Why you shouldn’t believe the alarmist headlines about erythritol, a naturally-occurring zero-calorie sweetener.
“Sugar substitute erythritol, common in keto foods, may increase your risk for stroke.” “Artificial sweetener in diet drinks and protein bars may increase risk of heart attack.” “Zero-calorie sweetener linked to heart attack and stroke, study finds.”The study in question was published in Nature Medicine in late February, and the media has predictably gone full throttle with the alarmist headlines suggesting cardiovascular doom and gloom for those who use erythritol. As is so often the case, the real story is much more nuanced and complicated.
In the new paper, the authors demonstrate that high blood levels of erythritol are associated with elevated risk of major cardiovascular events; additionally, consumption of erythritol was shown to increase blood levels of erythritol.
Before we get into the study, why does all of this matter? Almost all integrative doctors recommend cutting or restricting sugar and refined carbohydrates (like bread and pasta) in the diet. This is due to the many, many negative health effects from eating too much of these foods, including: type 2 diabetes, Alzheimer’s, heart disease, cognition, and decreased learning and memory. Sugar alternatives like erythritol allow health-conscious people to enjoy some sweetness while avoiding the terrible effects of eating sugar-laden foods. Many foods contain monk fruit extract, another popular sugar alternative, which is almost always combined with erythritol to tame down the sweetness (monk fruit extract is 200 times sweeter than sugar); erythritol is in fact the main ingredient in some monk fruit products.
So, is erythritol dangerous? There are many reasons to take the results of this new study, and the conclusions drawn by non-scientists at major media outlets writing sensationalist headlines, with a grain of salt. For one, this is an observational study that established a correlation between high blood levels of erythritol and cardiovascular risk. The study didn’t assess individual’s consumption of erythritol and link it to higher CVD risk. It simply measured people’s erythritol levels and compared those levels to CVD risk. But correlation is not causation, as the study authors point out. The two may be related, but higher blood levels of erythritol may not be the cause of higher cardiovascular disease (CVD) risk. As ANH Board Member Ron Hoffman, MD points out, it may be that overweight people, or those already at high CVD risk, are more motivated to use sugar substitutes. The analysis cannot be used to imply that eating erythritol raised CVD risk, but that didn’t stop the media from spinning the study’s results into misleading and sensationalist headlines.
Further, the body makes erythritol, and those who are overweight or have diabetes make more of it. This again undermines the notion that eating erythritol leads to higher CVD risk; those at higher CVD risk have elevated levels because their bodies produce more of it.
The study also includes an experiment in which 8 volunteers were given a drink containing 30 grams of erythritol, resulting in raised blood levels of erythritol. The issue is that 30g is much, much higher than most people would consume. Erythritol is naturally found in foods like melons, pears, and grapes, soy sauce, wine, miso paste, and sake. Consumption of a few common servings from these foods may add up to less than 0.5 g/day. Some people may add a few grams to sweeten their tea. This experiment does not reflect real world consumption, so it’s hard to draw sweeping conclusions.
Many of the foods listed above are popular in Japan, and indeed, per capita erythritol consumption from natural sources in Japan (106 mg/day) far exceeds that in the US (25mg/day). Yet residents of Japan have the highest life expectancy in the world, which is part due to low mortality rates from heart disease. Despite lower consumption of foods containing erythritol, the US has the second highest mortality rate from ischemic heart disease compared to the 38 other countries in the Organization for Economic Cooperation and Development.
The media is clearly driven to sensationalize news stories to get as many readers clicking on their outrageous headlines as possible. But the media ultimately rely on the support of their advertisers, and junk food companies are big spenders: food and beverage companies spent $2.54 billion on advertising in 2021. Junk food companies stand to benefit when healthier alternatives to their products are cut down in front of the public, and media companies are all too willing to serve their corporate supporters.
Scaring people away from otherwise healthy sugar alternatives does not serve public health. If the concern was legitimate, that would be one thing, but the above analysis shows that the conclusions being drawn by the media are not based in science.
