Erythritol and Heart Health: Is Your Favorite Low-Calorie Sweetener Putting You at Risk?

Low-calorie sweeteners (LCS), also known as non-nutritive or artificial sweeteners, have become a go-to option for people looking to reduce sugar intake and manage weight or blood glucose levels. But as these sweeteners gain popularity, important questions have emerged about their long-term safety—especially when it comes to heart health.

Understanding Low-Calorie Sweeteners

The U.S. Food and Drug Administration (FDA) has approved six low-calorie sweeteners as food additives:

• Aspartame

• Saccharin

• Acesulfame potassium

• Sucralose

• Neotame

• Advantame

These are many times sweeter than sugar but contain little to no calories.

Additionally, the FDA has recognized two other LCS as “Generally Recognized as Safe” (GRAS) under certain conditions:

• Steviol glycosides from the Stevia rebaudiana plant, commonly sold as Truvia® or PureVia®, are 200–400 times sweeter than sugar. However, unrefined stevia extracts and whole-leaf stevia are not GRAS-approved and cannot be marketed as sweeteners in the U.S.

• Monk fruit extract (Siraitia grosvenorii), also called luo han guo, is 100–250 times sweeter than sugar. While deemed safe, no official Acceptable Daily Intake (ADI) has been established.

These sweeteners are often marketed as natural, but like all food additives, moderation and context are key.

What About Sugar Alcohols?

Sugar alcohols, or polyols, such as sorbitol, xylitol, mannitol, and erythritol, occur naturally in some fruits and vegetables but are also manufactured for use in sugar-free products. They are not calorie-free, but they contain fewer calories than table sugar and don’t cause rapid blood sugar spikes.

Unlike other sugar alcohols, erythritol is generally well-tolerated and doesn’t cause significant gastrointestinal upset because it is mostly absorbed in the small intestine and excreted in the urine unchanged.

Do Artificial Sweeteners Increase Risk for Diabetes?

Emerging evidence suggests potential associations between high intake of artificially sweetened beverages and metabolic disease:

• A 14-year prospective study in France (E3N-EPIC cohort) found that both sugar-sweetened and artificially sweetened beverages were associated with increased risk of type 2 diabetes (T2D), with the highest quartile of ASB consumption linked to the highest risk.

• A 2015 meta-analysis of 17 cohort studies with over 38,000 cases confirmed this association, although authors cautioned that residual confounding and publication bias could not be ruled out.

These studies suggest a need for caution, though causality has not been firmly established.

Artificial Sweeteners and Cardiovascular Disease

A large-scale 2022 study from the NutriNet-Santé cohort (over 103,000 participants) found that higher intakes of artificial sweeteners were linked to increased cardiovascular risk:

• Aspartame was associated with a 17% increased risk of cerebrovascular events.

• Acesulfame potassium and sucralose were linked to a 40% higher risk of coronary heart disease.

These findings highlight a possible direct relationship between specific artificial sweeteners and heart disease risk.

Sweeteners and the Gut Microbiome

A 2022 randomized controlled trial published in Cell examined how four non-nutritive sweeteners—saccharin, sucralose, aspartame, and stevia—affect the microbiome and glucose tolerance in healthy adults. Over just two weeks, these sweeteners induced distinct changes in the oral and gut microbiome, and saccharin and sucralose raised post-meal glucose levels.

This study supports the growing evidence that artificial sweeteners are not inert and can influence metabolic health through microbiome alterations.

Erythritol: A Closer Look at the Newest Concerns

Erythritol, often used in “keto-friendly” foods, protein bars, and sugar-free desserts, has recently come under scientific scrutiny due to potential cardiovascular risks.

A major 2023 study published in Nature Medicine reported several key findings:

1. Plasma Erythritol and Cardiovascular Events

• In a U.S. cohort of 1,157 patients undergoing cardiac risk assessment, higher blood levels of erythritol were associated with increased risk of major adverse cardiovascular events (MACE) including heart attack and stroke.

• This association was confirmed in a U.S. validation cohort (n = 2,149), where the highest erythritol quartile had a 1.8-fold increased risk of MACE over 3 years, even after adjusting for other cardiovascular risk factors.

• In a European cohort of 833 participants, those in the top erythritol quartile had a 2.2-fold higher risk of MACE compared to the lowest quartile.

  
  

2. Erythritol and Blood Clotting

In lab experiments and animal models, erythritol appeared to increase platelet reactivity and enhance thrombosis potential, raising concerns that it could promote blood clot formation under certain conditions.

3. Real-World Consumption Effects

In a small pilot study, eight healthy volunteers consumed 30 grams of erythritol (about what you'd find in a can of sugar-free soda or a pint of keto ice cream). Blood levels of erythritol rose dramatically and remained elevated for over 48 hours, a duration long enough to potentially affect clotting risk.

So—Is Erythritol Dangerous?

While erythritol is naturally found in small amounts in fruits and fermented foods, the doses used in processed foods are significantly higher. Importantly, while our bodies can produce some erythritol endogenously, the contribution is minimal compared to dietary intake from sweeteners.

The evidence doesn’t definitively prove causality, but it raises valid concerns about the long-term cardiovascular safety of erythritol—especially in people at higher risk for heart disease.

Bottom Line

Low-calorie sweeteners—including erythritol—can be useful tools in reducing added sugar. However, they are not without risks. Growing evidence suggests they may not be metabolically inert and may impact cardiovascular health, gut microbiota, and glucose metabolism.

As cardiovascular disease remains the leading cause of death globally, caution is warranted. When choosing sweeteners, it's essential to:

• Focus on whole, minimally processed foods.

• Use sweeteners in moderation.

• Monitor emerging evidence about long-term effects.

Always consult your healthcare provider, especially if you have existing heart or metabolic conditions.

References

1. Fagherazzi G, et al. Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes. Am J Clin Nutr. 2013;97(3):517–23.

2. Imamura F, et al. Consumption of sweetened beverages and T2D risk: a meta-analysis. Br J Sports Med. 2015.

3. Debras C, et al. Artificial sweeteners and cardiovascular disease risk. PLoS Med. 2022;19(3):e1003950.

4. Suez J, et al. Personalized microbiome-driven effects of non-nutritive sweeteners. Cell. 2022;185(20):3621-3635.e18.

5. Witkowski M, et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med. 2023. https://doi.org/10.1038/s41591-023-02223-9