What is a sugar alcohol?

While neither a sugar nor an alcohol, the class of compounds known as sugar alcohols, also sometimes called polyols, share chemical characteristics of both sugar and alcohol. Other commonly known sugar alcohols are sorbitol and xylitol. Because sugar alcohols are incompletely absorbed and metabolized, they supply fewer calories (in the case of erythritol, no calories) and affect blood sugar less dramatically than other carbohydrate-based sweeteners.

Is erythritol “natural”?

Yes, erythritol is a natural sweetener. It naturally occurs in mushrooms, pears, grapes, melons, and fermented foods like cheese, soy sauce, wine, and beer.

How is it made?

Because the amount of erythritol found in food is very small, erythritol is commercially produced through fermentation by yeast and yeast-like fungi most commonly using corn, or dextrose from corn, as the fermentation substrate. Because corn is commonly genetically modified, it is best to look for erythritol that specifically verifies non-GMO on the package.

Erythritol is also produced by healthy human red blood cells through the pentose phosphate pathway (PPP), one of the pathways the body uses to metabolize glucose. Some hypothesize that the amount of erythritol being produced by the body could be a marker of a dysregulated PPP due to a diet rich in glucose or fructose or other conditions that impair blood sugar control.¹

How is erythritol metabolized by the body?

Dietary erythritol is absorbed in the small intestine but is not metabolized, and almost all of it is excreted in the urine unchanged. The small amount of erythritol that does remain in the intestines does not appear to be metabolized by the gut microbiota either.²

Does erythritol have any health benefits?

The fact that erythritol does not spike blood glucose or affect insulin levels is its greatest health benefit, but other research suggests it may have other benefits. Although there is only a little preliminary research, erythritol, like its cousin xylitol, may have a positive impact on oral health by inhibiting the growth of certain bacteria and decreasing dental plaque.^{3 4}  There is also some research to suggest that erythritol increases production of hormones associated with satiety, but what effects erythritol has on actual weight management have yet to be concluded.^{5 6}

Is erythritol safe?

Erythritol has been approved for commercial use in Japan since 1990 and 60 additional countries since then, including the United States, which has recognized it as GRAS (generally recognized as safe) since 2001.^{7 8} Many human and animal studies have found that consuming erythritol is safe.

Does erythritol increase the risk of cardiovascular disease?

Erythritol’s safety record was called into question in early 2023, when a study published in the journal Nature Medicine found that elevated blood levels of erythritol were associated with an increased risk of major adverse cardiac events in older, obese people with preexisting conditions such as high blood pressure and coronary heart disease. The authors of the study went on to find that, in test tubes and animals, erythritol increased blood clotting and that serum blood levels of erythritol do increase in response to erythritol ingestion in humans.⁹ While this study does find a correlation between serum erythritol levels and cardiovascular events, it does not tell us much more than that.

First, the researchers did not determine if the blood erythritol levels were due to consumption of erythritol or due to endogenous production. In fact, because most of the participants were enrolled prior to erythritol becoming a common sweetener, it is likely that the erythritol was almost entirely produced endogenously. Second, erythritol is a biomarker for cardiometabolic diseases¹⁰ and is increased by oxidative stress, inflammation, diets high in sugar, obesity, and other systemic metabolic disturbances.¹¹ Considering that the study participants were nearly all metabolically unhealthy, it is possible that the elevated erythritol was a marker of this dysfunction, but the study did not prove it caused the dysfunction.

For now, we know that elevated serum erythritol is associated with an increased risk of major adverse cardiac events, but we do not yet know if erythritol is involved in that risk or just a marker, nor do we know the role, if any, that dietary erythritol may play. At this point, with its long record of safety, erythritol is still considered safe to consume.

Are there any side effects to using erythritol?

While it is safe to consume, side effects from consuming high amounts of erythritol may include nausea, diarrhea, and bloating, although these are less of a risk than with other sugar alcohols.¹ Most GI issues can be avoided by consuming no more than 0.45 grams per pound of body weight per day, or about 5.5 tablespoons for a 150-pound adult.¹²

References

1. Mazi, T.A., Stanhope, K.L. (2023). Erythritol: an in-depth discussion of its potential to be a beneficial dietary component. Nutrients, 15(1), 204. doi: 10.3390/nu15010204
2. Hiele, M., Ghoos, Y., Rutgeerts, P., Vantrappen, G. (2007). Metabolism of erythritol in humans: comparison with glucose and lactitol. British Journal of Nutrition. 69(1), 169-176. DOI https://doi.org/10.1079/BJN19930019
3. De Cock, P., Mäkinen, K., Honkala, E., Saag, M., Kennepohl, E., Eapen, A. (2016). Erythritol is more effective than xylitol and sorbitol in managing oral health endpoints. Int J Dentistry, 2016. DOI  https://doi.org/10.1155/2016/9868421
4. Runnel, R., Mäkinen, K.K., Honkala, S., Olak, J., Mäkinen, P.L., Nõmmela, R., Vahlberg, T., Honkala, E., Saag, M. (2013). Effect of three-year consumption of erythritol, xylitol and sorbitol candies on various plaque and salivary caries-related variables. Journal of Dentistry, 41(12), 1236-1244. https://doi.org/10.1016/j.jdent.2013.09.007
5. Wölnerhanssen, B. K., Cajacob, L., Keller, N., Doody, A., Rehfeld, J. F., Drewe, J., Peterli, R., Beglinger, C., & Meyer-Gerspach, A. C. (2016). Gut hormone secretion, gastric emptying, and glycemic responses to erythritol and xylitol in lean and obese subjects. American journal of physiology. Endocrinology and metabolism, 310(11), E1053–E1061. https://doi.org/10.1152/ajpendo.00037.2016
6. Wölnerhanssen, B.K., Drewe, J., Verbeure, W., le Roux, C.W., Dellatorre-Teixeira, L., Rehfeld, J.F., Holst, J.J., Hartmann, B., Tack, J., Peterli, R., Beglinger, C., Meyer-Gerspach, A.C. (2021). Gastric empty of solutions containing the natural sweetener erythritol and effects on gut hormone secretion in humans: A pilot dose-ranging study. Diabetes Obes Metab, 23(6), 1311-1321.  doi: 10.1111/dom.14342
7. Regnat, K., Mach, R.L., Mach-Aigner, A.R. (2017). Erythritol as sweeteners—wherefrom and whereto? Applied Microbiology and Biotechnology, 102, 587-595. DOI https://doi.org/10.1007/s00253-017-8654-1
8. US Food and Drug Administration. (2001). GRAS No. 76: Erythritol. Accessed May 1, 2023 from https://www.cfsanappsexternal.fda.gov/scripts/fdcc/index.cfm?set=GRASNotices&id=76
9. Witkowski, M., Nemet, I., Alamri, H., Wilcox, J., Gupta, N., Nimer, N., Haghikia, A., Li, X.S., Wu, Y., Saha, P.P., Demuth, I., König, M., Steinhagen-Thiessen, E., Cajka, T., Fiehn, O., Landmesser, U., Tang, W.H.W., Hazen, S.L. (2023). The artificial sweetener erythritol and cardiovascular event risk. Nature Medicine, 29, 710-718. https://doi.org/10.1038/s41591-023-02223-9
10. Ortiz, S. R., & Field, M. S. (2020). Mammalian metabolism of erythritol: a predictive biomarker of metabolic dysfunction. Current opinion in clinical nutrition and metabolic care, 23(5), 296–301.
    https://doi.org/10.1097/MCO.0000000000000665
11. Birkenbach, K., Attia, P. (2023, March 4). More hype than substance: erythritol and cardiovascular risk. PeterAttiamd.com. Retrieved May 1, 2023 from https://peterattiamd.com/more-hype-than-substance-erythritol-and-cardiovascular-risk/
12. Axe, J. (2023, March 1). Erythritol: Is this “healthy” sweetener the real deal? Dr. Axe website. Retrieved from: https://draxe.com/nutrition/erythritol/