Erythritol & Stroke Risk: Should You Avoid This Sugar Alcohol?

New laboratory research from the University of Colorado at Boulder has identified cellular mechanisms that may explain why the popular sugar substitute erythritol is linked to an increased risk of stroke and blood clots. The findings, published in the Journal of Applied Physiology, provide biological context to epidemiological data that first emerged in 2023 suggesting a correlation between high blood levels of the sweetener and major cardiovascular events.

While erythritol has been marketed as a safe, natural alternative to sugar for weight loss and diabetes management, the new study indicates that consumption levels common in modern diets could negatively impact blood vessel function. Researchers exposed human cerebral microvascular endothelial cells to erythritol concentrations equivalent to a single serving of a zero-sugar beverage. Within three hours, the cells exhibited signs of constriction and reduced ability to regulate blood clotting.

Cellular Changes and Vascular Stress

The research team, led by the Integrative Vascular Biology Lab at CU Boulder, cultured cells that form a key part of blood vessels in the brain. When these cells were exposed to 30 grams of erythritol, the researchers observed significant biochemical shifts. The cells produced less nitric oxide, a signaling molecule essential for relaxing and widening blood vessels. Simultaneously, production of endothelin-1 increased. This amino acid acts as a potent constrictor of blood vessels and is often associated with inflammatory effects.

Oxidative stress also rose markedly in the presence of the sweetener. The study recorded highly reactive free radical oxygen compounds at roughly 75% higher concentrations in the cell cultures containing erythritol compared to the control group. These changes compounded risks related to clot regulation. When exposed to thrombin, an enzyme that generates blood clots, the cells treated with erythritol produced less tissue-type plasminogen activator (t-PA). This compound is responsible for naturally breaking down clots. The control cultures produced roughly 25% more t-PA than those exposed to the sugar alcohol.

Big picture, if your [blood] vessels are more constricted and your ability to break down blood clots is lowered, your risk of stroke goes up.

Auburn Berry, Graduate Researcher, CU Boulder

Building on 2023 Epidemiological Findings

The CU Boulder study was designed to investigate the mechanisms behind a landmark study published in Nature Medicine on February 27, 2023. That earlier research, led by Dr. Stanley Hazen at the Cleveland Clinic, examined over 1,000 people and tracked major adverse cardiovascular events over three years. The team found that elevated levels of erythritol in the blood were associated with an increased risk of heart attack and stroke. To confirm the result, researchers examined two additional groups in the U.S. And Europe totaling almost 3,000 people.

According to the National Institutes of Health, which funded the 2023 research, erythritol levels in the blood when used as a sweetener are typically more than 1,000-fold greater than levels found naturally in foods. While regulatory agencies generally consider artificial sweeteners safe, the NIH noted that little is known about their long-term health consequences. The 2023 results highlighted the need for further study of erythritol’s long-term risks for cardiovascular health.

Prevalence in Diet and Keto Products

Erythritol is a sugar alcohol, a category of carbohydrate derived from fruits and vegetables, though most commercial versions are synthetically produced through industrial fermentation of corn or wheat starch. It is a common ingredient in products marketed for weight loss, keto-friendly diets, and diabetes management. Unlike some other sugar alcohols, such as sorbitol or xylitol, erythritol is known for causing fewer digestive issues and having a very low glycemic index.

The sweetener appears in a wide range of items, including:

• Protein bars
• Zero-sugar energy drinks
• Keto-friendly desserts
• Sugar-free candy
• Some oral care products
• Blends with stevia and monk fruit

Christopher DeSouza, director of CU Boulder’s Integrative Vascular Biology Lab and a study coauthor, emphasized that while deeper clinical research is needed, the current findings warrant caution. He noted that the lab’s findings could be deemed conservative given that only a single serving amount of erythritol was tested. Individuals who consume multiple low-calorie protein bars or zero-sugar energy drinks in a single day could possibly experience more extreme versions of these effects.

Given the epidemiological study that inspired our work, and now our cellular findings, we believe it would be prudent for people to monitor their consumption of non-nutrient-sweeteners such as this one.

Christopher DeSouza, Director, Integrative Vascular Biology Lab

Ongoing Scientific Debate

Despite the alarming cellular data, some medical researchers argue it is too early to make broad assumptions about erythritol. Researchers at Romania’s University of Medicine and Pharmacy of Craiova co-published a letter in the Journal of Applied Physiology emphasizing that the human body produces erythritol naturally. This endogenous production occurs in red blood cells, the liver, and the kidney, often in response to caloric stress such as obesity, insulin resistance, and diabetes.

George Dan Mogoşanu, an associate professor at Craiova, and his colleagues noted that without addressing this dual origin, causality between dietary erythritol and vascular risk remains speculative. They argued that the large 2023 study found a strong correlation between blood levels of erythritol and stroke risk, but it remains unclear how much of that erythritol was produced due to patients’ underlying conditions rather than diet.

For individuals with a history of stroke, blood clots, heart disease, or related conditions, health resources suggest it may be worth discussing erythritol use with a doctor. While the Cleveland Clinic notes that artificial sweeteners can sound like a better choice than sugar, a growing body of evidence suggests they can sometimes pose serious health risks. As research continues, consumers are encouraged to review nutrition labels, keeping in mind that sugar alcohols are not always required to be listed individually on Nutrition Facts labels.