Spotlight on erythritol as a non-nutritive sweetener: applications,implications and complications in human health

Abstract

Non-nutritive sweeteners (NNS) are popular as sugar alternatives. Erythritol, in the last few years, has been extensively used as potentially safe NNS of choice for people with diabetes mellitus and obesity. However, its indiscriminate use has been questioned owing to potential health risks. The present review analysed the physicochemical properties of erythritol and explored the metabolism of erythritol, focusing on pathways of endogenous erythritol synthesis, absorption and elimination. The current work deliberated upon the metabolic impact, gastrointestinal effects and influence on gut microbiota as well as the recent recommendation by WHO against the long term use of erythritol for weight management owing to the potential cardiovascular complications. The need for further research to establish guidelines for the use of erythritol as a NNS is highlighted.

Keywords

Introduction

Non-nutritive sweeteners (NNS), also known as artificial sweeteners or low-calorie sweeteners, are sugar substitutes that are used to provide sweetness to foods and beverages without adding calories. They are generally sweeter than table sugar (sucrose), so only small amounts are needed to achieve the desired sweetness.¹ NNS are often used by people who are looking to reduce their calorie intake, manage their blood sugar levels, or simply prefer the taste of sweet foods and beverages.² While NNS sweeteners are generally considered safe for consumption, there is ongoing debate about their potential health effects and concerns about their long-term use.³ Erythritol has gained prominence as a potentially safe NNS; however, despite its advantages and regulatory approval, recent research prompts consideration of potential harmful effects associated with erythritol consumption. This review aims to assess the existing body of literature pertaining to erythritol usage, delineating knowledge gaps and elucidating how comprehensive analyses can contribute to its effective utilization as a NNS.

Materials and Methods

In conducting this review, an extensive literature search was performed utilizing the terms “non-nutritive sweeteners” and “erythritol” for a focused exploration of databases, including PubMed, Google Scholar, and Web of Science. Articles with duplicate or redundant content were eliminated through an assessment of their titles. Following the keyword search, data extraction involved examination of the retrieved articles, considering their titles, abstracts, and full texts when necessary to identify pertinent information.Non-Nutritive SweetenersThere are several commonly used NNS, including aspartame, sucralose, saccharin, stevia, neotame, acesulfame potassium and a variety of sugar alcohols. Aspartame is often used in diet sodas, chewing gum, and other low-calorie foods.⁴ Sucralose, derived from table sugar (sucrose), is commonly used in diet sodas, baked goods, and other low-calorie foods.⁵ Saccharin is one of the oldest NNS and is often used in diet drinks, table sweeteners, and baked goods.⁶ Stevia, a natural sweetener derived from the stevia plant, is often used in natural and organic foods, as well as in low-calorie and sugar-free products.⁷ Neotame is similar to aspartame and it is often used in baked goods, desserts, and other low-calorie foods.⁸ Acesulfame potassium, also known as Ace-K, is used in diet drinks, chewing gum, and other low-calorie foods.⁹ Sugar alcohols, also known as polyols, are derived carbohydrates commonly used as artificial sweeteners. They are structurally similar to sucrose but are not fully absorbed in the small intestine, thus they contribute fewer calories and have a lower glycemic index.^10-11 Xylitol, a sugar alcohol of the five-carbon monosaccharide xylose, is commonly used in sugar-free gum and mints due to its ability to prevent tooth decay. It is also used in baking as a sugar substitute.^12-13 Sorbitol, a sugar alcohol of glucose, is commonly used in sugar-free candies, chewing gum, and diet drinks.¹⁴ Erythritol, a sugar alcohol of the four-carbon monosaccharide erythrose, is commonly used as a sugar substitute in foods and beverages.¹³ Mannitol, a reduction product of mannose, is less commonly used as a sugar substitute due to its laxative effects when consumed in large amounts. It is administered intravenously to reduce intracranial pressure in patients with traumatic head injuries due to its action as an osmotic diuretic.¹⁴ Isomalt, produced from hydrogenation of isomaltulose, is commonly used in sugar-free hard candies, chewing gum, and chocolate. It has a lower glycemic impact than common sugar and does not promote tooth decay.^15-16 Lactitol is a sugar alcohol derived from lactose and is commonly used as a sugar substitute in chocolate, baked goods, and ice cream.¹⁷ The key chemical characteristics of these sweeteners are summarized in Table 1.ErythritolErythritol is about 70% as sweet as table sugar (sucrose), but has almost no calories and does not raise blood glucose levels in the same way as sugar does.¹⁸ Erythritol is generally recognized as safe (GRAS) by the US Food and Drug Administration (FDA) and is approved for use in many countries around the world.¹⁹Sources and SynthesisErythritol occurs naturally in some fruits, such as watermelon, grapes, and pears, as well as in some fermented foods, such as soy sauce, wine, and cheese.²⁰ However, the vast majority of erythritol used commercially is synthesized from natural sugars via a fermentation process that involves using specific strains of yeast, such as Moniliella pollinis or Trichosporonoides megachiliensis Yarrowia lipolytica, Aureobasidium and Pseudozyma tsukubaensis. Once the fermentation is complete, erythritol is separated from the fermentation broth via filtration and purification using ion-exchange resins and activated carbon.^21-22 A small amount of erythritol is also synthesized endogenously in humans through the pentose phosphate pathway (Figure 1).²³Physicochemical PropertiesErythritol is a four-carbon sugar alcohol or polyol, which belongs to a group of organic compounds called derived carbohydrates. Its chemical formula is C4H10O4, and it has a molecular weight of 122.12 g/mol (Table 1). Erythritol is classified as a tetritol, meaning it contains four carbon atoms. It has a unique molecular structure that consists of four hydroxyl (-OH) groups, with one of the carbon atoms bonded to two of these groups. The remaining two -OH groups are located on the adjacent carbon atoms (Figure 2).^18,20 The chemical structure of erythritol gives it several unique properties. Its four hydroxyl groups allow it to bind with water molecules, giving it a cooling effect on the tongue when consumed. It is resistant to fermentation by oral bacteria, which reduces the risk of tooth decay. Erythritol has a white, crystalline appearance and is water-soluble.^24-25Digestion and AbsorptionErythritol is digested and absorbed differently than regular sugar (sucrose). When consumed, it passes largely unchanged through the digestive system and is absorbed into the bloodstream from the small intestine (Figure 3). Erythritol is passively absorbed through the intestinal wall and into the bloodstream, without the need for digestive enzymes.²⁶ Only 10% of erythritol is not absorbed and remains available for colonic fermentation and potential production of short-chain fatty acids (Figure 3). Therefore, it does not cause the digestive discomfort that is sometimes associated with other sugar alcohols, such as bloating or diarrhea, when consumed in moderate amounts.^13,25 Recent studies have demonstrated erythritol to cause a dose-dependent slowing of gastric emptying, increased sense of fullness and stimulation of the release of gut hormones including cholecystokinin (CCK), active glucagon-like peptide-1 (aGLP-1) and peptide tyrosine tyrosine (PYY).^27-28-29Effect on Gut MicrobiotaThe intestinal microbiome is crucial for human health as it contributes to metabolism, immunity and growth. It is influenced by diet, and its composition and function can change quickly. Erythritol is neither fermented by gut microbiota nor does its consumption have a substantial impact on it. Erythritol does not produce lactic acid or organic acids when incubated with gut bacteria and it is also non-fermentable by freshly collected human fecal microbiota.³⁰ In vitro testing of erythritol on gut microbiota representatives also did not show any impact on bacterial growth. However, when tested using a human gut microbial community, erythritol led to an increase in the production of butyric and pentanoic acids which are by products of bacterial fermentation.³¹Metabolism and ExcretionAbsorbed erythritol reaches the liver through the portal circulation but is minimally metabolized there. Instead, it enters the systemic circulation and is taken to the kidneys for excretion (Figure 3). A dose ranging study has shown a small amount of ingested erythritol to be converted into erythronate which has recently been identified as a product of oxidative stress resulting from metabolic imbalance.²⁶ A study in murine cell lines has shown erythritol’s ability to protect against non-alcoholic fatty liver diseases (NAFLD) due to its function as an antioxidant, via activation of nuclear factor E2-related factor 2 (Nrf2) signaling pathway which can lead to the inhibition of endoplasmic reticulum stress and hepatic lipid accumulation.³² Erythritol is primarily excreted from the body via the kidneys without undergoing significant metabolism. The rate of renal excretion of erythritol is dose-dependent, meaning that the more erythritol that is consumed, the more is excreted in the urine. Renal clearance of erythritol has been shown to be nearly 50% that of creatinine, indicating tubular reabsorption of erythritol by the kidney.²⁸Effects on Human MetabolismMultiple previous studies shown that consumption of artificial sweeteners including erythritol does not have any adverse impact on serum lipid profile.³³ The findings from a murine study suggested that erythritol can effectively mitigate metabolic disorders associated with a high-fat diet by increasing short-chain fatty acids (SCFA) and modulating innate immunity. Consumption of erythritol by mice on a high-fat diet showed a lowering of body weight, improved glucose tolerance, and increased energy expenditure as well as reduced hepatic fat deposition, smaller adipocytes, and improved inflammatory profile in the small intestine. Erythritol supplementation led to higher concentrations SCFA, specifically acetic acid, propanoic acid, and butanoic acid, in the serum, feces, and white adipose tissue, as well as reduced inflammation in the colon, suggesting a potential anti-inflammatory effect.³⁴ A recent study by Witkowsky et al. investigated the relationship between erythritol and the risk of atherothrombotic disease. They initially conducted untargeted metabolomics studies in a group of patients undergoing cardiac risk assessment and found that elevated levels of erythritol and other polyol sweeteners were associated with a higher risk of major adverse cardiovascular events over a three-year period. This association was subsequently confirmed in independent validation cohorts consisting of stable patients undergoing elective cardiac evaluation. Physiological levels of erythritol were also shown to increase platelet reactivity and promote thrombosis. Ingestion of erythritol was reported to cause significant and sustained increases in plasma erythritol levels, exceeding thresholds associated with heightened platelet reactivity and thrombosis potential.¹⁶ These findings highlight the potential risks associated with erythritol and underscore the need for further investigation into its long-term safety.³⁵Glycemic Control in Diabetes MellitusErythritol has been suggested to be beneficial for glycemic control in people with diabetes mellitus. Erythritol has a low glycemic index, thereby it does not cause spikes in blood glucose levels following ingestion, and does not adversely impact insulin sensitivity.^36-37-38 Furthermore, a study investigating the potential role of erythritol in controlling postprandial blood glucose levels in diabetes mellitus (DM) reported that erythritol administration in diabetic mice demonstrated anti-postprandial hyperglycemic effects. Erythritol was shown to competitively inhibit α-glucosidase, a carbohydrate digestive enzyme, through electrostatic interactions involving specific amino acid residues at the enzyme’s active site.³⁹ A recent interventional study in streptozocin induced diabetic mice showed that 8 weeks of erythritol administration caused reduction in body weight, fluid and water intake, blood glucose, serum aminotransferases, serum creatine kinase and creatinine. Serum insulin level, lipid profile, glucose tolerance ability and pancreatic β-cell function were also improved.⁴⁰ Another study in young mice showed prolonged erythritol consumption had no adverse effect on body weight, composition, or glucose tolerance despite substantially high blood erythritol levels.⁴¹Anti-Oxidant EffectsErythritol has been reported to possess the ability to scavenge free radicals and reduce oxidative stress.⁴¹ A recent study tested erythritol for its antioxidant and glucose-regulating properties. In vitro assays highlighted its radical scavenging activity and inhibition of alpha-amylase and alpha-glucosidase enzymes. Molecular docking confirmed its interaction with these enzymes. Erythritol administered to diabetic rats also resulted in improved glucose tolerance, reduced blood glucose levels, and enhanced antioxidant status.⁴² A recent murine study in diabetic models has also shown that erythritol reduced oxidative stress.⁴⁰Weight ManagementErythritol has been used for weight management due to its low caloric value and ability to provide sweetness without contributing to weight gain or obesity. Some studies have shown erythritol to reduce adiposity and weight gain.^18,43-44 Additionally, a satiating effect of erythritol has also been documented. Since the sweetness of erythritol is less than sucrose as compared to other NNS which have very high sweetness, erythritol is used at high osmolarity to achieve sweetness to sucrose, which allows it to increase satiety at common doses. Osmolarity modulates satiety-related hormones leading to reduced hunger independently of caloric content.⁴⁵ However, owing to the safety concerns raised by findings from recent studies, the World Health Organization (WHO) has advised against the use of NNS for controlling body weight. Recent guidelines state that long-term use of NNS is associated with an increased risk of type 2 diabetes, cardiovascular diseases and mortality.^46-47

Conclusion

Overall, erythritol is a low-calorie sugar substitute that has minimal impact on metabolism. It does not lead to spikes in blood glucose following ingestion, is not dependent on insulin, and has antioxidant properties. These properties make erythritol a potentially safe NNS for patients with diabetes mellitus. However, recent evidence on long term use of erythritol suggests its association with an increased risk of cardiovascular complications. This prompted WHO to issue a statement advising avoidance of the use of NNS for weight management owing to the concerns of elevated cardiovascular and metabolic risks associated with their long term use. In light of these recent developments, further studies are needed to fully understand the impact of erythritol on human health. There is a dire necessity for adequately powered double-blind, randomized controlled trials to assess the safety and investigate the dual nature of erythritol. In the interim period, caution should be exercised in the consumption of NNS including erythritol.

References

1. Lohner S, Toews I, Meerpohl JJ. Health outcomes of non-nutritive sweeteners: analysis of the research landscape. Nutr J. 2017;16(1):55. doi:10.1186/s12937-017-0278-x
   Article · PubMed · Google Scholar
2. Mejia E, Pearlman M. Natural alternative sweeteners and diabetes management. Curr Diab Rep. 2019;19(12):142. doi:10.1007/s11892-019-1273-8
   Article · PubMed · Google Scholar
3. Gardner C, Wylie-Rosett J, Gidding SS, et al. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2012;126(4):509-519. doi:10.1161/cir.0b013e31825c42ee
   Article · PubMed · Google Scholar
4. Czarnecka K, Pilarz A, Rogut A, et al. Aspartame: true or false? Narrative review of safety analysis of general use in products. Nutrients. 2021;13(6):1957. doi:10.3390/nu13061957
   Article · PubMed · Google Scholar
5. AlDeeb OA, Mahgoub H, Foda NH. Sucralose. Profiles Drug Subst Excip Relat Methodol. 2013;38:423-462. doi:10.1016/b978-0-12-407691-4.00010-1
   Article · PubMed · Google Scholar
6. Serrano J, Smith KR, Crouch AL, et al. High-dose saccharin supplementation does not induce gut microbiota changes or glucose intolerance in healthy humans and mice. Microbiome. 2021;9(1):11. doi:10.1186/s40168-020-00976-w
   Article · PubMed · Google Scholar
7. Arumugam B, Subramaniam A, Alagaraj P. Stevia as a natural sweetener: a review. Cardiovasc Hematol Agents Med Chem. 2020;18(2):94-103. doi:10.2174/1871525718666200207105436
   Article · PubMed · Google Scholar
8. Chi L, Bian X, Gao B, et al. Effects of the artificial sweetener neotame on the gut microbiome and fecal metabolites in mice. Molecules. 2018;23(2):367. doi:10.3390/molecules23020367
   Article · PubMed · Google Scholar
9. Bian X, Chi L, Gao B, Tu P, Ru H, Lu K. The artificial sweetener acesulfame potassium affects the gut microbiome and body weight gain in CD-1 mice. PLoS One. 2017;12(6). doi:10.1371/journal.pone.0178426
   Article · PubMed · Google Scholar
10. Msomi NZ, Erukainure OL, Islam MS. Suitability of sugar alcohols as antidiabetic supplements: a review. J Food Drug Anal. 2021;29(1):1-14. doi:10.38212/2224-6614.3107
    Article · PubMed · Google Scholar
11. Godswill AC. Sugar alcohols: chemistry, production, health concerns, and nutritional importance of mannitol, sorbitol, xylitol, and erythritol. Int J Adv Acad Res. 2017;3(2):31-66.
    PubMed · Google Scholar
12. Salli K, Lehtinen MJ, Tiihonen K, Ouwehand AC. Xylitol’s health benefits beyond dental health: a comprehensive review. Nutrients. 2019;11(8):1813. doi:10.3390/nu11081813
    Article · PubMed · Google Scholar
13. Wölnerhanssen BK, Meyer-Gerspach AC, Beglinger C, Islam MS. Metabolic effects of the natural sweeteners xylitol and erythritol: a comprehensive review. Crit Rev Food Sci Nutr. 2020;60(12):1986-1998. doi:10.1080/10408398.2019.1623757
    Article · PubMed · Google Scholar
14. Deis RC, Kearsley MW. Sorbitol and mannitol. In: Sweeteners and Sugar Alternatives in Food Technology. 2012:331-346. doi:10.1002/9781118373941.ch15
    Article · PubMed · Google Scholar
15. Pereira S, Hernandez Salazar LT, Laska M. Taste detection threshold of human (Homo sapiens) subjects and taste preference threshold of black-handed spider monkeys (Ateles geoffroyi) for the sugar substitute isomalt. Primates. 2021;62(2):389-394. doi:10.1007/s10329-020-00868-5
    Article · PubMed · Google Scholar
16. Ziesenitz SC. Basic structure and metabolism of isomalt. In: Grenby TH, ed. Advances in Sweeteners. Springer; 1996:109-133. doi:10.1007/978-1-4613-1229-1_6
    Article · PubMed · Google Scholar
17. Zhang W, Chen J, Chen Q, Wu H, Mu W. Sugar alcohols derived from lactose: lactitol, galactitol, and sorbitol. Appl Microbiol Biotechnol. 2020;104(22):9487-9495. doi:10.1007/s00253-020-10929-w
    Article · PubMed · Google Scholar
18. Mazi TA, Stanhope KL. Erythritol: an in-depth discussion of its potential to be a beneficial dietary component. Nutrients. 2023;15(1):204. doi:10.3390/nu15010204
    Article · PubMed · Google Scholar
19. Tiefenbacher KF. Technology of main ingredients: sweeteners and lipids. In: Tiefenbacher KF, ed. Wafer and Waffle. Academic Press; 2017:123-225. doi:10.1016/b978-0-12-809438-9.00003-x
    Article · PubMed · Google Scholar
20. Ibrahim O. Erythritol chemical structure, biosynthesis pathways, properties, applications, and production. IJMB. 2021;6(3):59-70. doi:10.11648/j.ijmb.20210603.11
    Article · PubMed · Google Scholar
21. Rzechonek DA, Dobrowolski A, Rymowicz W, Mirończuk AM. Recent advances in biological production of erythritol. Crit Rev Biotechnol. 2018;38(4):620-633. doi:10.1080/07388551.2017.1380598
    Article · PubMed · Google Scholar
22. Moon HJ, Jeya M, Kim IW, Lee JK. Biotechnological production of erythritol and its applications. Appl Microbiol Biotechnol. 2010;86(4):1017-1025. doi:10.1007/s00253-010-2496-4
    Article · PubMed · Google Scholar
23. Hootman KC, Trezzi JP, Kraemer L, et al. Erythritol is a pentose-phosphate pathway metabolite and associated with adiposity gain in young adults. Proc Natl Acad Sci U S A. 2017;114(21). doi:10.1073/pnas.1620079114
    Article · PubMed · Google Scholar
24. Regnat K, Mach RL, Mach-Aigner AR. Erythritol as sweetener: wherefrom and whereto? Appl Microbiol Biotechnol. 2018;102(2):587-595. doi:10.1007/s00253-017-8654-1
    Article · PubMed · Google Scholar
25. de Cock P. Erythritol functional roles in oral-systemic health. Adv Dent Res. 2018;29(1):104-109. doi:10.1177/0022034517736499
    Article · PubMed · Google Scholar
26. Bordier V, Teysseire F, Senner F, et al. Absorption and metabolism of the natural sweeteners erythritol and xylitol in humans: a dose-ranging study. Int J Mol Sci. 2022;23(17):9867. doi:10.3390/ijms23179867
    Article · PubMed · Google Scholar
27. Wölnerhanssen BK, Drewe J, Verbeure W, et al. Gastric emptying of solutions containing the natural sweetener erythritol and effects on gut hormone secretion in humans: a pilot dose-ranging study. Diabetes Obes Metab. 2021;23(6):1311-1321. doi:10.1111/dom.14342
    Article · PubMed · Google Scholar
28. Bornet FR, Blayo A, Dauchy F, Slama G. Plasma and urine kinetics of erythritol after oral ingestion by healthy humans. Regul Toxicol Pharmacol. 1996;24(2 pt 2). doi:10.1006/rtph.1996.0109
    Article · PubMed · Google Scholar
29. Teysseire F, Bordier V, Budzinska A, et al. The role of D-allulose and erythritol on the activity of the gut sweet taste receptor and gastrointestinal satiation hormone release in humans: a randomized controlled trial. J Nutr. 2022;152(5):1228-1238. doi:10.1093/jn/nxac026
    Article · PubMed · Google Scholar
30. Arrigoni E, Brouns F, Amado R. Human gut microbiota does not ferment erythritol. Br J Nutr. 2005;94:643-646. doi:10.1079/bjn20051546
    Article · PubMed · Google Scholar
31. Mahalak KK, Firrman J, Tomasula PM, et al. Impact of steviol glycosides and erythritol on the human and Cebus apella gut microbiome. J Agric Food Chem. 2020;68(46):13093-13101. doi:10.1021/acs.jafc.9b06181
    Article · PubMed · Google Scholar
32. Jin M, Wei Y, Yu H, et al. Erythritol improves nonalcoholic fatty liver disease by activating Nrf2 antioxidant capacity. J Agric Food Chem. 2021;69(44):13080-13092. doi:10.1021/acs.jafc.1c05213
    Article · PubMed · Google Scholar
33. Movahedian M, Golzan SA, Ashtary-Larky D, Clark CCT, Asbaghi O, Hekmatdoost A. The effects of artificial- and stevia-based sweeteners on lipid profile in adults: a GRADE-assessed systematic review, meta-analysis, and meta-regression of randomized clinical trials. Crit Rev Food Sci Nutr. 2021;63(21):5063-5079.
    PubMed · Google Scholar
34. Kawano R, Okamura T, Hashimoto Y, et al. Erythritol ameliorates small intestinal inflammation induced by high-fat diets and improves glucose tolerance. Int J Mol Sci. 2021;22(11):5558. doi:10.3390/ijms22115558
    Article · PubMed · Google Scholar
35. Cramer T, Gonder U, Kofler B. Plasma erythritol and cardiovascular risk: is there evidence for an association with dietary intake? Front Nutr. 2023;10:11955210. doi:10.3389/fnut.2023.1195521
    Article · PubMed · Google Scholar
36. Ishikawa M, Miyashita M, Kawashima Y, Nakamura T, Saitou N, Modderman J. Effects of oral administration of erythritol on patients with diabetes. Regul Toxicol Pharmacol. 1996;24(2 pt 2). doi:10.1006/rtph.1996.0112
    Article · PubMed · Google Scholar
37. Shin DH, Lee JH, Kang MS, et al. Glycemic effects of rebaudioside A and erythritol in people with glucose intolerance. Diabetes Metab J. 2016;40(4):283-289. doi:10.4093/dmj.2016.40.4.283
    Article · PubMed · Google Scholar
38. Noda K, Nakayama K, Oku T. Serum glucose and insulin levels and erythritol balance after oral administration of erythritol in healthy subjects. Eur J Clin Nutr. 1994;48(4):286-292.
    PubMed · Google Scholar
39. Wen H, Tang B, Stewart AJ, et al. Erythritol attenuates postprandial blood glucose by inhibiting α-glucosidase. J Agric Food Chem. 2018;66(6):1401-1407. doi:10.1021/acs.jafc.7b05033
    Article · PubMed · Google Scholar
40. Msomi NZ, Erukainure OL, Salau VF, Olofinsan KA, Islam MS. Comparative effects of xylitol and erythritol on modulating blood glucose, inducing insulin secretion, and reducing dyslipidemia and redox imbalance in a type 2 diabetes rat model. Food Sci Hum Wellness. 2023;12(6):2052-2060. doi:10.1016/j.fshw.2023.03.023
    Article · PubMed · Google Scholar
41. Ortiz SR, Field MS. Chronic dietary erythritol exposure elevates plasma erythritol concentration in mice but does not cause weight gain or modify glucose homeostasis. J Nutr. 2021;151(8):2114-2124. doi:10.1093/jn/nxab130
    Article · PubMed · Google Scholar
42. Soetan OA, Ajao FO, Ajayi AF. Blood glucose lowering and antioxidant potential of erythritol: an in vitro and in vivo study. J Diabetes Metab Disord. 2023;22(2):1217-1229. doi:10.1007/s40200-023-01237-x
    Article · PubMed · Google Scholar
43. Laviada-Molina H, Molina-Segui F, Pérez-Gaxiola G, et al. Effects of nonnutritive sweeteners on body weight and BMI in diverse clinical contexts: systematic review and meta-analysis. Obes Rev. 2020;21(7).
    PubMed · Google Scholar
44. Sylvetsky AC, Rother KI. Nonnutritive sweeteners in weight management and chronic disease: a review. Obesity (Silver Spring). 2018;26(4):635-640. doi:10.1002/oby.22139
    Article · PubMed · Google Scholar
45. Sorrentino ZA, Smith G, Palm L, et al. An erythritol-sweetened beverage induces satiety and suppresses ghrelin compared with aspartame in healthy nonobese subjects: a pilot study. Cureus. 2020;12(11). doi:10.7759/cureus.11409
    Article · PubMed · Google Scholar
46. Kmietowicz Z. Artificial sweeteners do not aid weight loss or improve health, says WHO. BMJ. 2023;381:1112. doi:10.1136/bmj.p1112
    Article · PubMed · Google Scholar
47. Pafili K, Roden M. The sugar-free paradox: cardiometabolic consequences of erythritol. Signal Transduct Target Ther. 2023;8(1):251. doi:10.1038/s41392-023-01504-6
    Article · PubMed · Google Scholar

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