Sugar Substitute Linked to Heart Attack and Stroke

Key Takeaways

• Erythritol can make blood platelets more active, a new study finds, increasing the risk of blood clots.
• Blood clots raise the likelihood of heart attack and stroke.
• A food industry spokesperson criticizes the study as limited.

The popular sugar substitute erythritol, found in the artificial sweetener Truvia, as well as in low- and no-calorie drinks and keto-friendly foods, may increase the risk of heart attack and stroke .

In a new study, scientists found that drinking erythritol-sweetened water made platelets (a type of blood cell) more active, thereby increasing the risk of blood clots.

Blood clots are dangerous and can travel to the brain, heart, kidneys, arms and legs, and lungs, which can cause heart attack, stroke, and death.

Artificially Sweetened Drinks Spiked Erythritol Levels by 1000 Times

To look directly at how erythritol impacts clotting, researchers recruited 20 healthy volunteers with no history of heart disease, high blood pressure, or diabetes.

After a night of fasting, subjects had their blood tested before and then 30 minutes after drinking either water containing a typical amount of erythritol or sugar water.

Like cholesterol, erythritol can both be consumed in food and is also made by our bodies. Baseline levels vary from person to person.

Researchers found that the group that drank the artificially sweetened water had erythritol levels that were more than 1,000 times higher than their preconsumption levels and that their platelets were more susceptible to clotting.

In contrast, platelet activity stayed the same in the group that drank sugar water.

Findings Cast Doubt on the Safety of Erythritol

The U.S Food and Drug Administration (FDA) does not require food additives like erythritol that are designated as GRAS - "generally recognized as safe" - to undergo long-term safety studies.

More researchers are beginning to challenge this position, at least when it comes to specific artificial sweeteners . "Our study adds to the growing body of data showing sugar alcohols like erythritol may not be as safe as currently classified by food regulatory agencies. I believe the GRAS [generally recognized as safe] status of erythritol and xylitol [another artificial sweetener] should be reevaluated," says senior study author Stanley Hazen, MD, PhD , chairman of the department of cardiovascular and metabolic sciences at the Lerner Research Institute and co-section head of preventive cardiology at Cleveland Clinic in Ohio.

A previous study on erythritol found that people with heart disease who had naturally high erythritol levels were twice as likely to experience a major heart incident (like heart attack or stroke) in the following three years compared with those with the lowest low levels.

That same study discovered that adding erythritol to patients' blood or platelets in lab experiments increased clot formation.

Another study by the same group found that the artificial sweetener xylitol produced similar increases in plasma levels and affected clotting in the same way. Like erythritol, studies with xylitol showed that high xylitol levels were linked with increased risk of heart attack, stroke or death over the following three years.

Erythritol Levels in the Body Can Remain High for 2 to 4 Days After Consumption

Erythritol is about 70 percent as sweet as sugar and is produced through fermenting corn.

Erythritol is poorly metabolized by the body. Instead, it enters the bloodstream and leaves the body mainly through urine.

Because the body creates low levels of erythritol naturally, additional consumption can temporarily accumulate. Earlier studies showed that it takes about two to four days for erythritol levels to return to normal, says Dr. Hazen.

Findings Show That Erythritol Causes Increased Risk of Clotting

This is another study in a growing body of research that shows that platelet activity increases after consuming erythritol, says John Hwa, MD, PhD, professor of cardiovascular medicine at the Yale School of Medicine in New Haven, Connecticut.

The study design and observations of the blood cells support the theory that erythritol actually causes the increased risk for clotting, and reinforces all the previous studies, says Dr. Hwa, who was not involved in the current research.

That's concerning given that increased clotting is associated with many diseases, including heart attacks and strokes, he says.

Food Industry: Erythritol Is ‘Safe and Effective' for Sugar and Calorie Reduction

Food industry critics say that these findings should be interpreted with extreme caution given study limitations. They point out that only 10 subjects consumed erythritol, and at an amount that would normally add up to two to three artificially sweetened drinks.

"Importantly, erythritol levels were only measured once after consumption, and the pilot lacked control over lifestyle factors that may affect the outcome, which could introduce confounding variables and impact the reliability of the findings," said Carla Saunders , president of the Calorie Control Council.

Additionally, because erythritol levels were only measured at baseline and 30 minutes after consumption, there is no way to demonstrate any lasting effect of excessive consumption on any health outcome, says Saunders.

"Consumers need to rely on science, and for 30 years, science has shown that erythritol is a proven safe and effective choice for sugar and calorie reduction," she said.

Bottom Line: Should You Eat and Drink Products Containing Erythritol?

Given the current evidence, the study authors are calling for additional research on the long-term health impact of erythritol and other sugar alcohols that are commonly used as sugar substitutes, especially when sugar does not appear to cause the same issues.

Yet sugar is also problematic, and is associated with higher blood pressure, weight gain, inflammation, diabetes, and fatty liver disease. All those conditions are linked with an increased risk for heart attack and stroke.

Many professional societies, including the American Heart Association (AHA), recommend short-term replacement of sugar-sweetened beverages with beverages containing low-calorie sweeteners.

Hazen offers different advice. He recommends that people choose sugar-sweetened treats occasionally and in small amounts rather than consuming drinks and foods sweetened with these sugar alcohols.

He says this is especially important for people at elevated risk of clotting, which would include people with heart disease, diabetes, or metabolic syndrome.

"Cardiovascular disease builds over time, and heart disease is the leading cause of death globally. We need to make sure the foods we eat aren't hidden contributors," says Hazen.

Hwa agrees that limiting sugar intake and not consuming products with erythritol is the best strategy.

"Erythritol may not be a safe sugar substitute, particularly in at-risk cardiovascular patients," he says.

Editorial Sources and Fact-Checking

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Sources

1. Witkowski M et al. Ingestion of the Non-Nutritive Sweetener Erythritol, But Not Glucose, Enhances Platelet Reactivity and Thrombosis Potential in Healthy Volunteers. Arteriosclerosis, Thrombosis and Vascular Biology . August 8, 2024.
2. Generally Recognized as Safe (GRAS). U.S. Food & Drug Administration (FDA) . October 17, 2023.
3. Witkowski M et al. The Artificial Sweetener Erythritol and Cardiovascular Event Risk. Nature Medicine . March 2023.
4. Witkowski M et al. Xylitol Is Prothrombotic and Associated with Cardiovascular Risk. European Heart Journal . June 6, 2024.
5. The Sweet Danger of Sugar. Harvard Health Publishing . January 6, 2022.
6. Johnson RK et al. Low-Calorie Sweetened Beverages and Cardiometabolic Health: A Science Advisory From the American Heart Association. Circulation . July 30, 2018.

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Becky Upham

Author

Becky Upham has been professionally involved in health and wellness for almost 20 years. She's been a race director, a recruiter for Team in Training for the Leukemia & Lymphoma Society, a salesperson for a major pharmaceutical company, a blogger for Moogfest, a communications manager for Mission Health, a fitness instructor, and a health coach.

She majored in English at the University of North Carolina and has a master's in English writing from Hollins University.

Upham enjoys teaching cycling classes, running, reading fiction, and making playlists.

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