Dyslipidaemia (raised and unhealthy patterns of cholesterol and triglycerides and the lipoproteins that carry them in

the blood) is one of four main modifiable risk factors for cardiovascular disease. The others are diabetes, high blood

pressure and smoking. High total cholesterol is ranked number seven of the 20 leading risk factors which contribute

to the overall burden of disease in the UK.1

The prevalence of high cholesterolAverage UK cholesterol levels are decreasing but this is reflectiveof a population heavily medicated with statins. Over half of all UKadults still have a total cholesterol level above 5 mmol/L.

Recent changes in the Quality Outcomes Framework (QOF)mean that in future data on cholesterol levels may be lacking. GPs areno longer rewarded for measuring and recording the cholesterollevels of their patients, with the exception of diabetics. HEART UKhas raised concerns that the loss of this incentive to measure andrecord cholesterol levels in patients where cholesterol poses asignificant risk factor is misguided.2

Dyslipidaemia itself has many causes, both primary (inherited)and secondary to other problems. Familial Hypercholesterolaemia(FH) is an under-recognised inherited form of high cholesterol.FH is the most common condition to be caused by a single genealteration; it affects between 120,000 and 240,000 people in theUK of which 28,000 are children or teenagers. Less than 15% arecurrently diagnosed. Lifelong exposure to high cholesterol puts theundiagnosed and untreated at high risk of an early myocardialinfarction (MI) often in their 20s, 30s and 40s.

By contrast polygenic hypercholesteroleaemia results fromthe inheritance of many genes that negatively influence cholesterollevels. Familial Combined Hyperlipidaemia (FCH), in which bothcholesterol and triglycerides are raised, is also influenced by manygenes. Both these conditions are relatively more common than FH,however GPs, dietitians and practice nurses should be aware thatpatients with all these conditions will be seen in their clinical practiceat some time.

Recommended cholesterol levels For healthy individuals a total cholesterol level of ≤5 mmol/Land an LDL cholesterol of ≤3 mmol/L is associated with low risk.

Until recently those with existing, or higher risk of, cardiovasculardisease (CVD) were advised to aim for a total cholesterol ≤4 mmol/Land an LDL cholesterol ≤2 mmol/L. However, a recent revision of theNICE guidelines3 set no targets for cholesterol levels – preferring toadvise a 40% LDL cholesterol reduction from baseline for those witha 10% or more CVD risk. The Joint British Society (JBS3) guidelines,also updated in 2014, recommend an LDL target of 1.8 mmol/L forthose at high risk; equivalent to a non-HDL target of 2.5 mmol/L.4

Two other changes to the guidelines mean that for most people anon-fasting cholesterol test is now recommended and that non-HDL cholesterol (rather than LDL cholesterol) is now the target oftreatment. This is because non-HDL cholesterol represents thesum of all atherogenic lipoproteins, including VLDL and IDL. NICEguidelines also recommend a 50% LDL cholesterol reduction frombaseline for those individuals with FH. Whilst it is useful to havetargets, most lipidologists in the UK would agree that the lowerthe cholesterol the lower the risk of coronary heart disease (CHD).

The role of non starch polysaccharides(NSP)in heart healthDietary fibres, both soluble and insoluble, are defined as non starchpolysaccharides (NSP) and are neither digested nor absorbed in thesmall intestine in humans.

NSP is currently measured and reported in the UK by theEnglyst method of analysis. However, recently, the Scientific AdvisoryCommittee for Nutrition (SACN) recommended a move toward theAOAC method.5 This means that the UK population average dietaryreference value (DRV) for NSP for adults, currently set at 18 g usingthe Englyst method, would become 23-24 g using AOAC. In addition,SACN, having recognised the health benefits of increasing NSPintake, called for an increase in the average DRV for NSP to 30 g perday (AOAC) – an increase of around a third.

Oats and Oat Products inCholesterol Lowering DietsLinda Main, BSc RD, Dietetic Adviser at HEART UK– The Cholesterol Charity, and Freelance Dietitian

The reproduction of this article has been sponsored by Oatly

This is a reprint of an article that featured in Complete Nutrition Dec/Jan (2015); 15 (6): 63-65. The author and Complete Media & Marketing Ltd., do not endorse any particular companies’ productsor services. The design and layout of this article is © Complete Media & Marketing Ltd. 2015.

CNCNCN

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Many cohort studies have demonstrated abeneficial relationship between increasingNSP6 and whole grains7 in the diet andreducing the risk of cardiovascular disease.The mechanism for the reduction of risk isnot entirely known, but credible explanationsinclude an increase in fibre, vitamin ormineral intake, reduction in plasma lipid andglucose levels, as well as the displacementof other foods from the diet.8 Despite thisgood evidence, dietary intakes in the UKremain well below the current average DRVof 18 g/day,9 with lowest intakes in low incomepopulations. Cereals and cereal products arethe biggest contributor to NSP intakes.9

The role of beta glucanDiets high in soluble fibres (pectin, glucan,gums, psyllium) have been shown todecrease both total and LDL cholesterollevels.10, 11 In clinical studies the effect variesfrom 0% to 18% dependent upon the typeof soluble fibre, dosage, background dietand dietary control.10

Beta glucan is a water soluble fibrefound in cereals grains, particularly oatsand barley11 and is well known for itscholesterol-lowering ability. It is thoughtthat there may be a number of mechanismsbut the main one that is usually cited is thedisruption of the enterohepatic circulation,see Figure 1.

The enterohepatic circulation describesthe recycling of cholesterol rich bile acids. Bileacids are produced in the liver as breakdownproducts of cholesterol. Cholesterol richbile then passes, via the bile duct, into theduodenum in response to a meal. Bile actsas an emulsifier, breaking down dietary fatinto microscopic droplets with a very largesurface area, allowing dietary fat to mixintimately with digestive enzymes.

Bile is not altered by the process ofdigestion and under normal circumstancesmost bile acids are reabsorbed in the smallintestine returning to the liver where theycan be recycled. Beta glucan acts withinthe gut to reduce the absorption of bileand dietary cholesterol. As a result less bileis available for recycling and LDL receptorsare up-regulated to collect more cholesterolout of the circulation to produce more bilefor digestion. As a result blood cholesterollevels are lowered.

How beta glucan reducesbile and cholesterolabsorption Within the gut beta glucan fibres swelland become viscous. The viscosity of betaglucan is dependent upon the molecularweight (which in turn is dependent upon thepresence of mixed-linkage polysaccharides)

and the concentration. Ultimately, it is thisviscosity that helps bind bile acids andcholesterol and prevent their absorption.12

Other mechanisms, not dependent uponmolecular weight and viscosity, include thepossible fermentation of beta glucan bybacteria within the lower gut to short chainfatty acids which then inhibit a key enzymeinvolved in cholesterol synthesis,12, 13 and thedown regulation of genes involved in theintestinal uptake of lipids.14

Randomised control trials (RCTs) haveshown that beta glucan lowers totalcholesterol and LDL cholesterol but hasno effect on either HDL cholesterol ortriglycerides.5, 15-18 The magnitude of thereduction appears to be greater in thosewith higher baseline cholesterol.19 Whilsta dose response effect appears logical,5, 20

a recent meta-analysis of 28 oat betaglucan RCTs found no evidence of thiswithin a dose range of 3-12 g per day.19

A similar meta-analysis of 11 barley RCTsalso found no dose related effect.21

The Portfolio DietSoluble fibre, and specifically betaglucan, is a key element of the PortfolioDiet, an experimental diet shown tolower cholesterol in hypercholesterolaemicindividuals by 28% in metabolicstudies,22-25 and by 20% in free living

populations.26, 27 Jenkins theorised that aportfolio of four foods (almonds, soy,sterol fortified spread and soluble fibre)when eaten together, on top of a diet lowin saturated fat, would have additivecholesterol-lowering equal to the sum ofthe individual effects of each food. Thisdietary approach to cholesterol-loweringis becoming better established in the UKunder the guise of HEART UK’s UltimateCholesterol Lowering Plan (UCLP©).

The role of oats and oatproducts Oats contain around 10% total fibre andhave a greater proportion of soluble fibre(4%) than any other grain.11, 28 The oat grainalso provides a valuable source of protein(13%) and unsaturated fats (5.3%) and isnaturally low in saturated fats (1.2%). Oatsalso supply significant amounts of minerals(magnesium, calcium, iron, zinc) vitamins(vitamin E, thiamine, folate and B6) andphytochemicals (phytosterols, phenolicsand carotenoids).29

The consumption of oats has beenassociated with many cardiovascularbenefits, including the reduction in totaland LDL cholesterol.5, 17, 20, 29-31 Whitehead’s2014 meta-analysis19 indicated that ≥3 g oatbeta glucan lowered LDL cholesterol by 0.25mmol/L and total cholesterol by 0.3 mmol/L.

Hot Topic | Oats in Cholesterol Lowering Diets

Figure 1: Enterohepatic Circulation – this is disrupted by beta glucan reducingbile reabsorption and increasing faecal losses. More cholesterol is then takenfrom the circulation to replace the lost bile.

Bile is producedfrom the breakdownof cholesterolin the liver.

Liver

Gall bladder

Portal vein

Large intestine

Small intestine

Bile stored in thegall bladder issecreted into theintestines when foodis eaten.

Small amounts of bileare excreted in faeces. Normally most of the bile is absorbed

by the intestines and returned to theliver (via the portal vein) for recycling.

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Oats in Cholesterol Lowering Diets | Hot Topic

Although a small reduction, this can makea valuable contribution to a portfolio ofcholesterol-lowering strategies such asthose in the portfolio diet or UCLP©.

The inclusion of oats and beta glucanin the diet is also recommended in severalInternational and UK recommendations forthe management of dyslipidaemia.4, 32, 33

Oats have also been shown to havesmall beneficial effects on blood pressurecontrol,6, 34-36 incidence of Type 2 diabetes,5

post prandial blood sugars30, 37 and satiety.38

A number of health claims related tocholesterol-lowering have been approvedfor oat beta glucan worldwide, includingthe United States,39 Canada,40 Europe,41

Malaysia,42 Australia and New Zealand43 –see Table One for UK/EU Claims. With theexception of Malaysia, these approvalsare based on an intake of 3 g beta glucanper day, although the conditions of usemay vary. In the USA, a claim may be madewhere an individual serving contains ≥0.75 gof beta glucan; however across Europe1 g beta glucan per portion is needed tomake a similar claim. Approved health

claims enable informative food labellingand help spark new innovative products,such as oat milks, breakfast cereals andoat-containing breads. Although not acondition of the health claim, companiesshould be encouraged to conduct theirown research to demonstrate the efficacy ofthese products and alleviate any concernsthat processing may have had on theproducts ability to lower cholesterol.

One such study, using a well knownoat milk, demonstrated a 6% cholesterolreduction in hypercholesterolaemic menwhen consumed over five weeks andcompared to rice milk in a randomisedcontrolled crossover trial.44

Conclusion There is strong support for the hypothesisthat generous intakes of wholegrains,including oats, can be cardio-protective.Beta glucan has been extensively studiedand found to have significant total and LDLcholesterol lowering effects. The magnitudeof this effect is around 5% and appears toplateau out at intakes above 3 g per day.

For most individuals this will providecholesterol lowering of around 0.3 mmol/L,but the effect will be greater for individualswith higher baseline cholesterol levels.A number of novel products have madetheir way onto the UK market, making iteasier to achieve a 3 g/day intake. Including2-3 portions of oats (and barley) containingfoods each day as part of a portfolio ofcholesterol-lowering foods can have asignificant cholesterol lowering effect,either alongside of, or before resorting toa statin. Suitable foods and their portionsizes are illustrated in Table Two.

The Cholesterol Treatment Trialist’sCollaboration (CTTC) successfullydemonstrated that cholesterol reductioncan reduce the five year incidence of MI,stroke and coronary vascularisation byabout one fifth for every mmol reductionin LDL cholesterol.46 A 1 mmol reductionin cholesterol is entirely feasible for manypeople through sustained dietary andlifestyle intervention, and oats and oatproducts could account for one third ofthis reduction.

Table One: Health Claims Approved for Use in the UK

Joint HealthClaims InitiativeUK 200445

The inclusion of oats as part of a diet lowin saturated fat and a healthy lifestyle canhelp reduce blood cholesterol

EU 2009 – Article13.1 claim30

Beta glucans contribute to the maintenanceof normal blood cholesterol levels

EU 2010 – Article14 claim41

Oat beta glucan has been shown tolower/reduce blood cholesterol.High cholesterol is a risk factor in thedevelopment of coronary heart disease

Table Two: Oat Beta Glucans – Food servings providing1 or 3 grams

1 g oat beta glucan is provided by:

• A bowl of porridge (using 30 g of porridge oats)• 2 tablespoons of oatbran • 1 oat breakfast biscuit• 1 serving of Mornflake oatbran cereals • 3 oatcakes• 30 g of oats in recipes that are also low in saturated fat• 2 slices or 1 roll of LIV or Hovis Hearty Oats bread• 250 ml glass of oat drink/milk

3 g oat beta glucan is provided by a single portion of:

• OatWell products: bran powder, instant drink mix, crispy hearts breakfast cereal • BetaVivo

References: 1. Murray CJL, et al (2013). UK Health Performance: Findings of the Global Burden of Disease Study 2010 Lancet;. 2013; 381(9871): 997-1020. 2. HEART UK (2015). Data: Helping us beat cholesterol: The role of rigorousprimary care data collection, management and analysis in supporting cholesterol and CVD prevention and management. Accessed online: http://heartuk.org.uk/policy-and-public-affairs/campaigning-activities/resources-and-reports/data-helping-us-beat-cholesterol (September 2015) 3. NICE (2014). Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovasculardisease. NICE guidelines [CG181]. 4. JBS3 Board (2014). Joint British Societies consensus recomendations for the prevention of cardiovascular disease. Heart;.100:ii1-ii67. 5. SACN (2015). Carbohydrates and Health. Accessed online:www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf (September 2015). 6. Pereira MA, et al (2004). Dietary Fiber and Risk of Coronary Heart Disease:A Pooled Analysis of Cohort Studies. Archives of Internal Medicine; 164 (4): 370-6. 7. Mellen PB, Walsh TF, Herrington DM. (2008). Whole grain intake and cardiovascular disease: a meta-analysis. Nutr Metab Cardiovasc Dis.; 18(4):283-90. 8. Flight I, Clifton P (2006). Cereal grains and legumes in the prevention of coronary heart disease and stroke: a review of the literature. Eur J Clin Nutr.; 60(10): 1145-59. 9. NatCen, HNR, UCL National Diet and NutritionSurvey: Results from Years 1 to 4 (combined) of the rolling programme for 2008-2012. Accessed online: www.gov.uk/government/statistics/national-diet-and-nutrition-survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-2008-and-2009-to-2011-and-2012 (September 2015). 10. Brown L, et al (1999). Cholesterol Lowering Effects of Dietary Fibre: A meta-analysis. Americal Journal of Clinical Nutrition; 69: 30-42. 11. Theuwissen E(2008). Water-soluble dietary fibers and cardiovascular disease. Physiology and Behaviour; 285-92. 12. Chen J, Gislette T, Huang X (2010). The role of molecular weight and viscosity of oat b-glucan in hypercholesterolaemiceffect. Am J Clin Nutr.; 92. 13. Queenan KM, et al (2007). Concentrated oat β-glucan, a fermentable fiber, lowers serum cholesterol in hypercholesterolemic adults in a randomized controlled trial. Nutrition Journal; 6(6).14. Drozdowski LA, et al (2010). β-Glucan extracts inhibits the in vitro intestinal uptake of long-chain fatty acids and cholesterol and down-regulate genes involved in lipogenesis and lipid transport in rats. The Journal of NutritionalBiochemistry; 21(8): 695-701. 15. Keenan JM, et al (1991). Randomized, controlled, crossover trial of oat bran in hypercholesterolemic subjects. The Journal of Family Practice; 33(6): 600-8. 16. Davy BM DK, et al (2002). High-fiberoat cereal compared with wheat cereal consumption favorably alters LDL-cholesterol subclass and particle numbers in middle-aged and older men. Am J Clin Nutr;. 76(2): 351-8. 17. Saltzman E DS, et al (2001). An oat-containinghypocaloric diet reduces systolic blood pressure and improves lipid profile beyond effects of weight loss in men and women. J Nutr.; 131(5): 1465-70. 18. Romero AL, et al (1998). Cookies enriched with psyllium or oat bran lowerplasma LDL cholesterol in normal and hypercholesterolemic men from Northern Mexico. Am J Coll Nutr.; 17(6): 601-8. 19. Whitehead A, et al (2014). Cholesterol-lowering effects of oat beta-glucan: a meta-analysis of randomisedcontrollled trials. Am J Clin Nutr.; 100: 1413-21. 20. Ripsin CM, et al (1992). Oat products and lipid lowering. JAMA; 267(24): 3317-26. 21. AbuMweis SS Jew S, Ames NP (2010). ß-glucan from barley and its lipid-lowering capacity:a meta-analysis of randomized, controlled trials. Eu J of Clin Nutr.; 64: 1472-80. 22. Jenkins D, et al (2002). Dose Response of Almonds on Coronary Heart Disease Risk factors: Blood Lipids, Low density Lipoproteins, Lipoprotein(a),Homocysteine and Pulmonary Nitric Oxide: A Randomised, Controlled, Crossover Trial. Circulation; 106: 1327-32. 23. Jenkins D, et al (2003). Effects of Dietary Portfolio of Cholestetrol-Lowering Foods vs Lovastatin on SerumLipids and C-Reactive Protein. Journal of Americal Medical Association; 290: 502-10. 24. Jenkins D, et al (2003). The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia.Metabolism; 52(11): 1478-83. 25. Jenkins D, et al (2005). Direct Comparison of a Dietary Portfolio of Cholesterol-lowering Foods with a Statin in Hypercholesterolemic Participants. Americal Journal of Clinical Nutrition; 81: 380-7.26. Jenkins D, et al (2006). Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolaemia. Americal Journal of Clinical Nutrition; 83: 582-91. 27. Jenkins D, et al (2011). Effectof a dietary portfolio of cholesterol lowering foods given at 2 levels of intensity of dietary advice on serum lipids in hyperlipideamia JAMA; 306(8): 831-9. 28. Linda Van Horn P, RD. Fiber, Lipids, and Coronary Heart Disease: AStatement for Healthcare Professionals From the Nutrition Committee, American Heart Association (1997). Circulation; 95: 2701-4. 29. Chu Y and SC, Liu RH (2013). Health Benefits of Oat Phytochemicals. In Oats Nutrition andTechnology, John Wiley & Sons Ltd, Chichester; UK doi: 101002/9781118 354100ch7. 30. EFSA Panel on Dietetic Products (2011). Scientific Opinion on the substantiation of health claims related to beta-glucans from oats and barleyand maintenance of normal blood LDL-cholesterol concentrations, increase in satiety leading to a reduction in energy intake, reduction of post-prandial glycaemic responses, and “digestive function” pursuant to Article 13(1) ofRegulation (EC) No 1924/20061. EFSA Journal; 9(6): 2207. 31. Andon MB AJ (2008). State of the art reviews: The oatmeal cholesterol connections: 10 years later AJLM; 2: 51-7. 32. IAS (2013). An international atherosclerosis societyposition paper: Global recommendations for the manangement of dyslipidemia. Accessed online: www.athero.org/download/IASPPGuidelines_FullReport_20131011.pdf (September 2013). 33. AACE (2012). American associationfor clinicial endocrinologists guidelines for the manangement of dyslipidaemia and prevention of atherosclerosis. Accessed online: www.aace.com/files/lipid-guidelines.pdf (September 2015). 34. Maki KC, et al (2007). Effects ofconsuming foods containing oat beta-glucan on blood pressure, carbohydrate metabolism and biomarkers of oxidative stress in men and women with elevated blood pressure. Eur J Clin Nutr.; 61: 786-95.35. Tighe P, et al (2010).Effect of increased consumption of whole-grain foods on blood pressure and other cardiovascular risk markers in healthy middle-aged persons: a randomized controlled trial. Am J Clin Nutr.; 92(4): 733-40. 36. Whelton HA, etal (2005). Effect of dietary fiber intake on blood pressure: a meta-analysis of randomized, controlled clinical trials. J Hypertens.; 23(3): 475-81 37. Butt M(2008). Oat: Unique among the cereals Eur J Nutr.; 47(2): 68-79. 38. Salas-Salvado J, et al (2007). Effect of two doses of a mixture of soluble fibres on body weight and metabolic variables in overweight or obese patients: a randomised trial. British Journal of Nutrition; 99: 1380-7. 39. US FDA (1997).Health claims: soluble fiber from certain foods and the risk of CHD. Code of Federal Regulations Title 2; Section 10181 Silver Spring (MD). 40. Bureau of Nutritional Sciences FD, Health Products and Food Branch, Health Canada(2010). Oat products and blood cholesterol lowering: summary of assessment of a health claim about oat products and blood cholesterol lowering. Accessed online: www.hc-sc.gc.ca/fn-an/label-etiquet/claims-reclam/assess-evalu/oat-avoine-eng.php (September 2015). 41. EFSA (2010). Scientific Opinion on the substantiation of a health claim related to oat beta-glucan and lowering blood cholesterol and reduced risk of (coronary) heart diseasepursuant to Article 14 of Regulation (EC) No 1924/20061. Official Journal of the European Union;. 8(12): 1885. 42. Malaysia MoH (2010). Malaysian dietary guidelines—Key Message 14—make effective use of nutrition informationon food labels (Appendix 4). 43. Food Standards Australia and New Zealand (2013). Standard 1.2.7: Nutrition, health and related claims. Food Standards Gazette; 80. 44. Onning G, et al (1999). Consumption of Oat Milk for 5Weeks Lowers Serum Cholesterol and LDL Cholesterol in Free-Living Men with Moderate Hypercholesterolemia. Ann Nutr Metab.; 43: 301-9. 45. JHCI (2004). Final report on a generic claim for oats and reduced blood cholesterol.Accessed online: http://webarchive.nationalarchives.gov.uk/nobanner/20130404135254/http://www.jhci.org.uk/approv/oats.htm (September 2015). 46. CTTC (2005). Efficacy and safety of cholesterol-lowering treatment:prospective meta-analysis of dats from 90,056 participants 1n 14 randomised trials of statins. Lancet; 366: 1267-78.

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That wasn’t a very exciting headline but since it got you here we would like to mention that what is really great about our oat drink products (beside the taste of course) is what you find in the details which we have organised as well structured and informative bullet points below. So before we are tempted to fill this ad with sales oriented power slogans about how easy it is to cook with or enjoyable it is to pour on your morning cereal, perhaps we should take a look at those bullet points we wanted you to read.

So now you know, but before we let you go we should probably tell you that this handsome looking package is not always easy to find because the supermarkets usually place it in the specialist milk aisle and not at all because we thought it would be fun to hide it from you. Promise.

This headline would like you to read the bullet points

Totally dairy and soya free

Low in saturated fats (1.5g/100ml total fat of which 1.3g is unsaturated)

Lowers your cholesterol thanks to those wondrous fibres called beta-glucans*

Rich in vitamin D and a source of riboflavin, vitamin B12 and calcium

No added sugar

Sustainable for the environment (one third of the carbon footprint of milk)

* As a part of a varied and balanced diet and a healthy lifestyle, beta-glucans may help lower cholesterol levels in your blood. High cholesterol is a risk factor for heart disease. One 250ml glass of Oatly provides a third (1g) of the 3g suggested daily intake of beta-glucan.

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oatly.com/hcp

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