Erythritol, a popular artificial sweetener, may be linked to increased risk of heart attack, stroke, and blood clotting, according to a new study published in Nature Medicine. But many experts have been quick to point out that more evidence is needed before these risks can be directly tied to the sweetener.

Study details and key findings

Erythritol is a sugar alcohol that naturally occurs in low amounts in many fruits and vegetables. It is considered a zero-calorie sweetener and does not impact blood glucose. Because of this, it has become a popular artificial sweetener for many low-calorie, low-carb, and stevia and keto products, some of which are recommended for people with diabetes.

Researchers from Cleveland Clinic analyzed blood samples from 1,157 participants who had a risk of heart disease to determine whether there were chemical compounds that could predict their risk of heart attack, stroke, or death within the next three years.

Based on this analysis, the researchers determined that erythritol was most associated with an increased risk of heart attacks among the participants. Although the body naturally creates erythritol in low amounts, the levels measured in the participants were much higher.

To confirm the findings, the researchers analyzed two separate patient cohorts, including one with 2,149 participants from the United States and another with 859 participants from Europe. Overall, there were similar risks in both groups, with higher levels of erythritol increasing the risk of heart attacks, strokes, and other cardiac events.

"If your blood level of erythritol was in the top 25 percent compared to the bottom 25 percent, there was about a two-fold higher risk for heart attack and stroke," said Stanley Hazen, director of the Center for Cardiovascular Diagnostics and Prevention at Cleveland Clinic's Lerner Research Institute and the study's lead author. "It's on par with the strongest of cardiac risk factors, like diabetes."

The researchers also found that the sweetener appeared to cause blood to clot in laboratory experiments and may have increased the risk of clotting in mice. Oftentimes, heart attacks and strokes begin as clotted blood vessels.

After that, the researchers tested the effect of erythritol in eight volunteers, who were asked to drink a beverage with 30 grams of the sweetener, or the amount that might be found in a pint of low-sugar ice cream.

Using blood tests, researchers tracked the participants' erythritol levels and clotting risks and found that levels of the sweetener remained heightened even after three days, which could lead to an increased risk of clots.

"Thirty grams was enough to make blood levels of erythritol go up a thousandfold," Hazen said. "It remained elevated above the threshold necessary to trigger and heighten clotting risk for the following two to three days."

Commentary

According to Andrew Freeman, director of cardiovascular prevention and wellness at National Jewish Health, said the study "certainly sounds an alarm" about the potential risks of erythritol.

"Obviously, more research is needed, but in an abundance of caution, it might make sense to limit erythritol in your diet for now," Freeman said.

Similarly, Hazen said he believed that "there's sufficient data here to say stay away from erythritol until more studies are done," particularly among people "with existing cardiac disease or people with diabetes" who have an increased risk of clotting, heart attack, and stroke.

However, other nutrition researchers were more skeptical of the study's findings, saying that conditions that lead to heart disease might also result in high levels of erythritol in the blood.

Robert Rankin, executive director of the Calorie Control Council, said that the study's findings "are contrary to decades of scientific research showing reduced-calorie sweeteners like erythritol are safe, as evidenced by global regulatory permissions for their use in foods and beverages."

He also noted that the findings "should not be extrapolated to the general population, as the participants in the intervention were already at increased risk for cardiovascular events."

Some researchers have also said that consuming added sugar instead of artificial sweeteners could lead to even more serious health consequences.

"If you're a diabetic and you have a choice between eating sugar and eating this [erythritol], I would put my bets on this," said Karen Aspry, an associate professor of medicine at Brown University and chair of the American College of Cardiology's nutrition and lifestyle working group, adding that it's best for people to eat fruit if they want something sweet.

Overall, health experts have underscored a need for further research into erythritol and other artificial sweeteners. According to the Washington Post, the potential benefits and downsides of artificial sweeteners have been debated for years, and findings continue to be generally inconclusive.

"We have work to do on every single one of the artificial sweeteners," said Kimber Stanhope, a research nutritional biologist at the University of California, Davis. "It's ridiculous how understudied they are." (Herper, STAT, 2/27; LaMotte, CNN, 2/28; Weintraub, USA Today, 2/27; Ables, Washington Post, 2/28; Sforza, The Hill, 2/27; Etienne, People, 2/27)