A compound called erythritol, described as a natural sweetener and promoted as a “perfect and healthy” substitute for sugar, may be linked to elevated risks of heart attacks or strokes, researchers said in a study released on Monday.

People with diabetes or those who are obese are often advised to use products with sugar substitutes such as erythritol, which is about 70 per cent as sweet as sugar and made by fermenting corn.

Large-scale industrial production of erythritol during the 1990s has helped the sweetener emerge as a major sugar substitute, which is added to processed foods and is available via online shopping platforms in many countries, including India.

One online platform in India that sells erythritol powder describes it as a “perfect and healthy substitute for sugar and artificial sweeteners”.

The researchers, who studied over 4,000 people in Europe and the US, have found that people with higher erythritol levels in their blood are at increased risk of experiencing a major cardiovascular event such as a heart attack, stroke or death.

They also directly examined the effects of erythritol on whole blood and on platelets — a class of blood cells involved in clot formation — and observed that erythritol enhances the rate of platelet adhesion, the first step in clot formation.

“We need to make sure the foods we eat aren’t hidden contributors (to) cardiovascular disease which builds over time,” said Stanley Hazen, chair of cardiovascular and metabolic diseases at Cleveland Clinic in the US who led the study, published on Monday in the journal Nature Medicine.

In one component of the study, Hazen and his colleagues observed that when participants consumed artificially sweetened beverages with erythritol amounts found in many processed foods, their blood levels of erythritol increased for days to levels well above those seen to enhance clotting risks.

The findings, the researchers said, imply that dietary consumption of erythritol could put people at a potentially heightened risk of blood clots. This is of concern because the very people for whom non-sugar sweeteners are prescribed — people with diabetes, obesity or a history of cardiovascular disease — are typically themselves at risk of cardiovascular events.

The researchers said erythritol’s safety had been assessed earlier through short-term animal studies and human clinical studies with ingestion up to four weeks.

Based on these studies, erythritol was “generally recognised as safe” by both regulatory authorities of the European Union and the US. But a study from France, drawing on data from 103,000 participants, last September had flagged concerns about a potential direct association between artificial sweeteners and an increased risk of cardiovascular events such as heart attacks and strokes.

The French study had examined links to other sweeteners, including aspartame and sucralose. Hazen and his colleagues have called for further studies to more fully examine the impact of increased post-meal erythritol levels.

“It is important that further safety studies are conducted to examine the long-term effects of artificial sweeteners in general, and erythritol specifically, on the risks of heart attack and stroke, particularly in people eat higher risk of cardiovascular diseases,” Hazen said.