Erythritol and health risk: how much weight is behind the claims?

By Oliver Morrison

- Last updated on GMT

Image: Getty/Tatiana
Image: Getty/Tatiana

Related tags Artificial sweeteners Sweeteners Sugar substitute erythritol

Erythritol remains an important tool in long-term weight gain and disease risk, according to the international association representing the low- and reduced-calorie food and beverage industry, after research showed that the popular artificial sweetener is associated with an increased risk of heart attack and stroke.

In findings published in Nature Medicine, researchers studied over 4,000 people in Europe and the US. They found those with higher blood erythritol levels were at elevated risk of experiencing a major adverse cardiac event such as heart attack, stroke or death.

“Sweeteners like erythritol, have rapidly increased in popularity in recent years but there needs to be more in-depth research into their long-term effects,” said senior author Stanley Hazen, chairman for the Department of Cardiovascular & Metabolic Sciences in Lerner Research Institute. “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.”

Erythritol occurs naturally in a variety of foods, such as pears and watermelons, but in recent years has increasingly become a common ingredient in low-calorie foods as a sugar replacement sweetener. Artificial sweeteners, such as erythritol, are common replacements for table sugar in low-calorie, low-carbohydrate and ‘keto’ products.

What explains the association with elevated risk of experiencing heart attack or stroke? Erythritol is about 70% as sweet as sugar and is produced through fermenting corn. After ingestion, erythritol is poorly metabolized by the body. Instead, it goes into the bloodstream and leaves the body mainly through urine. The human body creates low amounts of erythritol naturally, so any additional consumption can accumulate, the study said.

This finding echoes a 2017 study that identified erythritol as a biomarker for increasing fat mass. In contrast to previous assumptions and research, this study found that erythritol can be metabolized by, and even produced in, the human body.

Researchers found that students who gained weight and abdominal fat over the course of the year had fifteenfold higher blood erythritol at the start of the year compared with their counterparts who were stable or lost weight and fat mass over the academic year.

But clinical observation studies demonstrate association and not causation

Sugar-free products containing erythritol are often recommended for people with obesity, diabetes or metabolic syndrome and are looking for options to help manage their sugar or calorie intake.

People with these conditions, however, are also at higher risk for adverse cardiovascular events like heart attack and stroke. This fact was seized on by the Calorie Control Council (CCC), the international association representing the low- and reduced-calorie food and beverage industry in response to that latest erythritol research.

Erythritol is incorrectly labelled an artificial sweetener as it exists naturally in a variety of fruits and also can be produced by the human body from glucose, stressed the CCC. In addition to the observational design, both the untargeted and targeted metabolomic analyses included individuals who were already at increased risk for adverse cardiovascular events.

“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, and should not be extrapolated to the general population, as the participants in the intervention were already at increased risk for cardiovascular events,” said CCC Executive Director Robert Rankin.

Further, in-vitro studies cannot mimic the complex physiological environment of the human body which include absorption, metabolism, and excretion, the CCC claimed.  Lastly, it said, as most commercial products containing erythritol usually contain a small amount, usually blended with other sweeteners, the intervention where subjects were instructed to consume 30 g of erythritol dissolved in 300 ml water within two minutes does not reflect a typical real-world serving. 

For more than 30 years, erythritol has been commercially produced and added to foods and beverages to provide sweetness, as well as enhance their taste and texture. In addition to providing zero calories, erythritol is well-tolerated, does not affect blood serum glucose or insulin levels and does not cause tooth decay.

The safety of erythritol as a food ingredient under conditions of its intended use is substantiated by a number of human and animal safety studies, including short- and long-term feeding, multi-generation reproduction and teratology studies. The WHO/FAO Joint Expert Committee on Food Additives (JECFA) reviewed the safety of erythritol in 1999 and established an ADI of “not specified,” the highest safety category possible. It has already been approved for use in foods in more than 50 countries, including Canada, US, Brazil, Mexico, Australia, and the European Union, and petitions have been submitted to additional governmental agencies throughout the world to expand the use of erythritol.

“Erythritol is a proven safe and effective choice for sugar and calorie reduction and, for more than 30 years, has been used in reduced-sugar foods and beverages to provide sweetness, as well as enhance their taste and texture,” added Rankin. “Along with exercise and a healthy diet, reduced-calorie sweeteners are a critical tool that can help consumers manage body weight and reduce the risk of non-communicable diseases, such as cardiovascular disease.”

The authors of the latest study did note it had several limitations, including that clinical observation studies demonstrate association and not causation. They insisted long-term safety studies erythritol into are still needed, however, despite its approval as safe for use in foods in the EU and US.

“Our study shows that when participants consumed an artificially sweetened beverage with an amount of erythritol found in many processed foods, markedly elevated levels in the blood are observed for days – levels well above those observed to enhance clotting risks,” said Dr. Hazen. “It is important that further safety studies are conducted to examine the long-term effects of artificial sweeteners in general, and erythritol specifically, on risks for heart attack and stroke, particularly in people at higher risk for cardiovascular disease.”


Cleveland Clinic study finds common artificial sweetener linked to higher rates of heart attack and stroke


Nature Medicine

DOI: 10.1038/s41591-023-02223-9

Common sweetener in low-cal foods also a marker for weight gain



Proceedings of the National Academy of Sciences

DOI: 10.1073/pnas.1620079114


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