Another study has raised concerns about the safety of the widely used sugar alcohol sweetener erythritol, a low-calorie sugar substitute used in “keto-friendly” foods, baked goods, and candy. Researchers at the Cleveland Clinic compared erythritol to common sugar and found that only erythritol caused worrisome cardiovascular effects.
Although the study is small, it is the first to directly compare blood levels in people after consuming products containing erythritol or sugar (glucose).
“When we compared the results, glucose did not cause any problems,” said Dr. Stanley Hazen, a cardiologist at the Cleveland Clinic and lead author of the study published Thursday morning in the journal Atherosclerosis, Thrombosis and Vascular Biology.
Erythritol is one of the non-sugar sweeteners found in low-calorie and sugar-free foods. Erythritol and xylitol are sugar alcohols that taste like sugar but have far fewer calories. Erythritol is often mixed with stevia, another sweetener, and xylitol is commonly found in gum, mouthwash, and toothpaste.
Previous studies from the Hazen lab (published last year and in June) have found a potential link between sugar alcohols and an increased risk of heart attack and stroke. The studies suggested that both types of sugar alcohols may make platelets stickier, which may make them more likely to clot and lead to clogged veins and arteries, which could lead to heart attacks and strokes.
For the new study, Hazen and his team analyzed the effects of erythritol and regular sugar (in this case, simple glucose) on the heart. They enrolled two groups of healthy, middle-aged male and female volunteers: 10 who consumed erythritol and 10 who consumed sugar.
Both groups fasted overnight. In the morning, blood was drawn to measure platelet activity. Half the volunteers then drank a glass of water mixed with 30 grams of glucose, and the other half drank a glass of water mixed with 30 grams of erythritol, an amount that is commonly found in foods sweetened with erythritol, Hazen said.
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About 30 minutes after each group had consumed the sweetened drink, their blood was drawn and retested. The researchers found that those who drank erythritol had increased platelet aggregation, meaning their blood was more likely to clot. Platelet aggregation was unchanged in the adults who drank regular sugary drinks.
The researchers measured a 1,000-fold increase in erythritol levels in the blood of the group that drank the erythritol drink. The group that drank the glucose water saw no change in erythritol levels and only a slight increase in blood sugar. This finding was remarkable to Hazen because it far exceeded the trace concentrations of erythritol naturally present in the blood.
“The amount of sugar alcohols in sugar substitutes is thousands of times higher than the amount produced by the body, so they cannot be considered ‘natural,'” he said. “Sugar substitutes, and especially sugar alcohols, dramatically increase the risk of thrombosis when consumed, so they should be avoided.”
The Food and Drug Administration considers artificial sweeteners like erythritol and xylitol to be GRAS (Generally Recognized as Safe), and Hazen hopes that the mounting evidence on sugar alcohols will prompt the FDA to look more closely at the data.
Outside the U.S., these concerns have caught the attention of food regulators: Last year, for example, the European Food Safety Authority recommended the European Commission request data on the amount of erythritol in foods, which could help shed light on the risks.
Do the findings suggest that erythritol is worse overall than high-calorie sugar? A diet high in sugary foods can lead to higher blood sugar levels, which can increase the risk of stroke and blood clots, says Valisa Hedrick, a registered dietitian at Virginia Tech who was not involved in the Cleveland Clinic study.
The study has some important limitations, including a small number of participants, and it only measured the effects of erythritol and glucose at one point in time, rather than continuing to take them over months or years, Hedrick noted.
And the amount of glucose in sugar water (about 30 grams) is equivalent to about 120 calories of sugar. Sweetened drinks, especially juices and sodas, often contain more sugar.
For example, a 12-ounce can of Coca-Cola contains 39 grams of sugar, and a 12-ounce can of Mountain Dew contains 46 grams of sugar.
It may also be worth comparing erythritol with both fructose and glucose, said Michael Golan, a professor of pediatrics at the Keck School of Medicine of the University of Southern California, whose combination of fructose and glucose is more commonly found in sweet juices and sodas than glucose alone, he said. Golan was not involved in the new study.
Hazen’s study only looked at glucose.
Although the Cleveland Clinic study found no adverse effects from sugar intake, researchers agreed that the data doesn’t mean sugar is safe: High sugar intake could have a similar effect on platelets, especially in diabetics who can’t effectively control high blood sugar.
Hazen’s study specifically focused on healthy people, not people with diabetes.
It may also be important to analyze whether consuming foods containing erythritol has different effects on the heart than consuming water containing erythritol, said gastroenterologist Dr. Michelle Pearlman, CEO and co-founder of Prime Laboratories in Miami.
“Factors such as protein, fat, fiber and other nutrients can influence this response,” she said.
Ultimately, Virginia Tech’s Hedrick said the new study highlights the need for more research comparing the health effects of sweeteners and sugar.
Hazen and his colleagues concluded their study by urging further research focusing on the cardiac risks of erythritol, particularly in people who are already at high risk for stroke and blood clots.
