The Cleveland Clinic has revealed research that found higher amounts of the sugar alcohol xylitol are associated with an increased risk of cardiovascular events like heart attack and stroke.

The findings of the team, led by Dr. Stanley Hazen, were published Thursday in the European Heart Journal.

Xylitol is a common sugar substitute used in sugar-free candy, gums, baked goods and oral products like toothpaste. Over the past decade, the use of sugar substitutes, including sugar alcohols and artificial sweeteners, has increased significantly in processed foods that are promoted as healthy alternatives, according to a media release from the Cleveland Clinic.

The same research team found a similar link between erythritol and cardiovascular risk last year. Xylitol is not as prevalent as erythritol in keto or sugar-free food products in the U.S. but is common in other countries.

“This study again shows the immediate need for investigating sugar alcohols and artificial sweeteners, especially as they continue to be recommended in combatting conditions like obesity or diabetes,” said Dr. Hazen, Chair of Cardiovascular and Metabolic Sciences at Cleveland Clinic’s Lerner Research Institute and Co-Section Head of Preventive Cardiology in the Heart, Vascular & Thoracic Institute.

Dr. Hazen says the findings don’t mean that people should throw out their toothpaste if it has xylitol in it, but people should be aware that consumption of a product containing high levels could increase the risk of blood clots.

The new study found that high levels of circulating xylitol were associated with an elevated three-year risk of cardiovascular events in an analysis of more than 3,000 patients in the U.S. and Europe.

One-third of patients with the highest amount of xylitol in their plasma were more likely to experience a cardiovascular event.

To confirm the findings, the research team conducted pre-clinical testing and found that xylitol caused platelets to clot and heightened the risk of thrombosis. Researchers also tracked platelet activity from people who ingested a xylitol-sweetened drink versus a glucose-sweetened drink and found that every measure of clotting ability significantly increased immediately following ingestion of xylitol but not glucose.

The researchers are urging further studies assessing the long-term cardiovascular safety of xylitol.

The report notes that while clinical observation studies demonstrate an association between xylitol and cardiac issues, they do not necessarily link the sweetener to the cause of such issues.

People are being urged to talk to their doctor or a certified dietitian to learn more about healthy food choices and for personalized recommendations.

The study was supported in part by the National Institutes of Health and the Office of Dietary Supplements.