The unwarranted fears over sugar alcohols
How relevant are some of the recently published studies, and how much sugar alcohol are you really consuming?
This post follows along with prior posts which have looked at the targeting of sugar alcohols as being associated with increased risk of heart attacks or strokes. Rather than look at the methodology of these studies I chose to look at the 30 grams of sugar alcohol Hazen, et al.’s team decided to use as a representation for what a consumer may come across in a typical product. After all, if this measure is so common we would be in serious trouble; if not, then there’s a lot unwarranted assumptions and fears being put out into the public. Unsurprisingly, readers will see that we are leaning towards the latter…
Note that either erythritol or xylitol may be mentioned in reference to a specific product. This is due to the fact that Hazen, et al.’s team is alleging that both sugar alcohols are prothrombotic. So although the recent study looked at erythritol I’m included foods with either sugar alcohols as as a reference.
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Sugar alcohols are back in the spotlight with a recent study1 from none other than Stanley L. Hazen’s team.
Over the past few years Hazen’s team has released various studies alleging that common sweeteners and supplements such as niacin may increase the risk of major adverse cardiovascular events (MACE) including heart attacks and strokes.
This time, Hazen’s team revisited the sugar alcohol erythritol and added onto the work they published in 2023 by examining the effects of erythritol in healthy individuals.
Here, Hazen’s team followed a similar methodology in which healthy participants were provided a drink sweetened with 30g of erythritol and had their blood measures, as well as factors related to blood clotting, measured and compared to consumption of a drink with 30g of glucose.
I haven’t been able to access the study and therefore can’t investigate the methodology. However, the approach seems very similar to a portion of their xylitol study I covered a few months ago, and it’s very likely the findings from that study spurred the findings of this one.
The results and discussions take from the abstract can be seen below:
RESULTS:
Dietary erythritol (30 g), but not glucose (30 g), lead to a >1000-fold increase in erythritol plasma concentration (6480 [5930–7300] versus 3.75 [3.35–3.87] μmol/L; P<0.0001) and exhibited acute enhancement of stimulus-dependent aggregation responses in all subjects, agonists, and doses examined. Erythritol ingestion also enhanced stimulus-dependent release of the platelet dense granule marker serotonin (P<0.0001 for TRAP6 [thrombin activator peptide 6] and P=0.004 for ADP) and the platelet α-granule marker CXCL4 (C-X-C motif ligand-4; P<0.0001 for TRAP6 and P=0.06 for ADP). In contrast, glucose ingestion triggered no significant increases in stimulus-dependent release of either serotonin or CXCL4.
CONCLUSIONS:
Ingestion of a typical quantity of the non-nutritive sweetener erythritol, but not glucose, enhances platelet reactivity in healthy volunteers, raising concerns that erythritol consumption may enhance thrombosis potential. Combined with recent large-scale clinical observational studies and mechanistic cell-based and animal model studies, the present findings suggest that discussion of whether erythritol should be reevaluated as a food additive with the Generally Recognized as Safe designation is warranted.
On the surface these findings would add to the growing fear over sugar alcohols, bringing the question of safety to the forefront as mentioned by many doctors and media outlets.
However, such claims are only as substantial as the methodologies utilized. In previous investigations into the work of Hazen’s team I have raised criticisms regarding the fact that these studies appear to be akin to a fishing expedition- dive into the blood and see whatever biomarkers one can tie to MACE, publish the findings, and create a great deal of publicity and paranoia over the research’s implications.
This is made even more egregious with their prior work on xylitol, in which the authors themselves never directly tie consumption of xylitol to the incidences of MACE reported within their cohort, and instead suggest that the elevated level of xylitol found within people’s blood may be related to endogenous production of xylitol. Again, no direct evidence of xylitol consumption and MACE events were ever reported by Hazen’s team, even though many media outlets ran with this unfounded assumption.
And it seems that the media is doing all the same in the case of the recent erythritol study with headlines that are no different than the ones we have seen previously:
It doesn’t seem necessary to rehammer the same issues as before as it appears that this study is using a similar methodology as the prior xylitol study, but what caught my attention was a comment made by Hazen to the press regarding the level of xylitol and erythritol they used within their study, as suggested by CNN’s article in the following excerpt:
However, the amount of erythritol used in each drink in the study — 30 grams — was the equivalent of what is included in typical sugar-free sodas, ice creams or muffins, of which people often eat more than one, Hazen said.
When I initially covered the xylitol article, I took this “30 grams being typical of commercial products” as being self-evident, as in many foods sweetened with these products likely contain a high degree of these sugar alcohols. After all, you wouldn’t know any better when news outlets make it out that these sugar alcohols are all around us and in large quantities.
It also diid’t help that Hazen repeated the alleged sugar alcohol content of many foods to the media, as is the case in a September 2023 CNN article highlighting their prior erythritol study:
Just how much is 30 grams of erythritol? The equivalent of eating a pint of keto ice cream, Hazen said.
“If you look at nutrition labels on many keto ice creams, you’ll see ‘reducing sugar’ or ‘sugar alcohol,’ which are terms for erythritol. You’ll find a typical pint has somewhere between 26 and 45 grams in it,” he said.
“My coauthor and I have been going to grocery stores and looking at labels,” Hazen said. “He found a ‘confectionery’ marketed to people with diabetes that had about 75 grams of erythritol.”
Hearing such comments one would assume that many ordinary products would be inundated with sugar alcohols, meaning that the risk of MACE is always there.
And it’s here where I grew skeptical about these claims made by Hazen’s team. As in, how much erythritol is in foods, and how likely are people to consume the levels of erythritol utilized by Hazen’s team in this study?
Because such fears over erythritol and other sugar alcohols are only warranted IF people are likely to be exposed to these high levels on a routine basis. Otherwise, these studies bare no real-world significance, and may in fact just be a way of stoking unwarranted fear in the otherwise uninformed.
Confusing food labels
In a few of the news articles I have read Hazen has mentioned that various food labels use code words that imply xylitol or erythritol use. This is evident in one of the excerpts above where Hazen suggests that “sugar alcohol” refers to erythritol, which on the surface seems like an inaccurate interpretation- or at least is a bit of a misrepresentation of the facts.
Remember that the implications from Hazen’s team allude to xylitol and erythritol alone being prothrombotic, and so it would be important to look for actual products that contain predominately these items to gain an understanding of the actual relevance of his team’s work or whether it’s all just histrionics.
This led me to search for erythritol-containing foods or foods that contain sugar alcohols, and in doing so I found the whole marketing of products to be confusing.
This is because erythritol and xylitol are categorized under the umbrella of “sugar alcohols” on food labels, which consists of various types of sugar alcohols.
An article from Yale New Haven Health listed various examples of sugar alcohols:
Common sugar alcohols are mannitol, sorbitol, xylitol, lactitol, isomalt, maltitol and hydrogenated starch hydrolysates (HSH). Sugar alcohols are not commonly used in home food preparation, but are found in many processed foods. Food products labeled "sugar-free," including hard candies, cookies, chewing gums, soft drinks and throat lozenges often consist of sugar alcohols. They are frequently used in toothpaste and mouthwash too.
In that regard it’s rather disingenuous to conflate “sugar alcohols” as referring to erythritol or xylitol alone, and may instead refer to the total collection of sugar alcohols within a product. That’s why it’s important that people read ingredient labels and understand what exactly they are looking at.
The FDA provides this little fact sheet as a good aide:
It appears that foods labeled “sugar free” or “no sugar added” must come with a nutrition label that outlines sugar alcohol content of said foods. Be aware that some items may contain sugar alcohols as well as added sugars, in which case an explicit label of sugar alcohols may not be included on the product. It’s important to corroborate nutrition labels with ingredient lists.
So with all that in mind how abundant and widespread is erythritol and xylitol?
How much sugar alcohol are you consuming?
For the most part I haven’t been able to find any drinks that actually use sugar alcohols- most products seem to use aspartame or sucralose as their sweetener of choice.
Be careful of reading information from websites suggesting popular soda brands of using erythritol. Again, in nearly all cases these companies are using either aspartame or sucralose. I’m not sure where these websites are getting their information from but they all appear to be highly inaccurate and misinformation… Remember that nutrition labels must contain a category for sugar alcohols if the product contains them, or at least allude to it within the “added sugars” portion of the ingredients list.
The only product that appears to contain any erythritol was Monster’s Zero Sugar line of energy drinks, and even within these products the levels of erythritol seem to hover around 1-2 grams per can.
Here’s the nutrition label for the original Monster Zero Sugar drink where the erythritol content is explicitly labeled:
To put this into perspective you would need to drink at least 15-30 cans of these energy drinks in order to reach the same level of erythritol used in Hazen’s study- you’re far more likely to die from the caffeine overdose than you are from anything prothrombotic related to the sugar alcohols!
Now, there may be other drinks out there that contain higher levels of sugar alcohols that I haven’t found, but if it’s been difficult for me to find any erythritol-containing drinks in the first place how likely is the regular consumer going to come across erythritol or xylitol-containing beverages?
This calls into questions the methodology proposed by Hazen’s team- it doesn’t seem reflective of the actual sugar alcohol levels that one is likely to come across on a daily basis.
The same issue arises in other products as well.
This keto-brand of gummies from Shameless Snacks uses erythritol, but each pack contains around 8 grams of erythritol meaning you would need to eat four packs of gummies to reach similar erythritol levels used by the researchers. Given that the Amazon listing labels the product as 6 packs of gummies per box, and retailing at $20/box that’s quite a pricey endeavor to reach the sugar alcohol levels Hazen’s team utilized. In fact, many keto products can be considered rather pricey by themselves.
This seems to be at the higher end of the candies I can find that contain erythritol alone. Many products appear to use isomalt- a sugar substitute containing a mixture of sugar alcohols mannitol and sorbitol.
This includes Jolly Rancher’s Zero Sugar hard candies, Werther’s Originals Sugar Free candies, and even this line of candies targeted at children as a guilt-free way of having a sweet treat that simultaneously cleans teeth contains a combination of isomalt as well as erythritol and xylitol, meaning that even in this instance the actual levels of each sugar alcohol won’t be explicitly known.
Whether or not isomalt and other sugar substitutes are harmful is besides the question, and quite frankly I wouldn’t be surprised if that is researched by Hazen’s team at some point in the future. But for the sake of this article we are looking at xylitol and erythritol specifically. Again, it doesn’t seem like it’s easy to reach the levels of erythritol or xylitol consumed as used by Hazen’s team.
When it comes to baked goods there’s usually a higher level of sugar alcohols available, but even then the levels are nowhere near the 30 grams alleged by Hazen’s team. The highest level of sugar alcohols I found through a cursory glance is within King Arthur’s Keto Muffin Mix as well as this prepared muffin product which hovers around 10g/prepared muffin. Although high relative to other products you would still need to indulge and eat around 3 muffins in one sitting to make this situation comparable to the study.
But what about gum? Gum is the most likely source of these sugar alcohols for the average consumer, and even then amount of gum needed would be extremely egregious.
From a quick glance the highest level of sugar alcohols I could find is ironically a gum I have on hand- Orbit White which appears to have around 2g of xylitol per gum piece.2 That’s quite a lot sugar alcohol relative to other products, but that being said I would need to chew 15 pieces of gum in one sitting to reach the same levels as Hazen’s team used- how likely is that to ever happen, and does anyone even have the jaw space for all that gum?!
The relevancy of science in manners of public health
When it comes to science there’s a serious issue in how information is relayed to the public. Far too often information gets misinterpreted or becomes grossly exaggerated by the time you see the information on a website or on TV.
Most people don’t care to understand the underlying science that gets reported, and most people may not care to put science into the context of their own daily habits and lifestyles. Hence, when research comes out that suggests sugar alcohols can be deadly you can instill fear in many people who would be none the wiser to the actual context in which they should view such research. It’s a reliance on wide scale public ignorance to push unfounded fears.
Rather than operate on fear and lean towards objectivity I wanted to examine how meaningful Hazen’s research would be for the average consumer. I searched around to find products containing erythritol and xylitol, and not only are products not as widespread as one would believe but levels are typically lower than one would expect.
This brings into question where Hazen’s team got the baseline 30 grams of sugar alcohol used in both their erythritol and xylitol studies- most drinks aren’t sweetened with sugar alcohols, and in the rare instances that they are such as the Monster drink shown above the sugar levels are far below what one would find. Most food items have erythritol and xylitol levels far below this 30 grams as well, so where did this number come from exactly?
The only answer I can think of is one item in particular- keto ice creams such as the very popular brand Halo Top.
Here, a pint of ice cream can reach up to 30 grams of erythritol, and yet even this appears to be apply to specific flavors or brands of keto ice cream. For instance, Kroger’s brand of keto ice cream called Rebel seems to average around 30 grams/pint. Many of Halo Top’s flavors appear to hover below 20 grams/pint- it seems that even in this case the average of 30 grams is an exception rather than commonplace, at least for Halo Top’s flavors.
More importantly, a pint of ice cream typically contains 3-4 servings a pint. As in, you’re not supposed to eat a pint of ice cream in one sitting, and it seems highly unreasonable to assume that people who are eating keto ice creams are eating pints of this stuff on a daily basis.
What all this means is that the situation presented by Hazen’s team is likely to occur in only the most rare of circumstances. It requires an individual that is constantly overindulging in these sugar alcohol-laced products, and doing so on a continuous basis in order to create a scenario in which someone may be at risk of thrombosis.
Otherwise, these sorts of studies seem meaningless for the common individual, and yet they continue to be propped up by the media. It doesn’t help that Hazen’s comments are ambiguous.
What drinks did Hazen’s team look at to make the assumption that 30 grams was typical of a beverage? And obviously if they’re basing their measures on keto ice creams they are using a value not typical found for most ice creams and only applies to consuming the entire pint. None of the products I looked up could align with the claims Hazen made to the press.
But by being ambiguous, and relying on journalists to not fact-check Hazen’s claim since he’s a so-called “expert” you can create the assumption that many consumers are at risk of dropping dead from a blood clot.
It’s a clear example of how public perception can be shaped through obfuscation and misinformation, ironically the things that the media claims they are intended to work against!
These studies are worthless for most people, and it’s a shame that journalists and those within the medical profession can’t be bothered to do their due diligence and criticize the relevancy of these studies.
Just because something gets published doesn’t mean that it’s relevant to the common man. And quite frankly, it’s up to the public to not fall for the hysteria that gets put out.
Read labels, understand what you are putting into your body, and make sense of the information you come across.
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Witkowski, M., Wilcox, J., Province, V., Wang, Z., Nemet, I., Tang, W. H. W., & Hazen, S. L. (2024). Ingestion of the Non-Nutritive Sweetener Erythritol, but Not Glucose, Enhances Platelet Reactivity and Thrombosis Potential in Healthy Volunteers. Arteriosclerosis, thrombosis, and vascular biology, 10.1161/ATVBAHA.124.321019. Advance online publication. https://doi.org/10.1161/ATVBAHA.124.321019
Note that both mannitol and sorbitol are listed within the “less than 2%” portion of ingredient lists. For the sake of simplicity I considered this negligible when considering overall sugar alcohol available in this gum.
Just looking at the names of these "food" products makes me feel ill.
While I agree with you with regard to the hypothetical dangers of these sugar alcohols, I do have friends who are diabetic and I can tell you they most definitely are eating an entire pint of ice cream in one sitting, along with other sugar-free treats on a regular basis.