Download Soy and Heart Disease

Top 10 Foods that Reduce
Heart Disease!
Jim Painter PhD, RD
Chair, School of Family & Consumer Sciences
Eastern Illinois University
LIPOPROTEIN INTERACTIONS
Small
Intestine
Chylomicron
VLDL
LIVER
LDL
HDL
Reducing Dietary Cholesterol
will Reduce Blood Cholesterol
Reducing dietary cholesterol has long been the
cornerstone of the public health policy to
reduce risk of heart disease.
Current data does not support this policy.
Dietary cholesterol has very little effect on
blood cholesterol levels.
Cholesterol: Where Science and Public
Health Policy Intersect
• Nutrition Reviews. 2010. 68(6):355-364
• Brownawell. A, Falk, M.
• Current recommendations (<300 mg of
cholesterol/d) are flawed.
• Recommendations:
• Increase variety, fruits and vegetables, fish and
polyunsaturated oils
• Decrease processed foods
Dietary Cholesterol and Coronary Artery
Disease: A systematic Review
• Current Atherosclerosis Reports. 2009. 11:418-422.
• Djousse, L. et al.
• Every 100 mg/d of dietary cholesterol would result
in an average 2.2 – 2.5 mg/dl increase in total
plasma cholesterol.
• LDL and HDL increase at about the same rate so the
ratio is not affected by dietary cholesterol.
Dietary Cholesterol and Coronary Artery
Disease: A systematic Review
• It is reasonable to conclude that there is little
evidence supporting a major association between
dietary cholesterol and CHD risk in the general
population.
• Dietary cholesterol may be detrimental for diabetics.
• So the current recommendations remain sound.
Will Reducing Total Dietary Fat
Reduce CHD Risk?
Public health policy to reduce risk of heart disease
has also long held that reducing total dietary fat
intake will also reduce risk for CHD:
Current data do not support this policy.
DRI for Energy…Fatty Acids & Cholesterol..
IOM, 2002
Change in Plasma Cholesterol (mg/dL)
ΔPlasma Cholesterol/100 mg/day
ΔDietary Cholesterol
for Quartiles of Fat Calories (%)
3.5
3
2.5
2
1.5
1
0.5
0
28
32
37
40
Dietary Fat Calories (%)
McNamara, J. American College of Nutrition, 19(5), 540S-548S, 2000
43
Egg Consumption and the Effect on
LDL:HDL Ratio
Cholesterol (mg/dL)
LDL:HDL Ratio
LDL
HDL
LDL:HDL
Baseline
130
50
2.60
+ 1 egg/day
134
51
2.63
Baseline
150
50
3.00
+ 1 egg/day
154
51
3.02
Baseline
170
50
3.40
+ 1 egg/day
174
51
3.41
% Change
1.2%
0.7%
0.3%
McNamara. 2000 J American College of Nutrition, 19(5), 540S-548S
I. Substitute Monounsaturated &
Polyunsaturated Fat for Saturated Fat
Recent data does not provide strong support that Saturated
fat is an independent risk factor for heart disease.
Substituting polyunsaturated fat for saturated fat in the
diet does lower LDL blood cholesterol.
Effects on CHD of Increasing
PUFA in Place of SFA
• Dariush Mozaffarian, Renata Micha &, Sarah
Wallace. 2010, PLoS Med 7(3)
• Meta-analysis of 8 randomized controlled trials
• 13,614 participants with 1,042 CHD events
• Intervention group consumed an average of 14.9%
PUFA
• Determined: 10% reduction in CHD risk with
every 5% increase in PUFA substitution
Mozaffarian, D., Renata, M., & Wallace, S. (2010) PLOS Medicine, 7(3), 1-10.
Effects on CHD risk: Consuming PUFA,
CHO, or MUFA in place of SFA
Mozaffarian et al., 2010
Effects of PUFA Substitution
for SFA on CHD Events
Burr 1989
Frantz 1989
Studies
Dayton 1968
Intervention
MRC 1968
Control
Turpeinen 1979
Miettinen 1983
Watts 1992
0
50
100
150
200
Number of CHD Events
Mozaffarian, D., Renata, M., & Wallace, S. (2010) Effects on coronary heart disease of increasing polyunsatruated fat in place of
saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLOS Medicine, 7(3), 1-10.
Sources: SFA, PUFA, & MUFA
Canola Oil Qualified Health Claim
• Limited and not conclusive scientific evidence
suggests that eating about 1½ tablespoons (19
grams) of canola oil daily may reduce the risk of
coronary heart disease due to the unsaturated fat
content in canola oil. To achieve this possible
benefit, canola oil is to replace a similar amount
of saturated fat and not increase the total number
of calories you eat in a day.
II. Balance Omega-3 and
Omega-6 Fatty Acids
• Effects:
– Reduction of high blood pressure
– Prevents vascular clotting
– Lowers triglyceride levels
– Reduction of atherosclerosis
– Anti-inflammatory effects
EPA and DHA
• They are polyunsaturated fatty acids that are part
of the omega-3 family
– EPA = eicosapentaenoic acid
– DHA = docosahexaenoic acid
• They have many roles in the body with
involvement in main areas:
– cardiovascular health
– brain and nervous system function
– eye health (visual function)
Fatty Fish/Fish Oils
• Most highly researched area is their relationship
with reduced risk for CVD
– Over 1,100 papers published on this topic
• Consuming 6 ounces of fatty fish per week may
decrease the risk of CVD
– Recommendation by the American Heart
Association
Omega-3 Intervention Studies
Study
N
Treatment
Results
Gissi et al. 11,324 0.850-0.882 g/d
of EPA + DHA
1999
for 3.5 years
Decreased CVD death
and non-fatal MI
Von
223
Schacky et
al.
6 g/d fish oil; 3
months
3g/d fish oil; 21
months
Decreased CVD death,
fatal and non-fatal MI
1.8 g/d EPA +
DHA for 1 year
Decreased cardiac
deaths and non-fatal MI
3 g/d fish oil for
2 years
Decreased CHD deaths
1999
Singh et al. 360
1997
Burr et al.
1994
227
Process of Inflammation
Omega-6
Omega-3
Arachidonic Acid
EPA/DHA
Cyclooxygenase pathway
PGE2
Pro-inflammatory
PGE3
anti-inflammatory
Sources: Omega-3 Fatty Acids
• Common sources:
– Fatty fish and fish oil
– Marine plants
– Olive oil, Canola oil
– Flaxseed
– Soybeans
– Many nuts and seeds
Sources: Fish and Seafood
Omega-3’s in 3.5oz, raw
•
•
•
•
•
•
•
•
Sardines (in oil, cooked)
Mackerel, Atlantic
Trout, lake
Salmon, pink
Oysters, Pacific
Tuna
Shrimp
Lobster
3.3g
2.5g
1.6g
1.0g
0.6g
0.5g
0.3g
0.2g
“Qualified” Health Claim
• February 8, 2002
• "Consumption of omega-3 fatty acids may reduce
the risk of coronary heart disease. FDA evaluated
the data and determined that, although there is
scientific evidence supporting the claim, the
evidence is not conclusive.”
III. Nuts
Effects:
• Lower the risk of coronary heart disease
• Lower TC and LDL when consumed in
moderation as part of a low fat diet
–
–
–
–
–
Fiber
Phytosterols
MUFA/PUFA
Antioxidants
Amino Acids
Research studies: Nuts
Study
Sample
description
Adventist Health
Studies
(3 studies total),
1976
Nurse’s Health
Study,
1984
35,000 California
Seventh-Day
Adventists for up
to 12 years
86,000 women
for 14 years
Iowa Women’s
Health Study,
1986
Physician’s
Health Study,
2002
Amount of nuts
Effects
Consume nuts 5 Reduced risk of
or more times per heart attack
week
Lower lifetime
risk of CHD
5 or more ounces 35% reduced
per week
risk for CHD
Reduced risk of
heart attack
35,000
Consume nuts
40% reduced
postmenopausal and seeds more
risk of CHD
women without than 4 times a
CHD for 7 years month
21,454 males
Consumed nuts 2 Reduced CHD
without CHD for or more times/wk risk by ~30%
12 months
Individual Research Studies: Nuts
Study
Rajaram et al.,
2009
Sample
description
25 normalhyperlipidemic
adults (23-65
years)
Sheridan et al.,
15 adults (36-75
2007
years) with
moderate
hypercholesterole
mia
Griel et al., 2007 25 healthy adults
(25-65 years)
Amount of nuts
Effects
42.5g walnuts
twice/wk for 4
weeks
Reduced CHD
risk ~18.6%
2-3 oz pistachio
nuts/day for 4
weeks
Reduced LDLC/HDL-C ~14%
Reduced LDLC ~9%
~1.5 oz
macadamia
nuts/day
Reduced TC
and LDL-C
concentration
Reduced MI
risk ~17%
IV. Stanol/Sterol Esters
• (Sterols)
• (Stanols)
Stanol/Sterol esters work by increasing cholesterol output
into the bile and by transferring cholesterol back into the
intestinal track.
Effects: Stanol Esters and CholesterolLowering
• Foods with plant stanol esters lower serum LDL levels
by about 14%
Source: Mensink & Plat.,1998, Postgrad Med., 27-31
• When incorporated into diets low in saturated fat and
cholesterol, average reductions in LDL cholesterol of up
to 24% have been achieved
Mechanism: Sterol/Stanol Esters
• ABCA1 & ABCG5/G8 transporters expressed in
liver and intestine
• Stimulate sterol efflux and biliary sterol
absorption
• “Competitively inhibit absorption of dietary and
biliary cholesterol by competing for space in
micelles”
Nies et al., 2006, Ann Pharmacother 40:1984-1992
Plat & Mensink, 2002; FASEB J 16:1248-1253
Stanol/Sterol Health Claim
• September, 2000: FDA authorized use of health
claims for the association between plant
sterol/stanol esters and reduced risk of CHD
• Products: cholesterol lowering margarine
– STEROLS: Promise Activ® (Lipton)
– STANOLS: Benecol® (McNeil)
• Foods bearing claim must contain at least
– 0.65 g of plant sterols per serving
– 1.7 g of stanol esters per serving
Recommendations
• Usual dose is 800 mg – 6.0 grams/d
• Divided equally and given before meals
• Doses above 2.0 g/day do not appear to
add additional benefits.
Nies, 2006. Complimentary and Alternative Therapies for the Management of Dyslipidemias
V. Soy/ legumes
• Low in saturated fat
• Contains protein and other compounds that help
lower blood cholesterol
Effect = reduced risk of heart disease
Effects: Meta-analysis of Soy protein on
Serum Lipids
• Reviewed 38 clinical studies on a total of
730 people over the past two decades:
- 20 studies used soy protein isolate
- 15 used textured vegetable protein
• Observed a lowering of serum cholesterol in 34 of
38 studies
• Observed no effect in 4 studies
•In all studies, cholesterol averaged <185 mg./dl.
James W. Anderson, M.D., Bryan M. Johnstone, Ph.D., and Margaret E. Cook-Newell, M.S., R.D.
N Engl J Med 1995; 333:276-282
Reduction of Total Cholesterol by Soy
Initial Cholesterol
(mg/dl)
>335
259-332
201-255
127-198
0
20
40
60
Average Total Cholesterol Reduction
(mg/dl)
Reduction in Blood
Cholesterol mg.
Reduction of Blood Cholesterol
with Soy Consumption
30
25
20
15
10
5
0
25
50
Soy Intake (grams)
75
Soy Protein Health Claim
• “Diets low in saturated fat and cholesterol that
include 25 grams of soy protein a day may reduce
the risk of heart disease.”
• Requirements to bear the health claim:
– low in saturated fat
– low cholesterol food
– minimum of 6.25 g of soy protein per serving
Sources: Soy Protein
Soy Food
Amount
Soy Protein
Soy milk, plain
1 cup
8g
Tofu
½ cup
10 g
Soy flour, defatted
¼ cup
8g
Soybeans, cooked
½ cup
13 g
Roasted soynuts
¼ cup
12 g
Tempeh
½ cup
16 g
Source: United Soybean Board
VI. Dietary Fiber
Effects:
• Reduces total and LDL cholesterol
• Reduces CHD risk
Psyllium or Oat Bran and LDL
Cholesterol in Normal and
Hypercholesterolemic Men
• Romero et al., 1998
• Journal of the American College of Nutrition
• 66 participants (normal= 36,
hypercholesterolemic=30) consumed 0.6g, 1.7g, or
2.8g soluble fiber from wheat bran, psyllium, or
oat bran respectively
• 8 wk controlled clinical trial
Changes between baseline and 8 weeks in LDL cholesterol of
normal (cholesterol<220 mg/dL) or hypercholesterolemic
(cholesterol>220mg/dL) subjects fed control, psyllium or oat
bran cookies.
160
140
120
100
Control
80
Psyllium
Oat bran
60
40
20
0
Baseline2
8 Weeks
Changes between baseline and 8 weeks in plasma HDL cholesterol and
triglyceride of normal (cholesterol<220 mg/dL) or hypercholesterolemic
(cholesterol>220mg/dL) subjects fed control, psyllium or oat bran
cookies.
60
50
40
Control
Psyllium
Oat bran
30
20
10
0
Baseline
8 Weeks
Wei et al., 2009, Euro J Clin Nutr, 63: 821-827.
Mechanism: Soluble Fiber
LIVER
Hepatic
Portal Vein
Bile Salt
Psyllium
Bile Duct
Duodenum
Ileum
Anderson, et al., Am. J. Clin. Nutr. 71:472, 2000
Recommendations: Fiber
• Recommended fiber intake is
• 38 grams/day for men
• 25 grams/day for women
• U.S. consumers average less than ½ of the
recommendation.
Oat Health Claim
• “An intake of 3 g or more per day of ß-glucan
soluble fiber from whole oats may help reduce the
risk of CHD.”
Recommendations: Oats
• 1 1/2 cups cooked oatmeal
• 1 cup cooked oat bran cereal
• 3 cups dry oat cereal
• 2-10 g of SOLUBLE fiber was associated with
reductions in total cholesterol and LDL cholesterol
– 1 g soluble fiber = approximately one 28 g (1
oz.) serving of oatmeal
Sources: Fiber
•
•
•
•
oatmeal, cooked
peas
kidney beans
potato, baked with
skin
• whole wheat bread
• bran flake cereal
• spinach
• certain fruits
– apples
– bananas
– oranges
– pears
• psyllium (grain found
in some cereal
products)
VII. Purple grape juice/wine
• Purple grape juice contains polyphenolic
compounds
• Many health-promoting compounds are found in
the seeds and the skin
Effects: Grapes
• Grapes contain a variety of antioxidants in both the
skin and the seeds
• The antioxidants in the skin have been shown to
– inhibit the oxidation of low-density
lipoproteins (LDLs)
– inhibit the stickiness of platelets that
leads to blood clotting
– promoting the relaxation of blood
vessel walls (dilation)
Grape Summary
• Preliminary research suggests several heart health
benefits of purple grape juice including:
– Inhibition of blood clotting
– Reduction of LDL oxidation
– Promotion of flexible arteries
Wine as a Medicine
• One of the earliest admonitions to drink wine as
remedy for disease was given by the Apostle Paul
when he told Timothy to “Stop drinking only
water, and use a little wine because of your
stomach and your frequent illnesses” (New
International Version, 1985)
Wine as a Medicine
• 1963: Lucia tells of the decline of the use of wine
as a medicine with the advent of aspirin and other
wonder drugs of the 19th and 20th centuries.
• 1976: First study by Folts on anticoagulation.
Circumflex Coronary Artery Blood Flow ml/min
Red Wine Infusion
Demrow 1995
Blood
Flow
100%
0%
|---------12 min--------|
Demrow, HS, et. al., 1995 Circulation 91:4, 1182-1188
Circumflex Coronary Artery Blood Flow ml/min
Red Wine Intragastric
Demrow 1995
100%
Blood
Flow
0%
|---------12 min--------|
Demrow, HS, et. al., 1995 Circulation 91:4, 1182-1188
Ischaemic Heart Disease Mortality/1000 Men
St. Ledger, et. Al, 1979
12
10
8
6
4
2
0
0
2
4
6
Ounces of wine
8
10
Platelet Aggregation Response in Humans
after Drinking Grape, Orange or Grapefruit
Juices for 1 wk:
*Significantly different from baseline, P = 0.0002. Values are means ± SD, n = 10.
Source: Keevil et al., J Nutr, 2000
Antioxidant Power
A study from the US Department of Agriculture found
that Purple 100% Grape Juice has more than three
times the antioxidant power of popular juices as
grapefruit, orange, tomato and apple.
Source: J. Agr. Food Chem. 1996
Inverse relationship between drinking frequency and one
estimate of platelet coagulability.
8
Rate of Blood Coagulation
Under Standard Conditions
7
6.8
6
5
3.5
4
2.7
3
1.8
2
1
0
rarely
weekends only
most days
Drinking Status
Goldberg, DM, et. al., 1995
every day
Incidence of Mortality from Coronary Heart
Disease in Different Regions:
Region
Plasma Cholesterol
(mg/dl)
Mortality
(per 10,000)
Japan
--France
General
216
Toulouse 224
33
USA
209
182
UK
240
380
102
78
Source: Table 1, JE Kinsella, Food Technology, 4/93
Inhibit LDL Oxidation
Frankel 1993
100
95
90
85
80
75
70
65
60
55
50
45
40
A tocopherol
35
30
25
20
15
Wine Phenolics
10
5
0
1
2
3
4
Micromoles of compound
5
Table 1. Phenolic Compound Concentrations in Several Grape Varieties and Wines
[i]
Grape/wine
Thomson seedless
Flame seedless
Black seedless
Cabernet Sauvignon
Petite Sirah
Phenolics, mg/L[ii]
260
850
920
1800
3200
[i] Phenolic compounds from grapes were extracted with 80% ethanol (without
distillation of the ethanol) and diluted by distilled water before being tested in model
systems.
[ii] Wine, liter; grapes, kilogram.
Recommendations: Grapes and
Grape Juice
• Most studies suggest drinking 1-2 cups (8-16 oz)
of purple grape juice per day may have
cardiovascular benefits
• 170 calories in 8 oz. Purple 100% Grape Juice
• Make sure you’re drinking 100% juice
VIII. Tea
• Second most consumed beverage in the world
– Estimated 2.5 billion cups drunk daily
• Tea leaves contain more than 35% of their dry
weight in polyphenols called catechins
Tea
• Second most consumed beverage in the world
– Estimated 2.5 billion cups drunk daily
• Among all the tea produced, 78% is black, 20% is
green, and 2% is Oolong tea
• Tea leaves contain more than 35% of their dry
weight in polyphenols called catechins
Effects: Tea
• By maintaining the health of the body’s
circulatory system of arteries and veins
• By reducing the risk of blood clots
• By reducing blood lipids
Recent Green Tea Research
• Compounds and antioxidants in green tea may exert
vascular protection
Source: European Journal of Pharmacology, 2002
• Green tea consumption was significantly associated
with lower levels of total cholesterol in 14,000 healthy
Japanese subjects
Source: Annals of Epidemiology, 2002
Recommendations: Tea
• Approx. 150 mg of flavonoids is needed to trigger
a rapid antioxidant effect
• Brewed tea contains 172 mg of flavonoids in one
8-ounce cup (brewed for 2 minutes)
• Therefore, 1-3.5 cups of tea would be expected to
have physiologic effects
– 1 cup ~ acute effects
– 3.5 cups ~ chronic effects
Source: Curr Opin Lipidol, 2002
Basic Four Food Groups
Tastes good
but bad for
you
Tastes bad
but good for
you
Was good for
you but not any
more
If you eat it
you will die
IX. Garlic
• Garlic has been used in traditional and folk
medicine for over 4,000 years
• Garlic contains sulfur compounds
• Eating one clove of garlic per day may help
decrease blood cholesterol levels
Effects: Garlic
•
•
•
•
•
Prevents platelet “stickiness”
Inhibits constriction of arteries
Reduces LDL oxidation (leads to clotting)
Prevents high blood pressure
Reduces blood lipids
Ackermann et al., 2001, Arch Intern Med, 161: 813-24.
Butt et al., 2009, Crit Rev Food Sci Nutr, 49(6): 538-51
Component Responsible for Lipid
Lowering
• Allicin, a sulfur compound
• Volatile sulfur compounds are not present in intact cells
• Release by:
– chopping
– steaming
– crushing
Garlic Compounds and the
Effect on HMG-CoA Reductase
Liu & Yeh, 2002, J Nutr 132: 1129-1134
Recommendations: Garlic
• Experts still researching optimal dose
• Conservative estimate = 1-3 cloves per day
X. Chocolate
•
•
•
•
Cocoa processed with alkali is not beneficial
High fat chocolate is not beneficial
High sugar chocolate is not beneficial
Cocoa is beneficial
Effects: Cocoa
Comparison of Antioxidant Content
•
•
•
•
Black tea (2gm bag) 1000 C for 2 min.
Green tea (2gm bag) 1000 C for 2 min.
Wine 140 ml. California Merlot.
2 tbs. commercial Cocoa pwd. 200 ml H20
Total Flavonoid and Phenolic
Content of Tea, Wine and Cocoa
(per serving)
700
600
500
400
mg
300
200
100
0
GAE
ECE
Black Tea
Green Tea
Wine
cocoa
Gallic acid equivalents (GAE), phenolic
Epicatechin equivalents (ECE), flavonoid
Lee et al. (2003). Cocoa Has More Phenolic Phytochemicals and Higher Antioxidant Capacity the Teas and Red Wine.
Journal of Agriculture and Food Chemistry, 51, 7292-7295.
Comparison of Antioxidant Action of
Tea, Wine and Cocoa ( DPPH Free
Radical Scavenging)
900
VCEAC mg.
800
700
600
500
400
300
200
100
0
Black Tea
Green Tea
Wine
Cocoa
DPPH, 2,2-diphenyl-1-picrylhydrazyl free radical assay
VCEAC, Vitamin C equivalent antioxidant capacity
Lee et al. (2003). Cocoa Has More Phenolic Phytochemicals and Higher Antioxidant Capacity the Teas and Red Wine.
Journal of Agriculture and Food Chemistry, 51, 7292-7295.
Cocoa Inhibits Blood flow and Vessel
Dilation
•
•
•
•
Subjects 20 individuals at risk of CHD
Consumed a cocoa drink
2 groups high and low flavanol
Brachial artery flow and dilation were measured
Sies, et al. 2005. Cocoa Polyphenols and Inflammatory Mediators. American Journal of Clinical
Nutrition, 81, 304s-12s.
Vaso-dilation with Cocoa Flavanols
7
6
5
% FMD 4
Before
2 hr After
3
2
1
0
Low flavanol
cocoa
High flavanol
cocoa
FMD (Flow-mediated Dilation)
Sies, et al. 2005. Cocoa Polyphenols and Inflammatory Mediators. American Journal of Clinical Nutrition, 81, 304s-12s.
Review: How much should I eat?
- Reducing dietary fat has little effect on blood cholesterol
- Reduce dietary cholesterol has little effect on blood cholesterol
1. Increase mono and polyunsaturated fat in place of saturated fat
2. Increase omega 3 fats, eat Fish: 2 servings per week (serving = 3oz.)
3. Nuts/Almonds: 2 oz./day
4. Phytosterols - Cholesterol-lowering margarine: 2-3 Tbsp/day
5. Soy protein: 25 g/day
6. Oats: 3 g beta-glucan soluble fiber/day
7. Wine or Grape Juice : ½ - 1 cup per day
8. Black or Green Tea: 1-2 cups per day
9. Garlic 1-3 fresh cloves per day
10.Chocolate 2 Tbsp cocoa powder/day
LDL Cholesterol lowering effects of
statins vs diet portfolio
• Plant sterols (1.0 g/1000 kcal)
• Soy protein foods including soy milks and soy
burgers, (21.4 g/1000 kcal)
• Almonds (14 g/1000 kcal)
• Viscous fibers from oats, barley, psyllium, okra
and eggplant (10 g/1000 kcal)
Jenkins, et al. Direct comparison of a dietary portfolio of cholesterol-lowering
foods with a statin in hypercholesterolemic participants, Am J Clin Nutr 2005;81:380 –7.
mmol/L
LDL Cholesterol
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Low SFA
Statin
Diet
week 0
week 2
week 4
Jenkins, et al. Direct comparison of a dietary portfolio of cholesterol-lowering
foods with a statin in hypercholesterolemic participants, Am J Clin Nutr 2005;81:380 –7.