You may have heard the expression, “There ain’t no such thing as a free lunch.” It means that few things are actually free; there’s often a hidden cost to “freebies.”

Our concierge primary care doctors in Jupiter were reminded of that saying when we heard the results of a new study on the sugar substitute erythritol, popular in keto diets, which suggested it can cause an increase in strokes and heart attacks.

The Study

Researchers from the Cleveland Clinic evaluated more than 4,000 Americans and Europeans who were being evaluated for heart disease. The results, published last month in the journal Nature Medicine, showed that those with the highest blood concentration of the artificial sweetener erythritol were at an increased risk of heart attack or stroke in the following three years.

The researchers examined the subjects’ blood platelets—the type of blood cell that sticks together to form blood clots—and found those with the highest level of erythritol showed increased platelet activity, thereby encouraging the greater formation of clots. Clots in the bloodstream have the potential to cause heart attacks or strokes when they block the normal flow of blood.

The researchers also injected mice with erythritol and found that clots formed more quickly after an injury than those who had been injected with saline.

Finally, they took blood samples from subjects who had consumed an erythritol-sweetened drink and found levels of the sweetener remained high for two days.

“Every way we looked at it, it kept showing the same signal,” Stanley Hazen, a cardiologist at the Cleveland Clinic, who also directs the Cleveland Clinic’s Center for Microbiome and Human Health, told The New York Times.

“People are trying to do something healthy for themselves but inadvertently may be doing harm,” he told the paper.

About Erythritol

Erythritol is a sugar alcohol like xylitol and sorbitol and is found naturally in many fruits, vegetables, and fermented foods. It is also manufactured artificially for use in food products.

It has become more popular than earlier types of artificial sweeteners because it has no lingering aftertaste, doesn’t spike blood sugar, and doesn’t cause the laxative effect common with other such additives.

USA Today reports that it is added to many processed foods and beverages and is commonly found in products aimed at those on the keto diet because it does not affect blood glucose. It is also an ingredient in the sweetener Truvia.

“Erythritol looks like sugar, it tastes like sugar, and you can bake with it,” Hazen told CNN.

“It’s become the sweetheart of the food industry, an extremely popular additive to keto and other low-carb products and foods marketed to people with diabetes,” he added.

The U.S. Food and Drug Administration (FDA) lists erythritol as generally recognized as safe or GRAS. Therefore, it is not required to be listed on a product’s ingredient list, according to Hazen. The label might simply say, “artificially sweetened with natural products,” or “zero sugar.”

Other Research

Robert Rankin, executive director of the Calorie Control Council, an association representing the low- and reduced-calorie food and beverage industry, told USA Today that the people in the study were at higher risk for cardiovascular disease (CVD), so the results shouldn’t be applied to the general population.

“The results of this study are contrary to decades of scientific research showing reduced-calorie sweeteners like erythritol are safe,” he said.

But other studies have raised the question about the safety of erythritol.

For example, Karsten Hiller, a biochemist, and specialist in human metabolism at the Braunschweig Institute of Technology in Germany published a paper in 2017 showing that Cornell University freshmen whose blood contained high levels of erythritol gained more weight than students with low levels, the USA Today reported. Which kind of defeats the purpose of using an artificial sweetener.

“Science needs to take a deeper dive into erythritol and in a hurry, because this substance is widely available right now,” Andrew Freeman, director of cardiovascular prevention and wellness at National Jewish Health, a hospital in Denver, told CNN. Freeman was not involved in Hazen’s research.

Hazen agreed.

“I normally don’t get up on a pedestal and sound the alarm,” he told CNN.

“But this is something that I think we need to be looking at carefully,” he added.

Eating Healthier

Artificial sweeteners in general have been called into question by numerous studies. For example, a 2020 study by a group of Yale researchers found that those who used the artificial sweetener sucralose (found in the brand names Splenda, Zerocal, and others) can result in high blood sugar levels in the blood. The Washington Post reports that sucralose is found in thousands of consumer-packaged goods such as baked goods, yogurt, canned soups, condiments, and syrups.

Another study at the Weizmann Institute of Science last year looked at what happened to subjects who consumed aspartame, saccharine, stevia, or sucralose in amounts well below the FDA’s daily allowances. The researchers found that these sweeteners caused changes in both the function and composition of the participants’ gut microbiomes, the communities of bacteria, viruses, and fungi that live in the intestines, The Post reported.

There’s no question that artificial sweeteners are hard to avoid these days. And we keep trying to have our sugar without paying the price.

But for the sake of your long-term health, we recommend sticking as closely as possible to fresh, natural, unprocessed foods and beverages.