Efficacy of yogurt drink with added plant stanol esters (Benecol®, Colanta) in reducing total and LDL cholesterol in subjects with moderate hypercholesterolemia: a randomized placebo-controlled crossover trial NCT01461798

Functional Lipids and Cardiovascular Disease Reduction: A Concise Review

Functional lipids are dietary substances that may have an impact on human health by lowering the risk of chronic illnesses and enhancing the quality of life. Numerous functional lipids have been reported to have potential health benefits in the prevention, management, and treatment of cardiovascular disease, the leading cause of death in the United States. However, there is still insufficient and contradictory information in the literature about their effectiveness and associated mechanisms of action. The objective of this review, therefore, is to evaluate available literature regarding these functional lipids and their health benefits. Various studies have been conducted to understand the links between functional lipids and the prevention and treatment of chronic diseases. Recent studies on phytosterols have reported that CLA, medium-chain triglycerides, and omega-3 and 6 fatty acids have positive effects on human health. Also, eicosanoids, which are the metabolites of these fatty acids, are produced in relation to the ratio of omega-3 to omega-6 polyunsaturated fatty acids and may modulate disease conditions. These functional lipids are available either in dietary or supplement forms and have been proven to be efficient, accessible, and inexpensive to be included in the diet. However, further research is required to properly elucidate the dosages, dietary intake, effectiveness, and their mechanisms of action in addition to the development of valid disease biomarkers and long-term effects in humans.

Phytosterol supplementation in capsules or tablets as adjunctive treatment for hypercholesterolemia: A systematic review of randomized controlled trials

BACKGROUND

The exploration of lipid-lowering resources, such as phytosterols, for the complementary nutritional treatment of hypercholesterolemia is relevant to reduce cardiovascular risk. The use of phytosterols in capsules or tablets can bring advantages in the context of diet therapy, but such format is still less studied when compared to fortified foods.

OBJECTIVE

Systematically review randomized clinical trials on the effects of phytosterol supplementation, in capsules or tablets, on the lipid profile and its use in the treatment of hypercholesterolemia in adults.

DESIGN

A systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, with a PROSPERO protocol registered under number CRD42021249539. The process was conducted by two independent reviewers. Only randomized clinical trials with phytosterol supplementation in adult individuals with hypercholesterolemia were included. The terms were searched in the databases: PubMed/MEDLINE, Cochrane Library/CENTRAL, Embase, LILACS and Web of Science, without restriction of time and language. The manual search was also performed through the list of references of articles included in this review.

RESULTS

The searches resulted in 977 articles. 22 articles were selected, whose full text was read, and according to the eligibility criteria 10 were incorporated into the review. The studies were separated into groups according to the association of the intervention with changes in lifestyle and the characteristics extracted from the studies were summarized and displayed in tables. Most studies have revealed a positive association between phytosterol supplementation and cholesterol reduction, despite the short duration of interventions.

CONCLUSION

The analyzed studies showed that phytosterol supplements can be useful to modulate the lipid profile, helping to reduce the plasma concentration of LDL cholesterol. However, more research with the aforementioned supplementation in such pharmaceutical formats should be encouraged.

Phyto-Enrichment of Yogurt to Control Hypercholesterolemia: A Functional Approach

Cholesterol is essential for normal human health, but elevations in its serum levels have led to the development of various complications, including hypercholesterolemia (HC). Cholesterol accumulation in blood circulation formsplaques on artery walls and worsens the individuals’ health. To overcome this complication, different pharmacological and non-pharmacological approaches are employed to reduce elevated blood cholesterol levels. Atorvastatin and rosuvastatin are the most commonly used drugs, but their prolonged use leads to several acute side effects. In recent decades, the potential benefit of ingesting yogurt on lipid profile has attracted the interest of researchers and medical professionals worldwide. This review aims to give an overview of the current knowledge about HC and the different therapeutic approaches. It also discusses the health benefits of yogurt consumption and highlights the overlooked phyto-enrichment option to enhance the yogurt’s quality. Finally, clinical studies using different phyto-enriched yogurts for HC management are also reviewed. Yogurt has a rich nutritional value, but its processing degrades the content of minerals, vitamins, and other vital constituents with beneficial health effects. The option of enriching yogurt with phytoconstituents has drawn a lot of attention. Different pre-clinical and clinical studies have provided new insights on their benefits on gut microbiota and human health. Thus, the yogurtphyto-enrichment with stanol and β-glucan have opened new paths in functional food industries and found healthy andeffective alternatives for HC all along with conventional treatment approaches.

Efficacy of Plant Sterol-Enriched Food for Primary Prevention and Treatment of Hypercholesterolemia: A Systematic Literature Review

Plant sterols/phytosterols (PSs) are molecules with a similar structure to cholesterol that have a recognized effect on elevated LDL concentrations (LDL-c). PSs are used as a natural therapy against elevated LDL-c in combination with a healthy diet and exercise. A systematic review was performed to evaluate the efficacy of PS-enriched foods in the treatment of hypercholesterolemia. Randomized controlled clinical studies reporting the use of PS-enriched foods to reduce LDL-c among adult individuals were retrieved and assessed for risk of bias. Meta-analyses were performed to assess changes in LDL-c by treatment, food matrix, LDL-c range, sterols dosage and risk of bias (RoB). In the 13 studies analyzed, LDL-c in PS-treated participants decreased by an average of 12.14 (8.98; 15.29) mg/dL. PS administration was statistically more effective in patients with LDL-c ≥ 140 mg/dL and for PS dosages > 2 g/day. It can be concluded that PSs can be used as an important primary prevention measure for hypercholesterolemia and as tertiary prevention for cardiovascular events in patients who already have mild to moderate LDL-c. However, in severe hypercholesterolemia and in cases of familial hypercholesterolemia, it is necessary to combine dietary treatment with the use of statins.

Biological and pharmacological effects and nutritional impact of phytosterols: A comprehensive review

Phytosterols (PSs), classified into plant sterols and stanols, are bioactive compounds found in foods of plant origin. PSs have been proposed to exert a wide number of pharmacological properties, including the potential to reduce total and low-density lipoprotein (LDL) cholesterol levels and thereby decreasing the risk of cardiovascular diseases. Other health-promoting effects of PSs include anti-obesity, anti-diabetic, anti-microbial, anti-inflammatory, and immunomodulatory effects. Also, anticancer effects have been strongly suggested, as phytosterol-rich diets may reduce the risk of cancer by 20%. The aim of this review is to provide a general overview of the available evidence regarding the beneficial physiological and pharmacological activities of PSs, with special emphasis on their therapeutic potential for human health and safety. Also, we will explore the factors that influence the physiologic response to PSs.

The Relationship Between Nutrition and Atherosclerosis

Atherosclerosis is the basic pathological process of many diseases, such as coronary atherosclerosis and stroke. Nutrients can affect the occurrence and development of atherosclerosis. At present, in nutrition science, the research on atherosclerosis focuses on which nutrients play an important role in its prevention strategy, and what are the possible mechanisms of its action. In the current study, the process of atherosclerosis can be affected by adjusting the proportion of nutrients in the diet. In this review, we pay attention to the effects of phytosterols, omega-3-polyunsaturated fatty acids, polyphenol, vitamin, and other nutrients on atherosclerosis, pay attention to their current epidemiological status, current nutritional research results, and prevention or a possible mechanism to reduce the risk of development of atherosclerosis. So that more personalized nutritional approaches may be more effective in terms of nutritional intervention responses to atherosclerosis.

Pathophysiology of atherosclerosis: Association of risk factors and treatment strategies using plant-based bioactive compounds

Under physiological conditions, endothelial cells act as protective barrier which prevents direct contact of blood with circulating factors via production of tissue plasminogen activator. Risk factors of metabolic disorders are responsible to induce endothelial dysfunction and may consequently lead to prognosis of atherosclerosis. This article summarizes the process of atherosclerosis which involves number of sequences including formation and interaction of AGE-RAGE, activation of polyol pathway, protein kinase C, and hexosamine-mediated pathway. All these mechanisms can lead to the development of oxidative stress which may further aggravate condition. Different pharmacological interventions are being used to treat atherosclerosis, however, these might be associated with mild to severe side effects. Therefore, plant-based bioactive compounds having potential to combat and prevent atherosclerosis in diabetic patients are attaining recent focus. By understanding process of development and mechanisms involved in atherosclerotic plaque formation, these bioactive compounds can be better option for future therapeutic interventions for atherosclerosis treatment. PRACTICAL APPLICATIONS: Atherosclerosis is one of major underlying disorders of cardiovascular diseases which occur through multiple mechanisms and is associated with metabolic disorders. Conventional therapeutic interventions are not only used to treat atherosclerosis, but are also commonly associated with mild to severe side effects. Therefore, nowadays, bioactive compounds having potential to combat and prevent atherosclerosis in diabetic patients are preferred. By understanding mechanisms involved in atherosclerotic plaque formation, bioactive compounds can be better understood for treatment of atherosclerosis. In this manuscript, we have focused on treatment strategies of atherosclerosis using bioactive compounds notably alkaloids and flavonoids having diverse pharmacological and therapeutic potentials with special focus on the mechanism of action of these bioactive compounds suitable for treatment of atherosclerosis. This manuscript will provide the scientific insights of bioactive compounds to researchers who are working in the area of drug discovery and development to control pathogenesis and development of atherosclerosis and its associated cardiometabolic disorders.

Recent progress in the use of functional foods for older adults: A narrative review

The number and proportion of older adults are increasing globally, and it is predicted that in 2020, there will be 723 million people worldwide aged 66 and older. In recent decades, numerous studies showed that healthy eating is positively associated with better nutritional status and quality of life, and the decreased incidence of noncommunicable diseases. As older adults become health conscious, the demand for foods and beverages rich in nutrients and bioactive compounds has increased. The increased demand for healthy food stimulated a recent rapid increase in designing, producing, and marketing functional foods to prevent or correct nutrient deficiencies and to improve the nutritional status of older adults. These functional products contain and/or are enriched with dietary fiber; omega-3 polyunsaturated fatty acids; phytoestrogens; polyphenols; carotenoids such as alpha- and beta-carotene; lutein and zeaxanthin; pre-, pro-, and synbiotics; and plant sterols and stanols. A limited number of publications have thoroughly addressed the effect of functional foods on the nutritional status of older adults. The goal of this review was to review existing recent research on the role of functional foods in healthy and active aging.

Role of Functional Fortified Dairy Products in Cardiometabolic Health: A Systematic Review and Meta-analyses of Randomized Clinical Trials

There is insufficient evidence on the role of functional fortified dairy products in improving health and in preventing risk factors associated with noncommunicable chronic diseases. This systematic review was conducted to summarize effects of the consumption of fortified dairy products on biomarkers of cardiometabolic risk. MEDLINE and SCOPUS databases were used to perform searches to include studies published up to 30 April 2018. Randomized clinical trials with human subjects consuming dairy products fortified with phytosterols, FAs, vitamins or minerals and relating this consumption with cardiometabolic health were included in this review. Risk of bias assessment according to Cochrane guidelines was performed to determine the quality of the trials. Forty-one studies were finally selected for this synthesis; the selected studies tested dairy products fortified with the following nutrients and bioactive components: phytosterols (n = 31), FAs (n = 8), and vitamin D (n = 2). We found that the consumption of phytosterol-fortified dairy, led to an overall LDL cholesterol reduction of -0.36 (-0.41, -0.31) mmol/L, P < 0.001; this decrease was mainly related to the dosage. Likewise, consumption of ω-3 FA-fortified dairy products resulted in a plasma LDL cholesterol reduction of -0.18 (-0.27, -0.09) mmol/L as well as a decrease of -0.18 (-0.32, -0.05) mmol/L in triacylglycerols (TG). Performing meta-analyses of the consumption of dairy products fortified with vitamin D or FAs other than ω-3 FAs and biomarkers of cardiometabolic risk was not possible because of the few available publications. Our results indicate that consumption of dairy products fortified with phytosterols and ω-3 FAs can lead to a reduction of LDL cholesterol and consumption of fortified dairy products fortified with ω-3 FAs can reduce TG concentration. However, more studies with homogeneous designs are needed to determine the advantages of using dairy products as fortification vehicles to prevent cardiometabolic risk.

Dietary non-nutrients in the prevention of non-communicable diseases: Potentially related mechanisms

Among the 10 leading causes of death in developed countries are chronic non-communicable diseases (NCDs). The effect of these multifactorial diseases on public health has stimulated considerable research aimed at investigating their primary risk factors (genetic factors, stress, food intake, and amount of physical exercise). Thus, healthful foods (e.g., fruits, vegetables, oils, grains, and seeds) are sources of bioactive compounds that promote good health and disease prevention. Among their components are non-caloric substances identified as non-nutrients (polyphenols, phytosterols, saponins, and phytates), which have been found to have a role in modulating metabolic pathways, maintaining health, and preventing NCDs. The aim of this study is to demonstrate and review the performance of some non-nutrients, such as their antioxidant and anti-inflammatory action, modulation of the antiatherogenic lipid profile (higher high-density lipoprotein cholesterol, lower oxidized low-density lipoprotein, and triacylglycerols), reduction of glucose and fat intestinal absorption, increase in insulin sensitivity, and stimulation of nitic oxide synthesis.

Phytosterols in the Treatment of Hypercholesterolemia and Prevention of Cardiovascular Diseases

Phytosterols are bioactive compounds found in foods of plant origin, which can be divided into plant sterols and plant stanols. Clinical studies consistently indicate that the intake of phytosterols (2 g/day) is associated with a significant reduction (8-10%) in levels of low-density lipoprotein cholesterol (LDL-cholesterol). Thus, several guidelines recommend the intake of 2 g/day of plant sterols and/or stanols in order to reduce LDL-cholesterol levels. As the typical western diet contains only about 300 mg/day of phytosterols, foods enriched with phytosterols are usually used to achieve the recommended intake. Although phytosterols decrease LDL-cholesterol levels, there is no evidence that they reduce the risk of cardiovascular diseases; on the contrary, some studies suggest an increased risk of atherosclerosis with increasing serum levels of phytosterols. This review aims to address the evidence available in the literature on the relationship between phytosterols and risk of cardiovascular disease.

Dairy Fats and Cardiovascular Disease: Do We Really Need to be Concerned?

Cardiovascular diseases (CVD) remain a major cause of death and morbidity globally and diet plays a crucial role in the disease prevention and pathology. The negative perception of dairy fats stems from the effort to reduce dietary saturated fatty acid (SFA) intake due to their association with increased cholesterol levels upon consumption and the increased risk of CVD development. Institutions that set dietary guidelines have approached dairy products with negative bias and used poor scientific data in the past. As a result, the consumption of dairy products was considered detrimental to our cardiovascular health. In western societies, dietary trends indicate that generally there is a reduction of full-fat dairy product consumption and increased low-fat dairy consumption. However, recent research and meta-analyses have demonstrated the benefits of full-fat dairy consumption, based on higher bioavailability of high-value nutrients and anti-inflammatory properties. In this review, the relationship between dairy consumption, cardiometabolic risk factors and the incidence of cardiovascular diseases are discussed. Functional dairy foods and the health implications of dairy alternatives are also considered. In general, evidence suggests that milk has a neutral effect on cardiovascular outcomes but fermented dairy products, such as yoghurt, kefir and cheese may have a positive or neutral effect. Particular focus is placed on the effects of the lipid content on cardiovascular health.

Double-Blind Randomized Placebo Controlled Trial Demonstrating Serum Cholesterol Lowering Efficacy of a Smoothie Drink with Added Plant Stanol Esters in an Indonesian Population

Indonesians have a high intake of saturated fats, a key contributing dietary factor to elevated blood cholesterol concentrations. We investigated the cholesterol lowering efficacy of a smoothie drink with 2 grams of plant stanols as esters to lower serum total and LDL-cholesterol concentrations in hypercholesterolemic Indonesian adults. The double-blind randomized placebo controlled parallel design study involved 99 subjects. Fifty subjects received control drink and dietary advice, and 49 subjects received intervention drink (Nutrive Benecol®) and dietary advice. Baseline, midline (week 2), and endline (week 4) assessments were undertaken for clinical, anthropometric, and biochemical variables. Compared to control, the smoothie drink with plant stanols reduced serum LDL-cholesterol concentration by 7.6% (p < 0.05) and 9.0% (p < 0.05) in two and four weeks, respectively. Serum total cholesterol was reduced by 5.7% (p < 0.05 compared to control) in two weeks, and no further reduction was detected after four weeks (5.6%). Compared to baseline habitual diet, LDL-cholesterol was reduced by 9.3% (p < 0.05) and 9.8% (p < 0.05) in the plant stanol ester group in two and four weeks, respectively. We conclude that consumption of smoothie drink with added plant stanol esters effectively reduces serum total and LDL-cholesterol of hypercholesterolemic Indonesian subjects already in two weeks. Trial is registered as NCT02316808.

Lipid-modifying effects of nutraceuticals: An evidence-based approach

The present review provides an up-to-date summary of the findings on the lipid-lowering effects of the most important nutraceuticals and functional foods. Based on current knowledge, nutraceuticals might exert significant lipid-lowering, and their use has several advantages: A number of important questions remain to be addressed, including whether longer durations of therapy would result in a better response and the exact safety profile of nutraceuticals, especially at doses higher than those consumed in an average diet. Additionally, data regarding the effects of nutraceutical supplementation on the incidence of cardiovascular outcomes are lacking, and it is not clear whether additional lipid lowering by nutraceuticals can modify the residual cardiovascular risk that remains after statin therapy.

Cholesterol Lowering Effect of Plant Stanol Ester Yoghurt Drinks with Added Camelina Oil

The aim of this study was to investigate the effects of yoghurt minidrinks containing two doses of plant stanol ester either with or without added camelina oil on the serum cholesterol levels in moderately hypercholesterolemic subjects. In this randomised, double-blind, parallel group study, 143 subjects consumed a 65 mL minidrink together with a meal daily for four weeks. The minidrink contained 1.6 or 2.0 grams of plant stanols with or without 2 grams of alpha-linolenic acid-rich camelina oil. The placebo minidrink did not contain plant stanols or camelina oil. All plant stanol treated groups showed statistically significant total, LDL, and non-HDL cholesterol lowering relative to baseline and relative to placebo. Compared to placebo, LDL cholesterol was lowered by 9.4% (p < 0.01) and 8.1% (p < 0.01) with 1.6 g and 2 g plant stanols, respectively. With addition of Camelina oil, 1.6 g plant stanols resulted in 11.0% (p < 0.01) and 2 g plant stanols in 8.4% (p < 0.01) reduction in LDL cholesterol compared to placebo. In conclusion, yoghurt minidrinks with plant stanol ester reduced serum LDL cholesterol significantly and addition of a small amount of camelina oil did not significantly enhance the cholesterol lowering effect. This trial was registered with ClinicalTrials.gov NCT02628990.

Functional food addressing heart health: do we have to target the gut microbiota?

PURPOSE OF REVIEW

Health promoting functional food ingredients for cardiovascular health are generally aimed at modulating lipid metabolism in consumers. However, significant advances have furthered our understanding of the mechanisms involved in development, progression, and treatment of cardiovascular disease. In parallel, a central role of the gut microbiota, both in accelerating and attenuating cardiovascular disease, has emerged.

RECENT FINDINGS

Modulation of the gut microbiota, by use of prebiotics and probiotics, has recently shown promise in cardiovascular disease prevention. Certain prebiotics can promote a short chain fatty acid profile that alters hormone secretion and attenuates cholesterol synthesis, whereas bile salt hydrolase and exopolysaccharide-producing probiotics have been shown to actively correct hypercholesterolemia. Furthermore, specific microbial genera have been identified as potential cardiovascular disease risk factors. This effect is attributed to the ability of certain members of the gut microbiota to convert dietary quaternary amines to trimethylamine, the primary substrate of the putatively atherosclerosis-promoting compound trimethylamine-N-oxide. In this respect, current research is indicating trimethylamine-depleting Achaea - termed Archeabiotics as a potential novel dietary strategy for promoting heart health.

SUMMARY

The microbiota offers a modifiable target, which has the potential to progress or prevent cardiovascular disease development. Whereas host-targeted interventions remain the standard, current research implicates microbiota-mediated therapies as an effective means of modulating cardiovascular health.