Some Not-So-Sweet News About Sugar Substitutes

Artificial sweeteners have enjoyed a love-hate relationship with consumers for as long as these products have been around. The first of its kind, saccharin, was discovered in the late 1800’s, and was popularized in the mid- to late-twentieth century as a calorie-free means of enjoying a sweet. This one and the numerous sweeteners to follow have shared the function of being up to hundreds of times sweeter than plain old sugar, having minimal to no calories, but have carried with them some minor and not-so-minor speed bumps.

From abdominal bloating and diarrhea to “tricking” the body to crave real sugar, to metabolic disorders to cancer risks, artificial sweeteners have always had some bitter risks under that sugar coating. Initially popularized as a weight-loss instrument as well as a means of reducing risks of diabetes, there continue to be some negatives that may outweigh the positives of avoiding real sugar.

One common sweetener used today, erythritol, has been the subject of a recent concerning finding. A study published in this week’s Nature Medicine reported on some increased association with blood clotting and cardiovascular disease. This substance is a form of sugar alcohol, often used to add bulk to other sugar substitutes such as stevia, monk-fruit or keto-based desserts, as some of the other sugar substitutes are just too sweet. Sugar alcohols, or polyols, are also used in many so-called “health” drinks, nutrition bars, and products labeled as “sweetened with fruit” or “no sugar added.” As erythritol is sometimes a component of other sugar substitutes, it is not always clearly labeled on packaging.

The study, which demonstrated association, but not causation, looked at both laboratory results and patient outcomes. Laboratory studies assessed erythritol’s effect on platelet activity, a key factor in forming blood clots. There was a clear connection of higher levels of erythritol leading to “stickier” platelets, which, in turn, leads to higher chances of forming blood clots in the vascular system. Clotting is a critical component of cardiovascular disease. Propensity of coronary arteries, which supply blood to the heart, as well as major and minor vessels throughout the circulatory system, especially in the brain, to form clots, are the primary causes of heart attacks and strokes.

The patient portion of the study showed that there was an association between higher blood levels of erythritol in patients who developed major adverse cardiovascular events than in those who did not. However, the study population was that of patients with already known cardiovascular risk factors. But the findings of nearly double the risk of cardiac events in those with higher erythritol levels was significant. A challenging component to this finding, not yet clarified, is whether or not the patients with higher levels of erythritol were ingesting specific diet-related foods and beverages due to other chronic conditions such as diabetes and obesity.

Another concern, albeit extraordinarily rare, is the risk of anaphylaxis, or life-threatening allergic reactions, to erythritol. As this substance is rarely consumed as a stand-alone product, it is often quite difficult to assess the source of these allergic reactions, which can range from rashes and itchiness to airway swelling, dangerous drops in blood pressure, and respiratory distress. Individual reports of such reactions are just starting to be described worldwide.

The current report on high levels of erythritol being associated with increased risk of cardiovascular events merits further study, as one cannot draw direct conclusions of causation based on such results. However, it does warrant more clarity on food labeling, especially on products labeled as “no added sugar”, “natural” or with “fruit” sweeteners.

Sugar itself, or sucrose, is hundreds of times less sweet than no-calorie sugar alcohol sweeteners. Sugar has been vilified as a major source of the obesity epidemic and climbing rates of childhood diabetes. Low-fat products have traded out fat content for increased sugar content, which has done a disservice to millions. As with most things, moderation is rarely a selling point, especially in the food and beverage industries.