Are artificial sweeteners bad for you? Research Links Erythritol to Strokes and Heart Attacks

Some doctors are urging patients to cut back on sugar substitutes as questions mount about their health effects.

In the latest study, published in February in the journal Nature Medicine, Cleveland Clinic researchers found that the commonly used zero-calorie sweetener erythritol was associated with an increased risk of heart attacks, strokes and death within three years.

Erythritol, a sugar alcohol produced naturally in the body, is used as a sugar substitute in low-calorie and low-carb products, often in those marketed as keto-friendly, such as ice cream, pastries and condiments. It is also often mixed with other sweeteners.

As low carb and ketogenic diets have become popular, people have turned to unsweetened products for a dose of sweetness with less sugar and carbs. Still, researchers warn that sugar substitutes could pose their own health problems.

“We can’t say conclusively that (sweeteners) are safe,” says Dariush Mozaffarian, dean and professor of nutrition and medicine at Tufts University’s Friedman School of Nutrition Science and Policy. “I think it’s really worrying.”

Researchers have long probed the possible health risks of alternative sweeteners, but many studies have used food diaries, which researchers say aren’t always a reliable record of what people actually eat. The latest erythritol study is more robust and comprehensive.

Other research has suggested that certain sugar alternatives such as sucralose and saccharin may increase the risk of developing type 2 diabetes.


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Most studies, including the recent one on erythritol, show an association between sugar alternatives and health risks, but don’t prove that sweeteners cause the problems.

Still, doctors and researchers say there’s enough evidence that people should limit their intake of sugar substitutes.

Doctors aren’t saying regular sugar is a good alternative, as it has clear links to the risks of diabetes, obesity, and heart disease. Instead, they recommend reducing your intake of sugar and sugar substitutes.

What the latest research has found

The findings recently published in Nature Medicine are the result of more than a decade of research. Initially, the researchers were looking for compounds in the blood that could predict the development of heart disease and stroke, says Stanley L. Hazen, lead study author and chair of the Department of Cardiovascular and Metabolic Sciences at the Cleveland Clinic. .

After analyzing the blood of more than 1,000 people, the chemical that seemed to most predict risk was erythritol, Dr. Hazen says. The samples were taken between 2004 and 2011, before erythritol was a common additive in the food industry. The researchers thought the erythritol they were measuring was naturally produced in the body.

The researchers then looked at levels in more than 2,000 people in the United States and more than 800 in Europe. Most of the participants, whose median age was between 60 and 70, already had heart disease or were at risk due to conditions such as high blood pressure and diabetes.

The biggest limitation of the Nature Medicine study is that the participants were largely people with risk factors for heart disease, says Dr. Mozaffarian. But it included many people, about 4,000.

Dr. Hazen says that in each group analyzed, participants with higher levels of erythritol were more likely to have a heart attack or stroke or to die within three years. The researchers also conducted animal and laboratory studies, finding that erythritol caused an increased risk of clotting in mice and in blood and platelet samples.

what you can do

Dr. Hazen says he tells patients to look carefully at the labels of foods they buy, although he notes that erythritol may not always be specifically named with amounts as an ingredient. Products with ingredients like “sugar alcohol” or “natural sweeteners” could include erythritol.

He recommends avoiding foods and drinks sweetened with sugar substitutes. Use fruit or honey in moderation, or a little sugar if you want to sweeten something, he suggests.

The Calorie Control Council, a trade group representing the low calorie food and drink industry, said in an email that the safety of erythritol is backed by years of research. He said the results of a study of people already at risk for cardiovascular problems should not be generalized to the general population.

A representative of the US Food and Drug Administration said the agency does not comment on specific studies, but assesses them as part of a broader body of evidence to better understand the issues and protect health. public.

Many of the studies the FDA relies on to establish the safety of sugar substitutes used small amounts, says Dana Small, professor of psychology and psychiatry at Yale University and director of its Food Research Center. and modern physiology. Dr. Small has conducted research on sugar substitutes, but was not involved in the Nature Medicine study.

According to researchers, many artificial sweeteners are used in very small amounts because they are much sweeter than sugar. Erythritol, on the other hand, is slightly less sweet and is therefore used in greater quantities in food products.

“The amount of erythritol people consume daily is higher than other artificial sweeteners,” says Jotham Suez, assistant professor of microbiology at the Johns Hopkins Bloomberg School of Public Health, who studies sugar alternatives and has no participated in the Nature Medicine study. .

Previous research has pointed to risks with other sweeteners. A 2022 study in the journal Cell found that two of them, sucralose and saccharin, were linked to high blood sugar, a risk factor for developing type 2 diabetes.

And a 2020 study in the journal Cell Metabolism found that people who consumed the sweetener sucralose in combination with carbohydrates for a week became less sensitive to sugar. Specifically, more insulin was released when consuming the same amount of sugar, which is similar to what happens in diabetes.

Write to Sumathi Reddy at

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