- An observational study found an association between erythritol and heart disease; the intake of erythritol was not known.
- Humans can make erythritol from excess sugar, so the source could be endogenous.
- The media has made unjustified claims of causality, alarming many diabetics and keto followers.
By giving us the opinions of the uneducated, journalism keeps us in touch with the ignorance of the community. –Oscar Wilde
A new study from the Cleveland Clinic has saturated the news lately, terrifying people who use sugar substitutes. The study asserts that erythritol, a very popular sweetener, is associated with potentially deadly cardiovascular events.
Erythritol’s low glycemic index makes it easy for people to enjoy sweet foods without incurring high blood sugar. It’s an important sugar replacement for diabetics and a common component of a keto diet. But is it a killer?
The study analyzed more than 1,000 cardiac patients and found that those with the highest levels of erythritol in their blood also had the highest risk for heart attack and stroke. So, is it time to dump your erythritol? Before you decide, let’s dig into the story a bit. The truth is less frightening and more interesting than the headlines would suggest.
Surprisingly, given the breathless press coverage, the study doesn’t say anything about how much erythritol the patients consumed. We might assume that these people, many of whom were diabetic, were using some kind of sugar substitute. However, that information wasn’t in the data set they used.
Erythritol Produced by the Body
But if the erythritol didn’t come from consumption, where did it come from? Several scientists, including Martha Field and colleagues at Cornell University, have shown that the human body actually makes erythritol on its own. This is called endogenous erythritol, and the amount produced tracks with metabolic disease. The sicker the patient, the greater the quantity of erythritol in their blood.
This home-grown erythritol is unrelated to its consumption. In fact, the body produces it in response to excess sugar, and it is a fruitful marker of cardiometabolic disease. In other words, the levels of erythritol found in these patients may be a consequence of not consuming erythritol, but sugar instead. Biology is deliriously complicated, so it’s not unusual for studies to clash. It typically indicates some interesting underlying science. It can be disconcerting for the layperson, but it’s gold for scientists—and science writers.
A diet high in sugar promotes the overgrowth of bacteria in the small intestine and can lead to a “leaky gut” where toxins and bacteria are able to enter the bloodstream and reach every organ in the body. Over time, this can morph into systemic inflammation, the root of many diseases, including metabolic syndrome, type 2 diabetes, heart disease, depression, dementia, and more. Bypassing sugar helps to keep your microbiota in good shape, and that, in turn, helps to keep your gut healthy and your mood upbeat—thus, the increasing use of sugar substitutes like erythritol.
The authors of the Cleveland Clinic study acknowledge that the body produces erythritol, yet they say, “We speculate that erythritol levels…originate from a combination of ingestion and endogenous production.” Unfortunately, the design of this study doesn’t warrant such speculation—the information simply isn’t in the data.
To address this shortcoming, another part of the study looked at what happens to the blood of test participants after consuming 30 grams of erythritol within two minutes. Blood clotting factors were increased, which is troublesome.
But there are several problems with this part of the study. First, there were only eight people involved, which makes the study underpowered. Second, 30 grams is a lot of erythritol to take at once, more than the average consumer uses in a day. Third, there were no control groups. There is an understandable urge to go with compelling stories, but small studies like this should be kept for internal use, not published in Nature. Better to wait until there is a larger, controlled study.
Widespread Media Coverage
Thus, the study has little to say about actual consumption of erythritol—except in large doses—and even that is speculative without a control group. That hasn’t stopped the click-baity news coverage.
Fox News said, “A new Cleveland Clinic study shows that a popular artificial sweetener, erythritol, is associated with an increased risk of heart attack and stroke.” The first thing to note is that erythritol, which occurs naturally, is labeled "artificial" both by the study and the press. However, it is a natural sugar alcohol found in many foods, including pears, grapes, watermelon, mushrooms, cheese, soy sauce, beer, sake, and wine. It’s also worth noting that erythritol has been affirmed as safe by the U.S. Food and Drug Administration (FDA), the World Health Organization, and the EFSA (the European version of the FDA). Second, by calling it a sweetener instead of a natural metabolite, they imply that the observational study looked at consumption. Unfortunately, as mentioned, consumption data wasn’t available.
The study has also gone global. The Indian Express chose the bold headline: “Does your artificial sweetener have Erythritol? Study says it raises risk of heart attack and stroke.“ The Indian Express is hardly a medical journal, but it should know the difference between an association and a causal risk.
According to many other scientists, there is not enough here to worry about. Robert Rankin, executive director of the Calorie Control Council, disputed the findings, saying, “The results of this study are contrary to decades of scientific research showing reduced-calorie sweeteners like erythritol are safe.” He added that the results “should not be extrapolated to the general population, as the participants in the intervention were already at increased risk for cardiovascular events.” That may be true, but many of those people are the prime demographic for sugar substitutes.
The Calorie Control Council represents the low-cal food and beverage industry, so they have a vested interest in sweeteners, but other scientists concur and decry the lax press coverage. Kevin Klatt, a metabolism researcher at UC Berkeley Metabolic Biology, says that “Erythritol is a great example of something that is in the diet but can also be made endogenously, where we are not sure if it is causally linked to disease but there is [speculation] that it might be, so the media and influencers will run with headlines about it.” So, don’t panic just yet.
What to Do While Awaiting Follow-Up Research
But until follow-up studies are done, you might want to keep your consumption of erythritol below 30 grams at one sitting. There are other natural sweeteners available, such as allulose and tagatose. Switch them up to ensure you don’t get too much of any of them. The poison is in the dosage, and these sugar substitutes have been used for decades with great results for people trying to reduce their blood sugar.
There was a time when we didn’t have access to so much refined sugar. Amazingly, people were still happy. There is joy to be found in sweet fruits, and we should reconnect with them. And maybe we don’t need donuts, candy bars, sodas, and ice cream every day. It’s a bitter pill to swallow, but dessert should be a treat, not a staple.
Witkowski, Marco, Ina Nemet, Hassan Alamri, Jennifer Wilcox, Nilaksh Gupta, Nisreen Nimer, Arash Haghikia, et al. “The Artificial Sweetener Erythritol and Cardiovascular Event Risk.” Nature Medicine, February 27, 2023, 1–9.
Ortiz, Semira, Doletha Szebenyi, and Martha Field. “Endogenous Synthesis of Erythritol, a Novel Biomarker of Weight Gain (P15-016-19).” Current Developments in Nutrition 3, no. Suppl 1 (June 13, 2019): nzz037.P15-016-19.
Ortiz, Semira R., and Martha S. Field. “Elevated Plasma and Urinary Erythritol Is a Biomarker of Excess Simple Carbohydrate Intake in Mice.” bioRxiv, December 4, 2022.