A recent study from the Cleveland Clinic raises questions about the safety of erythritol, a natural non-caloric sweetener that I have included in some of my recipes. This comes from the laboratory of Dr. Stan Hazen, who has–in my view—released suspect evidence in past regarding the atherogenicity (atherosclerotic plaque-causing) and cardiovascular event-promoting effects of trimethylamino oxide, TMAO. Because TMAO levels increase in the bloodstream with consumption of compounds such as carnitine that originate with animal products such as chicken, fish, and beef, the increased TMAO levels were declared a reason to avoid all animal products. The flaw in this argument is that TMAO is a product of microbes in the gastrointestinal (GI) microbiome. Unfortunately, in these studies, the GI microbiome was ignored, essentially being treated as a black box, despite the fact that GI microbial composition is a major determinant of TMAO levels and cannot be ignored. When this most recent study was released that questions the safety of erythritol, I was therefore skeptical. However, upon closer examination, they have indeed raised some important safety issues.

This comes as a surprise, since erythritol is a naturally-occurring sweetener found in small quantities in fruit, as well as a compound that the human body produces in modest amounts. Naturally-occurring compounds are usually safe to use. Erythritol may therefore be an exception.

Notably, majority of the report is observational, i.e., simply observations among people but not an intervention of, say, erythritol consumption versus placebo. Observational data is nearly always questionable, failing to yield cause-effect relationships. However, in this case, observations that suggest an increase in the incidence of cardiovascular events is 1) dose-related (i.e., the greater the consumption or blood levels, the greater the risk), 2) consistent across different groups of people (cohorts), and 3) potentially explained by their prospective demonstration of platelet activation (that underlies many cardiovascular events such as stroke and heart attack). While not conclusive, it does raise enough suspicion that, I believe, we should limit our exposure to the most minimal amounts or exclude entirely.

Notably, the increase in cardiovascular events appeared to occur in participants with the greatest consumption (fourth quartile) of erythritol. The increase in platelet responsiveness/clotting was provoked with ingestion of 30 grams of erythritol, about 7.5 teaspoons or 2.5 tablespoons.

It is therefore wise to limit consumption of products containing erythritol. This leaves us with stevia in its various forms, monk fruit, and allulose as our sweeteners of choice. Also note that, in our wheat/grain-sugar-free lifestyle, our sensitivity to sweetness is heightened, allowing us to use far less of any form of sweetener. And, of course, many of us lose our “sweet tooths” over time, making the choice of sweetener a non-issue.