CNN: Zero-calorie sweetener (erythritol) linked to heart attack and stroke, study finds

[ahimsa]

This sweetener was just mentioned on the forum a day or two ago. So when I saw this article I thought I'd post it here.

Fair warning, I have not looked at the study and don't have the ability to analyze it to see how accurate this CNN article is.

https://www.cnn.com/2023/02/27/health/zero-calorie-sweetener-heart-attack-stroke-wellness/index.html

A sugar replacement called erythritol – used to add bulk or sweeten stevia, monkfruit and keto reduced-sugar products – has been linked to blood clotting, stroke, heart attack and death, according to a new study.

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

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

“If your blood level of erythritol was in the top 25% compared to the bottom 25%, there was about a two-fold higher risk for heart attack and stroke. It’s on par with the strongest of cardiac risk factors, like diabetes,” Hazen said.

 

[Sean]

A sugar replacement called erythritol – used to add bulk or sweeten stevia,... – has been linked to blood clotting, stroke, heart attack and death, according to a new study.

Argh. That mix is one of the two sweeteners I use.

Is there any sweetener that won't kill us?

 

[Shadrach Loom]

Stevia users are presumably sweet-toothed people who have cause for concern about their weight or other risk factors, so there are a host of possible correlates involved.

 

[MeSci]

I would assume that being vegan would considerably reduce the risk, as I believe that veganism reduces clotting risk.

"Additional lab and animal research presented in the paper revealed that erythritol appeared to be causing blood platelets to clot more readily."

Animal research is extremely unreliable.

"the participants in the intervention were already at increased risk for cardiovascular events,” Rankin said."

"Oliver Jones, a professor of chemistry at RMIT University in Victoria, Australia, noted that the study had revealed only a correlation, not causation.

“As the authors themselves note, they found an association between erythritol and clotting risk, not definitive proof such a link exists,” Jones, who was not involved in the research, said in a statement.

“Any possible (and, as yet unproven) risks of excess erythritol would also need to be balanced against the very real health risks of excess glucose consumption,” Jones said."

 

[CRG]

Nature: The artificial sweetener erythritol and cardiovascular event risk

Abstract

"Artificial sweeteners are widely used sugar substitutes, but little is known about their long-term effects on cardiometabolic disease risks. Here we examined the commonly used sugar substitute erythritol and atherothrombotic disease risk. In initial untargeted metabolomics studies in patients undergoing cardiac risk assessment (n = 1,157; discovery cohort, NCT00590200), circulating levels of multiple polyol sweeteners, especially erythritol, were associated with incident (3 year) risk for major adverse cardiovascular events (MACE; includes death or nonfatal myocardial infarction or stroke). Subsequent targeted metabolomics analyses in independent US (n = 2,149, NCT00590200) and European (n = 833, DRKS00020915) validation cohorts of stable patients undergoing elective cardiac evaluation confirmed this association (fourth versus first quartile adjusted hazard ratio (95% confidence interval), 1.80 (1.18–2.77) and 2.21 (1.20–4.07), respectively). At physiological levels, erythritol enhanced platelet reactivity in vitro and thrombosis formation in vivo. Finally, in a prospective pilot intervention study (NCT04731363), erythritol ingestion in healthy volunteers (n = 8) induced marked and sustained (>2 d) increases in plasma erythritol levels well above thresholds associated with heightened platelet reactivity and thrombosis potential in in vitro and in vivo studies. Our findings reveal that erythritol is both associated with incident MACE risk and fosters enhanced thrombosis. Studies assessing the long-term safety of erythritol are warranted."

New Scientist article:
Artificial sweetener erythritol linked to heart attacks and strokes

"A commonly used sweetener called erythritol has been linked with a higher rate of heart attacks and strokes.
The claim comes after researchers spotted a correlation between cardiovascular problems and the concentration of erythritol in the blood. It is supported by laboratory work on animals, and by tests on human blood samples that show the sweetener can make blood clots more likely." Full story at link.

 

[MeSci]

Couild it be that erythritol users are more likely to be overweight, therefore having greater cardiovascular risk?

 

[Midnattsol]

Couild it be that erythritol users are more likely to be overweight, therefore having greater cardovascular risk?

And that if you have a high concentration of erythriol, that means you also eat a lot of whatever the erythriol is in that could be influencing an effect. In the case of erythriol, likely something processed, with low nutrient quality.

A very frustrating problem in nutrition research when say "potatoes" are labelled as "unhealthy", with little thought given to the potatoes in a study can be consumed in vastly different combinations with other foods... from being just boiled and eaten on the side of white fish, to fried on the side of ultraprocessed fried meat products.

Still, glad they are doing these studies. We need more information (and better ways to assess substitution foods before they are released on market!).

 

[CRG]

For those worried about using sweeteners that contain erythriol:

From the NS article:

"As what is termed “observational research”, the studies didn’t prove that erythritol was causing the higher risk – something else could explain the correlation. So the team then explored the effects of erythritol on blood, as both heart attacks and strokes can be caused by the formation of blood clots."

"When eight volunteers considered at low risk of heart attack or stroke consumed food and drinks containing 30 grams of erythritol – such as half a litre of low-carb ice cream – their blood levels of the sweetener jumped from about 4 micromoles (a measure of concentration) to about 6000 micromoles, and remained high for several hours."

"But Duane Mellor, a spokesperson for the British Dietetic Association, says most people wouldn’t be eating high enough quantities of it to reach the levels tested for clotting effects in this study. Mellor says the findings should not cause people to stop consuming food and drinks with the sweetener. “We need to reduce our sugar intake,” he says."

My bold - and half a litre of ice cream !!!

 

[Wonko]

Half a litre of ice cream is not a large amount for me to consume.

My understanding is that it's not a lot for anyone with control over access to consume.

However I am puzzled as to how something marketed as zero calories, due to being indigestible, manages to get into the blood stream.

 

[Midnattsol]

For those worried about using sweeteners that contain erythriol:

From the NS article:

"As what is termed “observational research”, the studies didn’t prove that erythritol was causing the higher risk – something else could explain the correlation. So the team then explored the effects of erythritol on blood, as both heart attacks and strokes can be caused by the formation of blood clots."

"When eight volunteers considered at low risk of heart attack or stroke consumed food and drinks containing 30 grams of erythritol – such as half a litre of low-carb ice cream – their blood levels of the sweetener jumped from about 4 micromoles (a measure of concentration) to about 6000 micromoles, and remained high for several hours."

"But Duane Mellor, a spokesperson for the British Dietetic Association, says most people wouldn’t be eating high enough quantities of it to reach the levels tested for clotting effects in this study. Mellor says the findings should not cause people to stop consuming food and drinks with the sweetener. “We need to reduce our sugar intake,” he says."

My bold - and half a litre of ice cream !!!

This assumes people get erythriol from products they buy, and that such products are "low carb". With a low carb ice cream, not being too worried about fat, the level of erythriol might not be so high as in other products.

Also, erythriol are used by consumers in their own recipes to make them lower in sugar. 30 grams of sugar are about ~1/3 of a dl, erytriol is very similar so I'm guessing they are about the same. If substituting erythriol for sugar in a recipe, erythriol is about 0.6-0.8 as sweet so one would generally use some extra to get the same level of sweetness. Tons of sweet stuff have more than 1/3 dl sugar in what would for many be considered a "normal" serving. Some people don't like to substitute sugar for erytrhiol 1:1 due to the cold aftertaste it has, while others are not bothered by this taste.

However I am puzzled as to how something marketed as zero calories, due to being indigestible, manages to get into the blood stream.

Zero calories doen't mean it doesn't enter the bloodstream, just that when it does it is not entering glycolysis or beta oxidation. For indigestability, the structure and size of erythriol is such that it doesn't need to be digested to be able to cross the gut lining into the blood. It's not a particulary large molecule, I think it is even absorbed by passive diffusion across the membrane.

 

[ahimsa]

My bold - and half a litre of ice cream !!!

I think half a liter of ice cream is roughly the size of a pint container. (someone please correct me if I've screwed this up!)

That's the small size often sold in stores.

The label on most pints have a suggested serving size of 1/2 cup (100 grams) = 4 servings in a pint. But many folks tend to eat larger servings than that.

I've never eaten a full pint (I think my largest serving would be 1/2 pint at the very most) but I have several friends who have complained that they can easily eat a pint of ice cream straight from the carton, as seen in this photo.

 

[hinterland]

I wonder about xylitol? That’s a sugar alcohol too. It’s good for your teeth as it inhibits bacterial adhesion, but is it molecularly similar to erythritol and would the same concerns apply?

 

[hinterland]

A sugar replacement called erythritol – used to add bulk or sweeten stevia,... – has been linked to blood clotting, stroke, heart attack and death, according to a new study.

Argh. That mix is one of the two sweeteners I use.

Is there any sweetener that won't kill us?

I think the stevia is okay so far as we know, just the erythritol that’s almost just used as a bulking agent in this case has been flagged up for concern.

I just use micro doses of stevia to sweeten cocoa for a hot chocolate drink and add some coconut plant milk, tastes delicious!

 

[NelliePledge]

I use this to make a cup of hot cocoa but as I only need 1/3 of a teaspoon of this stevia mix to replace 1 teaspoon of sugar I’m not too concerned. Less than 3 teaspoons a week.

 

[livinglighter]

I use approximately half a teaspoon of Truvia as it's so sweet. I just checked the ingredients; unfortunately, it's stevia mixed with erythritol.

Plain stevia might be the better option.

 

[Sean]

I think the stevia is okay so far as we know, just the erythritol that’s almost just used as a bulking agent in this case has been flagged up for concern.

I just use micro doses of stevia to sweeten cocoa for a hot chocolate drink and add some coconut plant milk, tastes delicious!

Plain Stevia is my other sweetener. I use it in my breakfast (either porridge or steamed brown rice, with banana).

 

[MeSci]

I wonder about xylitol? That’s a sugar alcohol too. It’s good for your teeth as it inhibits bacterial adhesion, but is it molecularly similar to erythritol and would the same concerns apply?

I avoid xylitol as much as possible as it's toxic to dogs. Really seriously toxic. But erythritol isn't, so they must have an important difference.

 

[Wyva]

I avoid xylitol as much as possible as it's toxic to dogs. Really seriously toxic. But erythritol isn't, so they must have an important difference.

I'm not sure about the other sweeteners but I have some diabetic people in my family and when I baked/cooked for them, I used xylitol, as you can substitute sugar 1:1 with it, so baking with it is less complicated. And ugh, xylitol is also a biological weapon in larger amounts, ehehe. (Namely it gives you diarrhea.) It is not necessarily obvious in a cake but we have some sweet soups here and the effect is quite strong in those. One needs to be careful with these sweeteners on many levels.

 

[cassava7]

Reactions from experts collected by the Science Media Centre (SMC): https://www.sciencemediacentre.org/...erythritol-and-cardiovascular-disease-events/

 

[Sly Saint]

I started using diluted xylitol as a mouth wash last year and in fact just ordered a big bag of the stuff.

Xylitol has been also highlighted as bad as erythritol by the same group of researchers.
However as they themselves have acknowledged it is not all that cut and dry.
This article explains why.
Xylitol Probably Won't Cause Heart-Related Death | American Council on Science and Health

what is xylitol:

Xylitol is a sugar alcohol with a low caloric value glycemic index. It is widely used by the food industry as an additive to improve the flavor, texture, and shelf life of sweets, chocolates, and chewing gums, among others. In the pharmaceutical industry, it is used to manufacture toothpaste due to its anti-cariogenic effect, protective action against tooth decay, and the production of cough syrups.

Because it has a sweetening power similar to sugar and does not leave an aftertaste, xylitol has gained popularity among people seeking alternatives to sugar. Furthermore, due to its low glycemic index, the ability to avoid causing abrupt spikes in blood glucose levels, it can be recommended for people with diabetes.

Although most of its production worldwide is achieved through chemical processing, xylitol is “natural,” found in

• Fruits, such as strawberries and bananas
• Vegetables, such as carrots and onions
• And, critically, in analyzing this study, inside our bodies. A healthy individual with a normal metabolism can produce 5 to 15 grams of xylitol daily.

eta: see also
Does the sweetener xylitol increase risk of stroke? | Eufic

What to keep in mind when reading the study’s conclusions?

• In the cohort studies, the participants blood was sampled after they had fasted overnight, so xylitol levels were likely not related to dietary intake.

The half-life of xylitol in the blood, which is the time it takes for half of it to be eliminated from the body, is about 13 minutes. In the human consumption study, levels of xylitol in the blood dropped back to baseline levels within 4-6 hours. Since the blood samples of the participants in the cohort study was taken after overnight fasting, the xylitol in their blood was likely from natural production in the body, not from the food they ate. This suggests that the cardiovascular risks observed in the cohorts were likely associated with endogenous (internally produced) xylitol, rather than dietary intake.

• The cohort studies that found the association between xylitol and increased cardiovascular risk did not collect data on what the participants ate.

The cohort studies did not collect data on dietary intakes of the participants. Many dietary factors influence our cardiovascular risk, like having diets high in sodium, low in fruit, or low in whole grains. Without dietary data, it is challenging to determine if xylitol intake or other dietary habits might have influenced the observed associations between xylitol levels and cardiovascular events.

• The studies that were carried out did not show that xylitol causes an increased cardiovascular risk.

While observational cohort studies cannot prove causation, the researchers complemented this work with a cell and animal study aimed at identifying possible mechanisms by which high levels of xylitol might increase cardiovascular risk. Although combining observational and experimental approaches is a strength of this study, it still does not prove that xylitol causes an increased cardiovascular risk. The experimental studies demonstrated that xylitol promotes clot formation in test tubes and mice. However, it remains unclear whether this eventually leads to cardiovascular events like heart attack or stroke in people who frequently consume high doses of xylitol. We would need more long-term research on xylitol consumption and cardiovascular health to establish this.

• The study population may not be representative of the general population.

The participants in both cohort studies were patients undergoing a cardiac risk assessment and therefore were at high-risk for a cardiovascular event. The findings may not be relevant for the general population as the study participants could have risk factors that differ from the overall population. Furthermore, the human experimental study included only 10 volunteers. A small study sample like this limits the generalisability of the findings