On February 27, 2023, a new headline grabbing study was published in Nature Medicine raising concerns about a potential link between erythritol and cardiovascular disease risk. The study has been widely criticized for being far from perfect, from a scientific point of view. It also does not show causation, only association. But we would be foolish to just brush it off on that account without first trying to understand the issue from both sides. After all, we are dealing with our health here.
What the study claims to show is that erythritol causes blood platelets to become sticky, thereby raising the risk of blood clotting, heart attack and stroke. The study is made up of three parts: a cohort study, an in vitro (test tube) and mouse study, and an in vivo (in actual people) study. Lets look at the three parts one by one.
The Cohort Study
This study suggests there is a connection between high levels of erythritol in the blood and an increased risk of cardiovascular events. This discovery was made after researchers set out to find compounds in blood which might predict a higher risk of heart attack or stroke. To do this, researchers tested more than 4,000 blood sample over a period of seven years. The samples came from both the United States and Europe. In these samples they came across one substance which seemed to play a big role in both heart attacks and strokes: erythritol.
The problem with this part of the study, critics say, is that all the blood samples tested came from people who were already pretty sick. Over 15% of them had heart failure; over 40% had already had a heart attack; over 70% had coronary artery disease; over 20% were type 2 diabetic; and over 70% had high blood pressure. The problem with this, critics of the study say, is that people with such metabolic profiles already have much higher levels of erythritol in their system compared to healthy people. This is due to something called the pentose phosphate pathway in which the body, when exposed to oxidative stress, creates erythritol all on its own. All the conditions mentioned above advances oxidative stress in the body so it is only natural, the critics say, that the samples tested showed a higher concentration of erythritol.
The In Vitro Study
To further prove their point, the researchers then went on to test their hypothesis in vitro (test tube) and in mice, where indeed erythritol appeared to cause platelets to stick together.
To this the critics say: tests done in a test tube environment and in lab animals cannot be assumed to show the same effect in humans. There are many examples of areas where this has been the case, critics say. Proper studies in people are required to know for sure if what is seen in a test tube or a mouse will also be seen in people.
The In Vivo Study
The researcher then went one step further and had eight people drink a beverage containing 30 grams of erythritol. To put that into context, that’s the equivalent of about two tablespoons of erythritol or what can be found (according to Dr. Hazen, one of the researchers behind the study) in one pint/half a liter of commercial erythritol sweetened ice cream. What they saw was that blood levels of erythritol shot straight up and stayed elevated above the threshold necessary to trigger and heighten clotting risk for the following two to three days.
The critique of this part of the study is that you cannot draw any conclusions from a group that small, and that 30 grams of erythritol is a lot more than most people will have at any one time. So again, a proper study is needed in order to draw any conclusions.
So what are we to believe? This is a complex issue that goes far beyond my pay grade, I’m afraid. Am I going to throw away my stash of erythritol? No. Not yet anyway. In my family we eat so little of it that it probably doesn’t make a difference either way. Which also makes me think that now that we have managed, over many years, to bring down our personal consumption of “sugar” considerably, switching back to honey, maple syrup, dates, or palm sugar probably won’t be a problem either, from a blood sugar perspective, that is. And it was the blood sugar issue which made us switch to erythritol to begin with.
But for people who have a sweet tooth and end up consuming a lot of erythritol during any given day because they intuitively reach for that low calorie / low glycemic treat? Well, that could potentially be a cause for concern going forward. But so could switching back to “regularly sweetened” foods. Any possible (and, as yet unproven) risks of excess erythritol would need to be balanced against the already proven health risks of excess sugar consumption.
So my thought here and now is this: Until more studies are done, causing experts to settle on a consensus, perhaps it is better to err on the side of caution and limit the use of erythritol, particularly if you are at risk of heart disease or stroke.
I found this video by Dr. Gil Carvalho from True Health Initiative insightful.
Also, I found this video, from Dr. Gregor from Nutritionfacts.org, to be helpful in trying to understand the significance of the pentose phosphate pathway.
***END OF UPDATE ***
Erythritol…. The name doesn’t exactly roll off the tongue. But this alternative to table sugar is definitely worth getting to know.
What is Erythritol?
Erythritol is a sugar alcohol. It exists naturally in various vegetables and fruits, including grapes, mushrooms, and watermelon. You can also find erythritol in fermented foods, such as soy sauce.
The body also creates erythritol when exposed to oxidative stress.
You may have heard of other sugar alcohols like xylitol, sorbitol and maltitol, which are all used throughout the food industry, but erythritol stands out by being the sugar alcohol with the least amount of calories.
- Table sugar: 4 calories per gram
- Xylitol: 2.4 calories per gram
- Erythritol: 0.24 calories per gram
And yet it contains 70% of the sweetness of regular table sugar.
Is erythritol safe to use?
Erythritol’s possible toxicity and its effects on metabolism have been studied in animals and despite long-term feeding of high amounts of the stuff, no serious side effects have been detected.
Sugar alcohols in general can cause a bit of an upset tummy in some people when eaten in large amounts. Due to the unique chemical structure of sugar alcohols, your body can’t digest them, and therefore they pass through most of your digestive system unchanged, or at least until they reach the colon. In the colon, they are fermented by the resident bacteria, which produce gas as a side product. It is for this reason that eating high amounts of sugar alcohols may cause bloating and digestive upset.
However, erythritol is different than the other sugar alcohols because most of it gets absorbed into the bloodstream before it reaches the colon.
It circulates in the blood for a little while, until it is eventually excreted unchanged in the urine. About 90% of erythritol is excreted this way.
But if it is so readily absorbed into the bloodstream doesn’t it cause havoc with blood sugar?
This is where erythritol really shines! Because it has absolutely no effect on your blood sugar, making it a really good sweetener to use if you are diabetic or insulin resistant or simply looking to limit your use of regular sweeteners to avoid that dreaded glycemic spike.
And as a bonus, erythritol also has no effect on cholesterol, triglycerides or other biomarkers.
In fact, some studies suggest that is can actually protect against heart disease. This is because, in the body, erythritol acts as an antioxidant. Here it reduces blood vessel damage which leads to improved function of blood vessels, thereby reducing the risk of heart disease.
Sounds great! But what about tooth decay?
Again, erythritol has no adverse effect on tooth health.
Unlike sugar, it doesn’t feed the bacteria that cause cavities.
In fact, erythritol (and also Xylitol) suppresses the growth of bacteria in the mouth.
So what’s not to love?
As far as I’m concerned nothing!
Well, except for the price. It is more expensive than regular table sugar.
- It contains almost no calories.
- It has 70% of the sweetness of sugar. And if mixed with a bit of stevia, which if often the case in commercial brands, then it comes across as every bit as sweet as cane sugar.
- It doesn’t raise blood sugar or insulin levels.
- It doesn’t cause tooth decay. In fact it helps to fight tooth decay.
- Studies in humans show virtually no side effects. Only people with known digestive issues should proceed with caution.
- Studies in which animals are fed massive amounts for long periods of time show no adverse effects.
So how do you use it?
It has the same consistency as regular table sugar and can be substituted one for one.
However, sugar alcohols in general have a cooling effect which I find can be a bit too much if used in excess.
I personally have never used more than 1/4 cup in any recipe and usually use as little as possible as I find that, despite it having “only” 70% of the sweetness of cane sugar, it is actually very sweet.
Perhaps this is because the brand I generally use contains a small amount of steviol glycosides, the active compound in stevia, which is many more times sweeter than cane sugar. Together this combination makes for a very sweet product. Most retail erythritol brands that I have come across have steviol glycosides added to it, all of them in amounts of less than 1%.
My best suggestion is the same as I always give when it comes to foods and recipes: experiment. Once you have used erythritol once or twice you will get a feel for how sweet it is and find your own perfect level of sweetness.
Want to dig deeper?
- This article as well as this one talk about how 90% of erythritol is absorbed into the bloodstream and therefore does not cause fermentation in the large intestine, almost eliminating the risk of bloating and gas.
- This article studies erythritol’s effect on blood sugar and insulin.
- This article and also this one looks into the possible health benefits of erythritol.
- This, this, as well as this study deal with erythritol and tooth decay.