As concerns rise about the potential health effects of sugar substitutes, several doctors are advising patients to reduce their intake. A recent study published in February in the journal Nature Medicine, conducted by researchers at the Cleveland Clinic, revealed that erythritol, a popular zero-calorie sweetener, was linked to a higher risk of heart attacks, strokes, and death within three years.
Erythritol is a natural sugar alcohol produced in the body and is utilized as a sugar substitute in low-calorie and low-carb products, especially in those promoted as keto-friendly, such as condiments, baked goods, and ice cream. Typically, it is blended with other sweeteners.
With the growing popularity of low-carb and ketogenic diets, people have been turning to sugar-free sweetened products as a substitute for the sweet taste of sugar with reduced sugar and carbohydrate content. Nonetheless, experts are cautioning that sugar substitutes might have their own health risks.
“We can’t firmly conclude that [sweeteners] are safe,” warns Dariush Mozaffarian, the dean and professor of nutrition and medicine at Tufts University’s Friedman School of Nutrition Science and Policy. “That’s genuinely worrying.”
Alternative sweeteners have been studied for potential health hazards for a long time, but numerous studies have used food diaries that are not always reliable in recording what people truly consume. The latest research on erythritol is more extensive and comprehensive.
Other studies have suggested that specific sugar substitutes like saccharin and sucralose might increase an individual’s risk of developing Type 2 diabetes.
The connection between sugar alternatives and health risks in most studies, including the recent one on erythritol, is observational, and causation cannot be established. Despite this, physicians and researchers recommend that individuals reduce their consumption of sugar substitutes based on the available evidence.
Doctors caution against using plain sugar as a substitute because it is associated with diabetes, obesity, and heart disease. Instead, they recommend limiting both sugar and sugar alternatives.
The recent research published in Nature Medicine is the result of more than a decade of study. Initially, researchers were seeking chemicals in the blood that could predict the risk of heart disease and strokes. After testing the blood samples of over 1,000 individuals, the chemical that predicted risk the most was erythritol, according to Dr. Stanley L. Hazen, the senior author of the study and chair of the department of cardiovascular and metabolic sciences at the Cleveland Clinic. The samples were taken between 2004 and 2011, before erythritol was a prevalent food industry additive. The researchers thought the erythritol they measured was generated naturally by the body.
Researchers then examined the levels of more than 2,000 individuals in the United States and over 800 individuals in Europe. Most participants, with a median age in their 60s and 70s, either had heart disease or were at risk of developing it due to conditions such as high blood pressure and diabetes.
The study’s most significant limitation, according to Dr. Dariush Mozaffarian, the dean and professor of nutrition and medicine at Tufts University’s Friedman School of Nutrition Science and Policy, is that participants were primarily individuals with risk factors for heart disease. However, it did include a large number of people, approximately 4,000.
Dr. Hazen claims that in every group they examined, participants with higher erythritol levels were more prone to having a heart attack or stroke or dying within three years. The researchers also conducted animal and laboratory experiments, revealing that erythritol increased the risk of clotting in mice and blood and platelet samples.
Dr. Hazen advises patients to scrutinize the labels on the foods they purchase, though he acknowledges that erythritol may not always be listed with amounts as an ingredient. Products containing ingredients such as “sugar alcohol” or “natural sweeteners” may include erythritol.
He advises avoiding foods and beverages sweetened with sugar substitutes. If you want to sweeten something, he recommends using fruit or honey in moderation or a small amount of sugar.
The Calorie Control Council, a trade group representing the low-calorie food and beverage industry, claims that erythritol’s safety is supported by years of research. It stated that findings from a study focusing on people already at risk for cardiovascular issues should not apply to the broader population.
The U.S. Food and Drug Administration representative stated that the agency does not comment on specific studies but evaluates them within the wider body of evidence to better understand issues and protect public health.
Many of the studies that the FDA relies on to establish the safety of sugar substitutes use small amounts, according to Dr. Dana Small, a professor of psychology and psychiatry at Yale University and director of its Modern Diet and Physiology Research Center. Dr. Small has conducted research on sugar substitutes but was not involved in the Nature Medicine study.
Many artificial sweeteners are used in very small quantities since they are much sweeter than sugar. In contrast, erythritol is slightly less sweet and used in higher quantities in food products.
Jotham Suez, an assistant professor of microbiology at Johns Hopkins Bloomberg School of Public Health who studies sugar alternatives and was not involved in the Nature Medicine study, stated that the amount of erythritol individuals consume daily is greater than that of other artificial sweeteners, highlighting the importance of examining its potential health risks.
Earlier research has raised concerns about other sweeteners. A 2022 study published in the journal Cell found that two sweeteners, sucralose and saccharin, were linked to elevated blood glucose levels, a risk factor for developing Type 2 diabetes.
Similarly, a 2020 study published in the journal Cell Metabolism discovered that individuals who consumed the sweetener sucralose in combination with carbohydrates for one week became less sensitive to sugar. Specifically, they released more insulin upon consuming the same amount of sugar, similar to what happens in diabetes.
In summary, while many studies, including the recent one on erythritol, have shown an association between sugar substitutes and health risks, further research is needed to establish causation. As a result, doctors and researchers recommend reducing consumption of sugar substitutes and plain sugar, and instead suggest using fruit or honey in moderation, or small amounts of sugar to sweeten food and drinks.