Effect of a novel functional tomato sauce (OsteoCol) from vine-ripened tomatoes on serum lipids in individuals with common hypercholesterolemia: tomato sauce and hypercholesterolemia

Abstract

Abstract Background Most studies focused on the benefits of lycopene on serum lipids but no studies have been specifically designed to assess the role of a tomato sauce from vine-ripened tomatoes on patients affected by polygenic hypercholesterolemia. The aim of this study was to compare the lipid-lowering effect of a novel functional tomato sauce with a well-known functional food with a lipid-lowering effect, i.e. a sterol-enriched yogurt. Methods In this cross-over study, we evaluated a population of 108 ambulatory patients affected by polygenic hypercholesterolemia of both gender, who were allocated to a tomato sauce (namely OsteoCol) 150 ml/day or a sterol-enriched yogurt (containing sterols 1.6 g/die) treatment, for 6 weeks. Carotenoids content was 3.5 mg per gram of product. We measured serum lipids and creatinine and transaminases at basal and follow-up visit. Results A total of 91 subjects completed the protocol. A significant difference in LDL-cholesterol change was found between participants taking yogurt, tomato sauce (high adherence) and tomato sauce (low adherence) (− 16; − 12; + 8 mg/dl respectively; p

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Ferroetal. J Transl Med (2021) 19:19
https://doi.org/10.1186/s12967-020-02676-3
RESEARCH
Eect ofanovel functional tomato sauce
(OsteoCol) fromvine-ripened tomatoes
onserum lipids inindividuals withcommon
hypercholesterolemia: tomato sauce
andhypercholesterolemia
Yvelise Ferro1, Elisa Mazza2, Elvira Angotti3, Roberta Pujia1, Angela Mirarchi1, Maria Antonietta Salvati2,
Rosa Terracciano1, Rocco Savino1, Stefano Romeo2,4, Antonio Scuteri5, Rosario Mare3,
Francesco Saverio Costanzo3, Arturo Pujia2 and Tiziana Montalcini3*
Abstract
Background: Most studies focused on the benefits of lycopene on serum lipids but no studies have been specifically
designed to assess the role of a tomato sauce from vine-ripened tomatoes on patients affected by polygenic hyper-
cholesterolemia. The aim of this study was to compare the lipid-lowering effect of a novel functional tomato sauce
with a well-known functional food with a lipid-lowering effect, i.e. a sterol-enriched yogurt.
Methods: In this cross-over study, we evaluated a population of 108 ambulatory patients affected by polygenic
hypercholesterolemia of both gender, who were allocated to a tomato sauce (namely OsteoCol) 150 ml/day or a
sterol-enriched yogurt (containing sterols 1.6 g/die) treatment, for 6 weeks. Carotenoids content was 3.5 mg per gram
of product. We measured serum lipids and creatinine and transaminases at basal and follow-up visit.
Results: A total of 91 subjects completed the protocol. A significant difference in LDL-cholesterol change was
found between participants taking yogurt, tomato sauce (high adherence) and tomato sauce (low adherence) (− 16;
− 12; + 8 mg/dl respectively; p < 0.001). We found a greater LDL-cholesterol reduction in the participants with a basal
LDL-cholesterol more than 152 mg/dl (15% for sterol-enriched yogurt and 12% for tomato sauce at high adherence).
Conclusion: A novel functional tomato sauce from vine-ripened tomatoes compares favourably with a commer-
cialised sterol-enriched yogurt in term of absolute LDL-cholesterol change. Intake of a tomato sauce with a high
carotenoid content may support treatment of patients affected by common hypercholesterolemia. The present study
has various limitations. The presence of other dietary components, which may have influenced the results, cannot be
ruled out. Of course, these results cannot be extrapolated to other populations. Furthermore, there was a low adher-
ence rate in the tomato sauce group. Moreover, we did not report serum carotenoids data.
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Open Access
Journal of
Translational Medicine
*Correspondence: tmontalcini@unicz.it
3 Department of Clinical and Experimental Medicine, Nutrition Unit,
University Magna Grecia, 88100 Catanzaro, Italy
Full list of author information is available at the end of the article
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Ferroetal. J Transl Med (2021) 19:19
Background
Carotenoids are a class of more than 700 naturally occur-
ring pigments synthesized by plants [1]. Dietary carot-
enoid intake as well as the intake of specific carotenoids
(such as α- and β-carotene, β-cryptoxanthin and lyco-
pene) have been inversely associated with coronary heart
disease, stroke, and mortality [2]. In addition, blood
carotenoid concentrations have been inversely associated
with cardiovascular disease, total cancer, and all-cause
mortality [2].
It has been suggested that it would be reductive to
explain the physiological effects of carotenoids solely
by their antioxidant activity [3]. In fact, it has also been
demonstrated that β-carotene regulates the expression
of the HMG-CoA reductase enzyme in rat liver [4], both
β-carotene and lycopene have been reported to inhibit
macrophage HMG-CoA reductase activity [5] and fucox-
anthin, a marine carotenoid, modulates both the HMG-
CoA reductase and acyl-coenzyme A [3], all resulting in
the inhibition of cholesterol synthesis.
It has been found that at least 25mg per day of lyco-
pene (obtained through both diet and supplementation)
elicit beneficial health effects, helping lower total choles-
terol levels by an average of 8mg/dl [6]. A study showed
an average 18mg/dl (9%) decrease with up to 35mg per
day [7]. In another study, consumption of astaxanthin 6
and 12mg/day significantly increased serum high-den-
sity lipoprotein cholesterol (HDL-C) versus baseline, and
doses of 12 and 18mg/day significantly decreased serum
triglyceride levels [8].
An intake of 300–400g/day of vegetables provides at
least 25mg of total carotenoids/day [9]. However, since
tomato (Solanum lycopersicum L.) is a fruits rich in
various carotenoid pigments, especially lycopene, and
it is among the most widely consumed crops, it repre-
sents the most important source of these molecules for
human health. Tomato contains a complex mixture of
carotenoids, including lycopene (35–96% total lycopene,
primarily in all trans-isomeric forms, and 1–22% cis-
lycopene), β-carotene andlutein, which all support cardi-
ovascular health. e regular consumption of tomato and
tomato-based products have been correlated to a reduc-
tion in risk of contracting cardiovascular diseases confers
cardiovascular benefits [10]. Several studies support the
notion that the intake of tomato-based foods improves
serum lipids and reduces the cardiovascular risk better
than lycopene supplementation [11–13].
In this regard, it has also been demonstrated that lyco-
pene or lycopene-containing products are effective in
lowering systolic blood pressure, in particular in hyper-
tensive subjects and at high dosage (> 12mg/day) [3, 14].
However, carotenoids content varies significantly
between cultivars, growing conditions as well as stage of
maturity and storage temperatures [15–17]. Tomatoes
picked green and ripened in storage usually have lower
levels of carotenoids than vine-ripened fruit. is is a
common commercial practice, although the quality of
tomatoes ripened on-the-vine may be better than toma-
toes ripened off-the-vine. Several studies have confirmed
that vine-ripened tomatoes maintain the phytochemi-
cal content better than tomatoes ripened off the plant
[18–20]. Currently there is a lack of information about
the influence of tomato ripeness stage on the carot-
enoids content. us, specific evaluations of the tomato
carotenoids content and the cardiovascular benefits are
required before conferring a nutraceutical/therapeutic
value to a tomato-based food.
Long-term adherence to diet and lipid-lowering agents
is a key issue. Functional foods and nutraceuticalscan be
natural alternatives and support to pharmacological ther-
apies in statin-intolerant patients, because they might
significantly reduce LDL-C [21]. Moreover, functional
foods exert other non–lipid-lowering properties, includ-
ing reduction of glucose, blood pressure and inflamma-
tion, and treatment with functional foods seems to be
very safe and well tolerated.
Our study investigated the effects of a tomato sauce
from vine-ripened tomatoes on lipids in individuals
affected by common hypercholesterolemia. We com-
pared the lipid-lowering effect of this functional tomato
sauce with a well-known commercialized functional food
with a lipid-lowering effect, i.e. a sterol-enriched yogurt.
Methods
Subjects
A population of one hundred and eight subjects (40 male
and 68 female), with newly diagnosed hypercholester-
olemia, not taking lipid-lowering medication, nutraceuti-
cals, supplements or functional food, and aged between
20–75 attending the outpatient lipid clinic of the “Mater
Domini” Azienda University Hospital in Catanzaro, Italy,
were enrolled for this study (enrolment period between
February 12, 2018 and July 19, 2018). e study’s pro-
tocol allowed to enroll individuals who had taken
Trial registration: ID: 13244115 on the ISRCTN registry, retrospectively registered in 2019-5-14. URL: http://www.isrct
n.com/ISRCT N1324 4115
Keywords: Functional food, Tomato sauce, Sterols, Carotenoids, Lipids, Cholesterol
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Ferroetal. J Transl Med (2021) 19:19
lipid-lowering drugs or other up to three months before
but we chose to enroll only those who had never used
these medications.
All of them were affected by polygenic hypercholes-
terolemia, that is the most common primary disorder
causing an increase in plasma LDL-C associated with
a low-moderate risk for coronary artery disease and
causing hyperlipidemia only in 10% of the first-degree
relatives [22]. We excluded individuals with familial
hypercholesterolemia causing an increase in total cho-
lesterol concentrations above the 95th percentile, hyper-
cholesterolemia in 50% of the first-degree relatives, the
presence of tendon xanthomata and a history of early
coronary heart disease [i.e. before age 55 in men or 65 in
women) [22].
Furthermore, according to the protocol of the study,
we excluded subjects with triglycerides concentration
over 150 mg/dl, and those with nephrotic syndrome,
chronic renal failure, and allergies to milk proteins, soy
and tomato and those suffering from gastrointestinal
diseases or who had cardiovascular events in the previ-
ous 6months. In addition, although not specified in the
protocol and according to other studies on this issue we
excluded those with secondary causes of hyperlipidemia
[as cholestasis,hypothyroidism, pregnancy, sepsis, acute
intermittent porphyria, oral contraceptive use, corticos-
teroid therapy, immunosuppression, past and current
alcohol abuse (> 20g of alcohol per day; 350mL (12oz)
of beer, 120mL (4oz) of wine, and 45mL (1.5oz) of hard
liquor each contain 10g of alcohol], or who was affected
by debilitating diseases, as ascertained from their clinical
records.
Study design
A cross-over study design was used. We performed a
study lasting 6weeks with the LDL-C as the main out-
come. Ninety-one subjects completed the treatments that
were as follows:
1. A functional tomato sauce [namely OsteoCol (reg-
istered Patent), from tomatoes ripened on-the-vine],
150ml/day (provided by C.G. Food, SRL, Soverato,
Italy);
2. A sterol-enriched yogurt (containing sterols
1.6g/100g/ day, provided by Danone, SPA, Milano,
Italy).
In this type of study, the participants cross over from
one arm of the study to the other and serve as their own
control group.
Due to the different packaging of the treatments, in
this study both the experimenters and participants were
aware of who was receiving the tomato sauce or the
yogurt, while data collectors and outcome adjudicators
were blind. Furthermore, due to the expiry of the supply
of yogurt in a very restricted period, we used a block ran-
domization. However, to eliminate selection bias, we ran-
domized patients in blocks at recruitment rather than as
they arrived. Furthermore, to help to minimize potential
bias, we assessed the baseline clinical characteristics of
participants according to allocation.
Participants received oral and written recommen-
dations to adhere to a Mediterranean dietary pattern,
without energy restriction by dietitians [23] who also
delivered the intervention. Both groups were under close
dietetic supervision by a registered dietician through the
entire study.
Macronutrient distribution as a percentage of total
energy range from 50 to 55% carbohydrate, 15–20% pro-
tein and 20–35% fat, with a recommended protein intake
of 1g/kg of ideal body weight [23]. Contrary to the proto-
col, the yogurt was delivery at the clinic and not at home.
Local ethical committee at the “Mater Domini” Azienda
University Hospital approved the protocol (06/2018/CE
approved 18 January, 2018). Written informed consent
was obtained from all participants. e investigation
conforms to the principles outlined in the Declaration of
Helsinki (e study is listed on the ISRCTN registry with
study ID ISRCTN13244115).
Figure1 shows the flow-chart of the study (Last fol-
low-up visit was in September, 1, 2018). Participants
were advised to avoid consuming other tomato products
throughout the study period. Subjects consumed their
regular diet during the 4weeks washout periods.
Carotenoids content analysis
Carotenoid concentration in the tomato sauce was
assessed by matrix-assisted laser desorption/ioniza-
tionTime of Flight (MALDI-TOF) mass spectometry
(ABSciex, Framingham, MA, USA) [24]. Carotenoids
content was 3.5mg/g.
Anthropometric measurements andcardiovascular risk
factors assessment
Body weight was measured before breakfast after a 12h
overnight fast with the subjects lightly dressed, subtract-
ing the weight of clothes. Body weight was measured on
a calibrated digital scale (model Tanita BC-418MA) accu-
rate to 0.1kg, and standing height was measured with
a wall-mounted stadiometer [23]. BMI was calculated
with the following equation: weight (kg)/height (m)2.
Waist circumferences and hip circumferences (WC and
HC) were measured with a no stretchable tape over the
unclothed abdomen at the narrowest point between cos-
tal margin and iliac crest and over light clothing at the
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Ferroetal. J Transl Med (2021) 19:19
level of the widest diameter around the buttocks, respec-
tively, as described in the past [23].
We assessed the presence of the classical cardiovascu-
lar (CV) risk factors, such as hypertension, diabetes and
smoking, from clinical records and patient interview [23,
25].
Blood pressure was determined at the time of the two
visits, as previously described [23]
Biochemical evaluation
Venous blood was collected after fasting overnight into
vacutainer tubes (Becton & Dickinson, Plymouth, Eng-
land) and centrifuged within 4 h. Serum glucose, total
cholesterol, high density lipoprotein (HDL)-cholesterol,
triglycerides, creatinine, high sensitivity C-reactive pro-
tein (CRP) and transaminases were measured by chemi-
luminescent immunoassay on COBAS 8000 (Roche,
Switzerland), according to the manufacturer’s instruc-
tions. LDL- C level was calculated by the Friedewald
formula [26]. Lipoprotein (a) was assessed with immu-
noturbidimetry method (normal value of < 75nmol/L).
Quality control was assessed daily for all determinations.
ree informed, consenting, healthy volunteers
between the ages of 30 and 45years and BMIs between
19–22kg/m2 were recruited for the evaluation of serum
lycopene concentration. Subjects were non-pregnant,
non-smoking adults who were free from metabolic dis-
eases. All subjects were instructed to not consume lyco-
pene-containing foods for 7days prior to serum lycopene
evaluation and during the 4 experimental days. Lycopene
concentration was assessed at the baseline and after four
days of the consumption of 150ml/day of the tomatoes
sauce ripened on-the vine. Lycopene was quantified by
HPLC method (Jasco LC-NET II).
Data analysis
Data are reported as mean ± standard deviation (SD).
Based on the assumption that the within-patient stand-
ard deviation of the response variable is 20, considering
a probability of 95% that the study will detect a treat-
ment difference at a two-sided 0.05 significance level, if
the functional tomato sauce is not inferior to the sterol-
enriched yogurt and the true difference between treat-
ments is inferior to 10mg, a total of 106 patients entered
this two-treatment crossover study [27] (Fig.1). Changes
in the clinical characteristics from baseline to follow-up
(within group variation) were calculated using paired
Student’s t test (two tailed). ANOVA was used to com-
pare the mean changes between LDL-C tertiles. e
General Linear Model (GLM) was used to adjust the
LDL-C reduction for potential confounders (such as
weight change).
We used both an indirect assessment method (i.e.,
bottle caps counts) and patients interview for assess-
ing adherence. We defined a participant as low adherent
(LA) when the participant took less than 80% of the pre-
scribed treatment.
Fig. 1 Flow-chart of the study
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Ferroetal. J Transl Med (2021) 19:19
Significant differences were assumed to be present at
p < 0.05 (two-tailed). All comparisons were performed
using SPSS 22.0 for Windows (IBM Corporation, New
York, NY, United States).
Results
Table1 shows the basal clinical characteristics of partici-
pants who completed the study (n = 91). e mean age
of the enrolled population was 54 ± 10years. e mean
basal LDL-C was 154 ± 18 mg/dl. A total of 40 (37%)
were male, and 26% had hypertension. e prevalence
remained stable during the entire study (also medica-
tions). In this study the drop-out rate was 15% and low-
adherence rate was 33% (only in the tomato sauce group).
In healthy volunteers, after four days of tomato sauce
consumption, serum lycopene (all trans isomer) was
1.26 ± 0.04µM/L while it was undetectable at baseline.
Changes in the clinical parameters after each treatment
period are shown in Table2. Both the sterol-enriched
yogurt and Tomato sauce (high adherence- HA) signifi-
cantly lowered serum LDL-C while the Tomato sauce-
LA increased LDL-C (absolute difference: − 16 ± 21;
− 12 ± 17; + 8 ± 15 mg/dl in the yogurt, Tomato
sauce-HA and Tomato sauce-LA group, respectively;
p < 0.001; p < 0.001 and p = 0.008 respectively; paired
t-test).
Body weight, WC, HC, TC and non HDL-C signifi-
cantly reduced after each treatment (for body weight:
− 1.2 ± 1; − 0.8 ± 1; − 1.1 ± 1, in the yogurt, Tomato
sauce-HA and Tomato sauce-LA group, respectively;
p < 0.001 for all; Table 2). SBP and DBP significantly
reduced only after the Tomato sauce (HA) (−3 ± 12 and
−3 ± 8 respectively; p = 0.04 and p = 0.001, Table2). Fur-
thermore, creatinine increased and HDL-C decreased
significantly after the sterol-enriched yogurt while TG
increased and HDL-C and glucose decreased after
the Tomato sauce-HA and TG increased and glucose
decreased after the Tomato sauce-LA. No other variables
significantly changed at follow-up visit.
LDL-C reduction, which was adjusted for body weight
change, was − 15.3 ± 2 and − 12.4 ± 2 mg/dl in the
yogurt and tomato sauce-HA, respectively (p = 0.35, se e
Fig.2);
e servings of various food categories consumed
daily or weekly during the study is presented in Addi-
tional file1: TableS1. Dietary intake was not significantly
Table 1 Baseline demographic andclinical characteristics ofparticipants who completed thestudy
BMI body mass index, WC waist circumference, HC hip circumference, SBP systolic blood pressure, DBP diastolic blood pressure, TC total cholesterol, HDL-C high
density lipoprotein cholesterol, LDL-C low density lipoprotein cholesterol, TG triglycerides, AST aspartate aminotransferase, ALT alanine aminotransferase
Variables Polygenic hypercholesterolemic patients
(n = 91)
Age (years) 54 ± 11
Weight (kg) 68 ± 11
BMI (kg/m2) 2 ± 3
WC (cm) 93 ± 9
HC (cm) 102 ± 6
SBP (mmHg) 120 ± 13
DBP (mmHg) 75 ± 8
Glucose (mg/dL) 91 ± 11
Creatinine (mg/dL) 0.8 ± 0.2
TC (mg/dL) 236 ± 20
HDL-C (mg/dL) 62 ± 13
LDL-C (mg/dL) 154 ± 18
TG (mg/dL) 102 ± 29
Non HDL-C (mg/dL) 174 ± 20
AST (IU/L) 20 ± 6
ALT (IU/L) 20 ± 10
Prevalence
Male % (n) 37 (34)
Menopause status % (n) 79 (45)
Smokers % (n) 34 (31)
Hypertension % (n) 26 (24)
Antihypertensive agents % (n) 26 (24)
Antiplatelet drug % (n) 7 (6)
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Ferroetal. J Transl Med (2021) 19:19
Table 2 Baseline andfollow-up clinical characteristics ofparticipants according totheintervention andadherence group
Δ, changes; BMI, body mass index; WC, waist circumference; HC, hip circumference; TC, total cholesterol; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; TG, triglycerides; AST,
aspartate aminotransferase; ALT, alanine aminotransferase
Variables Sterol-enriched yogurt (n = 91) Tomato sauce HA (n = 61) Tomato sauce LA (n = 30)
Before After Δp-value Before After Δp-value Before After Δp-value
Weight (kg) 67 ± 11 66 ± 11 − 1.2 ± 1 < 0.001 67 ± 10 66 ± 10 − 0.8 ± 1 < 0.001 67 ± 11 66 ± 11 − 1.1 ± 1 < 0.001
BMI (kg/m2) 25 ± 3 25 ± 3 − 0.4 ± 0.5 < 0.001 25 ± 3 25 ± 3 − 0.3 ± 0.6 < 0.001 25 ± 3 25 ± 2 − 0.4 ± 0.5 < 0.001
WC (cm) 91 ± 9 90 ± 9 − 1.5 ± 3 < 0.001 90 ± 9 89 ± 8 − 0.9 ± 3 0.05 90 ± 9 88 ± 8 − 2.4 ± 4 0.008
HC (cm) 100 ± 6 99 ± 6 − 1.5 ± 2 < 0.001 100 ± 7 99 ± 6 − 1.5 ± 2 < 0.001 99 ± 5 98 ± 6 − 0.8 ± 2 0.09
SBP (mmHg) 119 ± 13 117 ± 11 − 2 ± 10 0.06 119 ± 13 115 ± 12 − 3 ± 12 0.040 117 ± 11 116 ± 13 − 0.7 ± 11 0.74
DBP (mmHg) 74 ± 7 74 ± 6 − 0.01 ± 8 0.98 75 ± 8 72 ± 7 − 3 ± 8 0.010 74 ± 6 74 ± 8 0.2 ± 9 0.89
Glucose (mg/dL) 89 ± 11 89 ± 13 0.2 ± 10 0.87 91 ± 9 89 ± 9 − 2 ± 8 0.019 88 ± 8 84 ± 6 − 3 ± 7 0.010
Creatinine (mg/dL) 0.80 ± 0.2 0.83 ± 0.2 0.03 ± 0.1 0.003 0.80 ± 0.1 0.79 ± 0.1 − 0.01 ± 0.1 0.13 0.83 ± 0.2 0.80 ± 0.1 − 0.03 ± 0.1 0.035
TC (mg/dL) 230 ± 26 211 ± 26 − 18 ± 24 < 0.001 227 ± 25 216 ± 24 − 11 ± 18 < 0.001 220 ± 23 230 ± 27 10 ± 17 0.003
HDL-C (mg/dL) 60 ± 12 58 ± 12 − 3 ± 6 < 0.001 60 ± 14 59 ± 12 − 0.8 ± 6 0.031 56 ± 13 56 ± 12 0.1 ± 6 0.95
LDL-C (mg/dL) 148 ± 24 132 ± 23 − 16 ± 21 < 0.001 147 ± 20 135 ± 18 − 12 ± 17 < 0.001 142 ± 19 150 ± 23 8 ± 15 0.008
TG (mg/dL) 106 ± 38 106 ± 46 0.5 ± 40 0.91 100 ± 34 109 ± 44 9.0 ± 27 0.012 105 ± 32 117 ± 49 12 ± 31 0.049
Non HDL-C (mg/dL) 169 ± 26 154 ± 25 − 16 ± 22 < 0.001 167 ± 23 158 ± 22 − 9 ± 15 < 0.001 163 ± 21 174 ± 27 10 ± 16 0.002
AST (IU/L) 19 ± 5 19 ± 5 0.1 ± 4 0.86 19 ± 5 20 ± 5 0.4 ± 4 0.38 19 ± 3 19 ± 4 0.01 ± 3 0.94
ALT (IU/L) 19 ± 9 18 ± 6 − 0.5 ± 8 0.50 18 ± 7 19 ± 7 0.5 ± 4 0.32 17 ± 8 17 ± 7 − 0.8 ± 6 0.43
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Ferroetal. J Transl Med (2021) 19:19
different between groups except for a sterol-enriched
yogurt (1 serving/day in the yogurt group) and Osteocol
consumption (1 serving/day) in the Tomato sauce group.
Additional file 2: Figure S1 shows individual LDL-C
change for the participant after each treatment. Overall,
allocation to the Tomato-sauce resulted in a 10mg/dl
median reduction in LDLC. However, individual variabil-
ity in per cent LDLC reduction was wide ranging from
modest increases to reductions exceeding 50%.
Figure 3 shows the population categorised accord-
ing to the basal LDL-C tertiles. In the highest tertile
(with LDL-C more than 152mg/dl) the average LDL-C
decrease was − 15% for sterol-enriched yogurt and
−12% for Tomato sauce (HA).
Additional file3: Figure S2 shows the mean high sensi-
tive CRP change (−21%) as well as individual reduction
after Tomato sauce intake. Individual variability in per
cent CRP reduction was wide ranging, with reductions
exceeding 30%.
Moreover, in those in the Tomato sauce-HA group
there was a significant reduction of the Lp (a) concentra-
tion after 6weeks (at Baseline: Lp (a) 34.5 ± 43 nmol/L;
Fig. 2 LDL-C reduction according to the treatment
Fig. 3 LDL-C change in the treatment group according to LDL-cholesterol tertiles
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Ferroetal. J Transl Med (2021) 19:19
at 6week: 29.4 ± 36 nmol/L, p = 0.019; Additional file4:
Figure S3).
All the participants had no adverse symptoms during
the entire study period.
Discussion
With a constant increase in the overall age of the popula-
tion, chronic diseases of aging impose an enormous cost
of health care. Preventative healthcare strategies, which
include nutritional approaches, could save billion in
annual healthcare costs. An increasing numbers of con-
sumers are turning to their diet for well-being and con-
sumer interest in self-care is a leading factor motivating
functional foods consumption in place of several medi-
cations. Furthermore, due to statin-associated muscle
symptoms, adherence tostatintherapy for the reduction
of LDL-C is challenging in clinical practice. Certainfunc-
tional foods might be considered as an alternative oradd-
on therapy to statins. ese products could also exert
multiple non–lipid-lowering actions, including anti-
inflammatory and antioxidative properties.
In the present clinical trial, we demonstrate that a
novel functional tomato sauce (named OsteoCol) reduces
LDL-C concentrations by 5–10% (−7.6 to −16.1mg/dl)
in the participants with a high adherence to the protocol
(i.e.; > 80% of the prescribed treatment) after intervention
for six weeks.
e change observed in LDL-C was in the range of
those obtained with another recognized cholesterol-low-
ering functional food which was a sterol-enriched yogurt
(−6.6 to −12.6%). Furthermore, we found a significant
reduction in TC and non HDL-C.
It has been demonstrated, in postmenopausal women,
that consuming at least seven servings/week of lycopene-
based products decreases cardiovascular risk within
7 years [28]. Since a reduction of 10 mg/dl in LDL-C
concentration has been associated with a significant
reduction in the development of coronary heart disease
(6.6%), major vascular events (5.8%), stroke (4.1%), and
mortality (4.6%) [29], our results are of important clinical
significance.
Previous studies have demonstrated a modest reduc-
tion of LDL-C (of ~ 5 mg/dl) with lycopene-containing
foods or lycopene as a nutraceutical [6], while other
investigations have found a 10% reduction (mean ΔLDL
of ~ 10mg/dl) [30–34], therefore we choose a nutraceuti-
cals with proven efficacy as control.
We found a higher lipid-lowering effect in the partici-
pants of the highest basal LDL-C tertiles (−15% with a
sterol-enriched yogurt and − 12% with Tomato sauce).
With a mean reductions of 12%, the cholesterol-lowering
efficacy of the tomato sauce tested in the current trial
compares favourably with the results of other functional
foods or nutraceuticals containing oats-based fibers or
glucomannan or catechins or chitosan as well as a low
dosesofstatin drugs [35, 36].
According with the current dietary guidelines that are
instruments of public health policy to promote a healthy
diet [37] which suggest consuming a more than five cups/
week of red vegetables, in our study the daily consump-
tion of tomato sauce was 150ml. Furthermore, this study
is in line with recent guidelines [38] suggesting treating
patients with mild-to-moderate hypercholesterolemia
who already follow a healthy diet with cholesterol-lower-
ing functional foods (or nutraceuticals) to reduce LDL-C
levels.
Research into the treatment of hypercholesterolemia
is progressive. Other than classical medical treatments,
several forms of alternative therapies—such as functional
foods, nutraceuticals and other dietary supplements—
have also been tested for these patients.
e lipids reducing properties of tomato have been
associated with the suppression of cholesterol synthesis
via the inhibition of HMG-CoA-reductase and activation
of LDL-receptors [39]. In line with this potential mecha-
nism, we did not assessed any markers for cholesterol
absorption.
Since a tomato sauce can be defined as a functional
food only if, in addition to its nutritional properties, it
has additional properties for health, in this original study
we tested the lipid-lowering effects of a tomato sauce
from vine-ripened tomatoes in individuals affected by
common hypercholesterolemia. Todays, the vast major-
ity of tomato crops are harvested at a mature green stage
and are ripened off the plant with consequent lower
levels of carotenoids and lycopene compared to those
ripened on the vine [20]. Ripening‐induced changes in
tomato matrix influences the amount and bioaccessible
fraction of carotenoids in tomato‐based products. Using
a spectrophotometric method, a study demonstrated that
total carotenoids content markedly increased as fruits
ripened, ranging from 0.53 ± 0.11mg/kg at mature‐green
stage to 14.82 ± 1.62 mg/kg at the most advanced stage
of ripeness [40, 41]. Changes in lycopene content dur-
ing tomato ripening showed a similar pattern [40]. It has
been reported a maximum content of total carotenoids in
tomato juice samples of 60mg/kg and in dried tomato of
1.3g/kg [42].
In our tomato sauce the carotenoids content was of
3.5mg per gram of product, which is higher than other
cultivar or commercial varieties [40–44]. us, ripen-
ing tomato on the vine could be an excellent strategy to
positively influence the nutritional quality of tomato.
Of course, the overall health benefits observed with the
tomato sauce consumption could also be due to the com-
bined effects of all the carotenoids.
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Page 9 of 12
Ferroetal. J Transl Med (2021) 19:19
Body weight significantly changed during the study
but in a minimal extent (−1.2 ± 1; − 0.8 ± 1; − 1.1 ± 1,
in the yogurt, Tomato sauce-HA and Tomato sauce-LA
group, respectively; Table2). Our study was not designed
to explore this specific aspect. When fucoxanthin, a
marine carotenoid, at a dose of 24mg/die was adminis-
tered to obese women for 16weeks, a significant reduc-
tion of body weight, WC and liver fat content, with a
significant increase in resting energy expenditure, was
found [45]. By modulating the adaptive thermogenesis,
fucoxanthin plays a crucial role in energy expenditure
[3]. Future studies could elucidate if carotenoids from
vine-ripened tomato would have anti-obesity proprieties.
Interventions aimed at weight loss reduce lipids in blood.
However, weight loss did not explain LDL-C reduction
in our population. In fact, the LDL-C reduction, which
was adjusted for body weight change, was of the same
entity in both the yogurt and tomato sauce-HA groups
(− 15.3 ± 2 and − 12.4 ± 2 mg/dl, respectively; p = NS,
Fig.2);
e mechanisms underlying the reduction of LDL-C
may or may not be related to carotenoids or lycopene and
we cannot rule out the possible role of other nutrients.
For example, sterols are one of the classes of components
contained in tomato. Sterols are integral membrane com-
ponents of the tomato and may have both a structural
and a metabolic function [46]. Nevertheless, the content
of phytosterols in dried tomato is less than 100mg/kg
[47]. It has been reported that the concentration of phy-
tosterols in a vegetable juice is very low [48]. Only after
consuming more than 400 tomatoes one gets more than
1g of plant sterols, necessary to induce cholesterol low-
ering effect.
us, we did not assess phytosterols either in the
tomato sauce or in the serum of the participants. Further
studies are needed to better clarify the role of phytoster-
ols in tomato-based products.
In this study we found that a yogurt containing 1.6g of
plant sterols reduced HDL-C (~ −3mg/dl; Table2). is
finding is in line with a previous study in which a yogurt
providing 2 g per day of a plant stanol ester mixture,
containing sitostanol and campestanol for five weeks,
reduced HDL-C by 2.5% in hypercholesterolemic sub-
jects [49]. However, HDL-C also reduced significantly in
the tomato sauce –HA group (p = 0.003; Table2). ese
results are similar to those of other intervention studies
in which HDL-C reduced at the end of the study, inde-
pendent of the treatment [50–52]. At this moment, the
underline mechanism is unclear. Despite significant from
a statistical point of view, the clinical implications of
changes in HDL-C (−3mg/dl), creatinine (+ 0.03), glu-
cose (−2mg/dl), triglycerides (+ 9 mg/dl; Table2), may
be very modest or absent and a longer study is needed
to confirm these findings and better compare the two
functional foods tested in the current trial. In the case
of triglycerides it is possible that the cultivation tech-
nique increases the tomato fructose content [53]; in
some short-term controlled feeding studies, dietary fruc-
tose significantly increased TG levels [54]. However, this
effect is overwhelmed by the significative effect on Non-
HDL cholesterol (Table2).
With this study, it was not our intention to investigate
the efficacy of the sterols-enriched yogurt, which was
already well-established [55]. Since the health claims
relating to the cholesterol-lowering effect for tomato
sauces have not yet been approved by EFSA, we thought
that the best reference for our comparison could be a
sterols-enriched yogurt, for which health claims are
approved, but not a standard tomato sauce.
Furthermore, we have chosen a sterols-enriched yogurt
due to the fixed sterols dose, as well as for its wide com-
mercialization and acceptability. e use of other func-
tional foods, such as oats or barley, make less feasible to
assess the treatments adherence. Most important, both
the yogurt and the tomato sauce are consumed daily. e
tomato sauce is consumed daily in the Italian Mediter-
ranean cuisine. For all these reasons, we compared the
tomato sauce to a sterol-enriched yogurt.
In an our previous investigations, no significant vari-
ations in plasma lathosterol, campesterol or s-sitosterol
concentrations after 6weeks of treatment with a sterol-
enriched yogurt was found [56].
us, considering the aim of the study and the con-
siderable amount of heterogeneity in plasma phytoster-
ols concentrations amongst the studies [55], we did not
assess serum phytosterols. Moreover, in this study, all
participants took the yogurt daily as planned.
Although there are no RCTs showing the effects of
long-term plant sterol intake on cardiovascular disease
(CVD) outcomes, e.g., CV events [57], it seems reason-
able that sterol consumption may lower CVD risk based
on the established LDL-C lowering effect. Furthermore,
the demonstration of an association between moderately
increased plant sterol plasma levels and low risk for coro-
nary heart disease (CHD) may contributes to the under-
standing of the significance of dietary plant sterols for the
human health. e EPIC Spanish cohort [58] observed
that elevated levels of plasma sitosterol, the main dietary
phytosterol, was inversely related to CHD. e results
of a community-based study on elderly subjects showed
that high plant sterols concentrations were not associated
with an increased risk, but with a reduced risk for CHD
[59].
Consumption of plant sterol lead to a total phytos-
terol concentration which is far below levels seen in
homozygous sitosterolemics, who develop premature
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Page 10 of 12
Ferroetal. J Transl Med (2021) 19:19
atherosclerosis [55, 60]. We thus did not discourage
phytosterols use and we highlight that our study did not
allow to clarify the relation between serum phytosterols
and atherosclerosis.
Blood pressure and CRP lowering effect of our tomato
sauce (Table2 and Additional file 3: Figure S2) require
confirmation by additional studies, with the change in
blood pressure as the main outcome. Previously [10], the
antihypertensive effect have been attributed to the stimu-
lation of nitric oxide production in the endothelium by
lycopene. We cannot rule out that seasonal influences
or increased awareness of having elevated LDL-C led
to unintended changes in participants life style, which
may have influenced the blood pressure values. Unfortu-
nately we did not measure CRP in the participants taking
yogurt.
In our study, the treatment with tomato sauce was
associated with a significant reduction of Lp (a) (assessed
only in the HA group), that is a particular LDL particle
with an added apolipoprotein (a) attached to the apoli-
poprotein (b) component of the LDL particle, via a
disulphide bridge. Apo (a) has homology with plasmino-
gen and correlates with an increased risk of myocardial
infarction [61].
e magnitude of the changes in Lp (a) levels due to
dietary interventions is relatively modest and several
studies have failed to detect any significant effects with
a dietary intervention on Lp (a) concentrations [62–64].
Overall, it has been suggested that substitutions of satu-
rated fat with dietary mono- and polyunsaturated fatty
acids, as in the Mediterranean Diet, may be better over
protein or carbohydrates in relation to Lp (a) concentra-
tions [65].
Studies on the effect of tomato, or its components, and
Lp (a) do not exist. Although Lp (a) was only dosed in the
HA subgroup, our results confirm that the tomato sauce
under study has positive effects on plasma lipids.
e present study has various limitations that need to
be considered. First, our study focused on a biomarker,
while the effect on the consequently disease would have
to be tested. However, we know that abatement of hyper-
cholesterolemia has a statistically significant association
in the reduction of risk of CHD, and might there be other
beneficial effects as well. However, the presence of other
factors and dietary components, which may have influ-
enced the results, cannot be ruled out. Of course, the cost
for clinical studies resulting in a health claim is prohibi-
tive. Second, the results cannot be applied to other popu-
lations. We acknowledge that not all substances will have
the same effect on all or even a majority of consumers.
ird, in our study the low adherence rate was 33% (only
in the tomato sauce group). However, this was not sur-
prising. ere seemed to be a higher average adherence
rate for capsules intake compared to food, drink and
other forms of supplementation [66]. Moreover, we did
not report serum carotenoids data. Serum carotenoid
concentrations were quantified by HPLC in frozen sam-
ples but unfortunately carotenoids were undetectable.
However, in healthy volunteers, after 4 days of tomato
sauce consumption, serum lycopene was similar to a pre-
vious study [67, 68].
e strengths of this study are the cross-over design as
well as the method: we followed patients to assess adher-
ence to the intervention and, most importantly, reported
the adherence rate. Due to the finding of a worse lipid
profile in low adherent participants compared to those
with the highest adherence, and considering that base-
line characteristics of participants in the two groups were
similar, our results would seem to be confirmed.
Conclusions
In summary, the results of the present study demonstrate
cholesterol-lowering effects of a novel functional from
our tomatoes ripened on-the-vine, similar to statins or
nutraceuticals. Further studies with a longer duration of
intervention are warranted. In the meantime, the increas-
ing body of knowledge on this issue indicates that func-
tional foods may be a useful adjunct to a healthy diet in
the management of common hypercholesterolemia in
individuals.
Supplementary Information
The online version contains supplementary material available at https ://doi.
org/10.1186/s1296 7-020-02676 -3.
Additional le1: TableS1. Servings of various food categories
consumed daily or weekly during the study according with the dietary
treatment.
Additional le2: Figure S1. Individual LDL-C Reduction according to
treatment.
Additional le3: Figure S2. Individual high sensitive C reactive protein
Reduction after Tomato sauce.
Additional le4. Individual Lp(a) change after tomato-sauce intake in
high-adherence group.
Abbreviations
BMI: Body mass index; WC: Waist circumference; HC: Hip circumference; SBP:
Systolic blood pressure; DBP: Diastolic blood pressure; TC: Total cholesterol;
HDL-C: High density lipoprotein cholesterol; LDL-C: Low density lipoprotein
cholesterol; TG: Triglycerides; AST: Aspartate aminotransferase; ALT: Alanine
aminotransferase; CRP: C-reactive protein; HA: High adherence; LA: Low adher-
ence; MALDI-TOF: Matrix-assisted laser desorption/ionization Time of Flight.
Acknowledgements
Not applicable.
Authors’ contributions
YF: enrolment and integrity of data; RP: enrolment and integrity of data; AM:
enrolment and integrity of data; RT: MALDI/TOF measurements; RS: MALDI/
TOF measurements; EM: anthropometric assessments; MAS: anthropometric
assessments; SR: revised statistical analysis and interpretation of data; AP:
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 11 of 12
Ferroetal. J Transl Med (2021) 19:19
study design, data analysis, manuscript writing; EA: laboratory assessment;
FSC: laboratory assessment; TM: study design, data analysis, manuscript writ-
ing; AS: enrolment and integrity of data. All authors read and approved the
final manuscript.
Funding
The Italian Society for the Atherosclerosis Study (S.I.S.A.) supported this study
with a grant and Danone spa provided the sterol-enriched yogurt.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Ethics approval and consent to participate
Local ethical committee at the “Mater Domini” Azienda University Hospital
approved the protocol (06/2018/CE approved 18 January, 2018). Written
informed consent was obtained from all participants. The investigation con-
forms to the principles outlined in the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
Competing interest statement: The authors have no competing financial inter-
ests in relation to the work described. OsteoCol is a patent pending product
(registered patent N° 102019000000061).
Author details
1 Department of Health Science, University Magna Grecia, 88100 Catanzaro,
Italy. 2 Department of Medical and Surgical Science, Nutrition Unit, University
Magna Grecia, 88100 Catanzaro, Italy. 3 Department of Clinical and Experimen-
tal Medicine, Nutrition Unit, University Magna Grecia, 88100 Catanzaro, Italy.
4 Department of Molecular and Clinical Medicine, University of Gothenburg,
41101 Gothenburg, Sweden. 5 Primary Care Unit of Borgia, 88021 Catanzaro,
Italy.
Received: 19 October 2020 Accepted: 11 December 2020
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