A New Study Links Erythritol (Found in Stevia and Monk-Fruit) With Heart Disease

The sweeteners contain erythritol, which has been linked to stroke, heart attacks, and blood clotting.

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If you've ever eaten low-calorie sweeteners that contain stevia (like Truvia) or monk-fruit, they may also include erythritol, a natural sugar alcohol that offers a similar sweetness to sugar, but with zero calories.

But erythritol, which is popular in keto-friendly foods and low-sugar or sugar-free baked goods and foods, may have an unexpected and very unwelcome side effect, according to a new study published in Nature Medicine. When looking at people who had major cardiovascular events like heart attacks and strokes, they found that people who had them were far more likely to have high levels of erythritol circulating in their blood.

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The study also found that erythritol enhanced the reaction of platelets (the part of your blood associated with clotting) in test tube studies. And a very small pilot study that was part of this research had healthy volunteers drink a single beverage containing artificial sweeteners. They found that the levels of erythritol in their blood increased well above the levels that were associated with clotting in the study, and stayed high for more than two days after consumption in some participants.

“The degree of risk was not modest,” lead study author Stanley Hazen, M.D., director of the Center for Cardiovascular Diagnostics and Prevention at the Cleveland Clinic Lerner Research Institute, told CNN. "If your blood level of erythritol was in the top 25% compared to the bottom 25%, there was about a two-fold higher risk for heart attack and stroke. It’s on par with the strongest of cardiac risk factors, like diabetes.”

That's on top of research from 2022, published in the British Medical Journal, that found an increased risk of cardiovascular disease in the people with the highest intake of other artificial sweeteners, such as aspartame (found in NutraSweet and Equal) acesulfame potassium, and sucralose (found in Splenda).

That's led many experts to recommend avoiding artificial sweeteners altogether. "Artificial sweeteners have been linked to increases in body weight, insulin resistance, type 2 diabetes, and heart diseases," says Charles German, M.D., M.S., assistant professor of medicine in cardiology at the University of Chicago. "We can’t say definitively whether erythritol specifically has the same effects. The results of this study suggest this link may be mediated by increased clotting, which can lead to heart attack and stroke, though this result should be interpreted with caution given the small number of individuals used in this portion of the study."

The size of the study has other experts taking the findings with a grain of salt (or sugar). "It’s interesting that they found these associations with erythritol and with adverse cardiovascular events, but it doesn’t prove causality," says Sean Heffron, M.D., cardiologist at the Center for the Prevention of Cardiovascular Disease at NYU Langone Heart. "Certainly a lot more research needs to be done, and this needs to be investigated with a lot more rigor." Heffron is also a bit skeptical, because erythritol is a compound that's produced naturally within the body. "They didn’t show that the erythritol-based sweeteners are at play here."

So should you toss out your stevia and monk-fruit sweeteners? Not necessarily, though there's a case to be made for reducing your taste for something sweet altogether. Americans currently eat way more sugar than recommended—77 grams per person per day, which is more than three times the 25 grams recommended for women, according to the American Heart Association.

Dr. German specifically cautions about sugary drinks like sodas, whether they contain real sugar or an artificial sweetener. "Sugar-sweetened beverages, including those that use erythritol, should be limited or avoided given the potential link with cardiovascular disease," German says. And he also cautions against artificial sweeteners altogether. "This study adds to the well-known literature that any artificial sweetener is not healthy, and should be avoided to maintain cardiovascular health."

Bottom line: "I encourage everyone to eat a well-balanced, diverse diet," Dr. Heffron says. "Nothing in large quantities is good for you, so everything in moderation."

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  1. Witkowski M, Nemet I, Alamri H, et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med. 2023. doi:10.1038/s41591-023-02223-9

  2. Clinicaltrials.gov. Consumption of Oral Artificial Sweeteners on Platelet Aggregation and Polyol Excretion (COSETTE). Accessed March 14, 2023.

  3. Debras C, Chazelas E, Sellem L, et al. Artificial sweeteners and risk of cardiovascular diseases: results from the prospective NutriNet-Santé cohort. BMJ Clinical Research. 2022;378:e071204. doi:10.1136/bmj-2022-071204

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