Recent research published in the European Heart Journal has raised concerns about the artificial sweetener xylitol, suggesting it may increase the risk of blood clotting and, consequently, elevate the chances of a heart attack or stroke.
This study follows previous findings linking another sugar alcohol, erythritol, to similar health risks. Erythritol is widely used as a sweetener in popular brands like Truvia and found in numerous keto-friendly and no-sugar products.
Both erythritol and xylitol are marketed as healthier alternatives to sugar, particularly for people with obesity or type 2 diabetes. However, the emerging data suggests otherwise, according to Stanley Hazen, MD, PhD, a physician-scientists at Cleveland Clinic in Ohio.
“The evidence suggests that the very people who are already at higher risk for cardiovascular events may be increasing their risk even further by using these sugar substitutes,” says Dr. Hazen.
What Is Xylitol?
Xylitol is a sugar alcohol that is widely approved as an alternative sweetener. It is often used to reduce added sugars in diets, according to Joanne Slavin, PhD, RD, a professor of food science and nutrition at the University of Minnesota in St. Paul, who was not involved in the recent study.
Despite its name, xylitol does not actually contain alcohol; the term “sugar alcohol” refers to its molecular structure. It is naturally found in small amounts in various fruits and vegetables, such as strawberries, raspberries, mushrooms, and cauliflower. Additionally, xylitol is produced in the human body, although at much lower levels than what is typically added to processed food products.
The xylitol that is commercially used in foods, however, is not derived directly from these natural sources. Instead, it is usually synthetically produced, often through the processing of wood materials or microbial fermentation. Xylitol is roughly as sweet as sugar but contains about 40% fewer calories, making it an attractive option for those trying to manage their calorie intake or sugar consumption.
Though not as common as other artificial sweeteners, xylitol can still be found in various keto-friendly and low-calorie food products, according to Dr. Hazen. Most notably, xylitol is a key ingredient in sugar-free desserts, gum, and candies that are frequently marketed to people with type 2 diabetes. Moreover, it is also found in toothpaste and mouthwash. However, this is not considered a health concern since these products are typically not ingested.
Xylitol and Increased Blood Clotting
One of the key findings of the study involved the effect of xylitol consumption on blood clotting. Investigators measured xylitol levels in the blood plasma of more than 3,000 healthy participants after an overnight fast. This measurement was designed to capture the amount of xylitol naturally present in the body, without the influence of food consumption.
Following this, the researchers tracked the participants’ health outcomes over the next three years. They found that individuals with the highest levels of naturally occurring xylitol in their bloodstream were twice as likely to experience a heart attack, stroke, or death compared to those with the lowest xylitol levels.
Importantly, this study was observational, meaning that it did not prove causation. Other factors, such as diet and lifestyle, may have influence the outcomes. To further investigate the potential link, researchers conducted additional tests in both animal models and human blood samples.
They also gave a xylitol-sweetened beverage to 10 individuals whose natural xylitol levels were in the lowest 25 percent.
Across all these tests, the researchers found that xylitol sped up the formation of blood clots, a process that could eventually lead to heart attacks or strokes. Dr. Hazen highlighted the dramatic effect of xylitol on blood xylitol levels, stating that consuming xylitol-laden products caused a 1,000-fold increase in xylitol concentration compared to normal levels.
“Crazy levels — 1,000-fold elevated,” he says. Those levels go back down to normal within a few hours after a person consumes xylitol, but during that window, those people could be significantly increasing their risk for a cardiovascular event, says Hazen.
Though Hazen acknowledged that the absolute risk of experiencing a heart attack or stroke during this period is small, he raised an important point: “But who wants to eat something, especially when you’re reaching for it as a healthy option, and instead, you’re moving into a higher risk category for that period of time?”
Industry Response and Concerns
The study’s findings sparked a reaction from the food industry, particularly manufacturers of low-calorie and sugar-free products. The Calorie Control Council, an international group representing companies that produce and supply reduced-calorie food and beverages, issued a statement in response.
The organization disputed the study’s results, pointing to decades of research that supports the safety of low-calorie sweetener’s like xylitol.
“These findings are a disservice to those who rely on alternative sweeteners as a tool to improve their health. Xylitol has been trusted as a great-tasting low-calorie sweetener for over 60 years,” said Carla Saunders, the president of the Calorie Control Council.
The council further emphasized that the study only demonstrated an association between xylitol consumption and increased health risks, rather than a direct cause-and-effect relationship. This distinction is critical in scientific research, as observational studies often require further testing to establish definitive conclusions.
Evaluating the Risks and Benefits
As with many dietary concerns, the use of xylitol presents a complex issue. Dr. Slavin noted that this study contributes to the growing body of evidence on xylitol, but she cautioned against overreaction.
“It adds to our body of evidence on xylitol but should not scare consumers about the use of xylitol in the usual small doses,” she says.
Indeed, all food ingredients carry both risks and benefits, and it is up to individual consumers to evaluate whether the use of xylitol meets their dietary goals, Dr. Slavin explained.
For many, the benefits of alternative sweeteners – such as their low caloric content, lack of contribution to tooth decay, and ability to provide sweetness without spiking blood sugar levels – may outweigh the potential risks.
“Alternative sweeteners like xylitol offer benefits — not cariogenic, low calories, low added sugar, sweet taste — but in large doses can cause GI issues. Obesity and high calorie intake are linked to increased risk of heart disease and stroke — so for many consumers they will choose to continue to use alternative sweeteners like xylitol because of the benefits,” Dr. Slavin added.
The Challenge of Identifying Xylitol in Foods
For those looking to avoid xylitol entirely, the task may be more difficult than it seems. Careful label reading is necessary, as xylitol is often hidden under different names. While food and beverage products labeled as “sugar-free” or “no added sugar” are required to list sugar alcohols under the carbohydrates section, other products might use terms like “natural sweeteners” or “artificial sweeteners.”
In some cases, xylitol may be listed under alternative names such as birch sugar or the European code E967. Dr. Hazen offered a simple tip for identifying sugar alcohols: “Anything that ends with an ‘ol’ indicates that it’s a sugar alcohol.
He also pointed out that xylitol can be present in a wide range of foods that may not immediately seem like sources of artificial sweeteners, including energy bars, nut butters, and salad dressings.
“Xylitol may be in many more products than consumers realize, including energy bars, nut butters, and salad dressings,” says Dr. Hazen.
Should You Avoid Xylitol?
Whether to avoid xylitol entirely depends on individual perspective and personal health goals.
Dr. Hazen advises his patients to avoid xylitol and other sugar alcohols altogether, noting that the promotion of blood clotting could be a shared effect among different types of sugar alcohols. He advocates for a diet focused on whole foods and suggests that moderate consumption of natural sweeteners like sugar or honey may be a better option.
In contrast, Dr. Slavin believes that the findings of this single study are insufficient to definitively conclude that xylitol is harmful. “The amounts of xylitol that are approved for use in the U.S. are generally regarded as safe,” she said.
Elisabetta Politi, MPH, CDCES, RD, a certified diabetes care and education specialist at Duke Health, shared a balanced view. While acknowledged the potential risks, she recommends moderation and gradual reduction of sugar and sugar substitutes in the diet.
“Taste buds are adjustable. We aren’t going to perceive sweetness if we overload them with a lot of artificial sweeteners, and so they shouldn’t overly rely on them. My recommendation is to gradually reduce the amount of sugar and sugar substitutes and practice moderation,” Politi advised.
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