Erythritol, an ingredient in stevia, linked to heart attack and stroke, study finds
By Sandee LaMotte, CNN
(CNN) — A sugar replacement called erythritol β used to add bulk or sweeten stevia, monkfruit and keto reduced-sugar products β has been linked to blood clotting, stroke, heart attack and death, according to a study.
βThe degree of risk was not modest,β said lead study author Dr. Stanley Hazen, director of the Center for Cardiovascular Diagnostics and Prevention at the Cleveland Clinic Lerner Research Institute.
People with existing risk factors for heart disease, such as diabetes, were twice as likely to experience a heart attack or stroke if they had the highest levels of erythritol in their blood, according to the study, published February 27 in the journal Nature Medicine.
βIf your blood level of erythritol was in the top 25% compared to the bottom 25%, there was about a two-fold higher risk for heart attack and stroke,β Hazen said. βItβs on par with the strongest of cardiac risk factors, like diabetes.β
Additional lab and animal research presented in the paper revealed that erythritol appeared to be causing blood platelets to clot more readily. Clots can break off and travel to the heart, triggering a heart attack, or to the brain, triggering a stroke.
βThis certainly sounds an alarm,β said Dr. Andrew Freeman, director of cardiovascular prevention and wellness at National Jewish Health, a hospital in Denver, who was not involved in the research.
βThere appears to be a clotting risk from using erythritol,β Freeman said. βObviously, more research is needed, but in an abundance of caution, it might make sense to limit erythritol in your diet for now.β
In response to the study, the Calorie Control Council, an industry association, told CNN that βthe 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,β the councilβs Robert Rankin said in an email.
The results βshould not be extrapolated to the general population, as the participants in the intervention were already at increased risk for cardiovascular events,β Rankin said.
The European Association of Polyol Producers declined to comment, saying it had not reviewed the study.
What is erythritol?
Like sorbitol and xylitol, erythritol is a sugar alcohol, a carb found naturally in many fruits and vegetables. It has about 70% of the sweetness of sugar and is considered zero-calorie, according to experts.
Artificially manufactured in massive quantities, erythritol has no lingering aftertaste, doesnβt spike blood sugar and has less of a laxative effect than some other sugar alcohols.
βErythritol looks like sugar, it tastes like sugar, and you can bake with it,β said Hazen, who also directs the Cleveland Clinicβs Center for Microbiome and Human Health.
βItβs become the sweetheart of the food industry, an extremely popular additive to keto and other low-carb products and foods marketed to people with diabetes,β he added. βSome of the diabetes-labeled foods we looked at had more erythritol than any other item by weight.β
Erythritol is also the largest ingredient by weight in many βnaturalβ stevia and monkfruit products, Hazen said. Because stevia and monkfruit are about 200 to 400 times sweeter than sugar, just a small amount is needed in any product. The bulk of the product is erythritol, which adds the sugar-like crystalline appearance and texture that consumers expect.
Connection between erythritol and cardiovascular issues
The discovery of the connection between erythritol and cardiovascular issues was purely accidental, Hazen said: βWe never expected this. We werenβt even looking for it.β
Hazenβs research had a simple goal: find unknown chemicals or compounds in a personβs blood that might predict the risk for a heart attack, stroke or death in the next three years. To do so, the team began analyzing 1,157 blood samples in people at risk for heart disease collected between 2004 and 2011.
βWe found this substance that seemed to play a big role, but we didnβt know what it was,β Hazen said. βThen we discovered it was erythritol, a sweetener.β
The human body naturally creates erythritol but in low amounts that would not account for the levels they measured, he said.
To confirm the findings, Hazenβs team tested another batch of blood samples from more than 2,100 people in the United States and an additional 833 samples gathered by colleagues in Europe through 2018. About three-quarters of the participants in all three populations had coronary disease or high blood pressure, and about a fifth had diabetes, Hazen said. Over half were male and in their 60s and 70s.
In all three populations, researchers found that higher levels of erythritol were connected to a greater risk of heart attack, stroke or death within three years.
But why? To find out, researchers did further animal and lab tests and discovered that erythritol was βprovoking enhanced thrombosis,β or clotting in the blood, Hazen said.
Clotting is necessary in the human body, or we would bleed to death from cuts and injuries. The same process is constantly happening internally as well.
βOur blood vessels are always under pressure, and we spring leaks, and blood platelets are constantly plugging these holes all the time,β Hazen said.
However, the size of the clot made by platelets depends on the size of the trigger that stimulates the cells, he said. For example, if the trigger is only 10%, then you only get 10% of a clot.
βBut what weβre seeing with erythritol is the platelets become super responsive: A mere 10% stimulant produces 90% to 100% of a clot formation,β Hazen said.
βFor people who are at risk for clotting, heart attack and stroke β like people with existing cardiac disease or people with diabetes β I think that thereβs sufficient data here to say stay away from erythritol until more studies are done,β Hazen said.
Oliver Jones, a professor of chemistry at RMIT University in Australia, noted that the study had revealed only a correlation, not causation.
βAs the authors themselves note, they found an association between erythritol and clotting risk, not definitive proof such a link exists,β Jones, who was not involved in the research, said in a statement.
βAny possible (and, as yet unproven) risks of excess erythritol would also need to be balanced against the very real health risks of excess glucose consumption.β
Blood tests tracked erythritol levels and clotting risk
In a final part of the study, eight healthy volunteers drank a beverage that contained 30 grams of erythritol, the amount many people in the US consume, Hazen said, according to the National Health and Nutrition Examination Survey, which examines American nutrition each year.
Blood tests over the next three days tracked erythritol levels and clotting risk.
βThirty grams was enough to make blood levels of erythritol go up a thousandfold,β Hazen said. βIt remained elevated above the threshold necessary to trigger and heighten clotting risk for the following two to three days.β
Just how much is 30 grams of erythritol? The equivalent of eating a pint of keto ice cream, Hazen said.
βIf you look at nutrition labels on many keto ice creams, youβll see βreducing sugarβ or βsugar alcohol,β which are terms for erythritol. Youβll find a typical pint has somewhere between 26 and 45 grams in it,β he said.
βMy coauthor and I have been going to grocery stores and looking at labels,β Hazen said. βHe found a βconfectioneryβ marketed to people with diabetes that had about 75 grams of erythritol.β
There is no firm βaccepted daily intake,β or ADI, set by the European Food Safety Authority or the US Food and Drug Administration, which considers erythritol generally recognized as safe.
βScience needs to take a deeper dive into erythritol and in a hurry, because this substance is widely available right now. If itβs harmful, we should know about it,β National Jewish Healthβs Freeman said.
Hazen agreed: βI normally donβt get up on a pedestal and sound the alarm,β he said. βBut this is something that I think we need to be looking at carefully.β
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