Do “Internet celebrity” sugar substitutes increase the risk of heart disease? Can we still drink sugar-free beverages?

It is the nature of foodies to crave sweets. After all, sweet things really make people happy. However, eating too much added sugar is not good for health and will increase the risk of obesity, diabetes, gout and other diseases.

In order to enjoy sweets in a healthier way, sugar substitutes have gradually entered people's lives. For example, erythritol, mogroside, aspartame, saccharin sodium, stevioside, xylitol, etc. Among them, erythritol has been very popular in recent years and has become a celebrity in the sugar substitute industry, which is very popular.

But recently, a study published in the authoritative journal Nature Medicine dealt a heavy blow to erythritol - it may increase the risk of heart disease, which made many friends at a loss. What is going on?

Paper title image. "Artificial sweetener erythritol and the risk of cardiovascular events"

01

What is erythritol?

Erythritol is a naturally occurring substance and a natural sweetener. It is widely found in foods we eat, such as agricultural products such as mushrooms, watermelons, pears, and grapes, as well as fermented products such as wine, sake, beer, and soy sauce. The content can be as high as 0.13%. [1]

The erythritol currently used in industry mainly uses glucose as the raw material for production. It is converted into erythritol by fermentation using Candida lipolytica, Saccharomyces cerevisiae or Trichosporon, and then the food additive erythritol crystal product is obtained through refining and other processes.

The sweetness of erythritol is 60~80% of sucrose, and its energy coefficient is 0 kJ/g. It has a pure sweetness without any bitter aftertaste. It is also mentioned in my country's "GB 2760-2014 Food Additives Usage Standard" that erythritol can be used as a sweetener in various foods such as milk and dairy products, candy, baked goods, beverages, etc. in appropriate amounts according to production needs. We often see the word erythritol in sugar-free beverages, and it is not unfamiliar to our lives.

02

What's wrong with erythritol?

In previous studies, erythritol has been widely recognized for its safety, and early studies have also hinted at its potential benefits, including antioxidant potential reported in diabetic animal models and improved endothelial function in diabetic patients who drank erythritol-containing beverages for four weeks. [2] Subsequently, several countries have approved its use in regulated foods.

Although erythritol has developed rapidly in recent years and is well-liked by everyone, as research continues to deepen, a study recently published in the authoritative journal Nature Medicine mentioned the negative effects of erythritol.

The study mentioned that erythritol can significantly enhance collagen-dependent platelet adhesion and thrombosis, which is associated with a significantly increased risk of adverse cardiovascular events, including death or non-fatal myocardial infarction or stroke. It is called for further safety research on erythritol. [2]

However, although this study slaps erythritol in the face, there is no need to worry too much.
The study mainly focused on the United States and Europe, where the daily erythritol intake reached more than 30 grams. The study also monitored the postprandial erythritol plasma levels of healthy subjects after drinking an erythritol-sweetened beverage (containing 30 grams of erythritol, equivalent to a single can of beverage).

The amount of erythritol contained in sugar-free beverages in my country is mostly between 1% and 4%. For example, the commonly consumed sugar-free beverage in the picture below has an erythritol content of about 18 grams per can after rough calculation.
Furthermore, any behavior that only talks about toxicity without mentioning dosage is unreliable.

There is no definitive conclusion on the effects of long-term consumption of erythritol on health, and further research is needed. If you are worried about the potential harm of erythritol, don't indulge in it every day or drink beverages containing erythritol frequently. It's okay to satisfy your cravings occasionally, such as 1 to 2 times a month.
For people who already have cardiovascular disease, try to avoid sugar-free foods or drinks that contain erythritol in the ingredient list.

03

Watch out for these 5 sweeteners

In addition to erythritol, you should also pay attention to the following sugar substitutes when choosing sugar-free foods or drinks.

Aspartame:

Aspartame is also one of the commonly used sweeteners in food. my country's "GB 2760-2014 Food Additives Usage Standard" also has clear regulations on its usage. However, its safety has always been controversial. Some people claim that aspartame can cause depression, Parkinson's disease, brain cancer, epilepsy and other diseases, while some experiments have shown that it is not harmful to the human body. [3]

In particular, people with phenylketonuria need to pay special attention to foods containing aspartame in the ingredients, because one of the decomposition products of aspartame is phenylalanine, which cannot be effectively metabolized by people with phenylketonuria and can cause nerve and brain damage.

Sucralose:

It is 600 times sweeter than sucrose and has no bitterness. It is widely used in food.
Most studies on sucralose believe that it is safe and non-toxic, but some studies have found that sucralose and its hydrolysis products have certain toxicity, such as being able to damage DNA in the stomach and lungs of rats, and reducing sperm motility in mice and humans. [4] Further research is needed.

Stevioside:

The sweetness is 200 to 300 times that of sucrose, and the calories are only about 1/250 of sucrose. However, compared with sucrose, stevioside not only has a significantly delayed sweetness, but also has a significant aftertaste. [5]

Stevioside is generally considered safe to consume, but some studies have found that it may have certain carcinogenic effects. Hong Kong, Singapore, Macau and other places have banned the sale of foods containing stevioside. [6]

Saccharin Sodium:

The sweetness of saccharin sodium is 300 to 500 times that of sucrose, but it has a metallic bitter taste when used in large quantities. There is also some controversy about its safety, as the product may contain the carcinogen o-toluenesulfonamide. [6] my country has strict controls on its production and use, and does not allow its use in infant food.

Xylitol:

Since the 1970s, xylitol has been used to replace sucrose as a sweetener and has gradually been used to prevent tooth decay. It is also suitable for diabetic patients to enjoy "sweets". However, excessive intake can easily cause diarrhea, and adults should not exceed 50g/day. [7]

People who keep dogs at home should pay special attention. The US FDA states that xylitol is a toxic substance for dogs. After a dog eats xylitol, it will stimulate the secretion of insulin in a short period of time. The rapid release of insulin will cause a rapid drop in blood sugar and cause hypoglycemia. Generally, symptoms will appear 10 to 60 minutes after the dog eats it. If rescue is not timely, the dog may die. [8]

There are many types of sugar substitutes currently on the market, and research on sugar substitutes has been controversial. However, there is no need to worry too much, just look at it rationally and avoid excessive intake.
For those who like to drink sweet drinks, consuming too much added sugar will bring many health risks. Relatively speaking, choosing sugar-free drinks with sugar substitutes will indeed reduce the intake of added sugar.
However, since the potential hazards of many sugar substitutes are still controversial, you still need to pay attention to controlling your intake. If you are very worried, then give it up and just choose healthy boiled water.

Don’t indulge in sweeteners every day. Just eat them occasionally. They can add some “sweetness” to your life. There is no need to be overly nervous.

References:

[1] Chinese Society of Food Science and Technology. Scientific consensus on erythritol[J]. Journal of Chinese Institute of Food Science and Technology, 2022, 22(12): 405-412. DOI: 10.16429/j.1009-7848.2022.12.039

[2] Witkowski, M., Nemet, I., Alamri, H. et al. The artificial sweetener erythritol and cardiovascular event risk. Nat Med (2023). https://doi.org/10.1038/s41591-023-02223-9

[3] Chai Meimei, Hou Leilei, Jia Li, et al. Application of sweeteners in beverages and food safety [J]. Journal of Food Safety and Quality, 2018, 9(11): 2573-2577.

[4]. Zhao Shuqin, Bao Zhongjian, Jiang Xin, et al. Research progress on the biosafety of artificial sweetener sucralose[J]. Chinese Journal of Clinical Pharmacology, 2018, 034(022):2678-2680.

[5]. Zeng Yan, Pei Wenwen, Zhu Yueming, et al. Research progress on flavor, physiological function and application of three natural sweeteners[J]. Journal of Food Safety and Quality, 2019(15).

[6]. Sun Changhao (ed.). Nutrition and Food Hygiene. 8th edition. People's Medical Publishing House. 2017.

[7]. You Xin, Li Mingjie. Production technology and application of xylose and xylitol[M]. China Light Industry Press, 2006

[8]https://www.fda.gov/consumers/consumer-updates/paws-xylitol-its-dangerous-dogs

Author: Xue Qingxin, member of Chinese Nutrition Society, registered nutrition technician, health manager, public nutritionist

Reviewer: Song Shuang, Associate Researcher, Institute of Nutrition and Health, Chinese Center for Disease Control and Prevention