A low calorie sweetener often found in processed foods and drinks may be associated with higher risks of major adverse cardiovascular events such as heart attacks and stroke, according to new research.
The study, presented at the European Society of Cardiology Congress 2026, examined whether xylitol was associated with the risk of cardiovascular events in the general population.
Xylitol is a type of sugar alcohol: a carbohydrate that is a hybrid of sugar and alcohol molecules. Manufacturers often use it to add sweetness to food and oral care products without the calories or risk of tooth decay that sugar poses.
“In previous studies, we showed that xylitol can enhance the ability of platelets to form clots,” said study author Dr. Marco Witkowski from Charité University Hospital in Berlin, Germany, in a press release.
“We also found that high blood levels of xylitol were linked to cardiovascular events in high risk individuals over a three-year period,” he said.
What had yet to be established was whether xylitol might increase the risk of cardiovascular events within the general population. This was what the new study aimed to find out.
The researchers wanted to examine a larger study population than in previous research and follow them over a longer period.
To this end, they examined data from two large observational studies in North America and Europe, involving a total of 17,710 participants with a mean age of 60.9 years.
These studies were the Canadian Longitudinal Study on Aging (CLSA), which followed participants for 6 years, and the European Prospective Investigation into Cancer (EPIC)-Norfolk, which followed participants for 30 years.
The researchers adjusted the data to account for traditional risk factors for cardiovascular illness, such as age, smoking status, diabetes, and high blood pressure. They then split the cohorts into four groups based on the levels of xylitol in their blood plasma.
After these adjustments, they found that the group of participants with the highest levels of xylitol in their blood had a significantly higher risk of heart attack, stroke, or death from a cardiovascular event than those with the lowest levels of xylitol.
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During the 6-year follow-up period of the CLSA study, the researchers found that those with the highest xylitol levels had a 57% higher risk of a major adverse cardiovascular event (MACE) compared with those with the lowest xylitol levels.
The 30-year follow-up period of the EPIC-Norfolk study also found that the highest xylitol levels were associated with an increased risk of MACE compared with the lowest levels. Here, the associated risk was 18% higher in the group with the highest levels.
Looking at all the data together, the researchers found a dose-dependent relationship between xylitol and MACE. As the levels of xylitol rose, so too did the incidence of heart attacks, stroke, and death from cardiovascular events.
This association between xylitol and MACE was also independent of other factors that could lead to these adverse events and of the likelihood of using artificial sweeteners. These included having a high body mass index, diabetes, and high blood pressure.
“Our long-term findings in the general population highlight how little we know about the cardiovascular safety of xylitol and indicate that further studies are warranted, said Witkowski, “especially as the amount of xylitol in products continues to increase.”
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Many people regard xylitol and other sugar alcohols as a healthy alternative to sugar.
“Artificial sweeteners are widely embraced by modern society, and their safety ratings have been favorable and granted by regulatory authorities,” said Dan Atar, a member of the European Society of Cardiology Communication Committee, commenting on the study in the press release.
“In this observational work, however, it appears that xylitol has a negative long-term effect on cardiovascular events in the general population,” he said.
Medical News Today asked Stanley Hazen, MD, PhD, Chair of the Department of Heart, Blood & Kidney Research at the Cleveland Clinic in Ohio, who was not involved in the study, how people should approach xylitol in light of this research.
“A growing body of research suggests sugar alcohols like xylitol and erythritol may not be a simple substitute for sugar to avoid calories,” he said. “There is data showing they can enhance risk for clotting events like heart attack or stroke.
“I am recommending my patients avoid these non-nutritive sweeteners – especially those with cardiovascular disease or higher risk. This, of course, tends to be the very same subjects more likely to be using artificial sweeteners.”
— Stanley Hazen, MD, PhD
MNT also posed the same question to Cheng-Han Chen, MD, a board certified interventional cardiologist and medical director of the Structural Heart Program at MemorialCare Saddleback Medical Center in Laguna Hills, CA, who was also not involved with the study.
“When possible, I recommend choosing naturally sweet foods, such as whole fruit, which provide sweetness along with fiber and other beneficial nutrients,” he said.
Chen also noted that artificial sweeteners can still have a practical role for people with diabetes because they generally produce a smaller immediate increase in blood glucose than sugar.
“However, avoiding a short-term glucose spike does not necessarily mean that consuming large amounts of artificial sweeteners is beneficial for long-term health,” he said.
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“The bigger picture matters: overall dietary quality, portion sizes, physical activity, weight management, and blood glucose control are all important components of cardiovascular health,” Chen concluded.
It is worth noting that this study was observational, so the researchers can only state that xylitol appears to increase MACE risk rather than definitively establish it as the cause.
“It is important to emphasize that these findings do not prove that artificial sweeteners cause heart attacks or strokes. Rather, they suggest that we should be more cautious about automatically assuming that artificial sweeteners are always the healthier choice.”
— Cheng-Han Chen, MD
“More research, particularly well-designed prospective studies and randomized clinical trials where feasible, is needed to determine whether there is a direct cause-and-effect relationship,” Chen said.
“More preclinical (animal model) studies are needed,” said Hazen. “Existing human and animal model studies thus far have supported a direct link between ingesting xylitol and increased platelet responsiveness, and thrombosis potential.”
