March 6, 2023

Cleveland Clinic Health Essentials

This common sugar substitute is linked to heart attack and stroke.

It’s natural to think that foods labeled as “no sugar” or “less sugar” must be better for us. And artificial sweeteners can sound like a better choice than sugar, especially if you’re living with diabetes, following a keto diet or looking to lose weight.

But in truth, that might not be the case. A growing body of evidence suggests artificial sweeteners can be worse for you than table sugar.

And recent research is connecting one particular artificial sweetener, erythritol, with some very serious health risks.

“We were looking for compounds in blood that predict risk for experiencing a future heart attack or stroke. The top candidate that kept showing up was erythritol,” says Stanley Hazen, MD, PhD, a specialist in preventive cardiovascular medicine who was the senior author of the study.

Erythritol is one of the most common artificial sweeteners around. It’s a very popular ingredient in a lot of food marketed for weight loss and diabetes management.

“The very people who are being targeted for foods that contain erythritol are the same people who already are at increased risk for cardiovascular events, so this is very concerning,” he notes.

What’s even more concerning: Your foods may contain erythritol without you even realizing it.

Dr. Hazen explains what erythritol is, why it’s bad and how to avoid it.

What is erythritol?

Erythritol is a kind of artificial sweetener known as a sugar alcohol. (Though, it’s not actually sugar or alcohol in the way we typically think of those words.)

In addition to erythritol, common sugar alcohols include:

  • Xylitol.
  • Sorbitol.
  • Maltitol.
  • Mannitol.
  • Isomalt.
  • Lactitol.
  • Hydrogenated starch hydrolysates.

Sugar alcohols aren’t as sweet as sugar. Artificial sugars like aspartame (Equal®) and saccharine (Sweet and Low®), on the other hand, can be up to 700 times sweeter than sugar.

Our bodies naturally create sugar alcohols, including erythritol. Erythritol is also commercially manufactured by fermenting corn. That commercially made erythritol is added to foods — and that’s where things get messy.

“Erythritol is made by our own bodies as part of our metabolism, but at very low levels,” Dr. Hazen explains. “Naturally occurring erythritol isn’t the problem. It’s the high doses of erythritol from packaged foods that we’re seeing have very adverse effects.”

What are the dangers of erythritol?

Sugar alcohols like erythritol have long been known to cause digestive issues for some people. Dr. Hazen’s research shows that tummy trouble is just the beginning.

The study shows that erythritol is closely associated with risk for “major adverse cardiovascular events.” In other words, people who have high blood levels of erythritol are more prone to heart attacksstrokes and even death.

The researchers studied the blood of more than 4,000 people in the U.S. and Europe. They were looking for common threads that could indicate an increased risk for heart conditions. What they found was that people who had more erythritol in their blood were at elevated risk for major heart problems.

Taking it a step further, the researchers gave erythritol to animal models. They saw enhanced clot formation in models of arterial disease. They added erythritol to blood outside of the body. And found that adding erythritol to blood made it “clump up,” or form a blood clot by activating platelets.

Platelets are the tiny components in your blood that rush to the site of an injury to stop us from bleeding. That keeps you from bleeding out. But when they’re activated within our bodies, they cause blood clots, which can lead to heart attacks and strokes.

“A serving of erythritol in common ‘keto-friendly’ processed food products made blood levels of erythritol go up 1,000-fold, well above the levels linked to enhanced clotting risks,” Dr. Hazen states. “We found that the risk for clotting can be increased for several days after consumption of just one serving of artificially sweetened food containing erythritol.”

Dr. Hazen makes it clear that more studies will be needed to confirm these findings and to learn more. Importantly, the current research shows high erythritol in your blood is associated with heart attacks and strokes. It doesn’t prove erythritol actually causes those conditions.

But the results should be taken as a very serious warning sign.

“It wasn’t a modest effect. It was a very large effect that we were seeing reproduced across multiple groups and across geographies,” he says. “This research shows that we should be really cautious about eating processed foods containing erythritol.”

How is erythritol used?

Erythritol is often used as a replacement for table sugar in low-calorie and low-sugar products. It’s also included as an ingredient to “bulk up” some other artificial sweeteners.

It’s a favored additive for two big reasons. First, it’s very low in calories, which makes it ideal for “diet” foods. Second, its taste and texture are closer to table sugar than some other non-nutritive sweeteners.

Erythritol is added to many sugar substitutes that are sold as “natural” alternatives to sugar, including stevia and monk fruit sweeteners. That includes products like Truvia® and Splenda Naturals Stevia®.

Sugar-free products containing erythritol are often recommended for people who have obesity, diabetes or metabolic syndrome and are looking for options to help manage their sugar or calorie intake. And those products may not say on their nutrition labels whether they include erythritol or other sugar alcohols.

How to avoid it

Here’s where it gets really tricky. You could be eating foods that contain erythritol and not even know it.

Erythritol falls into the category of Generally Recognized as Safe (GRAS) by the U.S. Food and Drug Administration (FDA). That means long-term safety studies of erythritol aren’t required currently. It also means food companies don’t have to list erythritol on their nutrition labels.

The FDA considers erythritol safe because it’s a naturally occurring compound, Dr. Hazen explains. But the problem is that the quantities it’s used for in foods are much, much higher than what is natural and known to be safe for your body.

While your foods may not state specifically that they contain erythritol, Dr. Hazen adds that it’s commonly found in items like sugar-free varieties of ice cream, candy, gum, cookies, cakes, protein bars and fruit spreads.

And there are some red flags that can be a hint your food may contain erythritol, even if it’s not listed on the nutrition label. If the package includes these words or similar claims, it may indicate your food contains erythritol:

  • Contains sugar alcohol.
  • Keto-safe or diabetes-safe.
  • No sugar (or low sugar).
  • Artificially sweetened.
  • Naturally sweetened or sweetened with natural compounds.
  • Low calorie (or no calories).

“It’s very troubling,” Dr. Hazen says. “We know that people buying these products are trying to do something good for their health by eating foods that are promoted as better for them. But in reality, they may be inadvertently increasing their risk for harm.”

One sure way to avoid erythritol is to focus your diet on whole foods. That means, natural, non-packaged foods, like fresh fruits and vegetables. And if you need something a little sweet, Dr. Hazen says signs are pointing to table sugar as the healthier choice over the artificial stuff.

“With the knowledge we have now, it’s probably better to have moderate amounts of sugar itself, or honey, as opposed to artificial sweeteners,” Dr. Hazen advises. “Until we have further studies and long-term studies on the safety of these kinds of compounds, it’s hard to say that they’re safe.”

If you have questions about how to avoid sugars and artificial sweeteners, talking with a certified dietitian and other healthcare providers can help you learn more about food choices that are appropriate for your health.