Have you seen the headlines that erythritol can lead to heart attacks and strokes? 

Well, if you have, it’s probably got your attention. This comes from a study recently published in Nature Medicine. What it showed is that there is a connection between higher blood levels of erythritol and a higher risk of stroke and heart attacks. Does this mean that we should all stop all erythritol sweetened products?

Maybe, but what I think it really means is we need to reflect on why we’re eating them in the first place. 

I’m Dr. Bret Scher, the director of Metabolic Mind. Here at Metabolic Mind, we explore the concept of nutritional ketosis as a treatment for mental illness. If you are following a keto diet and trying to be in nutritional ketosis, you may be using erythritol-sweetened products to help you along your way. If that’s the case, this study should get your attention. In this article, we’re going to talk about what the study showed and some of the good and bad parts of this study. 

Most importantly, bringing this back to what this means for you, does it mean we should all stop eating erythritol-containing products? Or can we say we need more information and can continue?

Let’s get into it. 

First, what is erythritol? Erythritol is called an artificial sweetener, but really, it’s not artificial. Erythritol is something that exists normally within our bodies. Our bodies produce it. It exists normally in nature and in some foods, but at very, very small concentrations. 

When used as an artificial sweetener, it’s usually put in keto products to make them taste sweet but it doesn’t give you the glucose and insulin response that sugar does. Like a lot of other artificial sweeteners that aren’t really artificial – like monk fruit or others – it’s used in keto products like ice cream, cookies, pancakes, waffles, coffee and tea, or in keto cereals. For me, that’s how I use it every now and then: when I don’t feel like eggs, I don’t want to make eggs for my kids, or we don’t have time to make breakfast, I use this keto cereal that’s sweetened with erythritol. This study made me sit and reflect on where erythritol is in my life and that’s what I found. 

People may choose to have erythritol-sweetened products because they don’t want to feel deprived when they’re following nutritional ketosis or they like having something sweet and they feel they have to appease their sweet tooth. There are other reasons, and we’re going to get into that near the end of this article.

But first, what did the study find? Well, the first part of the study was an observational study, just looking at the blood concentration of erythritol in individuals. That led to an association to a higher risk of cardiovascular events, and they realized the higher the blood level of erythritol, the higher the risk of cardiovascular events.

But this is just an observation and these are just measuring blood levels. We have no idea if it was endogenously produced, meaning their bodies were producing more, or if it was exogenously ingested, meaning they were eating more erythritol. That part of the study doesn’t show that at all. All it shows is that there is a correlation with higher blood levels. To achieve higher blood levels, chances are you’re going to be eating some. I think that’s an assumption we can make, but it wasn’t proven in the study. 

And another thing: was it just because people who were at higher risk of heart disease were choosing to eat these products? Again, this study doesn’t show that. There’s the potential for reverse causation or healthy user bias. There’s so many problems with the observational studies that, usually, we can just sweep them under the rug, especially when the hazard ratio, meaning the degree of the increased risk is really low, but in this case, it actually wasn’t. 

A low hazard ratio is usually anything below 2.0. Once it’s above two, it gets our attention. Again, it may not necessarily be causative, but it’s certainly worthy of a closer look.

Now, what this study did, though, is it didn’t just stop with the observation. That’s one thing I really like about the study. They took the next step and said, “Okay, if this observation is true, why? Why would higher erythritol levels increase risk of heart disease or strokes?’” What they found is that, by raising the erythritol level in test tubes or  mice, you can increase platelet aggregation. So what is platelet aggregation? Basically, it’s how sticky your blood is and how likely it can be to form clots. 

Now, we have the observation and we have a mechanism. Even though that’s more of a red flag for the study to say maybe that’s showing something bad about erythritol, it’s still not conclusive.

I want to point you to some other resources online. The Twitter of Dr. Nick Norwitz and Dr. Adrian Soto-Mota and Dr. Nicola Guess. All three of them have done very good assessments of the study. If you want to learn more, go check them out. 

What Dr. Nicola Guess did is she said, “Look, we can’t trust this a whole lot.” She dug into the preregistration of the study. Anytime you’re doing a study, you should pre-register it to say what you’re looking for. There were six primary outcomes, which is a lot. It could be interpreted that they weren’t exactly sure what they were looking for. They were supposed to have 40 people in the study, but they only reported the results of eight and it wasn’t randomized.

All of those things do weaken the findings. They don’t completely negate the findings, but they definitely weaken it. Interestingly, they did say there are more studies going on and they’re going to be reporting more data later. I’m curious to see what that shows. Nicola Guess’s tutorials usually were pretty entertaining with good use of GIFs, so if you want some entertaining education, definitely check that out.

After a study like this – it’s got its pros and cons, its strengths and weaknesses – we’re really left with trying to decide: “What does this mean for me? Should I just get rid of all erythritol-sweetened products now? Or can I ignore it because it’s not a randomized controlled trial and has all these holes in it?”

There’s not an easy answer. If you’re looking for the yes/no answer, the study doesn’t show that. For me, what I think we should all do at this point is sit and reflect: why are we having erythritol-containing products? 

For me, it’s convenience. It’s because I want to have a cereal I can eat or feed my kids when I don’t have time to make eggs or when we’ve had eggs four days in a row. For me, it’s just convenience. For some others, it could be because, in order for them to stay in nutritional ketosis, they don’t want to feel deprived. They want to have their ice cream. They want to have their cookies or they want to have their pancakes or whatever it may be. For others, it may just be routine.

Here’s the thing that I think is so interesting: what I found – personally, in patients, in colleagues, and in friends – is that the longer you’re in nutritional ketosis, the more your taste buds change. What might once have been a sweet tooth now can really be something that you don’t need anymore because our taste buds change. Now, blueberries may be totally sweet. 

As for me, I’m going to get rid of my erythritol-containing cereal. I’ll just use another keto-type cereal or granola without an artificial sweetener and add some blueberries for the sweetener because now, the way my taste buds are, that is perfectly sweet and I don’t need anything more. I think a lot of people who have been eating mostly real food for a long time may find that, if they tried something natural like berries or a very small dose of a sweetener, they may find that it still is enough because their taste buds have changed over time.

I think that’s the big take home: do we need to be consuming sweetened products? For some people, they do great with artificial sweeteners. For some people, they will be triggered without it. They will just want to eat the sugar-containing foods and will be triggered for a craving that may just send them off the rails. If that’s the case, an artificial sweetener is definitely going to be beneficial, but that is not everybody.

We shouldn’t assume that we’re in that bucket, so to speak. Rather, this is a chance for us to sit, reflect, and maybe test to see if we can get off of sweetened products that we don’t need and realize there are also other sweeteners. Monk fruit is a big one. Maybe in a few months we’ll have a study about the dangers of monk fruit. Who knows? 

These sweeteners are relatively new at the doses they’re being used and consumed. They’ve been around for a long time, but at these doses, they’re a little bit new, so we don’t know their exact effects, but they’re generally recommended as safe. 

Now we see that, even when something’s generally recommended as safe, we may see some studies raising concern. The same can be said for the sweetener allulose.  

But please, please, please, if you’re going to take anything away from this study, I recommend it be a time for self-reflection about why we’re using sweetened products and if we really need them. I apologize if you were looking for a black-and-white answer around if erythritol is good or erythritol is bad. I don’t know that can be concluded with this study. I personally am going to reflect and probably get rid of it because I don’t think I need it, and now it’s time for you to decide if it’s something you need or not and what your other options are. 

I hope that change in perspective was helpful, even if it’s not the clear cut answer.

Thanks for reading and we’ll see you here next time at Metabolic Mind.

• Witkowski, Marco, et al. “The artificial sweetener erythritol and cardiovascular event risk.” Nature Medicine. (2023).