Results from a recent study need explaining
By Austin Perlmutter, MD
A recent study links erythritol, a popular "no-calorie" sugar alternative, to higher risk of death, stroke and heart attack.
The study has been touted as a clear reason to avoid erythritol but there are several reasons to push back on the strength of the data.
Generally, decreasing processed food and added sweeteners may be best for overall and brain health.
For years there’s been debate on the “healthier” sugar alternatives. One of the more popular is erythritol, a zero-calorie sugar alcohol that’s found in a number of sweetener brands. This week, a major study published in Nature found a correlation between erythritol levels (as measured in blood) and an increased risk for heart attack and stroke. While many are advising consumers to cut back on erythritol based-sweeteners, some have challenged the implications and methods of this work.
Erythritol is a sugar alcohol naturally in fruits and vegetables. We can also make it in our bodies from glucose. Yet the levels found in erythritol-sweetened foods can be over 1000x higher than what’s found naturally. These elevated levels of the molecule have been proposed to have the potential to increase platelet stickiness, leading to higher risk for clotting events including stroke.
It's worth noting that unconventional sweeteners have been under fire for their brain-harming effects for years. In a study published in the journal Stroke in 2018, researchers found an association between consumption of the sugar substitutes saccharin, acesulfame-K, and aspartame and an increased risk for dementia and stroke. Yet consumption of sugar alcohols (a group that includes both erythritol and xylitol) have previously been associated with positive effects on metabolic health (important in the context of research linking metabolic health and brain health).
In the recent study, researchers looked at thousands of people from multiple locations and tracked them for several years. These people were by and large not a healthy population, with the majority experiencing at least one risk factor for metabolic syndrome (for example, most people in the largest cohorts had existing coronary artery disease and hypertension). Blood from these participants was measured for a wide range of molecules including erythritol.
On looking at a range of metabolites, researchers found that people with elevated blood erythritol levels tended to be at higher risk for major adverse cardiovascular events stroke and heart attack. They went on to test the correlation between eating erythritol and levels of erythritol in blood and found dramatically higher levels of this sugar alcohol after consumption of a drink containing 30 grams. Notably, this intervention was only performed in 8 people.
Some have seen this study as solid evidence that erythritol should be avoided at all costs. Others have focused attention on potential issues with the study, including the fact that the studied population was rather unhealthy, that the researchers did not control for people who might have higher erythritol levels as a result of poor baseline health (instead of due to diet), and the size of the interventional group (only 8 people).
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What are the takeaways from this study?
Some feel these results are sufficient to recommend we decrease our consumption of added erythritol (which is found in Splenda, monkfruit, stevia-sweetened products and especially in keto-branded products). Others feel the results are still too preliminary to change our dietary choices and may not be as relevant for metabolically healthy people.
Independent of the specifics of this study, one of the most notable ideas represented by this type of research is simple: highly processed food is worth avoiding when possible. As much as we want to have our cake and eat it too (eat sweets without the negative health impacts), it’s tough to argue that this is an optimal plan. Previous research reveals that no-calorie sweeteners may negatively impact the microbiome and may even promote weight gain. For a society that consumes over 50 lbs a year of added sugar, re-sensitizing ourselves to enjoying less sweet foods seems to be key.
Based on the current research, are there better options for sweet alternatives? At this time, there may be reason to place an emphasis on allulose, stevia and monkfruit as potentially “safer” sweeteners, (aspartame and sucralose have already somewhat fallen out of favor). But it’s highly likely that in the years to come, additional research may demonstrate what seems already evident: there will always be more to learn.