When researchers found this unexpected association between erythritol levels in the blood and increased risk of cardiovascular events, they decided to dig a little deeper.
A new study links the use of a popular low-calorie sweetener with an increased risk of heart attacks and stroke. How worried should you be?
Nutrition Diva is hosted by Monica Reinagel. A transcript is available at Simplecast.
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Hello and welcome to the Nutrition Diva podcast. I’m your host, Monica Reinagel, and I’m bumping the topic I originally planned for this week in order to respond to a breaking news story that has caused some concern.
The headline that many of you probably saw was “Artificial sweetener linked to heart attacks, blood clots, and strokes.” That’s already pretty incendiary. Some news outlets sought to up the SEO ante further by identifying the sweetener as being one that is commonly used in “keto foods,” or products pitched to those following the trendy ketogenic diet.
Let’s take a closer look at what researchers found, what we still do not know, and how this information might apply to your own health risks and dietary decisions.
The paper was published in the journal Nature Medicine by an international consortium of researchers, and funded by the NIH as well as a variety of European foundations and agencies, and actually described a number of different studies, all leading to the conclusion that intake of erythritol, a popular low-calorie sweetener, was associated with an increased risk of forming blood clots, which could lead to an increased risk of heart attacks or strokes.
The whole thing started with some bloodwork that was done on about 1200 people, as part of a study looking at cardiovascular disease risk over time. The researchers detected the presence of several compounds called polyols (commonly known as sugar alcohols) in the subjects’ blood. And they noticed that the presence of sugar alcohols—especially erythritol—was associated with an increased risk of heart attacks, strokes, and deaths. Uh-oh. They went on to find the same association in two further, large study populations—and the effect was linear. The higher the erythritol levels in the blood, the higher the risk of cardiovascular events. Those in the top quartile (with the highest levels in their blood) had 3 to 4 times the risks as those in the lowest quartile.
How did we get here?
Many sugar alcohols (which include sorbitol, xylitol, and maltitol) are naturally occurring in the food supply in very low amounts. But they are also synthesized and used in food manufacturing to make sugar-free products such as gum, candies, soda, artificial sweeteners, and other processed foods.
Sugar alcohols taste sweet but are not metabolized as sugar. They contribute very few calories and—more importantly—do not affect blood sugar levels. And for this reason, they were originally used in products formulated for people with diabetes, such as diabetic candy and chocolate. But as low-carb dieting became more popular, sugar alcohols gained traction in that (much larger) market as a “natural” low-calorie sugar alternative.
But it wasn’t all upside. Sugar alcohols have an unfortunate side effect. Because they are not digested and absorbed the way regular sugar would be, they end up in the large intestine, where they ferment and can cause unpleasant side effects like gas, cramping, and diarrhea.
The rise of erythritol in the 1990s was a game-changer. Like other sugar alcohols, erythritol does not affect blood sugar. However, it seemed to produce far fewer digestive problems. Erythritol quickly became the leading sugar alcohol used in food manufacturing. You’ll find it in everything from energy bars to protein shakes to low-calorie cocktail mixes, ice cream, and sugar-free baking mixes. It’s used in combination with more concentrated sweeteners like stevia and monkfruit to give the products more bulk and a more sugar-like consistency. You can buy it as a sugar replacement to use in your coffee or your favorite recipes. (Truvia is the most well-known brand.)
Although marketers claim that you can use an erythritol-based sweetener to replace real sugar in any recipe, temper your expectations. Although the recipe may still work, there’s definitely going to be an impact on taste and (for baked goods) texture, moistness, and browning. You may also notice a slight cooling sensation on your tongue from products made with erythritol. And, despite the fact that it is generally more tolerable than other sugar alcohols, if you consume enough of it, you may still end up with a rumbly tummy.
Due to its popularity, we are definitely consuming a lot more erythritol than we used to. According to dietary survey data, people may now be consuming up to 30g (or 1 ounce) of erythritol a day. You may not even be aware of which products contain it. Because erythritol occurs naturally in foods (albeit at 1/1000th the levels that it’s commonly used today), the FDA doesn’t even require manufacturers to disclose erythritol in the ingredient list!
Now, of course, any ingredient widely used in food manufacturing must be safe, right? Indeed, erythritol has the status of a GRAS (generally recognized as safe) ingredient. And human studies have shown no ill effects (beyond rumbly tummies) in studies lasting up to 4 weeks. But what happens over longer periods of time? There aren’t a lot of data… except the data that are starting to emerge out of the ad hoc experiment that’s been unfolding over the last 20-30 years as erythritol has become ever more ubiquitous.
And that brings us to this recent paper. When the researchers found this unexpected association between erythritol levels in the blood and increased risk of cardiovascular events, they decided to dig a little deeper. After all, they noted, we really don’t have any studies looking at the long-term effects of sugar alcohols on cardiovascular health.
They designed some studies to look for something that would explain how erythritol might increase the risk. And they found a pretty convincing mechanism: erythritol (at quantities consistent with what you’d get by eating foods sweetened with it) promotes platelet aggregation in human blood. Platelet aggregation is a fancy word for blood clots. And blood clots can lead to heart attacks and strokes.
And the final piece of bad news is that it didn’t seem to take much. A single erythritol-sweetened soft drink or serving of ice cream was enough to put blood levels into the range where platelet aggregation was enhanced—and they stayed elevated for up to two days.
At this point, you’re probably wondering why every erythritol sweetened product has not been recalled from the market?
And the answer is that this is one study (actually, a series of studies) showing a robust association (which does not equal causation) as well as a plausible mechanism. But that still leaves plenty of room for doubt and debate.
Not surprisingly, a spokesperson for the Calorie Control Council (which is an industry group for producers of low and no-calorie foods and beverages), points to “decades of scientific research showing reduced-calorie sweeteners like erythritol are safe” as well as the fact that this study focused on people who were at increased risk of cardiovascular disease and that it can’t be applied to the general population.
Personally, I think the first defense is pretty lame. Those “decades of scientific research” involved mostly small, short studies that could never have detected this effect. As we like to say in the biz: absence of evidence is not evidence of absence.
The second argument, that these findings don’t necessarily apply to people who don’t have an elevated risk of heart disease, is certainly more valid. But, although the association was detected in a population at higher risk, the later studies which found that erythritol promoted platelet aggregation were done on blood samples from healthy volunteers.
But regardless of how long it takes the research and regulatory debate to unfold, we as consumers have decisions to make right now. Should you avoid erythritol, based on this new research?
Your answer will depend on your own personal risk tolerance as well as what benefits you feel erythritol is providing. Is having access to this non-caloric sweetener critical to maintaining your blood sugar or your body weight or your quality of life?
Finally, I want to point out that occasional use of erythritol poses a much different potential risk than daily, heavy use of erythritol. And this has always been my gripe about noncaloric sweeteners. Because we perceive them as “consequence-free,” we often consume them quite immoderately. We may actually eat and drink a lot more sweet stuff than we would if they contained actual sugar. Meanwhile, these artificially-sweetened foods and drinks usually aren’t adding much nutritional value to the diet–and may be displacing foods that would.
So, even if you don’t find this latest research particularly alarming, or you favor a different non-caloric sweetener that is not currently under the microscope, I still recommend consuming artificial sweeteners (and foods made with them) with the same degree of moderation that you would apply to their full-sugar counterparts.
The recommendation for added sugars is 25 grams or less per day. If you’re using artificial sweeteners, the equivalent for that is about 3 packets of sweetener. Alternatively, you can simply limit yourself to one sweetened food or beverage per day (so: one can of soda OR one sweetened tea or coffee drink OR one dessert) and do your best to avoid added sweeteners otherwise. And I’ll end with a piece of good news: the sugar in fruit does not count as added sugars.
Reducing their intake of sugar (and artificial sweeteners) is one of the top benefits that people who participate in my 30-Day Nutrition Upgrade program report. (The other is eating more vegetables.) And these benefits persist long after the program is over! If that sounds good to you, I hope you’ll join me for the next 30-day Nutrition Upgrade program, which kicks off on March 18th. You can get all the details at nutritionovereasy.com/upgrade
Nutrition Diva is a Quick and Dirty Tips podcast. It's audio-engineered by Nathan Semmes with script editing by Adam Cecil. Thanks also to Morgan Christianson, Holly Hutchings, Davina Tomlin, and Kamryn Lacy.
That's all for this episode. Thanks for listening! I'll see you next week.