A study that followed 2,149 North Americans and 833 Europeans for three years found that having elevated blood levels of artificial sweeteners such as erythritol was associated with increased risk for heart attacks and for death from a heart attack or stroke (Nature Med, Feb 27, 2023). Stanley L. Hazen of the Cleveland Clinic found that after taking the commonly-used artificial sweetener, erythritol, healthy people who did not suffer from heart disease had elevated blood levels of erythritol and increased risk for developing clots, a major cause of heart attacks and strokes.

Adding erythritol to the blood of healthy people in a test tube increased risk for forming clots. People who are obese or diabetic are the ones most likely to be taking these artificial sweeteners, and they are the ones most likely to suffer heart attacks. The Food and Drug Administration (FDA) has listed erythritol as generally regarded as safe, but artificial sweeteners such as sucralose have been shown to raise blood insulin levels (Diabetes Care, 2013;36:2530–5; Am J Clin Nutr, 2018;108:485–91), and to increase risk for insulin resistance (J Family Med Prim Care, 2020 Jan; 9(1): 69–71) and insulin resistant diabetes (Br J Nutr, 2014;112:725–34).

Approved Artificial Sweeteners
Artificial sweeteners are components of food that taste sweet in your mouth without causing the gain in calories and rises in blood sugar that you get when you eat sugars. They do this by being so sweet that you can get the taste of sugar when you use only a very small amount. Artificial sweeteners that have been approved by the FDA are Aspartame (Equal or NutraSweet), Acesulfame potassium, Neotame, Saccharin (Sweet ‘N Low, Sweet Twin and Sugar Twin), Sucralose (Splenda, Equal), and Advantame. Sugar alcohols, such as sorbitol, xylitol, lactitol, mannitol, erythritol, and maltitol, sweeten with far fewer calories than sugars but can be hard to digest. Extracts from intensely-sweet plants such as stevia or monk fruit may also be used as sugar substitutes. Check the list of ingredients when you shop, to see if any of these “artificial” sweeteners are included.

How Artificial Sweeteners May Increase Risk for Diabetes and Weight Gain
• Artificial sweeteners may increase risk for diabetes and weight gain by changing the bacteria in your colon (Nature, Oct 9, 2014;514(7521):181-6; Cell Metab, Nov 4, 2014;20(5):701-3). One week of consuming artificial sweeteners changed the gut bacteria of apparently healthy humans to cause higher blood sugar levels after taking sugared foods and drinks. Obese people who have taken aspartame or saccharin within 24 hours, have much higher blood sugar rises after taking sugar than those who do not use these artificial sweeteners (Applied Physiology, Nutrition, and Metabolism, May 24, 2016). High blood sugar levels call out more insulin and high insulin levels increase weight gain and case inflammation to increase diabetes risk.

• Artificial sweeteners may cause you to burn fewer calories. Rats that ate yogurt sweetened with saccharin consumed more calories, gained more weight, and were fatter than rats that ate yogurt sweetened with sugar (Behavioral Neuroscience, Feb 2008;122(1):). The rats that were kept on saccharin had a smaller rise in body temperature after eating than those who were fed sugar, and therefore they burned fewer calories.

• Artificial sweeteners may cause you to eat more calories. There is PET scan evidence that taking artificial sweeteners lights up the brain’s pleasure centers, which may indicate that you will want to eat more calories and since you don’t get extra calories in artificially sweetened foods and drinks, you would have to get them by eating more of other foods (Trends in Endocrinology & Metabolism, July 10, 2013).

Earlier Studies Showing That Artificial Sweeteners May Not Be Safe
Strokes: A study following 81,714 women for 11.9 years found a marked increase in stroke risk with artificial sweeteners (JAMA, 2019;321(16):1554-1555).
Cancer: High consumers of artificial sweeteners were found to be at a 13 percent increased risk for developing obesity-related cancers, including colorectal, stomach, liver, mouth, pharynx, larynx, esophageal, ovarian, endometrial, and prostate cancers (PLoS Med, 2022 Mar 24;19(3):e1003950. Aspartame was linked with a 15 percent increased risk for obesity-related cancers and a 22 percent increased risk for breast cancer.
Diabetes: Using artificial sweeteners was associated with increased risk for obesity and diabetes (Annals of Nutrition and Metabolism, Feb 23, 2017; Brit J of Nutrit, Sept 2014;112(5):725-734), even in people who were not overweight (BMJ, July 21, 2015).

Sugared Drinks Are Even More Harmful
It is well established that taking in too much sugar, particularly in sugar-sweetened beverages, is associated with weight gain, obesity, type II diabetes, high blood pressure and heart disease (JAMA Intern Med, 2014;174(4):516-524). Sugar in liquid form raises blood sugar more quickly than any other type of food. One can of sugar-sweetened soda contains 25 to 50 grams of sugar, the recommended upper limit for sugar for an entire day. Because of their high sugar content and lack of fiber, fruit juices and fruit drinks are just as unhealthful as sodas.

My Recommendations
Artificial sweeteners appear to be safer than sugared foods and drinks, but increasing numbers of scientific papers show that artificial sweeteners can change the bacteria in your colon to increase risk for gaining weight and developing diabetes. Artificial sweeteners are associated with higher blood sugar levels and weight gain. Even small amounts of weight gain increase your risk for diabetes.

I believe that both sugar-sweetened drinks and artificially-sweetened drinks can be harmful to your health. Sugared drinks may be useful during prolonged, vigorous exercise, but at all other times, I recommend that you drink water to quench your thirst. Unsweetened coffee and tea appear to be safe also.