Published Sep 10, 2026 | 7:00 AM ⚊ Updated Sep 10, 2026 | 7:00 AM
Xylitol is an organic compound used as a food additive and sugar substitute. Pictured, xylitol crystals.
Synopsis: A new study has linked higher blood levels of xylitol with increased risk of heart attack, stroke and cardiovascular death. While the findings do not prove causation, Indian cardiologists say regular users, particularly those with diabetes or existing heart disease, should exercise caution and await stronger evidence.
Xylitol has built a reputation as a smarter sugar swap. Manufacturers put it in chewing gum, oral-care products, foods and drinks, and it draws people who want to cut sugar without the same rise in blood glucose.
A new study now questions whether the cardiovascular effects of xylitol have received enough scrutiny.
Researchers presented the findings at the European Society of Cardiology Congress 2026 in Munich on 29 August. The study drew on data from 17,710 participants across two cohorts, the Canadian Longitudinal Study on Ageing and EPIC-Norfolk.
People with xylitol levels in the highest quartile carried a far greater risk of major adverse cardiovascular events, defined as cardiovascular death, heart attack or stroke, than those in the lowest quartile.
In the Canadian cohort, the risk was 57% higher over six years, after adjusting for age, sex, smoking, lipid levels, diabetes and hypertension. In EPIC-Norfolk, it was 18% higher over 30 years. Data from the middle quartiles suggested a dose-dependent pattern, with event rates climbing alongside xylitol levels. The association held regardless of age, sex, body mass index, hypertension, diabetes or lipid levels.
Dr Marco Witkowski of Charité University Hospital in Berlin presented the research. He said the findings build on earlier work linking xylitol to blood clotting.
“In previous studies, we showed that xylitol can enhance the ability of platelets to form clots. We also found that high blood levels of xylitol were linked to cardiovascular events in high-risk individuals over three years. Here we studied whether xylitol increases cardiovascular events in a larger sample of the general population over a much longer follow-up.”
For Indian consumers, the findings deserve attention without triggering alarm, said Dr P R L N Prasad, Consultant Interventional Cardiologist, Gleneagles BGS Hospital, Bengaluru.
“This is a well-conducted study and something that cannot be brushed aside. A 57% higher risk of heart attack, stroke or cardiovascular death in people is a substantial signal,” he told South First. “That said, this doesn’t mean it must cause panic. This is observational data, and it can indicate practising caution.”
Xylitol occurs naturally in the body as a byproduct of glucose metabolism and appears in small amounts in some foods. Manufacturers add it to products at levels more than a thousand times higher than what the body produces on its own. Yet, researchers have studied its long-term cardiovascular impact in little depth until now.
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The study observed a link between blood xylitol levels and cardiovascular events, but it cannot prove that xylitol causes those events. The researchers adjusted for known risk factors, but observational data could still miss other differences between people, a problem researchers call residual confounding.
“We should be cautious here. This study shows a link, not proof that xylitol causes these events. People with higher xylitol levels might differ in other ways, for example with their overall diet and other health factors that the study couldn’t fully rule out,” Dr Prasad said. “What the research does is raise a strong enough concern that we now need proper follow-up studies, ones that track what actually happens when people consume set amounts of xylitol.”
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Platelets help blood clot when a vessel sustains damage. When platelets activate too readily, they can form clots that block blood flow and trigger a heart attack or stroke. Earlier research from Dr Witkowski’s team suggested that xylitol raises platelet reactivity, which may explain the new cardiovascular association.
Dr Prasad called the pathway plausible, though not yet proven.
“Xylitol may make platelets more reactive than usual, meaning they can clump together more easily. This could translate to a higher tendency to form clots, which is a pathway to heart attacks and strokes. But this still needs to be researched in actual cardiovascular events and platelet behaviour in the lab before nailing this down firmly.”
People often choose xylitol because it barely moves blood glucose compared with sugar, which draws those managing diabetes. But a lower glucose impact does not guarantee lower cardiovascular risk.
“Xylitol was embraced because it doesn’t spike blood sugar the way regular sugar does, which made it seem like an obviously smart swap, especially for people with diabetes. But ‘doesn’t raise blood sugar’ and ‘is good for your heart’ are two different things,” Dr Prasad said. “Cardiovascular risk is more complex than glucose control alone.”
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The question is relevant in India, where manufacturers increasingly market sugar substitutes as healthier alternatives to sugar. Xylitol holds approval as a permitted food additive under India’s food safety regulations, and the Food Safety and Standards Authority of India (FSSAI) listed it among permitted polyols with specified uses.
A separate FSSAI note on non-sugar sweeteners, prepared after the WHO’s 2023 guideline, referred to a conditional WHO recommendation against using such sweeteners to control weight or reduce non-communicable disease risk, while noting the evidence for undesirable effects like cardiovascular disease carried low to very low certainty. FSSAI’s scientific panel called for country-specific research, noting that the WHO review had not referenced Asian or Indian populations, and recommended moderating artificially sweetened products.
The new findings did not establish a specific risk for Indian consumers. But they strengthen the case for examining long-term sweetener consumption within Indian populations.
People with diabetes, obesity, hypertension or existing heart disease may find the findings relevant, since they already carry higher baseline cardiovascular risk and doctors often steer them toward sugar substitutes in the first place.
“These are exactly the people who are often steered toward sugar substitutes, and they also happen to be at higher baseline cardiovascular risk to begin with,” Dr Prasad said. “If xylitol independently adds to that risk, those who reach for it most often are the ones who can least afford an extra hit. Given India’s very high burden of diabetes and heart disease, I’d want to see more India-specific data before we keep recommending xylitol as freely as we have.”
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The study measured blood xylitol levels rather than a specific daily dose linked to rising risk, so consumers cannot translate the 57% figure into a set number of gum sticks or servings.
“Brushing your teeth with a xylitol-based toothpaste or chewing a piece of gum now and then is a world away from consuming xylitol-sweetened foods and drinks as a daily habit,” Dr Prasad said. “The study looked at blood xylitol levels, which likely reflect more regular, higher-volume exposure. So while we can’t say a precise ‘safe dose’ yet, dose and frequency certainly matter here.”
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The researchers stopped short of urging people to abandon xylitol altogether. Instead, they pointed to how little the field understands about the long-term cardiovascular effects of sweeteners now used at scale.
“Artificial sweeteners are consumed by people who think they are healthier than sugar, and they are generally regarded as safe by regulatory agencies,” Dr Witkowski said. “Our long-term findings 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.”
Professor Dan Atar, Member of the ESC Communication Committee, urged caution given the limits of observational research.
“In this observational work, it appears that xylitol has a negative long-term effect on cardiovascular events in the general population. As with all observational studies, causalities are difficult to infer, but this work shows that further studies are mandated into this societally important topic.”
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The evidence did not support eliminating every xylitol-containing product today. The study showed an association, not causation, and fixes no threshold at which intake raises risk. Researchers still need to confirm whether the link is causal, whether a dose-response relationship exists, and whether the pattern holds across populations.
For Indian consumers with existing cardiovascular risk factors, the immediate lesson may be to stop treating any single sugar substitute as a guaranteed solution for heart health.
“I wouldn’t tell people to panic and throw out every product having xylitol. But if you regularly consume xylitol-sweetened foods or drinks, especially if you already have diabetes, obesity, or heart disease, this is a reasonable moment to dial back,” Dr Prasad said. “Moderation and variety are your safest bet. There is little reason to assume that because something is marketed as sugar-free, it automatically carries no cardiovascular considerations.”
A single stick of xylitol-containing gum gives no reason for alarm. But the findings challenged the assumption that swapping sugar for xylitol automatically protects the heart. For a country carrying a heavy burden of diabetes and cardiovascular disease, the larger question may not be which sweetener counts as healthier, but whether India needs to cut its dependence on sweet-tasting food and drink altogether.
(Edited by Majnu Babu).
