Supplement
Erythritol and Xylitol
Sugar alcohols · Erythritol, xylitol, sugar substitutes
Erythritol and xylitol sweeten, provide hardly any calories and practically do not raise blood sugar – which is why they are behind “sugar-free”. Since 2023 there has been a debate about their effect on blood vessels. The state of knowledge is undecided, not reassuring: after 30 grams of erythritol, the blood level rose more than a thousandfold and the platelets reacted more strongly, measured in ten people per group. Whether this leads to more heart attacks and strokes has not been proven.
What erythritol and xylitol are
Erythritol and xylitol are sugar alcohols. They replace sugar in bars, drinks and baking mixes because they taste sweet, provide hardly any calories and do not raise blood sugar. Xylitol is also found in dental care chewing gum. The body also produces both substances itself.
What is rated is the state of knowledge. The substances have been widely used for a long time, which makes the track record of use high. On the question of whether they put a strain on the heart and blood vessels, however, the human evidence is thin: a demonstrated mechanism, a small intervention study and observational data without measured intake.
How they work
Sugar alcohols taste sweet but provide considerably fewer calories than sugar and leave blood sugar practically unchanged. In larger amounts they have a laxative effect.
Since 2023 a second mechanism has been under discussion: in laboratory experiments and animal models, erythritol increased platelet reactivity and clot formation. In 2024 a small study showed the same pattern in humans. Platelet reactivity, however, is a surrogate marker, not a heart attack.
What is well supported
- Hardly any effect on blood sugar. Erythritol and xylitol practically do not raise blood sugar. That is the reason they are found in diabetic and low-carb products.
- Xylitol and teeth. For dental health, xylitol is well supported and is therefore contained in dental care chewing gum.
- Fewer calories. Both substances provide considerably fewer calories than sugar at a similar sweetening power.
- A clearly measured rise after erythritol. After 30 grams of erythritol, the plasma level in healthy volunteers rose from 3.75 to 6,480 micromoles per liter, more than a thousandfold, p less than 0.0001. This measurement is unambiguous, even if its significance is open.
What the studies show
Observation: higher level, more events
Witkowski 2023 (Nature Medicine) began with an untargeted metabolic analysis in 1,157 patients who came for cardiac risk assessment. Higher blood levels of several sugar alcohols, above all erythritol, were associated with more major cardiovascular events over three years, that is, death, heart attack or stroke. In two independent cohorts from the US (2,149 people) and Europe (833 people) the association was confirmed: the top versus the bottom quarter of erythritol levels had a hazard ratio of 1.80 (1.18 to 2.77) and 2.21 (1.20 to 4.07), respectively. What was measured was the blood level, not how much erythritol someone had eaten.
Intervention: 30 grams, ten people per group
Witkowski 2024 (Arteriosclerosis, Thrombosis, and Vascular Biology) gave healthy volunteers 30 grams of erythritol or 30 grams of glucose, ten people per group. After erythritol, the plasma level rose from 3.75 to 6,480 micromoles per liter. The platelets then reacted more strongly to stimulating agents, in all participants, with every agent and at every dose level. The release of the platelet markers serotonin and CXCL4 also increased. After glucose this rise did not occur. The study measures platelet function, not disease.
Where the data stop
- More heart attacks and strokes caused by erythritol. The association comes from observation in heart patients whose intake was never measured. A study that compares erythritol consumption and actual events in a controlled way does not exist.
- Cause or marker. The body produces both substances itself, and more of them when sugar metabolism is impaired. A high level can therefore be a consequence of the diet or merely indicate a metabolic state that is associated with higher risk anyway.
- Transferability to healthy people. The observational data come from people who came for cardiac assessment. With ten participants per group, the intervention study was very small and measures an acute effect.
- Small amounts and xylitol. The effects shown concern a single amount of 30 grams of erythritol. For xylitol in chewing gum the discussion plays practically no role; the amounts there are small.
Status, approval and legal
Erythritol and xylitol are widely used as sugar substitutes in food. Sweeteners of this kind are considered safe by the authorities in the US and the EU. According to the authors of the intervention study, there were no clinical studies on long-term cardiovascular risk for this.
The same authors consider a discussion warranted as to whether erythritol should be re-evaluated as a food additive. Such a re-evaluation is a demand of the study group, not a decision by the authorities.
Safety
The most common everyday side effect is the laxative effect of larger amounts.
The vascular question is open. After 30 grams of erythritol, the platelets of healthy volunteers reacted more strongly, which in the authors’ assessment could increase the potential for clotting. Whether this results in a measurable risk of heart attack or stroke has not been shown. Safety data therefore stand at 5 out of 10 points in the BK-Score. This text is information and does not replace medical advice.
BK-Score Thin human evidence
| Human evidence | 5 | |
|---|---|---|
| Mechanism | 7 | |
| Safety data | 5 | |
| Hype gap | 5 | |
| Track record of use | 9 |
Undecided, not cleared. The mechanism has been shown: after 30 grams of erythritol, the plasma level rose from 3.75 to 6,480 micromoles per liter – more than a thousandfold – and the platelets then reacted more strongly, in all participants, with every stimulating agent, at every level (ATVB 2024). Glucose as a comparison did not do this. The human evidence remains weak because this study had ten participants per group and the link with heart attack and stroke comes from observation in more than 4,000 heart patients whose intake was never measured – only the blood level. A complicating factor: the body produces both substances itself, and more of them when sugar metabolism is impaired. The same value can be a cause or a marker.
The score rates the state of knowledge, not the substance. “Safety data 9” means well studied – not harmless. “Track record of use 9” means used long and widely – that is not proof of efficacy.
Subjective assessment by Biohacking Kompakt based on published scoring rules – not a scientific rating and not a medical recommendation. Rules and all ratings (German)
Frequently asked questions about erythritol and xylitol
Do erythritol and xylitol raise blood sugar?
Practically not. That is exactly why both substances are found in diabetic and low-carb products. They taste sweet, provide considerably fewer calories than sugar and barely raise blood sugar.
Is erythritol bad for the heart and blood vessels?
That has not been settled. After 30 grams of erythritol, the platelets of ten healthy volunteers reacted more strongly; glucose did not have this effect. The link with heart attack and stroke comes from observational data on more than 4,000 heart patients in whom only the blood level was measured, not the intake. That is not proof that erythritol causes more events.
Why is the blood level of erythritol hard to interpret?
The body produces erythritol and xylitol itself, and more of them when sugar metabolism is impaired. A high value can therefore come from the diet or merely indicate a metabolic state that is associated with higher cardiovascular risk anyway. The measured value alone cannot separate cause from marker.
How much erythritol was used in the study?
In the intervention study, participants drank 30 grams of erythritol at once. That corresponds roughly to a large sweetened drink or several bars. Afterwards the plasma level rose from 3.75 to 6,480 micromoles per liter, that is, to more than a thousandfold.
What side effects do erythritol and xylitol have?
The most common everyday side effect is a laxative effect at larger amounts. It is open whether the stronger platelet reaction after erythritol matters for the heart and blood vessels. This information does not replace medical advice.
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Sources
- Witkowski M et al. 2024, Arterioscler Thromb Vasc Biol – erythritol, but not glucose, increases platelet reactivity in healthy people, ten participants per group (PMID 39114916)
- Witkowski M et al. 2023, Nature Medicine – erythritol and the risk of cardiovascular events, observation in three cohorts (PMID 36849732)
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Information only, not medical advice and not a usage or dosage recommendation. Prescription-only and unapproved substances belong in the hands of a physician. Last updated: 2026-10-05.