RHR: Erythritol: The ‘Safe’ Sweetener That’s Anything But

In this episode we discuss:

• Why erythritol became the go-to sweetener for “sugar-free” and keto products
• New evidence linking erythritol to increased risk of heart attack and stroke
• The FDA’s GRAS designation and how it failed to catch long-term risks
• Gut health effects of sugar alcohols, including IBS-like symptoms
• Safer alternatives to erythritol, including allulose, pure stevia, and monk fruit
• When small amounts of real sugar may be less harmful than chronic sweetener use
• Practical label-reading tips to avoid hidden erythritol and guidance for sweetener use

Show notes:

• “The non-nutritive sweetener erythritol adversely affects brain microvascular endothelial cell function” by Berry, A. R., et al.
• “The artificial sweetener erythritol and cardiovascular event risk” by Witkowski, M., et al.
• “Xylitol is prothrombotic and associated with cardiovascular risk” by Witkowski, M., et al
• Learn more about the Adapt Naturals Core Plus bundle, or take our quiz to see which products best suit your needs
• If you’d like to ask a question for Chris to answer in a future episode, submit it here
• Follow Chris on Instagram or Facebook

Hey everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. If you’re trying to lose weight, manage your blood sugar, or follow a keto diet, chances are you’ve reached for products labeled “sugar-free” or “zero calorie.” Maybe it’s a protein bar, a diet soda, or that pint of keto ice cream in your freezer. These products promise all the sweetness without the metabolic consequences of sugar, and for people with diabetes, obesity, or metabolic syndrome, they seem like the obvious choice. But what if I told you that one of the most common sweeteners in these products, an ingredient that’s been marketed as safe and even healthy, might be doing the exact opposite of what you think? What if it’s increasing your risk of heart attack and stroke?

I’m talking about erythritol, a sugar alcohol that’s found in hundreds of products, from Truvia to Monster Energy drinks to Halo Top ice cream. It’s in your protein bars, your electrolyte drinks, even blended into “natural” stevia and monk fruit sweeteners as a bulking agent. And for years it’s been considered Generally Recognized As Safe, or GRAS, by the FDA with virtually no requirement for long-term safety studies.

Here’s the problem. A series of rigorous studies from Cleveland Clinic and the University of Colorado Boulder have found that erythritol doesn’t just fail to protect your cardiovascular health, it appears to actively harm it. We’re talking about increased blood clotting, impaired blood vessel function, and a roughly two-fold increase in the risk of heart attack and stroke in people with the highest blood levels of this sweetener. The irony is painful. Erythritol is being marketed to the exact population at highest risk, people with diabetes and heart disease, and it may be making their condition worse.

I want to be clear up front, this doesn’t mean you need to panic if you’ve had erythritol in the past, and it doesn’t mean there are no safe alternatives. By the end of this episode, you’ll understand what the research shows, how erythritol affects your blood vessels at a cellular level, why the regulatory system failed to catch this, and most importantly, what safer options exist for people who need or want to avoid sugar. Let’s dive in.

Okay, let’s start with the basics. What is erythritol, and where is it hiding in your food? Erythritol is a sugar alcohol, technically a four-carbon polyol, that’s produced by fermenting corn. It’s about 70 percent as sweet as table sugar, but it has almost zero calories, doesn’t raise blood sugar or insulin levels, and unlike some artificial sweeteners, it doesn’t have that lingering chemical aftertaste. It looks like sugar, tastes reasonably close to sugar, and you can bake with it. For the food industry, it was perfect.

The human body does produce small amounts of erythritol naturally as a byproduct of glucose metabolism. That’s partly why regulators assumed it was safe. But here’s the critical difference– when erythritol is used as a sweetener in processed foods, you’re consuming levels that are more than a thousand times higher than what occurs naturally in fruits and vegetables or what your body produces on its own. And because erythritol is poorly metabolized by your body, it doesn’t get broken down. It goes into your bloodstream and stays there for days before eventually being excreted in your urine. Any additional consumption stacks up.

You’ll find erythritol in an enormous range of products. Diet sodas like Bai, Monster Energy, Gatorade G2, and Vitamin Water Zero. Frozen desserts like Halo Top, Nick’s, and Sambazon. Tabletop sweeteners including Truvia and Splenda Naturals. Protein bars from brands like SlimFast, think!, and certain flavors of Quest and Perfect Keto. And here’s the kicker– erythritol is the largest ingredient by weight in many products labeled as “stevia” or “monk fruit” sweeteners. Because stevia and monk fruit are 200 to 400 times sweeter than sugar, manufacturers only need a tiny amount for sweetness. The rest of the product, often 95 percent or more by weight, is erythritol serving as a bulking agent to give it that sugar-like texture and appearance.

The regulatory landscape makes this even more problematic. Erythritol is classified as GRAS by the FDA. This classification, which was granted in 2001, means there’s no requirement for long-term safety studies. Food manufacturers can use it without restriction. And here’s another issue– products aren’t required to list individual sugar alcohols on nutrition labels. They can just say “sugar alcohols” in the ingredients. So unless you’re reading carefully, you might not even know you’re consuming erythritol.

Erythritol’s Link to Increased Cardiovascular Risks

The discovery of erythritol’s cardiovascular risk was completely accidental. Dr. Stan Hazen, a cardiologist at Cleveland Clinic, wasn’t looking for problems with sweeteners. His research team was trying to identify unknown chemical compounds in people’s blood that might predict future risk of heart attack, stroke, or death. They were analyzing blood samples from over a thousand patients at risk for heart disease, collected between 2004 and 2011, using a technique called untargeted metabolomics. When they ranked all the compounds by their association with cardiovascular events over the next three years, erythritol rose to the top. Hazen has publicly said that they had no idea what this compound was initially. They weren’t even looking for it. Once they identified it as erythritol, they validated the finding in two additional independent cohorts, one with over 2000 patients in the United States and another with 833 patients in Europe. The results, published in Nature Medicine in February 2023, were striking. Patients in the highest quartile of blood erythritol levels, compared to those in the lowest quartile, had roughly double the risk of major adverse cardiovascular events over the next three years. In the US cohort, the hazard ratio was 1.8. In the European cohort, it was 2.21. These are not modest increases. To put this in perspective, Hazen noted that erythritol appeared to be on par with the strongest cardiac risk factors, comparable to having type II diabetes.

The team didn’t stop there. They wanted to understand the mechanism, so they conducted laboratory studies adding erythritol to blood and platelet samples at concentrations typically seen in patients. What they found was that erythritol made platelets, the cell fragments that form clots, significantly more reactive. It enhanced platelet aggregation, increased clot formation, and did so rapidly within minutes of exposure. Then in August 2024, the same research group published a human intervention study in healthy volunteers. Twenty people with no cardiovascular disease consumed a single beverage sweetened with erythritol, the kind of amount you’d find in a sugar-free soda or muffin. Their blood erythritol levels increased more than a thousand-fold compared to baseline, and those elevated levels persisted for days. Every measure of platelet clotting ability increased immediately after consumption. The researchers then gave the same volunteers a glucose-sweetened beverage for comparison. Glucose didn’t have these effects. This was specific to erythritol. What makes this particularly concerning is that these effects were seen in healthy people. If erythritol can enhance clotting risk in individuals with no underlying cardiovascular disease, the implications for people who already have diabetes, obesity, or heart disease, the very populations these products are marketed to, are troubling.

Now let’s talk about what’s happening at the cellular level, because this is where the story gets even more interesting. A research team at the University of Colorado Boulder, led by Dr. Christopher DeSouza, wanted to understand exactly how erythritol might be increasing stroke risk. Their study, published in the Journal of Applied Physiology in June 2025, examined human brain microvascular endothelial cells, the cells that line the small blood vessels in your brain. They treated these cells with six millimolar erythritol, which is equivalent to the amount you consume in a typical artificially sweetened beverage, about 30 grams. After just three hours of exposure, they found four distinct pathological changes.

First, erythritol caused a dramatic increase in oxidative stress. The cells produced roughly double the amount of reactive oxygen species, or free radicals, compared to untreated cells. These are the metabolic byproducts that damage cells, accelerate aging, and trigger inflammation. The cells responded by ramping up their antioxidant defenses, producing more superoxide dismutase and catalase, which tells you the cells were under significant stress.

Second, erythritol disrupted nitric oxide production. Nitric oxide is one of your body’s most important signaling molecules for vascular health. It relaxes and widens blood vessels, or vasodilates them, maintains healthy blood flow, and helps prevent clots. The total amount of the enzyme that produces nitric oxide, called endothelial nitric oxide synthase, or eNOS, didn’t change. But erythritol altered how that enzyme was regulated. It reduced the activating phosphorylation by about 33 percent and increased the inhibitory phosphorylation by 39 percent. The net result was a 20 percent drop in nitric oxide production. Less nitric oxide means your blood vessels are more constricted, blood flow is impaired, and you have a higher baseline risk for stroke.

Third, erythritol increased production of endothelin-1, a peptide that constricts blood vessels. Levels of its precursor protein, Big ET-1, were significantly elevated, and the amount of endothelin-1 released from the cells increased by roughly 30 percent. This is the opposite of what you want. You’re getting less of the molecule that opens blood vessels and more of the molecule that narrows them.

Fourth, and perhaps most concerning, erythritol, impaired the cells’ ability to break down blood clots. Under normal conditions, when cells are exposed to thrombin, a compound that signals clot formation, they respond by releasing tissue-type plasminogen activator, or t-PA, which helps dissolve clots. That’s one of your body’s natural defenses against stroke. In the untreated cells, t-PA release increased by about 25 percent in response to thrombin. In the erythritol-treated cells, there was no increase at all. The response was completely blunted. This means when your body needs to break down a clot, erythritol-exposed cells can’t do it effectively.

Put these four mechanisms together, more constricted blood vessels, increased oxidative damage, elevated clotting risk, and reduced clot-busting ability, and you have a perfect storm for stroke. This wasn’t some massive dose, this was the amount of erythritol in a single serving of a product most people would consider healthy.

Erythritol is everywhere—from keto snacks to “stevia” sweeteners—but new research suggests it may double the risk of heart attack and stroke. In this episode, Chris Kresser breaks down the science, explains who’s most at risk, and shares safer alternatives to sugar-free sweeteners. #ChrisKresser #erythritol

The FDA’s GRAS Designation

Here’s where I get frustrated with our regulatory system. Erythritol has been classified as GRAS since 2001. Under the GRAS designation, there’s no requirement for the kind of long-term cardiovascular safety studies that would have caught these risks decades ago. The assumption was simple: erythritol occurs naturally in small amounts in some fruits, and the body produces tiny amounts as part of normal metabolism, so adding it to food must be fine. But that logic breaks down when you’re consuming a thousand times the amount that occurs naturally when the substance accumulates in your bloodstream because it’s not metabolized, and when it’s being consumed daily by millions of people, many of whom already have cardiovascular risk factors. Remember the dose always makes the poison. The regulatory framework wasn’t designed to evaluate these kinds of long-term, population-level effects.

And it’s not just erythritol. The same Cleveland Clinic research team found nearly identical cardiovascular risk with xylitol, another sugar alcohol, in a study published in the European Heart Journal in June 2024. Xylitol is less common in US keto products, but it’s widely used in sugar-free gum, candy, and oral care products like toothpaste. The study showed that people with the highest xylitol levels had a 57 percent increased risk of cardiovascular events, and just like with erythritol, consuming a xylitol-sweetened drink caused immediate enhancement of platelet clotting in healthy volunteers.

Now, I want to emphasize that xylitol in toothpaste or mouthwash is unlikely to be a concern because you’re not swallowing meaningful amounts. The risk is specific to consumption in food products where you’re ingesting significant quantities. But the pattern is clear. Sugar alcohols as a class appear to have prothrombotic effects, meaning they promote blood clot formation. This wouldn’t be the first time we’ve seen well-intentioned dietary recommendations backfire for vulnerable populations. For decades, the American Diabetes Association has recommended low-fat, high-carbohydrate diets for people with Type II diabetes. Both research and my clinical experience have shown that a low-carbohydrate approach is far more effective for the vast majority of people with metabolic and blood sugar dysfunction. Yet the low-fat dogma persisted for years, likely making the diabetes epidemic worse. We’re seeing a similar pattern with sugar alcohols. They’re being recommended to people with obesity, diabetes, and heart disease, populations already at elevated risk. And the evidence suggests we may be making things worse.

Gut Health Effects of Sugar Alcohols

The cardiovascular risks are the most alarming findings, but they’re not the only concerns with sugar alcohols like erythritol. There’s also the issue of gut health, which comes up frequently in my practice. Sugar alcohols are only partially absorbed in the small intestine. The portion that’s not absorbed draws water into your colon through osmotic pressure and gets fermented by gut bacteria. For many people, this leads to diarrhea, gas, bloating, abdominal pain, and symptoms that can mimic or trigger irritable bowel syndrome, or IBS. People with existing IBS or sensitive guts are particularly prone to these effects. In fact, polyols, the category that includes erythritol, sorbitol, and xylitol, are one of the main groups of fermentable carbohydrates that people eliminate on a low-FODMAP diet (the P in FODMAP standing for polyols) specifically because they cause dysmotility and digestive symptoms.

Now, erythritol is considered better tolerated than some other sugar alcohols because more of it gets absorbed before reaching the colon. But tolerance varies widely, and I’ve had plenty of patients report digestive issues when consuming products with erythritol regularly. The threshold is individual, of course. Some people can handle moderate amounts without problems, others react to even small doses. The broader point is, we’re learning that these compounds, which were assumed to be inert because they pass through the body largely unmetabolized, are not inert at all. They interact with our physiology in ways we didn’t anticipate. The cardiovascular effects are again the most concerning, because they’re potentially life-threatening. But the gut effects matter too, especially for people who are already dealing with digestive issues.

Safer Alternatives to Erythritol

Now, before everyone listening throws out every sugar-free product in their pantry, let’s talk about context and alternatives. The key question is, compared to what? For someone with severe Type II diabetes or significant metabolic dysfunction, sugar should probably be avoided entirely. The blood sugar spikes, the insulin surges, the glycation, these are real problems that contribute to disease progression. In that context, you need alternatives, and fortunately, not all sugar substitutes carry the same risks as erythritol. The safest option based on current evidence is allulose. Allulose is a rare sugar that’s naturally found in small amounts in figs, raisins, and maple syrup. Structurally, it’s similar to fructose, but your body metabolizes it differently. It gets absorbed in the small intestine but then rapidly excreted without being converted to glucose. The result is virtually no calories, no impact on blood sugar or insulin, and it’s about 70 percent as sweet as sugar, similar to erythritol. What’s particularly interesting about allulose is that unlike erythritol, which appears to cause harm, allulose may have beneficial effects. Studies suggest it can improve insulin sensitivity, enhance fat oxidation, which supports ketosis if you’re on a keto diet, increase levels of GLP-1, the satiety hormone, and may even help reduce inflammation and prevent fat accumulation in the liver. The main downside is that in doses over about 10 grams, some people experience GI distress, similar to other sugar alcohols, though generally milder. It’s also more expensive than erythritol, which is why food manufacturers have not embraced it as widely.

Another safe option is pure stevia extract, or pure monk fruit extract. I emphasize “pure” because, as I mentioned earlier, many commercial stevia and monk fruit products use erythritol as a bulking agent. You’ll see a product labeled stevia sweetener, but if you check the ingredients, erythritol is often the second ingredient and makes up the vast majority of the product by weight. You need to look for products that are 100 percent pure stevia extract or monk fruit extract, usually in liquid or concentrated powder form. These are much sweeter than sugar, 200 to 400 times sweeter, so you use teeny amounts. They’re keto-friendly, they don’t affect blood sugar, and there’s no evidence linking them to cardiovascular harm. Some people find stevia has a bitter aftertaste, and there’s emerging research that high doses might affect gut bacteria, but at the levels you’d use as a sweetener, they appear to be relatively safe.

Now here’s where I’m going to say something that might surprise you. For people with mild blood sugar dysregulation, not severe diabetes, but maybe some insulin resistance or prediabetes, it may be that consuming a very small amount of actual sugar occasionally is a better choice than chronic consumption of erythritol. I’m not suggesting you go back to drinking regular soda or eating dessert every day, but if you’re having a cup of coffee and you add a teeny bit of real sugar, that’s probably less harmful than drinking a diet soda with erythritol multiple times a day, especially if you already have cardiovascular risk factors. The dose, again, makes the poison. And we’re learning that the chronic daily consumption of these sugar alcohols at levels far exceeding what the human body evolved to handle may carry risks that outweigh the benefits of voiding sugar in small amounts. It’s all about context.

Practical Guidance for Sweetener Use

So what do you do if you’re currently consuming erythritol regularly? Here’s my practical guidance. First, read labels obsessively. Don’t assume a product is safe just because it says “stevia,” “monk fruit,” “keto-friendly,” or “sugar-free.” Turn the package over and look at the ingredients. If you see erythritol or the phrase “sugar alcohols,” that’s your red flag. The same goes for xylitol. You want products sweetened with allulose, pure stevia extract, or pure monk fruit extract. These are harder to find, and often more expensive, but they don’t carry the cardiovascular concerns.

Second, if you’re using erythritol-based products daily, multiple servings a day, protein bars, diet sodas, keto desserts, consider scaling back significantly or switching to alternatives. The Cleveland Clinic studies showed that blood erythritol levels stay elevated for days after consumption. If you’re consuming these products every day, you’re maintaining chronically high levels. That’s the scenario where the cardiovascular risks appear most pronounced.

Third, and this is especially important if you have Type II diabetes, obesity, metabolic syndrome, or existing heart disease, talk to your doctor about these findings. You’re in the exact population that these products are marketed to, and unfortunately you’re also in the population at highest risk from erythritol’s effects. Your doctor may want to help you transition to safer alternatives or adjust your overall dietary approach.

Fourth, consider whether you really need a sugar substitute at all. I know that sounds like a cop-out, but hear me out. If you’re using these products because you’re trying to maintain a very low-carbohydrate or ketogenic diet for therapeutic reasons, managing epilepsy or severe insulin resistance, then, yes, you need good alternatives, and allulose is probably your best bet. But if you’re using them primarily for weight loss or general health, it may be worth reassessing whether the occasional small amount of real sugar in the context of an otherwise nutrient-dense, whole foods diet is actually a problem. A lot of people get stuck in the mindset that any sugar, even the teeniest amount, is toxic, but that’s not really supported by the evidence for people without significant metabolic dysfunction.

Finally, remember that the goal isn’t perfection. It’s making informed choices with the best available evidence. If you’ve consumed erythritol in the past, don’t panic. These studies show increased risk with chronic consumption and elevated blood levels, not from occasional exposure. What matters is what you do going forward. You now have information that wasn’t widely known even a year ago, and you can use it to make better decisions.

Okay, everyone. Thanks for listening. You can find show notes and links to all the studies I mentioned at ChrisKresser.com. If you have questions about anything we discussed today, head over to ChrisKresser.com/podcastquestion, and we’ll try to answer them on a future episode. And if you’d like to share this episode, please do. This is information a lot of people need to hear. I’ll talk to you next time.