Last year, I wrote a blog post about an advertorial which appeared in the Telegraph newspaper which featured the apparent effects Flora pro-activ drinks had on supposed ‘journalist’ Chris Jones’ cholesterol levels. I couldn’t trace Chris Jones, and although I was promised that her identity would be verified, this never happened. I did get an email purporting to know Chris Jones, but I’m afraid that won’t do.
But we’re getting side-tracked here, because the main issue for me is not whether Chris Jones exists or not, but the basis on which products like Flora pro-activ are marketed. In short, these and similar products (such as Benecol) contain ‘sterols’ or ‘stanols’ that block cholesterol absorption from the gut and can therefore lower blood cholesterol levels. Lowered cholesterol levels, we are led to believe, will help protect us against heart attacks and strokes. The marketing of products like Benecol and Flora pro.activ is based on these ideas.
But do these assumptions hold up to scrutiny? Do ‘beneficial’ changes in blood fat levels automatically lead to improved health? There’s plenty of evidence to suggest that the answer to this question is ‘no’. For example, here are five drugs or classes of drugs that have been found to ‘benefit’ blood fat levels, none of which have broad benefits for cardiovascular health, and some of which appear to damage health:
fibrates
resins
torcetrapib
ezetimibe
hormone replacement therapy
In fact, the only type of cholesterol-modifying drug that appears to improve cardiovascular outcomes are the statins. However, even these are pretty useless (see here for a recent blog post about this). Plus, questions have been raised about whether statins even exert their beneficial effects through cholesterol reduction. Statins have a number of different mechanisms of action in the body, including anti-inflammatory effects, which might account for their ability to reduce the risk of cardiovascular events. At least some supporting evidence for this idea comes in the form of studies which show that statins can reduce the risk of cardiovascular disease in people with normal or even low levels of cholesterol.
So, for me, the idea that products like Benecol and Flora pro.activ are good for the heart is not evidence-based. Oddly, even the PR representative (Clare Smith) for Flora pro.activ products seems to appreciate this when she comments after the original blog post that:
We absolutely agree that simply lowering cholesterol without making wider positive changes to one’s diet and lifestyle will not make a significant positive health impact.
The reason that I’m writing about this now is because I note that Raisio (manufacturer of Benecol range of foods) and Unilever (manufacturer of Flora pro.activ range of foods) have recently been petitioning the European Food Standards Agency (EFSA) regarding the claims that can be made over the cholesterol-lowering powers of their products. Previously, the claim was made that sterols and stanols can reduce LDL cholesterol by 7-10 per cent as part of a healthy diet. Now, EFSA is apparently happy with that claim be extended to say that these products can lower cholesterol ‘by up to 11.3 per cent’. You can read about this here.
So, these food conglomerates have managed to get the EFSA to up the stated maximum potency of these chemicals by 1.3 per cent (from 10.0 to 11.3 per cent). They’ve also managed to drop any reference to lower levels of benefit. And there’s no mention of average reductions either. Make no doubt about it, these food manufacturers here have done their level best to present their products’ effects in the best possible light.
And they’ve managed to do this by presenting the EFSA with new information, principally in the form of two ‘meta-analyses’ (grouping together of similar studies). These meta-analyses are not published, so you and I cannot read them. They have, most likely, been gathered together by employees of the food companies or ‘scientists’ in their pay. And it’s highly likely that the majority, if not all, of these studies was paid for by the food companies too. It’s well known that the source of funding can influence study design and influence results and how they are reported. Neither of these meta-analyses, by the way, will have been through the process of ‘peer review’ – the process by which researchers check studies for accuracy and veracity of their findings prior to publication.
But, all of this pales into insignificance when one considers the fact that there is simply no evidence that stanol- or sterol-enriched foods benefit health. We actually have some laboratory evidence that they may harm health. In fact, until 2010, sterol-enriched food products were banned in Canada because of concerns about their safety. So, when you see cholesterol-lowering foods being sold on the pretence of having benefits for health my advice is – don’t buy it.
Why not start from first principles and tell us why cholesterol levels matter anyway?
There’s something that’s always puzzled me about Benecol and Flora products and that is why they both made me feel very nauseous after a few days. I don’t take them any more anyway, but why should they have had such an effect on someone who has no problem with dairy products? What else is in these things, I wonder, apart from trans-fats and ‘plant’ sterols/ stanols?
Yossi
Yes, good point. LDL levels do not correlate well with risk of cardiovascular disease. But there’s plenty of money to be made in persuading people that they do.
I just would like to ask you what do you think about the latest reasearch regarding
calcium supplements? I am taking calcium citrate along with Vitamin D3, magnesium, boron,VitaminB complex, Vitamin K2, etc,etc, as you can see I am trying to look after my bones!, plus my health and weight with a low carb diet and intermittent fasting.
I just find difficult to believe in the mayority of the researchs because of the big corporation behind most of them.
My excellent Medical Herbalist put her mother on Red Yeast Rice capsules for high cholesterol and it reduced from over 6 ++ to 4.5. I have been taking 2 x 400 mg red yeast rice daily for two years and my Cholesterol has lowered . I am always sensitive to side effects of pharmaceutical drugs and have sensitive stomach and all herbal meds I have taken have never upset me – and they work. I neve take stanol based product but have seeds and healthy oils and daily fruit and veg – combine that with not sitting still for more than an hour – and I am keeping healthy at at 64 weigh a few lbs less than when I was 21!! I don’t trust US & UK systems of medicine which are ‘married’ to pharmaceutical industry.
Hi Dr:
Dr. Peter Attia over at waroninsulin.com just finished a 5-part blog series arguing that cholesterol is highly meaningful for disease. He insists that LDL particle count is critical and must be reduced, linking to lectures that discuss when to take statins, metformin, or both. So I guess he’s abandoned his friend Gary Taubes on this. Anyway if LDL particle count is so key, why do about 40% of those with CVD have normal LDL? I don’t know what to think any more; it’s too confusing. If LDL doesn’t count, why not? Is Attia’s long argument wrong?
@Diana – I take a similar combination for my bone health as well, and it is my understanding that one of the main functions of K2 is to remove calcium from the bloodstream and place it in the bone matrix.
I would like the answers to some questions: (1) What are the health risks of low cholestorol?
(2) Is raised cholestorol a health risk or just a symptom, bearing in mind that the liver produces three quarters of the body’s cholestorol irrespective of diet? (3) If the true cause of cardiovascular events and other degenerative disease is chronic inflammation, what is driving this? (4) Does the body overproduce cholestorol in an attempt to deal with chronic inflammation? (5) What is the point of blaming the sticking plaster for the wound? (6) Is the cholestorol saga just another example in the long running medical tradition of treating symptoms and not causes?
I wrote to Benecol a while ago asking about their products and I specifically asked if they contain trans fats. Yes they do ! This is what they wrote:
“Trans fats are only present within Benecol® foods at a very low level. The amount of trans fats in the Benecol® spreads are amongst the lowest in the market when compared to comparable products in the marketplace.”
Are trans fats heart healthy ? NO ! NO ! NO !
I have slightly above the line cholestorol levels which over the years since my first test have always been the same. I asked my G.P. what I could eat to lower my Cholestorol and her answer was “the food you eat only amounts to 10% of your Cholestorol the rest your body makes”. She then went through all the food I should be eating for a healthy life; then went on to tell me the foods I shouldn’t eat. When I explained that I already eat the healthy foods and have never eaten the ones I shouldn’t eat. She shrugged and said then there wasn’t much that I could do about my Cholestorol. My present G.P. and the consultant for geriatrics in my area asked me to stop my anti-inflammatory’s to bring down my blood pressure. I did and I also get to the surgery with enough time to sit quietly before going in to see my doctor – this also lowers my blood-pressure. I also walk to the surgery because I am sure the angst I have when trying to park anywhere near the surgery didn’t do my BP much good either.
One article I recently read was very interesting. The Influence of Sources of Dietary Oils on the Life Span of Stroke-Prone Spontaneously Hypertensive Rats by Ratnayake, et al. The life span of SHRSP rats was altered by the consumption of phytosterols. The higher the consumption, the quicker they died.
Confused
I’m not familiar with Paul Attia’s blog series, but do believe LDL particle number/size may be relevant. However, LDL-C concentrations don’t tell us about either of these parameters. Also, we have a ton of evidence which supports the idea that cholesterol reduction is not broadly benefifical for health. Plus, statins as they’re currently simply do not benefit the vast majority of people that take them, and may well not work through mechanisms that involve cholesterol anyhow.
If statins reduce inflammation in the body would it not be wise then to be taking them , if not for cholestrol lowering but to reduce the inflammation, therefore reducing the risk of heart disease? I am really confused about the whole thing.
30 years ago when the Cholesterol saga was kicking off, Scientific American put it pretty succinctly (I think it was March or April of 1980) – “Cholesterol levels are highly sensitive to stress. You can affect the level of cholesterol in your blood 4 times more by worrying about what you eat, than you can by eating it”.
Did you know that a reindeer has different levels of cholesterol in its tissue all the way down its legs? Cholesterol is needed to make cell membranes flexible. So in the core of the body, where the temperature is around 38*C (or is it 39.x in a reindeer), cholesterol is at normal levels of about 12% of the membrane. At the ankle (equivalent to a human’s ball of the foot – near the ground and near 0*C snow, anyway), cholesterol may make up 70% of the membrane because the lower temperature means it needs more cholesterol to be flexible.
There are safer ways to reduce inflammation, like fish oil
I would have thought that it would be a lot safer to take Omega 3 oil or turmeric, for instance, to lower inflammation, than it is to take statins, which are implicated in more and more nasty side effects.
Thanks Dr Briffa, it truly amazes me that some (many?) people are still being taken in by the health claims of margarines!
You can read Dr Attia detailed posts about Cholesterol here: The straight dope on cholesterol – Part VI… This series is, in my view, well worth reading, very enlightening but not yet complete.
@Confused, yes as Dr Briffa mentioned and as Dr Attia makes very clear: LDL-C which is what we normally get reported by the standard lipid/cholesterol blood test is NOT the same as LDL-P (LDL particle count) which is rarely if ever tested (so far). LDL-P seems to be the important one, while LDL-C is the one which statins are so very good at lowering… even if that does not good (and may even cause harm) for many of us.
I do not think Dr Attia has given up his support for Gary Taubes’ position 😉
@Rosemary Miles: as I understand it, Red Yeast Rice has the same action as most statins… it lowers LDL-C, which we have been convinced is important, but I am convinced ever more each day, is not.
I’m a good example. I have heterozygous familial Hypercholesterolaemia and over the years I have been on red yeast rice and lots and lots of what is called complex carbs, especially oats. Without the pills (I’m only on fibrates since our family very quickly develops rhabdomyolises on statins) the cholesterol went forever up. None of these things manged to bring it down a smidgen. Only the ketogenic diet managed that and extremely so too. It almost normalised my afore extremely high numbers – my numbers will have shocked this entire blog. My GP is ecstatic with the outcome. Of course, I had to go on the diet of my own accord. No doctor would have backed me. Now my one son has also gone onto it for the same problem. Not a single supplement or special grain or supplement has ever managed to bring down our type of cholesterol numbers. Doctors sighed and some were outright filled with trepidation when they see any of my family coming in. I can never go off this diet ever again. Got to get the rest of my family on it as well. There was never a single edible anything out there (I tried them all) which worked better or even equally as good as statins. None. Without meds whenever I tried these things like red rice, it simply shot up into the sky and I was always afraid and saddened with all outcomes. The ketogenic diet feels like something I have found out really late and I’m quite cross about that. Surely the science was there always in our faces? Sorry to sound negative about all the “goodies” out there, but for us, they were like homeopathic stuff (also went THAT sad route). Truly sorry about that.
Dr. Chris Masterjohn, a lipid researcher and ancestral nutrition advocate, parts company with Dr. Attia regarding the importance of LDL particle size. In his view, what’s ultimately important is LDL receptor function, and by implication, the time LDL particles spend in the bloodstream. The longer they stay there, the more likely they are to lose their cholesterol to other parts of the body. LDL particle size, therefore, may be a proxy for time spent in the blood and a marker for poor receptor function. He’s not convinced, though, that LDL particle size, per se, is directly relevant. You can get all the nitty gritty details in a 3-part interview that Dr. Chris Kessler did with Masterjohn on Kessler’s site (http://chriskresser.com/category/podcasts/). If you make it all the way through the interview, you are entitled to an honorary masters in lipid science.