New study links erythritol to increased blood clot risk

If you eat sugar-free or reduced-sugar foods or chew sugar-free gum that’s sweetened with non-nutritive sweeteners (meaning it doesn’t provide calories), there’s a good chance you’re consuming a sugar alcohol called erythritol. While erythritol occurs naturally in small amounts in certain foods like watermelon, grapes and pears, the erythritol used in sugar-free or reduced-sugar products is made in the lab by fermenting corn and is considered a food additive.

As a food additive, erythritol has been classified as generally recognized as safe (GRAS) by the U.S. Food & Drug Administration (FDA).However, there is growing evidence that while erythritol does not raise blood sugar levels and is therefore suitable for diabetics, its consumption may have other undesirable consequences – aside from the gas, bloating and diarrhea that some people with irritable bowel syndrome (IBS) experience. This is likely because sugar alcohols are a type of polyol – the “P” in FODMAPs.

A new study published on August 8, 2024 in Arteriosclerosis, thrombosis and vascular biology highlights some of these potential problemsLet’s look at what the study found and whether you should be concerned.

How was this study conducted and what did it show?

This study was fairly straightforward. Researchers at the Cleveland Clinic in Ohio took 20 volunteers and randomly divided them into two groups of 10 people each.

All volunteers were non-smokers, had no heart disease, high blood pressure or diabetes, and had normal kidney function. They had not taken antiplatelet medications in the past month and had no history of bleeding, bruising, or a documented bleeding disorder. The average age of the volunteers was 30 years, and the groups were approximately half female and half male.

The volunteers’ blood was tested for baseline data, including their blood erythritol levels. Remember, erythritol occurs naturally in some foods and there is evidence that our bodies also produce a small amount of this sugar alcohol, so most of us have some in our bodies..

The volunteers then fasted overnight. In the morning, one group drank a solution of water mixed with 30 grams of glucose (sugar) and the other group drank a solution of water mixed with erythritol. Their blood was drawn 30 minutes after drinking the solutions.

Unlike many other studies on erythritol, these researchers did not set out to find out whether erythritol increases blood sugar levels. Instead, they examined the blood of volunteers to see if erythritol affects blood clotting factors.

What does blood clotting have to do with it? Well, a certain level of blood clotting is necessary for cuts to stop bleeding and for a scab to form. However, when this clotting factor becomes too aggressive and clots form in your bloodstream, it can cause problems – such as a heart attack or stroke.

What the researchers found was that the blood erythritol levels of the group that drank the erythritol solution increased by 1,000% compared to their initial baseline levels. The volunteers in this group also had more active platelets and greater blood clotting, while the volunteers in the group that drank the sugar solution did not. Platelets are cells involved in blood clotting, and when they become too active, the risk of them forming potentially dangerous clots in your blood increases.

How does this apply to real life?

Often, researchers use a larger amount of a food than we would normally eat to show a link between it and disease or its prevention. In this case, however, they gave the erythritol group the amount of erythritol that would normally be found in a sugar-free soda or muffin—a real-world dose.

“This research raises concerns that a standard serving of a food or beverage sweetened with erythritol may acutely induce a direct clot-forming effect,” study co-author WH Wilson Tang, MD, director of research in heart failure and heart transplant medicine at the Cleveland Clinic, said in a press release.“Erythritol and other sugar alcohols commonly used as sugar substitutes should be evaluated for potential long-term health effects, particularly when such effects are not seen with glucose itself.”

We previously reported on a 2023 study conducted by the same researchers that found that people with existing risk factors for heart disease are twice as likely to have a heart attack or stroke if they have high levels of erythritol in their blood. And another study we reported on in 2022 suggests that people who get their “candy” primarily from artificial sweeteners have a 9% increased risk of heart disease.

In addition, researchers at the Cleveland Clinic published another study in June 2024 that found similar results to the current studybut this study used xylitol, another sugar alcohol used in sugar-free products.

So should you be concerned? And should you eat foods with sugar alcohols?

“I believe that occasional, small-scale consumption of sugar-sweetened treats is better than consuming beverages and foods sweetened with these sugar alcohols, especially for people at increased risk for thrombosis, such as those with heart disease, diabetes or metabolic syndrome,” said lead study author Stanley Hazen, MD, Ph.D., chief of the Division of Cardiovascular and Metabolic Sciences at the Cleveland Clinic Lerner Research Institute and co-division chief of Preventive Cardiology, in the same press release. “Cardiovascular disease develops over time, and heart disease is the leading cause of death worldwide. We need to make sure the foods we eat are not hidden contributors.”

But the FDA has given erythritol and other sugar alcohols like xylitol its GRAS seal of approval. This means that the scientific community as a whole currently believes that sugar alcohols are safe. There is even evidence that erythritol acts like an antioxidant in our bodies and does not raise blood sugar levels, making it safe for people with diabetes – at least as far as blood sugar levels are concerned..

However, the FDA’s stance on this issue may change as more research is conducted that either supports or disproves the link between sugar alcohols and the risk of blood clots. We saw this with brominated vegetable oil (BVO), which was found in some citrus-flavored sodas. Although BVO was originally on the GRAS list, after 50 years of research it had to be delisted and banned because the evidence was against its safety.

The same goes for trans fats. Scientists initially thought they were healthier than saturated fats – until enough research proved they were even more harmful. And today, trans fats, which are made by hydrogenating oils, are no longer allowed in our food.

The conclusion

This study suggests that a typical serving of erythritol – the amount you get in a sugar-free soda or muffin – can significantly increase your blood erythritol levels and activate platelet activity, increasing the risk of blood clots and possibly the risk of heart attack and stroke.

It’s important to note that this study was small, and research on this topic is still in its infancy. More – and larger, long-term – studies need to be done, as this study was only one day and only included 20 people. Until then, you have a choice whether to eat, drink, or chew (in the case of gum) erythritol and other sugar alcohols – or not, as long as they’re considered GRAS. It’s important to note that erythritol is often combined with other sweeteners, like stevia, so don’t assume a stevia product is pure stevia. Read the label, especially if you want to avoid sugar alcohols.

Since most of us eat more than the recommended amount of added sugar, sweeteners like erythritol can come in handy when we’re craving something sweet. But if you frequently snack and drink products that contain non-nutritive sweeteners like sugar alcohols or other sweeteners like sugar and high-fructose corn syrup, ask yourself if these are a substitute for more nutrient-dense foods. Could you start replacing some of your diet or regular sodas with water — even sparkling water if you need the carbonation? Could you replace your daily afternoon candy bar with a piece of dark chocolate and a handful of almonds? How about replacing breakfast pastries with a couple of eggs, a slice of whole-grain toast and a piece of fruit?

Yes, all foods fit into a balanced diet and can be enjoyed. It’s about patterns and the big nutritional picture. What does your pattern look like?