Getting To The Heart Of The Matter

Thursday, September 21st, 2017

Cardiovascular disease is the number one cause of death globally. While the statistics are alarming, most cardiovascular diseases can be prevented by reducing risk factors via lifestyle and diet changes. Everyday foods can also be fortified with the right ingredient to lower cholesterol, but how? By Dr Kai Lin Ek, regional manager, Scientific Marketing, BASF Asia Pacific

Life In The 21st Century

Health and longevity in this technologically advanced century has been the focus and discussion of international health organisations as well as food companies given the increase of life expectancy and better educated, highly-engaged consumers. The approach has been multi-faceted, from the fortification of everyday foods, to pharmaceutical solutions, through to medical breakthroughs in health care.

An increasing number of consumers are veering towards preventive measures instead of treatment, looking at convenient, fortified food and beverage solutions that are easy to adopt and sustainable while also delivering a health benefit.

And Now, The Bad News

However, despite all the medical advancement of this age, the magnitude of cardiovascular diseases (CVDs) continues to accelerate and is the leading cause of death globally. CVD is a general term for a disease of the heart or blood vessels, and according to the World Health Organisation (WHO), CVD is responsible for over 17.5 million deaths in 2012 (31 percent of total deaths).

In Asia Pacific, the numbers are alarming; in China they account for 45 percent of total deaths, in India 26 percent, in Indonesia 37 percent and 31 percent in Australia. Even in Japan, a country which boasts the longest average lifespans, an increasing percentage of premature deaths are due to CVD.

Although heart disease is the leading cause of death, it may not be your fate—that is, if you can take good care of yourself and manage the risk factors associated with this disease. That is the bottom line from a population analysis paper published in the Journal of the American Medical Association.

The analysis showed that those with an optimal risk factor profile—non-smoker, no diabetes, normal blood pressure and total cholesterol less than 180 mg/dL (~4.65mmol/L)—had a much lower lifetime risk of CVD.

Specifically, men and women with optimal profiles at age 55 were found to be almost 30-50 percent less likely to develop CVD than those with two or more major risk factors. They also lived an average of 14 years longer free of CVD.

Cholesterol, Triglycerides And Your Health

So what is your risk profile? Part of assessing yourself is understanding some of the figures on your blood test. You will usually be required to fast overnight before a blood sample is taken and the report will feature “lipid profile/panel” which generally includes the following:

  What it is Ideal blood lipid levels for healthy adults (mg/dL or mmol/L)*
Total cholesterol (TC) The total amount of cholesterol in your blood. < 200 mg/dL
< 5.0 mmol/L
Low density lipoprotein (LDL) cholesterol Also called “bad” cholesterol. These are smaller fatty particles that are more prone to cause arterial inflammation and fatty deposit build-up in arterial walls. <3.0 mmol/L
High density lipoprotein (HDL) cholesterol Also called “good” cholesterol. These are larger, more buoyant fatty particles that carry blood cholesterol back to the liver, and also help reduce fatty deposits in the arteries. >60 mg/dL
>1.0 mmol/L (men)
>1.2mmol/L (women)
Triglycerides (TG) This represents your body's ability to clear fat from the blood after a meal. <2.0 mmol/L 

Elevated cholesterol and TG levels are major risk factors for CVD; elevated TG concentration is associated with increased frequencies of CVD in men (14 percent) and women (37 percent).

Likewise for cholesterol levels, a 10 percent reduction in serum cholesterol in 40-year old men has been reported to result in a 50 percent reduction in heart disease within five years; the same reduction in serum cholesterol for 70-year old men can result in an average 20 percent reduction in heart disease occurrence within five years.

Changing The Way We Battle Cholesterol— Without A Single Drug In Sight

Back in the nineties, if you were worried about your cholesterol levels or heart health, you focused on the fats you ate—cutting back on foods which contained ‘bad’ saturated fat such as bacon and butter while allowing a little polyunsaturated oils in its place. Or, some even followed the Mediterranean diet approach by swapping all fats for olive oil.

Things have not changed that much as diet and lifestyle factors remain the cornerstone for managing raised blood fats to prevent cardiovascular disease. However, there have been some breakthroughs in the nutrition world that are changing the way heart disease is being treated. Research has shown that a specific combination of heart-healthy foods can be as effective as cholesterol-lowering medication your doctor may prescribe.

The Dietary Portfolio Approach

In a 2002 study, University of Toronto researchers showed that individuals already on a low saturated fat, low cholesterol diet, could get an even larger decrease in blood cholesterol levels if they added a ‘portfolio’ of specific foods. After four weeks, there was considerable reduction in ‘bad’ or low-density lipoprotein (LDL) cholesterol of around 30 percent, on par with a reduction expected from a cholesterol-lowering statin drug such as lovastatin and simvastatin.

Then in a larger follow-up study, the diet was put in a head-to- head test against the low-saturated fat diet traditionally recommended by the American Heart Association and a commonly prescribed statin drug (taken with a very low saturated fat diet).

Again, the Portfolio approach was the clear winner with an impressive lowering of LDL cholesterol by 29 percent; the low-fat diet plus statin lowered it by 31 percent, while the low-fat diet alone reduced levels by only eight percent. As an added benefit, the portfolio approach also lowered blood pressure and did not depress the level of beneficial high-density lipoprotein (HDL) cholesterol.

The four cholesterol-lowering foods in the diet included plant sterols, soluble fibres, soy protein and nuts. According to the researchers, each of these foods has an individual mode of action that may contribute to a combined effect. These four groups of cholesterol-lowering foods can be integrated into a typical 2,000 calorie-diet a day as follows:


Plant sterols: 2-3 grams a day, from some foods enriched in plant sterols such as spreads, yoghurts, milks and some breakfast cereals.


Soy protein: 45 grams a day, such as 100g of tofu or tempeh or a cup of soy milk.


Viscous or soluble fibre: Two servings a day of foods such as oatmeal, psyllium-enriched cereals, barley, and vegetables such as okra and eggplant.


A handful of nuts: 30 g each day—approximately one handful.

The only hitch in this diet was that, largely relying on plant food, it was a vegetarian one.

However, in 2006, a non-vegetarian variation of this diet was revealed. Wanting to test the diet based on real-world conditions, researchers followed 55 people around for one year as they purchased foods and prepared their own meals.

Results revealed that the groups who followed the diet most closely (about 33 percent) achieved the best results— decrease in LDL cholesterol of 20 percent or higher. Also, every group achieved a decrease in cholesterol by at least 10 percent. Furthermore, the study also showed that this dietary pattern could be sustained over a longer period of time of a year.

To provide greater clarity, the researchers also looked into the contributions of the individual components. In this 2008 study, participants followed the portfolio approach over a longer period of 80 weeks including all four components except between weeks 52-62.

What they observed was that when plant sterol was eliminated, the mean LDL cholesterol reduction was only nine percent compared to a mean LDL cholesterol reduction of 15 percent on the full diet. This meant that the contribution of plant sterols alone accounted for more than a third of the LDL reduction in the portfolio diet.

What is great about these studies is that it gives evidence to support a positive message “in with the good”, rather than always having to tell people what they need to give up to lower their cholesterol. If you have mildly elevated cholesterol, a heart-healthy diet that includes the elements of the portfolio diet may be all that is needed get cholesterol under control— no prescription necessary.

So, What Are Plant Sterols And How Do They Work?

Plant sterols are a group of natural, bioactive plant compounds with steroid structures similar to cholesterol. Like how cholesterol is an important compound in cell membranes in humans and animals, plant sterols play important structural roles in plant membranes and are abound in seeds and oils derived from them. The occurrence of sterols is widespread in plant foods at the level of 0.1-0.5 percent and the main food sources of plant sterols include vegetable oils, spreads, breads, cereals and vegetables. These contribute 50-80 percent of plant sterol intake, with fruits adding a further 12 percent.

Cholesterol in the blood comes from two main sources: the liver synthesises around 70 percent of this in which the cholesterol is released with the bile into the gut and 30 percent is derived from the diet, mainly from animal products. The cholesterol from these two sources both arrive at the gut and since plant sterols have similar chemical structures to cholesterol, they are able to compete with cholesterol for absorption in the gut reducing cholesterol reabsorption, and in turn lower blood cholesterol levels.

In general, the intake of naturally occurring plant sterols from the diet is about 200–400 mg per day. This amount is not quite enough to achieve the cholesterol lowering benefits that plant sterols confer. When the results of more than a hundred randomised clinical trials on plant sterols were summarised, it was clearly established that a daily intake of 1.5-3.0 g/s plant sterols reduces LDL-cholesterol by 7-12.5 percent.

Heart Health—Recommendations

In summary, there is a high level of evidence for the use of plant sterols in reducing CVD risk and are among the very few food ingredients for which health claims referring to the reduction of disease risk have been permitted, for example in the European Union, US and in Asia Pacific, namely Japan, China, Singapore and Australia.

Plant sterols can be considered for the reduction of LDL cholesterol if your cholesterol is only mildly elevated or if you are at intermediate to high risk but do not wish to use, or cannot tolerate, other cholesterol-lowering medications. In addition, plant sterols can be also be used in combination with statins for additional reduction of LDL cholesterol.

Therefore, to stay heart healthy, the current guidelines from the European Atherosclerosis Society and the European Society of Cardiology summarises it well: “There are multiple effective measures and these include the replacement of saturated fat and trans fat with mono- and polyunsaturated fat, the increase of dietary fibre, and omega-3 fatty acids and the intake of phytosterol-enriched foods.”