This content originally appeared on Everyday Health. Republished with permission.
A preliminary study showed that consuming erythritol, found in many keto-friendly foods — including the sweetener Truvia — can significantly increase heart disease risks.
Erythritol, a popular sugar substitute found in Truvia and used in a variety of no-sugar and keto-friendly products, may be linked to an increased risk of heart attack and stroke, according to a new study published today in Nature Medicine.
Researchers found that people with the highest levels of erythritol in their blood were twice as likely to have a heart attack, stroke, or death compared to people with the lowest levels.
“These results were striking. That puts this on par with the same risk of the strongest of the cardiac risk factors, such as having diabetes. It’s even arguably stronger than the risk of high cholesterol or blood pressure,” says senior author Stanley Hazen, MD, PhD, chairman for the department of cardiovascular and metabolic sciences at the Lerner Research Institute and co-section head of preventive cardiology at Cleveland Clinic in Ohio.
“This is an incredibly important study that provides significant evidence for how the use of artificial sweeteners, in particular the sugar substitute erythritol, may also increase the risk of cardiovascular disease such as heart attacks, stroke, and death,” says Mandeep Kainth, MD, associate director of preventive cardiology at the Stony Brook Heart Institute in Stony Brook, New York. Dr. Kainth was not involved in this research.
Having Naturally High Levels of Erythritol May Double Heart Disease Risk
Researchers didn’t set out to specifically study erythritol, says Dr. Hazen. While studying different compounds that naturally occur in the blood to see if any predicted later heart attack or stroke, the scientists discovered that people with naturally high levels of erythritol — which our bodies produce naturally as a byproduct of metabolism — appeared to be at higher risk.
Researchers then turned their focus on erythritol and measured it in nearly 3,000 participants in the United States and Europe. They found that people with the highest levels of erythritol (the top 25 percent) had twice the risk of heart attack, stroke, or death compared to people with the lowest levels of the compound.
Investigators also examined the effects of adding erythritol to either whole blood or isolated platelets, which are cell fragments that clump together to stop bleeding and help form blood clots. They found that erythritol made platelets easier to activate and form a clot. Blood clots can become dislodged and travel to the heart, leading to a heart attack, or to the brain, leading to stroke.
Consuming Erythritol in Processed Foods Can Increase Plasma Levels of the Compound by 1,000 Percent
Erythritol is made by fermenting corn. It can be sold alone or included as an ingredient in stevia- and monk fruit-based sweeteners. When used as a sugar substitute, it’s about 70 percent as sweet as sugar.
After being consumed, erythritol is poorly metabolized by the body. Instead, it goes into the bloodstream and leaves the body mainly through urine.
After uncovering the risk of high levels of erythritol and its impact on clotting, Hazen and colleagues decided to look at how it might accumulate in people who consumed it through processed foods. In a small pilot study, healthy volunteers were given one to two servings of erythritol in products such as sweetened ice cream or lemonade.
“The plasma levels of erythritol went about 1,000-fold higher, and then stayed above the levels that were observed, to enhance clotting risks in earlier experiments for days,” says Hazen.
Findings Strengthen Existing Concerns About Sugar Substitutes and Risk of Heart Disease
In 2018, the American Heart Association (AHA) advised short-term replacement of sugar-sweetened beverages with beverages containing low-calorie sweeteners, including artificially sweetened beverages, as a reasonable approach to calorie reduction and weight loss, says Kainth.
A lot of people with underlying cardiac risk factors have been consuming products sweetened with erythritol because they believed it would somehow reduce those risks, he says. “The results of this study imply that those very products are putting people at an even higher risk of cardiovascular disease.”
This study builds on research data from the Women’s Health Initiative that showed that women who consumed at least 24 ounces on average per day of artificially sweetened beverages had an elevated risk of cardiovascular disease.
“Given that the safety of these sugar substitutes has not been studied in detail, I believe the topic of artificial sweeteners and their impact on our health deserves more attention. This article brings up some very compelling questions that are important to address,” says Kainth.
More Studies Are Needed to Confirm the Findings About the Potential Risks of Erythritol
Follow-up studies are needed to confirm the findings in the general population, noted the authors. The study had several limitations, including that observation studies demonstrate association and not causation.
While it’s true that these findings show an association between erythritol and heart disease, rather than conclusive evidence of the link, it is certainly an important contribution to the growing body of literature on the topic, says Kainth.
“To further strengthen these findings, we need more solid scientific evidence in the form of randomized controlled trials with larger population sizes, which can effectively assess the direct impact these products have on cardiovascular disease,” he says.
Hazen adds that additional trials are needed on the long-term effects of artificial sweeteners in general, and erythritol specifically. Such studies should focus on any increased risk for heart attack and stroke, particularly in people at higher risk for cardiovascular disease, he says.
The FDA Does Not Require Long-Term Safety Data for Compounds Like Erythritol
Erythritol is “Generally Recognized As Safe (GRAS)” by the U.S. Food and Drug Administration (FDA), which means there is no requirement for long-term safety studies.
Partly because erythritol is considered natural, and it was generally regarded as safe, it wasn’t studied a lot before being used in a variety of different processed foods, says Hazen.
“In all fairness, there’s no one who could have predicted this. We certainly didn’t; we just stumbled on it. But now that we know, we think some cautionary alarms need to go up, and we need to study it to evaluate its safety,” he says.
Measuring artificial sweeteners is difficult, and labeling requirements are minimal and often do not list individual compounds.
Regarding erythritol, it’s now clear that this is something that people need to be informed about so that they can make healthy choices, says Hazen. “From a public health standpoint, we should require labeling so that people can be informed and choose,” he says.
Bottom Line: Should You Keep Eating Foods Sweetened With Erythritol?
“My hesitation for recommending artificial sweeteners is the lack of scientific knowledge about their long-term effects,” says Kainth. This study shows that rather than adding health benefits, use of erythritol has potential for harm, he adds.
“With the information we have so far, this would further strengthen my support for choosing lifestyle changes and reducing sugar intake over using artificial sugar substitutes for an overall reduced risk of cardiovascular events,” he says.
Hazen agrees, saying, “I’m going to tell my patients that it’s better to use a modest amount of sugar or honey — in moderation — rather than reach for the thing that has an enormous amount of artificial sweetener in it that has not been well studied in terms of long-term health effects.”
Kainth tells his patients to be patient and kind to themselves when making changes to their diet, and that making small, gradual changes is more likely to be successful.
“One way to do this is by cutting out sugary drinks such as carbonated beverages and replacing them with water or unsweetened tea. Reading food labels and paying attention to the sugar content of the foods we eat is also a good place to start,” he says.