Popular Sugar Substitute Linked to Increased Risk of Heart Attack and Stroke

According to a study published in Nature Magazine on Monday, researchers have found links between erythritol, a common low-calorie sugar substitute, and an increased risk for cardiovascular events such as heart attack and stroke.

In the past, medical researchers have raised concerns about the long-term safety of sugar substitutes companies frequently use in products marketed as sugar-free, low-calorie or light. These products often use polyol (sugar alcohol) sweeteners like erythritol as a common component of diet varietals of foods like yogurt, ice cream, puddings and candies.

Many so-called “natural” stevia and monk fruit products also contain erythritol as their primary, weight-based ingredient. Since even a tiny amount of stevia or monk fruit is 200 to 400 times sweeter than sugar, erythritol is often used as a bulking agent to give the product a sugary, crystalline appearance and texture consumers are used to.

Dr. Stanley Hazen, a cardiologist at the Cleveland Clinic and an author of the study, told The New York Times that while people opt for these diet meals and drinks to make a positive change, “They may inadvertently be doing harm.”

Researchers analyzed the blood erythritol levels of around 4,000 participants from the United States and Europe. They found that those with the highest sugar substitute concentration in their blood were more likely to have a stroke or heart attack.

“If your blood level of erythritol was in the top 25% compared to the bottom 25%, there was about a twofold higher risk for heart attack and stroke. It’s on par with the strongest of cardiac risk factors, like diabetes.”

When mice were given erythritol as part of the study, they were more likely to suffer from blood clots. Erythritol also induced clotting in human blood and plasma.

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The sugar alcohol remained in the blood of eight persons for more than two days after they ingested amounts similar to those found in a pint of keto ice cream or a can of an artificially sweetened beverage.

“Every way we looked at it, it kept showing the same signal,” Dr. Hazen said.

“It has long been believed that used sugar substitutes such as erythritol will reduce calories from carbohydrate intake while still allowing food to taste good,” Dr. Yu-Ming Ni, M.D., a cardiologist at Orange Coast Medical Center in Fountain Valley, California, told Yahoo News. “However, we have seen in repeated studies that sugar substitutes have side effects that go beyond simply imitating the taste of sugar.”

Dr. Ni notes that this work’s most significant contribution is demonstrating a possible mechanism by which artificial sweeteners can damage blood vessels. Until this correlation is confirmed and replicated by other research, we cannot conclude that erythritol consumption causes an increase in heart disease. Until then, it is unknown whether complete abstinence from all artificial sweeteners is required.

“I often advise my patients to eat food as naturally as possible, as that reduces the risk of exposure to potentially harmful chemicals like artificial sweeteners, and to consider sugar substitutes if it serves as a means to help overweight people with weight loss since overall weight loss has clearer evidence for health improvement.”

Dr. Dariush Mazaffarian, a cardiologist and professor of nutrition at the Friedman School of Nutrition Science and Policy at Tufts University, who was not involved with the study, told The New York Times that not enough studies have been conducted to determine the long-term health effects of sugar substitutes definitively.

“That’s the problem. Regardless of this study, there’s just not been enough evidence that they’re really safe.”

The Calorie Control Council, which represents the low and reduced-calorie food and beverage industry, said in a statement 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.”

“Erythritol is a proven safe and effective choice for sugar and calorie reduction and, for more than 30 years, has been used in reduced-sugar foods and beverages to provide sweetness, as well as enhance their taste and texture. Along with exercise and a healthy diet, reduced-calorie sweeteners are a critical tool that can help consumers manage body weight and reduce the risk of non-communicable diseases, such as cardiovascular disease.”

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Dr. Mozaffarian notes that there were several caveats to the study. Most of the participants were over the age of 60 and already suffered from cardiovascular disease or were already at high risk for developing it due to conditions like diabetes and high blood pressure.

The study also did not provide conclusive evidence to suggest erythritol caused heart attacks and strokes, only that it elevated cardiovascular risk.

Dr. Priya M. Freaney, a cardiologist at Northwestern University who was not involved with the study, told The New York Times that she agreed that the study requires further validation. However, “It’s concerning enough that it certainly deserves more investigation.”

Due to their rising popularity over the past decade, sugar substitutes have prompted scientists to research their possible impacts on human health more urgently. New York University emerita professor of nutrition, food studies and public health Dr. Marion Nestle, who was not involved in the study, commented on the large body of literature on artificial sweeteners and its often-contradictory findings.

Past studies examining links between artificial sweeteners and cancer and cardiovascular diseases have concluded that these chemicals may increase the risk of these conditions, but only marginally. They also conclude that more research is needed.

“There are going to be studies that show that it’s good, bad or indifferent. People have been consuming artificial sweeteners for years. It’s really hard to put your finger on any specific problem.”

Dr. Joanne Slavin, professor of food science and nutrition at the University of Minnesota-Twin Cities, told The New York Times that previous research has determined erythritol is a suitable replacement for sugar. However, much of the research was performed on animals. Examining sugar substitutes’ health effects when consumed as part of a larger diet further complicates things.

For example, those who consume high amounts of artificial sweeteners may already be at risk for cardiovascular issues, prompting the switch to sugar substitutes in the first place.

“That’s the really important thing, for people to not say, ‘Hey, this stuff is terrible, it’s giving us heart attacks.’ No. This is another data point that says, ‘Hey, we have to look into this.’”