Chronic diseases, but not cholesterol, on the agenda
Globally, a third of ischaemic heart disease is attributable to high cholesterol, says the WHO, and in high-income countries, over 50% of adults had raised total cholesterol.
In April 2014, former Commissioner for Health Tonio Borg decided to put chronic diseases on the EU’s agenda by launching a two-day summit in Brussels on the issue.
The main focus of the conference became the rise of diabetes and obesity, which are creating heavy burdens for European health systems, but the conclusions were rather vague, with no concrete strategy or targets at the EU level.
Meanwhile, experts said another chronic disease needs special attention: familial hypercholesterolemia (genetic disorder characterised by high levels of bad cholesterol).
This chronic disease is often overlooked, Alberico Catapano, professor of Pharmacology at the Faculty of Pharmacy at the University of Milan, told EURACTIV in an interview.
For every 250 people, there is one person living with familial hypercholesterolemia, which puts them at high risk of getting a cardiovascular disease.
Even though individuals with high levels of bad cholesterol do not have any symptoms, such as headaches, which affect persons with high blood pressure, many are living with the dangerous condition without knowing it. At the same time, those who are being treated, often tend to be more relaxed when taking their medicines as they do not feel any pain, Catapano stressed.
He added that the EU can play an important role in addressing the consequences of a chronic disease, such as familial hypercholesterolemia.
“The EU does have some ways to deal with the problems. At least it can stimulate the discussions around these points and show that there’s money available for research and implementation programmes. The EU can put money in the areas of education, prevention and research that are related to chronic diseases,” Catapano said.
Food marketing and health claims
The only EU policy which directly targets bad cholesterol among the member states’ populations is the programme from 2010, Two apples a day keep the doctor away, aimed at lowering cholesterol levels by 10%, with a budget of only €13.8 million.
Besides this programme, the EU has indirectly tried to tackle the issue by making health claims and food labeling easier to understand for consumers.
In December 2006, the Council and Parliament also adopted a regulation on nutrition and food labelling to harmonise the rules for health claims, such as “reducing blood cholesterol”, “low fat” and “high fibre”. The aim was to ensure that the health claims on food were “clear, accurate and evidence-based”, eliminating misleading products from the EU’s single market.
In 2008, the European Food Safety Authority (EFSA) furthermore concluded in an opinion that plant stanol esters can lower/reduce blood cholesterol and reduce the risk of coronary heart disease.
Problem expanding among new groups
High levels of bad cholesterol are now also affecting young people. Out of 100,000 heart disease incidents in France, 20,000 affect under 45-year-olds.
Young people are not usually associated with heart diseases, but their dietary habits are putting them more and more at risk of high cholesterol.
Researchers now say that hypercholesterolemia, or the excess of cholesterol in the bloodstream, increases the risk of heart disease and stroke especially when combined with early age smoking.
According to the French Federation of Cardiology (FFC), heart disease was responsible for 28% of all deaths in France in 2008. It is a silent killer that cannot be detected through simple blood tests. The French Academy for Medicine has called for hypercholesterolemia screening in young people since 2005.
“Almost 50% of people that suffered heart attacks at an early age, which can often be fatal, were not screened. Screening could have ensured urgent and important measures to tackle cardiovascular diseases,” claimed the Academy for Medicine in a recommendation to the French government in 2005.
Professor Jean Ferrières from FFC believes that more can be done to prevent hypercholesterolemia in young people. He says that prevention in France is insufficient.
“The problem with French society is that it concentrates on curative instead of preventive measures. Regarding hypercholesterolemia, pediatricians could concentrate on prevention, but they have too many time constraints. They are overwhelmed by seasonal diseases,” said Ferrières.
Therefore, efforts are insufficient even though it is well-known that early and efficient treatment could reduce strokes and heart attacks.
“When it comes to hypercholesterolemia: the earlier the treatment, the better. In cases of familial hypercholesterolemia, early treatment reduces the risk of arterial complications. Children could be treated from as early as 7 or 8 years of age,” he continued.
Tobacco and bad eating habits
Young smokers with hypercholesterolemia increase the risk of health complications. This has become evident as the number of young smokers across the EU’s 28 member states continues to increase.
A study by the Commission carried out in all member states shows that 5% of 13-year-olds smoke on a weekly basis. This percentage increases to 8% in the Czech Republic, Estonia, Lithuania, Romania and Slovakia. These trends lead to strokes and heart attacks from as young as 25-years-old.
"Hypercholesterolemia and tobacco is a potent cocktail. This is especially true for young women who are on the contraceptive pill. It can lead to serious cardiovascular problems," said professor Jean-Michel Mecerf, from the Pasteur Institute in Lille.
Along with reducing tobacco addiction, tackling bad eating habits can also decrease hypercholesterolemia in young people. High levels of cholesterol in fatty foods increase the chances of hypercholesterolemia.
"The food we consume contains high levels of fat and protein. We should eat less meat, and more fruit and vegetables to lower our cholesterol levels," said professor Ferrières.
In Health at a Glance: Europe 2012, a study on health and health systems in 35 European countries, the Commission emphasised the importance of a balanced diet from a young age.
“Childhood is an important period for forming healthy behaviours […] Studies show that locally focused interventions, targeting children to 12 years of age can be effective in changing behaviours,” the report stated.
New science questioning previous knowledge
Meanwhile, new science has challenged previous health claims and stated that butter and fatty acids are not as unhealthy as previously thought.
Using olive oil instead of butter when cooking a meal may not lower heart risk, according to new research by the British Heart Foundation.
Researchers at the BHF say that there is no evidence that changing the type of fat you eat from "bad" saturated fat to "healthier" fatty acids will cut heart risk. They came to the conclusion after reviewing data from 72 studies, spanning more than 600,000 participants.
Consumers have been widely encouraged to eating unsaturated fats such as olive and sunflower oils. But the research, led by scientists at Cambridge and published in the Annals of Internal Medicine, found no evidence to support this.
The research found that saturated fat, whether measured in the diet or in the bloodstream, was not linked to coronary disease risk, and that there was no such thing as "healthy" fat intake.
Researchers stressed, however, that findings do not mean it is fine to eat lots of cheese, pies and cakes. Eating too much saturated fat can still increase the amount of cholesterol in the blood.
Doctor Rajiv Chowdhury, the study's lead researcher, told the BBC that the findings could potentially stimulate new lines of scientific inquiry and current nutritional guidelines.
The British Heart Foundation stressed that the findings do not change the advice that eating too much fat is harmful for the heart.
Paris and Brussels debate yogurt and margarine
In June 2014, ANSES, the French national food safety agency, said that there’s no proof that food containing high levels of phytosterol prevents heart disease, which contradicts European food safety regulation.
Claims that yogurt and margarine with added phytosterols may have no effect on reducing the risks of heart disease, ANSES stated, are unfounded. It is impossible to determine "the effect of phytosterols on preventing cardiovascular risks," according to the French researchers.
In a notice published on 25 June, ANSES stated that "phytosterols contribute to reducing cholesterol in blood," but that "their value in heart disease prevention has not been proven".
The agency warns pregnant or breastfeeding women and children not to consume these products, even though according to their statistics 12.5% of consumers are children.
As well as undermining the relationship between lower blood cholesterol levels and lower risks of heart disease, ANSES also highlights the inefficiency of products with added phytosterol. "In 30% of consumers, consuming food with added phytosterols does not reduce LDL cholesterol levels (the bad cholesterol)."
ANSES's findings come after a referral by France's consumer association UFC Que-Choisir. The association has criticised producers for years over false marketing on their products’ nutritional benefits.
"Food products like 'PROACTIV' or 'FRUIT D'OR' margarine, and special milk-based products like 'DANACOL' by DANONE are marketed on the basis that phytosterol reduces blood cholesterol levels," said the consumer association.
The UFC-Que Choisir now calls on "national and European authorities to re-examine the authorisation to market these products."
The introduction to the market of products with added phytosterol comes under the framework of the European novel foods and food ingredients procedure.
"There is a weakness in the European procedure," said Olivier Andrault, member of the UFC Que-Choisir. "The European authorities have a lot less freedom than their French counterparts," he added.
Unlike the French agency, EFSA cannot issue own-opinion reports or widen the scope of its investigations during their decision-making process. This means EFSA can only delve into the safety aspect of food products, and not their marketing suitability.
"The French agency’s opinion is at odds with the European agency," said Andrault.
EU regulation authorises the labelling of products containing added phytosterols. Producers are allowed to claim that phytosterols reduce blood cholesterol levels and that lower blood cholesterol levels reduce the risk of heart disease. The recent findings by the French agency calls the regulation into question.
In order to find some harmony, both agencies will have to find common ground as is outlined in the European rules.