Erythritol, an alternative sweetener found in a wide range of products, has seen a fairly long life on the market. This article explains the connection between erythritol and stroke/ heart attack risks.

Erythritol was first discovered in the 1850s, but it wasn’t until 1990 that Japanese shelves saw it gaining traction as a new natural sweetener. [1] It eventually made its way into American products and can be found in drinks, health foods, and sweets. American and European Union regulatory agencies recognise it as safe. [2]

A new prospective study, however, has found that the popular sweetener may not be the miraculous, low-calorie sugar substitute we hoped it would be. It may even raise cardiovascular (CV) event risk, according to Cleveland Clinic research.[3]

Erythritol—a polyol or sugar alcohol—is naturally abundant in certain foods, like mushrooms, fermented foods, or grapes. It is sought for its sweetness and low-calorie content. But it’s not easy to make due to challenges in the process of chemically synthesising it. As recently as 2018, leading researchers were looking for ways to make the commercial production of erythritol more efficient. [4]

But by 2023, a study in Nature Medicine on more than 1,000 people found that elevated levels of erythritol were associated with CV event risk. [5] They found that people who had the highest erythritol levels saw double the risk of CV events compared to those with the lowest erythritol levels. 

Research published August 8 in Arteriosclerosis, Thrombosis and Vascular Biology doubled down on these findings. [2] The researchers cited recent studies reporting that erythritol is clinically associated with increased CV event risks, noting that the sweetener enhances thrombosis potential in vitro and experimental models. 

They also noted that there haven’t been any clinical trials to assess either long-term CV disease risks or short-term CV disease-relevant phenotypes concerning erythritol and that the “effects of dietary erythritol on thrombosis phenotypes in humans have not been examined.”

That’s why the study’s findings were unique, says Christopher Yi,a board-certified vascular surgeon at MemorialCare Orange Coast Medical Center in Fountain Valley, CA.  “Erythritol has been known to increase events, but there hasn’t been a direct biological link to how—so this study shows [how]—though platelet aggregation, or clotting.” 

The findings showed that dietary erythritol (30 g) resulted in a >1000-fold increase in erythritol plasma concentration, leading to enhanced “platelet reactivity in healthy volunteers, raising concerns that erythritol consumption may enhance thrombosis potential.” Specifically, it led to the release of platelet factor 4 and thrombin activator peptide 6, both of which are associated with platelet aggregation. Glucose didn’t have this effect.

Because of the findings, researchers suggested reevaluating the “Generally Recognised as Safe” designation of erythritol.

What the experts think about erythritol

Dr. Yi says that many patients use erythritol—including those on a ketogenic diet or those who simply want to limit their use of real sugar. “It’s one of the initial substitutes promoted for being a healthy alternative to sugar. It’s a popular healthy option, so it’s super concerning that it’s been shown in the studies to cause increased CV risk.”

He says that making patients aware of the potential risks is key—and that both the media and MDs have a responsibility to educate people. “But the big shift needs to come from the U.S. Food and Drug Administration (FDA),” he says. “We’ll need warnings on these products, and maybe take them off the shelves.”

An alternative sweetener that he does like? Monk fruit. “It hasn’t been shown to have adverse effects, but that’s not been fully studied,” he says. Monk fruit is Generally Recognised as Safe as well, according to a 2023 analysis of literature published in Frontiers in Nutrition. [6] 

“All the sugar substitutes haven’t been fully vetted and studied, so there’s still a lot that needs to be explored and figured out,” Dr. Yi adds. 

Dr Yi says that MDs should consistently educate patients on the negative effects of sugar, and encourage them to reduce their intake of complex carbohydrates. “We all know the effects of sugar intake in general,” he says. “Sugar initiates an inflammatory response in the blood vessels. This triggers a process that causes plaque buildup within the vessels. The plaque causes narrowing and restriction of blood vessels to vital organs, leading to heart attack and stroke and various other things.”

Regardless of the facts, he says educating patients on sugar intake is an uphill battle because it’s in everything, and it tastes good. “It’s hard for patients to avoid it,” he says. “They don’t even need to cut them out completely. Just a reduction will help,” Dr Yi says.

Phil Nimoityn, MD, clinical assistant professor of Medicine at Thomas Jefferson University, states that patients should be discerning when it comes to what they’re buying. “Food products often have ambiguous labelling, which makes it difficult to determine what supplements or chemicals are included without reading the ingredient section that is often extensive and in very small print,” he says.

Disclaimer: This story is contributed by  Lisa Marie Basile and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.