Earlier this week, someone sent me a link this article that reports on a recent decision made by the Advertising Standards Authority in the UK regarding two television adverts for the cholesterol-reducing margarine Flora pr.activ.
The television adverts included text and a voiceover informing us that: “No other food lowers cholesterol more”. Two people complained about this, questioning whether this claim was substantiated. In their defence, the people at Flora claimed they had not implied that the product was better at lowering cholesterol than any other food, only that no other food could lower cholesterol more. I’m not sure I quite understand the difference, and it anyhow, the ASA decreed this was a claim to far and subsequently ordered that the adverts should not be broadcast again. You can read the whole adjudication at the ASA website here.
The ASA also took exception to the fact that in neither advert contained the ‘permitted’ claim (according to European regulations) that: “high cholesterol is a risk factor in the development of coronary heart disease”. The Flora people claimed that this was superfluous, because it’s a commonly understood point, and I actually have some sympathy for their position: my experience is that the vast majority of people associate ‘raised cholesterol’ with an increased risk of heart disease.
None of this matters much in my opinion, though, because I think the ASA’s issues with the adverts fail to strike at the heart of the issue. If Unilever (the company that manufactures Flora) was to play by the rules then it could claim that raised cholesterol is a risk factor for heart disease, and that its product reduces cholesterol. What the public will generally take from this is the idea that ‘Flora reduces risk of heart disease’.
Leaving individuals with this impression would be fine if there was any evidence for it. In reality, though, there isn’t. Even if raised cholesterol causes heart disease (I have my doubts about it being as straightforward as this), the fact that something reduced cholesterol does not assure it reduces the risk of heart disease. For example, we have plenty of examples of drugs that have been effective for ‘improving’ cholesterol levelsbut have not reduced and sometimes have even increased heart disease risk.
For the idea that Flora pro.activ is good for heart health to be valid requires us to have studies that show these foodstuffs actually reduce the risk of heart disease. Not one single such study exists in the scientific literature.
But there’s even worse news to come for those who have been taken in by the slick marketing of the cholesterol theory and ‘remedies’ for ‘raised’ cholesterol in the form of foodstuffs enriched with ‘plant sterols’ (like Flora pro.activ) that lower cholesterol by inhibiting its absorption from the gut.
Sterols in food can also make their way from the gut into the bloodstream, and several studies link higher levels of sterols here with enhanced risk of cardiovascular disease [1-6]. This evidence is epidemiological in nature, which means we cannot conclude from it that sterols actually increase the risk of cardiovascular disease (only that the two are associated). However, more incriminating evidence comes of studies in which the effects of sterols have been tested on tissues or animals in the lab, and been found to have adverse effects. You can read an account of some of this evidence in a recent blog post here.
The issue with the Flora adverts, in my opinion, does not relate to claims about their cholesterol-lowering properties. I think the real crime is that there is no evidence that these foodstuffs do any good, and at least some evidence exists that suggests they have genuine potential for harm.
1. Relationships of serum plant sterols (phytosterols) and cholesterol in 595 hypercholesterolemic subjects, and familial aggregation of phytosterols, cholesterol, and premature coronary heart disease in hyperphytosterolemic probands and their first-degree relatives. Metabolism 1991;40:842–848
2. Independent association of serum squalene and noncholesterol sterols with coronary artery disease in postmenopausal women. J Am Coll Cardiol 2000;35:1185–1191
3. Association of plasma noncholesterol sterol levels with severity of coronary heart disease. Nutr Metab Cardiovasc Dis 1998;8:386–391
4. Baseline serum cholestanol as predictor of recurrent coronary events in subgroup of Scandinavian simvastatin survival study. Finnish 4S Investigators. BMJ 1998;316:1127–1130
5. Plasma sitosterol elevations are associated with an increased incidence of coronary events in men: results of a nested case-control analysis of the Prospective Cardiovascular Munster (PROCAM) study. Nutr Metab Cardiovasc Dis 2006;16:13–21
6. Abstract 4099: elevated campesterol serum levels–a significant predictor of incident myocardial infarction: results of the population-based MONICA/KORA follow-up study 1994–2005. Circulation 2006;114:II_884
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