Dietary protein effects on cholesterol and lipoprotein concentrations: a review

Effect of a High-Protein High-Fibre Nutritional Supplement on Lipid Profile in Overweight/Obese Adults with Type 2 Diabetes Mellitus: A 24-Week Randomized Controlled Trial

Background

Foods rich in protein and dietary fibre could potentially improve lipid profile in overweight or obese diabetic patients with dyslipidemia and, thereby, mitigate their risk of cardiovascular disease (CVD). In this study, the effect of providing high-protein high-fibre (HPHF) nutritional supplement in addition to standard care of type 2 diabetes mellitus (T2DM) on lipid profile was evaluated.

Methods

In this open-label, parallel-arm, prospective, randomized study, a total of 100 overweight/obese participants with T2DM were randomized to either an intervention group (25 g HPHF nutritional supplement given twice daily along with a standard care of T2DM) or a control group (standard care of T2DM) for 24 weeks. Change from baseline in lipid parameters such as total cholesterol (TChol), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) was assessed between the intervention and control group at week 12 and week 24. Participant compliance was assessed using the dietary 24-hour recall. Statistical analysis was performed to assess the main effects on within- and between-group changes from baseline to end of 24 weeks.

Results

Participants in the HPHF nutritional supplement group showed a statistically significant improvement in HDL-C levels by the end of 24 weeks (p=0.04) and a significant increase in protein and total dietary fibre intake (p=0.002 and p=0.00, respectively) compared to the control group. The TChol/HDL-C ratio was significantly lower (p=0.03) in the HPHF group from baseline to 24 weeks.

Conclusion

Twice-daily consumption of a HPHF nutritional supplement significantly improved HDL-C levels. Inclusion of the HPHF supplement would be a useful effective aid for managing dyslipidemia in overweight/obese individuals with T2DM.

Response to an oral fat load and effects on lipid profile, glycemia and high-sensitivity C-reactive protein after soybean extract consumption

INTRODUCTION

The aim of this study was to evaluate the response in terms of lipid profile, glycemia and high-sensitivity C-reactive protein after an oral fat load (OFL) with a non-dairy cheese cream containing fermented soybean extract soy, compared to a dairy cheese.

MATERIAL AND METHODS

One hundred twenty-four healthy subjects underwent an OFL performed using a mixture containing non-dairy cheese cream, containing 75% fermented soybean extract (Valsoia Lo spalmabile), or a dairy cheese cream.

RESULTS

During the OFL, total cholesterol and triglycerides at 6 h were lower with non-dairy cheese cream containing fermented soybean compared to dairy cheese cream. The value of low-density lipoprotein cholesterol recorded at 6 h with the active treatment was lower than the one recorded at the same time with the dairy cheese cream. A decrease of high-density lipoprotein cholesterol (HDL-C) was recorded with the dairy cheese cream, but not with the active treatment; moreover, the HDL-C value recorded with the active treatment was higher than the one observed with the dairy cheese cream. There was an increase of high-sensitivity C-reactive protein (hs-CRP) at 3, 6, and 9 h compared to 0 h with the dairy cheese cream, but not with the active treatment. The hs-CRP value observed with the active treatment was lower than the one observed with the dairy cheese cream.

CONCLUSIONS

A non-dairy cheese cream, containing 75% fermented soybean extract, caused a minor increase of lipid profile and of hs-CRP during OFL compared to a dairy cheese cream in healthy subjects.

Effect of Plant Protein on Blood Lipids: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

There is a heightened interest in plant-based diets for cardiovascular disease prevention. Although plant protein is thought to mediate such prevention through modifying blood lipids, the effect of plant protein in specific substitution for animal protein on blood lipids remains unclear. To assess the effect of this substitution on established lipid targets for cardiovascular risk reduction, we conducted a systematic review and meta-analysis of randomized controlled trials using the Grading of Recommendations Assessment, Development, and Evaluation system.

METHODS AND RESULTS

MEDLINE, EMBASE, and the Cochrane Registry were searched through September 9, 2017. We included randomized controlled trials of ≥3 weeks comparing the effect of plant protein in substitution for animal protein on low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B. Two independent reviewers extracted relevant data and assessed risk of bias. Data were pooled by the generic inverse variance method and expressed as mean differences with 95% confidence intervals. Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). The overall quality (certainty) of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system. One-hundred twelve randomized controlled trials met the eligibility criteria. Plant protein in substitution for animal protein decreased low-density lipoprotein cholesterol by 0.16 mmol/L (95% confidence interval, -0.20 to -0.12 mmol/L; P<0.00001; I2=55%; moderate-quality evidence), non-high-density lipoprotein cholesterol by 0.18 mmol/L (95% confidence interval, -0.22 to -0.14 mmol/L; P<0.00001; I2=52%; moderate-quality evidence), and apolipoprotein B by 0.05 g/L (95% confidence interval, -0.06 to -0.03 g/L; P<0.00001; I2=30%; moderate-quality evidence).

CONCLUSIONS

Substitution of plant protein for animal protein decreases the established lipid targets low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B. More high-quality randomized trials are needed to improve our estimates.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02037321.

Effects of different sources of protein on the growth performance, blood chemistry and polypeptide profiles in the gastrointestinal tract digesta of newly weaned piglets

To determine the effects of different sources of protein on the growth performance of newly weaned piglets, 72 newly weaned piglets were randomly assigned to three groups fed different diets (soya bean, casein and dried distillers' grain with solubles (DDGS) feeds). Casein and DDGS feeds consisted of soya bean feed in which 5% of the CP was replaced with casein- or DDGS-derived CP respectively. Blood and chyme samples were collected from each piglet 2 h post-feeding on days 0 and 28 of the feeding period. The DDGS feed decreased DMI (p = 0.024) and increased FCR (p = 0.025) due to lower nitrogen utilization (p = 0.078) than those of other feeds. Total amino acid content in chyme demonstrated that casein feed digested rapidly in the duodenum (p = 0.005), whereas DDGS feed was digested primarily in the distal jejunum (p = 0.003) and ileocecum (p = 0.002). However, polypeptide profiles in chyme exhibited a pattern different from those of amino acids. There were no differences in the polypeptide profiles in the stomachs of piglets fed soya bean or casein feeds (p > 0.05), but soya bean group had greater amounts of small polypeptides (mass under m/z 3000 Da) in the duodenum (p = 0.052) than other groups. In contrast, the DDGS feed group had more large polypeptides (m/z 3000-4000 Da) in the stomach than the other groups (p < 0.001). In addition, 10 pairs of polypeptides with matching masses were identified in the plasma and digesta, indicating that polypeptides may have been transported across the intestinal epithelial cells and into the blood. Taken together, substitution of 5% of the CP in soya bean meal-based feed with DDGS-derived CP decreased the growth performance of newly weaned piglets due to poor digestibility and N utilization of DDGS feed, as well as untimely digestion of casein feed.

Dietary interventions (plant sterols, stanols, omega-3 fatty acids, soy protein and dietary fibers) for familial hypercholesterolaemia

BACKGROUND

A cholesterol-lowering diet and several other dietary interventions have been suggested as a management approach either independently or as an adjuvant to drug therapy in children and adults with familial hypercholesterolaemia (FH). However, a consensus has yet to be reached on the most appropriate dietary treatment. Plant sterols are commonly used in FH although patients may know them by other names like phytosterols or stanols.

OBJECTIVES

To examine whether a cholesterol-lowering diet is more effective in reducing ischaemic heart disease and lowering cholesterol than no dietary intervention in children and adults with familial hypercholesterolaemia. Further, to compare the efficacy of supplementing a cholesterol-lowering diet with either omega-3 fatty acids, soya proteins, plant sterols or plant stanols.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Inborn Errors of Metabolism Trials Register, which is compiled from electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (updated with each new issue of The Cochrane Library), quarterly searches of MEDLINE and the prospective handsearching of one journal - Journal of Inherited Metabolic Disease. Most recent search of the Group's Inborn Errors of Metabolism Trials Register: 22 August 2013. We also searched PubMed to 05 February 2012.

SELECTION CRITERIA

Randomised controlled trials, both published and unpublished, where a cholesterol-lowering diet in children and adults with familial hypercholesterolaemia has been compared to other forms of dietary treatment or to no dietary intervention were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the trial eligibility and risk of bias and one extracted the data, with independent verification of data extraction by a colleague.

MAIN RESULTS

In the 2014 update of the review, 15 trials have been included, with a total of 453 participants across seven comparison groups. The included trials had either a low or unclear risk of bias for most of the parameters used for risk assessment. Only short-term outcomes could be assessed due to the short duration of follow up in the included trials. None of the primary outcomes, (incidence of ischaemic heart disease, number of deaths and age at death) were evaluated in any of the included trials. No significant differences were noted for the majority of secondary outcomes for any of the planned comparisons. However, a significant difference was found for the following comparisons and outcomes: for the comparison between plant sterols and cholesterol-lowering diet (in favour of plant sterols), total cholesterol levels, mean difference 0.30 mmol/l (95% confidence interval 0.12 to 0.48); decreased serum LDL cholesterol, mean difference -0.60 mmol/l (95% CI -0.89 to -0.31). Fasting serum HDL cholesterol levels were elevated, mean difference -0.04 mmol/l (95% CI -0.11 to 0.03) and serum triglyceride concentration was reduced, mean difference -0.03 mmol/l (95% CI -0.15 to -0.09), although these changes were not statistically significant. Similarly, guar gum when given as an add on therapy to bezafibrate reduced total cholesterol and LDL levels as compared to bezafibrate alone.

AUTHORS' CONCLUSIONS

No conclusions can be made about the effectiveness of a cholesterol-lowering diet, or any of the other dietary interventions suggested for familial hypercholesterolaemia, for the primary outcomes: evidence and incidence of ischaemic heart disease, number of deaths and age at death,due to the lack of data on these. Large, parallel, randomised controlled trials are needed to investigate the effectiveness of a cholesterol-lowering diet and the addition of omega-3 fatty acids, plant sterols or stanols, soya protein, dietary fibers to a cholesterol-lowering diet.

Estrogen receptor is activated by korean red ginseng in vitro but not in vivo

Ginseng has been used as a traditional medicine for treatment of many diseases and for general health maintenance in people of all ages. Ginseng is also used to ameliorate menopausal systems. We investigated the estrogenic activity of Korean red ginseng (KRG) in a transient transfection system, using estrogen receptor (ER) and estrogen-responsive luciferase plasmids in MCF-7 cells. The extract activated both ERα and ERβ. KRG modulated the mRNA levels of estrogen-responsive genes such as pS2 and ESR1 and decreased the protein level of ERα. In order to examine in vivo estrogenic activity of KRG, sixteen female Sprague-Dawley rats separated into four groups were studied for nine weeks: non-ovariectomized (OVX) rats treated with olive oil, OVX rats treated with olive oil, OVX rats treated with 17-β-estradiol (E2) in olive oil, and OVX rats treated with KRG extract in olive oil. The experiments were repeated for three times and the data of twelve rats were combined. Body weight of OVX rats was greater than that of sham-operated control rats and was decreased by E2 treatment. Uterine weight increased after E2 treatment compared to OVX rats. However, no difference in body or uterine weight was observed with KRG intake. KRG induced reductions in total cholesterol, low density lipoprotein cholesterol/total cholesterol, high density lipoprotein cholesterol/total cholesterol, and low density lipoprotein cholesterol/high density lipoprotein cholesterol, but not to the same degree as did E2 intake. These results show that KRG does contain estrogenic activity as manifested by in vitro study but the activity is not strong enough to elicit physiological responses.

Role of proteins in insulin secretion and glycemic control

Dietary proteins are essential for the life of all animals and humans at all stages of the life cycle. They serve many structural and biochemical functions and have significant effects on health and wellbeing. Dietary protein consumption has shown an upward trend in developed countries in the past two decades primarily due to greater supply and affordability. Consumption is also on the rise in developing countries as affluence is increasing. Research shows that proteins have a notable impact on glucose homeostasis mechanisms, predominantly through their effects on insulin, incretins, gluconeogenesis, and gastric emptying. Since higher protein consumption and impaired glucose tolerance can be commonly seen in the same population demographics, a thorough understanding of the former's role in glucose homeostasis is crucial both toward the prevention and management of the latter. This chapter reviews the current state of the art on proteins, amino acids, and their effects on blood glucose and insulin secretion.

Consumption of soymilk lowers atherogenic lipid fraction in healthy individuals

The effect of soy-based products on lipid profile has not been well established. Whereas some investigators have reported that soy is hypocholesterolemic, others could only demonstrate this in hypercholesterolemic subjects, while a few have not found any marked association between soy and cholesterol levels. This study was therefore aimed at investigating the effect of soymilk on lipid and lipoprotein profile of normocholesterolemic, apparently healthy Nigerian Africans. Five hundred milliliters of soymilk preparation was consumed daily by 42 apparently healthy young to middle-aged subjects for a period of 21 days. Forty-two other volunteers with similar characteristics, who did not drink the soymilk over this time frame, were randomly selected as controls. Plasma total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), and triglyceride (TG) concentrations were determined twice by standard spectrophotometric methods (at the initial visit and after 3 weeks). Low-density lipoprotein-cholesterol (LDL-C) was calculated from the TC, TG, and HDL-C concentrations. After 21 days, regulated soymilk consumption significantly reduced mean plasma TC by 11% and LDL-C by 25% (P < .001 and P < .001, respectively) and increased mean plasma HDL-C by 20% (P < .05) in the test population. Plasma TG was not significantly altered. In control subjects, no significant differences were observed in mean TC, LDL-C, HDL-C, and TG. Daily consumption of soymilk significantly decreased atherogenic plasma cholesterol concentration. This suggests that soy drink could be an important non-pharmacological cholesterol-reducing agent.

Dietary treatment for familial hypercholesterolaemia

BACKGROUND

A cholesterol-lowering diet and several other dietary interventions have been suggested as a management approach either independently or as an adjuvant to drug therapy in children and adults with familial hypercholesterolemia. However, a consensus has yet to be reached on the most appropriate dietary treatment.

OBJECTIVES

To examine whether a cholesterol-lowering diet is more effective in reducing ischaemic heart disease and lowering cholesterol than no dietary intervention in children and adults with familial hypercholesterolaemia. Further, to compare the efficacy of supplementing a cholesterol-lowering diet with either omega-3 fatty acids, soya proteins, plant sterols or plant stanols.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Inborn Errors of Metabolism Trials Register.Most recent search of the Group's Inborn Errors of Metabolism Trials Register: 09 October 2009.We also searched PubMed till 01 June 2008.

SELECTION CRITERIA

Randomised controlled trials, both published and unpublished, where a cholesterol-lowering diet in children and adults with familial hypercholesterolaemia has been compared to other forms of dietary treatment or to no dietary intervention were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the trial eligibility and methodological quality and one extracted the data, with independent verification of data extraction by a colleague.

MAIN RESULTS

In the present update, four new trials have been added making eleven trials with a total of 331 participants eligible for inclusion. Only short-term outcomes could be assessed due to the short duration of follow up in the included studies. None of the primary outcomes, (incidence of ischaemic heart disease, number of deaths and age at death) were evaluated in any of the included studies. No significant difference was noted for the majority of secondary outcomes for any of the planned comparisons. However, a significant difference was found only for the following comparison and outcome: total cholesterol levels for the comparison between plant sterols and cholesterol-lowering diet, mean difference 0.70 (95% confidence interval 0.19 to 1.21).

AUTHORS' CONCLUSIONS

No conclusions can be made about the effectiveness of a cholesterol-lowering diet, or any of the other dietary interventions suggested for familial hypercholesterolaemia, due to the lack of adequate data. Large, parallel, randomised controlled trials are needed to investigate the effectiveness of a cholesterol-lowering diet and the addition of omega-3 fatty acids, plant sterols or stanols, soya protein to a cholesterol-lowering diet.

Effect of soy protein varying in isoflavone content on serum lipids in healthy young men

BACKGROUND

Previous research supports a role for soy protein in reducing serum lipids; however, few studies involved healthy male subjects or focused on soy isoflavones (or did both).

OBJECTIVE

The objective was to ascertain the effects of soy protein varying in isoflavone content on serum lipids in healthy young men.

DESIGN

Thirty-five males (x +/- SD age: 27.9 +/- 5.7 y) consumed milk protein isolate (MPI), low-isoflavone soy protein isolate (low-iso SPI; 1.64 +/- 0.19 mg aglycone isoflavones/d), and high-isoflavone SPI (high-iso SPI; 61.7 +/- 7.4 mg aglycone isoflavones/d) for 57 d each, separated by 4-wk washout periods, in a randomized crossover design. Blood samples were collected at the beginning and end of each treatment period, and total, LDL, and HDL cholesterol; triacylglycerols; apolipoprotein (apo) B; apo A-I; and C-reactive protein (CRP) were measured in serum. Twenty-four-hour urine samples were collected for 3 consecutive days at the end of each treatment period and analyzed for isoflavones.

RESULTS

Urinary isoflavones were significantly greater with consumption of the high-iso SPI than with that of the low-iso SPI or MPI. The differences between the 3 treatments with respect to individual serum lipids were not significant, but the ratios of total to HDL cholesterol, LDL to HDL cholesterol, and apo B to apo A-I were significantly lower with both SPI treatments than with MPI treatment.

CONCLUSION

Soy protein, regardless of isoflavone content, modulates serum lipid ratios in a direction beneficial for cardiovascular disease risk in healthy young men.

A comparison of the effects of cheese and butter on serum lipids, haemostatic variables and homocysteine

Milk fat contains considerable amounts of saturated fatty acids, known to increase serum cholesterol. Little is known, however, about the relative effect of different milk products on risk factors for CHD. The aim of the present study was to compare the effects of Jarlsberg cheese (a Norwegian variety of Swiss cheese) with butter on serum lipoproteins, haemostatic variables and homocysteine. A controlled dietary study was performed with twenty-two test individuals (nine men and thirteen women) aged 23-54 years. The subjects consumed three isoenergetic test diets, with equal amounts of fat and protein, and containing either cheese (CH diet), butter + calcium caseinate (BC diet) or butter + egg-white protein (BE diet). The study was a randomised cross-over study and the subjects consumed each diet for 3 weeks, with 1 week when they consumed their habitual diet in between. Fasting blood samples were drawn at baseline and at the end of each period. Serum was analysed for lipids and plasma for haemostatic variables and homocysteine. Total cholesterol was significantly lower after the CH diet than after the BC diet (-0.27 mmol/l; P=0.03), while the difference in LDL-cholesterol was found to be below significance level (-0.22 mmol/l; P=0.06). There were no significant differences in HDL-cholesterol, triacylglycerols, apo A-I, apo B or lipoprotein (a), haemostatic variables and homocysteine between the diets. The results indicate that, at equal fat content, cheese may be less cholesterol increasing than butter.

Dietary raw peas (Pisum sativum L.) reduce plasma total and LDL cholesterol and hepatic esterified cholesterol in intact and ileorectal anastomosed pigs fed cholesterol-rich diets

Previous studies demonstrated the cholesterol-lowering effect of dietary legumes (mainly soybeans) in animals and humans, but the mechanisms by which they exert this effect are not completely understood. The contribution of the hindgut to this hypocholesterolemic effect is also not well documented. The present work was undertaken to investigate the effect of cholesterol-enriched (2.8 g/kg) casein (C) and raw pea seed (RP) diets on the cholesterol metabolism of intact (I) and ileorectal anastomosed (IRA) growing pigs. Four groups of 6 pigs were allocated to the treatments (C-I, C-IRA, RP-I, and RP-IRA pigs) for 3 wk. Plasma total cholesterol was lowered by the RP diet through a significant decrease in LDL cholesterol. The RP diet also decreased the hepatic concentration of esterified cholesterol and increased 3-hydroxy-3-methylglutaryl CoA reductase activity and LDL receptor synthesis. The biliary total cholesterol and bile acid concentrations were greater in RP- than in C-fed pigs. In addition, fecal bile acid output was higher in RP-fed pigs. The cecum-colon by-pass inhibited cholesterol and beta-sitosterol microbial transformation, lowered the bile acid output, and increased the primary to secondary bile acid output ratio, but its influence on cholesterolemia was negligible. These results suggest a hypocholesterolemic effect of the raw pea diet probably due to increased fecal bile acid output and an increased biliary bile acid concentration.

Interaction between dietary protein and fat in triglyceride metabolism in the rat: effects of soy protein and menhaden oil

The objective of the present study was to determine the mechanisms by which dietary proteins interact with dietary lipids in the regulation of triglyceridemia in rats. Male Sprague-Dawley rats (n = 56) were subjected to 28-d experimental diets containing different combinations of proteins (20% w/w) and lipid sources (14% w/w): (i) casein-menhaden oil, (ii) casein-beef tallow, (iii) soy protein-menhaden oil, and (iv) soy protein-beef tallow. Significant protein-lipid interactions were observed on triglyceridemia and hepatic cholesterol in fasted rats. The combination of casein and beef tallow was associated with high plasma TG and hepatic cholesterol concentrations, which were reduced by substitution either of soy for casein or of menhaden oil for beef tallow. Therefore, triglyceridemia and liver cholesterol remained low with soy protein feeding, independently of the lipid source, as well as with menhaden oil feeding, regardless of the protein source. The menhaden oil diets reduced plasma cholesterol, hepatic TG, and TG secretion compared with beef tallow diets independently of the dietary protein source. Modifying the source of dietary proteins and lipids had no effect on post-heparin plasma lipoprotein lipase activity. These results demonstrate that soy protein can lower rat triglyceridemia relative to casein when associated with beef tallow consumption, whereas menhaden oil can attenuate hypertriglyceridemia when rats are fed casein. The data further suggest that part of the hypotriglyceridemic effect of soy protein in the rat may be mediated by reduced hepatic lipid synthesis, as is the case for menhaden oil.

Comparison of AIN-76A and AIN-93G diets: a 13-week study in rats

Either purified or cereal-based diets may be used for toxicity testing in rats. Purified diets have advantages in terms of flexibility of formulation to meet specific study objectives and also assurance of relatively low levels of contaminants (e.g. heavy metals and pesticides). The American Institute of Nutrition recommended that the widely used purified diet AIN-76A be replaced by two newer diets, AIN-93G (for use during rapid growth, pregnancy and lactation) and AIN-93M (maintenance diet). The present study compared AIN-76A and AIN-93G by feeding these diets for 13 weeks to male and female rats. A cereal-based diet was also included for reference purposes. The groups fed purified diets had higher serum cholesterol and triglyceride levels than the chow-fed group. An increased incidence and severity of renal tubular mineralization in the purified diet groups was not observed in this study (in contrast to other published studies where rats were fed AIN-76A). Several histopathologic observations, including eosinophilic gastritis and mucification of gastric glands of the glandular stomach, occurred at higher rates in the AIN-76A group than the other dietary treatments. Hepatocellular fatty changes occurred in the purified diet groups at a significantly higher rate than in the chow diet group. In conclusion, AIN-93G is an appropriate diet for use in rat safety evaluation studies.

Dietary treatment for familial hypercholesterolaemia

BACKGROUND

Familial hypercholesterolaemia is an inherited disorder characterised by a raised blood cholesterol, the presence of xanthomatosis and premature ischaemic heart disease. The aim of treatment is the reduction of blood LDL cholesterol concentrations in order to reduce the risk of ischaemic heart disease. Current treatment is based on a cholesterol lowering diet alone or in combination with drug therapy. Many of the drugs found to be effective in treating adults with this disease are not licensed for use in children, therefore diet is the main treatment of children with familial hypercholesterolaemia. In addition to the cholesterol-lowering diet, several other dietary interventions have been suggested and consensus has yet to be reached on the most appropriate dietary treatment for children and adults with familial hypercholesterolaemia.

OBJECTIVES

To examine the evidence that in children and adults with familial hypercholesterolaemia, a cholesterol lowering diet is more effective at lowering cholesterol and reducing incidence of ischaemic heart disease than no intervention or than other dietary interventions.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Trials Register, a specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. Additional studies were identified from handsearching the Journal of Inherited Metabolic Disease (from inception, 1978 to 2000) and from the reference lists of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), both published and unpublished, where a cholesterol lowering diet in children and adults with familial hypercholesterolaemia has been compared to other forms of dietary treatment or to no dietary intervention. Trials which include patients with familial hypercholesterolaemia alongside patients with non-familial hypercholesterolaemia were only included if the group of familial patients was well defined and the results for these patients were available.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the trial eligibility and methodological quality and one reviewer extracted the data, with independent verification of data extraction by a colleague.

MAIN RESULTS

Only short term outcomes could be assessed in this review due to the length of the five eligible studies. Compliance to treatment, quality of life, mortality and evidence of ischaemic or atheromatous disease were not assessed in the studies identified. No differences were found between the cholesterol-lowering diet and all other diets for all of the short term outcomes assessed.

REVIEWER'S CONCLUSIONS

No conclusions can be made about the effectiveness of the cholesterol-lowering diet, or any of the other dietary interventions suggested for familial hypercholesterolaemia, due to the lack of adequate data. A large, parallel, randomised controlled trial is needed to investigate the effectiveness of the cholesterol-lowering diet and other dietary interventions for FH. It is also possible that data from trials including subjects with both familial and non-familial hypercholesterolaemia could alter the results of future updates of this review and until further evidence is available current dietary treatment of FH should continue to be observed and monitored with care.

Soy protein versus soy phytoestrogens in the prevention of diet-induced coronary artery atherosclerosis of male cynomolgus monkeys

Soy protein, long recognized as having cardiovascular benefits, is a rich source of phytoestrogens (isoflavones). To distinguish the relative contributions of the protein moiety versus the alcohol-extractable phytoestrogens for cardiovascular protection, we studied young male cynomolgus macaques fed a moderately atherogenic diet and randomly assigned to three groups. The groups differed only in the source of dietary protein, which was either casein/lactalbumin (casein, n = 27), soy protein with the phytoestrogens intact (soy+, n = 27), or soy protein with the phytoestrogens mostly extracted (soy-, n = 28). The diets were fed for 14 months. Animals fed soy+ had significantly lower total and LDL plus VLDL cholesterol concentrations compared with the other two groups. They soy+ animals had the highest HDL cholesterol concentrations, the casein group had the lowest, and the soy- group was intermediate. A subset was necropsied for atherosclerosis evaluations (n = 11 per group). Morphometric and angiochemical measures were done to quantify atherosclerosis. Coronary artery atherosclerotic lesions were smallest in the soy+ group (90% less coronary atherosclerosis than the casein group and 50% less than the soy- group), largest in the casein group, and intermediate in the soy- group. The effects of the diets on lesion size and arterial lipid measures of the peripheral arteries were similar to those in the coronary arteries, with greatest prevention of atherogenesis with soy+ and intermediate benefit with soy- relative to casein. We could not determine whether the beneficial effects seen in the soy- group relate to the protein itself or to the remaining traces of phytoestrogens. The beneficial effects of soy protein on atherosclerosis appear to be mediated primarily by the phytoestrogen component. Testicular weights were unaffected by the phytoestrogens.

Dietary soy protein and estrogen replacement therapy improve cardiovascular risk factors and decrease aortic cholesteryl ester content in ovariectomized cynomolgus monkeys

Estrogen replacement therapy (ERT) decreases the progression of coronary artery atherosclerosis in monkeys. Dietary soy protein also retards the progression of atherosclerosis relative to animal proteins such as casein. Soy protein contains weakly estrogenic compounds called isoflavones or phytoestrogens that may be responsible for the cardioprotective effects. This study was designed as a 2 x 2 factorial to determine the magnitude of soy protein's effects on cardiovascular risk factors relative to casein and lactalbumin, with or without estradiol treatment. Ovariectomized female monkeys were randomized to four treatment groups based on past dietary cholesterol consumption, their origin, and past reproductive history, and studied for 7 months. The animals were divided into (1) a group fed casein and lactalbumin as the protein source (n = 14), (2) a group fed casein and lactalbumin as the protein source plus 17 beta-estradiol (E2) (n = 13), (3) a group fed soybean protein isolate as the protein source (n = 11), and (4) a group fed soybean protein isolate as the protein source plus E2 (n = 10). Soy protein compared with casein consumption resulted in a significant improvement in plasma lipid and lipoprotein concentrations, a significant improvement in insulin sensitivity and glucose effectiveness as determined by minimal-model analyses, and a decrease in arterial lipid peroxidation. E2-treated monkeys had a significant reduction in fasting insulin levels and insulin to glucose ratios, total body weight, and amounts of abdominal fat, and had smaller low-density lipoprotein (LDL) particles. In addition, E2 treatment resulted in a significant reduction (P = .001) in aortic cholesteryl ester content. A similar trend (P = .14) was found for soy protein compared with casein. There also was a significant interaction (P = .02) with soy and E2, such that animals consuming soy protein +E2 had the least arterial cholesteryl ester content. These results suggest that both ERT and dietary soybean protein have beneficial effects on cardiovascular risk factors. Interestingly, the two treatments affected different risk factors and together resulted in the greatest reduction in arterial cholesterol content. Further studies are needed to determine the active component of the soy protein and to assess its long-term effects on the cardiovascular system and other organ systems (such as the bones and reproductive system).

Methionine deficiency in rats fed soy protein induces hypercholesterolemia and potentiates lipoprotein susceptibility to peroxidation

A number of studies have provided evidence that plant proteins, especially soy protein, have a cholesterol-lowering effect as compared with casein. However, dietary supply of sulfur amino acids may be deficient when soy protein is present in the diet at a suboptimal level, which could affect lipid metabolism. Accordingly, in rats fed 13% protein diets, soy protein feeding resulted in a cholesterol-increasing effect (+18%), which could be counteracted by methionine supplementation (0.4%). In contrast, soy protein was effective in decreasing plasma triglyceride, as compared with levels in rats fed casein; this triglyceride-lowering effect was entirely abolished by methionine supplementation. The hypercholesterolemic effect of soy protein was characterized by a higher cholesterol content in low-density lipoprotein (LDL) and high-density lipoprotein 1 (HDL1) fractions, together with a marked induction of hepatic hydroxymethyl glutaryl coenzyme A (HMG CoA) reductase activity and to a lesser extent cholesterol 7 alpha-hydroxylase. There was practically no induction of these enzymes, as compared with levels in rats fed casein diets, when the soy protein diet was supplemented with methionine. Very-low-density lipoprotein (VLDL) plus LDL susceptibility to peroxidation was higher in rats fed soy protein than in casein-fed rats, which could reflect in part the lack of sulfur amino acid availability, since methionine supplementation led to a partial recovery of lipoprotein resistance to peroxidation. These findings suggest that amino acid imbalance could be atherogenic by increasing circulating cholesterol and leading to a higher lipoprotein susceptibility to peroxidation.

Intake of 25 g of soybean protein with or without soybean fiber alters plasma lipids in men with elevated cholesterol concentrations

Twenty-one mildly hypercholesterolemic men consumed a diet that was low in fat (< 30% of energy) and cholesterol (300 mg/d) and were given muffins containing 25 g protein + 20 g dietary fiber daily from either isolated soybean protein + soybean cotyledon fiber, isolated soybean protein + cellulose, casein + soybean cotyledon fiber or casein + cellulose. All subjects progressed through the low fat, low cholesterol baseline period, lasting 2 wk, and then through all four dietary treatments, lasting 4 wk each, according to a Latin square design. Plasma concentrations of total, LDL, HDL and VLDL cholesterol, total and VLDL triacylglycerols, and apolipoprotein A-I and B were measured at the end of each period. When data from all subjects were analyzed, dietary treatments did not influence lipemia; however, in subjects with initial total cholesterol concentrations > 5.7 mmol/L, both isolated soybean protein treatments resulted in significantly lower total cholesterol compared with the two casein treatments (P < 0.05). In addition, a negative linear relationship was observed when a subject's total or LDL cholesterol change after each of the soybean treatments was regressed against the subject's baseline cholesterol concentration (P < 0.05). Apolipoprotein A-I varied dependent on baseline cholesterol with no apparent pattern, whereas apolipoprotein B levels were not affected. Results indicate that consumption of 25 g soybean protein/d is associated with lower total cholesterol concentrations in individuals with initial cholesterol concentrations > 5.7 mmol/L.

Diet, menopause, and serum cholesterol levels in women: the Framingham Study

Cross-sectional relationships between diet and total serum cholesterol levels were studied in a sample of 428 women from the Framingham Heart Study Cohort, aged 37 to 70 years, from 1957 to 1960. Multiple linear regression was used to control for total calorie intake, systolic blood pressure, physical activity, Metropolitan relative weight, glucose intolerance, and cigarette smoking. There was little evidence for a relationship between total serum cholesterol and dietary fat intake; whereas a marginally significant direct association was found with total fat in postmenopausal women, total and plant fat and cholesterol were inversely associated, and only cholesterol was significant in premenopausal women. A consistent inverse association was observed between total serum cholesterol levels and intake of protein, particularly from plant sources, and a weak inverse association was found with complex carbohydrate intake. Serum cholesterol in women may be influenced by a number of dietary factors and appears to differ according to menopausal status.

Plasma amino acids and the insulin/glucagon ratio as an explanation for the dietary protein modulation of atherosclerosis

The amino acid composition of the diet influences the postprandial levels of plasma amino acids along with the hormones insulin and glucagon in humans fed single test meals identical in composition except for protein source. Soy protein (hypocholesterolemic), vs. casein (hypercholesterolemic), contains a higher amount of arginine and glycine and induces an increase in postprandial arginine and glycine. Soy protein induces a low postprandial insulin/glucagon ratio in both hypercholesterolemic and normocholesterolemic subjects. Casein induces a high postprandial insulin/glucagon ratio among hypercholesterolemic subjects. Amino acids such as arginine and glycine are associated with a decrease, while lysine and branched-chain amino acids are associated with increased serum cholesterol levels. Our data are consistent with the hypothesis that the control of cholesterol by insulin and glucagon is regulated by dietary and plasma amino acids. From this hypothesis the insulin/glucagon ratio is proposed as an early metabolic index of the effect of dietary proteins on serum cholesterol levels, a risk factor and a common mechanism through which dietary and lifestyle factors influence cardiovascular disease.

Plasma amino acids and the insulin/glucagon ratio as an explanation for the dietary protein modulation of atherosclerosis

The amino acid composition of the diet influences the postprandial levels of plasma amino acids along with the hormones insulin and glucagon in humans fed single test meals identical in composition except for protein source. Soy protein (hypocholesterolemic), versus casein (hypercholesterolemic), contains a higher amount of arginine and glycine and induces an increase in postprandial arginine and glycine. Soy protein induces a low postprandial insulin/glucagon ratio in both hypercholesterolemic and normocholesterolemic subjects. Casein induces a high postprandial insulin/glucagon ration among hypercholesterolemic subjects. Amino acids such as arginine and glycine are associated with a decrease, while lysine and branched-chain amino acids are associated with increased serum cholesterol levels. Our data are consistent with the hypothesis that the control of cholesterol by insulin and glucagon is regulated by dietary and plasma amino acids. From this hypothesis the insulin/glucagon ratio is proposed as an early metabolic index of the effect of dietary proteins on serum cholesterol levels, a risk factor and a common mechanism through which dietary and lifestyle factors influence cardiovascular disease.

Effects of the nature of dietary proteins, lecithin and methionine on rat plasma lipids

In order to study the complex interrelationships between on the one hand, dietary proteins, lecithin and methionine and, on the other, blood cholesterol and triglyceride levels, groups of .10 rats were fed for six weeks with diets only differing by the nature of proteins which comprised 10% of the diet. These diets were composed of egg white, heated soybean flour, casein, heated soybean flour supplemented with 1% methionine, or with 4% of the lipids replaced by soybean lecithin, heated 5-day germinated soybean supplemented or not with 1% methionine and casein with 4% of the lipids replaced by lecithin. Egg white caused no change in blood cholesterol compared to heated soybean meal (0.955 +/- 0.18 vs 0.83 +/- 0.14), but caused a significant increase in blood cholesterol levels compared to casein (0.955 +/- 0.18 vs 0.81 +/- 0.11 g/l). No effect was found on blood triglycerides levels. Lecithin caused no change when it partially replaced lipids in the soybean or casein diets thought it increased triglycerides with the casein diet (1.16 +/- 0.31 vs 0.84 +/- 0.24 g/l). Supplementation of the heated soybean diet with 1% methionine led to an increase in blood triglycerides (0.85 +/- 0.26 vs 1.18 +/- 0.34 g/l). After germination, this effect disappeared. The effects of the type of protein, partial replacement of dietary lipids by lecithin and supplementation with methionine are discussed.

Arrest and reversal of atherosclerosis with parenteral nutrition

In a large subset of patients with atherosclerotic cardiovascular disease, all medical and surgical treatment alternatives have been exhausted or have proved to be ineffective. Intravenous infusion of specially formulated amino acid solutions, developed in the animal laboratory, has been efficacious in arresting and reversing atherosclerosis in humans for the first time. It is anticipated that the principles derived from these precise parenteral studies will eventually permit development of oral and enteral dietary formulations effective for the systemic control and management of atherosclerosis.

Cholesterol-lowering activity of various undigested fractions of soybean protein in rats

The undigested high-molecular-weight fraction (HMF) of soybean protein prepared after exhaustive digestion by microbial proteases significantly decreased serum cholesterol levels to approximately 45% (p less than 0.05) of those observed with the parent protein in rats fed diets containing cholesterol (0.5%) and sodium cholate (0.125%). HMF bound conjugated bile salts in vitro and significantly increased fecal excretion of both neutral and acidic steroids by 65-95% and 80-170% more, respectively (p less than 0.05), than did the intact protein. Extraction of HMF with methanol slightly decreased the activity, but the methanol-soluble fraction was not regarded as a principal determinant. Soybean saponin at the dietary level equivalent to that contained in HMF did not effectively lower serum cholesterol. The activity was not necessarily duplicated even when methanol-treated fractions were recombined. Further degradation of the methanol-extracted HMF by various proteases resulted in loss of activity. HMF obtained after pepsin digestion exerted a potential similar to that of HMF prepared after digestion by microbial proteases.

Alterations in plasma lipid levels resulting from tofu and cheese consumption in adult women

Changes in the concentration of plasma lipids were assessed in 10 normolipidemic adult women in response to alternate 3-week controlled feeding of similar low-fat diets containing either tofu or cheese. Plasma total cholesterol and LDL-cholesterol were significantly lower (p less than 0.01 and p less than 0.001, respectively) following consumption of the tofu compared to the cheese diet, whereas no significant differences were observed in VLDL-cholesterol, HDL-cholesterol, or in total triglycerides. To assess whether protein source (animal vs vegetable) exerted an independent effect on plasma lipids, lipid responses to alternate 3-week feeding of tofu-and cheese-containing diets in which the amount and type of dietary fat were equilibrated were examined in five additional women. The finding of similar plasma lipid responses to the modified treatments suggested the high P/S ratio of tofu was primarily responsible for the observed hypocholesterolemic response. An independent effect of protein source on plasma lipids was not supported.

Testing a mechanism of control in human cholesterol metabolism: relation of arginine and glycine to insulin and glucagon

Eight men were given 2 casein meals, one with and one without a supplement of arginine and glycine, to measure the effect on plasma amino acids, insulin and glucagon. Supplementation resulted in increased levels of plasma glucagon, glycine and arginine, a tendency to decreased insulin and significantly lower insulin/glucagon ratio, tryptophan and tyrosine. The data suggest that insulin and glucagon, which control cholesterol metabolism, respond to dietary and postprandial plasma amino acid levels of arginine and glycine.