A large prospective analysis of 17,710 people presented at the European Society of Cardiology (ESC) Congress 2026 in Munich found that high circulating blood levels of xylitol, a sugar alcohol widely used in chewing gum, mints, jams, yoghurts, and oral care products, were associated with substantially higher rates of major adverse cardiovascular events over follow-up periods of up to 30 years.
What Xylitol Is and Where It Appears
Xylitol is a sugar alcohol produced naturally in the body as a minor byproduct of glucose metabolism. It also occurs in small amounts in fruits and vegetables. When xylitol is added to food and oral care products as a sweetener, the amounts used are often more than 1,000 times higher than the concentrations the body produces on its own. It is approved for use by the U.S. Food and Drug Administration and the European Food Safety Authority, and has long been promoted as a tooth-friendly sugar substitute.
Sugar alcohols as a category have attracted growing scrutiny since a 2023 study linked a related compound, erythritol, to cardiovascular risk. Xylitol belongs to the same chemical family.
What the New Study Found
The research, led by Dr. Marco Witkowski of Charite University Hospital in Berlin, Germany, drew on two large prospective observational cohorts: the Canadian Longitudinal Study on Aging (CLSA) and the European Prospective Investigation into Cancer (EPIC)-Norfolk study, with a combined total of 17,710 participants.
Participants were divided into four equal groups (quartiles) based on their fasting blood xylitol concentrations. The primary outcome was major adverse cardiovascular events, defined as cardiovascular death, myocardial infarction, or stroke.
Over six years, those with the highest xylitol levels had a 57% greater risk of major adverse cardiovascular events after adjustment for recognized cardiovascular risk factors including age, sex, smoking, diabetes, hypertension, and lipid levels. In the EPIC-Norfolk cohort, which had a follow-up period of 30 years, the risk of major adverse cardiovascular events was 18% higher in those with the highest levels compared with the lowest levels.
Data from the middle quartiles in both cohorts suggested a dose-dependent relationship: the higher the xylitol blood levels, the higher the cardiovascular event rate. The association held across age groups and sexes, and was independent of body mass index.
A Proposed Mechanism: Platelet Activation
The 2026 ESC presentation builds on a mechanistic study published in the European Heart Journal in 2024 by Witkowski and colleagues, which offered a possible biological explanation for the observed association.
That study found that xylitol enhanced multiple indices of platelet reactivity and promoted thrombus formation in animal models at concentrations found in fasting human plasma. A separate clinical intervention study in 10 healthy volunteers found that xylitol consumption increased platelet responsiveness.
Platelets are the small blood cells involved in clotting. When they become more reactive than normal, blood clots can form more readily inside blood vessels. A clot blocking an artery supplying the heart causes a myocardial infarction; one blocking a brain artery causes a stroke. If xylitol genuinely enhances platelet reactivity in everyday consumers, that could provide a plausible pathway connecting high blood xylitol to cardiovascular events.
What the Evidence Cannot Yet Answer
Several important limitations apply to these findings.
The ESC 2026 study is observational. It measured blood xylitol levels at a single point in time and then tracked outcomes, but it cannot establish that xylitol caused the cardiovascular events. People who eat more processed, sugar-free foods may differ from those who do not in ways that observational adjustments cannot fully account for. The body also produces xylitol endogenously, so high blood levels do not necessarily mean high dietary intake.
The 2024 mechanistic study involved high-risk cardiac patients and a small volunteer sample for the intervention arm, limiting how well its findings generalize to healthy people eating typical amounts of xylitol-containing foods.
Dr. Witkowski has noted: "Artificial sweeteners are consumed by people who think they are healthier than sugar and they are generally regarded as safe by regulatory agencies. 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."
ESC Communication Committee member Professor Dan Atar offered a cautious interpretation: "As with all observational studies, causalities are difficult to infer, but this work shows that further studies are mandated into this societally important topic."
Neither the FDA nor the EFSA has changed its safety guidance on xylitol in response to these findings.
Context: A Pattern Emerging Across Sugar Alcohols
The xylitol findings are not isolated. The same research group published a study in 2023 linking erythritol, another sugar alcohol found in many keto-friendly and low-sugar products, to increased cardiovascular event risk. Together, these studies suggest that the sugar alcohol class as a whole may warrant more rigorous long-term safety evaluation than has been conducted to date.
Regulatory approval for food additives typically relies on short-term toxicology studies. Long-term cardiovascular outcome data in large general-population cohorts represent a different, and harder, standard of evidence that few sweeteners have been formally evaluated against.
What This Means for Consumers Now
The current evidence does not support stopping use of xylitol-containing products. The association observed is statistical and observational, not a proven cause-and-effect relationship. Xylitol in chewing gum continues to be recommended by dental organizations for its role in reducing cavity-causing bacteria.
People with existing cardiovascular risk factors who use large amounts of xylitol-containing products may wish to discuss this evidence with their doctor or a registered dietitian, particularly as researchers have noted that the amounts added to food products have been increasing.
The researchers have called for randomized controlled trials to determine whether reducing xylitol intake lowers cardiovascular risk. Until that evidence exists, moderation is reasonable, particularly for those consuming xylitol from multiple sources simultaneously.
References
- Witkowski M, et al. The association of Xylitol and incident cardiovascular events: the CLSA and EPIC-Norfolk cohort studies. Presented at ESC Congress 2026, Munich, Germany, 29 August 2026. European Society of Cardiology press release.
- Witkowski M, Nemet I, Li XS, et al. Xylitol is prothrombotic and associated with cardiovascular risk. Eur Heart J. 2024;45(27):2439-2452. doi: 10.1093/eurheartj/ehae244