Navigating the cardiovascular health category today.
Rob Brewster, President, Ingredients by Nature, Montclair, CA, www.ingredientsbynature.com
Annie Eng, CEO, HP Ingredients, Bradenton, FL, https://hpingredients.com
Steve Fink, Vice President of Marketing, PLT Health Solutions, Morristown, NJ, www.plthealth.com
Alex Goh, Head of Business, ExcelVite, Perak, Malaysia, www.excelvite.com
Dr. Karin Hermoni, Head of Science and Nutrition, Lycored, Branchburg, NJ, www.lycored.com
Jeff Lind, National Director B2B Sales, Novozymes OneHealth, Bagsvaerd, Denmark, https://novozymesonehealth.com
Dr. Kalyanam Nagabhushanam, President of R&D, Sabinsa, East Windsor, NJ, https://sabinsa.com/
Kate Quackenbush, Communications Director, Gnosis by Lesaffre, Marcq-en-Baroeul, France, https://gnosisbylesaffre.com
Charles Ross, Senior Vice President Americas, Aker BioMarine ASA, Lysaker, Norway, www.superbakrill.com
Andrea Zangara, Head of Scientific Communications & Marketing, Euromed Group, Barcelona, Spain and Bridgeville, PA, www.euromedgroup.com
With the FDA (U.S. Food and Drug Administration) having just put the clamp down on seven companies for “selling dietary supplements with claims to treat cardiovascular disease,” there is no better time to get insights and updates about this important category and responsible ways to market these ingredients and formulations. Here to help us sort it out is a distinguished panel of dietary supplement industry experts.
NIE: What is the state of the market for dietary supplement ingredients for cardiovascular health?
Brewster: According to an estimate, heart health supplements should stay on a steady sales track from 2022 to 2024. However, the supplement growth of the market is predicted to decline from 3.7 percent in 2022 to 1.6 percent in 2024. One factor that could play into this decline is the oversaturation of heart healthy claims from pharma, food and dietary supplementation industries, which is why clinical research is crucial to an ingredients success within the space. We need focus on long-term health and educate consumers on how heart health impacts overall well-being and which ingredients are clinically backed.
Fink: As the largest cause of mortality in the United States, the market for dietary supplement ingredients for cardiovascular health is always going to be strong. The need in this area is so great that we must consider an ‘all hands-on deck’ approach that includes diet, exercise, lifestyle modification and more. A lot of excellent research has shown us that supplements can play an important role in supporting better cardiovascular health and as an industry, we need to continue to do more research and to deliver better health promoting solutions to the public.
Hermoni: Cardiovascular wellness—in particular healthy circulation, blood flow and blood pressure, cholesterol levels and arteries—is one of the most important goals for supplement users. Consumers over the age of 50 have historically been seen as the most important target market, but there have been some interesting shifts in the space. In the past, cardiovascular wellness was closely associated with healthy aging but it is increasingly connected to areas like sports and performance, as well as energy support, and with a younger demographic.
Nagabhushanam: Cardiovascular health products are among the top dietary supplement products ranking equally with weight management products. One can classify these products into: heart function and support; blood vessel support; and products that support maintaining healthy lipid and sugar levels, as well as helping to maintain healthy blood pressure. All these approaches are equally important in the cardiovascular health category.
Goh: According to the 2022 CRN (Council for Responsible Nutrition) survey, consumers are using dietary supplements for the purpose of achieving health care and medical cost savings associated with chronic diseases and conditions that include coronary artery disease, which means the main objective of supplementation is for fending off un-health.
Known ingredients associated with positive heart benefits are, alpha-carotene, beta-carotene (both are ProVitamin A = precursors for vitamin A), tocotrienols (also known as super vitamin E). Market demand is high for these ingredients to promote healthy heart function. This is not surprising because not only older adults are concerned about heart health, but young adults who lead an active lifestyle want to ensure their heart health is at an optimum level to allow them to achieve fitness goals and excel at work performance.
Quackenbush: The market is very strong for supplements supporting cardiovascular health. What is interesting is that we are (thankfully) seeing younger consumers proactively working to support their heart health through supplementation.
Instead of people reaching their senior years, sadly discovering the impact age has had on their health and are then left with no choice but to begin taking pharmaceuticals to address those issues, consumers now recognize they must be proactive about protecting their health so they can age healthily, including shoring up their cardiovascular system to carry them into their senior years. They seek heart-healthy supplements, recognizing that obtaining proper nutrition can make a significant difference.
Zangara: The spread of COVID-19 has moved many consumers to prioritize immune health. While immune supplements are still leading, it is likely that sales of heart health supplements as a preventive measure will increase in the near term, as there is a strong link between COVID and cardiovascular health.
The pandemic has shown that poor cardiovascular health can increase disease susceptibility, leading to more consumer awareness of preventive measures: This has improved consumer consciousness about heart wellness as the pillar of physical and mental wellness and even how good we look.
Therefore, consumers concerned about immunity are also investigating and investing in dietary supplement to support their heart. This will certainly increase demand for holistic heart health ingredients addressing several concerns at once, for example from superfoods like pomegranate.
Lind: There is increased interest in supplements for heart health among consumers and the medical community alike, which is driven by new research. Supplements such as vitamin K2 can support cardiovascular health in significant ways, as a growing body of research demonstrates.
NIE: What specific advancements in cardiovascular health ingredient technology do you find the most interesting?
Quackenbush: The interesting thing about dietary supplements designed to address cardiovascular health is that they are often positioned as alternatives to pharmaceuticals—for example, products targeting cholesterol, blood pressure, blood fats, homocysteine, etc. But most fail to recognize that there is no pharmaceutical solution for hardening of the arteries. However, substantial research shows that a vitamin—specifically vitamin K2—can significantly impact the progression and even regression of hardening of the arteries. This is evidenced by the three-year MenaQ7 cardiovascular study and supported by the one-year MenaQ7 follow-up cardiovascular study.
Zangara: A patent-pending green technology by Euromed (Pure Hydro Process) gently concentrates water soluble and bioavailable compounds from botanicals that are staple in the heart friendly Mediterranean diet, with only physical means and osmotized water, no harsh solvents are used. Therefore, the extracts are minimally processed and are closer to the botanicals they came from, as in the case of olives and pomegranates, superfoods well known for their cardiovascular benefits.
In the real world, the content of polyphenols in commercial olive oils is extremely variable and on average, much less than the EFSA (European Food Safety Authority) recommended 5 mg per 20 ml, a dosage difficult to establish and achieve, likely requiring additional oil intake, with hundreds of extra calories. Euromed’s water extraction of the olives provides a polyphenols-rich extract that can be used to fortify Spanish extra virgin olive oil (and any edible oils) with a patented technology that delivers the recommended 5 mg polyphenols for 20 ml of fortified oil (Euromed’s Secret to Live extra virgin olive oil enriched with Mediteanox that is standardized to hydroxytyrosol [HT] that is 7 percent and higher). This has the obvious advantage of allowing a precise and recommended daily intake of beneficial compounds, without additional calories.
Hermoni: In terms of delivery, exciting things are happening with microencapsulation. For example, Capsudar is our unique precision microencapsulation technology. It turns fragile, volatile and easy-to-spoil ingredients into stable powders that remain viable throughout the rigors of processing, packaging and storage. Last year it enabled us to launch a new highly concentrated D3, creating opportunities for synergistic products that combine vitamin D with other ingredients.
NIE: What studies on cardiovascular health ingredients or formulations are the most compelling?
Hermoni: We’re constantly learning more about the potential of tomato phytonutrients in cardiovascular health. For example, in a 2019 study, Lycored’s tomato nutrient complex was found to be linked to a beneficial effect on blood pressure but lycopene alone was not (Wolak et al., Nutrients, 2019 April 26;11950). The results suggested that the myriad active nutrients in our extract work synergistically to drive significant benefits.
Ross: Recently, JAMA Network published a study showing that krill oil significantly reduces triglyceride levels in the blood, an important measure of heart health. This groundbreaking study is one of the largest clinical investigations of an omega-3 formulation in this patient group to date.
The publication presents the effects of krill oil supplementation on 520 patients with severely high triglyceride levels in their blood (hypertriglyceridemia). Participants were randomly assigned to receive krill oil capsules or placeboes over the course of the experiment. The patients’ triglyceride levels, plasma omega-3s and cholesterol levels were measured before, during and after the 26-week duration of the trials.
The findings show that patients consuming the krill oil experienced a significant reduction in triglycerides levels (12.7 percent reduction in 26 weeks) and there was no increase in LDL cholesterol. The krill oil treatment had even stronger effect in those who also took medication for hypertriglyceridemia.
This study proves that krill oil can help lessen the burden cardiovascular disease has on society by helping to improve the health condition of millions of people worldwide and helping to reduce healthcare costs.
Quackenbush: MenaQ7 has been the source material for 22-plus published human clinical trials confirming safe and efficacious bone and cardiovascular benefits, with more currently underway. Due to this expansive body of evidence, MenaQ7 is the only K2 as MK-7 patented for cardiovascular health.
Zangara: A Spanish-government supported 20-week intervention study at La Paz University Hospital (Madrid), investigated the combined oral administration of two extracts rich in hydroxytyrosol (9.9 mg) and punicalagin (195 mg) from olives and pomegranates, or a placebo, to 67 middle-aged, seemingly healthy adults After eight weeks of daily intake, compared to a placebo, participants showed significantly improved test results of crucial early warnings of the initial phase and in general, all phases of atherosclerosis: endothelial functions, elevated circulating levels of oxidized LDL cholesterol, blood pressure and lipid profile. The significant improvement was greater in subjects who initially showed alterations in such markers.
Nagabhushanam: A recently published clinical study on Saberry, with its active ingredient β-glucogallin, has shown impressive potential to confer cardiovascular benefits by maintaining healthy sugar and lipid levels (Majeed et al.,Food Funct, 2002:Sept 22;13:9523–9531). Sabinsa’s Gugulipid is another vital product for controlling lipid levels in the context of heart health.
Healthy lipid and sugar levels are an integral component of heart health. These studies demonstrate that healthy ingredients in food offer tremendous possibilities for cardiovascular health maintenance.
NIE: What are the most important botanical ingredients for cardiovascular health?
Fink: PLT’s cardiovascular health ingredients include diverse antioxidants based on polyphenols and vitamin K2. The most active of these in the market right now are MegaNatural-BP Cardio Health Support and menatto Vitamin K (MK-7). One other intriguing ingredient is Hytolive Olive Fruit Polyphenol which can deliver the benefits of the Mediterranean Diet in a supplement form.
Eng: Bergamot Citrus bergamia grows abundantly in Italy’s Calabrian region. It has a unique profile of flavonoid and flavonoid glycosides present in its juice and pith, such as neoeriocitrin, neohesperidin, naringin, rutin, neodesmin, rhoifolin and poncirin.
Bergamot differs from other citrus fruits not only in the composition of its flavonoids, but in their particularly high content. Among them is naringin, which has already been reported to be active in animal models of atherosclerosis, while neoeriocitrin and rutin have been shown to inhibit LDL oxidation. Importantly, bergamot juice is rich in neohesperidosides of hesperedin and naringenin, such as melitidine and brutieridine. These flavonoids possess a 3-hydroxy-3-methylglutaryl moiety with a structural similarity to the natural substrate of HMG-CoA reductase, and exhibit strong cholesterol support properties.
Bergamonte has several persuasive human clinical trials all resulting in the demonstration of substantial support of cardiometabolic health, including helping to promote favorable cholesterol profiles. We feel this is a remarkable ingredient because it promotes heart health by working beyond simply supporting healthy cholesterol. Hermoni: Our two tomato-derived (and plant-based) ingredients for cardiometabolic health are Lycomato and Cardiomato.
Lycomato is a standardized tomato extract consisting of carotenoids, tocopherols and phytosterols, which are all naturally abundant in the tomato, a staple of the Mediterranean diet. It has been shown to help maintain blood pressure within normal range and support a healthy circulatory system.
Cardiomato is a proprietary mix for cardiovascular supplements based on our flagship tomato extract but is patented for unique ratios of the lycopene and phytosterols designed specifically to support cardiometabolic wellness. In addition to the benefits of the tomato extract, this composition has been shown to balance levels of oxidized LDL—the most impactful form of cholesterol—and improve cardiometabolic response in areas such as insulin sensitivity.
Zangara: Euromed’s patented extracts Mediteanox and Pomanox, from olive and pomegranate fruits respectively, are supported by compelling scientific evidence related to cardiovascular health and are obtained from locally sourced and quality controlled fruits close to Euromed’s dedicated manufacturing plant, in Southern Spain.
The olives and pomegranates are extracted with purified water only and the supply chain is verticalized, with Euromed controlling each step of the supply chain, from the orchards to the final extracts. Euromed’s Pomalive, a patent pending synergistic and precise combination of the most active compounds from Pomanox and Mediteanox punicalagin and hydroxytyrosol, is supported by authoritative clinical studies on the combination and the individual extracts, with results indicating primary cardiovascular prevention and reported in several peer reviewed publications.
NIE: Speaking of botanicals (and harvesting them), talk about sustainability.
Goh: Sustainability certifications are important to reflect proper procedures for ensuring compliance to established environmental standards. Some of the important aspects are related to traceability, transparency, fair trade, human rights and sustainable sourcing from the nature that preserves biodiversity.
ExcelVite is certified with the Malaysian Sustainable Palm Oil (MSPO) and Roundtable on Sustainable Palm Oil (RSPO) Supply Chain Certification Standards. Achieving these certifications meant that ExcelVite is recognized locally and internationally for our commitment and practices in supporting the use of certified sustainable palm oil (CSPO).
Zangara: Euromed has been successfully audited by EcoVadis and Sedex, two of the most prestigious certification bodies for our sector. The Sedex (Supplier Ethical Data Exchange) Members Ethical Trade Audit (SMETA) 4-pillar audit encompasses all aspects of responsible business and ethical practices throughout the supply chain. The “green” ISO 14001 certification, earned by Euromed Barcelona factory, is an international standard that lists the stringent requirements for environmentally friendly manufacturing processes.
The E.U.-regulated organic certification is the pinnacle of documentation control from the cultivation of the plant material to the extract production. Euromed Earth Harmony Organic Extracts—an organic-certified version of the company’s dietary supplements—guarantees ingredient traceability and environmental sustainability. Blockchain technology can also provide evidence of the product’s origin and its journey across the supply chain.
Since 2017, Euromed`s waste production from saw palmetto extraction is upcycled to develop natural-based dyes for the textile industry (EarthColors by Archroma). This sustainable, environmentally friendly process is fully traceable from nature to fashion through smart tags attached to clothing items. Within the circular economy scheme, the waste materials from our milk thistle production are used for animal composting and all our electricity comes from renewable sources.
Eng: Bergamonte hits all the right notes with today’s discerning socially conscious consumer. Our bergamot fruits are harvested using traditional sustainable farming techniques handed down by generations of local farmers in Calabria. We ensure the farmers and their families are well compensated.
Hermoni: We recently carried out consumer research showing that sustainability related considerations are growing in importance as purchasing factors. Along with a shift to plant-based products and action to reduce emissions, a key area is the minimization of waste.
At Lycored we adopt a holistic approach to make the best possible use of everything nature gives us. We’ve been working to reduce water use and minimize waste by repurposing the seeds, stems, skins and vines as animal feed.
And because the tomato oleoresin we extract accounts for just 5 percent of the composition of tomatoes, we’ve also found techniques to use the rest of the fruit to create a variety of ingredients including our natural taste enhancer, SANTE, which can help reduce sodium and sugar levels in foods and beverages, helping support cardiometabolic wellness from another direction.
Nagabhushanam: Certifications are less important than a company’s track record in sustainable practices. For example, Sabinsa’s product Pterosol is obtained from the heartwood of the Indian Kino tree, Pterocarpus marsupium. In order that the supplies will be sustainable and not have any negative impact at all on the environment, Sabinsa is participating in a conservation project involving a reforestation program of planting Kino trees with Indian Central and Madhya Pradesh State Governments in India.
Fink: Consumers want to have a relationship with the ingredients that are in the supplements they take. Origin stories—beyond just issues of sustainability—are becoming an important part of the messaging landscape for supplement formulators. At PLT Health Solutions, we are seeing interest in an ingredient’s origin—from what the raw materials are, how and where they are harvested, how sustainable the plant-based materials are and whether harvesting practices are equitable for local populations. Other issues like ingredient identity, traceability and quality control are also part of the origin stories we are being asked to provide for our customers.
PLT has always been concerned with the sustainability of the plants that form the foundation of our botanicals. In the cardio health category, PLT innovation partner, California Natural Color, is a division of E. & J. Gallo Winery, the largest premium wine company in the world. This gives the company access to an abundant supply of fresh wine grapes, grown in California’s Central Valley and coastal regions, where it retains complete control over the entire growing and manufacturing process—from the initial selection of wine grapes to final extraction of finished material.
MegaNatural grape seed extracts are traceable to the exact California vineyard where they were grown. Not all grape seed extract suppliers are able to make the same claim. Through relentless testing and painstaking record keeping, California Natural Color can guarantee that MegaNatural grape seed extracts remain adulterant free, which is an increasing concern surrounding some grape seed extracts.
NIE: Considering carotenoids—whether derived from land or marine sources—what carotenoid do you believe is superior for heart health?
Goh: Instead of focusing on a single carotenoid, the consumption of mixed carotenoids that are naturally sourced is more encouraged. It is likely that a diversity of carotenoids could confer optimum health benefits through synergistic cooperation. Unlike the single source of beta-carotene, the beta-carotene in concert with alpha-carotene and a minute amount of lycopene sourced from palm could confer stronger antioxidant and cardioprotective effects.
ExcelVite’s EVTene Mixed-carotene Complex contains high levels of alpha- and beta-carotene, wherein the carotenoids’ ratio and composition are very similar to that of the carrots.
NIE: Looking at other vitamins and also minerals for heart health, what branded vitamin and mineral should formulators be aware of?
Hermoni: There is some evidence suggesting that Individuals with low levels of vitamin D have an increased risk of heart attacks, stroke and hypertension, so maintaining adequate levels is advised. However, too much vitamin D may be associated with risk factors, so it’s important to consult a health care practitioner.
Lind: While vitamin K2 was discovered about 80 years ago, scientists are just now beginning to understand the major role in the body that this vitamin plays, including for heart health. In fact, the main benefits of vitamin K2 include heart and bone health support, as vitamin K2 is responsible for removing calcium from the tissues and shuttling it back into the bone. Although we think of calcium as being for bone health, formulating it with vitamin K2 has heart health benefits.
Goh: There are several sources in which tocotrienols can be found in nature, however, only palm oil contains appreciable amounts of tocotrienol in all four isoforms. In other sources, the tocotrienol profile could be missing certain isoforms making it an incomplete tocotrienol complex.
Our branded ingredient, EVNol SupraBio is a patented and bioenhanced tocotrienol ingredient that ExcelVite manufactures out of our PIC/S cGMP (current good manufacturing practice) and FSSC 22000-certified facility.
Fink: A mounting body of evidence is pointing to the importance of vitamin K in supporting cardiovascular health. In 2022, PLT Health Solutions began marketing menatto Vitamin K2 (MK-7) in North America. A three-year, randomized, double-blind, placebo-controlled study of healthy post-menopausal women found that three years of supplementation with the menatto vitamin K2 material supported healthy blood vessel elasticity by helping maintain the right type of matrix Gla protein in the blood vessel wall. This action may support healthy blood flow, contributing to cardiovascular health.
NIE: As to branded antioxidants, what is a “best in class” example?
Fink: In November of 2022, PLT Health Solutions, Inc. was selected by California Natural Color (CALCOLOR) to market its portfolio of cardiovascular health and antioxidant ingredients in North America. The long-term agreement will cover CALCOLOR’s MegaNatural lines with the potential for further products to come online in the near future.
MegaNatural–BP is a patented FDA no-objection GRAS (generally recognized as safe) grape seed extract that has been shown to help support healthy blood pressure metabolism and normal arterial function. It is standardized to over 94 percent polyphenol content. Human studies conducted at the University of California, Davis, Department of Preventive Cardiology showed that a 150–300 mg per day dose supports healthy systolic and diastolic blood pressure after six weeks.
As a premium, branded antioxidant, the polyphenol content of MegaNatural Gold is not less than 90 percent by weight.
Both ingredients are highly water soluble making them ideal for use in supplements and in functional foods and beverages.
NIE: What branded heart-healthy EFA ingredient should be on formulators’ radar?
Ross: Krill oil is a heart health staple due to its many health benefit applications and its unique, natural composition of omega-3s EPA and DHA, phospholipids and choline. Superba Krill oil, Aker BioMarine’s flagship ingredient, has been associated with heart health since inception. When it comes to science, we have multiple clinical studies proving the health benefits of krill oil and how krill oil supports the three markers of heart health which includes reducing triglycerides, increasing the omega-3 index and modulating inflammation.
Furthermore, some research shows that getting enough choline might help keep the heart and blood vessels healthy, partly by reducing blood pressure. Phospholipids are foundational to our cellular composition, affecting our brain function, immune health, gut health, liver health and many other systems besides.
Phosphatidylcholine is especially critical to cellular function and structure, and most of us aren’t getting enough through our diets.
Quackenbush: Some nutraceuticals work in concert, providing a benefit that is greater together than alone. That is the case regarding vitamins K2 as MK-7 and D3, for example. Then some nutrients pair well because they deliver benefits that the other does not, providing a more robust picture of health. This is the case for vitamin K2 as MK-7 and omega-3s.
Hermoni: It’s well known that omega-3s are a very important ingredient for cardiometabolic health. What’s perhaps less well known is how well it can work synergistically with other ingredients. For example, a study has suggested that low concentrations of EPA in combination with Lycored’s tomato nutrient complex may help prevent cognition deﬁcit. Although the study addressed brain health, this synergy is highly relevant and suggests potential for cardiovascular health.
NIE: What tips do you have for formulators in developing products for this category?
Quackenbush: Formulators should seek out a raw material supplier who is a true partner in their efforts and invested in your success. This partner should offer clinically validated ingredients confirming their material delivers promised health benefits, while also being there to guide you through the formulation process to bring your finished product to life.
Regarding cardio-support products, Gnosis by Lesaffre’s MenaQ7 Vitamin K2 as MK-7 is proven and patented for cardiovascular health, and Quatrefolic is the bioavailable folate shown to deliver heart benefits beyond folic acid.
Eng: First, decide your audience—who will be the regular, loyal consumers for this product? Active seniors? Middle-aged adults with parents/grandparents who had CVD (cardiovascular disease)? Athletes who want to ensure their cardiometabolic system is functioning optimally? People who are more concerned about cholesterol profiles than energy?
Most suppliers of patented, proprietary ingredients have a formulation-assistance department that will help apply the research most advantageously to achieve the goal of the formula.
Hermoni: We’ve carried out consumer research that might offer useful insights for brands who are considering the positioning of heart health products. We found that the idea of “calm” resonates powerfully, with over a third (35 percent) of consumers saying that they would be more likely to buy a product for cardiovascular health if its packaging included the word “calm.”
NIE: What do you see on the horizon for this category?
Fink: It is always imperative that our industry embrace quality clinical science when formulating products and talking to consumers. Gold-standard double-blind placebo-controlled clinical human trials with relevant endpoints will lead the way.
Goh: With the increased availability of genetic testing to the general consumers, more personalized nutritional supplements would be very much the norm for health-conscious consumers to adopt into their daily self-care regimen in the future.
ExcelVite’s EVNol range of flagship tocotrienol complex is very much relevant in this picture due to its list of scientifically substantiated beneficial effects on brain, heart, liver, and metabolic health. In addition, tocotrienol plays an important role in promoting beauty from the inside out.
That’s we anticipate that innovative formulators will seek out ingredients such as EVNol tocotrienol complex when developing personalized applications and products.
Eng: We see that the cardiovascular/cardio-metabolic wellness category will become more important to younger adults (30s, early 40s) than previous generations in that same age range.
Lind: As awareness of vitamin K2’s benefits continues to increase among medical practitioners and consumers alike, we anticipate ongoing growth in this category, especially in the cardio support segment. Historically the focus on heart health has been primarily on the male population in terms of research and development, but there is finally more emphasis on understanding heart health in women.
Ross: Leaning into the future, we believe it’s imperative that we keep the topic of heart health high on the agenda by continuing to explore new innovation as well as educate on supplements that promote a healthy heart. The team at Superba Krill oil is continually looking ahead to all of the new product possibilities and what it takes for brands to evolve and succeed in our space.
Hermoni: We are starting to see formulas designed for specific dietary regimens, such as the ketogenic diet, intermittent fasting support, and of course formulas designed for vegan and vegetarian diets.
That said, at the end of the day, it’s not about an extreme lifestyle, it’s about balance and a holistic journey combining the physical and mental aspects of wellness. We would like to see formulas and marketing campaigns that take this holistic approach to wellness, incorporating science that addresses multiple cardiometabolic parameters, but also inspiring self-love and self-care to complement the journey. NIE