The artificial sweetener xylitol is independently associated with the incident risk for major adverse cardiovascular events (MACE) in the general population, according to a study presented at the annual meeting of the European Society of Cardiology, held from Aug. 28 to 31 in Munich.
T.M. Zheng, from McGill University in Montreal, and colleagues examined the association between xylitol and cardiovascular event risk in the general population. The analysis included data from two prospective observational studies across both North America and Europe (Canadian Longitudinal Study on Aging [CLSA]: 7,651 participants; the European Prospective Investigation into Cancer [EPIC]-Norfolk: 10,059 participants).
The researchers found that during six years of follow-up for CLSA and 30 years for EPIC-Norfolk, a total of 2,950 major adverse cardiovascular events occurred in CLSA and 5,670 occurred in EPIC-Norfolk. Circulating xylitol levels were associated with incident MACE risk, independent of traditional cardiovascular risk factors (CLSA: Q4 versus Q1; adjusted hazard ratio [aHR], 1.47; EPIC-Norfolk: aHR, 1.18). In both cohorts, there was a consistent significant increase in MACE risk across different subpopulations, irrespective of baseline characteristics and preexisting cardiometabolic factors.
“In previous studies, we showed that xylitol can enhance the ability of platelets to form clots,” coauthor Marco Witkowski, M.D., Ph.D., from the Charité University Hospital in Berlin, said in a statement. “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, especially as the amount of xylitol in products continues to increase.”
New and emerging cardiovascular risk factors deserve attention in populations already experiencing significant disparities in heart disease, stroke, hypertension, and diabetes.
For clinicians caring for patients at elevated baseline cardiovascular risk, the findings raise another question: Should conversations about heart-healthy eating habits include not only reducing added sugar but also examining the ingredients patients use to replace it?
Patients managing diabetes, obesity, hypertension, or weight may intentionally turn to products marketed as:
The clinical concern isn’t whether patients should go back to sugar. Rather, it’s whether replacing sugar with heavily processed alternatives automatically makes a product heart-healthy.
These findings strongly connect with recent research on ultra-processed foods, with researchers discovering a stronger association between high ultra-processed food intake and ASCVD events among Black Americans.
For clinicians, it’s important to evaluate the whole food environment, rather than treating a sugar substitute as inherently healthy.
Here are some approaches clinicians can take to discuss xylitol with patients:
Providers working to reduce persistent cardiovascular disparities may need to go beyond the basics during dietary counseling. As research continues to examine the health effects of sugar substitutes and other food additives, asking patients what they’re actually eating and what they have been encouraged to substitute may become an increasingly important part of cardiovascular prevention.
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