New Study Links Erythritol with Higher Blood Clot Risk

If you eat sugar-free or reduced-sugar foods or chew sugar-free gum that is sweetened with non-nutritive sweeteners (meaning they don’t contribute any calories), there’s a good chance you’re ingesting a sugar alcohol called erythritol. While erythritol occurs naturally in small amounts in certain foods, like watermelon, grapes and pears, the erythritol used in sugar-free or reduced-sugar products comes from a lab by fermenting corn and is considered a food additive. 

As a food additive, erythritol has been deemed generally recognized as safe (GRAS) by the U.S. Food & Drug Administration (FDA). But there is growing evidence that while erythritol may not raise blood sugar, making it suitable for those with diabetes, there may be some other unwanted consequences of consuming it—beyond the gas, bloating and diarrhea that some people with irritable bowel syndrome (IBS) experience. This is likely because sugar alcohols are a type of polyol—the “P” in FODMAPs. 

A new study published on August 8, 2024 in Arteriosclerosis, Thrombosis, and Vascular Biology highlights some of these potential issues. Let’s see what they study found and whether you should be concerned.

How Was This Study Conducted & What Did It Show?

This study was pretty straightforward. Researchers at the Cleveland Clinic in Ohio took 20 volunteers and randomly split them into two groups, 10 people in each group. 

All the volunteers were nonsmokers without heart disease, hypertension or diabetes, and had normal kidney function. They had no history of taking antiplatelet medication within the previous month, and no clinical history of bleeding, bruising or a documented bleeding disorder. The average age of the volunteers was 30, and the groups were made up of about half women and half men.

The volunteers’ blood was tested for baseline data, including their blood levels of erythritol. Remember, erythritol occurs naturally in some foods, and there is evidence that our bodies also produce a small amount of this sugar alcohol, so most of us will have some in our bodies. 

The volunteers then fasted overnight. In the morning, one group drank a solution of water mixed with 30 grams of glucose (sugar) and the other group drank a solution of water mixed with erythritol. Their blood was drawn 30 minutes after drinking the solutions. 

Unlike a lot of studies done on erythritol, these researchers were not looking to see if erythritol raised blood sugar levels. Instead, they were testing volunteers’ blood to see if erythritol affected blood clotting factors. 

What does blood clotting have to do with anything? Well, you need some level of blood clotting so that when you get cut, the bleeding stops and a scab forms. But when that clotting factor becomes too aggressive and clots form in your bloodstream, it can cause problems—like a heart attack or stroke. 

What the researchers found was that the blood levels of erythritol in the group that drank the erythritol solution rose by 1000% compared to their initial baseline levels. The volunteers in this group also had more active platelets and blood clot formation, but the volunteers in the group that drank the sugar solution did not. Platelets are cells that are involved in clotting. When they become too active, it increases the risk that they will form potentially dangerous clots in your blood. 

How Does This Apply to Real Life?

Many times, researchers will use a larger dose of a food than we would normally eat to try and show a link between it and disease or disease prevention. But in this case, they gave the erythritol group the amount of erythritol that would typically be found in a sugar-free soda or muffin—so a real-life dose.

“This research raises some concerns that a standard serving of an erythritol-sweetened food or beverage may acutely stimulate a direct clot-forming effect,” says study co-author W. H. Wilson Tang, M.D., research director for Heart Failure and Cardiac Transplantation Medicine at Cleveland Clinic, in a press release. “Erythritol and other sugar alcohols that are commonly used as sugar substitutes should be evaluated for potential long-term health effects especially when such effects are not seen with glucose itself.”

We previously reported on a 2023 study done by these same researchers that suggested that people with pre-existing risk factors for heart disease were twice as likely to experience a cardiac event or stroke if they had high levels of erythritol in their blood. And another study we reported on in 2022 suggests that people who get most of their “sweets” from artificial sweeteners had a 9% increased risk of heart disease.

In addition, the Cleveland Clinic researchers published another study in June 2024 that had similar findings as this current study, but that study used xylitol, another sugar alcohol used in sugar-free products. 

So, should you be concerned? And should you eat foods with sugar alcohols?

“I feel that choosing sugar-sweetened treats occasionally and in small amounts would be preferable to consuming drinks and foods sweetened with these sugar alcohols, especially for people at elevated risk of thrombosis such as those with heart disease, diabetes or metabolic syndrome,” says senior study author Stanley Hazen, M.D., Ph.D., chair of Cardiovascular and Metabolic Sciences in Cleveland Clinic’s Lerner Research Institute and co-section head of Preventive Cardiology, in the same press release. “Cardiovascular disease builds over time, and heart disease is the leading cause of death globally. We need to make sure the foods we eat aren’t hidden contributors.”

But the FDA has given erythritol and other sugar alcohols, like xylitol, their GRAS stamp of approval. What this means is that the scientific community as a whole currently believes that sugar alcohols are safe to ingest. There is even evidence that erythritol acts like an antioxidant in our bodies, and does not raise blood sugar levels, making it safe for people with diabetes—at least as far as blood sugar levels are concerned.

With that said, as more research is conducted that either strengthens or dissipates the connection between sugar alcohols and blood clot risk, the FDA’s stance on this topic may change. We’ve seen this with brominated vegetable oil (BVO), which was found in some citrus-flavored sodas. While BVO was initially on the GRAS list, after 50 years of research, it had to be taken off and banned because the evidence mounted against its safety. 

We also saw this with trans fats. Scientists initially thought they were healthier than saturated fats—until enough research proved they were even more harmful. And now, trans fats, which were made by hydrogenating oils, are no longer allowed in our food supply.

The Bottom Line

This study suggests that one typical serving of erythritol—the amount you’d get in a sugar-free soda or muffin—may significantly increase your blood levels of erythritol and activate platelet activity. This increases the risk of blood clots, potentially increasing the risk of heart attack and stroke. 

It’s important to note that this study was small and that research on this topic is in its infancy. More—and larger, long-term—studies need to be done since this study was a one-day deal that only included 20 people. Until then, as long as erythritol and other sugar alcohols are considered GRAS, you have a choice to eat, drink or chew them (in the case of gum)—or not. It’s important to note that erythritol is often combined with other types of sweeteners, like stevia, so be careful about assuming a stevia product is pure stevia. Read the label, especially if you’re trying to avoid sugar alcohols.  

Since most of us eat more than the recommended amount of added sugar, sweeteners like erythritol can come in handy when we want something sweet. But if you frequently nosh and imbibe products that contain non-nutritive sweeteners, like sugar alcohols, or other sweeteners, like sugar and high fructose corn syrup—ask yourself if they are taking the place of more nutrient-dense foods. Could you start replacing some of your diet or regular sodas with water—even sparkling water if you need the bubbles? Could you replace your daily afternoon candy bar with a piece of dark chocolate and a handful of almonds? How about swapping that breakfast pastry with a couple of eggs, a slice of whole-grain toast and a piece of fruit? 

Yes, all foods can fit into a balanced diet and can be enjoyed. It’s about patterns and the big nutrition picture. What does your pattern look like?