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The impact of structured advice from dietitians on dietary and lifestyle changes when compared with standard physician advice

  • Dietitian delivered structured advice increases adherence to recommended diet and lifestyle changes and lowers low-density lipoprotein (LDL)-cholesterol.
  • Structured advice from a dietitian resulted in the consumption of more servings of foods with added plant sterols both during the study and afterwards when no longer provided.
  • This study demonstrates a beneficial effect on blood lipids of dietary advice including use of food with added plant sterols when individuals are followed up after the intervention has ended.

Although it is well known that a healthy diet and regular exercise are important for cardiovascular health, consumer adherence to lifestyle and dietary change is poor.  A parallel, randomised, placebo-controlled study, set in Athens, Greece, enrolled one hundred participants with hypercholesterolaemia and allocated 50 to a standard physician advice group and 50 to a dietitian group for a structured programme of behavioural change. Both groups were given food with added plant sterols (three servings a day).

At baseline, all individuals had EAS/ESC1 defined borderline to mildly elevated total cholesterol levels of 200-239 mg dL-1 (5.18-6.19 mmol L-1) and were not on any cholesterol-lowering medication nor consuming plant sterols or stanols.

The intervention phase of the study lasted for six weeks and those in the dietitian group benefited from weekly, face-to-face behavioural advice. The physician group received one face-to-face meeting with brief information on cholesterol, plant sterols and information on which foods to avoid or increase.  An additional follow up period of six weeks was included in the study in order to observe any difference between the groups under real-life conditions.  Blood cholesterol levels were measured at baseline, 6 and 12 weeks and 3-day diet diaries were kept at weeks 1, 6 and 12.

Plant sterols were provided to all the study participants for the 6 week intervention period only. They were able to choose from a combination of spreads, milk and yoghurt.

A significant difference in dietary habits, physical activity and increased plant sterols consumption was observed in the group that received structured advice from a dietitian. It is of interest that although at week 6 both groups showed a comparable decrease in LDL-cholesterol levels from baseline it was the dietitian intervention arm only which demonstrated a further significant improvement in LDL-cholesterol (P=0.006) at 12 weeks when compared with the 6 week measure.  Similar results were seen for total cholesterol and triglycerides at week 12. Participants in the dietitian group consumed more plant sterols during the study and purchased more plant sterols for themselves in the follow up period. This indicates that the structured advice delivered by a dietitian was more effective for sustaining a healthy behavioural change and a cholesterol lowering effect.

The dietitian led behavioural intervention sessions included education about:   Healthy diet e.g. Mediterranean style diet

Understanding food labels

Diet and lifestyle plans

Goal setting

Advice on; dietary fat intake, reducing salt and alcohol, fruit and vegetable consumption, whole grain products and plant sterols/stanols

Advice about increasing physical activity

General information about cholesterol

To know more on the risk cholesterol poses on developing heart disease and ways to control cholesterol, do not forget to listen to our Voices For Lowering Cholesterol

 

References

  1. Catapano AL, Graham I, De Backer G et al. (2016) 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias. Eur Heart J 37, 2999-3058.

 

For further information see: Sialvera T.E, Papadopoulou A, Efstathiou SP, et al. 2017 Structured advice provided by a dietitian increases adherence of consumers to diet and lifestyle changes and lowers blood low-density lipoprotein (LDL) – cholesterol: the Increasing Adherence of Consumers to Diet & Lifestyle Changes to Lower (LDL) Cholesterol (ACT) randomised controlled trial. Journal of Human Nutrition and Dietetics.

IPSSA @ Food Matters Live 2017

IPSSA was invited to participate at two seminars during the Food Matters Live 2017 Expo that took place from 21 to 23 November in London Excel.

Professor Elke Trautwein made two presentations on:

  1. 22 November, Seminar Programme – Functional Nutrition “Cradle to Grave”, where Professor Trautwein presented on The role of plant sterols/stanols in life-long management of blood cholesterol – from science to claims and
  2. 23 November, Seminar – NCDs, dietary patterns and cardiovascular disease, where Professor Trautwein gave a presentation entitled Plant sterols/stanols for cholesterol lowering and prevention of cardiovascular disease

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Feel free to download the presentations at the links above and reach out to us via email or Twitter!

IPSSA Comments on EU Commission’s draft implementing regulation for establishing the Union List of novel foods

The EU Commission has drafted an implementing regulation for establishing the Union List of novel foods in accordance with Regulation (EU) 2015/2283 of the European Parliament and of the Council on novel foods.

To this initiative, EU Commission publicly asked for feedback in period 5 October 2017 – 2 November 2017. 1)

The International Plant Sterols and Stanols Association (IPSSA), the leading association in the sector of plant sterols and stanols comprised of the major international companies in the sector (Arboris, BASF, Cargill, Raisio, Unilever), submitted comments with the following major items2):

 

  • The draft implementing regulation does not include notifications while this is addressed in the Regulation (EU) 2015/2283 as well as in the recitals of the draft implementing regulation.
    IPSSA sees the need to also include notifications in the Union List to avoid mismatch in the implementing regulation as such as well as to Regulation (EU) 2015/2283.
    Further, it should be realized that notifications were seen as a clarification and acceptance of the legal novel food status of individual products in the EU, whereas uncertainty to the legal status of notified products might arise when there is no information to notified products at all in the new regulation.
  • The draft implementing regulation summarizes the individual provisions applicable to plant sterols, stanols and their esters.
    However, it did not take the chance to harmonize, simplify or clarify the totality of provisions applicable to plant sterols, stanols and their esters.
    To approved food categories there could have been alignment with other current EU legislations, i.e. the definition of food categories as defined for the use of Food Additives.
    IPSSA also addressed whether specifications of plant sterols, stanols and their esters could have been harmonized.
  • The draft implementing regulation contains several editorial mistakes compared to the initial approvals for plant sterols, stanols and their esters by past EU Commission decisions.
    IPSSA addressed the individual necessary corrections, i.e. to approved food categories or the defined sterols/stanols profile.

 

IPSSA welcomes the EU Commission’s activity on novel foods and the establishing of a Union List.

At the same time, IPSSA sees this as a chance for improvement in clear regulations while keeping the legal status of products on the market to the benefit of the consumers.

 

1)

https://ec.europa.eu/info/law/better-regulation/initiatives/ares-2017-4851094_en

2)

https://ec.europa.eu/info/law/better-regulation/initiatives/ares-2017-4851094/feedback/F7474_en

Expert working group makes recommendations for lifestyle changes and cardiovascular disease prevention

  • Experts agree that lifestyle changes including a healthy diet are important for cardiovascular disease (CVD) prevention.
  • A healthy diet is recommended for everyone and should be adapted to local culture and environment.
  • Amongst functional foods and food supplements, plant sterols/stanols at doses of 2-3 g/day are recommended as they have a proven cholesterol-lowering effect. Clinical studies support their LDL-cholesterol-lowering effect, but there is yet no evidence on CVD event reduction.

The expert working group reviewed existing guidelines, clinical practice and research evidence to provide recommendations on ten proposed lifestyle changes and their impact on cardiovascular disease (CVD) risk prevention.

They agreed that:

  1. A Mediterranean diet high in fruits, vegetables, seeds, nuts, fish, whole cereals and extra-virgin olive oil is beneficial to all for CVD prevention. Tailoring diets to the needs of specific communities and patients is also important.
  2. Moderate alcohol consumption of mostly wine or beer is probably beneficial to heart health but may increase the risk of several cancers.
  3. Encourage people to eat a healthy food-based diet based on whole foods with the mantra ‘Unwrap less, peel more”.
  4. There is not enough evidence that a low-fat diet is beneficial for CVD prevention, but there is strong evidence for promoting a Mediterranean diet.
  5. Functional foods: Phytosterols at 1.6-3 g per day reduce LDL-C by 10% in those not on medications or on a stable statin dose. In diets designed to reduce LDL-C, phytosterol-enriched foods may be recommended. There is no evidence to support the use of omega-3 supplementation. Diets should be high in natural sources of dietary fibre.
  6. Exercise, e.g. at least 30 minutes five days a week should be recommended but CV fitness should be assessed and high-risk patients and those engaging in high-intensity sport should be screened before starting exercise.
  7. Smoking cessation is a major modifiable risk factor for CVD. Hence, clinicians need to ask the right questions and be available with the right advice to help patients stop smoking.
  8. Nutritionists form an important part of any CV risk multidisciplinary team. Food-related advice needs to form an important part of daily practice in primary care and especially cardiologists would benefit from basic knowledge about how to talk with patients about CVD risk and nutrition. Public and occupational education is also required.
  9. Tools such as questionnaires to assess lifestyle and plan lifestyle modifications and interventions are useful.
  10. Rehabilitation programmes and a multidisciplinary team approach are needed when encouraging lifestyle changes. Motivational interviewing and a psychological assessment are recommended. Positive messages instead of negative ones are vital.

Taken together, lifestyle modification plays a key role in the prevention of CVD and experts agree on the evidence-based changes that can save lives and ill health. This review provides guidance and useful advice for clinicians and healthcare professionals on the role of lifestyle changes in the prevention of CVD.

 

Masana L, Ros E, Sudano I , Angoulvant D and the lifestyle expert working group. 2017 Atherosclerosis Supplements 26 2-15.

IPSSA Call for Action on World Heart Day 2017: Measure Your Blood Cholesterol!

Brussels, 29 September 2017:

Today is World Heart Day; a landmark date established by the World Heart Federation. According to the World Heart Federation, cardiovascular disease (CVD) continues to be the leading cause of death and disability in the world today: over 17.5 million people die from cardiovascular disease (CVD) every year[1]. It is also an established fact that one key modifiable risk factor for developing CVD is high blood cholesterol.

The International Plant Sterols and Stanols Association (IPSSA), the leading association in the sector of plant sterols and stanols comprised of the major international companies (Arboris, BASF, Cargill, Raisio, Unilever), fully supports the messages of the World Heart Foundation for World Heart Day and we are calling for the public to get their blood cholesterol measured and act to reduce or maintain healthy LDL-cholesterol levels.

According to the 2016 ESC/EAS guidelines on the management of dyslipidemias[2](Table 10 p. 298), as a general guide, LDL-blood should be:

  • For adults in low to moderate risk of developing CVD: LDL-C <1.8 mmol/L (70 mg/dL)
  • For adults in high risk of developing CVD: LDL-C <2.6 mmol/L (100 mg/dL)
  • For adults in very high risk of developing CVD: LDL-C <1.8 mmol/L (70 mg/dL)

Where mmol/L are units called millimoles per litre of blood.

Elevated LDL-cholesterol has no physical symptoms that could alert someone and yet it is a significant heart disease risk factor. The public needs to act as early as possible and measure their cholesterol through a simple blood test. The good news is that through a healthy and active lifestyle and diet, LDL-cholesterol levels can be lowered significantly, Geert van Poppel, IPSSA Chairman comments. But people must act, measure, and become aware of their cholesterol levels sooner rather than later, he concludes.

Maintaining LDL-blood cholesterol at desirable levels and generally lowering the risk for developing CVD requires lifestyle modifications towards a healthier diet and a more active living. Including to a balanced, healthy diet foods with added plant sterols and stanols can make an important contribution:  it has been scientifically proven that a daily consumption of foods and food supplements with 1.5 – 3.0g of added plant sterols or stanols can lower blood LDL-cholesterol dose-dependently by 7-12.5% in 2-3 weeks as part of the daily diet.

[1] https://www.worldheartday.org/whdcvd/

[2] http://www.atherosclerosis-journal.com/article/S0021-9150(16)31267-9/pdf Table 10 page 298

Phytosterols-enriched low-fat milk lowered both total and LDL cholesterol in a Chinese population

  • A randomised, double-blind, placebo-controlled trial showed that phytosterol- enriched low-fat milk consumption led to a significant reduction in total and LDL-cholesterol
  • Daily intake of 1.5 g phytosterols for 3 weeks lowered LDL-cholesterol by 9.5%; diastolic blood pressure was also lowered with phytosterol intake
  • Milk consumption was generally well tolerated and only mild gastrointestinal side-effects occurred which did not reduce the cholesterol lowering effect of phytosterols
  • Low calcium intake and osteoporosis are common problems in Asian people and hence the milk with added phytosterols is therefore also useful for providing a daily source of calcium

 

Researchers in Hong Kong randomised 221 non-diabetic southern Chinese participants aged 24-79 years to receive either phytosterol-enriched low-fat milk (1.5 g of phytosterols daily) or a conventional low-fat-milk for a three-week period. The participants were not on any cholesterol lowering medication.

They found that in comparison with the standard low-fat milk those receiving the phytosterol-enriched milk had a significant reduction in serum LDL-cholesterol of 0.265 mmol/L or 9.5% (p<0.0001). Total cholesterol was also significantly lowered (p<0.0001, while HDL-cholesterol and triglycerides were not affected. Interestingly, diastolic (but nor systolic) blood pressure was also lower with phytosterols p<0.01.

The Chinese population has a high prevalence of lactose intolerance when compared to Caucasians. However, despite 30% of study participants experiencing at least one adverse event, e.g. diarrhoea and flatulence this did not affect the LDL-cholesterol lowering effect of the phytosterol added milk in this study group.

This is further evidence showing that phytosterols can reduce blood cholesterol also in the Chinese population. This finding is significant as the traditional diet of the Chinese population is characterised by a high intake of plant-based food and more moderate consumption of animal products.

Low calcium intake and osteoporosis are common in Asian populations. This study further showed that low-fat milk with added phytosterols not only lowered cholesterol, but also provides an important daily source of calcium and protein.

Ching-Lung Cheung, Daniel Ka-Chun Ho, Chor-Wing Sing et al. 2017 Randomized controlled trial of the effect of phytosterols-enriched low-fat milk on lipid profile in Chinese.  Scientific Reports, Nature. Available @ https://www.nature.com/articles/srep41084

Publication by Frost & Sullivan commissioned by FSE on Healthcare Cost Savings of Phytosterol Food Supplements in the European Union

In order to understand better the potential value of supplementation to society, Food Supplements Europe (FSE) has commissioned economic consultants of Frost & Sullivan to evaluate the potential healthcare cost savings that could be derived from supplement intake in the European Union. This newly published report, entitled “Healthcare Cost Savings of Phytosterol Food Supplements in the European Union. Economic Implication of Managing Cardiovascular Disease with Phytosterol Food Supplements with Demonstrated LDL-cholesterol Reduction Capabilities” addresses the health care cost savings of phytosterols (comprising plant sterols and stanols).

The report addresses in a form of a case study the possible direct economic benefits from the daily use of phytosterols added to food sources or as food supplements. As target group, individuals at the highest risk of developing CVD, i.e. people with severe hypercholesterolemia were chosen.

  • 1 million people over 55 years in the EU have severe hypercholesterolemia defined as a total cholesterol of >6.2 mmol/L. They have an expected 24.3% risk of experiencing a CVD-attributed hospital event.
  • Consumption of 1.7 g/day of phytosterols (in the form of a food supplement), is expected to reduce LDL-cholesterol by about 0.37 mmol/L among severe hyper-cholesterolemic adults aged 55 years and older.
  • Assuming an optimal daily phytosterol intake of 2 g (defined as 0.3 g coming from the habitual diet plus 1.7 g from taking a food supplement), this would translate into an absolute risk reduction of experiencing a CVD attributed hospital event of 2.3%.
  • In numbers, this relates to 170,542 possible CVD-attributed hospital events that could be avoided throughout the EU per year.
  • Estimated risk reduction benefits from using phytosterols vary between EU countries, based on the observed CVD-attributed event rates of each country.
  • Total health care cost savings of 26.5 billion Euro could be achieved in the EU over 5 years through regular use of 1.7 g/d of PS from supplements by the target population. This is equivalent to 5.3 billion Euro of avoidable costs per year.
  • The total net benefit (taking the cost for phytosterol supplements into account) for the entire EU target population (all adults 55 years and older with severe hypercholesterolemia) is 4.09 billion Euro per year.
  • The benefits per potential user (all adults 55 years and older with severe hypercholesterolemia) of avoiding CVD-attributed costs are expected to be ca. 170 Euro per user per year for the EU as a whole.

This new report describes that significant health care cost savings can be realised through a concerted effort to identify high CVD risk populations in Europe (i.e. adults 55 years and older with severe hypercholesterolemia) and to encourage them to use phytosterol food supplements as a means to help minimise their risk of CVD. Therefore, this latest health care cost savings assessment adds to the available evidence based on previous assessments of this kind making the case that phytosterol use is a cost-effective strategy.

FSE have also published an infographic summarizing the key messages of the report that you can view and download here

Plant stanol and sterol containing foods further lower blood cholesterol in patients treated with statin medication

  • Plant stanols/sterols work in a different way to statins and can help people who take statin medication achieve further cholesterol reduction
  • Current expert advice supports a lower the better strategy for blood cholesterol
  • Healthy diet is an important factor for reducing cardiovascular disease risk

A new systematic review of the current literature combined with a detailed meta-analysis has further confirmed that plant stanol/sterol-containing foods can add additional cholesterol lowering benefits for people already on statin therapy.

Data from a total of 500 participants was analysed from 15 suitable randomized controlled trials (RCTs) published between 1996 and December 2015. Intervention lasted from 4 to 85 weeks with a median intervention of 6 weeks. Plant sterol/stanol intake ranged from 1.8 to 6 g/d with a median intake of 2.5 g/d.

The results showed that in addition to the cholesterol lowering effect of the statin a further 0.30 mmol/l reduction in both total cholesterol and low-density lipoprotein (LDL) cholesterol could be achieved with foods containing added plant sterols/stanols. High-density lipoprotein (HDL) and triglycerides remained the same.

Overall, the results of this new meta-analysis are fully comparable to the previously reported findings from the meta-analysis by Scholle et al (Scholle et al, J Am Coll Nutr, 2009).

Plant sterols/stanols lower LDL-cholesterol by inhibiting intestinal cholesterol absorption, while statins lower serum LDL-cholesterol by inhibiting cholesterol synthesis, mainly in the liver. Because plant sterols/stanols and statins work through different, complementary mechanisms, this leads to the described additive beneficial cholesterol-lowering effect.

In line with the “lower the better” strategy advocated by leading health authorities such as the American College of Cardiology and the American Heart Association (ACC-AHA) and the European Atherosclerosis Society (EAS), such extra reduction in cholesterol may further reduce the risk of cardiovascular disease (CVD).

This meta-analysis gives important evidence of an additional benefit in terms of cholesterol reduction that can be gained from using plant sterols/stanols in combination with statin medication. This will also be useful in treating patients who fail to achieve LDL-C targets or are statin intolerant, a target population for whom plant sterols/stanols is considered as described in the EAS consensus panel paper (Gylling et al Atheroscleosis 2014). This is in keeping with current guidelines that place diet and lifestyle modification at the cornerstone of CVD risk reduction.

For further information see Han S., Jiao J., Xu J. et al. 2016 Effects of plant stanol or sterol-enriched diets on lipid profiles in patients treated with statins: systematic review and meta-analysis. Sci. Rep. 6, 31337;doi: 10.1038/srep31337.

Study shows the cholesterol-lowering efficacy of plant stanols in a new type of food supplement

  • A new study shows that a chewable food supplement with added plant stanol esters can be used to help reduce elevated blood cholesterol levels
  • Plant stanols work by reducing the absorption of cholesterol from the gut by displacing cholesterol from the mixed micelles (vehicles that carry fat, bile and cholesterol) in the gut
  • The new chewable food supplement is easy to use and no side effects were reported

Researchers in Finland have studied a new format of a supplement with added plant stanols for blood cholesterol management.

A new, sugar-free chewable and easy to swallow food supplement with added plant stanols was studied in a recent randomized, double-blind, controlled trial with results showing that it is both easy to use and effective in reducing serum total and LDL cholesterol.

This chewable supplement is based upon emulsified plant stanol esters in a gelled water matrix that allows effective release of the plant stanol esters from the product matrix and enables it to mix with emulsified fat in the stomach. In order to displace cholesterol from mixed micelles in the gut, plant stanol esters are hydrolysed by enzymes in the gut into free plant stanols. Release of bile in the upper part of the small intestine triggered by a meal is required allowing free plant stanols to displace cholesterol from the formed mixed micelles in the gut, the underlying mechanism involved in inhibiting cholesterol absorption. This process requires the plant stanol supplement to be consumed with a meal in order to be effective.

The study recruited 131 moderately hypercholesterolemic volunteers and randomised 110 of them into two study groups. The participants were asked to consume four pieces of the test supplement each day, a dose of 2g plant stanols for those in the active arm, consumed at two meals.  The participants kept a  diary on the intake of the test supplements including any symptoms.

The results showed that after four weeks of taking the supplement LDL cholesterol concentration was reduced by an average of 7.6% when compared with the control group. Total serum cholesterol was lowered by 4.9% and non-HDL cholesterol by 6.6%. HDL cholesterol and serum triacylglycerol remained unchanged.

No side effects were reported and 78% of the responders rated it easy or very easy to use this supplement. The taste of the supplement was described as good or very good by 68% of the participants making it a practical as well as a convenient solution for long term use.

This study is important because it supports the cholesterol-lowering benefit of plant stanols administered in the format of a newly developed chewable and easy to swallow food supplement. Furthermore, this new study supports the overall available evidence that food supplements with added plant stanols/sterols can play a role in lowering elevated serum cholesterol concentrations

Laitinen K, Gylling H and Kaipiainen et al Journal of Functional Foods 2017 30 119-124

Current evidence suggests plant-based diets reduce the risk of cardiovascular disease, type 2 diabetes and obesity

  • A review of the current evidence indicates that plant-based diets can reduce the risk of cardiovascular disease and type 2 diabetes by around 20-25%.
  • Plant-based diets can also help with weight management; they have a low energy density and are high in fibre. Fibre can help with feelings of fullness and thus improve satiety.
  • A move towards including more plants in the diet appears to be the most important factor for these health gains rather than trying to adhere to a totally vegetarian or even vegan diet.

Harland and Garton searched the published literature from January 2015 to August 2016 in order to understand if plant-based diets have an impact on the incidence of or risk factors for cardiovascular disease (CVD), type 2 diabetes (T2D) and obesity.  A plant-based diet is one in which there is an emphasis on plant foods rather than an exclusion of all animal products. This can include vegetarian, vegan, Mediterranean and combination diets. Recent research findings from meta-analyses, European cohort studies and randomised controlled trials (RCTs) were studied in the review.

They discovered that plant based diets are associated with a 20-25% lower risk of developing CVD or T2D. Risk factors for developing these metabolic diseases such as total cholesterol, low-density lipoprotein-cholesterol and blood pressure were lower in those on a plant based diet.

Better overall weight management was achieved with a plant based diet compared to a calorie controlled diet and a higher intake of plant-based foods is associated with a lower BMI and a smaller waist circumference.

Portfolio or combination diets are plant-based diets that further focus on specific plant foods or plant-based ingredients that have been shown to reduce blood cholesterol such as soya, nuts, soluble fibre (such as oats and psyllium) and foods with added plant stanols and stenols, Such type of diets also lower high blood pressure such as the DASH eating plan. The DASH diet is plant-based with an emphasis on vegetables, fruit, whole grain cereals, legumes, seeds and nuts. It includes low fat dairy products and lean proteins such as poultry and fish. It is low in fat, red meat and sugar-containing food and drink. Combination diets can contribute to a reduction in the risk factors for CVD and diabetes.

When compared with “Western” diets plant-based diets have higher unsaturated fats and fibre and lower saturated fats and energy density. Plant-based diets are also high in antioxidant vitamins and phytonutrients. It may be these qualities that are responsible for the health benefits found with plant based foods or it could be that eating more plants in the diet is of benefit in its own right. People with plant-based eating patterns tend to have healthier blood lipid-profiles, better glucose management, reduced blood pressure and lower biomarkers of inflammation in their body. As well as this plant-based diets are more sustainable for our environment.

Harland J and Garton L 2016 An update of the evidence relating to plant-based diets and cardiovascular disease, type 2 diabetes and overweight. Nutrition Bulletin, 41, 323-338