Association of natural intake of dietary plant sterols with carotid intima-media thickness and blood lipids in Chinese adults: a cross-section study

Comparison of Functional and Morphological Estimates of Vascular Age

BACKGROUND/AIM

Vascular age (VA) is an emerging metric in preventive cardiovascular (CV) medicine. VA can be derived from morphological parameters such as carotid intima-media thickness (CIMT), or functional parameters such as pulse wave analysis (PWA), which celebrates its 100th birthday. This study aimed to investigate whether the results of both approaches are comparable.

PATIENTS AND METHODS

On the occasion of the double 100th anniversary of PWA and the Mannheim Clinic, 100 volunteers underwent a) bilateral CIMT assessment using high-resolution ultrasound and b) oscillometric PWA at the brachial forearm site. The respective VAs were calculated using previously published equations.

RESULTS

Median age of the participants was 53.6 years (range=39.8-62.6 years), and 56% were female. Median CIMT was 632.5 μm (range=548.8-730.0 μm). Median PWA-derived VA was 55.3 years (36.5-70.5 years). Different values were obtained for CIMT-derived VA, depending on the reference cohort used as calculation basis, ranging from median 43.7 (26.2-59.5 years) to median 64.0 years (43.5-82.1 years). In 46% of the participants divergent VAs were found, that is, the calculated age was higher according to one method and lower according to the other. Correlation analysis revealed a strong dependence of VA (both PWA- and CIMT-derived) and chronological age, as well as an increase in CV risk factors and the detection of plaques with age.

CONCLUSION

Different approaches for estimating VA are not comparable and often produce contradictory results. The current methods and their validity must be critically assessed if they are not standardized.

The effect of nutrition on stroke risk: A systematic review

Background: An estimated 33% reduction in cardiovascular events can be achieved when incorporating whole grains, fruits, vegetables, poultry, nuts, and vegetable oils in the diet along with reduced consumption of refined carbohydrates, processed meats, and sugar sweetened beverages. We performed a systematic review to analyze the impact of nutritional intervention on stroke risk, as there is no current consensus concerning dietary recommendation for primary and secondary stroke prevention. Methods: A literature search of the PubMed database from January 2010 to June 2020 was performed using combinations of the following search terms: carotid disease, carotid artery disease, carotid stenosis, carotid intima-media thickness (CIMT), diet, nutrition, micronutrition, embolic stroke, and stroke. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist. Results: 28 studies met our inclusion criteria. Multiple studies showed an inverse relationship between consumption of vegetables and fruits and stroke risk. Vitamin B12 or a combination of B Vitamins was the most common supplement studied in stroke prevention. Only one RCT showed the use of B12 (500 micrograms/day) correlated with lower CIMT at follow up in healthy vegetarians. Discussion: The key findings from this systematic review indicate that adopting a diet rich in fruits and vegetables earlier in life may lower stroke risk compared with meats and fat intake. B vitamins also appear to confer some protection against stroke. However, not enough data exists to support the use of multivitamins, calcium, soy products and other supplements for primary or secondary stroke prevention.

Higher S-adenosylhomocysteine and lower ratio of S-adenosylmethionine to S-adenosylhomocysteine were more closely associated with increased risk of subclinical atherosclerosis than homocysteine

Aim

To examine the relationship of C1 metabolites of the methionine cycle with the risk of subclinical atherosclerosis (SA) in the Chinese population.

Methods

A total of 2,991 participants aged 45–75 years old were included for data analyses based on the baseline data of the Guangzhou Nutrition and Health Cohort. Three core serum methionine metabolites including serum S-adenosylmethionine (SAM), S-adenosylhomocysteine (SAH), and homocysteine (Hcy) were measured by UPLC-MS/MS. SA was determined by B-mode ultrasound measured carotid intima-media thickness (CIMT) at the common artery and bifurcation segments. Multivariable logistic and linear regression models were performed to estimate the associations of C1 metabolites of the methionine cycle with SA risk or CIMT.

Results

After controlling for potential cofounders and other C1 metabolites, in comparison with the lowest quartile, participants in the highest quartile had lower risk of SA by 27.6% (OR = 0.724; 95% CI:0.563–0.93, P_trend = 0.007) for SAM and 32.2% (OR = 0.678; 95% CI:0.538–0.855, P_trend < 0.001) for SAM/SAH, while increased SA risk by 27.9% (OR = 1.279; 95% CI: 1.065–1.535, P_trend < 0.001) for SAH. No significant association was observed for Hcy with SA after further adjustment of SAH and SAM. The results of multivariable linear regression showed similar findings. The highest two standardized coefficients were observed for SAH (β = 0.104 for CCA and 0.121 for BIF, P< 0.001) and SAM/SAH (β = −0.071 for CCA and −0.084 for BIF, P< 0.001). Subgroup analyses suggested more evident associations of SAH with SA were observed in participants of higher cardiovascular risk profiles.

Conclusion

Our cross-sectional data showed higher serum SAH, but lower SAM/SAH were independently associated with increased risk of SA among the Chinese middle-aged and elderly population.

Dietary Plant Sterols and Phytosterol-Enriched Margarines and Their Relationship with Cardiovascular Disease among Polish Men and Women: The WOBASZ II Cross-Sectional Study

Dietary cholesterol has been suggested to increase the risk of cardiovascular disease (CVD). Phytosterols, present in food or phytosterol-enriched products, can reduce cholesterol available for absorption. The present study aimed to investigate the association between habitual intake of total and individual plant sterols (β-sitosterol, campesterol, and stigmasterol) or a diet combined with phytosterol-enriched products and CVD in a cross-section of Polish adults, participants of the Multicenter National Health Survey II (WOBASZ II). Among men (n = 2554), median intakes of plant sterols in terciles ranged between 183−456 mg/d and among women (n = 3136), 146−350 mg/d in terciles. The intake of phytosterols, when consumed with food containing phytosterols, including margarine, ranged between 184−459 mg/d for men and 147−352 mg/d for women. Among both men and women, beta-sitosterol intake predominated. Plant sterol intake was lower among both men and women with CVD (p = 0.016) compared to those without CVD. Diet quality, as measured by the Healthy Diet Index (HDI), was significantly higher in the third tercile of plant sterol intake for both men and women and the entire study group (p < 0.0001). This study suggests that habitual dietary intake of plant sterols may be associated with a lower chance of developing CVD, particularly in men.

Associations between SNP83 of phosphodiesterase 4D gene and carotid atherosclerosis in a southern Chinese Han population: a case-control study

Atherosclerosis was an important pathophysiological basis of atherothrombotic stroke, and phosphodiesterase 4D (PDE4D) polymorphism (SNP83/rs966221) was reported to be associated with the susceptibility to atherothrombotic stroke. Aim of the present study was to explore the potential association between SNP83 and carotid atherosclerosis (CAS). 204 southern Chinese Han participants were divided into two groups according to the carotid intima-media thickness (IMT) of the carotid artery: CAS group (carotid IMT ≥ 1.0 mm) and non-CAS group (carotid IMT < 1.0 mm). Carotid IMT was measured by color Doppler ultrasound. The PDE4D SNP83 polymorphism was determined by SNaPshot technique. Our study found that SNP83 was associated significantly with CAS susceptibility under the dominant, overdominant and codominant models. After adjusting for age, gender, low-density lipoprotein cholesterol, Hemoglobin A1c, cigarette smoking, hypertension history, and diabetes mellitus history, the association still remained significant (dominant model: crude OR = 2.373, 95% CI: 1.268-4.442, P = 0.007; adjusted OR = 3.129, 95% CI: 1.104-8.866, P = 0.032; overdominant model: crude OR = 1.968, 95% CI: 1.043-3.714, P = 0.037; adjusted OR = 2.854, 95% CI: 1.005-8.108, P = 0.049; codominant: crude OR = 2.102, 95% CI: 1.110-3.979, P = 0.023; adjusted OR = 2.984, 95% CI: 1.047-8.502, P = 0.041). Carotid IMT of carriers with CT + CC genotypes was higher than carriers with TT genotype (P = 0.016). Our results indicated that the SNP83/rs966221 located on PDE4D gene was significantly associated between CAS susceptibility and carotid IMT independently of conventional risk factors in a southern Chinese Han population.

Cross-Sectional Study of Plant Sterols Intake as a Basis for Designing Appropriate Plant Sterol-Enriched Food in Indonesia

Coronary heart disease (CHD) is one of the leading causes of mortality in many low-income and middle-income countries, including Indonesia, with elevated blood cholesterol level being one of significant risk factors for this condition. The problem should be addressed by combining healthy lifestyle and diet, where functional foods having a cholesterol-lowering activity could play a significant role. A group of compounds that had been proven to show cholesterol-lowering ability are plant sterols. To develop more suitable functional foods that could substantially contribute to hypercholesterolemia prevention in Indonesian population, up-to-date data about plant sterols dietary intake are required, and were not available until this research was done. This study aimed to estimate daily plant sterols intake and to determine the consumption pattern of foods containing plant sterols in rural and urban area of Bogor, West Java, Indonesia. The research was conducted with a cross-sectional design, with 200 respondents. The study revealed that the level of plant sterols intake in Bogor reached on average 229.76 mg/day and was not significantly different between urban and rural area. Cereals, vegetables, and fruit products were the main food sources of plant sterols in both areas. In addition, a list of several surveyed food items possible to be enriched with plant sterols was developed within the study. These results provide baseline data to develop functional foods fortified with plant sterols suitable for the Indonesian needs and taste. However, further studies are needed to confirm efficacy and safety of introducing such phytosterol-enriched products into a habitual diet, especially considering possible long-term side effects of plant sterol treatment.

Dietary choline, rather than betaine intake, is associated with hepatocellular carcinoma mortality

The dietary intakes of choline and betaine have been related to the mortality of some neoplasms, but their effects on hepatocellular carcinoma (HCC) mortality are still unknown. We examined the associations between dietary choline, five choline-containing compounds, different choline forms, betaine intake and HCC mortality. In total, 905 newly diagnosed HCC patients were enrolled in the Guangdong Liver Cancer Cohort study. Dietary intake was assessed by a valid food frequency questionnaire. Liver cancer-specific mortality (LCSM) and all-cause mortality (ACM) were calculated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were computed by Cox proportional hazards models. It was found that a higher total choline intake was associated with lower ACM, Q4 vs. Q1: HR = 0.72, 95% CI: 0.53-0.97, Ptrend = 0.012 in the fully adjusted model. The associations between total choline intake and LCSM were not significant. Similar associations were found between water-soluble choline intake and HCC mortality, where the fully adjusted HR for ACM was 0.72, 95% CI: 0.53-0.98, Ptrend = 0.017. However, null associations were found between neither phosphatidylcholine (the most abundant lipid-soluble choline) nor total lipid-soluble choline intake and HCC mortality. These results implied that the favorable associations between the total choline intake and ACM were more attributed to water-soluble choline. Furthermore, no significant associations were observed between betaine intake and HCC mortality. Future human intervention trials regarding choline supplementation and liver disease recovery should take the forms into consideration rather than just the total amount alone.

Association of Dietary Phytosterols with Cardiovascular Disease Biomarkers in Humans

Cardiovascular disease (CVD) is a leading cause of death worldwide. Elevated concentrations of serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) are major lipid biomarkers that contribute to the risk of CVD. Phytosterols well known for their cholesterol-lowering ability, are non-nutritive compounds that are naturally found in plant-based foods and can be classified into plant sterols and plant stanols. Numerous clinical trials demonstrated that 2 g phytosterols per day have LDL-C lowering efficacy ranges of 8-10%. Some observational studies also showed an inverse association between phytosterols and LDL-C reduction. Beyond the cholesterol-lowering beneficial effects of phytosterols, the association of phytosterols with CVD risk events such as coronary artery disease and premature atherosclerosis in sitosterolemia patients have also been reported. Furthermore, there is an increasing demand to determine the association of circulating phytosterols with vascular health biomarkers such as arterial stiffness biomarkers. Therefore, this review aims to examine the ability of phytosterols for CVD risk prevention by reviewing the current data that looks at the association between dietary phytosterols intake and serum lipid biomarkers, and the impact of circulating phytosterols level on vascular health biomarkers. The clinical studies in which the impact of phytosterols on vascular function is investigated show minor but beneficial phytosterols effects over vascular health. The aforementioned vascular health biomarkers are pulse wave velocity, augmentation index, and arterial blood pressure. The current review will serve to begin to address the research gap that exists between the association of dietary phytosterols with CVD risk biomarkers.

Erythrocyte Membrane Polyunsaturated Fatty Acids Are Associated with Incidence of Metabolic Syndrome in Middle-Aged and Elderly People-An 8.8-Year Prospective Study

BACKGROUND

The total and specific types of polyunsaturated fatty acids (PUFAs) related to metabolic syndrome (MetS) remain inconsistent.

OBJECTIVE

We assessed the association of erythrocyte n-3 and n-6 PUFAs with MetS and the components of MetS in a cohort population.

METHODS

This prospective analysis included 2754 participants (aged 40-75 y) from the Guangzhou Nutrition and Health Study (2008-2019) in China. Erythrocyte PUFAs at baseline were measured using gas chromatography. MetS was assessed every 3 y according to the updated National Cholesterol Education Program Adult Treatment Panel III criteria. Multivariable Cox proportional hazard models were used to evaluate HRs and 95% CIs.

RESULTS

We identified 716 incident cases of MetS. The primary analyses showed that the HRs (95% CIs) of MetS (tertile 3 versus 1) were 0.67 (0.56, 0.80) for n-3 PUFAs and 0.70 (0.58, 0.85) for n-6 PUFAs (all Ps trend <0.001). The secondary outcomes showed that, higher erythrocyte very-long-chain (VLC) PUFAs [20:3n-3, docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), arachidonic acid (ARA), and 22:4n-6], but lower α-linolenic acid (ALA) and γ-linolenic acid (GLA), tended to be associated with lower incidences of MetS and its components; among individual MetS components, the associations of PUFAs were more pronounced for hypertriglyceridemia (HTG) and hypertension, followed by low high-density lipoproten (HDL) cholesterol. Significantly higher concentrations of n-3 PUFAs (total, DPA, and DHA) and n-6 PUFAs (total, ARA, and 22:4) were observed in participants with improved (versus progressed) status of MetS (all Ps trend ≤0.003).

CONCLUSION

This study reveals that higher erythrocyte VLC n-3 and n-6 PUFAs, but lower 18-carbon PUFAs (ALA and GLA), are associated with lower risks of MetS components (HTG, hypertension, and low HDL cholesterol) and thereby lower MetS incidence in Chinese adults.

Association of body composition with predicted hip bone strength among Chinese postmenopausal women: a longitudinal study

Body composition and bone strength are closely associated. How lean mass (LM) and fat mass (FM) contribute to bone strength remains ambiguous. We investigated the associations of total body LM and FM with changes in predicted hip bone strength over a period of 3 years in 1,743 postmenopausal Chinese women from the communities of Guangzhou, China. The body compositions of the women were obtained with dual-energy X-ray absorptiometry. We used the hip structure analysis program to obtain the bone parameters at the femoral neck region, including the bone mineral density (BMD), cross-sectional area (CSA), cortical thickness (CT), section modulus (SM) and buckling ratio (BR). We found the FM and LM were positive predictors for hip bone strength (β > 0, P < 0.05). The LM had a larger contribution to the BMD, CSA, CT, SM and/or their annual percent changes (βLM > βFM), while the contribution of FM to the BR and its annual percent change was higher than LM (|βFM| > |βLM|). Further analysis found that the associations of FM and LM with bone parameters were stronger in the underweight and normal weight participants (|βBMI1| > |βBMI2|). Overall, FM and LM had positive but differential effects on predicted hip bone strength, with a higher impact in the thinner participants.

Higher dietary and serum carotenoid levels are associated with lower carotid intima-media thickness in middle-aged and elderly people

Several studies have suggested that higher carotenoid levels may be beneficial for atherosclerosis patients, but few studies have examined this relationship in the Chinese population. This cross-sectional study examined the association between the levels of carotenoids in diet and serum and carotid intima-media thickness (IMT) in Chinese adults aged 50-75 years in Guangzhou, China. Dietary intake was assessed using a FFQ. HPLC was used to assay the serum concentrations of α-carotene, β-carotene, lutein+zeaxanthin, β-cryptoxanthin and lycopene. The IMT at the common carotid artery (CCA) and bifurcation of the carotid artery was measured by B-mode ultrasound. A total of 3707 and 2947 participants were included in the analyses of dietary and serum carotenoids. After adjustment for demographic, socio-economic and lifestyle factors, all the serum carotenoids levels except lycopene were found to be inversely associated with the IMT at the CCA and bifurcation (P trend<0·001 to 0·013) in both men and women. The absolute mean differences in the IMT between the subjects in the extreme quartiles of serum carotenoid levels were 0·034 mm (α-carotene), 0·037 mm (β-carotene), 0·032 mm (lutein+zeaxanthin), 0·030 mm (β-cryptoxanthin), 0·015 mm (lycopene) and 0·035 mm (total carotenoids) at the CCA; the corresponding values were 0·025, 0·053 0·043, 0·050, 0·011 and 0·042 mm at the bifurcation. The favourable associations were also observed between dietary carotenoids (except lycopene) and the CCA IMT. In conclusion, elevated carotenoid levels in diet and serum are associated with lower carotid IMT values (particular at the CCA) in Chinese adults.

Tea Consumption Is Associated with Increased Bone Strength in Middle-Aged and Elderly Chinese Women

OBJECTIVES

Previous studies found that tea consumption was related to a reduction in the risks of some chronic diseases, but limited data are available on bone health. This study aimed to examine the associations of tea consumption with hip bone strength in Chinese women.

DESIGN

Cross-sectional study.

SETTING

The participants were from the ongoing Guangzhou Nutrition and Health Study. This was a cohort study started in 2008. The examination data conducted between June 2010 and December 2013 were used.

PARTICIPANTS

A total of 1,495 Chinese women aged more than 40 years were included.

MEASUREMENTS

Tea consumption, socio-demographic information and lifestyle habits were collected by a face-to-face questionnaire. Hip bone mineral density (BMD) and geometric parameters, i.e. cross-sectional area (CSA), section modulus (Z) and buckling ratio (BR), were generated by dual-energy X-ray absorptiometry. The associations of tea consumption with bone phenotypes were detected by analysis of covariance and multiple linear regression models after adjusting for age, body mass index, years since menopause, physical activity, dietary-protein intake, dietary-calcium intake, calcium tablet intake, drinking status and smoking status.

RESULTS

Tea drinkers (n = 732) had approximately 1.9% higher BMD (p < 0.05) and 3.6% lower BR (p < 0.05) than non-tea drinkers (n = 763). The dose-response relationships of BMD, BR or CSA with total tea consumption were identified (p-trend < 0.05). Tea drinking was found to be a significant and independent predictor of BMD (β = 0.068, p < 0.05) or BR (β = -0.079, p < 0.05).

CONCLUSION

Tea consumption was associated with increased bone strength in middle-aged and elderly Chinese women.

Effect of a short-term dietary supplementation with phytosterols, red yeast rice or both on lipid pattern in moderately hypercholesterolemic subjects: a three-arm, double-blind, randomized clinical trial

Background

Phytosterols and red yeast rice are largely studied cholesterol-lowering nutraceuticals, respectively inhibiting the bowel absorption and liver synthesis of cholesterol. Our aim was to test the effect on lipid profile of phytosterols, red yeast rice and their association.

Methods

We performed a three parallel arms, double blind, clinical trial randomizing 90 moderately hypercholesterolemic subjects to treatment with phytosterols 800 mg (group 1), red yeast rice standardized to contain 5 mg monacolins from Monascus purpureus (group 2), or both combined nutraceuticals (group 3).

Results

After 8 weeks of treatment, in group 1 no significant variation of lipid parameters has been detected. In group 2 a significant reduction (p < 0.001) of LDL-Cholesterol (−20.5% vs. baseline) and Apolipoprotein B (−14.4% vs. baseline) as it occurred in group 3 (LDL-Cholesterol vs. baseline: −27.0%, Apolipoprotein B vs. baseline: -19.0%) (P < 0.001). LDL-Cholesterol and Apolipoprotein B changes were significantly different comparing group 2 with group 1 (P < 0.05), and group 3 with group 1 (P < 0.05). LDL-Cholesterol change was also significantly higher in group 3 than in group 2 (P < 0.05).

Conclusion

The association of phytosterol and red yeast rice seems to have additive cholesterol lowering effect, reaching a clinically significant LDL-Cholesterol reduction in mildly hypercholesterolemic patients.

Trial registration

ClinicalTrial.gov ID: NCT02603276, Registered 27/08/2015.

Fat Mass Is Positively Associated with Estimated Hip Bone Strength among Chinese Men Aged 50 Years and above with Low Levels of Lean Mass

This study investigated the relationships of fat mass (FM) and lean mass (LM) with estimated hip bone strength in Chinese men aged 50-80 years (median value: 62.0 years). A cross-sectional study including 889 men was conducted in Guangzhou, China. Body composition and hip bone parameters were generated by dual-energy X-ray absorptiometry (DXA). The relationships of the LM index (LMI) and the FM index (FMI) with bone phenotypes were detected by generalised additive models and multiple linear regression. The associations between the FMI and the bone variables in LMI tertiles were further analysed. The FMI possessed a linear relationship with greater estimated hip bone strength after adjustment for the potential confounders (p < 0.05). Linear relationships were also observed for the LMI with most bone phenotypes, except for the cross-sectional area (p < 0.05). The contribution of the LMI (4.0%-12.8%) was greater than that of the FMI (2.0%-5.7%). The associations between the FMI and bone phenotypes became weaker after controlling for LMI. Further analyses showed that estimated bone strength ascended with FMI in the lowest LMI tertile (p < 0.05), but not in the subgroups with a higher LMI. This study suggested that LM played a critical role in bone health in middle-aged and elderly Chinese men, and that the maintenance of adequate FM could help to promote bone acquisition in relatively thin men.

The role of nutraceuticals in the prevention of cardiovascular disease

Cardiovascular disease (CVD) ranks among the most common health-related and economic issues worldwide. Dietary factors are important contributors to cardiovascular risk, either directly, or through their effects on other cardiovascular risk factors including hypertension, dyslipidemia and diabetes mellitus. Nutraceuticals are natural nutritional compounds, which have been shown to be efficacious in preventative medicine or in the treatment of disease. Several foods and dietary supplements have been shown to protect against the development of CVD. The aim of this review is to present an update on the most recent evidence relating to the use of nutraceuticals in the context of the prevention and treatment of CVD.

Greater Intake of Fruit and Vegetables Is Associated with Greater Bone Mineral Density and Lower Osteoporosis Risk in Middle-Aged and Elderly Adults

Objective

A few studies have suggested that the consumption of fruit and vegetables (FV) may benefit bone health, but limited data are available in Asian subjects. We examined the association between FV intake and bone mineral density (BMD) and osteoporosis in Chinese adults.

Methods

This population-based cross-sectional study involved 2083 women and 1006 men aged 40–75 years in Guangzhou, China. Habitual dietary data was collected from a 79-item food frequency questionnaire by face-to-face interviews. The BMD was measured for the whole body (WB), lumbar spine (LS), total hip (TH) and femur neck (FN) with dual-energy X-ray absorptiometry.

Results

After adjustment for potential covariates, we observed dose-dependent associations between total FV intake and BMD and osteoporosis risk. The mean BMD was higher in tertile 3 vs. tertile 1 by 1.33% (TH) and 1.31% (FN) for FV, and 1.10% (WB), 1.57% (TH), and 2.05% (FN) for fruit (all P-trends < 0.05). Significant beneficial associations with BMD at some sites were also found in most fruit categories but not in total vegetables or their subgroups. The odds ratios (95% confidence interval) of osteoporosis (T-score ≤ −2.5) in tertile 3 (vs. 1) were 0.73 (0.58–0.92), 0.37 (0.22–0.60), and 0.71 (0.52–0.97) for FV; 0.82 (0.66–1.03), 0.48 (0.30–0.77) and 0.89 (0.61–1.12) for fruit; and 0.80 (0.64–1.01), 0.57 (0.35–0.92) and 0.76 (0.55–1.05) for vegetables at the LS, TH, and FN, respectively. The favorable association between FV intake and the occurrence of osteoporosis was evident only in subjects with lower BMI (<24.0 kg/m², P-trends < 0.05).

Conclusions

Greater intake of FV was independently associated with a higher BMD and a lower presence of osteoporosis in middle-aged and elderly Chinese subjects with lower BMI. Fruit tended to have more contribution to the favorable association than vegetables.

Joint position statement on "Nutraceuticals for the treatment of hypercholesterolemia" of the Italian Society of Diabetology (SID) and of the Italian Society for the Study of Arteriosclerosis (SISA)

AIM

Evidence showed that LDL-cholesterol lowering is associated with a significant cardiovascular risk reduction. The initial therapeutic approach to hypercholesterolemia includes dietary modifications but the compliance to recommendations is often inadequate. Some dietary components with potential cholesterol-lowering activity are present in small amounts in food. Therefore, in recent years the use of "nutraceuticals" (i.e., nutrients and/or bioactive compounds with potential beneficial effects on human health) has become widespread. Such substances may be added to foods and beverages, or taken as dietary supplements (liquid preparations, tablets, capsules). In the present manuscript, the cholesterol-lowering activity of some nutraceuticals (i.e. fiber, phytosterols, soy, policosanol, red yeast rice and berberine) will be discussed along with: 1) the level of evidence on the cholesterol-lowering efficacy emerging from clinical trial; 2) the possible side effects associated with their use; 3) the categories of patients who could benefit from their use.

DATA SYNTHESIS

Based on the current literature, the cholesterol-lowering effect of fiber, phytosterols and red yeast rice is consistent and supported by a good level of evidence. Over berberine, there is sufficient evidence showing significant cholesterol-lowering effects, although the results come from studies carried out almost exclusively in Asian populations. Data on the effects of soy are conflicting and, therefore, the strength of recommendation is quite low. The evidence on policosanol is inconclusive.

CONCLUSION

Although health benefits may arise from the use of nutraceuticals with cholesterol-lowering activity, their use might be also associated with possible risks and pitfalls, some of which are common to all nutraceuticals whereas others are related to specific nutraceuticals.

Urinary Sodium and Potassium Excretion and Carotid Atherosclerosis in Chinese Men and Women

Limited studies have examined the association between sodium (Na) and potassium (K) levels and the risk of atherosclerosis. This study examined whether higher Na and Na/K levels and low K levels were independent risk factors for atherosclerosis. This community-based cross-sectional study included 3290 subjects (1067 men and 2223 women) 40 to 75 years of age in Guangzhou, China, between 2011 and 2013. Urinary excretion of Na and K were measured from the first morning void, and creatinine-adjusted values were used. The intima-media thickness (IMT) of the carotid common artery and the carotid bifurcation was measured with high-resolution B-mode ultrasonography. Dietary K and Na intake and other covariates were obtained by face-to-face interviews. A significant positive association was seen between urinary Na excretion and carotid atherosclerosis after adjustment for age, sex, and other lifestyle covariates. The odds ratios (OR) and 95% confidence interval (CI) of the highest (vs. lowest) quartile of urinary Na were 1.32 (1.04-1.66) for carotid plaques, 1.48 (1.18-1.87) for increased common carotid artery IMT, and 1.55 (1.23-1.96) for increased carotid bifurcation IMT (all p-trend < 0.01). A similar positive association was observed between urinary Na/K levels and carotid plaque and increased IMT, and between dietary Na intake and increased bifurcation IMT. Regarding potassium data, we only found a significantly lower presence of carotid plaque (OR 0.72, 95% CI 0.57-0.91) for quartile 2 (vs. 1) of urinary K. Our findings suggest that higher levels of urinary excretion Na and Na/K are significantly associated with greater presence of carotid atherosclerosis in Chinese adults.

Greater serum carotenoid concentration associated with higher bone mineral density in Chinese adults

This cross-sectional study has been performed to investigate the relationship between serum carotenoids and bone mineral density (BMD) in Chinese population. We found that women with higher serum β-cryptoxanthin, lycopene, or α-carotene exhibited higher BMD at various bone sites. Similar association was observed between α-carotene and BMD in men.

INTRODUCTION

Carotenoids may positively regulate bone metabolism through their antioxidant properties; however, few studies have examined the relation between serum carotenoids and bone health. We aimed to determine the associations between the serum concentration of several carotenoid subclasses and BMD in a Chinese population.

METHODS

This study was a community-based cross-sectional study. We measured 1898 women and 933 men aged 59.6 years who completed serum β-cryptoxanthin, zeaxanthin + lutein, lycopene, and α-carotene concentration analyses and BMD assessments. Serum individual carotenoids were assessed by the methods of reverse-phase high-performance liquid chromatography. Dual-energy X-ray absorptiometry was applied to determine BMD at whole body, lumbar spine, total hip, femur neck, and trochanter. ANCOVA was used to examine the correlations between categorized individual carotenoids and BMD at measured sites.

RESULTS

After adjusting for potential covariates, a monotonic dose-response positive correlation between circulating levels of β-cryptoxanthin, lycopene, and α-carotene and BMD at various skeletal sites was observed in women. Women in the top (vs. bottom) quartiles of serum β-cryptoxanthin, lycopene, or α-carotene exhibited 1.8-2.3, 1.5-2.0, or 1.3-2.7 % higher BMD at the bone sites with significant results (P-trend <0.05), respectively. For men, the corresponding values were 2.6-4.0 % for α-carotene at the whole body and hip regions (P-trend <0.001-0.023).

CONCLUSION

These results suggest that serum carotenoids have a favorable association with bone health in the study population, especially in women.

Association of dietary and serum vitamin E with bone mineral density in middle-aged and elderly Chinese adults: a cross-sectional study

Previous studies have suggested that vitamin E (VE) may affect bone health, but the findings have been inconclusive. We examined the relationship between VE status (in both diet and serum) and bone mineral density (BMD) among Chinese adults. This community-based study included 3203 adults (2178 women and 1025 men) aged 40-75 years from Guangzhou, People's Republic of China. General and dietary intake information were collected using structured questionnaire interviews. The serum α-tocopherol (TF) level was quantified by reversed-phase HPLC. The BMD of the whole body, the lumbar spine and left hip sites (total, neck, trochanter, intertrochanter and Ward's triangle) were measured using dual-energy X-ray absorptiometry. In women, the dietary intake of VE was significantly and positively associated with BMD at the lumbar spine, total hip, intertrochanter and femur neck sites after adjusting for covariates (P(trend): 0·001-0·017). Women in quartile 3 of VE intake typically had the highest BMD; the covariate-adjusted mean BMD were 2·5, 3·06, 3·41 and 3·54% higher, respectively, in quartile 3 (v. 1) at the four above-mentioned sites. Similar positive associations were observed between cholesterol-adjusted serum α-TF levels and BMD at each of the studied bone sites (P(trend): 0·001-0·022). The covariate-adjusted mean BMD were 1·24-4·83% greater in quartile 4 (v. 1) in women. However, no significant associations were seen between the VE levels (dietary or serum) and the BMD at any site in men. In conclusion, greater consumption and higher serum levels of VE are associated with greater BMD in Chinese women but not in Chinese men.

Associations between the dietary intake of antioxidant nutrients and the risk of hip fracture in elderly Chinese: a case-control study

The role of oxidative stress in skeletal health is unclear. The present study investigated whether a high dietary intake of antioxidant nutrients (vitamins C and E, β-carotene, animal-derived vitamin A, retinol equivalents, Zn and Se) is associated with a reduced risk of hip fracture in elderly Chinese. This 1:1 matched case-control study involved 726 elderly Chinese with hip fracture and 726 control subjects, recruited between June 2009 and May 2013. Face-to-face interviews were conducted to determine habitual dietary intakes of the above-mentioned seven nutrients based on a seventy-nine-item FFQ and information on various covariates, and an antioxidant score was calculated. After adjustment for potential covariates, dose-dependent inverse associations were observed between the dietary intake of vitamin C, vitamin E, β-carotene, and Se and antioxidant score and the risk of hip fracture (P for trend ≤ 0·005). The OR of hip fracture for the highest (v. lowest) quartile of intake were 0·39 (95 % CI 0·28, 0·56) for vitamin C, 0·23 (95 % CI 0·16, 0·33) for vitamin E, 0·51 (95 % CI 0·36, 0·73) for β-carotene, 0·43 (95 % CI 0·26, 0·70) for Se and 0·24 (95 % CI 0·17, 0·36) for the antioxidant score. A moderate-to-high dietary intake of retinol equivalents in quartiles 2-4 (v. 1) was found to be associated with a lower risk of hip fracture (OR range: 0·51-0·63, P< 0·05). No significant association was observed between dietary Zn or animal-derived vitamin A intake and hip fracture risk (P for trend >0·20). In conclusion, a higher dietary intake of vitamins C and E, β-carotene, and Se and a moderate-to-high dietary intake of retinol equivalents are associated with a lower risk of hip fracture in elderly Chinese.

Soy food consumption, cardiometabolic alterations and carotid intima-media thickness in Chinese adults

BACKGROUND AND AIM

The associations between soy food consumption, cardiometabolic disturbances and subclinical atherosclerosis remain controversial due to limited evidence. We examined the associations of habitual soy food consumption with cardiometabolic disturbances and carotid intima-media thickness (CIMT).

METHODS AND RESULTS

We included 2939 subjects (2135 women and 804 men) aged 50-75 years in this community-based cross-sectional study. Dietary data and other covariates were collected using interviewer-administered questionnaires. We determined CIMT in relation to each subject's common carotid artery, internal carotid artery, carotid bifurcation, blood lipids, glucose and urine acid, blood pressure and waist circumference. A logistic regression model was applied to estimate the odd ratios (ORs) and 95% confidence intervals (CIs), and linear regression was used to estimate the regression coefficient and 95% CIs. After adjusting for potential confounders, we found that greater consumption of soy protein (6.1 vs. 0.5 g/d) was inverse associated with the presence of elevated total cholesterol (TC), dyslipidemia, abdominal obesity and hyperuricemia in women, and with abdominal obesity in men, although no significant sex-soy interactions were observed (P: 0.145-0.985). The consumption of soy protein and isoflavones was inversely associated with the number of cardiometabolic disturbances among women, but not men. There were no significant associations of soy protein and isoflavones with CIMT thickening and other cardiometabolic disturbances.

CONCLUSION

Greater soy consumption was associated with a lower presence of elevated TC, dyslipidemia, hyperuricemia and less number of cardiometabolic disturbances components in women.

Nutraceuticals for the treatment of hypercholesterolemia

Hypercholesterolemia is a well-established modifiable cardiovascular risk factor and its treatment is an essential aim in preventing cardiovascular disease. Current guidelines highlight lifestyle intervention as a primary issue in the treatment of the patient with hypercholesterolemia. Therapeutic lifestyle changes are often insufficient to achieve desirable cholesterol levels. This is particularly true for high risk patients; however, also low risk patients, whose cholesterol levels are not necessarily far from recommended targets, have either sub-optimal or even significantly increased lipid levels. Nutraceuticals are borderline devices between nutrients and drugs providing a supplementation of particular nutrients with beneficial effects on health. Several nutraceuticals have been suggested to improve plasma lipid profile. The literature counted over 40 nutraceutical substances with a supposed beneficial effect on lipid metabolism; for some of them a number of clinical trials highlighted a cholesterol lowering effect and a possible positive influence on cardiovascular prognosis. The aim of this article is to review the main evidences supporting or denying the efficacy and safety of some of the most commonly used nutraceuticals with supposed cholesterol lowering activity.

The validity of the body adiposity index in predicting percentage body fat and cardiovascular risk factors among Chinese

OBJECTIVE

Recent research has suggested that body adiposity index (BAI) correlates more closely with percentage body fat (PBF) than body mass index (BMI). Here, we aimed to evaluate BAI's predictive power for PBF and for obesity-associated risk factors in the Chinese population.

SUBJECTS

A total of 1707 women and 680 men aged 51-77 years were analysed in this community-based cross-sectional study.

MEASUREMENTS

Body weight, height, waist circumference (WC) and hip circumference (HC) were measured, and BMI and BAI were calculated. Percentage body fat was determined by dual-energy X-ray absorptiometry (DXA). Blood pressure, fasting lipid profiles, glucose and Carotid ultrasound examination determined intima-media thickness (IMT) at the common carotid arteries (CCA) were also measured.

RESULTS

The Pearson correlation analysis indicated a stronger correlation between BAI and PBF when women and men were pooled together, but this effect disappeared in sex-stratified analysis. Bland-Altman plots suggested that BAI underestimated 5·8% of PBF in women and slightly overestimated 0·28% of PBF in men, but the magnitudes of these biases showed a fat mass-dependent manner. Both the logistic regression and the receiver operating characteristic curve (ROC) analysis indicated that BAI has an inferior predictive power for the presence of hypertension, dyslipidaemia, metabolic syndrome and CCA-intima-media thickening, compared with BMI and WC.

CONCLUSION

We concluded that BAI was neither a better predictor for PBF nor for cardiovascular risks in Chinese population compared with BMI and WC.

Association of simple anthropometric indices and body fat with early atherosclerosis and lipid profiles in Chinese adults

Objective

The discriminatory capability of different adiposity indices for atherosclerosis and lipid abnormalities remains uncertain. This study aimed to identify the best adiposity index for predicting early atherosclerosis and abnormal lipid profiles among anthropometric parameters and body fat measures in middle-aged and elderly Chinese.

Method

A total of 2,063 women and 814 men (57.6±5.2 y) were recruited for this community-based cross-sectional study. Body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were assessed. Body fat mass and its percentage values for the whole body and trunk were measured by bioelectrical impedance analysis (BIA). The intima-media thicknesses (IMTs) of the common carotid arteries (CCA), internal carotid arteries (ICA) and bifurcation (BIF) were determined via B-mode ultrasound. The fasting lipid profiles were assessed.

Results

With per SD increase of adiposity indices, the magnitude of the changes of IMT values and lipid profiles was more substantial for WC, WHR and WHtR in both genders. A multivariate logistic regression analysis indicated that WC, WHR and WHtR were more sensitive in predicting the presence of intima-media thickening at the three segments as well as the lipids disturbances in women and men. In general, BIA-derived measures have no added predictive value for IMT-thickening as opposed to those three traditional abdominal measures.

Conclusion

Our findings suggest that abdominal anthropometric measures including WC, WHR and WHtR are sensitive for discriminating carotid atherosclerosis and lipids abnormalities. WC is the best index because of its simplicity in routine use.

The effect of nutritional supplements on serum high-density lipoprotein cholesterol and apolipoprotein A-I

One of the factors contributing to the increased risk of developing premature atherosclerosis is low plasma concentrations of high-density lipoprotein (HDL) cholesterol. Multiple potential mechanisms account for the cardioprotective effects of HDL and its main protein apolipoprotein A-I (apo A-I). Diet has an important role in modulating HDL cholesterol level. The widespread use of nutritional supplements may also alter the biology of HDL. In this review, we discuss the effect of select nutritional supplements on serum HDL cholesterol and apo A-I levels. Some nutritional supplements, such as phytosterols, soy proteins, and black seed extracts, may increase HDL cholesterol levels, while others such as cholic acid and high doses of commonly used antioxidant vitamins may downregulate HDL cholesterol levels and reduce its cardioprotection. Multiple mechanisms are involved in the regulation of HDL levels, so changes in production and clearance of HDL may have different clinical implications. The clinical relevance of the changes in HDL and apo A-I caused by nutrient supplementation needs to be tested in controlled clinical trials.

Higher erythrocyte n-3 PUFAs are associated with decreased blood pressure in middle-aged and elderly Chinese adults

Previous studies suggested that blood fatty acids (FAs) might affect blood pressure (BP), but the findings have been inconclusive. This study evaluated the cross-sectional and prospective associations of erythrocyte FAs with BP in middle-aged and elderly Chinese individuals. Between 2008 and 2010, 1834 participants (1364 women and 470 men) aged 57 ± 5 y had baseline measurements taken of their erythrocyte FAs and BP. A total of 1477 participants (1103 women and 374 men) had their BP measured again after 3.09 ± 0.32 y (range: 2.91-3.26 y). In the cross-sectional analyses (n = 1834), the erythrocyte saturated FA (SFA) content was positively associated with BP, whereas total cis polyunsaturated FAs (PUFAs), their subtypes cis n-3 (ω-3) PUFAs and cis n-6 (ω-6) PUFAs, and the PUFA-to-SFA ratio were inversely associated with BP (all P-trends < 0.05). The longitudinal results (n = 1477) showed marginally inverse associations between cis n-3 PUFAs and the n-3:n-6 PUFA ratio and BP. For individual cis n-3 PUFAs, higher contents of 20:5n-3, 22:5n-3, and 22:6n-3 were significantly associated with reduced increases in SBP over time (the mean change range between quartile 4 and quartile 1 was -0.917 to -0.749 mm Hg for SBP; all P-trends < 0.01), and 20:5n-3 was inversely associated with DBP change (the mean change between quartile 4 and quartile 1 was -0.631; P-trend < 0.001). Path analyses suggested that the associations between cis n-3 PUFAs and BP might be mediated by decreasing serum triglycerides (TGs) and body mass index (BMI). Our findings revealed that a higher content of cis n-3 PUFAs (mainly very long-chain cis n-3 PUFAs) may benefit BP progress, probably mediated by decreasing serum TGs and BMI.

Comparison of predictive value of cardiometabolic indices for subclinical atherosclerosis in Chinese adults

Objectives

Metabolic disturbances are well-known risk factors for atherosclerosis, but it remains unclear which cardiometabolic components are the predominant determinants. This study aimed to compare and identify the key determinants of carotid atherosclerosis in asymptomatic middle-aged and elderly Chinese.

Methods

A community-based cross-sectional study including 3,162 apparently healthy residents aged 37–75 years was performed from July 2008 to June 2010 in Guangzhou, China. Carotid artery intima-media thickness (IMT) was assessed by B-mode ultrasound, and increased IMT was defined as IMT>1.00 mm. Obesity indices, blood pressure, fasting blood lipids, glucose and uric acid levels were determined. Principal components factor analysis was used to extract common factors underlying 11 metabolic factors.

Results

Four common factors, defined as “adiposity,” “blood lipids,” “triglycerides/uric acid (TG/UA)” (in men) or “triglycerides/uric acid/glucose (TG/UA/Glu)” (in women), and “blood pressure,” were retained for both sexes. After adjustment for potential covariates, the “adiposity” factor showed the strongest positive association with increased IMT in men. Comparing the extreme quartiles, ORs (95% CI) of increased IMT were 4.64 (2.04–10.59) at the CCA and 2.37 (1.54–3.64) at the BIF), followed by “blood pressure”, the corresponding OR (95% CI) was 2.85 (1.37–5.90) at the CCA. Whereas, the four common factors showed comparable and weak relationship with increased IMTs, the ORs for quartile 4 vs. quartile 1 varied from 0.89 to 3.59 in women.

Conclusions

Among the metabolic factors, “adiposity” and “blood pressure” play predominant roles in the presence of carotid atherosclerosis in men, but no key factor is identified in women.

Dietary intake of naturally occurring plant sterols is related to a lower risk of a first myocardial infarction in men but not in women in northern Sweden

Dietary intake of naturally occurring plant sterols is inversely related to serum cholesterol concentrations. Elevated serum cholesterol increases the risk of myocardial infarction (MI), but it is unknown if this can be reduced by dietary intake of naturally occurring plant sterols. Our aim was to investigate if a high intake of naturally occurring plant sterols is related to a lower risk of contracting a first MI. The analysis included 1005 prospective cases (219 women, 786 men) and 3148 matched referents (723 women, 2425 men), aged 29-73 y at baseline, from the population-based Northern Sweden Health and Disease Study. A food frequency questionnaire (FFQ) was completed at baseline. Absolute plant sterol intake was inversely related to the risk of a first MI in men (OR highest vs. lowest quartile = 0.70; 95% CI: 0.53, 0.85; P-trend = 0.006) but not in women. After adjustment for confounders, the estimated risk was somewhat attenuated (OR highest vs. lowest quartile = 0.71; 95% CI: 0.55, 0.92; P-trend = 0.067), suggesting that increasing sterol intake from 150 to 340 mg/d reduces the risk of a first MI by 29%. Energy-adjusted plant sterol intake was not related to the risk of a first MI in either men or women. In conclusion, the findings of this observational study show that a high absolute intake of naturally occurring plant sterols is significantly related to a lower risk of a first MI in men in northern Sweden, whereas no significant relation was seen for energy-adjusted plant sterol intake. In women, no significant associations were found. The results from this study show that intake of plant sterols may be important in prevention of MI.

Comparison of various anthropometric and body fat indices in identifying cardiometabolic disturbances in Chinese men and women

Background

Although many adiposity indices may be used to predict obesity-related health risks, uncertainty remains over which of them performs best.

Objective

This study compared the predictive capability of direct and indirect adiposity measures in identifying people at higher risk of metabolic abnormalities.

Methods

This population-based cross-sectional study recruited 2780 women and 1160 men. Body weight and height, waist circumference (WC), and hip circumference (HC) were measured and body mass index (BMI), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) were calculated. Body fat (and percentage of fat) over the whole body and the trunk were determined by bioelectrical impedance analysis (BIA). Blood pressure, fasting lipid profiles, and glucose and urine acid levels were assessed.

Results

In women, the ROC and the multivariate logistic regression analyses both showed that WHtR consistently had the best performance in identifying hypertension, dyslipidemia, hyperuricemia, diabetes/IFG, and metabolic syndrome (MetS). In men, the ROC analysis showed that WHtR was the best predictor of hypertension, WHtR and WC were equally good predictors of dyslipidemia and MetS, and WHtR was the second-best predictor of hyperuricemia and diabetes/IFG. The multivariate logistic regression also found WHtR to be superior in discriminating between MetS, diabetes/IFG, and dyslipidemia while BMI performed better in predicting hypertension and hyperuricemia in men. The BIA-derived indices were the second-worst predictors for all of the endpoints, and HC was the worst.

Conclusion

WHtR was the best predictor of various metabolic abnormalities. BMI may be used as an alternative measure of obesity for identifying hypertension in both sexes.

Plant sterols and atherosclerosis

PURPOSE OF REVIEW

Plant sterols as ingredients to functional foods are recommended for lowering LDL cholesterol. However, there is an ongoing discussion whether the use of plant sterols is safe.

RECENT FINDINGS

Genetic analyses showed that common variants of the ATP binding cassette transporter G8 (ABCG8) and ABO genes are associated with elevated circulating plant sterols and higher risk for cardiovascular disease. However, these data do not prove a causal role for plant sterols in atherosclerosis because the risk alleles in ABCG8 and ABO are also related to elevated total and LDL cholesterol levels. The ABO locus exhibits still further pleiotropy. Moreover, analyses in the general population indicated that moderately elevated circulating plant sterols are not correlated with present or future vascular disease. In agreement, novel studies using food frequency questionnaires, studies in experimental animals, and dietary intervention studies support that ingestion of plant sterols may be beneficial to cardiovascular health.

SUMMARY

Taken together, current evidence supports the recommendations for the use of plant sterols as LDL cholesterol-lowering agents. Nevertheless, a prospective, randomized, controlled, double-blinded, intervention trial conclusively showing that plant sterol supplementation will prevent hard cardiovascular endpoints is not available to date.