Artificial sweetener associated with heart attack and stroke risk in high-risk patients

The popular artificial sweetener erythritol may be associated with a risk of heart attack, stroke, and even death, according to a recent Cleveland Clinic–led study published in Nature Medicine.^[] 

Erythritol is a sugar alcohol, or polyol, and is naturally found in fermented foods, fruits, and vegetables. It can be synthetically made as well, usually by fermenting certain kinds of yeasts.^[] 

The study examined over 4,000 people based in both the United States and throughout Europe. Those with higher blood levels of erythritol were found to have a greater risk of major adverse cardiac events. More so, the researchers also found that erythritol potentially enhanced thrombosis. 

People with certain risk factors for heart disease—like diabetes—were doubly as likely to experience major adverse cardiac events if they had higher levels of erythritol in their blood, Mary Wirtz, MS, RDN, CSSD told MDlinx after reading the findings. 

One of the study’s chief limitations was the fact that many of the subjects already showed a high prevalence of cardiovascular disease. Therefore, the authors wrote, “Translatability of our findings to the general population needs to be determined.” However, they go on to say that in their sensitivity analyses, “the clinical prognostic value of erythritol was widely observed, including numerous lower-risk subgroups.” Other limitations include the possibility that other variables were at play, including diet, “that may have (directly or indirectly) impacted our results by factors that are not included in our models,” the study authors note.

The overall message? “Studies assessing the long-term safety of erythritol are warranted,” the authors summarize. 

A closer look at erythritol 

Erythritol only came into the picture as a food additive in the 1990s, according to researchers writing in Critical Reviews in Food Science and Nutrition.^[] Nowadays, it can be found everywhere—and has earned a “Generally Recognized as Safe” (GRAS) classification by the Food and Drug Administration (FDA). There are many criticisms of the GRAS process, however.^[]  

The Cleveland Clinic’s press release on the study gives some facts about erythritol. “After ingestion, erythritol is poorly metabolized by the body. Cleveland Clinic. Instead, it goes into the bloodstream and leaves the body mainly through urine.”^[]

The sweetener is commonly sought after by consumers looking for lower-carb or lower-sugar options. Coffee lovers who add Truvia’s original sweetener to their morning cup, for example, are ingesting erythritol, along with stevia leaf extract. 

Many artificial sweeteners like erythritol are also recommended to people with health conditions such as diabetes, obesity, or other metabolic issues, as the Cleveland Clinic says. On this issue, the World Health Organization (WHO) has reservations: The WHO states, “Non-sugar sweeteners are low- or no-calorie alternatives to free sugars that are generally marketed as aiding weight loss or maintenance of healthy weight….but there is no clear consensus on whether non-sugar sweeteners are effective for long-term weight loss or if they are linked to other long-term health effects at habitual intakes within the [acceptable daily intake].”^[][]

To the WHO’s point, erythritol isn’t the only artificial sweetener under fire in recent times. In a study published by PLOS Medicine, people who consumed artificial sweeteners—especially aspartame and acesulfame-K—were found to have higher cancer risks, particularly for breast cancer and cancer-related to obesity.^[] 

Talking to your patients

So, what are other healthcare professionals thinking about erythritol—and how can you discuss its potential risks with patients?

There doesn’t seem to be a justification for panic; more research is still needed, as the study found the sweetener was associated with—and not a clear cause for—major adverse cardiac events. 

Cardiologist Yu-Ming Ni, MD, who commented on the study, says that while it offers a glimpse into “potential mechanisms by which artificial sweeteners can harm blood vessels,” there’s really no way to say with absolute certainty that erythritol is the culprit behind increased risk of heart disease.

To find out for sure,  he recommends that researchers continue to examine the effects of erythritol in larger studies. As for guidance for patients, Dr. Ni suggests physicians drive home the importance of natural, whole foods that don’t rely on artificial sweeteners for a sugary kick. 

Wirtz is on the same page. “Until more research is published, it is wise for physicians to discuss this with their patients and encourage them to avoid it, particularly for those individuals with a heightened risk for heart disease,” she recommends. 

For patients who are looking for a low-calorie sweetener, Wirtz says that “opting for stevia or an alternative rather than erythritol may be wise.” She also recommends that patients read the ingredients list on any packaged food labels. “If erythritol is contained in that food product,” she says, “I would encourage individuals to err on the side of caution—and if they are overwhelmingly concerned, then avoid it entirely.”