The Erythritol Study That Shocked Doctors — What the Nature Medicine 2023 Research Actually Found

A Sweetener Safety Wake-Up Call

If you've been using erythritol-based keto sweeteners thinking they're perfectly safe, a landmark 2023 study published in Nature Medicine should make you pause. The research, conducted by the Cleveland Clinic, found that people with the highest levels of erythritol in their blood were more than twice as likely to experience a major cardiovascular event ^[1] — including heart attack and stroke — compared to those with the lowest levels.

For millions of keto and low-carb dieters who've relied on erythritol as their go-to sugar substitute, this study was a seismic shift. And it raises an uncomfortable question: Has the sweetener you trusted been quietly working against your health goals?

At SweetMonkFruit, we've always believed that pure monk fruit sweetener without erythritol is the smarter choice. This study is exactly why.

What the Nature Medicine Study Actually Found

The research, led by Dr. Stanley Hazen at the Cleveland Clinic and published in February 2023, was no small investigation. It analyzed data from over 4,000 participants across the United States and Europe, and the findings were striking:

• Higher erythritol levels = higher risk: Participants in the top 25% of erythritol blood levels had roughly 2x the risk of heart attack and stroke compared to those in the bottom 25% ^[1].
• Platelet reactivity: In lab tests, erythritol made platelets — the cells responsible for blood clotting — more reactive. That means they were more likely to clump together and form clots.
• Thrombus formation: Animal models showed that adding erythritol to the diet increased the size and stability of blood clots that formed in injured blood vessels.
• Rapid absorption: Unlike other sugar alcohols that pass through the digestive system, about 90% of ingested erythritol is absorbed directly into the bloodstream ^[1] before reaching the colon. This is critical — it means erythritol circulates in your blood at levels high enough to potentially affect platelet function.

This wasn't a small pilot study with shaky statistics. It was a rigorous, multi-cohort investigation published in one of the world's most prestigious medical journals.

Why This Matters for Keto Dieters

Here's the uncomfortable reality: the vast majority of "monk fruit" and "keto" sweeteners on the market use erythritol as their primary ingredient. If you check the label on popular brands like Lakanto, Swerve, or Monk Fruit in the Raw, you'll see erythritol listed first — often making up 80-99% of the product.

That means every time you sweeten your coffee, bake keto cookies, or sprinkle something on your oatmeal, you could be consuming grams of erythritol at a time. The Cleveland Clinic researchers noted that consuming a single erythritol-sweetened beverage or muffin could raise blood erythritol levels high enough to potentially affect platelet function.

For keto dieters — who often use sweeteners multiple times a day — the cumulative erythritol exposure could be significant.

The "But It's Natural" Argument — Debunked

One common defense of erythritol is that it's "natural." And technically, erythritol does exist in small amounts in fruits like grapes, pears, and watermelon. But here's the critical distinction:

• Natural dietary erythritol intake: Approximately 0.01 to 0.07 grams per day from whole foods — a trivial amount that your body can easily handle.
• Processed erythritol intake: A single serving of a keto sweetener can contain 4-16 grams of erythritol — up to 1,600 times more than what you'd get from eating fruit.

The erythritol in your keto sweetener isn't coming from fruit. It's manufactured industrially by fermenting corn or wheat starch with specific yeast strains. The resulting white crystalline powder may look "clean," but your body is processing quantities it never evolved to handle.

The Cleveland Clinic researchers were explicit about this concern: they called for follow-up safety studies on erythritol ^[1], noting that the current "Generally Recognized as Safe" (GRAS) designation was based on older, limited data that didn't investigate cardiovascular outcomes.

How Erythritol Is Different From Other Sugar Alcohols

Most sugar alcohols — like xylitol, sorbitol, and maltitol — have a well-known downside: they cause digestive distress. Bloating, gas, and diarrhea are common complaints, especially at higher doses. This is because sugar alcohols reach the colon largely intact, where gut bacteria ferment them.

Erythritol was supposed to be the exception. Because it's absorbed into the bloodstream before reaching the colon, it was marketed as the "gentle" sugar alcohol — the one that doesn't cause digestive issues.

But that same absorption into the bloodstream is exactly what makes it uniquely concerning from a cardiovascular perspective. Other sugar alcohols mostly pass through your digestive system. Erythritol circulates through your blood vessels — the very system the Nature Medicine study linked to clotting risk.

It's a trade-off most consumers were never told about:

Why Monk Fruit Sweetener Without Erythritol Is Different

Here's where the story changes direction. Pure monk fruit sweetener — like what we sell at SweetMonkFruit.co — doesn't contain erythritol. Period.

Monk fruit's sweetness comes from mogrosides, the unique sweet compounds found exclusively in monk fruit, which also have antioxidant properties (Siraitia grosvenorii). When you use pure monk fruit extract:

• Zero erythritol — no sugar alcohol, no blood absorption concerns
• Zero calories — mogrosides aren't metabolized for energy
• Zero glycemic impact — no blood sugar spikes, no insulin response
• Antioxidant properties — mogrosides have demonstrated anti-inflammatory and antioxidant activity in research
• No cooling aftertaste — that minty, cooling sensation in your mouth? That's the erythritol. Pure monk fruit tastes like sugar, not like sucking on a peppermint.

The problem with most monk fruit products on the market is that they dilute the monk fruit with erythritol as a bulking agent. Why? Because pure monk fruit extract is 150–250 times sweeter than sugar in pure extract form, making it impractical to use in a 1:1 ratio without a carrier. At SweetMonkFruit, we solved this differently: our monk fruit sweetener (monk fruit juice powder + tapioca fibre) is designed to bake like sugar, taste like sugar — without a single gram of erythritol. 1g of our powder equals approximately 4g of sugar, giving you a practical, easy-to-use conversion. We ship across Canada from sweetmonkfruit.co.

What Independent Experts Are Saying

The Nature Medicine study generated significant reaction from the medical community:

• Dr. Stanley Hazen (study senior author, Cleveland Clinic) ^[4]: "It's important to explore further the safety of erythritol, especially when consumed at levels far above what occurs naturally in the diet."
• The World Health Organization later issued guidance recommending against the use of non-sugar sweeteners ^[2] for weight control, citing both limited evidence of long-term benefit and emerging safety concerns.
• The European Food Safety Authority (EFSA) has been re-evaluating erythritol ^[3]'s safety profile in light of the new cardiovascular data.

While no regulatory body has yet banned erythritol, the scientific conversation has clearly shifted. The assumption of safety has been challenged, and until long-term safety studies are completed, many health-conscious consumers are choosing to err on the side of caution.

The Cooling Aftertaste Nobody Talks About

Beyond the cardiovascular concerns, there's a practical reason erythritol is problematic in recipes: it produces a distinctive cooling sensation on the tongue. If you've ever noticed a minty, almost menthol-like aftertaste when eating keto desserts, that's the erythritol.

This cooling effect is a dead giveaway. It's why keto baked goods often taste... off. It's why your keto cheesecake has a weird minty finish. It's why your sugar-free frosting tastes like it was made in a chemistry lab.

Pure monk fruit doesn't have this problem. Without erythritol, there's no cooling aftertaste — just clean, natural sweetness that tastes like sugar. If you've been disappointed by keto desserts in the past, erythritol is likely the culprit.

How to Read Your Sweetener Label

Not sure if your current sweetener contains erythritol? Here's a quick label-reading guide:

• ✅ If the ingredient list says "monk fruit extract" or "monk fruit" only — you're in the clear. This is pure monk fruit.
• ⚠️ If "erythritol" appears first — it's the primary ingredient. The monk fruit is just flavoring at that point.
• ⚠️ Look for "ol" endings — xylitol, sorbitol, maltitol, erythritol are all sugar alcohols with potential GI or cardiovascular concerns.
• ⚠️ "Natural flavors" can hide things — some companies use this catch-all to mask fillers and additives.

Check out our FAQ page for more on what goes into our pure monk fruit sweetener — and what we deliberately leave out.

What About People With Diabetes?

If you're managing diabetes or prediabetes, this conversation is even more critical. You chose a sugar alternative specifically to protect your cardiovascular health — because diabetes already puts you at elevated risk for heart disease and stroke.

The irony is painful: the sweetener marketed as "diabetes-friendly" might actually be adding cardiovascular risk on top of what diabetes already creates. When erythritol circulates in your bloodstream and makes platelets stickier, it's potentially working against the very health goals that drove you to ditch sugar in the first place.

Pure monk fruit sweetener, by contrast, provides:

• Zero glycemic impact — no blood sugar spikes
• No cardiovascular red flags — mogrosides don't affect platelet function
• Anti-inflammatory properties — research on mogrosides shows they may actually reduce inflammation

For a deeper dive, see our guide on Monk Fruit vs Stevia vs Erythritol.

Making the Switch: What to Expect

If you're ready to ditch erythritol, here's what happens when you switch to pure monk fruit:

• Week 1: Your tastebuds adjust. Erythritol-trained palates expect that cooling hit. Pure monk fruit tastes warmer, rounder — closer to actual sugar. Give it a few days.
• Week 2: You'll notice your keto baked goods taste better. No weird minty aftertaste in your cheesecake. No chemical finish in your cookies.
• Week 4: Your body has fully adjusted. And knowing that you're no longer circulating grams of a sugar alcohol through your blood vessels? That's peace of mind you can taste.

Try pure monk fruit sweetener — erythritol-free, zero calories, and it bakes like sugar.

The Bottom Line

The 2023 Nature Medicine study didn't definitively prove that erythritol causes heart attacks. It showed a strong association, demonstrated a plausible biological mechanism (platelet activation), and called for urgent follow-up research. That's how science works — and it's enough to warrant caution.

When a sweetener that's absorbed into your bloodstream at levels thousands of times higher than what occurs in nature is linked to increased blood clotting, it deserves serious attention — not dismissal.

Pure monk fruit sweetener gives you everything you want from a sugar alternative — zero calories, zero glycemic impact, and clean sweetness that actually tastes like sugar — without the erythritol concerns that are reshaping how scientists and consumers think about keto sweeteners.

You chose keto for your health. Make sure your sweetener is on the same team.

References

1. Witkowski M, et al. The artificial sweetener erythritol and cardiovascular event risk. Nature Medicine. 2023;29(4):718-725. doi:10.1038/s41591-023-02223-9
2. World Health Organization. Use of non-sugar sweeteners: WHO guideline. 2023. WHO guideline
3. European Food Safety Authority. Re-evaluation of erythritol (E 968) as a food additive. EFSA Journal. 2023. doi:10.2903/j.efsa.2023.7822
4. Hazen SL. Cardiovascular risks of erythritol: what the data show. Cleveland Clinic Health Essentials. 2023. Cleveland Clinic Newsroom

This article is for informational purposes only and is not intended as medical advice. Consult your healthcare provider before making dietary changes, especially if you have a cardiovascular condition.

Related: The Complete Guide to Monk Fruit Without Erythritol | Shop the Best Erythritol-Free Monk Fruit (2026) | Monk Fruit vs Erythritol: The Full Breakdown