July 17, 2025, 11:21 am | Read time: 7 minutes

Many Believe Sweeteners Are Healthier Than Sugar

Excessive sugar in the diet is known to lead to obesity and metabolic diseases such as type 2 diabetes. But avoiding sugar is not easy. The calorie bomb, which raises our insulin levels and thus suppresses the body’s fat-burning, is part of countless foods. Sugar is not only obviously present in sweets like chocolate, pastries, and candies but also hidden as an additive in other industrially processed foods such as tomato sauces, sausages, soups, and pasta dishes. Therefore, avoiding sugar is not easy. That’s why many people turn to alternatives like sugar substitutes, including erythritol. For a long time, the substance was considered harmless, partly because it hardly affects blood sugar levels. Erythritol is one of eight sugar substitutes approved in the EU.¹ However, research increasingly suggests that consuming erythritol could be harmful, especially for the brain and heart.

How Erythritol Affects Brain Vascular Cells

While previous observational studies could show links between erythritol consumption and the risks of strokes and heart diseases, mechanistic evidence was lacking.² What exactly does erythritol do in the body that increases disease risks? A recent study from the U.S. sought to answer this question. The researchers aimed to find out what biological changes erythritol causes in the cells of the vascular system.³

Study Design and Methods

For this purpose, the researchers conducted a laboratory study using a cell culture model. They used human brain capillary endothelial cells (hCMECs)—cells that line the blood vessels in the brain. The cells were treated with six millimoles of erythritol for 24 hours—a concentration equivalent to about 30 grams, as found in a typical light beverage.

The focus was on changes in key markers for vascular health:

• Oxidative stress
• Nitric oxide (NO) availability
• Endothelin-1 (ET-1) production
• Release of t-PA

Also of interest: The Different Names of Sugar

Erythritol Led to Harmful Changes in Brain Cells

The study found that erythritol indeed had a negative impact on the in vitro treated cells.

The researchers observed a significant increase in oxidative stress. This was evidenced by a 75 percent increase in the production of free oxygen radicals (ROS). This was accompanied by an increased formation of antioxidant enzymes, likely as a compensatory physical “response” to the elevated ROS levels.

Another observed effect was impaired nitric oxide (NO) availability. NO production decreased significantly, by 20 percent. At the same time, ET-1 production increased. Why can this be harmful? Because it is a peptide (a molecule formed from amino acids) that can have a strong vasoconstrictive effect.

Finally, the cell treatment with erythritol also caused impaired fibrinolysis. The release of t-PA, which is important for vascular permeability and the prevention of thrombotic events, was significantly inhibited.

In summary, the laboratory study revealed biological changes triggered by erythritol that indicate a significant impairment of vascular function, which is particularly critical for the brain.

Interpretation of the Study Results

For the first time, researchers provided evidence in a lab experiment of how erythritol could directly impair the function of brain vascular cells. In the long term, these could increase the risk of stroke. The observed effects are considered classic early signs of impaired endothelial function in medicine. Especially in the fine brain vessels, this can have fatal consequences: reduced vasodilation, increased tendency to clot, and circulatory disorders up to ischemic stroke.

However, it should be noted that this is an in vitro study, and therefore, no direct conclusions can be drawn for humans. The cell study was also conducted over a period of only 24 hours. Whether the observed effects would persist long-term is unclear. Additionally, physiological factors such as blood pressure, immune cells, or other cell types that interact in the body could not be considered in the experiment. Therefore, it is also uncertain what interactions they might have introduced in the experiment. Clinical studies would be necessary to assess the actual relevance of the results.

Nevertheless, the study provides a biologically plausible mechanism that supports and complements the observations of previous studies. The biological changes identified in the cell cultures are quite alarming, especially since even a small amount of erythritol was sufficient—as much as a typical light beverage contains.

2023 Study: Link Between Erythritol and Stroke and Heart Attack Risk

One of the previously mentioned observational studies also comes from the U.S., from the Cleveland Clinic. It suggests that erythritol increases the risk of cardiovascular diseases such as heart attack and stroke in older adults who are at risk.⁴

Study Procedure

In the first part of the study, data from an older metabolic study of 1,157 participants with an average age of 65 were evaluated. This already showed that a high concentration of sugar substitutes in blood plasma, particularly erythritol, seemed to be associated with an increased risk of heart attack, stroke, and premature death.

In the second part of the study, 2,149 Americans (average age 63) were used for comparison, and their metabolic data were compared with those of the first group. In the third part of the study, 833 Europeans (average age 75) were also examined for erythritol content in the body. And in both comparison groups, there was an observed association between elevated erythritol levels in blood plasma and heart attack, stroke, and premature death.

What Happens in the Body Due to Sugar Substitutes?

The researchers explained the observed associations by suggesting that erythritol apparently causes blood platelets, which are responsible for wound healing, among other things, to clump together. Thus, the intake of the sugar substitute could likely promote the formation of blood clots. These could ultimately block brain arteries or coronary arteries, causing a stroke or heart attack.

The researchers found it particularly concerning that even small amounts (about one soft drink daily) could increase the risk. And this, despite the fact that erythritol is usually excreted through urine because the body cannot easily metabolize it. However, because the body itself produces erythritol in small amounts, it can quickly accumulate in the bloodstream.

However, it must be considered that the study was conducted on individuals at risk for cardiovascular diseases. Whether erythritol is harmful to healthy people needs to be investigated in further studies. “It is important that further studies are conducted to examine the long-term effects of artificial sweeteners in general and erythritol in particular on the risk of heart attack and stroke,” says Stanley Hazen, one of the responsible scientists. 

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Conclusion

Erythritol can have harmful effects. This is indicated by both observational studies and the current experiment on cell cultures. Many questions—such as dosage, long-term effects, and method of intake (are foods with erythritol possibly unhealthy due to other ingredients?)—remain open.

Our assessment: As is often the case, the dose makes the poison. Those who occasionally consume a light or zero-calorie drink with erythritol do not necessarily have to expect a stroke or heart attack soon. However, research shows that erythritol and other sweeteners do not represent a completely harmless substitute for sugar. Those who want to do as much good as possible for their health in the long term should therefore avoid both as much as possible.