Calorie-free sweetener linked to heart attack, stroke, study finds


A sugar substitute called erythritol — used to add bulk or sweeten reduced-sugar stevia, monk fruit, and keto products — has been linked to blood clotting, strokes, heart attacks and death, according to a new study.

“The degree of risk was not modest,” said lead author Dr. Stanley Hazen, director of the Cleveland Clinic’s Center for Cardiovascular Diagnosis and Prevention. Lerner Research Institute.

People with existing risk factors for heart disease, such as diabetes, were twice as likely to suffer a heart attack or stroke if they had the highest levels of erythritol in their blood, the study found. published Monday in the journal Nature Medicine.

“If your erythritol blood level was in the upper 25% versus the lower 25%, your risk of heart attack and stroke was about twice as high. That’s on par with the strongest of heart risk factors, like diabetes,” Hazen said.

Additional laboratory and animal research presented in the article found that erythritol seemed to cause blood platelets to clot more easily. Clots can break off and travel to the heart, triggering a heart attack, or to the brain, triggering a stroke.

“It certainly rings an alarm bell,” said Dr. Andrew Freeman, director of cardiovascular prevention and wellness at National Jewish Health, a hospital in Denver, Colorado, who was not involved in the research.

“There appears to be a risk of clotting with erythritol use,” Freeman said. “Obviously more research is needed, but with a lot of caution, it might be a good idea to limit erythritol in your diet for now.”

In response to the study, the Calorie Control Council, an industry association, told CNN that “the results of this study run counter to decades of scientific research showing that low-calorie sweeteners like erythritol are safe. , as evidenced by global regulatory approvals for their use in food and beverages,” Robert Rankin, executive director of the council, said in an email.

The results “should not be extrapolated to the general population, as intervention participants were already at increased risk for cardiovascular events,” Rankin said.

The European Polyol Producers Association declined to comment, saying it had not yet reviewed the study.

Like sorbitol and xylitol, erythritol is a sugar alcohol – a naturally occurring carbohydrate found in many fruits and vegetables. It has about 70% the sweetness of sugar and is considered zero calories, according to experts.

Artificially made in massive amounts, erythritol has no lingering aftertaste, does not raise blood sugar, and has less of a laxative effect than some other sugar alcohols.

“Erythritol looks like sugar, it tastes like sugar, and you can cook with it,” said Hazen, who also directs the Cleveland Clinic’s Center for Microbiome and Human Health.

“It has become the darling of the food industry, an extremely popular additive for keto and other low carb products and foods marketed to people with diabetes,” he added. “Some of the foods labeled for diabetes that we looked at contained more erythritol than anything else by weight.”

Erythritol is also the largest ingredient by weight in many “natural” stevia and monk fruit products, Hazen said. Since stevia and monkfruit are about 200-400 times sweeter than sugar, a small amount is enough in any product. The bulk of the product is erythritol, which adds the crystalline appearance and sweet texture that consumers expect.

The discovery of the link between erythritol and cardiovascular problems was purely accidental, said Hazen: “We did not expect this. We weren’t even looking for it.

Hazen’s research had a simple goal: to find unknown chemicals or compounds in a person’s blood that could predict their risk of heart attack, stroke, or death over the next three years. To do this, the team began analyzing 1,157 blood samples from people at risk for heart disease taken between 2004 and 2011.

“We found this stuff that seemed to play a big role, but we didn’t know what it was,” Hazen said. “Then we found out it was erythritol, a sweetener.”

The human body naturally creates erythritol, but in very small amounts that wouldn’t account for measured levels, Hazen said.

To confirm the results, Hazen’s team tested another batch of blood samples from more than 2,100 patients in the United States and 833 additional samples collected by colleagues in Europe through 2018. About three-quarters of Participants from all three populations had coronary heart disease or high blood pressure. pressure and about a fifth had diabetes, Hazen said. More than half were men and were between 60 and 70 years old.

In all three populations, the researchers found that higher levels of erythritol were linked to an increased risk of heart attack, stroke, or death within three years.

But why? To find out, the researchers did further animal and lab tests and found that erythritol “caused increased thrombosis,” or clotting in the blood, Hazen said.

Clotting is necessary in the human body, otherwise we would bleed to death from cuts and wounds. The same process happens constantly internally as well.

“Our blood vessels are always under pressure and we’re causing leaks, and blood platelets are constantly plugging up those holes,” Hazen said.

However, the size of the clot formed by the platelets depends on the size of the trigger that stimulates the cells, he explained. For example, if the trigger is only 10%, you only get 10% of a clot.

“But what we see with erythritol is that the platelets become super-responsive – just a 10% stimulant produces 90 to 100% of a clot to form,” Hazen said.

“For people at risk of clotting, heart attack and stroke – like people with existing heart disease or people with diabetes – I think there’s enough data here to say stay put. apart from erythritol until further studies are done,” Hazen said.

Oliver Jones, a professor of chemistry at RMIT University in Victoria, Australia, who was not involved in the research, noted that the study found only correlation, not causation.

“As the authors themselves note, they found an association between erythritol and clotting risk, no definitive evidence that such a link exists,” Jones said in a statement.

“Any possible (and as yet unproven) risks of excess erythritol should also be weighed against the very real health risks of excessive glucose consumption,” Jones said.

In a final part of the study, eight healthy volunteers drank a beverage containing 30 grams of erythritol, the amount consumed by many people in the United States, Hazen said, according to the National Health and Nutrition, which reviews American nutrition annually.

Blood tests over the next three days tracked erythritol levels and risk of clotting.

“Thirty grams was enough to increase blood levels of erythritol a thousandfold,” Hazen said. “It remained elevated above the threshold needed to trigger and increase the risk of clotting for the next two to three days.”

How much is 30 grams of erythritol? The equivalent of eating a pint of keto ice cream, Hazen said.

“If you look at the nutrition labels on many keto ice creams, you’ll see ‘reduce sugar’ or ‘sugar alcohol,’ which are terms for erythritol. You will find that a typical pint contains between 26 and 45 grams,” he said.

“My co-author and I went to grocery stores and looked at the labels,” Hazen said. “He found a ‘confectionery’ marketed to people with diabetes that contained about 75 grams of erythritol.”

There is no firm “Accepted Daily Intake”, or ADI, established by the European Food Safety Authority or the United States Food and Drug Administration that considers erythritol generally recognized as safe (GRAS). .

“Science needs to dig deeper into erythritol and hurry, because this substance is widely available right now. If it’s harmful, we should know about it,” said Freeman of National Jewish Health.

Hazen agreed, “Normally I don’t get up on a pedestal and sound the alarm,” he said. “But it’s something I think we need to look at carefully.”

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