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CN
Oats and Oat Products in
Cholesterol Lowering Diets
CN
Linda Main, BSc RD, Dietetic Adviser at HEART UK
– The Cholesterol Charity, and Freelance Dietitian
CN
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 cholesterol
Average UK cholesterol levels are decreasing but this is reflective
of a population heavily medicated with statins. Over half of all UK
adults 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 are
no longer rewarded for measuring and recording the cholesterol
levels of their patients, with the exception of diabetics. HEART UK
has raised concerns that the loss of this incentive to measure and
record cholesterol levels in patients where cholesterol poses a
significant 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 gene
alteration; it affects between 120,000 and 240,000 people in the
UK of which 28,000 are children or teenagers. Less than 15% are
currently diagnosed. Lifelong exposure to high cholesterol puts the
undiagnosed and untreated at high risk of an early myocardial
infarction (MI) often in their 20s, 30s and 40s.
By contrast polygenic hypercholesteroleaemia results from
the inheritance of many genes that negatively influence cholesterol
levels. Familial Combined Hyperlipidaemia (FCH), in which both
cholesterol and triglycerides are raised, is also influenced by many
genes. Both these conditions are relatively more common than FH,
however GPs, dietitians and practice nurses should be aware that
patients with all these conditions will be seen in their clinical practice
at some time.
Recommended cholesterol levels
For healthy individuals a total cholesterol level of ≤5 mmol/L
and an LDL cholesterol of ≤3 mmol/L is associated with low risk.
Until recently those with existing, or higher risk of, cardiovascular
disease (CVD) were advised to aim for a total cholesterol ≤4 mmol/L
and an LDL cholesterol ≤2 mmol/L. However, a recent revision of the
NICE guidelines3 set no targets for cholesterol levels – preferring to
advise a 40% LDL cholesterol reduction from baseline for those with
a 10% or more CVD risk. The Joint British Society (JBS3) guidelines,
also updated in 2014, recommend an LDL target of 1.8 mmol/L for
those 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 a
non-fasting cholesterol test is now recommended and that nonHDL cholesterol (rather than LDL cholesterol) is now the target of
treatment. This is because non-HDL cholesterol represents the
sum of all atherogenic lipoproteins, including VLDL and IDL. NICE
guidelines also recommend a 50% LDL cholesterol reduction from
baseline for those individuals with FH. Whilst it is useful to have
targets, most lipidologists in the UK would agree that the lower
the cholesterol the lower the risk of coronary heart disease (CHD).
The role of non starch polysaccharides
(NSP)in heart health
Dietary fibres, both soluble and insoluble, are defined as non starch
polysaccharides (NSP) and are neither digested nor absorbed in the
small intestine in humans.
NSP is currently measured and reported in the UK by the
Englyst method of analysis. However, recently, the Scientific Advisory
Committee for Nutrition (SACN) recommended a move toward the
AOAC method.5 This means that the UK population average dietary
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,
SACN, having recognised the health benefits of increasing NSP
intake, called for an increase in the average DRV for NSP to 30 g per
day (AOAC) – an increase of around a third.
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’ products
or services. The design and layout of this article is © Complete Media & Marketing Ltd. 2015.
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Hot Topic | Oats in Cholesterol Lowering Diets
Many cohort studies have demonstrated a
beneficial relationship between increasing
NSP6 and whole grains7 in the diet and
reducing the risk of cardiovascular disease.
The mechanism for the reduction of risk is
not entirely known, but credible explanations
include an increase in fibre, vitamin or
mineral intake, reduction in plasma lipid and
glucose levels, as well as the displacement
of other foods from the diet.8 Despite this
good evidence, dietary intakes in the UK
remain well below the current average DRV
of 18 g/day,9 with lowest intakes in low income
populations. Cereals and cereal products are
the biggest contributor to NSP intakes.9
and the concentration. Ultimately, it is this
viscosity that helps bind bile acids and
cholesterol and prevent their absorption.12
Other mechanisms, not dependent upon
molecular weight and viscosity, include the
possible fermentation of beta glucan by
bacteria within the lower gut to short chain
fatty acids which then inhibit a key enzyme
involved in cholesterol synthesis,12, 13 and the
down regulation of genes involved in the
intestinal uptake of lipids.14
Randomised control trials (RCTs) have
shown that beta glucan lowers total
cholesterol and LDL cholesterol but has
no effect on either HDL cholesterol or
triglycerides.5,
15-18
The magnitude of the
The role of beta glucan
reduction appears to be greater in those
Diets high in soluble fibres (pectin, glucan,
gums, psyllium) have been shown to
decrease both total and LDL cholesterol
levels.10, 11 In clinical studies the effect varies
from 0% to 18% dependent upon the type
of soluble fibre, dosage, background diet
and dietary control.10
Beta glucan is a water soluble fibre
found in cereals grains, particularly oats
and barley11 and is well known for its
cholesterol-lowering ability. It is thought
that there may be a number of mechanisms
but the main one that is usually cited is the
disruption of the enterohepatic circulation,
see Figure 1.
The enterohepatic circulation describes
the recycling of cholesterol rich bile acids. Bile
acids are produced in the liver as breakdown
products of cholesterol. Cholesterol rich
bile then passes, via the bile duct, into the
duodenum in response to a meal. Bile acts
as an emulsifier, breaking down dietary fat
into microscopic droplets with a very large
surface area, allowing dietary fat to mix
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
and dietary cholesterol. As a result less bile
is available for recycling and LDL receptors
are up-regulated to collect more cholesterol
out of the circulation to produce more bile
for digestion. As a result blood cholesterol
levels are lowered.
with higher baseline cholesterol.19 Whilst
How beta glucan reduces
bile and cholesterol
absorption
Within the gut beta glucan fibres swell
and become viscous. The viscosity of beta
glucan is dependent upon the molecular
weight (which in turn is dependent upon the
presence of mixed-linkage polysaccharides)
populations.26, 27 Jenkins theorised that a
portfolio of four foods (almonds, soy,
sterol fortified spread and soluble fibre)
when eaten together, on top of a diet low
in saturated fat, would have additive
cholesterol-lowering equal to the sum of
the individual effects of each food. This
dietary approach to cholesterol-lowering
is becoming better established in the UK
under the guise of HEART UK’s Ultimate
Cholesterol Lowering Plan (UCLP©).
a dose response effect appears logical,5, 20
a recent meta-analysis of 28 oat beta
glucan RCTs found no evidence of this
within a dose range of 3-12 g per day.19
A similar meta-analysis of 11 barley RCTs
also found no dose related effect.21
The Portfolio Diet
Soluble fibre, and specifically beta
glucan, is a key element of the Portfolio
Diet, an experimental diet shown to
lower cholesterol in hypercholesterolaemic
individuals
by
28%
in
metabolic
studies,22-25 and by 20% in free living
The role of oats and oat
products
Oats contain around 10% total fibre and
have a greater proportion of soluble fibre
(4%) than any other grain.11, 28 The oat grain
also provides a valuable source of protein
(13%) and unsaturated fats (5.3%) and is
naturally low in saturated fats (1.2%). Oats
also supply significant amounts of minerals
(magnesium, calcium, iron, zinc) vitamins
(vitamin E, thiamine, folate and B6) and
phytochemicals (phytosterols, phenolics
and carotenoids).29
The consumption of oats has been
associated with many cardiovascular
benefits, including the reduction in total
and LDL cholesterol.5, 17, 20, 29-31 Whitehead’s
2014 meta-analysis19 indicated that ≥3 g oat
beta glucan lowered LDL cholesterol by 0.25
mmol/L and total cholesterol by 0.3 mmol/L.
Figure 1: Enterohepatic Circulation – this is disrupted by beta glucan reducing
bile reabsorption and increasing faecal losses. More cholesterol is then taken
from the circulation to replace the lost bile.
Liver
Bile is produced
from the breakdown
of cholesterol
in the liver.
Bile stored in the
gall bladder is
secreted into the
intestines when food
is eaten.
Portal vein
Gall bladder
Small intestine
Large intestine
Small amounts of bile
are excreted in faeces.
Normally most of the bile is absorbed
by the intestines and returned to the
liver (via the portal vein) for recycling.
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Oats in Cholesterol Lowering Diets | Hot Topic
Although a small reduction, this can make
a valuable contribution to a portfolio of
cholesterol-lowering strategies such as
those in the portfolio diet or UCLP©.
The inclusion of oats and beta glucan
in the diet is also recommended in several
International and UK recommendations for
the management of dyslipidaemia.4, 32, 33
Oats have also been shown to have
small beneficial effects on blood pressure
control,6, 34-36 incidence of Type 2 diabetes,5
post prandial blood sugars30, 37 and satiety.38
A number of health claims related to
cholesterol-lowering have been approved
for oat beta glucan worldwide, including
the United States,39 Canada,40 Europe,41
Malaysia,42 Australia and New Zealand43 –
see Table One for UK/EU Claims. With the
exception of Malaysia, these approvals
are based on an intake of 3 g beta glucan
per day, although the conditions of use
may vary. In the USA, a claim may be made
where an individual serving contains ≥0.75 g
of beta glucan; however across Europe
1 g beta glucan per portion is needed to
make a similar claim. Approved health
claims enable informative food labelling
and help spark new innovative products,
such as oat milks, breakfast cereals and
oat-containing breads. Although not a
condition of the health claim, companies
should be encouraged to conduct their
own research to demonstrate the efficacy of
these products and alleviate any concerns
that processing may have had on the
products ability to lower cholesterol.
One such study, using a well known
oat milk, demonstrated a 6% cholesterol
reduction in hypercholesterolaemic men
when consumed over five weeks and
compared to rice milk in a randomised
controlled crossover trial.44
Conclusion
There is strong support for the hypothesis
that generous intakes of wholegrains,
including oats, can be cardio-protective.
Beta glucan has been extensively studied
and found to have significant total and LDL
cholesterol lowering effects. The magnitude
of this effect is around 5% and appears to
plateau out at intakes above 3 g per day.
Table One: Health Claims Approved for Use in the UK
Joint Health
Claims Initiative
UK 200445
The inclusion of oats as part of a diet low
in saturated fat and a healthy lifestyle can
help reduce blood cholesterol
EU 2009 – Article Beta glucans contribute to the maintenance
of normal blood cholesterol levels
13.1 claim30
EU 2010 – Article
14 claim41
Oat beta glucan has been shown to
lower/reduce blood cholesterol.
High cholesterol is a risk factor in the
development of coronary heart disease
For most individuals this will provide
cholesterol lowering of around 0.3 mmol/L,
but the effect will be greater for individuals
with higher baseline cholesterol levels.
A number of novel products have made
their way onto the UK market, making it
easier to achieve a 3 g/day intake. Including
2-3 portions of oats (and barley) containing
foods each day as part of a portfolio of
cholesterol-lowering foods can have a
significant cholesterol lowering effect,
either alongside of, or before resorting to
a statin. Suitable foods and their portion
sizes are illustrated in Table Two.
The Cholesterol Treatment Trialist’s
Collaboration
(CTTC)
successfully
demonstrated that cholesterol reduction
can reduce the five year incidence of MI,
stroke and coronary vascularisation by
about one fifth for every mmol reduction
in LDL cholesterol.46 A 1 mmol reduction
in cholesterol is entirely feasible for many
people through sustained dietary and
lifestyle intervention, and oats and oat
products could account for one third of
this reduction.
Table Two: Oat Beta Glucans – Food servings providing
1 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 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-andreports/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:
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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-rollingprogramme-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
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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
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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 Serum
Lipids 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.
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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). Effect
of 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: A
Statement 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 and
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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
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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. SalasSalvado 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/assessevalu/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
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oatly.com/hcp
This headline would
like you to read
the bullet 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.
-------------------------------------------------------* 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.