Do You Really Need to be Concerned About Erythritol?

Guiding Stars updated its guidance for non-nutritive sweeteners on March 18, 2024. Learn more.

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It’s rare that a nutrition study gets as much immediate buzz as the recent one about erythritol. Have you heard of it? Erythritol is a sugar alcohol that’s used as a low-calorie sweetener. Media reports quickly spread the news on a new study that linked erythritol with cardiovascular events like heart attacks and stroke. Unfortunately, much of the coverage was too brief to provide any context to the findings. And context can make all the difference. Here I will break down the major points about this study to help you consider erythritol in your diet.

What exactly is erythritol?

I’ve covered sugar and sugar substitutes in several Guiding Stars blog post in the past. But none of those went into detail about erythritol, so let’s start there. Sugar alcohols (including erythritol) occur naturally in small amounts in certain fruits and vegetables. They are sometimes found in fermented foods like beer, cheese, soy sauce, and wine as well. Erythritol is also manufactured and used to sweeten sugar-free and low-sugar food products. These include candies, gum, and baked goods, and as an alternative to sugar for home use in cooking and baking.

Erythritol’s sweetness level is 60% – 80% that of table sugar, so it’s not a high-intensity sweetener. This makes it easy for the food industry to swap erythritol for the real thing in sugar-free and low-sugar products. There’s no need to adjust formulations drastically like there is with high-intensity sweeteners. Erythritol doesn’t contribute carbohydrates, sugar, or calories, so it doesn’t affect blood glucose levels or insulin levels. In fact, most of it is excreted unchanged. Our bodies also produce some erythritol naturally, as a result of glucose metabolism (even if we don’t consume it).

What was the erythritol study about? 

Cleveland Clinic researchers led this study and the Nature Medicine journal published it. The study analyzed 1,157 subjects undergoing assessment for cardiovascular risk for three years. The results? The subjects with the highest blood levels of erythritol also had the highest incidence of adverse cardiovascular events. The researchers confirmed this association through data analysis from additional subjects in the U.S. and Europe. Follow-up in vitro (test-tube) research and animal work also suggested that erythritol enhanced blood clotting. However, the animal study used erythritol doses double that of the highest concentrations used in the other studies.

These findings prompted the researchers to call for additional research into the safety of erythritol consumption. They also concluded that high blood levels of erythritol correlate with pre-existing conditions that include increased cardiovascular risk. In cases where people have both, they may be more likely to suffer from heart attack or stroke. (It’s important to note that the published study involved blood erythritol levels only. Erythritol from foods was not part of the data collection or analysis.)

Why the controversy?

The researchers did demonstrate that cardiovascular risk may be associated with erythritol levels. However, their results were not specific to erythritol as a sweetener. They also failed to show any increased risk in the majority of the subjects—those with typical blood levels of erythritol. In addition, the researchers make another key distinction about the study subjects. Most of them were assessed before erythritol became a widely used sweetener in the food supply. So it’s safe to assume that most of the measured blood levels in the study reflect naturally produced erythritol.

There are several other reasons why many nutrition experts are not concerned about the results of this study:

  • The main investigation is observational, and therefore it cannot prove that erythritol caused the increased cardiovascular effects. Observational studies must be followed by experimental research in order to draw cause and effect conclusions. 
  • Erythritol levels vary across individuals, and also increase in response to certain health conditions, such as pre-diabetes and diabetes. In the study, the group of subjects with the higher erythritol levels also had more pre-diabetes/diabetes cases. (They were also the oldest group.) So it’s possible that increased erythritol levels might simply be a biological marker for those diseases. Diabetes itself is associated with increased cardiovascular risks.  
  • Erythritol consumption was not part of the published study. The data sets used in the study did not contain any information about how much erythritol the subjects ingested. It’s a big jump to make conclusions about dietary levels of a substance from blood level data. (This is especially true when it’s impacted by multiple variables.)

How does Guiding Stars handle sugar alcohols like erythritol?

Guiding Stars’ initial algorithm included sugar alcohols in the added sugars calculation because they are caloric sweeteners. (Erythritol’s calories are negligible though.) In the 2023 algorithm update, however, the Scientific Advisory Panel decided to align with FDA Nutrition Fats label guidance and measure sugar alcohols separately from added sugars. Guiding Stars now debit foods that contain sugar alcohols by 1 star. Why? They may cause gastric issues like gas, bloating, and diarrhea. This is because they are not completely absorbed and can ferment in the GI tract. In addition to potentially causing gastric distress, sugar alcohols are found with increasing frequency in highly processed low carbohydrate products that typically provide little nutritional value.

What foods typically contain sugar alcohols?

Sugar alcohols have a long history of use in “diet” hard candies, chewing gum, chocolates, and fruit spreads/jams. As demand for sugar-free and low-carbohydrate products increased, so did the use of sugar alcohols. Pudding mixes, soft drinks, baked goods, and ice creams now often include them. Most recently, the popularity of “keto” foods means erythritol and other sugar alcohols are in more foods than ever before. Erythritol is especially popular with those following a ketogenic diet, and can be found in products like:

  • Baking mixes
  • Protein and energy bars
  • Frosting
  • Cereals
  • Packaged desserts
  • A stand-alone sugar substitute (in granular or powdered form) for home cooking and baking

Bottom line:

  • Erythritol is not a new sweetener. More than 60 countries approve its use. Health authorities like the World Health Organization and the U.S. Food and Drug Administration confirm its safety. 
  • It’s not known if consuming high amounts of erythritol over long periods of time is safe. This new study adds to the overall research on erythritol’s potential effects on cardiovascular health, but is certainly not definitive.
  • There are many other sugar substitutes available if you wish to limit or avoid erythritol.
  • In an effort to cut back on sugar intake, the use of alternative sweeteners appeals to many consumers. Weigh the benefits of decreased sugar intake against any potential harm that may arise from consuming erythritol.