Take the Latest Sugar Study With a Grain of Salt

By giving us the opinions of the uneducated, journalism keeps us in touch with the ignorance of the community. -Oscar Wilde

A new Cleveland Clinic study by Stanley Hazen and colleagues has recently saturated the news and scared people who use sugar substitutes. The study claims that erythritol, a very popular sweetener, is linked to potentially fatal cardiovascular events.

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Erythritol’s low glycemic index makes it easy for people to enjoy sweet foods without causing high blood sugar. It’s an important sugar substitute for diabetics and a common part of a ketogenic diet. But is it a killer?

The study analyzed more than 1,000 heart patients and found that those with the highest levels of erythritol in their blood also had the highest risk of heart attack and stroke. So is it time to ditch your erythritol? Before you decide, let’s dive into history a bit. The truth is less scary and more interesting than the headlines suggest.

Surprisingly, given the breathless press coverage, the study says nothing about how much erythritol the patients consumed. We might assume that these people, many of whom were diabetics, were using some type of sugar substitute. However, this information was not in the dataset they used.

Erythritol produced by the body

But if the erythritol doesn’t come from consumption, then where does it come from? Several scientists, including Martha Field and colleagues from Cornell University, have shown that the human body actually makes erythritol itself. This is called endogenous Erythritol and the amount produced traces with metabolic diseases. The sicker the patient, the greater the amount of erythritol in his blood.

This home-grown erythritol is not related to its consumption. In fact, the body produces it in response to excess sugar, and it’s a fertile marker for cardiometabolic disease. In other words, the erythritol levels found in these patients may be a result of not consume erythritol, but sugar instead. Biology is insanely complicated, so it’s not uncommon for studies to clash. It usually points to some interesting underlying science. It can be unsettling to the layperson, but it’s gold for scientists – and science writers.

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A high-sugar diet encourages the overgrowth of bacteria in the small intestine and can lead to “leaky gut,” which allows toxins and bacteria to leak into the bloodstream and reach every organ in the body. Over time, this can turn into systemic inflammation, the cause of many diseases including metabolic syndrome, type 2 diabetes, heart disease, depression, dementia and more. Cutting out sugar helps keep your microbiota in good shape, which in turn helps keep your gut healthy and your mood upbeat — hence the increased use of sugar substitutes like erythritol.

The authors of the Cleveland Clinic study acknowledge that the body produces erythritol, but say, “We speculate that erythritol levels…result from a combination of ingestion and endogenous production.” Unfortunately, the design of this study does not warrant such speculation – the information are simply not included in the data.

To address this deficiency, another part of the study looked at what happens to test participants’ blood after consuming 30 grams of erythritol within two minutes. Blood clotting factors were elevated, which is disturbing.

But there are several problems with this part of the study. First, only eight people were involved, making the study underpowered. Second, 30 grams is a lot of erythritol at once, more than the average consumer consumes in a day. Third, there were no control groups. There is an understandable urge to write compelling stories, but small studies like this should be kept for internal use and not published in Nature. Better to wait until there’s a larger, controlled study.

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Widespread media coverage

Therefore, the study says little about actual consumption of erythritol – except in large doses – and even that is speculative without a control group. That didn’t stop the click-baity coverage.

Fox News said: “A new one Cleveland Clinic Study shows a popular artificial sweetener, erythritol, is associated with an increased risk of heart attack and stroke.” First of all, it’s worth noting that naturally occurring erythritol is labeled as “artificial” by both the study and the press. However, it is a natural sugar alcohol found in many foods, including pears, grapes, watermelon, mushrooms, cheese, soy sauce, beer, sake, and wine. It’s also worth noting that erythritol has been approved as safe by the US Food and Drug Administration (FDA), the World Health Organization, and EFSA (the European version of the FDA). Second, by calling it a sweetener instead of a natural metabolite, they imply that the observational study looked at consumption. Unfortunately, consumption data were not available, as I said.

The study has also gone global. The Indian Express chose the bold headline: “Does your artificial sweetener contain erythritol? According to the study, it increases the risk of heart attack and stroke.” The Indian Express is hardly a medical journal, but should know the difference between an association and a causal risk.

According to many other scientists, there is not enough to worry about here. Robert Rankin, executive director of the Calorie Control Council, disputed the findings, saying, “The results of this study contradict decades of scientific research showing that reduced-calorie sweeteners such as erythritol are safe.” should be extrapolated to the general population as participants in the intervention were already at increased risk of cardiovascular events”. That may be true, but many of these people are the main demographic for sugar substitutes.

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The Calorie Control Council represents the low-calorie food and drink industry, so they have a vested interest in sweeteners, but other scientists agree and denounce the lax press coverage. Kevin Klatt, a metabolic researcher at UC Berkeley Metabolic Biology, says: “Erythritol is a great example of something that is found in the diet but can also be manufactured endogenously where we are not sure if it is causally linked to disease , but there are [speculation] that it could be, so the media and influencers will make headlines about it.” So, don’t panic just yet.

What to do while waiting for follow-up research

But until follow-up studies are complete, keep your erythritol consumption below 30 grams per session. There are other natural sweeteners like allulose and tagatose. Switch them up to make sure you don’t get too much of them. The poison is in the dosage, and these sugar substitutes have been used for decades with great results for people trying to lower their blood sugar.

There was a time when we didn’t have access to that much refined sugar. Amazingly, people were still happy. There is joy in sweet fruits and we should reconnect with them. And maybe we don’t need donuts, candy bars, sodas, and ice cream every day. It’s a bitter pill to swallow, but dessert should be a treat, not a staple.


Witkowski, Marco, Ina Nemet, Hassan Alamri, Jennifer Wilcox, Nilaksh Gupta, Nisreen Nimer, Arash Haghikia, et al. “The artificial sweetener erythritol and the risk of cardiovascular events.” naturopathyFebruary 27, 2023, 1-9.

Ortiz, Semira, Doletha Szebenyi and Martha Field. “Endogenous synthesis of erythritol, a novel biomarker of weight gain (P15-016-19).” Current developments in nutrition 3, no. Attachment 1 (June 13, 2019): nzz037.P15-016-19.

Ortiz, Semira R., and Martha S. Field. “Elevated plasma and urinary erythritol is a biomarker of simple carbohydrate overconsumption in mice.” bioRxiv, December 4, 2022.


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