Epidemiologic studies of artificial sweetener use in children have generally shown a positive association between artificial sweetener intake (most commonly as diet soda) and weight gain. In interpreting such studies, it is critical to consider the conditions required to support causality in such studies, including the strength of the association, consistency in findings, temporality, biological gradient, plausibility, coherence between epidemiological and laboratory findings, and strength of the dose-response relationship (
58). Based on these criteria, causality is far from established with regard to artificial sweetener use and weight gain in children. It is particularly difficult to establish causality between artificial sweetener consumption, weight gain, and metabolic abnormalities, as artificial sweetener intake is likely to be an indicator for other variables. For example, the decision to consume artificial sweeteners is often made by individuals who are concerned about their weight in an effort to reduce their caloric intake. In the case of children, this decision is frequently made by parents who are concerned about their own weight and consequently the weight of their offspring, thus further confounding the choice to use artificial sweeteners with genetic and behavioral variables.