By Mila McManus MD and Nancy Mehlert MS

You may have seen several news stories recently about Erythritol, the zero-calorie sweetener, being found in a study to be “linked to increased cardiovascular risk”. The study, published by Nature Medicine, on the surface sounds concerning.  The researchers measured levels of erythritol in the blood and found that those with higher serum erythritol levels had an increased risk of stroke, heart  attack, and death. The research has been ongoing for over ten years.

When hearing news stories such as these, it is wise to take a closer look at what really occurred in the study. In fact, more often than not, the media outlet has not shared the whole story. There are at least three flaws to examine more closely in this study before we toss out the erythritol.

First, this study was not based on the intake or consumption of erythritol[1].  In fact, this study began before erythritol was approved as a sweetener, nor was it widely used as the study progressed. Serum samples from participants, therefore, reflected erythritol levels from another source. A 2017 study[2] found that humans produce erythritol endogenously ( i.e., produced inside the body) in response to the consumption of both glucose and fructose via the pentose phosphate pathway, or PPP.

Second, endogenous erythritol is a marker for a poor diet and metabolic dysfunction. Unlike erythritol, glucose and fructose are widely consumed in enormous amounts in both the U.S. and Europe, explaining why the study participants may have had high serum erythritol. This endogenous production of erythritol is correlated with cardiometabolic disease. For example, the PPP pathway is shown to modulate insulin sensitivity and obesity-induced inflammation and becomes dysregulated in people with obesity and metabolic disease. It seems likely that insulin resistance and high blood sugar are underlying causes of elevated endogenous erythritol levels.

Third, it is still unknown if high serum erythritol caused cardiovascular risk or was just associated with it. (It requires more than a suspect being at the scene of the crime to conclude that s/he was the culprit!) Nature Medicine did conduct a small experiment at the end of their study with eight human participants who were fed 30 grams of erythritol for seven days.  Their serum levels of erythritol increased significantly, but the researchers did not gather markers for blood clotting or note any adverse effects. So, we do know that high serum erythritol levels are associated with a higher risk of cardiac events and death, but again, correlation is not causation. Moreover, a study with only 8 participants, a good study, it does not make.  Sample size matters.

Studies in the past where animals were fed erythritol, the serum erythritol levels increased but no adverse effects were noted. In one study, rats were given a diet made up of 10% erythritol for two years and researchers observed positive effects on body weight with no adverse changes on numerous biomarkers related to metabolic health[3].

Chris Kresser summarized the results by saying “The study does not tell us that high serum erythritol causes cardiac events or deaths. Nor does it suggest that consuming erythritol in the diet increases the risk of cardiac events or death. In fact, given prior research, there is reason to believe that serum erythritol is simply a marker for sugar intake and or underlying metabolic dysfunction.”

We cannot be sure of either until more research is done.  In the meantime, we can offer some recommendations/reminders:

First, if you are consuming primarily packaged food bars, waters, protein powders, gummy candies, baked keto goods, and sweetening drinks with erythritol numerous times every day, err on the safe side and cut back on the excessive erythritol. 

Second, no matter what sweetener you use, be it sugar, artificial sweeteners, or more natural sweeteners like erythritol, xylitol, monk fruit, and stevia, constant use overstimulates your sweet taste buds and your pleasure centers of the brain.  This keeps you addicted to sweets, and possibly leads to overeating, or craving constantly. Moreover, this may mean that you fail to eat the meat, vegetables, nuts, seeds, and natural fruit for which humans are best suited.  So work toward less and less sweet drinks and foods, especially those that are “man”ufactured, and stick with the whole real foods and water our bodies are wired for and thrive on.  Fruit is the ideal sweet treat and, even so, should be consumed in moderation. Aim to make 80-90% or more of everything you eat real, whole, nature-made food.

[1] https://chriskresser.com/does-erythritol-increase-the-risk-of-heart-attack-and-early-death/, March 3, 2023

[2] Hootman KC, Trezzi JP, Kraemer L, Burwell LS, Dong X, Guertin KA, Jaeger C, Stover PJ, Hiller K, Cassano PA. Erythritol is a pentose-phosphate pathway metabolite and associated with adiposity gain in young adults. Proc Natl Acad Sci U S A. 2017 May 23;114(21):E4233-E4240. doi: 10.1073/pnas.1620079114. Epub 2017 May 8. PMID: 28484010; PMCID: PMC5448202.

[3] Lina BA, Bos-Kuijpers MH, Til HP, Bär A. Chronic toxicity and carcinogenicity study of erythritol in rats. Regul Toxicol Pharmacol. 1996 Oct;24(2 Pt 2):S264-79. doi: 10.1006/rtph.1996.0108. PMID: 8933643.