2:59pm Feb 28, 2023
A common sugar replacement called erythritol, which is used to add bulk or sweeten stevia, monkfruit and keto-reduced sugar products, has been linked to blood clotting, stroke, heart attack and death, according to a new study from the US.
"The degree of risk was not modest," said lead study author Dr Stanley Hazen, director of the Centre for Cardiovascular Diagnostics and Prevention at the Cleveland Clinic Lerner Research Institute.
People with existing risk factors for heart disease, such as diabetes, were twice as likely to experience a heart attack or stroke if they had the highest levels of erythritol in their blood, according to the study, published Monday in the journal Nature Medicine.
"If your blood level of erythritol was in the top 25 per cent compared to the bottom 25 per cent, there was about a two-fold higher risk for heart attack and stroke. It's on par with the strongest of cardiac risk factors, like diabetes," Hazen said.
Additional lab and animal research presented in the paper revealed that erythritol appeared to be causing blood platelets to clot more readily. Clots can break off and travel to the heart, triggering a heart attack, or to the brain, triggering a stroke.
"This certainly sounds an alarm," Dr Andrew Freeman, director of cardiovascular prevention and wellness at National Jewish Health, a hospital in Denver, said. Freeman was not involved in the research.
"There appears to be a clotting risk from using erythritol," he said.
"Obviously, more research is needed, but in an abundance of caution, it might make sense to limit erythritol in your diet for now."
In response to the study, the Calorie Control Council, an industry association, told CNN that "the results of this study 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," said Robert Rankin, the council's executive director, in an email.
The results "should not be extrapolated to the general population, as the participants in the intervention were already at increased risk for cardiovascular events," Rankin said.
The European Association of Polyol Producers declined to comment, saying it had not reviewed the study.
What is erythritol?
Like sorbitol and xylitol, erythritol is a sugar alcohol, a carb found naturally in many fruits and vegetables. It has about 70 per cent of the sweetness of sugar and is considered zero-calorie, according to experts.
Artificially manufactured in massive quantities, erythritol has no lingering aftertaste, doesn't spike blood sugar and has less of a laxative effect than some other sugar alcohols.
"Erythritol looks like sugar, it tastes like sugar, and you can bake with it," Hazen said. He also directs the Cleveland Clinic's Centre for Microbiome and Human Health.
"It's become the sweetheart of the food industry, an extremely popular additive to keto and other low-carb products and foods marketed to people with diabetes," he added.
"Some of the diabetes-labelled foods we looked at had more erythritol than any other item by weight."
Erythritol is also the largest ingredient by weight in many "natural" stevia and monkfruit products, Hazen said. Because stevia and monkfruit are about 200 to 400 times sweeter than sugar, just a small amount is needed in any product. The bulk of the product is erythritol, which adds the sugar-like crystalline appearance and texture consumers expect.
An unexpected discovery
The discovery of the connection between erythritol and cardiovascular issues was purely accidental, Hazen said: "We never expected this. We weren't even looking for it."
Hazen's research had a simple goal: find unknown chemicals or compounds in a person's blood that might predict their risk for a heart attack, stroke or death in the next three years. To do so, the team began analyzing 1,157 blood samples in people at risk for heart disease collected between 2004 and 2011.
"We found this substance that seemed to play a big role, but we didn't know what it was," Hazen said.
"Then we discovered it was erythritol, a sweetener."
The human body naturally creates erythritol but in very low amounts that would not account for the levels they measured, he said.
To confirm the findings, Hazen's team tested another batch of blood samples from over 2100 people in the United States and an additional 833 samples gathered by colleagues in Europe through 2018. About three-quarters of the participants in all three populations had coronary disease or high blood pressure, and about a fifth had diabetes, Hazen said. Over half were male and in their 60s and 70s.
In all three populations, researchers found that higher levels of erythritol were connected to a greater risk of heart attack, stroke or death within three years.
But why? To find out, researchers did further animal and lab tests and discovered that erythritol was "provoking enhanced thrombosis", or clotting in the blood, Hazen said.
Clotting is necessary in the human body, or we would bleed to death from cuts and injuries. The same process is constantly happening internally, as well.
"Our blood vessels are always under pressure, and we spring leaks, and blood platelets are constantly plugging these holes all the time," Hazen said.
However, the size of the clot made by platelets depends on the size of the trigger that stimulates the cells, he explained. For example, if the trigger is only 10 per cent, then you only get 10 per cent of a clot.
"But what we're seeing with erythritol is the platelets become super responsive: A mere 10 per cent stimulant produces 90 per cent to 100 per cent of a clot formation," Hazen said.
"For people who are at risk for clotting, heart attack and stroke – like people with existing cardiac disease or people with diabetes – I think that there's sufficient data here to say stay away from erythritol until more studies are done," Hazen said.
Oliver Jones, a professor of chemistry at RMIT University in Victoria, Australia, noted that the study had revealed only a correlation, not causation.
"As the authors themselves note, they found an association between erythritol and clotting risk, not definitive proof such a link exists," Jones, who was not involved in the research, said in a statement.
"Any possible (and, as yet unproven) risks of excess erythritol would also need to be balanced against the very real health risks of excess glucose consumption," he said.
In a final part of the study, eight healthy volunteers drank a beverage that contained 30 grams of erythritol, the amount many people in the US consume, Hazen said, according to the National Health and Nutrition Examination Survey, which examines American nutrition each year.
Blood tests over the next three days tracked erythritol levels and clotting risk.
"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."
Just how much is 30 grams of erythritol? The equivalent of eating a pint of keto ice cream, Hazen said.
"If you look at nutrition labels on many keto ice creams, you'll see 'reducing sugar' or 'sugar alcohol,' which are terms for erythritol. You'll find a typical pint has somewhere between 26 and 45 grams in it," he said.
"My co-author and I have been going to grocery stores and looking at labels," Hazen said.
"He found a 'confectionery' marketed to people with diabetes that had about 75 grams of erythritol."
There is no firm "accepted daily intake," or ADI, set by the European Food Safety Authority or the US Food and Drug Administration, which considers erythritol generally recognized as safe (GRAS).
"Science needs to take a deeper dive into erythritol and in a hurry, because this substance is widely available right now. If it's harmful, we should know about it," National Jewish Health's Freeman said.
"I normally don't get up on a pedestal and sound the alarm," he said.
"But this is something that I think we need to be looking at carefully."
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Other Risks and Side Effects
Why is erythritol bad for you, according to some research? Below are the major concerns with sugar alcohols, including erythritol.
Usually Genetically Modified
The World Health Organization defines genetically modified organisms (GMOs) as “foods derived from organisms whose genetic material (DNA) has been modified in a way that does not occur naturally, e.g. through the introduction of a gene from a different organism.”
Although there are non-GMO varieties available, much of the erythritol used in foods and beverages today is derived from cornstarch from genetically modified corn.
While this is still a controversial topic with ongoing research, animal studies have linked consumption of GMOs with potential problems, such as:
faulty Insulin regulation
changes in major organs and gastrointestinal system
Commonly Combined with Artificial Sweeteners
Erythritol is not as sweet as sugar on its own, so it’s often combined in foods and beverages with other questionable sweeteners, usually ones that are artificial.
When combined with artificial sweeteners like Aspartame, the Erythritol-laden product can become even more troublesome for your health. For example, possible Erythritol side effects when combined with Aspartame may include:
short-term memory loss
Can Cause Gastrointestinal Problems
Sugar alcohols pass through your body essentially untouched, much like dietary fiber does. This is why they can produce abdominal gas, bloating and diarrhea in some individuals — as they are not completely absorbed by the body and are fermented by bacteria in the large intestine.
The good news, however, is that compared to other sugar alcohols, erythritol seems less likely to ferment in the gut and less likely to trigger digestive issues.
Some of the most common erythritol side effects are undesirable gastrointestinal side effects that children are especially susceptible to.
Unfortunately, the gastrointestinal issues don’t necessarily stop at some rumbling in your stomach. Diarrhea is a well-known common erythritol side effect, although less so than with xylitol.
Especially when consumed in excess, unabsorbed erythritol can attract water from the intestinal wall and cause diarrhea.
The likelihood of diarrhea appears to be even greater when erythritol is consumed along with fructose. Diarrhea might sound harmless, but it can lead to dehydration, electrolyte imbalances and malnutrition.
When consumption is high (50 grams or more per day), digestive upset — including gas, cramping, bloating, stomachaches and diarrhea — becomes even more likely. One study specifically showed that the intake of 50 grams of erythritol caused stomach rumbling and nausea.
For this reason, it’s important to keep intake in moderation to help prevent negative side effects and consider scaling back if digestive issues occur.
In terms of impacting one’s microbiome, one study found that erythritol plus stevia had no negative impact on bacterial growth in the gut, however ingestion did cause some changes to the gut microbial structure and diversity.
May Trigger Allergic Reactions
Although very rare, erythritol can cause an allergic skin reaction in some people, as demonstrated in a study published in 2000 in the Journal of Dermatology.
A 24-year-old woman developed a severe rash and “wheals” all over her entire body after having one glass of a beverage sweetened with erythritol. A wheal, often called a welt or hives, is a raised, itchy area of skin that’s sometimes an obvious sign of an allergy to something you’ve consumed or come in contact with.
Linked to Cardiovascular Issues
A study published in Nature Medicine examined the use of erythritol and atherothrombotic disease risk. Atherothrombotic disease is defined as “a progressive disease characterised by the accumulation of lipids, fibrous material, and minerals in the arterial wall leading to narrowing of the arterial lumen. Arterial stenosis by itself may remain silent for decades and seldom cause acute vascular events.”
The researchers evaluated patients who underwent cardiac risk assessment, and initial studies found that “circulating levels of multiple polyol sweeteners, especially erythritol, were associated with incident (3 year) risk for major adverse cardiovascular events (MACE; includes death or nonfatal myocardial infarction or stroke).”
Upon further examination, they concluded: “Our findings reveal that erythritol is both associated with incident MACE risk and fosters enhanced thrombosis. Studies assessing the long-term safety of erythritol are warranted.”
“If your blood level of erythritol was in the top 25% compared to the bottom 25%, there was about a two-fold higher risk for heart attack and stroke. It’s on par with the strongest of cardiac risk factors, like diabetes,” lead study author Dr. Stanley Hazen, director of the Center for Cardiovascular Diagnostics and Prevention at the Cleveland Clinic Lerner Research Institute, told CNN.
Remember that many erythritol substitutes are available if you can’t find any or if you prefer a different product because you’re experiencing erythritol side effects. These include raw honey, molasses and genuine maple syrup if you don’t mind consuming actual sugar and calories.
This is a pure, unfiltered and unpasteurized sweetener made by bees from the nectar of flowers. Unlike processed honey, raw honey does not get robbed of its incredible nutritional value and health powers. It has been scientifically proven to help with allergies, diabetes, sleep problems, coughs and wound healing. Look for a local beekeeper to source your raw honey. This makes it even more likely to help with seasonal allergies.
(Dr Josh Axe)