A sugar replacement called erythritol – 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.
“The degree of risk was not modest,” said lead study author Dr.
Stanley Hazen, director of the Center 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% 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,” 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,” said Dr. Andrew Freeman,
director of cardiovascular prevention and wellness at National Jewish
Health, a hospital in Denver, who was not involved in the research.
“There appears to be a clotting risk from using erythritol,”
Freeman 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.
Like sorbitol and xylitol, erythritol is a sugar alcohol, a carb
found naturally in many fruits and vegetables. It has about 70% 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,” said Hazen, who also directs the Cleveland Clinic’s
Center 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-labeled 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.
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 2,100 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%, then you only get 10% of a clot.
“But what we’re seeing with erythritol is the platelets become
super responsive: A mere 10% stimulant produces 90% to 100% 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,” Jones 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.
Hazen agreed: “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.”
