There is ongoing controversy around sugar substitutes, and the debate has only intensified as new research emerges. Sugar is widely criticized for its negative impact on metabolic health and chronic disease risk. At the same time, the “sugar-free” alternatives created to replace sugar often receive similar scrutiny. Although much of the conversation is overstated, erythritol has become a central point of concern. Growing scientific evidence has placed this popular low-calorie sweetener under renewed evaluation, especially regarding cardiovascular health.
New Research Links Erythritol to Increased Cardiovascular Risk
A landmark 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 concerns are not limited to observational associations. A follow-up interventional study found that when healthy volunteers consumed 30 g of erythritol, which is an amount commonly found in sugar-free drinks, protein bars, and keto products, blood erythritol levels spiked 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). These results suggest that erythritol intake can create an environment that may increase clotting risk.
Cell Studies Show Possible Effects on Vascular and Brain Health
In 2025, researchers at the Medical College of Wisconsin exposed human brain microvascular endothelial cells to erythritol at physiologically relevant concentrations. The cells showed increased oxidative stress and reduced nitric oxide production, two changes known to impair vascular function and increase stroke susceptibility (Dierker et al., 2025). This raises the possibility that erythritol may affect not only cardiovascular health but also cerebral blood vessel function.
Genetic Evidence Points to a Potential Causal Link
A 2025 two-sample Mendelian randomization analysis added another layer of evidence. The study 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). Because Mendelian randomization uses genetic variants as natural experiments, these findings help reduce the influence of confounding and strengthen the case for a possible causal link.
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 the concerning data, important gaps remain. There are no long-term randomized controlled trials that directly link erythritol consumption to heart attacks, strokes, or cardiovascular death. We also do not know whether small, occasional doses pose meaningful risk in otherwise healthy individuals. At the population level, absolute risk remains unclear. However, the biological mechanisms and the consistency of recent findings suggest that frequent or high-dose erythritol intake may not be harmless.
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 health.
Above all, this is a reminder to return to the basics of nutrition. Whole foods, balanced macronutrients, and fiber-rich meals offer far greater health benefits than processed products marketed as sugar-free. As clinicians and dietitians, we play an important role in helping patients understand that sugar-free does not always mean risk-free.
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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