistical analysis The data collected were entered into MS Excel and analyzed via Jamovi version 2.6.26. Descriptive statistics are presented as frequencies and proportions with 95% CIs. The associations between various sociodemographic variables and awareness of various types of NSSs, side effects of NSSs, and consumption patterns of NSSs were analyzed via the chi-square test and/or Fisher’s exact test, and a P value < 0.05 indicated that there was a statistically significant association between the independent and dependent variables. An adjusted odds ratio with 95% CI was reported for the associations with the consumption of NSSs. An enter method/manual imputation technique was used to include the variables up to a p-value of 0.2 to construct the model. Nagelkerke’s R 2 and overall model fitness (chi-square test) are reported. Ethical considerations The study was approved by the Institutional Ethics Committee, Kastruba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India(Ref: IEC/KMC/MLR/07/2024/507 dated 17/07/2024). All necessary permissions from the heads of all streams were. taken before starting the study. The interpersonal data were kept confidential and protected. All participants had the right to withdraw at any stage of the study, and all incomplete responses were considered withdrawn and excluded from the analysis. The data are available upon request to the corresponding author. The study adhered to the principles of the Declaration of Helsinki throughout the study. The study was reported as per STROBE guidelines for a cross-sectional study of the EQUATOR network. (a ttached as a Related material) Results Sociodemographic details of the participants The study included 387 undergraduate healthcare students with a mean age of 20.5 years (SD = 1.4 years). Females accounted for 58.9% of the participants. Most participants (68.5%) resided in hostels, followed by independent houses (17.1%). The majority were MBBS students (71.5%), followed by BDS (19.4%) and AHS (9.1%). About half, 50.6% of the participants were from urban areas, and half, 50.1%, were second-year students. ( Table 1 ) Awareness and perceptions of non-sugar sweeteners and their side effects The majority, three-fourths (73.6%, 95% CI: 69.1 to 77.7%), were aware of different names of NSS, primarily through social media and advertisements (47.6%), followed by family and friends (21.5%) and healthcare professionals (4.7%). The perceptions of NSS safety were mixed: 30% of them considered it safe, 34.4% considered it unsafe, and the rest were unsure. Regarding NSSs as alternatives to natural sugar, 27.4% viewed them as better, 45.5% believed both are equally harmful, and 27.1% were uncertain. Only 15.3% (95% CI: 12.1 to 19.2%) were aware of the FDA-approved Acceptable Daily Intake (ADI) for NSS. Over half (53.5%) knew of potential NSS side effects, with perceived side effects including increased sweet cravings/risk of diabetes (64.7%), abdominal discomfort/bloating (61%), and allergic reactions (48.3%). Accurate product labeling was deemed important by 60.2% of the participants. Taste satisfaction with the NSS was reported by only 35.9% (95% CI: 31.3 to 40.8%) of the participants. A majority, nearly two-thirds (64.1%), were likely to switch to healthier alternatives. ( Table 2 ) Consumption pattern of non-sugar sweeteners Overall, 243 [62.8%, 95% CI: 57.8 to 67.4%] out of 387 consumed any amount of NSS. Preference for NSS products varied, as 8.5% always chose them, 23% sometimes chose them, 41.1% rarely chose them, and 27.4% never chose them. Only 23% (95% CI: 19.1 to 27.4%) sought NSS information on product labels. The commonly consumed NSS products included diet soda/juice and health bars/jellies/candy (62.8% each), jams/preserves (41.3%), and sugar-free TM (13.7%). Among diet beverage consumers (n = 243), nearly half (51.9%) consumed ≤ 200 ml of beverages weekly, whereas 37.4% consumed 200–600 ml of beverages. Among the sugar-free food products (n = 243), two-thirds (64.2%) consumed ≤ 200 g weekly, whereas 28.8% consumed 200–600 g weekly. Among sugar-free TM users (n = 53), stevia (32.1%) and sucralose (18.9%) were commonly consumed, although 43.4% were unaware of the specific sweetener or used others. ( Table 3 ) Health-seeking behavior of the participants and physicians' advice on non-sugar sweeteners Healthcare visits in the past year were reported as often (> 10 visits) by 10.1%, sometimes (5 to 9 visits) by 43.7%, rarely (< 4 visits) by 37.7%, and never by 8.5%. Among those who had ever visited (n = 354), common reasons included acne and hair fall (29%), gastrointestinal issues (28%), general check-ups (25.1%), endocrine disorders (9.6%), allergic disorders (5.1%), and musculoskeletal issues (3.1%). Health effects from the NSS were noted by 39%, and 14.5% discussed NSS consumption with a physician. Of these, more than half (55%) were advised to reduce intake or switch, 18% to continue, and 27% received no advice. ( Table 4 ) Associations of awareness and side effects of non-sugar sweeteners with demographic variables Awareness of NSS types was significantly associated with the course of study (p = 0.014), with MBBS students (77.6%) showing greater awareness than do BDS (61.3%) and AHS (68.6%) students. No significant associations were found with age (p = 0.532), sex (p = 0.983), year of study (p = 0.248), or nativity (p = 0.17) with respect to awareness of various NSS types. Awareness of NSS side effects was not significantly associated with any demographic variable (p > 0.05). ( Table 5 ) Associations between consumption patterns of non-sugar sweeteners and various variables Consumption patterns were significantly associated with course of study (p < 0.001), with AHS students showing greater preferences for sugar-free products (45.7% sometimes) than for MBBS (18.4% sometimes) and BDS (25.3% sometimes) students. Health-seeking behavior was associated with consumption patterns (p = 0.028), particularly for acne and hair fall (p = 0.043), but not for gastrointestinal issues (p = 0.65), general check-ups (p = 0.863), allergic disorders (p = 0.065), or endocrine disorders (p = 0.266). ( Table 6 ) Table 6 Association between consumption patterns and various variables (N = 387) Variables Consumption pattern P value Courses Always Sometime Rare Never AHS 1 (2.9%) 16 (45.7%) 11 (31.4%) 7 (20.0%) < 0.001 BDS 6 (8.0%) 19 (25.3%) 29 (38.7%) 21 (28.0%) MBBS 11 (4.0%) 51 (18.4%) 91 (32.9%) 124 (44.8%) Health seeking Behavior Often 4 (10.3%) 12 (30.8%) 9 (23.1%) 14 (35.9%) 0.028 Sometimes 5 (3.0%) 47 (27.8%) 57 (33.7%) 60 (35.5%) Rarely 6 (4.1%) 20 (13.7%) 57 (39.0%) 63 (43.2%) Never 3 (9.1%) 7 (21.2%) 8 (24.2%) 15 (45.5%) Acne and hair fall No 11 (3.9%) 56 (19.7%) 95 (33.5%) 122 (43.0%) 0.043 Yes 7 (6.8%) 30 (29.1%) 36 (35.0%) 30 (29.1%) Gastrointestinal issues No 13 (4.5%) 66 (23%) 100 (34.8%) 108 (37.6%) 0.65 Yes 5 (5%) 20 (20%) 31 (31%) 44 (44%) Allergic disorder No 18 (4.7%) 86 (22.6%) 125 (32.9%) 151 (39.7%) 0.065* Yes 0 (0.0%) 0 (0.0%) 6 (85.7%) 1 (14.3%) General checkup No 18 (4.8%) 83 (22.3%) 126 (33.8%) 146 (39.1%) 0.863 Yes 0 (0.0%) 3 (21.4%) 5 (35.7%) 6 (42.9%) Endocrine Disorder No 17 (4.5%) 86 (22.6%) 128 (33.7%) 149 (39.2%) 0.266* Yes 1 (14.3%) 0 (0.0%) 3 (42.9%) 3 (42.9%) * Fischer exact test Associates of consumption of non-sugar sweeteners According to the univariate analysis, MBBS students were 70% fewer consumers of NSSs than AHS students were (COR = 0.3, 95% CI: 0.1–0.7, p value < 0.001). Participants with a neutral perception of the importance of clear labeling of NSS products were 60% less likely to be consumers of NSSs than those who thought labeling was very unimportant. (COR: 0.4, 95% CI: 0.2–0.9, p = 0.04). After adjusting for gender, awareness of the side effects of NSSs, ever seeking information, and ever discussed with healthcare professionals, it was found that the course of the participants was independently associated with NSS consumption, with MBBS students being 70% less likely to consume NSS products than AHS students were. (AOR = 0.3, 95% CI: 0.8–3.1, p value < 0.001), with a model accuracy of 62.4% and an area under the curve of 0.639. ( Supplementary Table S1 ) Discussion The present study examined undergraduate healthcare students’ awareness, perceptions, consumption patterns, perceived health risks and health-seeking behavior toward non-sugar sweeteners, offering important new information about this crucial population. The study revealed that a high proportion of healthcare students demonstrated awareness of NSS (73.6%), primarily through social media and advertisements (47.6%). This elevated general awareness aligns with the widespread presence and aggressive marketing of these sugar substitutes by their makers, which has resulted in increased consumer knowledge and a continuous radical shift in favor of using artificial sweeteners.[ 26 ] However, a critical gap was identified in their specific knowledge, as only 15.3% were aware of the Food and Drug Administration (FDA)-approved acceptable daily intake (ADI) levels. This contrasts with the FDA's role in establishing ADIs for various NSSs to ensure safety. The acceptable daily intake (ADI) for aspartame is 50 mg/kg body weight per day in the United States and 40 mg/kg in the European Union, whereas for saccharin, the ADI is set at 5 mg/kg body weight.[ 27 ] This discrepancy between general awareness and detailed knowledge is consistent with broader population studies in which approximately half of the participants in the United Kingdom expressed a high-risk perception regarding nonnutritive sweeteners and demonstrated limited awareness of relevant regulations.[ 20 ] Furthermore, a study among university health and science students indicated that 62.3% were unable to provide an effective definition of NNS, highlighting poor in-depth knowledge.[ 6 ] Currently, many merchants deliberately conceal part of the product information to promote the product, resulting in situations in which the information of consumers and merchants is not equal. 7 The study participants rely on social media as a primary information source, which may contribute to this informational asymmetry, as such platforms can be prone to misinformation, potentially hindering informed decision-making. The perceptions of NSS safety among these future healthcare professionals were markedly mixed (30% safe, 34.4% unsafe, 35.7% unsure). This mirrors the ongoing scientific debate and public scepticism surrounding the long-term health effects of NNSs, as several organisations, such as the American Heart Association (AHA), the American Diabetes Association (ADA) and the British Dietetic Association (BDA), issued statements recommending their safety. A US survey revealed that 64% of the population is bothered by the safety of NNSs, as reported by Gardner et al.[ 28 , 29 ] A majority of the students were aware of potential side effects, such as sweet cravings, diabetes risk (64.7%), and abdominal discomfort (61%). These concerns are substantiated by a growing body of literature linking NNSs, particularly artificial types such as sucralose and aspartame, to various adverse outcomes, including altered gut microbiota composition, glucose intolerance, insulin resistance, systemic inflammation, and metabolic syndrome.[ 30 ] Among the specific NNSs used, stevia (32.1%) was most common among Sugar Free™ users, aligning with its perception as a "natural" and often safer alternative, followed by sucralose (18.9%), an artificial sweetener with documented metabolic impacts. Similarly, a survey conducted among a population with reduced sugar intake requirements revealed that natural sweeteners (45.30%), such as stevia, were the most preferred sweetener products.[ 19 ] Despite widespread awareness, the preference for sugar-free products was low (41.1% rarely, 27.4% never chose them). However, in another study, only a small percentage of participants (17.51%) reported frequently consuming nonnutritive sweeteners to replace sucrose (table sugar) in their diet, highlighting a discrepancy between preferences and actual behavior regarding sweetener consumption.[ 19 ] This could be influenced by factors such as taste preferences, unpleasant aftertaste, and personal beliefs about the risks or benefits of nonnutritive sweeteners, which may shape participants’ dietary choices.[ 31 ] However, the students reported consuming NNS-containing products, with diet soda/juice and health bars being common (62.8%). This seemingly contradictory pattern may reflect unintentional consumption due to the ubiquity of NNSs in processed foods and beverages. A study on low-calorie sweeteners (LCSs) reported that 14.5% of current consumers were unaware that the product they are consuming contains LCSs. The study also reported that foods containing LCSs were the most consumed, followed by beverages, pills, and powders.[ 32 ] Weekly consumption volumes for diet beverages (≤ 200 ml) and sugar-free foods (≤ 200 gm) were relatively low in this cohort. This contrasts with global trends showing increasing, often unintentional, consumption of NNSs, particularly in beverages. A study by Cong et al. reported that among adults, the percentage reporting consumption rose from 21.1% in 2003–2004 to 24.9% in 2009–2010, whereas among children, it increased from 7.8% to 18.9% over the same period.[ 33 ] The consumption patterns were significantly linked to the course of study (p < 0.001), with allied health sciences (AHS) students showing a greater preference for sugar-free products than MBBS students did. This highlights the potential for different educational backgrounds to influence dietary choices. Other factors associated with NSS consumption include living with obesity, white ethnicity, high physical activity levels, living for weight loss and adopting healthy lifestyle programs, and dieting.[ 32 , 34 ] The strong value placed on accurate NSS labeling (60.2%) and the high likelihood of switching to healthier alternatives (64.1%) underscore the importance of clear and transparent communication. Authoritative sources emphasize the necessity of providing reliable, evidence-based information to consumers through clear product labels and public health campaigns to counteract misinformation. Furthermore, a study performed among the UK adult population reported that even though it is mandatory to display NNS content on food labels, 83% of respondents preferred adding information about NNS on food packages, which has been deemed the suggested method for better consumer education.[ 20 ] The finding that 39% of the students reported NSS-related health effects and that 14.5% discussed these effects with physicians (with 55% advised reducing/switching) is significant. This finding indicates that despite their status as future healthcare providers, students themselves are concerned with seeking medical advice and suggesting opportunities for targeted education within healthcare curricula. Healthcare professionals play a crucial role in advising patients on NNSs, necessitating updated, evidence-based knowledge to guide individualized dietary plans. Future health professionals who are particularly involved in the treatment and management of diet-related diseases (such as type 2 diabetes and obesity) are best encouraged to advocate for the health benefits of NNS.[ 20 ] The association between health-seeking behavior and NSS consumption patterns, particularly for issues such as acne/hair fall (p = 0.043), further emphasizes the need for a holistic approach to understanding and addressing NSS impacts. This study has few strengths and limitations. A few strengths of the study are that it focuses on healthcare students who will counsel their patients in future regarding diet and health, and on a very important public health issue of unregulated use of NSS. The use of PPS sampling enhances the representativeness of the sample within the selected healthcare institutions, thereby improving the internal validity. The study is not without limitations. The cross-sectional design of the study defers the causal relationship between awareness and consumption patterns of NSS. Self-reported data on consumption patterns introduces potential recall bias and social desirability bias. Also, the assessment of the actual intake of NSS could not be measured to relate to the acceptable daily intake of NSS Conclusion This study highlights the complex relationship between healthcare students and NSSs. Nearly three out of four healthcare students were aware of various types of NSS; two out of three were likely to switch to healthier alternatives and consumed NSS in terms of diet soda/juice and health bars/jellies, respectively. While general awareness is high, specific knowledge gaps and mixed safety perceptions persist and are influenced by diverse information sources and academic training. The findings advocate for tailored educational interventions within healthcare curricula, focusing on evidence-based information regarding NNS benefits, risks, and regulatory guidelines, to empower future healthcare professionals to make informed personal choices and provide effective patient counseling. Declarations Ethics approval statement: The study was approved by the Institutional Ethics Committee, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India (Ref: IEC/KMC/MLR/07/2024/507 dated 17/07/2024). Consent to participate statement and publication: Written informed consent was obtained from all the participants regarding collecting the information for research and result dissemination in terms of publication in a standard national/international journal Conflict of interest statement: The authors have no conflicts of interest to declare. Funding sources: This study was not supported by any sponsor or funder Author contributions (CRediT statement): Conceptualisation: JS, KSaha, RR; Data curation : AS, SB, SS, JNO, RM; Data analysis : JS, KS, RR, AN; Methodology: JS, KS, KSaha, SB, PM; Supervision : PM, JS; Writing-original draft : KSaha, JS, KS, AS; Writing-review & editing : all authors [JS-Jithin Surendran; KS-Karthika Suresh, RR-Rajath Rao, PM-Prasanna Mithra, AN- AN-Aishwariya Narasimhan, KSaha-Krishanu Saha, AS-Arohi Sharma, SB-Suhanee Bhogra, SS-Shreya Shreya, JNO-Janaki Neeliyath Othayoth, RM-Riddhima Mishra] Acknowledgment The authors would like to acknowledge the dean of all the courses for permitting us to conduct the study. 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Goal 3 | Department of Economic and Social Affairs. https://sdgs.un.org/goals/goal3#targets_and_indicators Goal 2 | Department of Economic and Social Affairs. https://sdgs.un.org/goals/goal2 Goal 12 | Department of Economic and Social Affairs. https://sdgs.un.org/goals/goal12 Executive summary. in. Use of non-sugar sweeteners: WHO guideline. World Health Organization; 2023. Sharma A, Amarnath S, Thulasimani M, Ramaswamy S. Artificial sweeteners as a sugar substitute: Are they really safe? Indian J Pharmacol. 2016;48:237–40. Malik VS, Hu FB. The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases. Nat Rev Endocrinol. 2022;18:205–18. British Dietetic Assosiation. The Use of Artificial Sweeteners, Policy Statement. Gardner C, et al. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care. 2012;35:1798–808. Shon W-J, et al. Sugar-sweetened beverages exacerbate high-fat diet-induced inflammatory bowel disease by altering the gut microbiome. J Nutr Biochem. 2023;113:109254. Yunker AG, Patel R, Page KA. Effects of Non-nutritive Sweeteners on Sweet Taste Processing and Neuroendocrine Regulation of Eating Behavior. Curr Nutr Rep. 2020;9:278–89. Daher M, Fahd C, Nour AA, Sacre Y. Trends and amounts of consumption of low-calorie sweeteners: A cross-sectional study. Clin Nutr ESPEN. 2022;48:427–33. Cong W, et al. Long-term artificial sweetener acesulfame potassium treatment alters neurometabolic functions in C57BL/6J mice. PLoS ONE. 2013;8:e70257. Ali SS, et al. Prevalence and Factors Associated with the Use of Artificial Sweeteners in Nonpregnant, Nonlactating Females of Reproductive Age – A Systematic Review. Curr Dev Nutr. 2025;9:107478. Table 1 To 5 Table 1 and 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Surendran","email":"data:image/png;base64,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","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":true,"prefix":"","firstName":"Jithin","middleName":"","lastName":"Surendran","suffix":""},{"id":581682555,"identity":"3a2624ee-551b-4f1b-93d3-95774746e642","order_by":1,"name":"Karthika Suresh","email":"","orcid":"","institution":"Manipal Academy of Higher 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Education","correspondingAuthor":false,"prefix":"","firstName":"Aishwariya","middleName":"","lastName":"Narasimhan","suffix":""},{"id":581682559,"identity":"559502d4-b967-4320-92e4-e4d8243577af","order_by":5,"name":"Krishanu Saha","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Krishanu","middleName":"","lastName":"Saha","suffix":""},{"id":581682560,"identity":"109c8b05-ebdf-44d0-99f7-6e37752c8799","order_by":6,"name":"Aarohi Sharma","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Aarohi","middleName":"","lastName":"Sharma","suffix":""},{"id":581682561,"identity":"81549f83-db49-4a97-9b06-2cff68ee3bc5","order_by":7,"name":"Suhanee Bhogra","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Suhanee","middleName":"","lastName":"Bhogra","suffix":""},{"id":581682562,"identity":"262274d6-28a8-4cb6-93b6-81448356d1ae","order_by":8,"name":"Shreya Shreya","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Shreya","middleName":"","lastName":"Shreya","suffix":""},{"id":581682563,"identity":"2311a0c8-01cf-4472-bb6c-45efbd99d21c","order_by":9,"name":"Janaki Neeliyath Othayoth","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Janaki","middleName":"Neeliyath","lastName":"Othayoth","suffix":""},{"id":581682564,"identity":"71cd3e2c-8899-4789-9158-ebbe37dc2584","order_by":10,"name":"Riddhima Mishra","email":"","orcid":"","institution":"Manipal Academy of Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Riddhima","middleName":"","lastName":"Mishra","suffix":""}],"badges":[],"createdAt":"2026-01-23 16:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8681082/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8681082/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102294802,"identity":"376938ae-c32d-4fc0-8374-7cf1a58b6f63","added_by":"auto","created_at":"2026-02-10 09:58:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1171833,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8681082/v1/8e80f448-dd3a-43b6-872a-0ec9d181c9fa.pdf"},{"id":101389708,"identity":"e5baba29-96b8-4051-a9d6-02ffb2ffa336","added_by":"auto","created_at":"2026-01-29 08:08:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19298,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-8681082/v1/224477d74ee3d1d476b5c621.docx"},{"id":101389709,"identity":"2e340c8a-88f7-4416-aca8-3fb6fa25edc6","added_by":"auto","created_at":"2026-01-29 08:08:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25786,"visible":true,"origin":"","legend":"","description":"","filename":"Table1to5.docx","url":"https://assets-eu.researchsquare.com/files/rs-8681082/v1/f09a4439006de85a41536370.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Awareness, consumption patterns, and perceived health risks of non-sugar sweeteners among healthcare students in southern India: A cross-sectional study","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eMany health-conscious individuals use non-sugar sweeteners (NSS) like stevia, aspartame to avoid calories, but their long-term consequences on metabolic health remain debated. This study surveyed 387 healthcare students in southern coastal India to evaluate their awareness and habits related to NSS/sugar substitutes. While 74% of students knew of NSS products, largely through social media, most lacked deep technical knowledge regarding the same. Only 15% were aware of official safety limits for daily intake. Despite nearly half believing NSS and sugar are equally harmful, nearly two-thirds of the participants still consumed products like diet soda, health bars. Only a small proportion of these participants discussed this with their doctors. The findings suggest a significant knowledge gap even among future medical professionals, highlighting the need for a better education on nutrition and clear product labelling to help consumers make truly informed health choices.\u0026nbsp;\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe global prevalence of non-communicable diseases (NCDs) has emerged as a significant public health concern and thus imposes a substantial burden on healthcare systems.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Excessive consumption of added or free sugar, particularly from sugar-sweetened beverages (SSBs), is strongly associated with these noncommunicable diseases, such as obesity, type 2 diabetes, and downstream complications of hypertension and coronary heart disease.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Consequently, international health authorities, including the World Health Organization (WHO), recommend limiting total sugar intake to less than 10% of daily caloric consumption.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn response to this public health imperative and a desire for sweet flavors, non-sugar sweeteners (NSS), also known as artificial sweeteners (ASs), nonnutritive sweeteners (NNS) or low-calorie sweeteners (LCS), have become increasingly popular as sugar substitutes.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] These food additives offer an intense sweet taste with minimal or no calories and are widely incorporated into an extensive range of processed foods, beverages, and even nonfood products such as toothpaste and medicines.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe FDA-approved, widely recognized NSSs include saccharine, sucralose, aspartame, neotame, acesulfame-K, and stevia for use in humans and are generally recognized as safe (GRAS).[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The consumption of these NSS has substantially increased globally, with notable increases in usage among both children and adults in countries such as the United States, and beverages frequently represent a primary source of intake.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhile NSSs were initially accepted as beneficial strategies for weight management, glycemic control, and dental health, their long-term health implications have become a subject of intense scientific and public debate.[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEmerging research paradoxically links high NSS consumption to increased risks of metabolic disorders, including weight gain, and a higher incidence of type 2 diabetes and cardiovascular diseases, as well as overall mortality.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] The proposed mechanisms for these potential adverse effects often involve disruption of the gut microbiota, causing dysbiosis, impaired glucose tolerance, insulin resistance, and systemic inflammation.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFurthermore, concerns regarding potential neurotoxicity and carcinogenicity have been raised for certain artificial sweeteners, such as aspartame, with the WHO's International Agency for Research on Cancer (IARC) classifying it as \"possibly carcinogenic to humans\" on the basis of minimal evidence from animal studies and human observational research.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Additionally, adverse pregnancy outcomes, including preterm delivery and impacts on offspring metabolism, have been associated with NSS consumption on the basis of the speculation that younger fetuses are more susceptible to interleukins that cause inflammation.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eDespite the widespread availability and consumption of NSS, studies indicate that the general population often possesses poor knowledge, holds pessimistic attitudes, and exhibits suboptimal practices toward nonnutritive sweeteners.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Findings from the United Kingdom revealed that many consumers express significant concerns about potential health impacts, harbor high-risk perceptions, and demonstrate limited awareness of regulations governing NSS use.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] This scepticism is frequently fuelled by miscommunication, the perceived \"artificial\" nature of some sweeteners (with natural alternatives such as stevia often perceived as safer), and conflicting scientific information.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, the extensive use of NSS and research on awareness and views among university students, including those in health and science fields in India, is limited. Given these ongoing debates and the critical role healthcare students will play as future providers of health advice, it is essential to assess their awareness, consumption patterns, and perceived health risks of NSS. Their understanding needs to be robust and evidence-based to effectively guide patients, particularly those with metabolic conditions, who often rely on the NSS as a dietary tool. Additionally, Sustainable Development Goal (SDG) 3, Target 3.4 aims to reduce premature mortality from NCDs by one-third by 2030.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Reducing dietary sugar and NSS intake is a crucial preventive measure to achieve this target. Additionally, SDGs 2 (zero hunger) and 12 (responsible consumption and production) are indirectly related to this, which promotes healthy eating choices and policies to create a more nutritious food environment by reducing the degree of marketing of the NSS and is critical.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] With this background, this study aimed to assess the awareness, perceptions, and consumption patterns of non-sugar sweeteners (NSS) and the perceived potential side effects and health-seeking behavior toward the use of NSS among healthcare students.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and duration\u003c/h2\u003e \u003cp\u003eThis facility-based cross-sectional study was conducted over a period of six months (July to December 2024).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in the city of Mangalore, a coastal city in the South Indian state of Karnataka. There are approximately six medical colleges and seven dental colleges in the city. The study was performed under the supervision of the Department of Community Medicine of a medical college hospital in this region and included undergraduate students enrolled in Bachelor of Medicine and Bachelor of Surgery (MBBS), Bachelor of Dental Surgery (BDS), and Allied Health Sciences (AHS) courses at the same university.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study included all undergraduates from the 1st to 4th years of their courses, as well as interns, who were aged 18 years or older and who provided informed written consent to participate.\u003c/p\u003e\n\u003ch3\u003eSample size and sampling techniques\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated on the basis of the assumption that 50% of the subjects in the population were aware of the side effects associated with the consumption of NSS, which was used as our anticipated proportion, 5% absolute precision, and 95% confidence interval. The minimum sample size calculated was 385 students on the basis of the following formula:\u003c/p\u003e \u003cp\u003eN= Zα2(\u0026#119901; \u0026times; \u0026#119902;)/\u0026#119889;2 (Z\u0026thinsp;=\u0026thinsp;1.96, 95% confidence interval; p\u0026thinsp;=\u0026thinsp;0.50; q\u0026thinsp;=\u0026thinsp;1-p\u0026thinsp;=\u0026thinsp;0.50, and d is 5% absolute precision)\u003c/p\u003e \u003cp\u003eThe population proportion to the sample size was applied to 385 participants. A total of 270 were MBBS (70%) students, 75 were BDS (20%) students, and 40 were AHS (10%) students.\u003c/p\u003e \u003cp\u003eA convenient sampling method was employed for the three distinct streams of study participants. The study protocol was approved by the Institutional Ethics Committee, followed by obtaining permission from the Heads of the Institute.\u003c/p\u003e\n\u003ch3\u003eStudy tool and procedure\u003c/h3\u003e\n\u003cp\u003eThe study tool was written in Google Forms in English. The data collection tool was a validated questionnaire containing open- and closed-ended questions, which included details such as sociodemographic data such as age, gender, and course; awareness level of the NSS, such as the type of NSS, side effects, and ADI of the NSS; long-term side effects, such as gastrointestinal disturbance, sugar craving, and risk of diabetes mellitus; and perceptions, such as switching to healthier alternatives; self-satisfaction with taste preferences; consumption patterns, such as the consumption of diet beverages; sugar-free food items; and health-seeking behavior; and experienced side visits. The study tool was face validated by three experts from public health and nutrition and underwent a content validity assessment from six experts from community medicine, public health, and nutrition backgrounds. The content validity index (CVI) was 0.89, which is acceptable. The tool was then pretested among 30 participants who were not a part of this study. The tool was found to have good internal reliability.\u003c/p\u003e \u003cp\u003eThe study subjects were approached through the Google form and administered via an online mode to the students, and the nature and purpose of the study were explained to them in detail at the beginning of the form. Consent from participants\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age was obtained, and participants\u0026thinsp;\u0026lt;\u0026thinsp;18 years of age were excluded.\u003c/p\u003e \u003cp\u003eThe standard definition for non-sugar sweeteners was \u0026lsquo;a food additive that provides a sweetness like that of sugar while containing significantly less food energy than sugar-based sweeteners, making it a zero-caloric or low-caloric sweetener\u0026rsquo;.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data collected were entered into MS Excel and analyzed via Jamovi version 2.6.26. Descriptive statistics are presented as frequencies and proportions with 95% CIs. The associations between various sociodemographic variables and awareness of various types of NSSs, side effects of NSSs, and consumption patterns of NSSs were analyzed via the chi-square test and/or Fisher\u0026rsquo;s exact test, and a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated that there was a statistically significant association between the independent and dependent variables. An adjusted odds ratio with 95% CI was reported for the associations with the consumption of NSSs. An enter method/manual imputation technique was used to include the variables up to a p-value of 0.2 to construct the model. Nagelkerke\u0026rsquo;s R\u003csup\u003e2\u003c/sup\u003e and overall model fitness (chi-square test) are reported.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe study was approved by the Institutional Ethics Committee, Kastruba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India(Ref: IEC/KMC/MLR/07/2024/507 dated 17/07/2024). All necessary permissions from the heads of all streams were. taken before starting the study. The interpersonal data were kept confidential and protected. All participants had the right to withdraw at any stage of the study, and all incomplete responses were considered withdrawn and excluded from the analysis. The data are available upon request to the corresponding author. The study adhered to the principles of the Declaration of Helsinki throughout the study.\u003c/p\u003e \u003cp\u003eThe study was reported as per STROBE guidelines for a cross-sectional study of the EQUATOR network. (a\u003cb\u003ettached as a Related material)\u003c/b\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003eSociodemographic details of the participants\u003c/h2\u003e\n \u003cp\u003eThe study included 387 undergraduate healthcare students with a mean age of 20.5 years (SD = 1.4 years). Females accounted for 58.9% of the participants. Most participants (68.5%) resided in hostels, followed by independent houses (17.1%). The majority were MBBS students (71.5%), followed by BDS (19.4%) and AHS (9.1%). About half, 50.6% of the participants were from urban areas, and half, 50.1%, were second-year students. \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;1\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003eAwareness and perceptions of non-sugar sweeteners and their side effects\u003c/h2\u003e\n \u003cp\u003eThe majority, three-fourths (73.6%, 95% CI: 69.1 to 77.7%), were aware of different names of NSS, primarily through social media and advertisements (47.6%), followed by family and friends (21.5%) and healthcare professionals (4.7%). The perceptions of NSS safety were mixed: 30% of them considered it safe, 34.4% considered it unsafe, and the rest were unsure. Regarding NSSs as alternatives to natural sugar, 27.4% viewed them as better, 45.5% believed both are equally harmful, and 27.1% were uncertain. Only 15.3% (95% CI: 12.1 to 19.2%) were aware of the FDA-approved Acceptable Daily Intake (ADI) for NSS. Over half (53.5%) knew of potential NSS side effects, with perceived side effects including increased sweet cravings/risk of diabetes (64.7%), abdominal discomfort/bloating (61%), and allergic reactions (48.3%). Accurate product labeling was deemed important by 60.2% of the participants. Taste satisfaction with the NSS was reported by only 35.9% (95% CI: 31.3 to 40.8%) of the participants. A majority, nearly two-thirds (64.1%), were likely to switch to healthier alternatives. \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;2\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003eConsumption pattern of non-sugar sweeteners\u003c/h2\u003e\n \u003cp\u003eOverall, 243 [62.8%, 95% CI: 57.8 to 67.4%] out of 387 consumed any amount of NSS. Preference for NSS products varied, as 8.5% always chose them, 23% sometimes chose them, 41.1% rarely chose them, and 27.4% never chose them. Only 23% (95% CI: 19.1 to 27.4%) sought NSS information on product labels. The commonly consumed NSS products included diet soda/juice and health bars/jellies/candy (62.8% each), jams/preserves (41.3%), and sugar-free TM (13.7%). Among diet beverage consumers (n = 243), nearly half (51.9%) consumed ≤ 200 ml of beverages weekly, whereas 37.4% consumed 200–600 ml of beverages. Among the sugar-free food products (n = 243), two-thirds (64.2%) consumed ≤ 200 g weekly, whereas 28.8% consumed 200–600 g weekly. Among sugar-free TM users (n = 53), stevia (32.1%) and sucralose (18.9%) were commonly consumed, although 43.4% were unaware of the specific sweetener or used others. \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;3\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003eHealth-seeking behavior of the participants and physicians' advice on non-sugar sweeteners\u003c/h2\u003e\n \u003cp\u003eHealthcare visits in the past year were reported as often (\u0026gt; 10 visits) by 10.1%, sometimes (5 to 9 visits) by 43.7%, rarely (\u0026lt; 4 visits) by 37.7%, and never by 8.5%. Among those who had ever visited (n = 354), common reasons included acne and hair fall (29%), gastrointestinal issues (28%), general check-ups (25.1%), endocrine disorders (9.6%), allergic disorders (5.1%), and musculoskeletal issues (3.1%). Health effects from the NSS were noted by 39%, and 14.5% discussed NSS consumption with a physician. Of these, more than half (55%) were advised to reduce intake or switch, 18% to continue, and 27% received no advice. \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;4\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eAssociations of awareness and side effects of non-sugar sweeteners with demographic variables\u003c/h2\u003e\n \u003cp\u003eAwareness of NSS types was significantly associated with the course of study (p = 0.014), with MBBS students (77.6%) showing greater awareness than do BDS (61.3%) and AHS (68.6%) students. No significant associations were found with age (p = 0.532), sex (p = 0.983), year of study (p = 0.248), or nativity (p = 0.17) with respect to awareness of various NSS types. Awareness of NSS side effects was not significantly associated with any demographic variable (p \u0026gt; 0.05). \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;5\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003eAssociations between consumption patterns of non-sugar sweeteners and various variables\u003c/h2\u003e\n \u003cp\u003eConsumption patterns were significantly associated with course of study (p \u0026lt; 0.001), with AHS students showing greater preferences for sugar-free products (45.7% sometimes) than for MBBS (18.4% sometimes) and BDS (25.3% sometimes) students. Health-seeking behavior was associated with consumption patterns (p = 0.028), particularly for acne and hair fall (p = 0.043), but not for gastrointestinal issues (p = 0.65), general check-ups (p = 0.863), allergic disorders (p = 0.065), or endocrine disorders (p = 0.266). \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;6\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eAssociation between consumption patterns and various variables (N = 387)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eConsumption pattern\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCourses\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSometime\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRare\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAHS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e16 (45.7%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e11 (31.4%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e7 (20.0%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBDS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e6 (8.0%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e19 (25.3%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e29 (38.7%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e21 (28.0%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMBBS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e11 (4.0%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e51 (18.4%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e91 (32.9%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e124 (44.8%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth seeking Behavior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (35.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (33.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (35.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (13.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (43.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (24.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcne and hair fall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (19.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95 (33.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e122 (43.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrointestinal issues\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (34.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e108 (37.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAllergic disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e125 (32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151 (39.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.065*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral checkup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (22.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e126 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e146 (39.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.863\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndocrine Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e86 (22.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128 (33.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e149 (39.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.266*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e* Fischer exact test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eAssociates of consumption of non-sugar sweeteners\u003c/h2\u003e\n \u003cp\u003eAccording to the univariate analysis, MBBS students were 70% fewer consumers of NSSs than AHS students were (COR = 0.3, 95% CI: 0.1–0.7, p value \u0026lt; 0.001). Participants with a neutral perception of the importance of clear labeling of NSS products were 60% less likely to be consumers of NSSs than those who thought labeling was very unimportant. (COR: 0.4, 95% CI: 0.2–0.9, p = 0.04). After adjusting for gender, awareness of the side effects of NSSs, ever seeking information, and ever discussed with healthcare professionals, it was found that the course of the participants was independently associated with NSS consumption, with MBBS students being 70% less likely to consume NSS products than AHS students were. (AOR = 0.3, 95% CI: 0.8–3.1, p value \u0026lt; 0.001), with a model accuracy of 62.4% and an area under the curve of 0.639. (\u003cstrong\u003eSupplementary Table S1\u003c/strong\u003e)\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study examined undergraduate healthcare students\u0026rsquo; awareness, perceptions, consumption patterns, perceived health risks and health-seeking behavior toward non-sugar sweeteners, offering important new information about this crucial population.\u003c/p\u003e \u003cp\u003eThe study revealed that a high proportion of healthcare students demonstrated awareness of NSS (73.6%), primarily through social media and advertisements (47.6%). This elevated general awareness aligns with the widespread presence and aggressive marketing of these sugar substitutes by their makers, which has resulted in increased consumer knowledge and a continuous radical shift in favor of using artificial sweeteners.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, a critical gap was identified in their specific knowledge, as only 15.3% were aware of the Food and Drug Administration (FDA)-approved acceptable daily intake (ADI) levels. This contrasts with the FDA's role in establishing ADIs for various NSSs to ensure safety. The acceptable daily intake (ADI) for aspartame is 50 mg/kg body weight per day in the United States and 40 mg/kg in the European Union, whereas for saccharin, the ADI is set at 5 mg/kg body weight.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] This discrepancy between general awareness and detailed knowledge is consistent with broader population studies in which approximately half of the participants in the United Kingdom expressed a high-risk perception regarding nonnutritive sweeteners and demonstrated limited awareness of relevant regulations.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Furthermore, a study among university health and science students indicated that 62.3% were unable to provide an effective definition of NNS, highlighting poor in-depth knowledge.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCurrently, many merchants deliberately conceal part of the product information to promote the product, resulting in situations in which the information of consumers and merchants is not equal.\u003csup\u003e7\u003c/sup\u003e The study participants rely on social media as a primary information source, which may contribute to this informational asymmetry, as such platforms can be prone to misinformation, potentially hindering informed decision-making.\u003c/p\u003e \u003cp\u003eThe perceptions of NSS safety among these future healthcare professionals were markedly mixed (30% safe, 34.4% unsafe, 35.7% unsure). This mirrors the ongoing scientific debate and public scepticism surrounding the long-term health effects of NNSs, as several organisations, such as the American Heart Association (AHA), the American Diabetes Association (ADA) and the British Dietetic Association (BDA), issued statements recommending their safety. A US survey revealed that 64% of the population is bothered by the safety of NNSs, as reported by Gardner et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA majority of the students were aware of potential side effects, such as sweet cravings, diabetes risk (64.7%), and abdominal discomfort (61%). These concerns are substantiated by a growing body of literature linking NNSs, particularly artificial types such as sucralose and aspartame, to various adverse outcomes, including altered gut microbiota composition, glucose intolerance, insulin resistance, systemic inflammation, and metabolic syndrome.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Among the specific NNSs used, stevia (32.1%) was most common among Sugar Free\u0026trade; users, aligning with its perception as a \"natural\" and often safer alternative, followed by sucralose (18.9%), an artificial sweetener with documented metabolic impacts. Similarly, a survey conducted among a population with reduced sugar intake requirements revealed that natural sweeteners (45.30%), such as stevia, were the most preferred sweetener products.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDespite widespread awareness, the preference for sugar-free products was low (41.1% rarely, 27.4% never chose them). However, in another study, only a small percentage of participants (17.51%) reported frequently consuming nonnutritive sweeteners to replace sucrose (table sugar) in their diet, highlighting a discrepancy between preferences and actual behavior regarding sweetener consumption.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] This could be influenced by factors such as taste preferences, unpleasant aftertaste, and personal beliefs about the risks or benefits of nonnutritive sweeteners, which may shape participants\u0026rsquo; dietary choices.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHowever, the students reported consuming NNS-containing products, with diet soda/juice and health bars being common (62.8%). This seemingly contradictory pattern may reflect unintentional consumption due to the ubiquity of NNSs in processed foods and beverages. A study on low-calorie sweeteners (LCSs) reported that 14.5% of current consumers were unaware that the product they are consuming contains LCSs. The study also reported that foods containing LCSs were the most consumed, followed by beverages, pills, and powders.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWeekly consumption volumes for diet beverages (\u0026le;\u0026thinsp;200 ml) and sugar-free foods (\u0026le;\u0026thinsp;200 gm) were relatively low in this cohort. This contrasts with global trends showing increasing, often unintentional, consumption of NNSs, particularly in beverages. A study by Cong et al. reported that among adults, the percentage reporting consumption rose from 21.1% in 2003\u0026ndash;2004 to 24.9% in 2009\u0026ndash;2010, whereas among children, it increased from 7.8% to 18.9% over the same period.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] The consumption patterns were significantly linked to the course of study (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with allied health sciences (AHS) students showing a greater preference for sugar-free products than MBBS students did. This highlights the potential for different educational backgrounds to influence dietary choices. Other factors associated with NSS consumption include living with obesity, white ethnicity, high physical activity levels, living for weight loss and adopting healthy lifestyle programs, and dieting.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe strong value placed on accurate NSS labeling (60.2%) and the high likelihood of switching to healthier alternatives (64.1%) underscore the importance of clear and transparent communication. Authoritative sources emphasize the necessity of providing reliable, evidence-based information to consumers through clear product labels and public health campaigns to counteract misinformation. Furthermore, a study performed among the UK adult population reported that even though it is mandatory to display NNS content on food labels, 83% of respondents preferred adding information about NNS on food packages, which has been deemed the suggested method for better consumer education.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe finding that 39% of the students reported NSS-related health effects and that 14.5% discussed these effects with physicians (with 55% advised reducing/switching) is significant. This finding indicates that despite their status as future healthcare providers, students themselves are concerned with seeking medical advice and suggesting opportunities for targeted education within healthcare curricula. Healthcare professionals play a crucial role in advising patients on NNSs, necessitating updated, evidence-based knowledge to guide individualized dietary plans. Future health professionals who are particularly involved in the treatment and management of diet-related diseases (such as type 2 diabetes and obesity) are best encouraged to advocate for the health benefits of NNS.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe association between health-seeking behavior and NSS consumption patterns, particularly for issues such as acne/hair fall (p\u0026thinsp;=\u0026thinsp;0.043), further emphasizes the need for a holistic approach to understanding and addressing NSS impacts.\u003c/p\u003e\u003cp\u003eThis study has few strengths and limitations. A few strengths of the study are that it focuses on healthcare students who will counsel their patients in future regarding diet and health, and on a very important public health issue of unregulated use of NSS. The use of PPS sampling enhances the representativeness of the sample within the selected healthcare institutions, thereby improving the internal validity. The study is not without limitations. The cross-sectional design of the study defers the causal relationship between awareness and consumption patterns of NSS. Self-reported data on consumption patterns introduces potential recall bias and social desirability bias. Also, the assessment of the actual intake of NSS could not be measured to relate to the acceptable daily intake of NSS\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the complex relationship between healthcare students and NSSs. Nearly three out of four healthcare students were aware of various types of NSS; two out of three were likely to switch to healthier alternatives and consumed NSS in terms of diet soda/juice and health bars/jellies, respectively. While general awareness is high, specific knowledge gaps and mixed safety perceptions persist and are influenced by diverse information sources and academic training. The findings advocate for tailored educational interventions within healthcare curricula, focusing on evidence-based information regarding NNS benefits, risks, and regulatory guidelines, to empower future healthcare professionals to make informed personal choices and provide effective patient counseling.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval statement:\u0026nbsp;\u003c/strong\u003eThe study was approved by the Institutional Ethics Committee, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, India (Ref: IEC/KMC/MLR/07/2024/507 dated 17/07/2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate statement and publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all the participants regarding collecting the information for research and result dissemination in terms of publication in a standard national/international journal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement:\u0026nbsp;\u003c/strong\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u0026nbsp;\u003c/strong\u003eThis study was not supported by any sponsor or funder\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions (CRediT statement):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualisation:\u003c/strong\u003e JS, KSaha, RR; \u003cstrong\u003eData curation\u003c/strong\u003e: AS, SB, SS, JNO, RM; \u003cstrong\u003eData analysis\u003c/strong\u003e: JS, KS, RR, AN; \u003cstrong\u003eMethodology:\u003c/strong\u003e JS, KS, KSaha, SB, PM; \u003cstrong\u003eSupervision\u003c/strong\u003e: PM, JS; \u003cstrong\u003eWriting-original draft\u003c/strong\u003e: KSaha, JS, KS, AS; \u003cstrong\u003eWriting-review \u0026amp; editing\u003c/strong\u003e: all authors\u003c/p\u003e\n\u003cp\u003e[JS-Jithin Surendran; KS-Karthika Suresh, RR-Rajath Rao, PM-Prasanna Mithra, AN- AN-Aishwariya Narasimhan, KSaha-Krishanu Saha, AS-Arohi Sharma, SB-Suhanee Bhogra, SS-Shreya Shreya, JNO-Janaki Neeliyath Othayoth, RM-Riddhima Mishra]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the dean of all the courses for permitting us to conduct the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReporting guidelines:\u0026nbsp;\u003c/strong\u003eSTROBE checklist by the Equator network was followed for reporting the manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe data that supports the study findings of this study are not publicly available as it is from a single university, but the data will be shared upon request to the corresponding author via email\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHaslam DW, James WPT, Obesity. 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Effects of consuming sugars and alternative sweeteners during pregnancy on maternal and child health: evidence for a secondhand sugar effect. \u003cem\u003eProc. Nutr. Soc.\u003c/em\u003e 78, 262\u0026ndash;271 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Q, Zhang Y, Li H. Knowledge, attitude, and practice toward non-nutritive sweeteners among the population with reduced sugar intake requirement. Front Nutr 10, (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarhat G, Dewison F, Stevenson L. Knowledge and Perceptions of Non-Nutritive Sweeteners Within the UK Adult Population. Nutrients. 2021;13:444.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarela P, Fiszman SM. Exploring consumers\u0026rsquo; knowledge and perceptions of hydrocolloids used as food additives and ingredients. Food Hydrocoll. 2013;30:477\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoal 3 | Department of Economic and Social Affairs. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sdgs.un.org/goals/goal3#targets_and_indicators\u003c/span\u003e\u003cspan address=\"https://sdgs.un.org/goals/goal3#targets_and_indicators\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoal 2 | Department of Economic and Social Affairs. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sdgs.un.org/goals/goal2\u003c/span\u003e\u003cspan address=\"https://sdgs.un.org/goals/goal2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoal 12 | Department of Economic and Social Affairs. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sdgs.un.org/goals/goal12\u003c/span\u003e\u003cspan address=\"https://sdgs.un.org/goals/goal12\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExecutive summary. in. 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Curr Dev Nutr. 2025;9:107478.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1 To 5","content":"\u003cp\u003eTable 1 and 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sugar substitutes, Non-communicable diseases, Obesity, Nutrition, Artificial sweeteners, Health behavior","lastPublishedDoi":"10.21203/rs.3.rs-8681082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8681082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe widespread use of non-sugar sweeteners (NSS) is a major public health concern, given the potential risks to metabolic and cardiovascular health. This study aims to assess the awareness, perceptions, and consumption patterns of NSS while exploring their potential health effects among healthcare students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted among 387 adult health care students. The study tool captured details regarding awareness and perception levels, consumption patterns, side effects and health-seeking behavior toward NSS. The proportions of awareness, perception, consumption patterns and side effects of NSSs were reported with 95% CI. Univariate and multivariable analysis were performed, and the adjusted odds ratio was reported.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of the 387 students, 73.6% (95% CI: 69.1\u0026ndash;77.8) were aware of the NSS by name; only 59 [15.2%, 95% CI: 12.1\u0026ndash;19.2] knew the FDA\u0026rsquo;s acceptable daily intake limits and recognised side effects such as abdominal discomfort (61%). Diet sodas (62.8%), health bars/jellies (62.8%), and jams/preserves (41.3%) were the most consumed NSS products. Around 14.5% discussed NSS consumption with consulting physicians.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study reveals a significant awareness gap among healthcare students regarding NSS and their long-term health effects, emphasising the need for targeted education on the health risks of NSS consumption within this population.\u003c/p\u003e","manuscriptTitle":"Awareness, consumption patterns, and perceived health risks of non-sugar sweeteners among healthcare students in southern India: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 08:08:02","doi":"10.21203/rs.3.rs-8681082/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe491ec4-43e8-4dbb-b06f-ac088e70093c","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-31T00:53:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-29 08:08:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8681082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8681082","identity":"rs-8681082","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}