Erythritol: What the 2023 Heart Study Actually Found

What is erythritol and where does it come from?

Erythritol is a four-carbon sugar alcohol (polyol) that occurs naturally in small amounts in grapes, pears, watermelon, and fermented foods including wine and sake. Commercially, it is produced by fermenting glucose — typically derived from corn starch — using the yeast Moniliella pollinis or similar organisms. The result is a white crystalline powder that tastes about 60–70% as sweet as sucrose.

Unlike most sugars, erythritol is absorbed almost entirely in the small intestine before reaching the colon, which is why it causes far less gastrointestinal distress than other polyols such as sorbitol or xylitol. Roughly 90% of ingested erythritol is excreted unchanged in urine within 24 hours. It contributes approximately 0.2 kcal per gram — effectively negligible. Its glycemic index is zero: it does not raise blood glucose or trigger an insulin response.

The FDA granted erythritol GRAS status via GRN 382 in 2001. The European Food Safety Authority approved it as food additive E968 and completed a full safety re-evaluation in 2015, concluding no ADI was necessary. This is the regulatory baseline that was in place before the 2023 study.

The 2023 Nature Medicine study: what it found

In February 2023, Witkowski et al. from the Cleveland Clinic published a study in Nature Medicinetitled "The artificial sweetener erythritol and cardiovascular event risk." The research unfolded in three parts.

Part 1: observational cohort

The researchers measured blood erythritol in approximately 4,000 patients who had undergone cardiac risk assessment at the Cleveland Clinic between 2004 and 2011. Over a median follow-up of three years, patients in the highest erythritol quartile had roughly twice the risk of a major adverse cardiac event (MACE — defined as heart attack, stroke, or death) compared to those in the lowest quartile. A replication cohort of about 2,100 European patients produced a similar pattern.

Part 2: platelet aggregation experiments

In laboratory experiments, erythritol at concentrations similar to those found in human blood after consuming a typical sweetened product enhanced platelet aggregation — the clumping of platelets that initiates clot formation. The researchers proposed this as a plausible biological mechanism linking erythritol to thrombotic cardiovascular events.

Part 3: dietary exposure measurements

Eight healthy volunteers consumed a single erythritol-sweetened drink (30g erythritol). Blood erythritol levels rose sharply and remained elevated for more than two days. The researchers concluded that dietary consumption can sustain blood levels in the range associated with the increased cardiac risk observed in the cohort.

The scientific and industry response

The study generated significant peer commentary. Several independent researchers and industry groups raised methodological concerns.

The Calorie Control Council, an industry group representing reduced-calorie food manufacturers, issued a statement arguing that the study could not establish causation, that the cohort was not representative of the general population, and that endogenous erythritol production in metabolically compromised patients likely explained much of the observed association.

Multiple nutritional epidemiologists noted that the lack of dietary measurement is a critical limitation: knowing someone has high blood erythritol does not confirm they consumed large amounts of erythritol in food. Given that erythritol is a natural human metabolite elevated in diabetes and metabolic syndrome, reverse causation is possible — the underlying metabolic disease elevates erythritol and simultaneously drives cardiac risk.

The authors acknowledged these limitations in the paper itself. The senior author, Dr. Stanley Hazen, subsequently called for randomized controlled trials examining whether dietary erythritol intake directly increases cardiovascular risk — a study design that would be capable of establishing causation.

Regulatory status as of 2026

Neither the FDA, EFSA, Health Canada, nor JECFA has changed erythritol's approval status following the 2023 study. The table below summarizes current regulatory positions.

EFSA stated in its 2015 re-evaluation that erythritol does not raise any safety concern for the general population at current and anticipated use levels. That assessment remains the operative regulatory position in the EU. In the US, erythritol's GRAS status has not been challenged by FDA as of this writing.

Erythritol in commercial products

Erythritol is widely used as a bulking agent in products that would otherwise contain very concentrated high-intensity sweeteners. The most prominent examples are Truvia (erythritol + stevia rebaudioside A, marketed by Cargill) and Splenda Naturals Stevia. It also appears in many keto-labeled snacks, protein bars, sugar-free chocolates, and reduced-calorie baked goods.

A single packet of Truvia contains roughly 3g of erythritol. A serving of erythritol-sweetened chocolate can contain 20–30g. The dietary exposure study in the Witkowski paper used 30g in a single drink — achievable in one serving of many keto products. This is relevant context, though it still does not establish that such consumption causes cardiac events in healthy individuals.

For comparison with other sweeteners, see our artificial sweeteners compared guide and our breakdown of aspartame safety evidence. All approved sweeteners in the US are listed under our sweetener category.

Practical context for consumers

The 2023 study does not justify concluding that erythritol causes heart attacks, nor does it justify dismissing the question entirely. It identified a plausible concern in a high-risk population that warrants further investigation. That is how science is supposed to work.

For healthy adults consuming erythritol occasionally, current regulatory guidance does not suggest a problem. For individuals with existing cardiovascular disease, metabolic syndrome, or diabetes — the populations most likely to consume erythritol as a sugar substitute — the Witkowski findings may be worth discussing with a physician. That is not medical advice; it is a reasonable application of precautionary reasoning to a population that was specifically implicated in the study.

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