re-print - Oatly - Vol15 No6 2015_2015 14/12/2015 12:47 Page 1 CN CN Linda Main, BSc RD, Dietetic Adviser at HEART UK – The Cholesterol Charity, and Freelance Dietitian

Dyslipidaemia (raised and unhealthy patterns of cholesterol and triglycerides and the lipoproteins that carry them in CNthe 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 Otoa thet ovserall baurdenn of ddiseas e Oin thea UK. 1t Products in

The prevalence of high cholesterol Until recently those with existing, or higher risk of, cardiovascular Cholesterol Lowedisearse (CiVDn) werge adv isDed to aiim efor at totsal cholesterol ≤4 mmol/L Average UK cholesterol levels are decreasing but this is reflective and an LDL cholesterol ≤2 mmol/L. However, a recent revision of the of a population heavily medicated with statins. Over half of all UK NICE guidelines 3 set no targets for cholesterol levels – preferring to adults still have a total cholesterol level above 5 mmol/L. advise a 40% LDL cholesterol reduction from baseline for those with Recent changes in the Quality Outcomes Framework (QOF) a 10% or more CVD risk. The Joint British Society (JBS3) guidelines, mean that in future data on cholesterol levels may be lacking. GPs are also updated in 2014, recommend an LDL target of 1.8 mmol/L for no longer rewarded for measuring and recording the cholesterol those at high risk; equivalent to a non-HDL target of 2.5 mmol/L. 4 levels of their patients, with the exception of diabetics. HEART UK Two other changes to the guidelines mean that for most people a has raised concerns that the loss of this incentive to measure and non-fasting cholesterol test is now recommended and that non- record cholesterol levels in patients where cholesterol poses a HDL cholesterol (rather than LDL cholesterol) is now the target of significant risk factor is misguided. 2 treatment. This is because non-HDL cholesterol represents the Dyslipidaemia itself has many causes, both primary (inherited) sum of all atherogenic lipoproteins, including VLDL and IDL. NICE and secondary to other problems. Familial Hypercholesterolaemia guidelines also recommend a 50% LDL cholesterol reduction from (FH) is an under-recognised inherited form of high cholesterol. baseline for those individuals with FH. Whilst it is useful to have FH is the most common condition to be caused by a single gene targets, most lipidologists in the UK would agree that the lower alteration; it affects between 120,000 and 240,000 people in the the cholesterol the lower the risk of coronary heart disease (CHD). UK of which 28,000 are children or teenagers. Less than 15% are currently diagnosed. Lifelong exposure to high cholesterol puts the The role of non starch polysaccharides undiagnosed and untreated at high risk of an early myocardial infarction (MI) often in their 20s, 30s and 40s. (NSP)in heart health By contrast polygenic hypercholesteroleaemia results from Dietary fibres, both soluble and insoluble, are defined as non starch the inheritance of many genes that negatively influence cholesterol polysaccharides (NSP) and are neither digested nor absorbed in the levels. Familial Combined Hyperlipidaemia (FCH), in which both small intestine in humans. cholesterol and triglycerides are raised, is also influenced by many NSP is currently measured and reported in the UK by the genes. Both these conditions are relatively more common than FH, Englyst method of analysis. However, recently, the Scientific Advisory however GPs, dietitians and practice nurses should be aware that Committee for Nutrition (SACN) recommended a move toward the patients with all these conditions will be seen in their clinical practice AOAC method. 5 This means that the UK population average dietary at some time. reference value (DRV) for NSP for adults, currently set at 18 g using the Englyst method, would become 23-24 g using AOAC. In addition, Recommended cholesterol levels SACN, having recognised the health benefits of increasing NSP For healthy individuals a total cholesterol level of ≤5 mmol/L intake, called for an increase in the average DRV for NSP to 30 g per and an LDL cholesterol of ≤3 mmol/L is associated with low risk. day (AOAC) – an increase of around a third.

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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’ products or services. The design and layout of this article is © Complete Media & Marketing Ltd. 2015. re-print - Oatly - Vol15 No6 2015_2015 14/12/2015 12:47 Page 2

Hot Topic | Oats in Cholesterol Lowering Diets

Many cohort studies have demonstrated a and the concentration. Ultimately, it is this populations. 26, 27 Jenkins theorised that a beneficial relationship between increasing viscosity that helps bind bile acids and portfolio of four foods (almonds, soy, NSP 6 and whole grains 7 in the diet and cholesterol and prevent their absorption. 12 sterol fortified spread and soluble fibre) reducing the risk of cardiovascular disease. Other mechanisms, not dependent upon when eaten together, on top of a diet low The mechanism for the reduction of risk is molecular weight and viscosity, include the in saturated fat, would have additive not entirely known, but credible explanations possible fermentation of beta glucan by cholesterol-lowering equal to the sum of include an increase in fibre, vitamin or bacteria within the lower gut to short chain the individual effects of each food. This mineral intake, reduction in plasma lipid and fatty acids which then inhibit a key enzyme dietary approach to cholesterol-lowering 12, 13 glucose levels, as well as the displacement involved in cholesterol synthesis, and the is becoming better established in the UK down regulation of genes involved in the of other foods from the diet. 8 Despite this under the guise of HEART UK’s Ultimate intestinal uptake of lipids. 14 © good evidence, dietary intakes in the UK Cholesterol Lowering Plan (UCLP ). Randomised control trials (RCTs) have remain well below the current average DRV shown that beta glucan lowers total The role of oats and oat of 18 g/day, 9 with lowest intakes in low income cholesterol and LDL cholesterol but has populations. Cereals and cereal products are products no effect on either HDL cholesterol or the biggest contributor to NSP intakes. 9 Oats contain around 10% total fibre and 5, 15-18 triglycerides. The magnitude of the have a greater proportion of soluble fibre The role of beta glucan reduction appears to be greater in those (4%) than any other grain. 11, 28 The oat grain 19 Diets high in soluble fibres (pectin, glucan, with higher baseline cholesterol. Whilst also provides a valuable source of protein 5, 20 gums, psyllium) have been shown to a dose response effect appears logical, (13%) and unsaturated fats (5.3%) and is decrease both total and LDL cholesterol a recent meta-analysis of 28 oat beta naturally low in saturated fats (1.2%). Oats levels. 10, 11 In clinical studies the effect varies glucan RCTs found no evidence of this also supply significant amounts of minerals from 0% to 18% dependent upon the type within a dose range of 3-12 g per day. 19 (magnesium, calcium, iron, zinc) vitamins of soluble fibre, dosage, background diet A similar meta-analysis of 11 barley RCTs (vitamin E, thiamine, folate and B6) and and dietary control. 10 also found no dose related effect. 21 phytochemicals (phytosterols, phenolics Beta glucan is a water soluble fibre and carotenoids). 29 found in cereals grains, particularly oats The Portfolio Diet The consumption of oats has been and barley 11 and is well known for its Soluble fibre, and specifically beta associated with many cardiovascular cholesterol-lowering ability. It is thought glucan, is a key element of the Portfolio benefits, including the reduction in total that there may be a number of mechanisms Diet, an experimental diet shown to and LDL cholesterol. 5, 17, 20, 29-31 Whitehead’s but the main one that is usually cited is the lower cholesterol in hypercholesterolaemic 2014 meta-analysis 19 indicated that ≥3 g oat disruption of the enterohepatic circulation, individuals by 28% in metabolic beta glucan lowered LDL cholesterol by 0.25 see Figure 1. studies, 22-25 and by 20% in free living mmol/L and total cholesterol by 0.3 mmol/L. The enterohepatic circulation describes the recycling of cholesterol rich bile acids. Bile Figure 1: Enterohepatic Circulation – this is disrupted by beta glucan reducing acids are produced in the liver as breakdown bile reabsorption and increasing faecal losses. More cholesterol is then taken products of cholesterol. Cholesterol rich from the circulation to replace the lost bile. bile then passes, via the bile duct, into the duodenum in response to a meal. Bile acts Liver

as an emulsifier, breaking down dietary fat Bile is produced into microscopic droplets with a very large from the breakdown surface area, allowing dietary fat to mix of cholesterol in the liver. intimately with digestive enzymes. Bile is not altered by the process of digestion and under normal circumstances most bile acids are reabsorbed in the small intestine returning to the liver where they can be recycled. Beta glucan acts within the gut to reduce the absorption of bile Bile stored in the gall bladder is and dietary cholesterol. As a result less bile secreted into the Gall bladder is available for recycling and LDL receptors intestines when food are up-regulated to collect more cholesterol is eaten. out of the circulation to produce more bile Portal vein for digestion. As a result blood cholesterol levels are lowered. Small intestine How beta glucan reduces bile and cholesterol absorption Large intestine Within the gut beta glucan fibres swell and become viscous. The viscosity of beta Small amounts of bile Normally most of the bile is absorbed are excreted in faeces. glucan is dependent upon the molecular by the intestines and returned to the weight (which in turn is dependent upon the liver (via the portal vein) for recycling. presence of mixed-linkage polysaccharides) re-print - Oatly - Vol15 No6 2015_2015 14/12/2015 12:47 Page 3

Oats in Cholesterol Lowering Diets | Hot Topic

Although a small reduction, this can make claims enable informative food labelling For most individuals this will provide a valuable contribution to a portfolio of and help spark new innovative products, cholesterol lowering of around 0.3 mmol/L, cholesterol-lowering strategies such as such as oat milks, breakfast cereals and but the effect will be greater for individuals those in the portfolio diet or UCLP ©. oat-containing breads. Although not a with higher baseline cholesterol levels. The inclusion of oats and beta glucan condition of the health claim, companies A number of novel products have made in the diet is also recommended in several should be encouraged to conduct their their way onto the UK market, making it International and UK recommendations for own research to demonstrate the efficacy of easier to achieve a 3 g/day intake. Including the management of dyslipidaemia. 4, 32, 33 these products and alleviate any concerns 2-3 portions of oats (and barley) containing Oats have also been shown to have that processing may have had on the foods each day as part of a portfolio of small beneficial effects on blood pressure products ability to lower cholesterol. cholesterol-lowering foods can have a control, 6, 34-36 incidence of Type 2 diabetes, 5 One such study, using a well known significant cholesterol lowering effect, post prandial blood sugars 30, 37 and satiety. 38 oat milk, demonstrated a 6% cholesterol either alongside of, or before resorting to A number of health claims related to reduction in hypercholesterolaemic men a statin. Suitable foods and their portion cholesterol-lowering have been approved when consumed over five weeks and sizes are illustrated in Table Two . for oat beta glucan worldwide, including compared to rice milk in a randomised The Cholesterol Treatment Trialist’s the United States, 39 Canada, 40 Europe, 41 controlled crossover trial. 44 Collaboration (CTTC) successfully Malaysia, 42 Australia and New Zealand 43 – demonstrated that cholesterol reduction see Table One for UK/EU Claims. With the Conclusion can reduce the five year incidence of MI, exception of Malaysia, these approvals There is strong support for the hypothesis stroke and coronary vascularisation by are based on an intake of 3 g beta glucan that generous intakes of wholegrains, about one fifth for every mmol reduction per day, although the conditions of use including oats, can be cardio-protective. in LDL cholesterol.46 A 1 mmol reduction may vary. In the USA, a claim may be made Beta glucan has been extensively studied in cholesterol is entirely feasible for many where an individual serving contains ≥0.75 g and found to have significant total and LDL people through sustained dietary and of beta glucan; however across Europe cholesterol lowering effects. The magnitude lifestyle intervention, and oats and oat 1 g beta glucan per portion is needed to of this effect is around 5% and appears to products could account for one third of make a similar claim. Approved health plateau out at intakes above 3 g per day. this reduction.

Table One: Health Claims Approved for Use in the UK Table Two: Oat Beta Glucans – Food servings providing 1 or 3 grams

Joint Health The inclusion of oats as part of a diet low 1 g oat beta glucan is provided by: Claims Initiative in saturated fat and a healthy lifestyle can UK 2004 45 help reduce blood cholesterol • 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 EU 2009 – Article Beta glucans contribute to the maintenance • 30 g of oats in recipes that are also low in saturated fat 13.1 claim 30 of normal blood cholesterol levels • 2 slices or 1 roll of LIV or Hovis Hearty Oats bread • 250 ml glass of oat drink/milk EU 2010 – Article Oat beta glucan has been shown to 14 claim 41 lower/reduce blood cholesterol. 3 g oat beta glucan is provided by a single portion of: High cholesterol is a risk factor in the • OatWell products: bran powder, instant drink mix, crispy development of coronary heart disease 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 rigorous primary 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 cardiovascular disease. 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 Nutrition Survey: 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 hypercholesterolaemic effect. 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 Nutritional Biochemistry; 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-fiber oat 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-containing hypocaloric 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 lower plasma 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 randomised controllled 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. 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Scientific Opinion on the substantiation of health claims related to beta-glucans from oats and barley and 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) of Regulation (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 society position paper: Global recommendations for the manangement of dyslipidemia. Accessed online: www.athero.org/download/IASPPGuidelines_FullReport_20131011.pdf (September 2013). 33. AACE (2012). American association for 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 of consuming 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, et al (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 disease pursuant 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 information on 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 5 Weeks 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. re-print - Oatly - Vol15 No6 2015_2015 14/12/2015 12:47 Page 4

oatly.com/hcp This headline would like you to read the bul et points

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.

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)

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.

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* 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.