Erythritol, a low-calorie sugar replacement widely used in modern diets, is facing serious medical re-evaluation.

Commonly found in "no sugar" beverages, protein bar, chewing gum, and even hygiene products, erythritol has long been considered a safe alternative for individuals aiming to manage blood sugar levels or reduce caloric intake.

However, recent high-quality evidence suggests this compound may contribute to conditions far more dangerous than weight gain—specifically, increased risk of heart attack, and possibly neurological events.

A Cardiovascular Red Flag: What the Latest Studies Reveal

In a large-scale, multi-country study published in Nature Medicine (2023), scientists from the Cleveland Clinic analyzed blood samples from over 4,000 adults in both the United States and Europe. Elevated levels of erythritol in plasma were significantly correlated with a higher incidence of major adverse cardiovascular events. These included, myocardial infarction, and cardiovascular death.

Dr. Stanley Hazen, a physician-scientist and lead author of the study, emphasized, "We were not expecting this association to be so strong. The connection between erythritol levels and platelet activation presents an urgent need for clinical awareness." Importantly, the study observed that people who consumed erythritol-containing products showed elevated blood concentrations for several hours after ingestion—long enough to potentially influence thrombosis pathways.

Blood Clot Risk: Mechanistic Evidence Grows Stronger

What makes this concern especially alarming is the biological plausibility behind the findings. Erythritol appears to alter platelet function, leading to enhanced clot formation. Laboratory experiments showed that when blood cells were exposed to erythritol concentrations typical of those found post-consumption, platelet aggregation increased substantially.

In animal models, including rodent thrombosis simulations, erythritol exposure led to quicker clot formation in response to vascular injury. This was accompanied by upregulation in pathways associated with calcium signaling and intracellular adhesion—a known contributor to arterial thrombogenesis. These findings raise questions about the safety of erythritol not only as a dietary additive but also as a possible enhancer of preexisting pro-thrombotic conditions.

Brain Health: Potential Implications for Neurology

The brain, highly sensitive to changes in vascular function, may also be affected by erythritol's interference with blood flow. While clinical trials specifically linking erythritol to cognitive decline are still lacking, researchers have raised theoretical concerns grounded in cerebrovascular physiology.

Dr. Ayesha Sherzai, a neurologist specializing in cognitive disorders prevention, stated in a 2024 expert panel discussion, "When a compound promotes endothelial disruption or increases clot risk, even subtly, the brain is often one of the first organs to suffer. Microclots in cerebral vessels can accelerate neurodegenerative processes or trigger transient ischemic events."

Particularly in older adults or patients with mild cognitive impairment, even minor reductions in perfusion can have meaningful long-term consequences.

Endogenous Production: Not Just from Diet

Another complicating factor is that erythritol is not only ingested—it's also produced naturally by the human body. Through the pentose phosphate pathway, especially under conditions of oxidative stress or hyperglycemia, erythritol is synthesized endogenously. This means elevated levels in blood may reflect not only dietary habits but also underlying metabolic abnormalities.

A recent biochemical analysis from the University of Cambridge suggested that erythritol may serve as both a metabolic marker and a disease mediator, particularly in patients with type 2 diabetes or metabolic syndrome. This duality complicates interpretation and raises questions about the substance's role in disease progression versus disease response.

At-Risk Groups: Who Should Be Most Concerned?

Emerging evidence suggests that individuals with preexisting cardiometabolic disorders, such as obesity, insulin resistance, or coronary artery disease, may face a disproportionately high risk from erythritol exposure. In subgroup analysis, those with known vascular conditions and higher erythritol levels had almost double the incidence of adverse cardiovascular outcomes.

This is particularly troubling since sugar substitutes are frequently marketed to these exact populations. Many diabetic patients, for instance, switch from glucose-based products to those containing erythritol under the belief that they are choosing the safer option. The irony is stark: a compound intended to protect heart and metabolic health may, in some contexts, exacerbate disease risk.

Regulatory Status and Medical Response

As of early 2025, erythritol remains on the U.S. FDA's Generally Recognized As Safe (GRAS) list, and no formal regulatory changes have been issued. However, international bodies such as the European Food Safety Authority (EFSA) and the World Health Organization (WHO) are now reviewing the latest evidence.

In the clinical community, physicians and cardiologists are beginning to include erythritol intake in dietary assessments, particularly for patients presenting with unexplained thrombotic episodes or multiple vascular risk factors. Some hospital systems are also launching observational registries to collect real-world data on erythritol exposure and cardiovascular outcomes.

A Cautionary Path Forward

While the current data are not yet sufficient to warrant universal restrictions, the medical principle of primum non nocere—first, do no harm—suggests caution is prudent. Unlike natural sugars, whose metabolic effects are well-characterized, erythritol's long-term influence on endothelial health, cerebral perfusion, and thrombotic risk is still being understood.

Until larger randomized controlled trials are completed, physicians may consider advising patients with advanced age, diabetes, or cardiovascular disease to reduce or avoid products high in erythritol.

Erythritol's reputation as a "safe" sweetener is no longer without challenge. What once seemed like a metabolic shortcut—sweetness without glycemic consequence—is now under serious medical scrutiny. From altering platelet function to possibly affecting brain circulation, erythritol's systemic impact appears more complex than once believed.

The next few years will be critical in determining how medical professionals, regulators, and researchers choose to classify and manage this compound. For now, it represents a reminder that dietary interventions, even those marketed as healthy, deserve rigorous scientific evaluation.