Erythritol: The Sugar Alcohol Behind the 2023 Heart Risk Study

Erythritol had a good decade. It solved problems that other sugar alcohols didn’t: close to sugar’s sweetness, almost no calories, no blood sugar spike, and far less GI distress than xylitol or sorbitol. The keto food industry loved it. Then in February 2023, a paper appeared in Nature Medicine and the headlines got complicated.

Understanding what the study actually found — and what it didn’t — requires looking at the science carefully.

What Erythritol Is

Erythritol is a four-carbon sugar alcohol (polyol) naturally present in small amounts in grapes, pears, watermelons, and fermented foods like sake and wine. Commercially, it’s made by fermenting glucose with a yeast called Moniliella pollinis or Yarrowia lipolytica.

The result is 60 to 70% as sweet as sugar, with 0.24 calories per gram compared to 4 calories per gram for sugar. More importantly for people watching blood glucose: erythritol has essentially no glycemic impact. The 1994 Noda et al. study confirmed that oral erythritol causes no significant change in blood glucose or insulin in healthy subjects.

About 90% of consumed erythritol is absorbed in the small intestine and excreted unchanged in urine. The remaining 10% reaches the colon, where it may be partially fermented. This absorption pattern is why erythritol causes much less GI distress than other sugar alcohols — it barely reaches gut bacteria.

Why It’s Popular in Keto and Diabetic Products

The combination of near-sugar sweetness, negligible calories, and zero glycemic impact made erythritol a key ingredient in low-carb and keto products when that market expanded significantly after 2015.

It’s also commonly blended with stevia (Truvia is the most recognized example) because neither is ideal alone. Erythritol provides bulk, texture, and cooling mouthfeel. Stevia provides intense sweetness. Together they approximate sugar’s functional properties better than either does alone.

Unlike xylitol (which is toxic to dogs and has an unpleasant cooling effect at high doses), erythritol is considered safer for accidental pet ingestion and has a milder mouthfeel in most applications.

The 2023 Nature Medicine Study

The study that changed the conversation was published in February 2023: Witkowski, Nemet, et al. in Nature Medicine.

The researchers did two things. First, they measured blood erythritol levels in a cohort of roughly 4,000 patients who were being evaluated for cardiovascular disease at the Cleveland Clinic. They followed those patients for about three years. Patients with the highest blood erythritol quartile at baseline had a roughly 2-fold increased risk of major cardiovascular events (heart attack, stroke, death) compared to those in the lowest quartile.

Second, they ran controlled experiments: giving 30 grams of erythritol to healthy volunteers and measuring how long blood erythritol stayed elevated (2-3 days) and testing whether erythritol enhanced platelet aggregation (clumping) in vitro.

The in vitro platelet results were striking. Erythritol at concentrations achievable in blood after a typical serving appeared to enhance the tendency of platelets to clump together — a key mechanism in blood clot formation.

The Significant Limitations

This study deserves serious attention. It also has important limitations.

The main cohort was observational. Observational studies can identify associations, not causes. The patients in the Cleveland Clinic cohort were being evaluated specifically for heart disease — they already had elevated cardiovascular risk. People with metabolic syndrome, diabetes, and other conditions produce more endogenous erythritol. The elevated blood erythritol in high-risk patients may reflect their metabolic state rather than their dietary erythritol intake.

In plain terms: sicker people may have higher erythritol because their metabolism is impaired, not because erythritol made them sicker. The causal arrow might point the other way.

The platelet aggregation experiments were in vitro — blood cells in a lab dish, not circulating in a living person’s cardiovascular system. These findings need replication in human clinical studies before they change guidelines.

The study measured blood erythritol without detailed dietary records. It’s difficult to separate the effect of consumed erythritol from endogenous production.

The Regulatory Response

The FDA, EFSA, and most national food safety authorities have not changed their erythritol safety assessments in response to the Witkowski study. EFSA established erythritol as a safe food additive. The FDA received a GRAS notice for erythritol that was not contested.

Several researchers and dietitians have publicly called for follow-up prospective studies before making dietary recommendations. That’s a reasonable position given the evidence: one well-conducted study with significant methodological limitations doesn’t rewrite 30 years of safety data.

The erythritol industry disputed the study’s methodology and conclusions, which is expected. But some independent researchers expressed genuine concern about the cardiovascular mechanism and called for urgent follow-up trials.

Where the Science Stands

The 2023 study is a legitimate signal that warrants attention and further research. It is not proof that erythritol causes cardiovascular harm at normal dietary levels.

The safety_verdict here is caution — not because harm is established, but because a specific mechanism was identified and the population most likely to use erythritol heavily (people with metabolic syndrome, obesity, and cardiovascular risk) happens to overlap with the population where the signal appeared.

For healthy adults using erythritol occasionally in cooking or low-carb baking, the current evidence doesn’t call for elimination. For people with established heart disease, multiple cardiovascular risk factors, or diabetes, the Witkowski study is worth raising with a cardiologist or internist. That’s a different risk-benefit calculation.

The research will continue. Pay attention to what comes next.