There is ongoing debate around sugar substitutes, and the discussion has intensified as new research emerges. Sugar is widely criticized for its impact on metabolic health and chronic disease risk. At the same time, “sugar-free” alternatives are often viewed with similar skepticism.
Although much of the conversation can be overstated, erythritol has started to be a topic of concern. Growing scientific evidence has placed this popular low-calorie sweetener under renewed evaluation, particularly in relation to cardiovascular health.
Many patients and clinicians are now asking a simple question: is erythritol safe for heart health?
New Research Links Erythritol to Increased Cardiovascular Risk
A 2023 study published in Nature Medicine reported that higher circulating levels of erythritol were strongly associated with a significantly increased risk of major adverse cardiovascular events (MACE), including myocardial infarction, stroke, and cardiovascular death (Witkowski et al., 2023).
Individuals in the highest quartile of plasma erythritol had nearly double the risk of cardiovascular events over a three-year period compared to those in the lowest quartile.
The study also included in vivo mouse models and ex vivo human blood assays showing that erythritol increased platelet aggregation and clot formation. The authors concluded that erythritol increases thrombosis potential and emphasized the need for further safety evaluation.
Human Studies Show Large Blood Spikes After Erythritol Intake
These findings are not limited to observational data. A follow-up interventional study found that when healthy volunteers consumed 30 g of erythritol, an amount commonly found in sugar-free drinks, protein bars, and keto products, blood erythritol levels increased more than 1,000-fold within 30 minutes and remained elevated for over 48 hours.
Platelet reactivity also increased significantly, an effect that did not occur in individuals who consumed a glucose control beverage (Witkowski et al., 2024).
This raises concerns about how frequently consuming sugar-free products may impact clotting risk over time.
Cell Studies Show Possible Effects on Vascular and Brain Health
In 2025, researchers exposed human brain microvascular endothelial cells to erythritol at physiologically relevant concentrations. The cells demonstrated increased oxidative stress and reduced nitric oxide production, two changes known to impair vascular function and increase stroke susceptibility (Dierker et al., 2025).
These findings suggest that erythritol may influence both cardiovascular and cerebrovascular health.
Genetic Evidence Points to a Potential Causal Link
A 2025 two-sample Mendelian randomization analysis evaluated whether genetically predicted higher erythritol levels were associated with cardiovascular disease. The results showed modest but consistent associations with coronary artery disease, ischemic stroke, and deep vein thrombosis (Liu et al., 2025).
It’s important to note that Mendelian randomization uses genetic variants as natural experiments, Because these genetic differences are assigned at birth, they aren’t influenced by things like diet, exercise, or lifestyle. This makes it less likely that the results are simply due to diet or lifestyle habits, and more likely that the substance itself is playing a role in disease risk.
What This Means for Heart Health
The body of evidence suggests the following:
- Erythritol is rapidly absorbed and causes extremely high and long-lasting spikes in blood concentration.
- It increases platelet activation, clotting potential, oxidative stress, and endothelial dysfunction.
- Higher circulating erythritol levels are associated with increased long-term cardiovascular risk across multiple independent cohorts.
These findings are supported by mechanistic studies, human intervention research, and genetic evidence
What We Still Do Not Know About Erythritol Safety
Despite these findings, important uncertainties remain.
There are no long-term randomized controlled trials directly linking erythritol consumption to heart attacks, strokes, or cardiovascular death. It is also unclear whether small or occasional doses meaningfully impact risk in otherwise healthy individuals.
At a population level, absolute risk remains uncertain. However, the consistency of mechanistic and clinical findings suggests that frequent or high-dose intake may not be without consequence.
Bottom Line
For individuals with cardiovascular disease, diabetes, metabolic syndrome, or a history of clotting disorders, limiting erythritol intake is a reasonable precaution.
Replacing erythritol with alternatives such as allulose or monk fruit may provide sweetness without the same potential impact on platelet activity or vascular function.
More importantly, reducing reliance on highly processed “sugar-free” products can improve overall dietary quality. Whole foods, balanced macronutrients, and fiber-rich meals remain the foundation of long-term cardiometabolic health.
About the Author
Joseph Lehrberg, MS, RD is a registered dietitian specializing in cardiovascular and metabolic health and founder of CardioFunction Integrative Nutrition Services, a nutrition practice based in Boston. He works with patients with elevated cholesterol, high coronary artery calcium scores, high triglycerides, statin intolerance, and other cardiometabolic risk factors to develop evidence-based nutrition strategies for long-term heart health.
Learn more about working with him here.
References
Witkowski, M., et al. (2023). The artificial sweetener erythritol and cardiovascular event risk. Nature Medicine, 29, 710–718.
Witkowski, M., et al. (2024). Acute effects of erythritol consumption on thrombosis potential in humans. Arteriosclerosis, Thrombosis, and Vascular Biology, 44(5), 845–857.
Dierker, C., et al. (2025). Popular sugar substitute may harm brain and heart health. American Journal of Physiology: Heart and Circulatory Physiology.
Liu, Y., et al. (2025). Genetically predicted erythritol levels and cardiovascular disease. Circulation: Genomic and Precision Medicine, 18(1), e004567.
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