Should you be avoiding erythritol?

Confession: I prefer a little something sweet in my morning cup of tea. Decaf coffee, I drink black. But Scottish Breakfast Tea or Earl Grey call for a little added sweetness. I avoid “tilk”—tea laced with milk—because dairy vitiates the uptake of the valuable polyphenols found in tea or coffee.

My go-to has been various monkfruit or stevia sweeteners, but I noticed they are often “balanced” with the non-caloric sugar alcohol, erythritol. The popular natural sugar substitute Truvia®️, for example, is stevia plus erythritol.

I recently ran out of my latest healthy pleasure, “Monkfruit in the Raw”, and was about to buy some more, when a new erythritol study (“The non-nutritive sweetener erythritol adversely affects brain microvascular endothelial cell function”) caught my eye.

Concerns over potential cardiovascular harms of erythritol have been raised before, in 2023. At that time, I weighed in with a newsletter article entitled “Should you chuck your erythritol-sweetened products?”

In that article I concluded: 

“Bottom line: It may be advisable for people with known cardiovascular risk factors or previously diagnosed arterial blockage to avoid erythritol. But for healthy persons, it remains an open question, and additional research may dispel concerns.”

Mostly, I agreed with experts who, upon reading the initial study implicating higher blood levels of erythritol with heightened risk of stroke or heart, felt that it wasn’t clear whether the higher levels of erythritol that were associated with risk came from the body’s own production, or from outside sources.

In other words, it may not be that consumed erythritol is the culprit, just as it remains controversial that dietary cholesterol causes heart disease; rather, high cholesterol production by the liver, responsible for 80% of circulating cholesterol, is associated with cardiovascular risk. Another case of correlation is not causation.

We get small amounts of erythritol from fruits (e.g. melons, grapes, and pears) and from wine, but non-sugar sweeteners considerably add to our exposure. Thus it raises the question—is all that extra erythritol from sugar substitutes natural?

Nevertheless, I kept using erythritol, albeit a little, preferring it to straight sugar or other sweeteners with known risks like NutraSweet, Splenda, and saccharin.

Reconsidering Erythritol . . .

The new study moves us closer to implicating dietary erythritol intake as a cardiovascular disease promoter. According to ScienceAlert.com: 

“In the new study, researchers exposed blood-brain barrier cells to levels of erythritol typically found after drinking a soft drink sweetened with the compound. They saw a chain reaction of cell damage that could make the brain more vulnerable to blood clots – a leading cause of stroke.”

It must be emphasized that this is an in-vitro (test-tube) study, but it does clarify a mechanism by which erythritol could potentially damage blood vessels. Further . . . 

“The laboratory findings align with troubling evidence from human studies. Several large-scale observational studies have found that people who regularly consume erythritol face significantly higher risks of cardiovascular disease, including heart attacks and strokes.”

Confound It!

But nutritional science is complicated and nuanced, seldom yielding pat answers. A recent review of erythritol’s potential role in disease promotion noted:

“Disentangling the relationship between artificial sweeteners and cardiovascular outcomes is complex because of the inevitable confounding effect of enhanced use of artificial sweeteners in poor–nutritional quality food. Artificial sweetener intake has been shown to be associated with increased CHD and stroke in a large prospective study (mean age 42.22 years, median follow-up 9 years); however, individuals with high artificial sweetener intake also had poorer diet (less fruits, vegetables, and fiber and more processed meat, dairy, and sodium), were less physically active and more likely to smoke, and had a higher BMI, all risk factors for CHD and stroke.”

Back to Sugar?

Notwithstanding, the net effect on me is that I didn’t buy that new box of erythritol-containing monkfruit sweetener. I’ve disciplined myself to consume my tea unsweetened, or, if I’m in the mood, I go back to adding a half teaspoon of good ol’ fashioned brown sugar. 

I rationalize these minor transgressions by reminding myself that this was the way sugar was consumed in the old days, as an occasional condiment; these days, we mainline it via sodas, sports drinks, candies, baked goods, desserts, dressings and virtually every processed food that’s “flavor-enhanced”. 

Try as we might, we may not be able to fool Mother Nature with ersatz zero-calorie sugar substitutes.

Erythritol Backlash?

It’ll be interesting to see if the emerging research on erythritol sparks a consumer backlash, regulatory action, or worse yet for makers of natural non-caloric sweeteners, a tide of class-action lawsuits.

Oh, and incidentally, where does most of our erythritol supply come from? China! Last year, US food ingredient manufacturer Cargill filed a petition in trade court against Chinese makers of erythritol . . .

“ . . . alleging that the imports are dumped and unfairly subsidized. Cargill’s petition asks the U.S. government to impose antidumping (“AD”) and countervailing duties (“CVD”) on these imports from China.”

Europe Takes Action on Erythritol 

European regulators already have erythritol in the cross-hairs. In 2023, they lowered the recommended threshold for consumption of erythritol to no more than 0.5 grams per kilogram of bodyweight per day. Children, especially, can get diarrhea from too much. Nevertheless, they acknowledge Europeans are already overconsuming it:

“The agency reports that, in all groups of people across the EU population included in the assessment, both acute and chronic exposure to erythritol is above the newly set ADI.”

They haven’t yet concluded erythritol has cardiovascular risks, but reserve judgement:

“However, EFSA [Europe’s version of the FDA] calls for further research to clarify the nature of the association between erythritol and cardiovascular diseases found in some observational studies.”

(This, as they say, is a developing story)