Popular Sweetener Linked to Increased Risk of Blood Clots, Heart Attack, and Stroke

A new Cleveland Clinic intervention study in healthy volunteers reports concerning findings.

Breaking down the study linking erythritol and cardiovascular risk, on March 29, 2023. Kabachki.photo via shutterstock

Erythritol is a popular choice for those looking to cut down on sugar without losing flavor, but its health effects are often debated. New Cleveland Clinic research reveals a concerning finding: Erythritol makes platelets—blood cells involved in clotting—more active, leading them to react more strongly and increasing the risk of blood clots, heart attack, and stroke.

Cleveland Clinic researchers say this discovery, part of a series exploring the physiological effects of common sugar substitutes, may prompt a reassessment of how we use this sweetener.

The new findings build on the research team’s prior erythritol study. The previous study was limited because some of the participants had poor health, with more than 70 percent having cardiovascular issues. The new study addresses these limitations by recruiting healthy adults.

“This research adds to increasing evidence that erythritol raises cardiovascular risk. In a small group of healthy volunteers, we show ingesting erythritol made platelets more hyper-responsive ... which can raise the risk of blood clots,” senior and corresponding author Dr. Stanley Hazen, chair of Cardiovascular and Metabolic Sciences in Cleveland Clinic’s Lerner Research Institute and co-section head of Preventive Cardiology, told The Epoch Times in an email.

Unlike Sugar, Erythritol Can Promote Excess Blood Clotting

Erythritol is a popular sugar substitute used in many “low-carb” and “keto” foods. It is about 70 percent as sweet as sugar and is produced by fermenting corn or wheat starch. Health and weight-loss professionals often recommend it as a safer alternative to sugar for individuals with high cardiovascular risk factors, such as obesity, diabetes, or metabolic syndrome.

Although erythritol is classified as generally recognized as safe (GRAS) by both the U.S. Food and Drug Administration (FDA) and the European Food Safety Authority and is naturally found in fruits and vegetables, recent studies by Hazen’s group indicate that consuming typical amounts of erythritol may pose an increased cardiovascular risk.

“This paper builds on our earlier studies with erythritol,” Hazen said. The large-scale clinical observation studies in the United States and Europe, which were published in 2023 in Nature Medicine, showed that cardiac patients with higher levels of erythritol in their blood were twice as likely to suffer a major cardiac event—such as heart attack, stroke, or death—within the next three years compared to those with lower levels. The study also showed that adding erythritol to blood or platelets increased clot formation. Preclinical studies confirmed these findings.

The previous study had some limitations. Dr. Jayne Morgan, a cardiologist and clinical director of the COVID-19 Task Force at Piedmont Healthcare in Atlanta, told The Epoch Times that it was a clinical observation study, which means it could show correlations but not establish causation. Additionally, the study’s participants were in poor health; they were overweight, had high blood pressure, diabetes, smoking habits, and existing cardiovascular issues. So it was unknown if their elevated risks were due to their poor health or due to erythritol consumption.

The new human intervention study, published in Arteriosclerosis, Thrombosis and Vascular Biology, was designed to closely monitor how erythritol ingestion affects platelets at a dose typically contained “in commercial products,” such as an erythritol-sweetened soda or muffin, Hazen said.

In 20 healthy volunteers—nonsmokers without cardiovascular disease, high blood pressure, or diabetes—blood samples were taken after an overnight fast. Participants then consumed a solution with either 30 grams of glucose or erythritol. Blood samples taken 30 minutes later showed that erythritol levels increased more than 1,000 times in those who ingested erythritol.

Results also “revealed participants showed a significant increase in the susceptibility for blood clot formation after consuming erythritol,” Hazen wrote. “In stark contrast, no change was observed in participants after consuming a comparable amount of glucose. A significant new finding in these studies was the direct comparison of results with sugar (glucose), which did not have this effect.”

Hazen said that erythritol makes platelets more responsive, meaning they become more reactive and prone to forming clots. Consequently, even a minor trigger can cause a more robust activation of platelets, increasing the likelihood of blood clots. This heightened responsiveness can lead to excessive clotting.

“This was seen [in the previous paper] in whole blood, with platelet rich plasma, with isolated platelets, in animal models of disease,” he added. “The results of these mechanistic studies are all aligned with the prior large scale clinical observation data showing higher erythritol levels track with higher risk of major adverse cardiac events.”

1 Serving of Erythritol May Trigger Clot Formation

“This research raises some concerns that a standard serving of an erythritol-sweetened food or beverage may acutely stimulate a direct clot-forming effect,” study co-author Dr. W. H. Wilson Tang, research director for Heart Failure and Cardiac Transplantation Medicine at Cleveland Clinic, said in a statement. “Erythritol and other sugar alcohols that are commonly used as sugar substitutes should be evaluated for potential long-term health effects especially when such effects are not seen with glucose itself.”

He added that these findings are particularly significant because they follow a recent study by the same research group, which found that xylitol, another common sweetener, also increased blood levels and affected how blood cells clump together in healthy volunteers.

Like erythritol, Hazen noted in the email, “the investigations with xylitol also included large-scale clinical observation studies showing that elevation in plasma xylitol levels is associated with increased risk for heart attack, stroke or death over three years of follow-up.”

These findings underscore the importance of further long-term clinical studies to reassess the safety of erythritol and other sugar substitutes, according to both researchers.

The Rise of Erythritol: A ‘Natural’ Alternative to Synthetic Sweeteners

Concerns about the long-term effects of synthetic sweeteners have led many to seek “natural” alternatives such as erythritol, a widely used substitute for artificial sweeteners such as sucralose (Splenda), saccharin (Sweet’N Low), and aspartame (Equal, Nutrasweet).

While these artificial sweeteners were once favored for their calorie-free sweetness, they now face increasing scrutiny. For instance, aspartame has been linked to potential cancer risks, while saccharin has been associated with obesity and diabetes in animal studies.

In May 2023, the World Health Organization (WHO) advised against using nonsugar sweeteners, citing evidence that they do not support long-term weight loss and come with other health risks. The recommendations apply to everyone except those with preexisting diabetes.

Erythritol, on the other hand, is often recommended for diabetics because it doesn’t raise blood sugar levels and reduces dental plaque and tooth decay.

Reconsidering Erythritol: What the Latest Research Means for Your Diet

Based on the evidence, Hazen said, “Choosing sugar-sweetened treats occasionally and in small amounts would be preferable to consuming drinks and foods sweetened with these sugar alcohols, especially for people at elevated risk of thrombosis such as those with heart disease, diabetes or metabolic syndrome.”

He added that future research will “explore how broadly the pro-thrombotic effect is in alternative sugar substitutes. Including both alternative sugar alcohols and common artificial sweeteners.”