Currently 2.3 million people in the UK are living with heart disease, at an annual cost of £953m to the NHS. We’re involved in an on-going battle to try to reduce it.
For those in the health industry, the link between high cholesterol and heart disease is well known. Meta-analyses, genetic studies and randomised controlled trials totalling more than 2 million participants, 20 million person-years of follow up and 150,000 cardiovascular events demonstrate a close correlation between cardiovascular disease (CVD) and high levels of low-density lipoprotein cholesterol (LDL-C).
What’s less known is the impact plant stanol esters can have on lowering cholesterol.
Changing behaviours of those at risk of heart disease
GPs and practice nurses are key influencers when it comes to persuading people to change their lifestyle to improve their health. So it’s vital to make sure these healthcare professionals (HCPs) have the facts – and materials – they need to support this.
In a survey we undertook this year of HCPs on behalf of Benecol, we found that persuading patients to improve their diet change is a key priority when it comes to reducing cholesterol – along with cutting smoking and increasing physical exercise.
We discovered that while the HCPs are well aware of the importance of cutting saturated fat and sugar, and want to communicate about healthier eating to patients, they are less likely to know the impact plant stanol esters can have on lowering cholesterol.
Plant stanols and sterols can reduce cholesterol by up to 10% in two to three weeks.
Over 70 clinical studies have demonstrated that plant stanols effectively lower cholesterol.
How do they work?
Consumption of foods with added plant stanols or sterols (1.5 – 2.4g/day) should take place at meal times. Mixing with food and digestive juices results in the displacement of dietary and biliary cholesterol in the fat absorption pathways in the gut.
Cholesterol absorption is reduced by about 50% and studies have shown a dose-dependent reduction in circulating LDL-C of 7 – 10% on average.
Cholesterol begins to lower immediately. With continued use full reduction is achieved within 2 – 3 weeks and is sustained over the longer term. What’s more, if used alongside statin therapy, plant stanols lower LDL-C by an additional 10% – an effect greater than doubling the statin dose, which, at best, only provides a 6% additional LDL-C reduction.
Plant stanols provide an easy diet-based solution to all hypercholesterolaemic patients, including those with mildly elevated serum cholesterol level. They would also be especially recommended for those averse to taking statins, anxious to keep statin doses low, or at higher risk from potential statin-related side effects.
They are recommended by a number of prevention and treatment guidelines as part of a cholesterol-lowering diet, including the European Society of Cardiology, the Atherosclerosis Society, UK JBS3 guidelines and the World Health Organisation.
Our holistic communications approach to help reduce cholesterol
As a result of our research, we created a holistic communications approach in association with HEART UK – the Cholesterol Charity and leading heart health dietary specialists – to support practice nurses and GPs, and their patients.
- We created information sheets for the healthcare professionals with full information about dietary changes patients can make to lower LDL-C levels. Included in this was the latest evidence not only on plant stanols but on all dietary recommendations for lowering LDL-C.
- Alongside this were fact sheets for patients, clearly explaining the problem of high cholesterol and the lifestyle changes that would have a significant impact on their health.
We highlighted the key motivators for patients – the fact that a small change would bring quick results.
Companies are accused of only being interested in their profits – and of course, they are ultimately accountable to stakeholders, so money is always going to come into it.
But what we found with Benecol’s approach is that they are genuinely determined to help combat the huge problem of heart disease that exists. Reaching out to health professionals they wanted to understand issues fully and how best to communicate lifestyle change – not just dietary, which would help promote the message of plant stanols, but also more widely, include all dietary matters as well as smoking and exercise.
The materials tell the whole story, educating the professionals and patients and then leaving it in their hands how to act.
Health professionals responsible for communicating heart health cholesterol lowering advice can order these packs by calling the Benecol Helpline 0800 018 4010 and asking for your health professional Benecol Toolkit ‘Small Change, Big Results’ pack.
Each week we analyse some of the hot headlines in health and nutrition news. This week cheese; obesity & diabetes/cancer risk; and sugar reduction in Kellogg’s cereals.
HEADLINE 1: A piece of cheese a day keeps the doctor away
Picked up in the news this week by the Daily Mail, The Express, The Sun, The Independent and The Guardian is the suggestion that eating cheese could reduce the risk of heart attacks and strokes.
This is based on a meta-analysis of studies which concluded that consuming 40g of cheese per day reduced the risk of heart attack by 14% and stroke by 10%.
Behind the headlines: the Nutrilicious dietetic view
While cheese lovers are likely to have rejoiced, there are limitations to the research on which the headlines were based. The lack of randomised controlled trials included within the meta-analysis means that no causal relationship can be assumed between eating cheese and risk of heart disease. There are far too many factors which could interfere with the results.
Interestingly, there are previous large studies that have found no association between heart disease and eating cheese. Again, it can be hard to prove that it is the cheese eating that is causing the effects.
The harm that eating too much cheese can cause to health is well documented. Although it is a good source of protein, calcium, phosphorous and vitamin B12, it can also be high in saturated fats. Having too much saturated fat in the diet can increase levels of LDL cholesterol in the blood, which is an established risk factor for heart disease. A 30g portion of cheddar cheese (a matchbox size) contains 6.5g saturated fat (over a quarter of the reference intake for saturated fat – 20g). It can also be quite easy to go above this recommended portion size.
Some cheeses can be high in salt and there is a lot of evidence to show that too much salt can increase the risk of high blood pressure, another risk factor for cardiovascular disease.
Cheese can be enjoyed as part of a healthy diet if eaten in moderation and can provide a valuable source of various nutrients. Sticking to the recommended 30g portion size and opting for lower fat varieties such as lighter/reduced fat cheddars, cottage cheese and ricotta, can help ensure we don’t exceed our recommended maximum amount of saturated fat.
Moreover, foods such as low-fat yogurts and lower fat milks can also provide us with calcium and protein (two of the key nutrients found in cheese) but provide less saturated fats (as well as fewer calories, which would be helpful for those trying to lose weight).
For more information, go to British Heart Foundation and the NHS
HEADLINE 2: Diabetes is a key factor in WORLDWIDE cancer surge
The Express, The Sun and The Daily Mail reported on a finding that diabetes and obesity have been linked to causing cancer.
Researchers found that people with a high BMI (defined as above 25kg/m) who also had diabetes were behind 5.6% of new cancer cases globally, affecting 792,600 people in 2012. The method used was through assessing the increase in new cases of 18 cancers based on the prevalence of diabetes and high BMI in 175 countries (using data about BMI and diabetes in 2002 and cancers recorded in 2012).
Behind the headlines: the Nutrilicious dietetic view
This is an interesting study as it is the first study to have looked at the combined effect of having diabetes and obesity on cancer risk. Whilst the headlines alert us to the finding that over 5% of cancers were attributable to diabetes and cancer, there were significant differences between various groups of people, regions and types of cancer which should be noted. These are discussed in the original study. For example, cancers attributable to diabetes and being overweight were nearly twice as common in women (496,700 cases) as they were in men (295,900 cases).
It should be noted that there were limitations of the study. It is questionable whether the 10-year gap used between recording diabetes and high BMI to cancer incidence is entirely appropriate to enable conclusions to be drawn, as recognised by the researchers.
What we understand already is that obesity is certainly a risk factor for cancer. Analysis conducted by the World Cancer Research Fund has found that being overweight (BMI 25kg- 29.9/m) or obese (BMI 30kg/m and above) increases the risk of 11 types of cancer.
The Diabetes UK website outlines the link between diabetes and cancer. Some of the complications associated with diabetes can increase the risk of cancer. However, well-managed diabetes can help reduce the risk of any complications. Diabetes UK have given their thoughts on this study and stated that, “Diabetes doesn’t directly cause cancer, but this study adds to the evidence that having diabetes can increase the risk of certain types of cancer.”
The main message to take home from these headlines is that the increasing prevalence of obesity and diabetes may lead to an increase in risk of certain cancers. Maintaining a healthy weight, eating well, keeping physically active, not smoking, and not exceeding the government guidelines for alcohol consumption can all help lower the risk of diabetes and cancer.
For more information, go to Diabetes UK and WCRF
HEADLINE 3: Kellogg’s to cut sugar in kids’ cereals by up to 40%
Also in the news this week is the announcement that Kellogg’s will cut the sugar levels in children’s cereals by up to 40%. This was reported by the BBC, the Daily Mail, the Evening Standard, The Times and The Sun.
Kellogg’s have said they will reduce sugar levels by 20-40% by the middle of 2018 for Coco Pops, Rice Krispies and Rice Krispies Multi-Grain Shapes. They are also going to stop making Ricicles from January 2018, due to the amount of sugar in the cereal, and are putting a stop to on-pack promotions aimed at children on Frosties.
Behind the headlines: the Nutrilicious dietetic view
This is a very positive and encouraging move from Kellogg’s as the battle to reduce sugar consumption in the UK continues.
In March this year, officials at Public Health England called on food firms to cut sugar by 5% by the end of this year and by 20% by 2020. The Scientific Advisory Committee on Nutrition currently advise that free sugar intake in the UK should account for no more than 5% of our daily energy intake. Advice for the different age groups is as follows:
- Children 4-6 years – no more than 19g free sugars per day (5 teaspoons)
- Children 7-10 years – no more than 24g free sugars per day (6 teaspoons)
- Children 11 years + and adults – no more than 30g free sugars per day (7 teaspoons)
Although not the highest source of sugar in our diets, cereals do contribute to daily intake, with the most recent National Diet and Nutrition Survey highlighting that cereals are responsible for 5% of the added sugar intakes of adults and 6-8% of that of 4-10-year olds and teens. In our blog post last year A Health Check on New Breakfast Opportunities we discussed the need for more breakfast options to offer lower sugar choices and so this certainly is a positive step forward. With gradually a lesser number of options available that are high in sugar, it may be less overwhelming for consumers to make healthier choices.
Here is how much sugar is currently in the Kellogg’s products and how much they are to be reduced by:
- Coco Pops – 9g sugar per 30g serving. To be reduced to 5.1g per 30g serving (40% reduction, changing from about 2 teaspoons of sugar to just over 1 teaspoon).
- Rice Krispies – 3g sugar per 30g serving. To be reduced to 2.4g per 30g serving (20% reduction, changing from ¾ teaspoon of sugar to a little under 2/3 teaspoon of sugar).
- Rice Krispies Multi-Grain Shapes – 6.3g sugar per 30g serving. To be reduced to 4.5g per 30g serving (30% reduction, changing from about 1.5 teaspoons of sugar to just over 1 teaspoon)
A step forward to reduce the sugar content of any foods available on the market can only surely be a positive one.
For more information, go to Kellogg’s – Sugar and Breakfast Cereal and SACN 2015 – Carbohydrates and Health Report
The European Commission Group on Nutrition and Physical Activity is a high-level group covering all matters related to nutrition and physical activity for tackling obesity in children. They’re creating frameworks to address the health problems endemic in every country in the Western world. As health professionals, we’re delighted.
Government representatives from all EU countries, plus Norway and Switzerland, attend the group. The UK government is represented by the Department of Health.
The driver for the obesity problem to be taken seriously at last? The ever-growing drain on economies caused by obesity-related health problems: from the cost of healthcare provision to increasing numbers of sick days taken by workers.
Meeting at least three times a year, they share experiences and strategies for tackling obesity. To date, they have published an EU Action Plan on Childhood Obesity for 2014-2020, aiming to reduce exposure of foods with high saturated fat, sugars and salt (HFSS), as well as increasing exercise.
They’ve also set frameworks that can be taken up by any country on reformulation of commercial products, focusing on reductions in HFSS. Food categories currently under review are:
- Sugar-sweetened beverages
- Sweetened dairy and dairy imitates
- Breakfast cereals
- Bread and bread products
- Bakery products (for example cakes and cookies)
- Ready meals (including ready to prepare products like dry soups, dried mashed potatoes, rice mixture)
- Savoury snacks
- Sauces (including ketchup)
- Sugars sweetened desserts, ice cream and topping
- Canned fruits and vegetables
- School food offer
- Catering meals
Interestingly, baby foods are not yet covered, although it would not be a surprise if this is the next step once Public Health England’s (PHE) sugar reduction strategy for this category gets under way end of this year.
The EU-specific Commercial Food Reformulation Framework for Added Sugars is set – and is really a reflection of the PHE’s sugar reduction strategy:
- They have proposed benchmarks for each of the above food categories.
- They have recommended that countries set an added sugars reduction benchmark of a minimum of 10% by 2020 (vs. 2015 baseline levels).
- They have used the same definition for ‘added sugars’ as PHE, including fruit juice, fruit juice concentrate and fruit purees.
The frameworks are guidelines with minimum requirements, rather than exact rules every country is bound to. This makes sense – countries can choose to apply them as appropriate, taking into consideration different consumer attitudes to food and nutrients.
So, for example, in the UK, the first nine food categories to come under the sugar reduction targets also used 2015 data as baseline, but we went to 5% reductions by year one and 20% reductions by year 2020.
The Group next meets at the end of the month, with an evolved nutrition labelling initiative one of the points on the agenda. Major multi-national companies are on board, including The Coca-Cola Company, Mars, Mondelez, Nestle, PepsiCo and Unilever.
Let’s hope that what comes out of it actually makes an impact, that it’s not just words no one follows up on. We’re certainly moving in the right direction.
Over the last few years, coconut products – in particular coconut oil – have become very trendy. Celebrities such as Gwyneth Paltrow and Angelina Jolie are enthusiastic consumers of the oil and one in 10 UK 16–24 year-olds currently buys it. Sales rose from around £1 million to £16.4 million in the three years up to 2016, according to the consumer research group Kantar Worldpanel.
The main driver? The popular belief that coconut oil or fat* is more nutritious than other types of fats.
But do the alleged health benefits stand up to scrutiny?
A summary of our assessment
Around 87% of coconut oil is saturated fat – more than in lard or butter. Despite what advocates of a ‘low carb, high fat’ diet suggest, scientific reviews and respected health organisations including the NHS and the British Nutrition Foundation concur that consuming too much saturated fat overall is bad for us.
As a result, the growing consumption of coconut products – especially coconut oil – is of great concern to those who work with scientific evidence-based nutrition. Coconut’s popularity is likely to add to the burden of obesity and heart disease, not reduce it.
So coconut products should be sold as an indulgent product, not a health food. Manufacturers, retailers and the media need to stop exploiting any health associations.
The scientific evidence on coconut oil
Coconut is bursting with cholesterol-raising saturated fats. Some companies marketing coconut products over-simplify what is a very complex topic. They assert that medium-chain length saturated fatty acids (MCTs) in coconut oil can actively protect heart health.
However, while some studies suggest some MCTs in isolation might have benefits, coconut oil contains a mix of fatty acids. Focusing on any benefits of a few MCTs while ignoring the detriments of the other fatty acids is at the least misleading and at worst very damaging for consumer health.
Saturated fats – a complex story
There are over 30 different types of saturated fatty acids. While there’s good evidence that some will have little, if any, effect on cholesterol, three in particular have been proven beyond a doubt to elevate cholesterol levels and are all contained in coconut oil in high amounts.
- Lauric acid, an MCT, makes up 14% of coconut oil (and is also found in palm kernel oil and cow’s and goat’s milk).
- Myristic acid, a long chain fatty acid (LCT), makes up 20% of coconut oil, and is in palm kernel oil and butter.
- Palmitic acid, an LCT, is found mainly in palm kernel oil, meat and full cream dairy milk and products, but also makes up 8% of coconut oil.
Clinical studies have consistently demonstrated that coconut oil increases total and LDL cholesterol – directly linked to higher cardiovascular disease risk. Despite some (not all) studies also demonstrating an increase in HDL (‘good’) cholesterol through the consumption of coconut oil, this is common with other saturated fats and does not negate the effect on LDL cholesterol.
Coconut products – putting statistics into context**
- Highest of all are the coconut oils and coconut butter, which are higher in saturated fat than any other commonly eaten food. Most coconut oils contain just short of nearly 90% saturated fat, compared with butter at 52%. Just 1½ tablespoons will provide the entire recommended daily intake of saturated fat.
- Four 100% natural coconut yogurt alternatives are currently on the market as ‘healthy alternatives’. Three of these provide between 17% and 20.5% saturated fat; the other a more modest 4.2% – which is still higher than full cream dairy yogurt. So an average 125g serving of three out of the four coconut yogurts will provide 21.3g to 25.6g saturated fat. That’s up to 128% of the maximum saturated fat daily recommendation. Other yogurt alternatives with coconut added to ingredients such as soya may not be high in saturated fat. It’s important to check the label.
- Creamed coconut (the block sort added to dishes like curries) is on average 58% saturated fat (some almost 70% saturated fats), which is more than butter (52%) and lard (44%)
- Canned coconut milk (made with coconut extract and water) averages 14.6% saturated fat, with reduced fat coconut milk weighing in at a somewhat lower 6.3% (three times greater than full cream dairy milk).
- Desiccated coconut is over 50% saturated fat and crops up increasingly in energy balls and similar products.
- Coconut drinks are not of concern in terms of saturated fat. On average a 200ml glass of coconut drink contains only 1.5g saturated fat (7.5% of the Reference Intake). Coconut water contains no saturates at all, or only a tiny trace.***
What needs to be done differently?
We think more responsibility is needed
Chefs, celebrities, manufacturers, retailers and the media all share a responsibility in how coconut products are positioned and portrayed. In some cases, there is a genuine ignorance and misunderstanding of the science, which could perhaps be addressed through more public health messaging.
HEART UK, the British Heart Foundation and Department of Health already advise that coconut oil should be consumed only in small quantities and the Change4Life website lists coconut oil within a category of foods labelled ‘leave these on the shelf!’
But these messages need more reinforcement. Manufacturers see that the market for coconut products is a lucrative one, so they are harder to influence. However, given that the majority of coconut products are excessively high in saturated fat (with the exception of waters and drinks), we believe that responsible manufacturers should position the products of concern as an indulgence rather than something that provides any health benefits.
The products should have clear nutrition labels, ideally using the traffic light system. Consumers should look out to see which are classified as high, medium or low, to help them cut down on their intake. The classifications are:
High: More than 5g saturates per 100g. May be colour-coded red.
Medium: Between 1.5g and 5g saturates per 100g. May be colour-coded amber.
Low: 1.5g saturates or less per 100g. May be colour-coded green.
*’Coconut oil’ and ‘coconut fat’ are synonymous. A fat is usually called an oil when it’s liquid at room temperature.
**Using data from Forestfield Software Ltd. Dietplan7 (2017)
***On-pack labelling of current leading brands on the market (October 2017)