A study links erythritol to heart attacks. Should you be concerned?

Sugar substitutes may be linked to heart attacks and strokes. Don’t throw away your stock just yet.

Sugar substitutes are ubiquitous in foods and beverages. Despite their ubiquity, scientific opinion on whether they pose health risks remains elusive. However, every now and then, a study comes out with a shocking finding that forces people to reevaluate their food stores. A study published on February 27 in the journal Nature Medicine appears to have dealt a major blow to the sweetener erythritol, with data suggesting a link between this ingredient and cardiovascular conditions such as thrombosis, stroke, and heart attack.

But before you clear your shelves of all products containing erythritol, remember that no study—including this one—should be considered the final word on whether a product is healthy or not. Research is still evolving.

The researchers recruited multiple groups of people with pre-existing heart risk factors across the United States and Europe and tracked their health over time after taking blood samples to measure the levels of various compounds in the body. Stanley Hazen, director of the Center for Cardiovascular Diagnosis and Prevention at the Cleveland Clinic Lerner Research Institute, says his team had no real intention of studying erythritol, but rather stumbled upon their new findings by accident. “Our original goal was to see if we could find compounds in the blood whose levels predicted future development of heart attacks, strokes, or death,” he says. “When we looked at the data, the most significant compound… was erythritol.” Among the 4,000 people included in the study data, those with higher levels of erythritol in their blood were more likely to have a serious heart attack within three years than those with lower levels. The study includes several other experiments to clarify the link between erythritol and heart disease—including feeding the sweetener to mice, which researchers found promotes blood clot formation, and feeding it to eight people, showing the researchers that it was still present in their blood plasma after a day of fasting. Other experiments, involving exposing blood, platelets, and plasma in the lab to erythritol, showed the same risk of clotting. In washed human platelets, an almost immediate increase in collagen viscosity was observed. The amounts of erythritol they tested in these lab experiments were “within the range of what we see in the circulation of patients,” says Hazen. “And the effect is very rapid. Just being in the presence of erythritol for a few minutes was enough to alter platelet function and make them more susceptible to clotting.”

Erythritol is one of the “natural” sugar substitutes that have emerged as an alternative to the synthetic options that have proliferated over the past half-century. This older group of artificial sugar substitutes includes sucralose (found in the original Splenda), saccharin (found in Sweet’N Low), and aspartame (found in Equal, NutraSweet, and others). While these artificial options are generally considered safe in small amounts, studies in animal models (and some observational research in humans) have linked them to varying health risks. For example, aspartame has been found to have a possible causal link to cancer, while long-term consumption of saccharin has been linked to obesity, diabetes, and other diseases in animal models.

Over the past decade or so, food manufacturers have begun favoring more “natural” types of sweeteners other than sugar to avoid these potential health problems. This category includes sweeteners such as stevia leaf and monk fruit extracts, as well as erythritol and other sugar alcohols, or polyols—similars to low-calorie substances found in fruits and plants. (If you shop at a traditional grocery store, you’re likely to find something in your kitchen that contains erythritol.) Erythritol is also popular as a keto-friendly sugar substitute for baking, known for its less artificial taste than some other sweeteners. Despite extensive research, erythritol and other polyols have not been linked to any long-term health risks or illnesses, although they may cause laxative effects and other gastrointestinal issues in the short term. But when determining how concerning the current study is, it’s important to note that the presence of erythritol in the blood before a heart attack doesn’t necessarily mean that erythritol is the culprit. Previous research has found that excess erythritol—which the body produces and metabolizes—tends to remain at higher concentrations in the blood before a heart attack, as London-based nutritionist Nicole Jess noted in an Instagram post about the study. Erythritol in the body could be an indicator of cardiometabolic disease, but it’s unclear whether this amount is determined by diet or what the body doesn’t eliminate.

Erythritol production in the body has been shown to increase when a person is under oxidative stress—a condition that often leads to disease, says Dr. Idris Mughal, a British physician with a Master’s degree in Nutrition Research. These potentially confounding variables mean that the alarming headlines about erythritol don’t always match the more complex reality, because correlation doesn’t imply causation. He says, “I think the main problem in the media was simply the common claim that consuming this sweetener increased the risk of stroke or heart attack.”

Experts also took issue with the fact that the dataset used in the analysis included only people over 60 years old, all of whom had pre-existing cardiovascular disease or were classified as at high risk.

Of course, it would be difficult to definitively link erythritol consumption to heart disease. “You wouldn’t easily do a randomized trial to try to see if it causes a heart attack,” says Hazen.

So should people ditch erythritol-laced snacks? “At this point, I would advise avoiding erythritol altogether and not worrying or being bothered by very small amounts of natural sweeteners,” such as honey or pure sugar. He believes that reducing sweets is safer and more effective than using sugar substitutes. For example, for those seeking weight loss, the data does not confirm that eliminating sugar in favor of low- or no-calorie alternatives contributes to weight loss. However, Mughal adds that excessive sugar consumption does have health risks, and he believes that “the risks associated with excessive refined sugar consumption far outweigh those of any other sweetener.”