A popular no-calorie artificial sweetener that’s used in keto and other diets and some low-calorie foods may increase the likelihood of stroke, heart attack and even death, according to a new study by Cleveland Clinic researchers published in the journal Nature Medicine.

Erythritol increased the likelihood of blood clot formation in the research, which involved nearly 4,000 patients in the United States and Europe who were being evaluated for heart health. Those with higher levels of the sweetener in their blood had more clotting.

But the study authors also emphasized that each of those involved in the study was already undergoing voluntary cardiovascular disease risk evaluation at the time they were recruited for the study, suggesting a need for more research to see how well findings can be generalized to the population. The study also shows a link only, not causation.

As The Washington Post reported, “Still, the results offer a significant challenge to product marketing that pitches erythritol as a healthy, natural sugar alternative. And the insights arrive as erythritol has come into vogue, with plant-based, keto and low-carb diet trends spurring interest in alternative sweeteners sold as ‘natural.’”

Initially, the researchers weren’t studying particular products at all. They were analyzing blood samples of those at risk of heart disease collected over about eight years to see what chemicals and compounds might be linked to cardiovascular events.

Per The Hill, “After discovering the link between the high levels and increased risk, the researchers confirmed their results by testing a larger sample from 2,100 people in the United States and 833 samples in Europe through 2018.”

The article added that “‘Sugar-free’ products with erythritol are often recommended to individuals with obesity, diabetes or metabolic syndrome — who are already at risk for such cardiovascular health problems” according to the study.

In a news release from Cleveland Clinic, the study’s senior author, Dr. Stanley Hazen, who chairs the Department of Cardiovascular & Metabolic Services and co-leads Prevention Cardiology, said, “Sweeteners like erythritol have rapidly increased in popularity in recent years but there needs to be more in-depth research into their long-term effects. Cardiovascular disease builds over time, and heart disease is the leading cause of death globally. We need to make sure the foods we eat aren’t hidden contributors.”

The Cleveland Clinic release said that erythritol is “about 70% as sweet as sugar and is produced through fermenting corn. After ingestion, erythritol is poorly metabolized by the body. Instead, it goes into the bloodstream and leaves the body mainly through urine. The human body creates low amounts of erythritol naturally, so any additional consumption can accumulate.”

It added that erythritol is “generally recognized as safe” by the U.S. Food and Drug Administration, so long-term studies have not been required.

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“Our study shows that when participants consumed an artificially sweetened beverage with an amount of erythritol found in many processed foods, markedly elevated levels in the blood are observed for days — levels well above those observed to enhance clotting risks,” Hazen said. “It is important that further safety studies are conducted to examine the long-term effects of artificial sweeteners in general, and erythritol specifically, on risks for heart attack and stroke, particularly in people at higher risk for cardiovascular disease.”

According to the American Heart Association, cardiovascular disease, which includes heart attacks and strokes, accounted for 874,613 deaths in the United States in 2019.

Other sweeteners

ABC News quoted dietitian Anna Taylor, who suggested using fresh or frozen fruit as a sweetener. She “also suggests looking for other sugar substitutes like Stevia-based sweeteners that are herbal as opposed to artificial.

“However, the study warns that erythritol is often combined with other sugar substitutes to help add bulk to the sweeteners,” per ABC News.

Using natural sugars doesn’t remove all the risk, either. “Natural sugars like raw honey, maple syrup, agave nectar and raw sugar provide more nutrients than table sugar, including antioxidants, vitamins and prebiotic gut bacteria, but there are often hidden ingredients like high-fructose corn syrup, which has been linked to long-term metabolic complications, according to Taylor,” ABC reported.