The cholesterol juggle

Top cholesterol-fighting oils

When did cholesterol get so complicated? Years ago, people were advised to keep their "cholesterol" below 200. Science found out simply having elevated cholesterol did not lead to full-blown cardiovascular disease (CVD). Total cholesterol was then broken down into "good" and "bad" forms of cholesterol; now the bad cholesterol is further characterized by severity of density and level of oxidation.

Cholesterol is a fat-like compound in the steroid family. It is either taken in from food or produced in the liver; other body cells, including those lining the small intestines, can also produce cholesterol. Despite its negative connotation, cholesterol has beneficial actions in the body, including the production of sex hormones, the formation and maintenance of cell membranes, the production of bile salts (helps digestion) and the synthesis of vitamin D.

Cholesterol may be necessary for these and other functions, but most of the cholesterol the body needs is produced endogenously. It stands to reason then that high dietary intake of cholesterol is not only unnecessary but could be unhealthy. Surplus cholesterol can contribute to artery clogs and plaques that restrict blood flow at the clog site, or possibly break apart and travel to another part of the body and clog another vessel.

How cholesterol is carried in the bloodstream is important. Proteins called apoproteins combine with triglycerides and transport cholesterol in the bloodstream. Called a lipoprotein, this combination can have varying ratios of protein-to-cholesterol. Low amounts of protein in the combo results in low-density lipoprotein (LDL). This is known a "bad" cholesterol, because high levels of LDL have been associated with increased arterial clogging and plaques (atherosclerosis), contributing to poor heart health. When the amount of protein is higher, the combo is called high-density lipoprotein (HDL). This is known as "good" cholesterol, because HDL generally takes cholesterol from the bloodstream and returns it to the liver for disposal.

Two other variations include very-low-density lipoprotein (VLDL) and oxidized LDL, although neither of these has become common in cholesterol health screenings, due to challenges in accurately measuring these compounds. VLDL has the highest amount of triglycerides among the lipoproteins. High triglyceride levels have been shown to contribute to coronary artery disease, heart attacks and strokes. As noted in its name, oxidized LDL contains a free radical, which contributes to increased thrombosis and plaque formation, and can damage the endothelial cells lining the artery.

Genetics can be a major factor in endogenous levels of LDL and HDL, but diet is a major source of cholesterol and is a controllable risk factor. Cholesterol is found only in animal-based foods. However, the American Heart Association (AHA) warns foods high in cholesterol are not the only problem, as foods high in saturated fats contribute to high cholesterol. In fact, plant foods can be high in saturated fats, meaning they are not as healthy as they might seem as a cholesterol-free food. Other factors in cholesterol levels include age, gender, weight and lifestylestress, alcohol, exercise and smoking can all affect levels.

Natural ingredients for cholesterol control

Coenzyme Q10 (CoQ10) has proven useful in cholesterol management for a couple of reasons. First, levels of CoQ10, which is vital for energy production in body cells, including heart cells, are depleted by statins, the princes of the pharmaceutical heart health kingdom. CoQ10 uses the same biosynthetic pathway as cholesterol. Statins lower cholesterol by blocking 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGR), the enzyme responsible for cholesterol production in the liver. However, blocking HMGR also inhibits production of CoQ10 and other important compounds. This has been suspected in numerous statin-use side effects, including myopathy, anemia, chronic fatigue syndrome and temporary memory loss. Second, CoQ10 has documented antioxidant properties useful against the oxidation of lipids, such as LDL.

In Australian research, the reduced form of CoQ10, ubiquinol, inhibited lipid peroxidation in the arterial wall of hypercholesterolemic animals.¹ In a human trial, patients taking statins and CoQ10 (as ubiquinol) had decreased lipid peroxidation compared to various controls.²

In 2011, German researchers found two weeks of ubiquinol supplementation in healthy men reduced LDL levels.³ The men took ubiquinol (supplied by Kaneka Corp.) for two weeks, and researchers took blood samples at baseline and 14 days. Ubiquinol reduced plasma LDL by 12%; researchers noted a particularly pronounced effect in small, dense LDL particles. However, there was no significant effect on triglycerides, total cholesterol, HDL or oxidized LDL.

CoQ10's essential functions in the body are much like vitamins. Like CoQ10, some vitamins have been found to act within the cholesterol synthesis pathway and balance cholesterol levels. Vitamin E compounds called tocotrienols act on HMGR synthesis of cholesterol, but in a manner different than statins. Instead of competitive inhibition, tocotrienols dial down HMGR, resulting in lowered cholesterol production in the liver. Further, while statins decrease CoQ10, tocotrienols increase CoQ10 levels, according to pilot studies from American River Nutrition. In the research, 75 mg/d of annatto tocotrienols (as DeltaGold®) increased CoQ10 by 20%, decreased total cholesterol by 13%, and reduced LDL by 15%; HDL was slightly, but significantly, increased in the patients in the treatment group.

The discovery of the ability of tocotrienols to lower LDL is credited to University of Wisconsin, Madison, researchers led by Asaf Qureshi, Ph.D., after isolating alpha-tocotrienol from barley and finding it had cholesterol-lowering properties.⁴ Only later did he discover delta- and gamma-tocotrienols were the most potent of the bunch in inhibiting endogenous cholesterol synthesis.⁵ Subsequently, he found tocotrienol supplements free from tocopherols worked better at cholesterol reduction than did supplements containing both vitamin E forms.⁶

In 2006, an animal study demonstrated a tocotrienol-rich-fraction (TRF) of palm oil produced a dose-response (50 ppm to 2,000 ppm) lowering of serum total and LDL cholesterol levels by 22% and 52% (P<0.05), respectively, compared with the control group.⁷ According to the results, alpha-tocopherol did not affect total or LDL cholesterol levels, but supplemental alpha-tocotrienol (within the 50 ppm to 500 ppm range) dose-dependently lowered total (17%) and LDL (33%) cholesterol levels. The more potent gamma and delta isomers also yielded dose-response (50 ppm to 2,000 ppm) reductions of serum total (32%) and LDL (66%) cholesterol levels. HDL cholesterol levels were minimally impacted by the tocotrienols, and the HDL/LDL cholesterol ratios were markedly improved (123% to 150%).

In another study, tocotrienol-rich fraction (TRF25) of stabilized and heated rice bran administered to hypercholesterolemic human subjects reduced LDL and other lipid health markers.⁸ A dose of 100 mg/d of TRF25, along with the AHA Step 1 diet, produced maximum decreases of 20%, 25%, 14% and 12%, respectively, in serum total cholesterol, LDL-cholesterol, apolipoprotein B and triglycerides compared with the baseline values.

Gamma-tocotrienol and alpha-tocotrienol, but not delta-tocotrienol, reduced ischemia in hypercholesterolemic hearts in an animal study conducted by University of Connecticut School of Medicine researchers and published in 2011.⁹ Rabbits were kept on a cholesterol diet for 60 days, and were supplemented with gamma-tocotrienol, alpha-tocotrienol and delta-tocotrienol for the last 30 days. Blood cholesterol levels fell by 50% in the gamma-tocotrienol group and by 39% in the alpha-tocotrienol supplemented group, compared to the control group, while the delta-tocotrienol-supplemented group did not show any significant reduction. After comparing left ventricular function and myocardial infarct size between control (hypercholesterolemic) and tocotrienol supplemented groups after induction of ischemia and reperfusion, researchers found left ventricular function (including aortic flow and developed pressure) exhibited significantly improved recovery with gamma- and alpha-tocotrienol, but not with delta-tocotrienol.

Another 2011 study showed six months of supplementation with 300 mg/d of a bioenhanced palm mixed tocotrienol complex (as Tocomin SupraBio® from Carotech Inc.) significantly reduced total cholesterol and LDL cholesterol concentrations in humans with high cholesterol levels.¹⁰ By the fourth month of the study, subjects in the Tocomin SupraBio® group had a significant reduction in total and LDL cholesterol levels, and a continuous significant reduction was seen on fifth and sixth month of supplementation in total cholesterol (8.9% ± 0.9%and 10.8 ± 1.3% respectively) and LDL cholesterol levels (12.8% ± 2.6% and 17.3% ± 1.8% respectively). Subjects in the placebo group had negligible changes in their total and LDL cholesterol levels compared to baseline regardless of the duration of supplementation.

B Vitamins and healthy fats

Earlier in the nutrient alphabet, vitamin B can also help address cholesterol concerns. In a 2011 study led by John Rumberger, Ph.D., former professor of medicine and consultant in the Department of Cardiovascular Diseases at the Mayo Clinic in Rochester, MN, a biologically active derivative of vitamin B5 (as Pantethine® from Kyowa Hakko USA), significantly lowered LDL cholesterol levels in subjects with low-to-moderate CVD risk.¹¹ In the trial, 120 subjects ate a therapeutic lifestyle change (TLC) diet four weeks before randomization (baseline) and maintained the diet throughout the 16-week study period. At baseline, subjects were randomized in a triple blinded manner to either pantethine (600 mg/d for eight weeks, and 900 mg/d for the remaining eight weeks) or an identically labeled, nonbiologically active placebo (n=60 per group). The researchers found sustaining a TLC diet and supplementing with pantethine for 16 weeks led to significant (P<0.005) and sustained reductions in total cholesterol (6 mg/dL, 0.16 mmol/L, 3% reduction), LDL cholesterol (4 mg/dL, 0.10 mmol/L, 4% reduction) and apolipoprotein B (4 mg/dL, 0.04 g/L, 5% reduction) compared to placebo plus the TLC diet.

Vitamin B3, also known as niacin, takes a different approach to cholesterol health, focusing on levels of beneficial HDL cholesterol. Research has found niacin used in conjunction with statins can increase HDL cholesterol and decrease overall cholesterol.¹²

Raising HDL is an often overlooked aspect of cholesterol regulation. Fish oil has been credited with decreasing triglycerides, but it also can raise HDL and lower other non-HDL cholesterol.¹³ Fish oil may be as effective as statins in reducing unhealthy cholesterol levels in hypercholesterolaemic patients, according to a Japanese intervention trial involving the fish-oil derivative eicosapentaenoic acid (EPA).¹⁴ In this large study, researchers examined more than 18,000 Japanese men with total cholesterol of 6.5 mmol/L, randomly assigning them to receive either 1,800 mg/d of EPA with a statin (EPA group; n=9,326) or statin only (controls; n=9,319). At mean follow-up of 4.6 years, the researchers found a 19% relative reduction in major coronary events (P=0.011), with post-treatment LDL cholesterol concentrations decreasing by 25%, from 4.7 mmol/L in both groups.

A meta-analysis published in the Journal of Nutrition in late 2011 looked at 11 randomized, controlled trials with 485 healthy participants that evaluated the relation between supplementation with docosahexaenoic acid (DHA) from algal oil and lipid profile (triglycerides, LDL and HDL).¹⁵ They concluded DHA from algae may reduce serum triglycerides and increase both HDL and LDL in people without coronary heart disease.

Krill oil is another marine source of EPA and DHA that has been increasingly studied for effects on cholesterol. A 2010 Norwegian study found krill oil (as Superba from Aker BioMarine) significantly improved the HDL cholesterol/triglyceride ratio, compared to fish oil.¹⁶

This past year has been a busy one for krill research, including cholesterol studies. Italian researchers reported in early 2011 krill oil inhibited liver fat production and reduced levels of triglycerides and cholesterol more significantly than did fish oil.¹⁷ Rats were treated for six weeks with diets containing 2.5% krill oil or 2.5% fish oil, or a control diet without supplementation of omega-3 fatty acids. Krill oil reduced liver triglycerides by 20%, compared to 10% in the fish oil group, whereas the cholesterol levels decreased by 33% (krill oil) and 21% (fish oil).

A 2011 Norwegian report suggested omega-3 fatty acids in the phospholipids form (krill oil) have a greater impact on health compared to the triglyceride form (fish oil).¹⁸ Results showed krill oil downregulated the activity of pathways involved in hepatic glucose production as well as lipid and cholesterol synthesis. Fish oil modulated fewer pathways than a krill-oil-supplemented diet and did not modulate key metabolic pathways regulated by krill oil, including glucose metabolism, lipid metabolism and the mitochondrial respiratory chain. Also, fish oil upregulated the cholesterol synthesis pathway, the opposite of what krill oil did.

Another 2011 study out of Norway showed Superba krill not only helped normalize the endocannabinoid system, which is dysregulated in obesity, better than two other krill oil formulations, but it also demonstrated lowering effects on triglyceride, cholesterol and a marker of inflammation.¹⁹

Seeds also contain omega-3s and have been studied for cholesterol lowering effects. A rich source of alpha-linolenic acid (ALA), lignans (a type of phytosterol) and soluble fiber, flaxseed, can modestly reduce serum total cholesterol and LDL cholesterol. In one double blind, randomized study, postmenopausal women who were not on hormone replacement therapy took 40 g/d of either ground flaxseed or wheat-based comparative control regimen for three months.²⁰ Flaxseed reduced both serum total cholesterol and LDL cholesterol by 6%, while the control regimen had no such effect.

Nuts also contain omega-3s and lignans. According to a 2010 JAMA pooled analysis of data from 25 trials, consuming nuts was associated with improvements in blood cholesterol levels.²¹ Subjects in the studies analyzed were not taking lipid-lowering medications; they consumed an average of 67 g/d (about 2.4 ounces) of nuts, which was associated with an average 5.1% reduction in total cholesterol concentration, a 7.4% reduction in LDL cholesterol and an 8.3% change in ratio of LDL cholesterol to HDL cholesterol.

A University of Barcelona, Spain, study looked at a Mediterranean diet wherein walnuts replaced approximately 35% of the energy obtained from monounsaturated fat for six weeks.²² In the randomized, crossover trial, 49 men and women (mean age, 56 years) with polygenic hypercholesterolemia ate either a regular Mediterranean diet or one with the added walnuts. The walnut diet decreased total cholesterol levels by 4.1%, LDL cholesterol levels by 5.9% and lipoprotein levels by 6.2%, compared to the regular diet.

Olive oil, which is comprised mainly of the omega-9 oleic acid, is a staple in the Mediterranean diet, and may confer antioxidant benefits in heart health and cholesterol management. European researchers reported in 2011 a study showing olive oil polyphenols promote the growth of antibodies that help reduce oxidative LDL.²³ They assigned 200 healthy men to three-week sequences of 25 mL/day of three olive oils with high (366 mg/kg), medium (164 mg/kg) and low (2.7 mg/kg) phenolic content. They measured plasma concentration of oxidized LDL auto antibodies (OLAB), which have shown in previous studies to protect against atherosclerosis. Olive oil phenolics increased OLAB generation, with a stronger effect at higher concentrations of oxidized LDL. OLAB concentrations, adjusted for oxidized LDL, increased directly in a dose-dependent manner with the polyphenol content of the olive oil administered. Plasma OLAB concentration was inversely associated with oxidized LDL.

Anitoxidants and soy

Hydroxytyrosol, one of the many phenols found in olive oil, is known for its antioxidant capabilities and for modulating several enzymatic activities linked to CVD. In 2011, University of Madrid researchers studied the effect of hydroxytyrosol-enriched sunflower oil (HSO) on certain CVD biomarkers , including oxidized LDL.²⁴ Subjects taking HSO had a significantly higher level of arylesterase activity and significantly lower levels of oxidized LDL cholesterol and sVCAM-1 (an inflammatory marker), compared to those taking the control sunflower oil without the phenolic compound.

Phenols are common in botanicals, many of which have proven effective in managing cholesterol. Polyphenols in cocoa may be key to its heart health benefits. One study found moderate cocoa consumption, providing 260 mg/d of polyphenols, can lower both total cholesterol and LDL levels by about 6 mg/dL.²⁵ Researchers reviewed eight trials (involving 215 participants) and focused on short-term data to evaluate the effects of cocoa on plasma lipid profile.They found cocoa consumption significantly lowered LDL cholesterol by 5.87 mg/dL and mildly lowered total cholesterol by 5.82 mg/dL. No significant change was seen in LDL cholesterol in high-quality studies, and subgroup analyses suggested a cholesterol-lowering effect only in subjects who consumed a low dose of cocoa and had CVD risks.

Yerba maté (Ilex paraguariensis) is also rich in polyphenols and is thought to protect HDL and LDL from oxidation. In one study, a polyphenol-rich extract from yerba maté prevented the loss of an antioxidant enzyme (PON-1) carried mainly by HDL that conveys cardioprotective effects.²⁶ Healthy volunteers drank either 0.5 L of I. paraguariensis extract, 0.5 L of coffee and milk, or nothing. In those taking the extract drink, PON-1 activity increased an average of 10% above that observed in the coffee and milk group. The scientists concluded yerba maté extract may prevent the loss of HDL's antiatherogenic function when the PON-1 is under oxidative stress. A 2007 review of yerba maté tea found the beverage can be hypocholesterolemic; protect DNA from oxidation and in vitro LDL lipoperoxidation; and offer a high antioxidant capacity.²⁷

Phytosterols are another heart healthy compound found in numerous plants. Structurally, phytosterols are similar to cholesterol, and they compete with each other for absorption in the intestines. Thus, increased phytosterol intake can curtail cholesterol absorption and result in lowered plasma cholesterol levels.²⁸ Most recently, a 2011 study from Finland reported rye bread enriched with 2 g/d to 4 g/d of nonesterified plant sterols reduced total and LDL cholesterol in subjects with normal cholesterol levels.²⁹

One review of 16 published human studies (590 subjects) on phytosterols and reduction of plasma cholesterol levels found phytosterol therapy resulted in an average 10% reduction in total cholesterol and 13% reduction in LDL cholesterol levels.³⁰ Another review reported many clinical trials have proven plant sterols can effectively decrease high serum total and LDL cholesterol by reducing intestinal absorption of cholesterol.³¹ And a 2010 study found daily consumption of up to 9 g/d of fellow plant esters called stanols reduced serum LDL cholesterol concentrations up to 17.4%.³²

FDA has authorized a claim that plant sterols/stanols may reduce the risk of CHD when combined with a diet low in cholesterol and saturated fats.

Phytoestrogens have also been studied in this arena. A 12-week trial conducted by Metagenics showed postmenopausal women following a dietary program combining a low-glycemic index diet with a functional food (30 g/d of phytoestrogen-rich soy protein and 4 g/d of phytosterols) had 15.8% lower total cholesterol and 14.8% lower LDL cholesterol than did subjects who followed the AHA Step 1 diet.³³ Researchers noted significant improvements in ratios of total-to-HDL cholesterol. In another study, subjects with metabolic syndrome and hypercholesterolemia taking a food fortified with soy protein and phytosterols as part of a Mediterranean-style, low-glycemic-load diet showed improved cardiometabolic risk factors, including reductions in cholesterol, non-HDL cholesterol and cholesterol/HDL ratios.³⁴

On its own, soy protein reduced total cholesterol and non-HDL cholesterol more than did milk proteins.³⁵ In the randomized, controlled, parallel arm trial from Solae, men and women with hypercholesterolemia followed the TLC diet for four weeks, followed by a two-week lead-in with 3.75 g/d colesevelam HCl, a bile-acid binding drug. After a three-week washout, subjects whose LDL cholesterol was lowered by 5.0% or more while on colesevelam HCl were randomly assigned to take either 25 g/d of an insoluble fraction of partially hydrolyzed soy protein or 25 g/d total milk proteins. Results showed soy protein reduced total cholesterol by 7.4%, while milk protein reduced it by 3.6%. Similarly, soy proteins reduced non-HDL cholesterol by 10.8%, and milk reduced it by 3.9%.

In a recent study on soy phytoestrogen genistein (as geniVida® from DSM Nutritional Products) and prostate-specific antigen (PSA) in men with early prostate cancer, researchers found a secondary benefit on cholesterol.³⁶ They reported 30 mg/d geniVida supplementation not only reduced PSA, but also significantly reduced total cholesterol, compared to placebo.

Soy also has an FDA-approved health claim on reduction of CHD with a diet rich in soy (25 g/d soy protein), but low in saturated fat and cholesterol.

More plant compounds

Phytoestrogens are non-steroidal, but a compound in guggul, the resin of mukul myrrh tree (Commiphora mukul), called guggelsterone, is considered a plant steroid. Researchers from Baylor College of Medicine, Houston, showed guggulsterone treatment decreased hepatic cholesterol in wild-type mice fed a high-cholesterol diet.³⁷ Another study also found guggul and guggulsterone effectively inhibited LDL oxidation.38 A 2003 analysis of 25 randomized clinical trials identified guggul as one of the 11 herbal medicinal products that have been most extensively studied and have demonstrated reductions in total serum cholesterol levels between 10% and 33%.³⁸ Then, a 2005 meta-analysis from Massachusetts General Hospital involving nine databases, 20 additional journals and bibliographies from 50 selected secondary references found scientific evidence suggested guggulipid may contribute to significant reductions in serum total cholesterol.³⁹

Other plant compounds garnering attention from cholesterol researchers include beta-glucans, polysaccharides found in the cell walls of mushrooms, yeast, oats and barley. FDA approved a health claim to be made for foods containing 3 g oat bran to be marketed as cholesterol-reducing.

According to one study, consuming at least 3 g/d of bioactive beta-glucan (from OatWell oat bran) may significantly lower LDL-cholesterol levels in individuals who have high cholesterol levels.⁴⁰ A controlled, double blind study of 66 men who were randomly assigned to either oat milk (0.5% beta-glucan) or rice milk (control) for five weeks found oat milk significantly reduced serum total cholesterol (6%) and LDL cholesterol (6%) levels.⁴¹

Beta-glucan derived from barley was also found to lower cholesterol in mildly hyperchesterolemic subjects.42 A 2010 meta-analysis found barley and beta-glucan isolated from barley lowered total and LDL cholesterol concentrations by 0.3 mmol/l and 0.27 mmol/l, respectively, compared with controls.⁴³

Chitin-glucan, which is the main component of the cellular walls of the fungus Aspergillus niger, has generated similar benefits. In a clinical trial on healthy humans with normal cholesterol levels, a combination of 1,3 beta-glucans and chitin-glucan (as ARTINIA by Stratum Nutrition) reduced oxidized LDL by 26% after four weeks of supplementation.⁴⁴

Still, other plant compounds have demonstrated an impact on cholesterol. Pterostilbene, a natural analog of resveratrol found in certain berries, functions as an activator of PPAR-alpha, which decreases the bodys synthesis of triglycerides and VLDL, and helps to regulate cholesterol levels.⁴⁵ Activation of PPAR may also increase HDL levels.⁴⁶ In the study, USDA Researchers tested the effect of pterostilbene, resveratrol, and the pharmacuetical ciprofibrate (control) on PPAR-alpha activation in rat liver cells. They found pterostilbene induced PPAR-alpha; activation eight-fold over the control and almost two-fold more than ciprofibrate; resveratrol was toxic to cells. At a dose of pterostilbene induction of PPAR grew to 14-fold over control, suggesting pterostilbene supplementation should decreased triglyceride and VLDL synthesis, as well as increase plasma HDL cholesterol similar to results from PPAR-alpha activation by drugs like ciprofibrate.

Citrus bioflavanoids called polymethoxylated flavones (PMFs) may affect total and LDL cholesterol. A study conducted by KGK Synergize Inc. on its ingredient Sytrinol (a combination PMF-tocotrienol product available from Proprietary Nutritionals) found diets containing 1% significantly reduced serum total by 19 to 27% and VLDL by 32% to 40%.⁴⁷ The researchers achieved reductions by feeding a 3% mixture of the PMFs hesperidin and naringin (1:1, w/w), which indicates a lower potency of hesperidin/naringin, compared to the full range of PMFs. The researchers concluded, "PMFs are novel flavonoids with cholesterol- and triacylglycerol-lowering potential and that elevated levels of PMF metabolites in the liver might be directly responsible for their hypolipidemic effects in vivo."

A 2007 study involved hypercholesterolemic men and women (cholesterol levels >230 mg/dL) between the ages of 19 and 65 years, who were randomized to consume either 270 mg citrus flavonoids plus 30 mg tocotrienols (as Sytrinol), or placebo daily for four weeks; a third group took the intervention for 12 weeks.⁴⁸ Researchers measured fasting levels of blood cholesterol LDL, HDL and triglycerides at baseline and four weeks (all groups) and at eight weeks and 12 weeks for group three. Daily treatment with Sytrinol significantly improved cardiovascular parameters compared to placebo in all groups, signficantly reducing total cholesterol (20% to 30%), LDL (19% to 27%), apolipoprotein B (21%) and triglycerides (24% to 3%). HDL levels were unchanged in all but group three, which saw a 4% increase deemed non-significant.

Understanding the increasingly complex field of cholesterol health and the potential development of arterial disease can be overwhelming. Research on various natural ingredients has become more focused on the specific forms of cholesterol, including LDL , HDL and VLDL, which helps match the right supplement ingredient with a specific desired outcome, advancing the management of cholesterol and helping to improve heart health products.

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