Effects of casein versus soy protein diets on serum cholesterol and lipoproteins in young healthy volunteers

Cumulative Meta-Analysis of the Soy Effect Over Time

Background

Soy protein foods have attracted attention as useful plant protein foods with mild cholesterol‐lowering effects that are suitable for inclusion in therapeutic diets. But on the basis of the lack of consistency in significant cholesterol reduction by soy in 46 randomized controlled trials, the US Food and Drug Administration (FDA) is reassessing whether the 1999 heart health claim for soy protein should be revoked.

Methods and Results

We have, therefore, performed a cumulative meta‐analysis on the 46 soy trials identified by the FDA to determine if at any time, since the 1999 FDA final rule that established the soy heart health claim, the soy effect on serum cholesterol lost significance. The cumulative meta‐analysis for both total cholesterol and low‐density lipoprotein cholesterol demonstrated preservation of the small, but significant, reductions seen both before and during the subsequent 14 years since the health claim was originally approved. For low‐density lipoprotein cholesterol, the mean reduction in 1999 was −6.3 mg/dL (95% CI, −8.7 to −3.9 mg/dL; P=0.00001) and remained in the range of −4.2 to −6.7 mg/dL (P=0.0006 to P=0.0002, respectively) in the years after 1999. At no time point did the total cholesterol or low‐density lipoprotein cholesterol reductions lose significance or were the differences at individual time points in the cumulative meta‐analysis significantly different from those seen in 1999 when the health claim was approved.

Conclusions

A cumulative meta‐analysis of the data selected by the FDA indicates continued significance of total cholesterol and low‐density lipoprotein cholesterol reduction after soy consumption and supports the rationale behind the original soy FDA heart health claim.

See Editorial Petersen and Kris‐Etherton

A Meta-Analysis of 46 Studies Identified by the FDA Demonstrates that Soy Protein Decreases Circulating LDL and Total Cholesterol Concentrations in Adults

BACKGROUND

Certain plant foods (nuts and soy protein) and food components (viscous fibers and plant sterols) have been permitted by the FDA to carry a heart health claim based on their cholesterol-lowering ability. The FDA is currently considering revoking the heart health claim for soy protein due to a perceived lack of consistent LDL cholesterol reduction in randomized controlled trials.

OBJECTIVE

We performed a meta-analysis of the 46 controlled trials on which the FDA will base its decision to revoke the heart health claim for soy protein.

METHODS

We included the 46 trials on adult men and women, with baseline circulating LDL cholesterol concentrations ranging from 110 to 201 mg/dL, as identified by the FDA, that studied the effects of soy protein on LDL cholesterol and total cholesterol (TC) compared with non-soy protein. Two independent reviewers extracted relevant data. Data were pooled by the generic inverse variance method with a random effects model and expressed as mean differences with 95% CI. Heterogeneity was assessed and quantified.

RESULTS

Of the 46 trials identified by the FDA, 43 provided data for meta-analyses. Of these, 41 provided data for LDL cholesterol, and all 43 provided data for TC. Soy protein at a median dose of 25 g/d during a median follow-up of 6 wk decreased LDL cholesterol by 4.76 mg/dL (95% CI: -6.71, -2.80 mg/dL, P < 0.0001; I2 = 55%, P < 0.0001) and decreased TC by 6.41 mg/dL (95% CI: -9.30, -3.52 mg/dL, P < 0.0001; I2 = 74%, P < 0.0001) compared with non-soy protein controls. There was no dose-response effect or evidence of publication bias for either outcome. Inspection of the individual trial estimates indicated most trials (∼75%) showed a reduction in LDL cholesterol (range: -0.77 to -58.60 mg/dL), although only a minority of these were individually statistically significant.

CONCLUSIONS

Soy protein significantly reduced LDL cholesterol by approximately 3-4% in adults. Our data support the advice given to the general public internationally to increase plant protein intake. This trial was registered at clinicaltrials.gov as NCT03468127.

Dietary Protein and Energy Balance in Relation to Obesity and Co-morbidities

Dietary protein is effective for body-weight management, in that it promotes satiety, energy expenditure, and changes body-composition in favor of fat-free body mass. With respect to body-weight management, the effects of diets varying in protein differ according to energy balance. During energy restriction, sustaining protein intake at the level of requirement appears to be sufficient to aid body weight loss and fat loss. An additional increase of protein intake does not induce a larger loss of body weight, but can be effective to maintain a larger amount of fat-free mass. Protein induced satiety is likely a combined expression with direct and indirect effects of elevated plasma amino acid and anorexigenic hormone concentrations, increased diet-induced thermogenesis, and ketogenic state, all feed-back on the central nervous system. The decline in energy expenditure and sleeping metabolic rate as a result of body weight loss is less on a high-protein than on a medium-protein diet. In addition, higher rates of energy expenditure have been observed as acute responses to energy-balanced high-protein diets. In energy balance, high protein diets may be beneficial to prevent the development of a positive energy balance, whereas low-protein diets may facilitate this. High protein-low carbohydrate diets may be favorable for the control of intrahepatic triglyceride IHTG in healthy humans, likely as a result of combined effects involving changes in protein and carbohydrate intake. Body weight loss and subsequent weight maintenance usually shows favorable effects in relation to insulin sensitivity, although some risks may be present. Promotion of insulin sensitivity beyond its effect on body-weight loss and subsequent body-weight maintenance seems unlikely. In conclusion, higher-protein diets may reduce overweight and obesity, yet whether high-protein diets, beyond their effect on body-weight management, contribute to prevention of increases in non-alcoholic fatty liver disease NAFLD, type 2 diabetes and cardiovascular diseases is inconclusive.

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.

Animal Proteins as Important Contributors to a Healthy Human Diet

Adequate protein intake is critical for health and development. Generally, protein of animal origin is of higher quality for humans owing to its amino acid pattern and good digestibility. When administered in mixtures it can enhance the quality of plant proteins, but its availability is often low in low-income communities, especially in young children, the elderly, and pregnant and lactating women, who have increased requirements and in whom high-quality protein also stimulates (bone) growth and maintenance. Although high protein intake was associated with increased type 2 diabetes mellitus risk, milk and seafood are good sources of branched chain amino acids and taurine, which act beneficially on glucose metabolism and blood pressure. However, high consumption of protein-rich animal food is also associated with adverse health effects and higher risk for noncommunicable diseases, partly related to other components of these foods, like saturated fatty acids and potential carcinogens in processed meat but also the atherogenic methionine metabolite homocysteine. In moderation, however, animal proteins are especially important for health maintenance in vulnerable persons.

The role of casein in the development of hypercholesterolemia

Atherosclerosis remains the leading cause of severe cardiovascular complications such as cardio- and cerebrovascular events. Given that prevention and early intervention play important roles in the reduction of cardiovascular complications associated with atherosclerosis, it is critical to better understand how to target the modifiable risk factors, such as diet, in order to best minimize their contributions to the development of the disease. Studies have shown that various dietary sources of protein can affect blood lipid levels, a modifiable risk factor for atherosclerosis, either positively or negatively. This clearly highlights that not all proteins are "created equal." For example, consumption of diets high in either animal- or vegetable-based sources of protein have resulted in varied and inconsistent effects on blood cholesterol levels, often depending on the amino acid composition of the protein and the species investigated. Careful consideration of the source of dietary protein may play an important role in the prevention of atherosclerosis and subsequent cardiovascular complications. Given the recent focus on high protein diets, an emphasis on controlled studies in the area is warranted. The goal of this review is to present the current state of the literature that examines the effects of casein, a commonly utilized animal-based protein, on blood cholesterol levels and the varying effects noted in both animals and humans.

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.

Soy protein reduces serum cholesterol by both intrinsic and food displacement mechanisms

The apparently smaller LDL cholesterol (LDL-C)-lowering effect of soy in recent studies has prompted the U.S. FDA to reexamine the heart health claim previously allowed for soy products. We therefore attempted to estimate the intrinsic and extrinsic (displacement) potential of soy in reducing LDL-C to determine whether the heart health claim for soy continues to be justified. The intrinsic effect of soy was derived from a meta-analysis using soy studies (20-133 g/d soy protein) included in the recent AHA Soy Advisory. The extrinsic effect of soy in displacing foods higher in saturated fat and cholesterol was estimated using predictive equations for LDL-C and NHANES III population survey data with the substitution of 13-58 g/d soy protein for animal protein foods. The meta-analysis of the AHA Soy Advisory data gave a mean LDL-C reduction of 0.17 mmol/L (n = 22; P < 0.0001) or 4.3% for soy, which was confirmed in 11 studies reporting balanced macronutrient profiles. The estimated displacement value of soy (13-58 g/d) using NHANES III population survey data was a 3.6-6.0% reduction in LDL-C due to displacement of saturated fats and cholesterol from animal foods. The LDL-C reduction attributable to the combined intrinsic and extrinsic effects of soy protein foods ranged from 7.9 to 10.3%. Thus, soy remains one of a few food components that reduces serum cholesterol (>4%) when added to the diet.

Soy protein, isoflavones, and cardiovascular health: an American Heart Association Science Advisory for professionals from the Nutrition Committee

Soy protein and isoflavones (phytoestrogens) have gained considerable attention for their potential role in improving risk factors for cardiovascular disease. This scientific advisory assesses the more recent work published on soy protein and its component isoflavones. In the majority of 22 randomized trials, isolated soy protein with isoflavones, as compared with milk or other proteins, decreased LDL cholesterol concentrations; the average effect was approximately 3%. This reduction is very small relative to the large amount of soy protein tested in these studies, averaging 50 g, about half the usual total daily protein intake. No significant effects on HDL cholesterol, triglycerides, lipoprotein(a), or blood pressure were evident. Among 19 studies of soy isoflavones, the average effect on LDL cholesterol and other lipid risk factors was nil. Soy protein and isoflavones have not been shown to lessen vasomotor symptoms of menopause, and results are mixed with regard to soy's ability to slow postmenopausal bone loss. The efficacy and safety of soy isoflavones for preventing or treating cancer of the breast, endometrium, and prostate are not established; evidence from clinical trials is meager and cautionary with regard to a possible adverse effect. For this reason, use of isoflavone supplements in food or pills is not recommended. Thus, earlier research indicating that soy protein has clinically important favorable effects as compared with other proteins has not been confirmed. In contrast, many soy products should be beneficial to cardiovascular and overall health because of their high content of polyunsaturated fats, fiber, vitamins, and minerals and low content of saturated fat.

The A2 milk case: a critical review

This review outlines a hypothesis that A1 one of the common variants of beta-casein, a major protein in cows milk could facilitate the immunological processes that lead to type I diabetes (DM-I). It was subsequently suggested that A1 beta-casein may also be a risk factor for coronary heart disease (CHD), based on between-country correlations of CHD mortality with estimated national consumption of A1 beta-casein in a selected number of developed countries. A company, A2 Corporation was set up in New Zealand in the late 1990s to test cows and market milk in several countries with only the A2 variant of beta-casein, which appeared not to have the disadvantages of A1 beta-casein. The second part of this review is a critique of the A1/A2 hypothesis. For both DM-I and CHD, the between-country correlation method is shown to be unreliable and negated by recalculation with more countries and by prospective studies in individuals. The animal experiments with diabetes-prone rodents that supported the hypothesis about diabetes were not confirmed by larger, better standardised multicentre experiments. The single animal experiment supporting an A1 beta-casein and CHD link was small, short, in an unsuitable animal model and had other design weaknesses. The A1/A2 milk hypothesis was ingenious. If the scientific evidence had worked out it would have required huge adjustments in the world's dairy industries. This review concludes, however, that there is no convincing or even probable evidence that the A1 beta-casein of cow milk has any adverse effect in humans. This review has been independent of examination of evidence related to A1 and A2 milk by the Australian and New Zealand food standard and food safety authorities, which have not published the evidence they have examined and the analysis of it. They stated in 2003 that no relationship has been established between A1 or A2 milk and diabetes, CHD or other diseases.

Lipoprotein response to diets high in soy or animal protein with and without isoflavones in moderately hypercholesterolemic subjects

OBJECTIVE

The objective of this study was to assess the independent effect of soy relative to common sources of animal protein and soy-derived isoflavones on blood lipids.

METHODS AND RESULTS

Forty-two subjects with LDL cholesterol levels > or =3.36 mmol/L were fed each of four diets in randomized order for 6 weeks per phase. Diets contained a minimum of 25 g animal protein or isolated soy protein/4.2 MJ, with each containing trace amounts or 50 mg of isoflavones/4.2 MJ. Soy protein had a modest effect on total, LDL and HDL cholesterol, and triglyceride concentrations (-2%, P=0.017; -2%, P=0.042; +3%; P=0.034, -11%, P<0.001, respectively). Soy protein had no significant effect on plasma lipids in individuals with LDL cholesterol <4.14 mmol/L and significantly reduced total and LDL cholesterol and triglyceride concentrations in individuals with LDL cholesterol > or =4.14 mmol/L (-4%, P=0.001; -5%, P=0.003; -15%, P<0.001, respectively). No significant effect of isoflavones on plasma lipid levels was observed either constituent to the soy protein or supplemental to the animal protein.

CONCLUSIONS

Although potentially helpful when used to displace products containing animal fat from the diet, the regular intake of relatively high levels of soy protein (>50 g/day) had only a modest effect on blood cholesterol levels and only in subjects with elevated LDL cholesterol levels (> or =4.14 mmol/L). Soy-derived isoflavones had no significant effect.

The cardiovascular effects of soy products

In human clinical intervention trials, soy product consumption reduced levels of total cholesterol and low-density lipoprotein cholesterol (LDL-C). In October 1999, the US Food and Drug Administration approved a health claim for the relationship between consumption of soy protein and reduced risk of coronary heart disease. This article provides an overview of the cardiovascular effects of various soy products, including their effects on blood lipids, LDL-C oxidation, blood pressure, and vascular reactivity. Potential mechanisms of effect are discussed, emphasizing human clinical intervention trials. Soy consumption improves plasma lipids, although this effect appears to be more pronounced in individuals with elevated cholesterol. Soy and its associated isoflavones also reduce LDL oxidation and improve vascular reactivity.

Usual dietary isoflavone intake is associated with cardiovascular disease risk factors in postmenopausal women

Intervention data suggest a cardioprotective role for supplemental isoflavones; however, few studies have examined the cardiovascular disease (CVD) benefit of usual dietary isoflavone intake. This cross-sectional study examined the association between usual dietary isoflavone intake and CVD risk factors, including lipids and lipoproteins, body mass index (BMI) and fat distribution, blood pressure, glucose and insulin. Subjects were postmenopausal women (n = 208) aged 45-74 y, who attended screening and baseline visits for a randomized, double-blind, placebo-controlled trial examining the effects of isoflavone use. At screening, total cholesterol, triglycerides, HDL cholesterol and LDL cholesterol were measured, and demographic, behavioral and menopausal characteristics were assessed. One month later, dietary intake over the past year was assessed with a standardized questionnaire. Anthropometric measurements and blood pressure were obtained, and a 75-g oral glucose tolerance test was administered. Isoflavone consumption did not vary by age, exercise, smoking, education or years postmenopausal. Women with high genistein intake had a significantly lower BMI (P-trend = 0.05), waist circumference (P-trend = 0.05) and fasting insulin (P-trend = 0.07) than those with no daily genistein consumption. In adjusted analyses, genistein, daidzein and total isoflavone intake were each positively associated with HDL cholesterol (P = 0.05) and inversely associated with postchallenge insulin (P = 0.05). These data suggest a protective role for dietary soy intake against CVD in postmenopausal women.

Hypocholesterolemic effect of soymilk supplementation with usual diet in premenopausal normolipidemic Japanese women

BACKGROUND

The hypocholesterolemic effect of soy protein concentrates on normolipidemic subjects still remains unclear. Our objective is to assess the effect of soymilk supplementation, a whole soy product, with usual diet on serum lipids in normolipidemic subjects.

METHODS

We conducted a randomized controlled trial on 60 premenopausal normolipidemic Japanese women. After excluding 8 subjects whose initial serum concentration of total cholesterol or triacylglycerol was higher than 220 mg/dL (5.69 mmol/L) or 160 mg/dL (1.81 mmol/L), respectively, we encouraged the subjects in the soymilk-supplemented group (n = 27) to consume 400 mL (408 g) of commercial regular soymilk daily during two menstrual cycles. There were no significant differences in variables, including nutrient intake, between the soymilk-supplemented and control (n = 25) groups before the intervention.

RESULTS

After the trial, we observed a significant decrease of 10.9 mg/dL, or 5.3%, in serum concentration of total cholesterol in the soymilk-supplemented group. During the intervention, nutrient intake assessment showed significant increases in nutrient densities of vitamin E, polyunsaturated fatty acids, isoflavones, and P/S ratio and decreases in total energy and nutrient densities of vitamin C and green tea in this group. A statistically significant decrease in serum total cholesterol could still be observed even after excluding the estimated hypocholesterolemic effects of soymilk's polyunsaturated fatty acids.

CONCLUSIONS

Our results suggest the hypocholesterolemic effect of soymilk, a traditional whole soy product, in Asian countries in normolipidemic subjects.

Effects of soybean protein and very low dietary cholesterol on serum lipids, biliary lipids, and fecal sterols in humans

Soy-base texturized vegetable protein (TVP; Archer Daniels Midland, Decatur, IL) has been used to decrease serum cholesterol and as a substitute for animal protein to achieve very low levels of dietary cholesterol. The effect of very low dietary cholesterol and of TVP on biliary lipids and fecal sterols is unclear. The study objective was to determine the effects of very low intake of dietary cholesterol, as well as TVP itself, on serum lipids, biliary lipids, and fecal sterols. We studied eight normal subjects living on a metabolic ward during three randomly ordered 6- to 7-week periods: (1) standard cholesterol diet (190 to 550 mg/d), (2) TVP-low-cholesterol diet (17 to 30 mg/d), and (3) TVP-standard cholesterol diet. By analysis of covariance (ANCOVA), reducing dietary cholesterol to these very low levels significantly decreased serum low-density lipoprotein (LDL) cholesterol (P=.048) but did not affect high-density lipoprotein (HDL) cholesterol or triglyceride. TVP resulted in a borderline significant reduction in LDL cholesterol (P=.058) with a highly significant reduction in HDL cholesterol (P=.004) and an increase in serum triglyceride (P=.010). During TVP ingestion, there was a highly significant increase in the output of fecal neutral sterols (P=.005) and a tendency for a higher output of fecal acidic sterols (P=.100). Fecal sterol balance was significantly more negative (indicating increased cholesterol synthesis) during TVP ingestion (P=.016). Neither TVP nor the very-low-cholesterol diet appreciably affected the gallbladder bile molar percent cholesterol or saturation index. The data are consistent with the hypothesis that to the extent TVP decreases serum LDL cholesterol (an effect of borderline significance in this study), the effect occurs via a reduction in the absorption of cholesterol and perhaps bile acid. However, the potential benefit of decreasing LDL cholesterol in this way seems to be at least partially offset by a concomitant reduction in HDL cholesterol and an increase in serum triglycerides.

Decreased serum total cholesterol concentration is associated with high intake of soy products in Japanese men and women

The relationship between soy product intake and serum total cholesterol concentration was examined in 1242 men and 3596 women who participated in an annual health check-up program in Takayama City, Japan, provided by the municipality in 1992. The intake of soy products and various foods and nutrients was assessed by a semiquantitative food-frequency questionnaire. Blood samples were collected from fasting subjects to measure the serum total cholesterol concentration. A significant trend (P for trend = 0. 0001) was observed for decreasing total cholesterol concentration with an increasing intake of soy products in men after controlling for age, smoking status and intake of total energy, total protein and total fat. This negative trend (P for trend = 0.0001) was also noted in women after controlling for age, menopausal status, body mass index and intake of total energy and vitamin C. An additional adjustment for physical activity, coffee and tea consumption, and intake of cholesterol, carbohydrates, fiber and vitamin E did not change the results. These data suggest a role for soy products in human cholesterol homeostasis.

Effects of soy protein on plasma cholesterol and bile acid excretion in hamsters

The effect of dietary casein and soy protein on lipoprotein metabolism was compared in the Golden Syrian hamster (Mesocricetus auratus). Total plasma cholesterol was similar in animals fed either protein, but significant differences were seen in lipoprotein profile. In animals fed soy protein, cholesterol concentrations were lower in very-low-density lipoproteins (VLDL) but higher in low-density and high-density lipoproteins, compared with those fed casein. Significant differences were also seen depending on the nutritional state of the animals. In casein-fed hamsters, total plasma triacylglycerol and chylomicron + VLDL cholesterol and triacylglycerol were significantly higher when blood was collected during feeding, compared with animals that had been fasted overnight. By contrast, no significant change was seen in animals on the soy protein diet. This suggests that either intestinally derived lipoproteins are more rapidly cleared on the soy protein diet or that soy inhibits feeding-induced VLDL secretion. Fecal bile acid excretion was higher in the soy protein group, and there was a significant correlation between soy intake and bile acid excretion. Hepatic cholesterol decreased as the amount of soy protein consumed increased, suggesting that it is this pool of cholesterol that is used to replace the excreted bile acids. No significant difference was seen in plasma insulin or glucagon between hamsters fed the two proteins. Plasma triiodothyronine concentrations were, however, significantly higher and thyroxine concentrations lower in the soy protein-fed animals. This study shows specific effects of dietary proteins on plasma lipoprotein concentrations dependent on nutritional status of the animal.

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.

Meta-analysis of the effects of soy protein intake on serum lipids

BACKGROUND

In laboratory animals, the consumption of soy protein, rather than animal protein, decreases serum cholesterol concentrations, but studies in humans have been inconclusive. In this meta-analysis of 38 controlled clinical trials, we examined the relation between soy protein consumption and serum lipid concentrations in humans.

METHODS

We used a random-effects model to quantify the average effects of soy protein intake on serum lipids in the studies we examined and used hierarchical mixed-effects regression models to predict variation as a function of the characteristics of the studies.

RESULTS

In most of the studies, the intake of energy, fat, saturated fat, and cholesterol was similar when the subjects ingested control and soy-containing diets; soy protein intake averaged 47 g per day. Ingestion of soy protein was associated with the following net changes in serum lipid concentrations from the concentrations reached with the control diet: total cholesterol, a decrease of 23.2 mg per deciliter (0.60 mmol per liter); 95 percent confidence interval, 13.5 to 32.9 mg per deciliter [0.35 to 0.85 mmol per liter]), or 9.3 percent; low-density lipoprotein (LDL) cholesterol, a decrease of 21.7 mg per deciliter (0.56 mmol per liter); 95 percent confidence interval, 11.2 to 31.7 mg per deciliter [0.30 to 0.82 mmol per liter]), or 12.9 percent; and triglycerides, a decrease of 13.3 mg per deciliter (0.15 mmol per liter; 95 percent confidence interval, 0.3 to 25.7 mg per deciliter [0.003 to 0.29 mmol per liter]), or 10.5 percent. The changes in serum cholesterol and LDL cholesterol concentrations were directly related to the initial serum cholesterol concentration (P < 0.001). The ingestion of soy protein was associated with a nonsignificant 2.4 percent increase in serum concentrations of high-density lipoprotein (HDL) cholesterol.

CONCLUSIONS

In this meta-analysis we found that the consumption of soy protein rather than animal protein significantly decreased serum concentrations of total cholesterol, LDL cholesterol, and triglycerides without significantly affecting serum HDL cholesterol concentrations.

Influence of diets containing cow's milk or soy protein beverage on plasma lipids in children with familial hypercholesterolemia

The present article summarizes the effects of diets containing either cow's milk or soy protein beverage on plasma lipids and lipoproteins in children with familial hypercholesterolemia. After a stabilization period of 6 weeks without any hypolipemic medication, 10 subjects aged 6-12 years were randomly assigned to either cow's milk or soy protein beverage with subsequent crossover after a washout period, each of 4 weeks duration. During the experimental periods, subjects were fed diets containing 20% of energy as protein, of which 35% was from cow's milk protein or soy protein isolate, 28% of energy as fat with a polyunsaturated:monounsaturated:saturated fat ratio of 1:3:3, and less than 200 mg/day of cholesterol. The soy protein beverage, compared to cow's milk, induced significant reductions in plasma triglycerides and very-low-density lipoprotein cholesterol, as well as a significant increase in high-density lipoprotein cholesterol, indicating that consumption of soy protein beverage may be beneficial for the prevention of coronary heart disease in children with familial hypercholesterolemia.

The hypocholesterolemic effect of dietary soybean protein vs. casein in hamsters fed cholesterol-free or cholesterol-enriched semipurified diets

Golden Syrian hamsters fed a cholesterol-free diet containing 25% casein had higher plasma total triglyceride and cholesterol levels and VLDL + LDL cholesterol levels than animals fed a 25% soybean protein diet. Hamsters fed the cholesterol-free casein diet also had higher HDL cholesterol levels than animals fed the soybean protein diet, but these differences were not statistically significant. Addition of cholesterol to the diets caused even greater mean differences between the animals fed different types of protein, but the increased inter-animal variability of response to the added cholesterol resulted in less statistically significant differences. Although less responsive than the nonhybrid Golden Syrian hamsters, hybrid F1B hamsters showed similar effects of dietary casein vs. soybean protein on plasma lipids. These results indicate that the hamster may be a useful model to examine the effect of different types of protein and the interaction with dietary cholesterol on various plasma lipids and lipoproteins.

Effects of a soy-protein beverage on plasma lipoproteins in children with familial hypercholesterolemia

The effects of soy protein (35% of protein energy) given as a beverage and those of cow-milk proteins were investigated on plasma lipoprotein concentrations in children with familial hypercholesterolemia (FH). Subjects were randomly assigned to either the soy-protein or cow-milk-protein experimental period, with subsequent crossover after a washout period, each period lasting 4 wk. Diets were planned to provide 20% energy as protein, 28% as fat (polyunsaturated:monounsaturated:saturated fatty acids, 1:3:3) and less than 200 mg cholesterol/d. No changes were observed in either plasma cholesterol, low-density-lipoprotein cholesterol, or apolipoprotein concentrations. However, the soy beverage significantly reduced the concentrations of triglyceride and very-low-density-lipoprotein cholesterol (P less than 0.05) and significantly increased the concentrations of high-density-lipoprotein cholesterol (HDL-C) and HDL3-C (P less than 0.04 and P less than 0.03, respectively). These results indicate that the administration of soy protein may induce clinically beneficial effects in children with FH.

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.

Intestinal apolipoprotein B-48 synthesis and lymphatic cholesterol transport are lower in swine fed high fat, high cholesterol diet with soy protein than with casein

Effects of dietary proteins on intestinal lipoproteins were studied in 8 Yorkshire swine fed a high fat, high cholesterol diet with either casein or soy protein. After 5 weeks of feeding, the casein group exhibited moderately elevated levels of serum cholesterol (334 +/- 46 mg/dl). The soy protein group showed significantly less hypercholesterolemia as compared to the casein group (122 +/- 8 mg/dl). Swine were subjected to cannulation of mesenteric lymph duct under halothane anesthesia. A single dose of 250 microCi [14C]cholesterol and 10 mCi [3H]leucine was infused into the upper jejunum 2 h after one-fifth of daily food was given. The 3-h lymphatic transport of cholesterol in casein-fed swine was significantly higher than in those fed soy protein. Triglyceride transport values were similar in the 2 groups. The [3H]leucine incorporation study revealed that transport of apo B-48 bore a significant positive relationship to transport of cholesterol in both chylomicron and VLDL fractions of mesenteric lymph. A greater apo B-48 secretion with higher specific activity was probably responsible for the greater transport of cholesterol in chylomicrons in casein-fed than in soy protein-fed swine. Similarly, the transport of lymph VLDL cholesterol in swine fed casein or soy protein paralleled the amount of accompanying apo B-48. Dietary proteins probably influence the intestinal synthesis of apo B-48 which in turn affects cholesterol transport into the lymphatics.

Soy products and the human diet

This review focuses upon the nutritional significance of soy products in the human diet. The impact of the consumption of soy foods on a range of diet and health issues are discussed, including protein quality and growth promoting effects of soy protein, allergies in children, hypocholesterolemic effects of soy protein and soy fiber, effects of soy products upon glucose tolerance, and the bioavailability of zinc and iron from soy foods. Recent research reports involving humans and relevant animal studies are reviewed.

Effect of dietary protein on serum insulin and glucagon levels in hyper- and normocholesterolemic men

This study was designed to test the effect of dietary protein on blood levels of insulin and glucagon. Twelve normocholesterolemic (less than 200 mg/dl) and 11 hypercholesterolemic greater than 240 mg/dl) healthy male subjects, 31-62 years of age, were randomly given 3 liquid test meals 1 week apart. Meals were identical except for the protein source (soybean, casein, or protein free). Blood was drawn at fasting, and 0.5 and 2 h postprandially. Insulin and glucagon levels were measured by radioimmunoassay. Hypercholesterolemic subjects had a higher (P less than 0.05) insulin/glucagon ratio (1.5) than normocholesterolemic subjects (0.7) 2 h post-prandially when fed the casein test meal. There was no significant difference following the soybean test meal. This implies that the post-prandial insulin/glucagon ratio was affected by the amino acid composition of the diet. There was a consistently higher insulin response to all test meals among hyper- versus normocholesterolemic subjects. These results are consistent with our hypothesis that the hypocholesterolemic effects of soybean protein and the hypercholesterolemic effects of casein were mediated by altered levels of insulin and glucagon.

Effects of soy protein and casein in low cholesterol diets on plasma lipoproteins in normolipidemic subjects

Dietary plant proteins may lower plasma cholesterol and LDL concentrations in hypercholesterolemic patients when substituted for animal proteins, particularly in diets with low cholesterol and saturated fat content. Plant protein diets appear, however, to be without effect on plasma lipoprotein levels in normal subjects. In the present study, we have examined whether the origin of the dietary protein, i.e. plant (soy) or animal (casein), affects the plasma lipoproteins in normolipidemic subjects when these proteins are presented as components of diets low in cholesterol and saturated fat. The study followed a crossover design. Five men and 5 women consumed liquid formula diets containing 20% of calories as casein or soy protein, 28% as fat (mainly monounsaturated), and 52% as carbohydrate; the intake of cholesterol was less than 100 mg per day. The two dietary periods, each of 1 month duration, were separated by an interim period of 1 month on self-chosen food. Following an initial 30% reduction of cholesterol and LDL plasma levels on both diets, the concentrations of each of the major lipoprotein classes (VLDL, IDL, LDL, HDL2 and HDL3) were similar during the two experimental dietary periods. Body weights were essentially constant. Dietary soy protein and casein could not be distinguished in their effects on the plasma concentrations and chemical composition of the major lipoprotein classes in normolipidemic subjects.

Bile acid and cholesterol excretion in human beings given soya-bean- and meat-protein-based diets: a study in ileostomy subjects

1. The effect of partial replacement of meat protein with three different soya-bean-protein products on bile acid and cholesterol excretion was studied in seven ileostomy subjects. Four different tests diets containing 60 g meat, rice and bread protein, or a replacement of 250 g protein/kg total dietary protein by soya-bean protein from soya-bean flour, soya-bean concentrate or soya-bean isolate, were randomly assigned to the subjects in 2-d periods. 2. Ileostomy contents were collected at 2-h intervals during the day and in one portion during the night, and immediately deep-frozen to avoid bacteriological degradation. Bile acids and cholesterol were quantified by gas-liquid chromatography. 3. No difference in daily excretion of bile acids and cholesterol was noted between test diets. Ileostomy sterol concentrations were lower when soya-bean products were fed. 4. Incorporation of moderate amounts of soya-bean products in solid diets does not seem to affect short-term sterol balance in man.

Dietary protein and atherogenesis

Different dietary proteins determine different serum cholesterol levels if fed in a semisynthetic diet to some, but not all, animal species. In one species, the rabbit, this metabolic response is elicited without adding high sucrose or cholesterol supplements that have to be added to rat or pig diets in order to cause a similar response. Eleven out of 13 studies show that casein and soy protein do not induce different serum cholesterol levels in normal man. More important, protein-induced differences of serum cholesterol concentrations have not been reported when appropriate nutritional methodology has been applied. We conclude that no protein-induced hypercholesterolemia is observed in primates, particularly not in the human species. Dietary recommendations urging the general public to reduce consumption of animal protein because of a higher atherogenicity are not supported by the present data. The biochemical basis of the metabolic responses has been studied by many investigators, but no convincing unifying concept has yet been identified. The recent observation of higher serum thyroxine concentrations following soy protein consumption (and vegetable protein in general) when compared to casein shed new light on this problem. This endocrine response explains a wide array of metabolic features of soy-fed rodents: the lower hepatic VLDL secretion, the higher hepatic HMG-CoA reductase activity, the higher hepatic apo B, E receptor activity, the higher fecal bile acid excretion, and finally the lower serum cholesterol concentrations.

Soybean protein diet increases low density lipoprotein receptor activity in mononuclear cells from hypercholesterolemic patients

The effect of two diets containing different protein sources (animal vs. soybean) on the low density lipoprotein (LDL) receptor activity was tested in freshly isolated mononuclear cells from 12 individuals with severe type II hyperlipoproteinemia. The two diets, both taken for 4 wk in a crossover design were of otherwise identical composition. During the soybean protein diet period, total cholesterol was reduced by 15.9% and LDL-cholesterol by 16.4%. The diet containing animal proteins exerted no significant change in plasma lipid levels vs. the baseline findings. The soybean diet regimen dramatically affected the degradation of LDL by mononuclear cells. Degradation was increased 16-fold vs. the basal activity and 8-fold compared with the standard low lipid diet with animal proteins. There was, however, no clear relationship between the reduction of total and LDL-cholesterolemia and the increased LDL degradation. These findings confirm similar data previously obtained in cholesterol-fed rats and suggest that some factor/s, most likely of a protein nature, may regulate the expression of lipoprotein receptors in peripheral cells, particularly when receptor activity is suppressed by experimental diets and/or spontaneous hypercholesterolemia.

Effect of soy fiber and soy protein on cholesterol metabolism and atherosclerosis in rabbits

The effect of dietary fiber isolated from dehulled, defatted soybean seeds on cholesterol (CHOL) metabolism and atherosclerosis in rabbits was studied alone and in combination with isolated soy protein (ISP). Soy fiber (SF) contains both cellulosic and non-cellulosic dietary fiber. Based on the official AOAC method, soy fibers contains 75% total dietary fiber. Rabbits at 6 months of age were randomly assigned to 1 of 4 dietary treatments. All rabbits received either a casein or ISP-based diet with cellulose or SF as the only dietary fiber source for 36 weeks. Fasting blood samples and feces were collected and analyzed for lipids from individual rabbits. The entire aorta was removed and fixed, and sudanophilic stained lesions were examined visually. Rabbits consuming the SF and/or ISP diets had lower plasma CHOL levels and lower incidence of atherosclerotic lesions relative to the rabbits fed the casein-based cellulose diets. Rabbits consuming the SF and/or ISP diets also had a lower CHOL content in their liver and heart. Rabbits fed ISP-based diets had consistently increased fecal bile acid excretion, whereas rabbits fed diets containing SF had increased fecal and cholesterol concentration. These results suggest a complementary role for SF and ISP in preventing atherosclerosis in rabbits.

Substitution of mixed amino acids resembling soy protein for mixed amino acids resembling casein in the diet reduces plasma cholesterol in slowly, but not rapidly fed nor fasted baboons

Studies of cholesterol and triglyceride metabolism were conducted under steady-state conditions in conscious restrained female baboons to ascertain whether the cholesterol- and triglyceride-lowering effects of soy protein v casein in nonrodents can be explained by differences in amino acid composition between the two proteins and whether the lipid-lowering effects of soy protein are influenced by fasting or the rate of feeding, ie, the nutritional state. The metabolic changes underlying the changes in serum cholesterol and triglyceride concentration were also investigated. Isocaloric diets consisting of 45% mixed amino acids (soy or casein type), 50% glucose and 5% corn oil, including all nutritional requirements, were infused intraduodenally for five days. There were no differences in lipid levels between the soy and casein diets in fasting baboons (days 4 or 5) or when the daily diet (calculated to equal 24 hours of energy utilization) was given rapidly by constant intraduodenal infusion over seven hours (day 4). During rapid feeding there was, unexpectedly, no significant change in plasma cholesterol concentration, but the estimated rate of cholesterol oxidation to bile acids fell significantly by 38 +/- 6% (from 39 +/- 4 to 24 +/- 3 mg/d). Significant differences between the soy and casein diets were observed only in the fed state produced by the slow constant isocaloric intraduodenal infusions of the diets [5.8 mg mixed amino acids (soy or casein type) plus 7.2 mg glucose/min/kg body wt0.75] on day 5. These diets were calculated to equal the simultaneous rate of energy utilization.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct and indirect effects of dietary fibre on plasma lipoproteins in man

In clinical practice two effects of dietary fibre should be distinguished: A direct, and an indirect effect. An indirect effect of dietary-fibre-rich foods is that they displace from the diet foods high in saturated fat and cholesterol. Thus legumes may displace meat, and whole-wheat bread may displace cookies and cakes. As a result, diets high in fibre-rich foods tend to cause low levels of plasma low-density-lipoprotein (LDL) cholesterol. Direct effects of fibre are those seen in strictly controlled experiments where intake of all other nutrients is forcibly held constant. Under those conditions we and others observed the following effects: Wheat bran fibre does not cause a fall of plasma cholesterol, but may even induce a slight rise. Pectin, both isolated or as a constituent of vegetables and fruits, can lower cholesterol by up to 10%. The fibre of soy beans present in soy protein concentrate does not have a favourable effect on plasma lipoproteins. Addition of fibre-rich foods such as pulses, oats, fruits and vegetables to a conventional lipid-lowering diet caused an extra fall of 10% in plasma cholesterol on top of the 20% fall already caused by the reduction of saturated fats and cholesterol and the increased intake of polyunsaturated fatty acids. The decrease in high-density lipoprotein (HDL) cholesterol caused by the lipid-lowering diet was partly reversed by the addition of plant foods. Extreme high-carbohydrate fat-restricted diets cause a fall in HDL as well as in LDL, and the decrease in HDL cannot be completely prevented by the presence of fibre in the diet.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between dietary proteins, their in vitro digestion products, and serum cholesterol in rats

A relationship was assessed between the amino acid composition of 9 protein sources or of their in vitro digestion products and total serum cholesterol in rats. Three animal proteins (casein, beef, fish) and 6 vegetable proteins (soy, pea, peanut meal, rapeseed, oatmeal, wheat gluten) were tested. The intact protein sources were submitted to an enzymatic proteolysis according to a new in vitro digestion method. Each protein source was hydrolyzed for 30 min with pepsin at pH 1.9, then with 10 mg pancreatin at basic pH in a dialysis cell. The digestion products diffused through the dialysis membrane of the cell and were collected by a circulating sodium phosphate buffer over a 6-h period. They were likely to correspond to end products luminal in vivo digestion. The aromatic and the basic amino acids were present in higher proportions in the digestion products than in the intact protein sources, reflecting the specificity of the proteolytic enzymes. Total serum cholesterol was measured on male Sprague-Dawley rats fed cholesterol-free or cholesterol-enriched (1% cholesterol, 0.5% cholic acid) semipurified diets containing protein sources. Total serum cholesterol ranged from 70 mg/dl with the pea diet to 98 mg/dl with the peanut meal diet in rats fed cholesterol-free diets and from 163 mg/dl with the wheat gluten diet to 313 mg/dl with the casein diet in rats fed the cholesterol-enriched diets. These results suggested no specific effect of protein from animal or vegetable origin on total serum cholesterol in rats. In rats fed cholesterol-enriched diets, significant correlations were observed between total serum cholesterol and tyrosine content or leucine/isoleucine ratio of digestion products. These correlations were stronger than those observed with intact protein sources.