Erythritol has a glycemic index of zero and an insulinemic index of 2 (out of 100), making it one of the most blood-sugar-friendly sweeteners available. For most people with diabetes, it does not raise blood glucose or trigger meaningful insulin release. However, a 2023 study linking high blood levels of erythritol to cardiovascular risk has complicated the picture, especially for diabetics who already face elevated heart disease risk.
Why Erythritol Doesn’t Spike Blood Sugar
Erythritol is a sugar alcohol found naturally in small amounts in fruits and fermented foods, though the version in products is commercially manufactured. It contains roughly 0.2 calories per gram, compared to 4 calories per gram for table sugar, and it’s about 60 to 80 percent as sweet. Unlike sugar, your body handles erythritol in a way that essentially bypasses your metabolism: more than 90% of what you consume is absorbed into the bloodstream from the small intestine, circulates without being broken down, and is excreted unchanged through urine. The small remainder passes to the large intestine, where gut bacteria ferment it.
Because erythritol isn’t metabolized for energy, it produces no rise in blood glucose and almost no insulin response. That glycemic index of 0 is not an approximation. It genuinely does not register on blood sugar measurements in clinical testing. For someone managing diabetes through carb counting or blood sugar monitoring, erythritol behaves as though it isn’t there.
The Cardiovascular Concern
In 2023, a study published in Nature Medicine raised a significant flag. Researchers at the Cleveland Clinic measured blood levels of erythritol in over 4,000 patients undergoing cardiac risk assessment in the U.S. and Europe. They found that people with the highest circulating erythritol levels had roughly 1.8 to 2.2 times the risk of a major cardiovascular event (heart attack, stroke, or death) over three years, compared to those with the lowest levels. This association held even after adjusting for traditional cardiovascular risk factors like high blood pressure, cholesterol, and diabetes itself.
This matters for diabetics specifically because cardiovascular disease is already the leading cause of death in people with type 2 diabetes. Anything that could further elevate that risk deserves attention. The study also showed that erythritol appeared to enhance platelet clotting activity in lab and animal experiments, suggesting a possible biological mechanism rather than just a statistical coincidence.
There are important caveats. The study measured erythritol levels in the blood, not dietary intake. Your body produces small amounts of erythritol naturally through a metabolic pathway, and people with obesity, insulin resistance, or diabetes tend to produce more of it endogenously. So it’s possible that high blood erythritol is a marker of metabolic dysfunction rather than a cause of cardiovascular problems. The study could not definitively prove that eating erythritol causes heart attacks. Still, the FDA reviewed the findings and acknowledged the statistical significance of the association.
Digestive Tolerance
One practical advantage erythritol has over other sugar alcohols like sorbitol or maltitol is that it’s far easier on the gut. Because most of it is absorbed in the small intestine before reaching the colon, it causes much less bloating, gas, and diarrhea than its relatives. Clinical studies have shown that people can tolerate up to 1 gram per kilogram of body weight daily without gastrointestinal symptoms. For a 70-kilogram (154-pound) person, that’s 70 grams per day, which is a substantial amount. Most people consume far less than that through sweetened foods and beverages.
This is a relevant advantage for diabetics, since many sugar-free products contain other sugar alcohols that can cause significant digestive discomfort, sometimes leading people to abandon sugar substitutes altogether.
Dental Benefits
People with diabetes are at higher risk for gum disease and dental problems, which makes erythritol’s oral health profile worth noting. Unlike sugar, erythritol actively inhibits the growth of the bacteria most responsible for tooth decay. It reduces plaque formation and decreases the ability of cavity-causing bacteria to stick to tooth surfaces. Research has found it more effective than both xylitol and sorbitol at managing oral health, partly because the small molecule can pass directly into bacterial cells and disrupt their internal processes.
What the ADA Says
The American Diabetes Association’s 2024 Standards of Care doesn’t single out erythritol with a specific recommendation. Its general guidance on nonnutritive sweeteners states that water is the preferred beverage, but using sugar substitutes in moderation is acceptable if doing so reduces your overall calorie and carbohydrate intake. The ADA acknowledged that the Cleveland Clinic cardiovascular study has added to public confusion about sweetener safety, but stopped short of recommending against erythritol specifically.
Practical Takeaways for Blood Sugar Management
From a pure blood sugar perspective, erythritol is among the safest sweetener options for people with diabetes. It won’t affect your glucose readings, won’t require insulin dosing adjustments, and won’t add meaningful calories. If your primary concern is glycemic control, erythritol performs as well as or better than virtually any other sweetener on the market.
The open question is cardiovascular risk. If you have existing heart disease, a history of stroke, or multiple cardiovascular risk factors on top of your diabetes, the 2023 findings are worth discussing with your care team. The research isn’t conclusive enough to say erythritol causes heart problems, but it’s strong enough that dismissing it entirely would be premature. For people with diabetes but low cardiovascular risk, moderate erythritol use remains a reasonable choice, particularly as a replacement for sugar in baked goods, beverages, or packaged foods where it helps keep carbohydrate intake down.