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As rates of diabetes and prediabetes continue to soar in the US and worldwide, which also increases the risk for heart disease, many health experts have recommended that people avoid sugar.  Instead, artificial sweeteners have been recommended and their use has increased dramatically over the last several decades, exceeding 7 billion dollars in sales in 2022.

As I mentioned in a recent blog, Are artificial sweeteners worse than sugar? the more common artificial sweeteners (aspartame, sold as Equal and NutraSweet) and sucralose, sold as Splenda) appear to cause more harm than using sugar.

This has created a push for consumers to use more natural sweeteners such as Stevia, Monk Fruit, Xylitol, and Erythritol.

The challenge is that nobody has studied these natural agents and compared the clinical outcomes with a placebo to confirm that they are safe.

Plus, the idea that artificial sweeteners, even natural ones, promote weight loss long-term turns out not to be the case, again see the blog link above.

The recent publication in Nature Medicine on February 27th, 2023 has left many people unsettled if not alarmed after Erythritol, which was thought to be a safe, natural alternative to sugar, has been associated with an increased risk for heart disease.

But before you panic over the news, let’s look at the details of this important study.

Researchers monitored several thousand subjects from the US and Europe at high risk for a heart attack, stroke, or cardiac-related death for three years and measured their blood levels of erythritol. Almost half of these subjects had had a prior heart attack, almost three-quarters had been diagnosed with coronary heart disease, and three-quarters had hypertension—they were clearly not average healthy people, but mostly people with very advanced heart disease. So for the moment, nobody should say from this study that healthy people would be at elevated risk for heart disease if they consumed erythritol.

The researchers divided these subjects into four groups based on blood levels of erythritol into four quartiles (from low, to modest, to mildly elevated, and to high levels). They also controlled for other factors like smoking, cholesterol, blood sugar levels, and blood pressure.

Over three years, those in the fourth quartile (highest levels) had double the risk for heart disease events compared to the first quartile (low levels). Please keep in mind that this is an association with heart disease and does not prove that erythritol was the cause for the event. Although honestly from reading the media reports, the news regarding erythritol sounded pretty concerning to me.

What the media did not mention was that for those with modest to mildly elevated levels of erythritol (quartiles 2 and 3), there was no significant increased risk for heart disease, only for those with very high levels showed a compelling risk.

As the authors pointed out, erythritol is in many food products now and many people do have very high intakes. The researchers also shared data showing that drinking just one can of erythritol-sweetened soda raised blood levels for two days.

The authors shared a separate study that they had conducted showing how people with high levels of erythritol have an increased risk for platelet aggravation and clotting, thus providing a mechanism for how the risk for heart disease might occur as well.

Until we conduct randomized trials with erythritol and a placebo, and hopefully other artificial sweeteners as well, we will not know if erythritol truly causes heart attacks or not.

Currently, the US Food and Drug Administration (FDA) and the European Union generally consider artificial sweeteners to be safe based on limited short-term studies. This despite more recent observational studies have concluded that artificial sweeteners and sweeteners do not provide the intended benefits and are instead associated with weight gain, increased body fat, type 2 diabetes, and cardiovascular events.

In the meantime, it seems warranted that we should be reading labels and trying to keep our erythritol intake to a minimum or at least only modest.

As labeling rules for artificial sweeteners are nebulous, the only way to totally avoid artificial sweeteners is to avoid processed food entirely.

Until clinical outcome studies show that even natural non-caloric sweeteners are safe, this caution and use in moderation should also apply to other sweeteners including stevia, monk fruit, and xylitol.

Our best choice is to enjoy food that is unsweetened, natural, and unprocessed! Food can still taste delicious without overwhelming our taste buds with sweetness.

For an occasional treat, when you want to celebrate a special occasion, stick with a natural ingredient, such as a small quantity of honey or maple syrup.

Although not always as sweet as sugar or artificial sweeteners, fresh fruit offers our palate some sweetness, without a jump in blood sugar levels and it nourishes our healthy gut microbes and provides valuable life-sustaining nutrients. Fresh fruit is good for us, and we should eat 2-3 servings daily.

I wish you the best of health!

Steven Masley, MD, FAHA, FACN, CNS


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  2. Jotham Suez et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. NATURE 9 October 2014;514:181-86. doi:10.1038/nature13793
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