Emilia Ruggiero

Background: Non-nutritive sweeteners (NNS) are chemical substances developed by the food industry to reduce sugar and calories while preserving sweetness. Epidemiological studies have indicated a potential increased risk of certain cancers, including breast cancer (BC), associated with NNS consumption. However, the evidence has exclusively relied on self-reported dietary information rather than objective measurements of NNSs. We examined the association of urinary concentrations of NNS with BC risk in women from the large Moli-sani Study. Methods: Using a case-cohort design, a sample of 988 middle-aged women (mean age 55 ± 12 y) was randomly selected as a sub-cohort and compared to 272 women with incident BC (38 premenopausal and 234 postmenopausal). A total of 6 commonly used NNSs (i.e., aspartame, acesulfame, saccharin, sucralose, cyclamate, and steviol glycosides) were measured through liquid chromatography–mass spectrometry in spot urine samples (creatinine-adjusted concentrations; µg/mg) collected at baseline (2005–2010). The multivariable hazard ratios (HRs) were estimated using weighted Cox regression models for the case-cohort design, with each NNS modelled as a binary variable (i.e., presence vs. absence). The sum of these values produced a total urinary NNS score, which could range from 0 to 6, and was further categorised as low (0–1) or high (2–5). Results: The predominant NNS detected in urine was saccharin (E954), contributing to 77% of total NNSs, followed by steviol glycosides (E960;11%). In multivariable-adjusted Cox analyses, neither individual NNSs nor total NNS urinary concentrations were associated with overall BC risk (HR = 1.09; 95% CI 0.80–1.48 for high vs. low). However, the presence of sucralose (E955) was directly linked to premenopausal BC (HR = 5.90; 95% CI 1.44–24.20; p = 0.014), although this estimate was based on only 38 cases and was imprecise. Conclusions: Urinary NNS concentrations were not associated with overall BC risk. The observed association between urinary sucralose and premenopausal BC should be considered exploratory and hypothesis-generating and requires independent replication.

The planetary health diet proposed by the EAT-Lancet Commission provides a global framework to integrate human health and environmental sustainability through plant-based dietary patterns. Its 2025 update refined quantitative targets and emphasised the need for regional adaptation. This study compares the EAT-Lancet reference diets, the FAO/WHO Sustainable Healthy Diets, and Mediterranean dietary models represented by national guidelines from Italy, Spain, Greece, and Portugal, alongside the Italian Mediterranean Diet Pyramid proposed by the Italian Society of Human Nutrition. Quantitative recommendations were harmonised into weekly intakes, and qualitative features were systematically analysed. Overall, strong convergence was observed, particularly for whole grains, fruits, vegetables, and unsaturated fats. However, the EAT-Lancet model recommends higher intakes of legumes and nuts than the Mediterranean guidelines. Differences also emerged for dairy products and olive oil, reflecting regional adaptations. The Mediterranean Diet represents a culturally grounded and feasible model for translating planetary health principles into practice.

This file shows associations of group-specific ultra-processed food (UPF) intake with cancer and non-CVD/non-cancer mortality among cancer survivors in the Moli-sani Study cohort. Footnotes describe the multivariable Cox model covariates and the modeling approach for each UPF group.

This file shows the contribution (%) of each food group to total ultra-processed food (UPF) intake among cancer survivors (n = 802) from the Moli-sani Study cohort in Italy (2005–2010). Values represent the mean percentage contribution of individual food groups to total UPF consumption.

This file presents the distribution of baseline cancer sites among participants in the Moli-sani Study cohort, overall and by levels of ultra-processed food (UPF) consumption.

This file lists ultra-processed foods and their assigned food group categories used in the analysis of the Moli-sani Study cohort.

This file shows associations of group-specific ultra-processed food (UPF) intake with all-cause and cardiovascular disease (CVD) mortality among cancer survivors in the Moli-sani Study cohort. Footnotes describe the multivariable Cox model covariates and the modeling approach for each UPF group.

This file shows subgroup and sensitivity analyses for the association of ultra-processed food (UPF) consumption with all-cause and cancer mortality among cancer survivors in the Moli-sani Study cohort. Footnotes describe the multivariable Cox models, covariates, and definitions of subgroups and sensitivity analyses.