The Cardio Conundrum

First, the good news: The single most powerful tool for substantively reducing our heart disease risk is our willingness to make simple diet and lifestyle changes. Now, the bad news: The single most powerful tool for substantively reducing our heart disease risk is that same willingness to make simple diet and lifestyle changes. This endorsement of personal responsibility is both blessing and curse because, as anyone whos tried to shake a bad habit can attest, theres nothing easy about "simple" changes.

Heart disease, already the leading cause of death among American women and men, swallows significant health resources and will continue to do so until a whole lot of us work to reverse it. According to 2005 estimates from the American Heart Association (AHA), Dallas, 80,700,000 American adultsthats one in threehave one or more types of cardiovascular disease, or CVD. In 2004, nearly 2,400 Americans died of CVD each day. Directly and indirectly, CVD and stroke could cost our nation $448.5 billion in 2008 alone.

Faced with such numbers, do we just throw up our hands and concede that people will eat what they want, even it if kills them and costs us? Do we take the opposite tack and enact a sort of nutritional Stalinism that demands orthodoxy of all eaters? Or do wethe clever food technologists and product developers of the worldoffer a middle way that, if not quite letting us have our cake and eat it, too, at least provides options that make feeding a healthier heart a relatively effortless lifestyle change?

More than high or low

The takeaway is that, if we hope to fight heart disease with dietary weapons, well need a full arsenal capable of going after all the different factors that trigger it: circulating triglycerides; the ratio of "bad" low-density lipoprotein (LDL) cholesterol to "good" high-density lipoprotein (HDL) cholesterol; LDL oxidation; and inflammation. "I dont think anyone questions the fact that cholesterol is playing a role," says Karen Lapsley, D.Sc., director of scientific affairs, Almond Board of California, Modesto, "but its probably not as simplistic as high or low. Its going to be multifactorial."

Carol Berg Sloan, R.D., health and nutrition consultant, California Walnut Commission, Folsom, agrees: "When people go to the doctor, they dont just check your cholesterol anymore. They check inflammatory markers such as C-reactive protein (CRP), cytokinesall these substances that will appear when there is inflammation going on." She notes the importance of LDL oxidation, as well. "If you start looking specifically at the different-sized particles of the cholesterol in the body and how they attach themselves as plaques to vascular walls," she says, "you see that oxidation has a huge role, because those oxidized molecules can wreak havoc. They become too large. Theyre sticky."

Figuring out which foods and nutrients affect these processes may be the food industrys "moon shot" in the coming years. As Hartley Pond, technical sales manager, VDF FutureCeuticals, Santa Rosa, CA, says: "There are food products that are good for controlling blood pressure. There are others that are good for controlling cholesterol. There are some that are for controlling oxidation of cholesterol. Then there are others aimed at metabolic syndrome, syndrome X and diabetes. Its a broad range." But broad can be overwhelming. Even so, he says, "theres just a wealth of opportunity to develop products in this area."

Being able to clinch any of FDAs heart-health claims positions a product to sell handily. The agency currently sanctions heart-health claims relating to fruits, vegetables and grain products containing fiber; products containing dietary soluble fiber from oats, psyllium seed husk and barley; whole-grain foods; soy protein; and sterol and stanol esters. Potassium earned a health claim in 2000 for its ability to reduce the risk of high blood pressure and stroke, and qualified heart-health claims exist, as well, for tree nuts such as almonds and walnuts, and for the long-chain omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA).

Fiber: The beta version

Such statements count to consumers, who spent $4.7 billion on foods with heart-health claims in 2006, according to an April 2007 report from Datamonitor, New York. Yet, product developers still have a lot to do to determine which ingredients can deliver on their promise, and in which products.

Take soluble fibers from oats and barley, for example. The specific fermentable form, known as beta-glucan, creates a viscous gel in the gastrointestinal tract that research shows reduces blood cholesterol by decreasing the cholesterol or fatty-acid absorption, and by decreasing absorption of biliary cholesterol or bile acids. Animal models have shown glucan fibers alter cholesterol metabolism, perhaps by affecting serum concentrations of hormones and short-chain fatty acids involved in lipid metabolism. Still more studies hint at the actions of tocotrienols and vitamin E found in oats and barleyeven of oats arginine-to-lysine ratioin lowering cholesterol. But much of this buzz is as-yet provisional.

In any case, numerous studies show "the value of incorporating whole grains in ones diet," Pond says. His companys line of patented soluble-fiber products "allows formulators to achieve higher levels of soluble fiber of the beta-glucan fraction, and improve mouthfeel and textural qualities in many food applications." Made from oats and barley, and in some cases including soy protein and brown rice bran, the line is produced using USDA-developed mechanical processes.

"Consumers have long associated whole grainsparticularly oat bran and, more recently, barley branwith good heart health," Pond says. And some of the products in the line qualify for that coveted health claim. The lines flagship oat-bran ingredient clocks in at 10% oat beta-glucan fiber. So, to hit the 0.75-gram-per-serving floor the FDA claim requires, a formulation would need only 7.5 grams of the product per serving, he says.

What Pond really likes about the product is its effect on texture and quality. Anyone whos tried to formulate with traditional oat bran can appreciate its "functional limitations." In contrast, he says, the products "provide a creamy, fat-mimetic mouthfeel that allows formulators to replace fats in formulations without losing the sensory and textural qualities of a high-fat food"all with a little kick of fiber.

Somethings fishy

Another formulation challenge was fortification with fish oils rich in omega-3 fatty acids. But the heart-health benefits of these polyunsaturated fats have led to improved ingredient lineups, now appearing in a wider range of foods.

Western medicine first took an interest in omega-3s after noting the surprisingly low rates of CVD and sudden cardiac deaths in Alaskan natives, Greenland Eskimos and Japanese who eat fish frequently. Consumption of coldwater fatty fish correlated with the highest levels of coronary protection, and researchers zeroed in on the long-chain omega-3s DHA and EPA as the likely benefactors. Research to date holds that they decrease the risk of arrhythmias that can lead to sudden cardiac death, decrease triglyceride levels, slow the growth rate of atherosclerotic plaque, slightly lower blood pressure, and may act as anticoagulants to prevent blood clotting.

Yet DHA and EPA are not created equal. "Both of them are important. That has to be emphasized," says Ernesto Hernandez, Ph.D., director of process development, Omega Protein, Inc., Houston. But, whereas DHA acts more as a building block in our neural and ocular tissues"our brains, the eyes, the retina, the neurological system: theyre loaded with DHA," he notesEPA, on the other hand, acts more directly on heart health.

One theory points to its role as an anti-inflammatory, Hernandez says. In fact, he adds, its ethyl-ester form has even received FDA approval as a drug for heart patients. As for the link between omega-3s and prevention of sudden cardiac death, that, too, may trace to EPA. "EPA can help our heart beat at a regular rhythm, if you will," he explains. "And thats important, because heart attacks sometimes can happen from arrhythmia, for example."

Another omega-3, alpha-linolenic acid, or ALA, is the short-chain precursor to DHA and EPA found largely in plant sources such as flaxseed, walnuts, seaweed and soybean oil. But, its not as actively involved in heart health, nor is its conversion into long-chain products very biologically efficient. Hernandez says this conversion is only about 5%, "so the consumer would have to take 20 times the amount of omega-3 short-chain fat to get the benefits of the long-chain omega-3s."

So, ingredient suppliers and product developers have made long-chain omega-3s, frequently in the form of fish oils, the ingredients of choice for fortification. "Our oil comes from menhaden fish," Hernandez says, "and the ratio of EPA to DHA is about 1:1." That ratio varies by source, with a sardine oil being closer to 1.5:1, and oil from tuna leaning heavily toward DHA. "But, as for what is the right ratio," he says, "not much information is available on that. As long as you take some of both, youll be OK."

Equally uncertain is how much EPA and DHA we need to add to a product. "Thats the $64,000 question for nutritionists and food scientists like myself," Hernandez says. "Several health institutions recommend 0.5 to 1.0 grams of EPA and DHA per day." The AHA recommends healthy adults eat at least two servings a week of fatty fish to buck up their stores, and it also cites evidence from prospective secondary prevention studies suggesting that EPA and DHA doses in the range of 0.5 grams to 1.8 grams per day, either from fatty fish or via supplements, significantly reduce deaths from heart disease and all causes. Suggested ALA totals are a bit higher, with 1.5 grams to 3.0 grams per day appearing beneficial.

Whatever the amounts, formulators need to take care when fortifying with omega-3s, because of their sensitivity to oxidation. "Omega-3 fish oils are refined and purified, but as polyunsaturated fats, they are very unstable, and exposure to air, light and heat will cause them to degrade and turn rancid," says Mary Ann Siciliano, national sales manager, Arista Industries, Inc., Wilton, CT. "The ideal conditions for omega-3 fatty acids are in closed systems without exposure to air, light or heat." Given this, she says, "the most success with incorporating omega-3 fatty acids in food products has been in refrigerated dairy products, such as yogurt, and in some bakery items."

Encapsulated fish oils provide a degree of oxidation resistance, but even so, Hernandez says, "you want to add the fish oil or encapsulated fish oil into food blends where there is just a moderate amount of heating and minimum exposure to air." But the oil does "behave very well in a dry environment," he says, opening up applications in nutrient coatings on flaked cereal, or in compound coatings on an energy bar. "As long as the product is packaged properly and kept away from air, shelf life of foods with fish oil is reasonable," he continues.

Cholesterols vegetarian cousin

Omega-3s give the lie to the popular perception of all fat as cardiac enemy No. 1. Another apparent paradox: Consuming the plant worlds equivalent of cholesterol might actually help us lower our own.

Plant sterols, or phytosterols, are components of plant membranes whose chemical structure mirrors that of animal cholesterol. When we take in small amounts of plant sterols in fruits, vegetables, nuts, seeds, grains, legumes, vegetable oils and fortified foods, the sterols resemblance to cholesterol causes our digestive system to mistake them for the latter. "As you digest a meal, plant sterols compete with the cholesterol, so you absorb less of the cholesterol," says Pam Stauffer, global marketing programs and communications manager, Cargill Health & Nutrition, Minneapolis.

More specifically, a diet with a high phytosterol-to-cholesterol ratio gives plant sterols the advantage in "beating" cholesterol at forming mixed micelles that transport cholesterol and allow its absorption through the intestinal wall. With fewer cholesterol-laden micelles, we reduce the amount of cholesterol we absorb, and the overall effect in clinical trials, Stauffer says, "has been an average LDL cholesterol decline of 8% to 15%, with no known side effects."

Plant sterols have attracted considerable clinical study over the past half-century, and the evidence of their cholesterol-lowering ability has led the U.S. National Cholesterol Education Program of the National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, to include them in their dietary recommendations, Stauffer says. Adding to their credibility is FDAs heart-health claim stating that foods with at least 0.4 grams of plant sterols per serving eaten twice a day with meals for a daily total intake of at least 0.8 grams, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease.

Stauffers company offers soybean-derived plant sterols that permit fortification of "a wide variety of food, beverage and dietary supplement applications," she says. The line includes water-insoluble sterols, as well as an emulsified sterol and a dispersible sterol ester for aqueous systems. The ingredients are inert and relatively easy to work with. "The only thing to watch out for is typical fat oxidation when using the sterol ester forms," she says. The sterols themselves have a much higher melt pointabout 285°Fthan do the esters, which melt at around 95°F, which means that "retort and HTST temperatures are safe for sterols," she points out. The sterols and their esters can withstand the temperatures and pressures of homogenization, a process that disperses the ingredients throughout the food matrix. "This provides a homogeneous mixture, which is nutritionally important," she says.

Heart health at the micro level

Despite their diversity of action and effects, phytosterols, omega-3s and fiber share a key commonality: Theyre all macronutrients. But what about the heart-health effects of micronutrient vitamins, minerals and phytochemicals?

FDA has granted good food sources of potassium (if theyre also low in sodium) a health claim touting their ability to reduce the risk of high blood pressure and stroke, and also allowed a qualified health claim for B vitamin supplements stating that folic acid, vitamins B₆ and B₁₂, as part of a diet low in saturated fat and cholesterol, may reduce vascular disease risk. Folic acid, in particular, has promise for reducing levels of the inflammatory marker homocysteine.

Other, less well-known micronutrients are getting into the picture, too. For example, vitamin K₂ might help solve the "calcium paradox." As Rodger Jonas, food scientist, P.L. Thomas, Morristown, NJ, explains: "Supplementation with calcium doesnt do everything you think it does. We have extensive studiessomething like 4,700 people over 10 years in one studythat indicate that, when you take high levels of calcium, it doesnt necessarily go where you want it to. Some of it goes into the bones, where you want it to go. However, some of it winds up in the blood serum and in the arteries. As a result, this may wind up being a bigger causal factor of heart attacks than cholesterol." Why? "What better way to harden your arteries than to put calcium in them?" he says.

P.L. Thomas markets a natural form of vitamin K₂ that, Jonas says, "takes calcium out of the arteries and capillaries and puts it into the bones." The result: "Your blood flow improves," he says. "Your blood pressure goes down, because theres nothing clogging those pathways. Our studies showed a direct correlation with a 50% reduction of arterial calcification and a 50% reduction in coronary heart attacks. Twenty to 35 micrograms per day is all you need." At that level, no noticeable effects on product flavor, color or other sensory properties arise. "We tell you to break it up into multiple doses10 micrograms per dose. And youll never notice it," he says. Despite being fat-soluble, its available in powdered and water-dispersible forms for any number of products. And, while clear beverages probably arent the best choices, he says dairy items make great vitamin K₂ applications.

Also looking at vascular health, P.L. Thomas has seized on grape seed extracts, antioxidant polyphenols with a very high ORAC value. Weve all heard about the French paradoxs wine polyphenols that supposedly protect the heart against the ravages of LDL oxidation. Grape seed antioxidants might do the same thing, as well as provide blood-pressure-lowering capabilities. Studies have shown it lowers diastolic pressure by 8% and systolic by 5%. While FDA wont let you plaster that all over a label, verbiage such as "promotes normal blood pressure" could pass the test, Jonas says.

Whole foods for heart health

Theres a gee-whiz appeal to isolating polyphenols, coenzyme vitamins or heart-healthy fats from whole-food sources and transplanting them into popular everyday products, like snacks, beverages and bars. But the whole food is naturally effective at effectuating heart health.

For example, walnuts contain gamma-tocopherol, a form of vitamin E that acts as a potent antioxidant. "And then there are numerous polyphenol antioxidants in walnuts that havent even been identified yet," Berg Sloan says. Walnuts contain the ALA precursor to long-chain omega-3s, and a Nov. 2004 study published in the Journal of Nutrition (134:2,991-2,997) found a 30% reduction in CRP in subjects who ate walnuts every day. "Weve done about 17 clinical studies, and we try to make a realistic portion size. It takes between 1.0 and 1.5 oz. per day for you to see the benefits," she says.

Almonds have also demonstrated heart-healthy properties that might result from healthful monounsaturates, polyphenolic content and relatively high levels of vitamin E. After researchers in Canada determined that almond skins contain four different types of flavanol glycosides, a team at Tufts University, Medford, MA, looked into what effects those antioxidant-rich skins had on LDL oxidation. They learned the polyphenols prevent LDL oxidation and that almonds vitamin E "synergizes" with them, further halting oxidation. In a separate meta-analysis of seven almond studies, researchers found a 5.3% to 7.2% decrease in total cholesterol attributable to almonds, while LDL levels dropped to an even greater extent6.8% to 10%in hypercholesterolemic subjects.

For applications where the whole food might be a little too whole for the good of the product, the happy medium might come in the form of ingredients that carry a natural pedigree without being stripped of all the constituents that make it healthy to begin with. Take, for example, pectin, a soluble fiber found in abundance in many fruits. Pectin is reported to lower serum cholesterol, particularly LDL, but adding whole fruit to many products just is not always feasible.

Instead, says Camille Nava-Janssens, director of sales, North America, Marroquin Organic International, Santa Cruz, CA, formulators might want to consider a new ingredient set to be launched by the company, a non-GMO citrus pectin/fiber pomace product with approximately 8% pectin, "derived from domestic juiced citrus. It is the peel, which has been deoiled, with sugars and alcohol removed, and the deseeded pulp," she says. "Then it is dried and milled into powder or small, but meal-type, mesh." It not only provides approximately 80% total dietary fiber, but maintains a good dose of the fruits antioxidant bioflavonoids: narirutin, naringin and hesperidin. Several animal studies indicate these flavonoids might exert a positive influence on cholesterol. Plus, she notes, it functions as a prebiotic and, as an added bonus, increases baked goods shelf life, too.

"People want science. They want evidence-based research," Berg Sloan says. But "were at a very new stage of research for many foods, finding out how they fit into a healthy diet. And I think that a lot more research needs to be done. This pulling components or nutrients out of foodsI dont know if thats a good way to go, because I think that theres a lot to be said for the synergistic effects of whole foods in the diet."

Pond would agree: "When people were putting Gingko biloba into potato chips back in the late90s, I think that did more harm to the industry than good. People see through that as a fad, a gimmick. Most consumers see through a disingenuous strategy of putting a heart-healthy halo on a clearly unhealthy product, and most marketers and formulators recognize the downside of such formulations." FDA doesnt allow heart-health claims on foods that are egregiously high in saturated fat, sodium or cholesterol. And, "as time has gone on, and particularly with heart health, I havent had too many people come to us with a product that seemed to be a gimmick," he continues. "Most companies we work with are really trying to do the right thing." And when they do, they make it that much easier for consumers to do the same.

Kimberly J. Decker, a California-based technical writer, has a B.S. in Consumer Food Science with a minor in English from the University of California, Davis. She lives in the San Francisco Bay area, where she enjoys eating and writing about food. You can reach her at [email protected].