A popular artificial sweetener called erythritol is linked to increased rates of heart attack and stroke, according to a study conducted by Cleveland Clinic, an American academic medical centre based in Cleveland, Ohio. The study was published February 27 in the journal Nature Medicine. 


What are artificial sweeteners? Who uses them?


Artificial sweeteners are commonly used as sugar substitutes. People who have obesity, diabetes or metabolic syndrome are often advised to consume sugar-free products containing erythritol. These conditions put people at higher risk for adverse cardiovascular events. 


How is erythritol produced?


About 70 per cent as sweet as sugar, erythritol is produced through fermenting corn. The artificial sweetener is poorly metabolised by the body after ingestion. Instead of being metabolised, erythritol enters the bloodstream and leaves the body mainly through urine. 


Since the human body produces low amounts of erythritol naturally, any additional consumption can accumulate. 


It is difficult to measure artificial sweeteners, and the labelling requirements are minimal. The individual compounds present in erythritol are mostly not mentioned on the label. 


The United States (US) Food and Drug Administration (FDA) has classified erythritol as "Generally Recognized As Safe (GRAS). This means there is no requirement for long-term safety studies. 


However, not much is known about their long-term effects on cardiometabolic disease risks. Therefore, Cleveland Clinic researchers studied erythritol, and examined its atherothrombotic disease (disease occurring due to plaque blockage) risk. 


How the study was conducted


After studying over 4,000 people in the United States and Europe, the researchers found that those with higher blood erythritol levels were at increased risk of experiencing a major adverse cardiac event such as heart attack, stroke or death. 


Erythritol increased clot formation 


Upon examining the effects of adding erythritol to either whole blood or isolated platelets, the researchers found that erythritol made platelets easier to activate and form a clot. 


The ingestion of erythritol increases clot formation, according to pre-clinical studies. 


In a statement released by Cleveland Clinic, Stanley Hazen, the senior author on the paper, said sweeteners like erythritol have rapidly increased in popularity in recent years but there needs to be more in-depth research into their long-term effects. 


Hazen also said that cardiovascular disease builds over time, and heart disease is the leading cause of death globally. Therefore, it is important to ensure that the foods humans eat are not hidden contributors. 


Significance of the research


In order to confirm the findings of the new study in the general population, it is important to conduct follow-up studies, according to the authors. One of the limitations to the study includes the fact that clinical studies demonstrate association and not causation. This means that the study has shown that erythritol consumption is associated with increased risk of heart attack and stroke, but has not established the cause. 


Hazen said the study shows that when participants consumed an artificially sweetened beverage with an amount of erythritol found in many processed foods, markedly elevated blood levels were observed for days. These levels were well above those observed to enhance clotting risks. 


Hazen said it is important that further safety studies are conducted to examine the long-term effects of artificial sweeteners in general, and erythritol specifically, on the risks for heart attack and stroke, particularly in people at higher risk for cardiovascular disease. 


The authors concluded that the findings reveal that erythritol is both associated with risk or major adverse cardiovascular events, which includes death, non-fatal myocardial infarction (blockage of blood flow to heart muscle), or stroke, and fosters enhanced thrombosis, a condition in which blood clots block veins or arteries.