Erythritol, a non-calorie sweetener that has been linked to an increased risk of heart attack and stroke

Erythritol, a non-calorie sweetener that has been linked to an increased risk of heart attack and stroke

The popular artificial sweetener erythritol has been linked to an increased risk of heart attack and strokeNaturopathyalso found that erythritol can promote blood clotting in human whole blood and mice. More research is needed on the link between erythritol and cardiovascular health, but experts say people should consider limiting their intake of sugar and sugar substitutes.

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Erythritol, a popular zero-calorie sweetener used in many low-carb and low-calorie foods, has been linked to an increased risk of heart attack and stroke, new research suggests. This has led some experts to urge people to reduce the amount of sugar substitutes they consume.

The study, published last week in the journalNaturopathyexamined circulating erythritol levels in blood samples from over 4,000 people and found that those with the highest levels had the greatest risk of a major adverse cardiac event over a three-year period.

"We followed subjects over time and monitored who had a nonfatal heart attack or stroke or died," said lead study author Stanley Hazen, MD, PhD, a specialist in preventive cardiovascular medicine at the Cleveland ClinicHealth. “Erythritol predicted increased risks of heart attack, stroke or death in all subgroups studied.”

Although more research is needed, the news has the potential to significantly impact the production of erythritol-sweetened foods, which are often recommended for people with diabetes and obesity - and could eventually lead to new dietary guidelines around erythritol for people at risk of cardiovascular disease.

Here's what you should know and what experts recommend if the artificial sweetener is part of your daily diet.

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What is erythritol?

Although first identified in 1852, erythritol has only become mainstream in the American food supply in recent years, adding sweetness to newer beverages, oatmeal, baked goods and more.

Since it contains almost no calories or carbohydrates, the alternative sweetener has been touted as a saving grace for people on diabetic, ketogenic, or low-calorie diets. “Unlike table sugar, it has not been found to increase blood sugar or insulin levels,” Erin Palinski-Wade, RD, CDCES, author of2 day diabetes diettoldHealth.

Erythritol, which is processed by fermenting corn, is not as sweet as cane sugar, but many people find it an acceptable alternative. “It has 70% of the sweetness of table sugar, but without the aftertaste that can come with some artificial sweeteners,” Palinski-Wade said. “Because of its similar volume and sweetness, erythritol is an easy substitute for table sugar in recipes.”

In addition to these benefits, erythritol is considered a superior alternative sweetener due to its limited side effects. Because the body cannot metabolize erythritol very well, it is absorbed into the bloodstream and excreted in the urine.

"For this reason, it causes little GI distress, unlike many other sugar alcohols, which in large quantities can cause gas and bloating," Palinski-Wade said.

Humans also naturally make erythritol in small amounts, and when paired with dietary erythritol, the compound can build up in the body. “Erythritol is made in all cells, just like cholesterol,” said Dr. Hazen. “Like cholesterol, we see that erythritol is a risk marker for heart disease.”

Although alternative sweeteners such as erythritol are widely used in the American food supply, they are difficult to measure and do not have specific product labeling requirements. Ultimately, erythritol is considered generally recognized as safe (GRAS) by the FDA, indicating no need for long-term safety studies.

Erythritol linked to increased cardiovascular risk

At the beginning, Dr. Hazen and his colleagues first looked at erythritol levels in over 4,000 human blood samples from 2004 to 2011, taken from both Americans and Europeans.

In the first group of about 1,100 people who underwent cardiac risk assessment, researchers looked at erythritol levels in blood test results. The more erythritol there is in a person's blood, the higher their chance of suffering a major cardiac event such as a heart attack or stroke within three years.

Based on these results, the researchers examined additional groups - about 2,150 people in the US and more than 800 people in the UK - and found similar results. “In our validation cohorts, the top quartile of blood erythritol was approximately twice as likely to develop MACE during three years of follow-up compared to subjects in the bottom quartile,” said Marco Witkowski, MD, the study's first authorHealth.

After confirming that higher levels of erythritol in the blood led to an increased risk of cardiovascular events, researchers sought to investigate whether erythritol had an impact on platelet function or the mechanism by which blood clots form. In both human whole blood and mouse blood, supplemental erythritol induced platelet activity and increased blood clotting.

“Adding erythritol to the blood of healthy volunteers quickly alters platelet function and makes them more susceptible to clots,” said Dr. Hazen. He noted that blood clots can block the arteries leading to the heart or brain - which can then cause a heart attack or stroke - explaining the likely link between erythritol and serious cardiac events.

Finally, the researchers were curious to learn how large amounts of erythritol—such as those found in “zero-calorie” or “ketogenic” foods and drinks—affect circulating erythritol levels in the blood shortly after exposure.

After giving a group of eight people erythritol-sweetened drinks containing 30g of erythritol (a similar amount to that found in a pint of keto ice cream), the researchers observed extremely elevated levels in the blood that remained elevated for over two days.

Overall, the new research suggests a very clear link between erythritol, blood clotting and cardiovascular risk - and experts are urging further studies to examine dietary erythritol and its effects on health.

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Does this mean you should avoid erythritol?

The new research may seem alarming — especially if you knowingly consume erythritol on a regular basis — but it's important to note that it has only shown a link between erythritol and cardiovascular disease risk, not the cause. The researchers also said follow-up studies are needed to confirm the results in a larger population.

“The additional finding that increased platelet reactivity and aggregation were noted in individuals with higher circulating erythritol levels suggests a plausible mechanism of action, but this does not prove causality,” Elizabeth Klodas, MD, FACC, board-certified cardiologist, founder of the Preventive Cardiology Clinic near Minneapolis and founder of Step One Foods, saysHealth.

Palinski-Wade also noted that the study did not specifically examine dietary consumption of erythritol and that its subjects were already at risk for adverse cardiovascular events.

But Dr. Witkowski, a cardiologist and doctoral student in Dr. Hazen's lab believes his team's research warrants caution when consuming erythritol in foods. “Our studies show that at high concentrations like those in erythritol-sweetened keto foods, erythritol in the blood increases 1,000-fold upon ingestion and remains well above threshold levels associated with increased clotting risks for days,” he said.

If you have risk factors for cardiovascular disease and erythritol has been part of your diet, you may want to discuss this with your doctor - but there are not necessarily steps you need to take to address past consumption. "There is no 'antidote' to erythritol and you cannot eat what you have eaten in the past," said Dr. Klodas.

Whether you should continue to eat foods with erythritol — especially if you have risk factors for cardiovascular disease, but even if you don't — experts recommend reducing your intake.

"Regardless of whether you have risk factors for heart disease or are otherwise healthy, the more productive action would be to reduce exposure to erythritol and probably other sugar alcohols in the future," said Dr. Klodas.

As with most things, moderation is key when it comes to alternative sweeteners. “When it comes to adding sweeteners, it is best to maintain intakealladded both calorie and non-calorie sweeteners in moderation," Palinski-Wade said. "If you are at high risk for cardiovascular disease, consult your doctor and a registered dietitian to see what the best recommendation might be for you."