Heart health: why low cholesterol is no longer the focus

By Lynda Searby

- Last updated on GMT

Foods such as fish, olive oil, vegetables and nuts, can increase ‘good’ cholesterol
Foods such as fish, olive oil, vegetables and nuts, can increase ‘good’ cholesterol

Related tags: Heart health, Atherosclerosis

Products aimed at lowering cholesterol have long been the focus of heart health reformulation – but a new trend is emerging.

Key points

Hugely complex, cardiovascular health is influenced by multiple factors – from family history, age and gender, to weight, blood pressure and physical inactivity.

Yet, to date, the majority of food and drink products targeting heart health have focused on lowering cholesterol.

In western Europe, the market for cholesterol-lowering packaged foods and beverages was worth a whopping $2bn in 2015, says Euromonitor.

A reason for this, suggests Victoria Taylor, senior dietician at the British Heart Foundation, is that cholesterol is one risk factor that can be modified.

“There are a number of factors that put people at higher risk of heart attack and stroke, and while you can’t control some, others you can, such as your cholesterol levels,”​ she says.

Cholesterol reduction is also a health platform that is well served by the ingredients industry. Oat beta-glucans and plant sterols and stanols are some of the established options for firms looking to target heart health.

However, a scientific consensus is emerging that suggests it is the relationship between the different types of cholesterol – rather than simply the level consumed – that has the most impact on health. This creates an opportunity for food manufacturers to move away from the crowded low-cholesterol market, and develop more varied products accordingly.

The limitations of focusing on cholesterol intake alone (return to top)

“There are a number of ingredients, including DSM’s OatWell oat beta-glucan, that carry approved EU health claims related to cholesterol reduction,”​ says Ruedi Duss, global marketing manager at DSM Nutritional Products.

However, cholesterol intake alone has its limitations as a focus for reducing the risk of heart disease. Dr Ioannis Zabetakis, lecturer on food lipids at the University of Limerick’s Department of Life Sciences, goes as far as dismissing total cholesterol as a “meaningless”​ measure.

“Since the 1990s, industry and the medical community has been preoccupied with lowering cholesterol. But, when you look at research such as the Seven Countries Study, there is no correlation between high levels of low-density lipoprotein [LDL] cholesterol and heart disease,”​ he says.

High-density lipoprotein (HDL) cholesterol and inflammation are far more important dietary markers than LDL or total cholesterol, he argues.

“As long as you have high HDL cholesterol, it doesn’t matter if you have high LDL cholesterol – it is the ratio that counts,”​ Zabetakis says.

Foods that feature in the Mediterranean diet pyramid, such as fish, olive oil, vegetables and nuts, can increase ‘good’ HDL cholesterol and reduce inflammation, a biochemical trigger in the development of cardiovascular disease, high blood pressure, cancer, HIV, type-2 diabetes and Alzheimer’s.

But how can manufacturers draw on this when developing products?

Fortifying products with ‘good’ food compounds (return to top)

One possibility is to fortify products with the active compounds in these ‘good’ foods.

Zabetakis’ work has identified polar lipid fractions in foods such as red wine, fish and olive oil as potential modulators of atherogenesis – the formation of abnormal fatty or lipid masses in arterial walls.

As an example, omega-3 fatty acids can lower the AA/EPA (arachidonic acid/eicosapentaenoic acid) ratio – a marker of cellular inflammation.

Antioxidants such as polyphenols and flavonols are also thought to have anti-inflammatory properties, he says.

“A decade ago, scientists thought antioxidants had a positive effect on heart health because they prevented oxidation. Now, there is strong evidence to suggest that they prevent inflammation,”​ Zabetakis says.

But translating these benefits into finished products is not always as simple as adding an ingredient.

“When you make a supplement or food product, you need to make sure the active compound is in the form in which it is present in nature,”​ he adds.

“For example, omega-3 needs to be structured as a polar lipid to reach the target tissue.”

Moving away from cholesterol reduction (return to top)

The view that dietary heart health interventions could focus on areas other than cholesterol reduction is also supported by ingredient makers.

“The reliance on cholesterol-lowering as a key determinant in the risk of cardiovascular disease has reduced and it is now well accepted by the medical profession that cardiovascular disease has a wide range of causes,”​ claims DSM’s Duss.

“Other heart health benefits include lowering blood pressure and the maintenance of healthy blood flow.”

DSM’s Fruitflow was the first ingredient to obtain an approved 13.5 health claim back in 2009. The positive assessment recognised the role of the tomato concentrate in maintaining normal platelet aggregation and contributing to healthy blood flow, and the ingredient has since achieved commercial success in Sirco juice.

Offering another heart health platform are EPA and DHA (docosahexaenoic acid), both of which have approved EU claims in relation to blood pressure reduction.

Dutch biotech firm BioActor has developed an ingredient that offers a “holistic”​ alternative to the cholesterol-lowering route to market.

Cordiart is a flavonoid-rich fruit extract that is said to “protect your endothelium”​, or, in other words, take care of your arteries.

The ingredient has been tested in two clinical studies, which found that 500mg daily protects the endothelium by maintaining arterial flexibility, reducing plaque formation and protecting arteries against inflammation.

“All those benefits come from the capacity of Cordiart to increase nitric oxide biosynthesis – the key molecule synthesised by the endothelium to regulate diverse functions,”​ says Marika Guillaume, marketing manager at BioActor.

Cordiart is already being used commercially in two supplement products – Capicor, marketed in Italy by Capietal, and NitroVasc with Cordiart from Life Extensions, on sale in the US.

The low success-rate of heart-health products (return to top)

While technically, there is scope to extend the heart health message beyond cholesterol lowering, in practice, the chances of heart health products succeeding tend to be slim.

“In food and beverage products, cardiovascular has been the scene of some of the biggest failures of the last 20 years,”​ says Julian Mellentin, consultant, author and director of New Nutrition Business.

He believes this is because if people have a condition or show signs of one, their doctor will prescribe drugs.

“They aren’t going to take the risk of prescribing something less potent – which is food,”​ he says.

If people do look to food for maintaining heart health, Mellentin says they will change their diet and go straight to the many natural foods that have a benefit, such as oats, oily fish, dark chocolate, dark fruit etc.

“Specially formulated foods can’t compete against these. So they have found no place, except for the sterol/stanol-based cholesterol-lowering niche.”

Data from Euromonitor supports this rather gloomy prognosis. In western Europe, retail value sales of packaged foods with a heart health message declined by 11% between 2010 and 2015 and are expected to fall by a further 2.3% by 2020.

Hope for the future (return to top)

Beverages performed slightly better, growing by $1M over that period and predicted to grow by 2% in five years.

In eastern Europe, the picture is more positive. Sales of packaged foods with a heart health positioning grew by 54% between 2010 and 2015, albeit from a very small base.

Euromonitor forecasts that this $124M market will grow by a further 17% by 2020.

However, with the cholesterol-lowering category reaching saturation point and seven million people affected by cardiovascular disease in the UK alone, other heart health platforms offer huge potential.

And while supplements and heart-healthy beverages may grab the lion’s share of market, food producers can stake their claim as well.

Related topics: Food Ingredients, Health & Nutrition

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