The effect of intake of plant sterols and olive oil in cardiovascular disease risk factors in patients with metabolic syndrome

The metabolic syndrome, which currently affects about ¼ of the population, is defined as a constellation of interrelated risk factors, which appears to directly promote the development of cardiovascular disease and increased risk for type II diabetes. Several epidemiological studies have shown that the prevalence of coronary artery disease is low in several countries that consume high levels of monounsaturated fat. On the other hand, the intake of phytosterols from human volunteers under a wide range of study conditions, has contributed to lowering total and LDL cholesterol by 0.5-26% and 2-33%, respectively.Primary purpose of the pilot study was to investigate whether monounsaturated fatty acids and phytosterols have a synergistic effect on plasma lipid levels. Twenty patients with metabolic syndrome, male sex, age 35-65 years, volunteered. The study was conducted in a parallel, single-blind model that included two 4-week intervention periods. During each dietary intervention, patients followed their usual diet. In the control group A was given a 30 g package olive oil/day and a control yogurt 1/day. In the intervention group B was given a packet of 30 grams green olive oil/day and 2 yogurt drinks which contained 4 grams phytosterols/day. The weight remained stable in the 2 groups during the four weeks. No statistically significant differences in clinical characteristics of participants, were observed, only a trend in total cholesterol, LDL- and HDL-cholesterol and triglycerides. The pilot study gave an important first impression of the action of phytosterols, but not their synergy with olive oil.For this reason the design of our study turned to the addition of phytosterols, only, as also the patients with metabolic syndrome exhibit simultaneously high LDL-cholesterol levels. The main study involved 108 patients with metabolic syndrome, with 2 intervention and control groups. In the intervention group were asked to consume 2 yogurt mini drinks/day, that gave them 4 grams phytosterols/day and in the control group were given a yogurt drink without phytosterols. The duration of the intervention was 2 months and the patients followed the usual Westernized diet. In the intervention group we observed significantly decreased total cholesterol (-15.9%), LDL-cholesterol (-20.3%) and triglycerides (-19.1%), although they haven’t changed their eating habits. Furthermore, in the intervention group there was a reduction in levels of small and dense LDL particles and in the apolipoprotein B (ApoB) levels. There were no changes in HDL-cholesterol, apoA1, blood glucose, C-reactive protein, fibrinogen levels and in blood pressure. Of course, because several studies have observed reduced levels of lipophilic antioxidants such as carotenoids and tocopherols, after eating foods containing plant sterols and stanols, the secondary objective of this study was to examine the effect of plant sterols in the total antioxidant plasma capacity. According to the results, there were no differences in the intakes of macro-and micro-nutrients between the 2 groups and their activities. The total antioxidant capacity of plasma after 2 months of intervention did not change significantly between and within intervention and control groups, or by using measurement of FRAP (Ferric Reducing Antioxidant Power of plasma), or the ORAC assay (Oxygen Radical Absorbance Capacity).To our knowledge, this is the first clinical study that observed reduced levels of small dense LDL particles, after the supplementation with phytosterols in patients with metabolic syndrome in free living conditions. Although there is still no readily available evidence of the ability of phytosterols to reduce the incidence of cardiovascular disease, well documented and established hypolipidemic action, is the basis for recommendations to include in their strategies for lowering LDL-cholesterol.Το μεταβολικό σύνδρομο, το οποίο σήμερα επηρεάζει περίπου το ¼ του πληθυσμού, ορίζεται ως ένα σύνολο από αλληλοσχετιζόμενους παράγοντες κινδύνου, οι οποίοι φαίνεται να προωθούν άμεσα τόσο την ανάπτυξη καρδιαγγειακής νόσου όσο και τον αυξημένο κίνδυνο για την εμφάνιση σακχαρώδη διαβήτη τύπου ΙΙ. Αρκετές επιδημιολογικές μελέτες έχουν δείξει οτι ο επιπολασμός της στεφανιαίας νόσου είναι χαμηλός σε διάφορες χώρες, στις οποίες καταναλώνονται υψηλά επίπεδα μονοακόρεστου λίπους. Από την άλλη πλευρά, η πρόσληψη φυτοστερολών από εθελοντές κάτω από μια ευρεία κλίμακα συνθηκών μελέτης, έχει συμβάλλει στη μείωση των επιπέδων ολικής και LDL χοληστερόλης κατά 0,5-26% και 2-33% αντίστοιχα. Σκοπός της πρωταρχικής πιλοτικής μελέτης ήταν να διερευνηθεί εάν τα μονοακόρεστα λιπαρά οξέα και οι φυτοστερόλες έχουν συνεργιστική δράση στα επίπεδα των λιπιδίων πλάσματος. Συμμετείχαν εθελοντικά είκοσι ασθενείς με μεταβολικό σύνδρομο, άνδρες, ηλικίας 35-65 ετών. Η μελέτη που πραγματοποιήθηκε ήταν παράλληλου, μονού-τυφλού μοντέλου, που περιελάμβανε δύο 4-εβδομάδων περιόδους παρέμβασης. Κατά τη διάρκεια κάθε διαιτητικής παρέμβασης οι ασθενείς ακολουθούσαν τη συνήθη δίαιτά τους. Στην ομάδα ελέγχου Α δόθηκε πακέτο 30 γρ. ελαιόλαδο κλασικό/ ημέρα και 1 γιαούρτι ελέγχου/ ημέρα. Στην ομάδα παρέμβασης Β δόθηκε ένα πακέτο 30 γρ. αγουρέλαιου/ ημέρα και 2 ροφήματα γιαουρτιού τα οποία περιείχαν 4 γρ. φυτοστερολών/ ημέρα. Το βάρος διατηρήθηκε σταθερό και στις 2 ομάδες κατά τη διάρκεια των τεσσάρων εβδομάδων. Δεν παρατηρήθηκαν στατιστικά σημαντικές διαφορές στα κλινικά χαρακτηριστικά των συμμετεχόντων, παρά μόνο μία τάση στην ολική χοληστερόλη, στην LDL- και HDL-χοληστερόλη και στα τριγλυκερίδια. Η πιλοτική μελέτη έδωσε μία σημαντική πρώτη εικόνα για τη δράση των φυτοστερολών, όχι όμως και για τη συνέργειά τους με το ελαιόλαδο.Για το λόγο αυτό ο σχεδιασμός της μελέτης μας στράφηκε προς την προσθήκη φυτοστερολών, δεδομένου, επίσης, ότι οι ασθενείς με μεταβολικό σύνδρομο παρουσιάζουν ταυτόχρονα και υψηλά επίπεδα LDL-χοληστερόλης. Στην κύρια μελέτη συμμετείχαν 108 ασθενείς με μεταβολικό σύνδρομο με 2 ομάδες παρέμβασης και ελέγχου. Στην ομάδα παρέμβασης ζητήθηκε να καταναλώνουν 2 ροφήματα γιαουρτιού την ημέρα, που τους παρείχαν 4 γρ. φυτοστερολών/ ημέρα και στην ομάδα ελέγχου δόθηκε ένα ρόφημα γιαουρτιού χωρίς φυτοστερόλες. Η διάρκεια της παρέμβασης ήταν 2 μήνες και οι ασθενείς ακολούθησαν τη συνήθη δυτικού τύπου δίαιτά τους. Στην ομάδα παρέμβασης παρατηρήθηκε σημαντική μείωση της ολικής χοληστερόλης (15.9%), στην LDL- χοληστερόλη (20.3%) και στα επίπεδα τριγλυκεριδίων (19.1%) αν και δεν άλλαξαν τις διατροφικές τους συνήθειες. Επιπλέον, στην ομάδα παρέμβασης παρατηρήθηκε μείωση των επιπέδων των μικρών πυκνών LDL σωματιδίων και της απολιποπρωτεΐνης Β (ApoB). Δεν παρατηρήθηκαν αλλαγές στην HDL-χοληστερόλη, στην apoA1, στην γλυκόζη αίματος, στην C-αντιδρώσα πρωτεϊνη, στα επίπεδα ινωδογόνου και στην αρτηριακή πίεση. Βέβαια, επειδή αρκετές μελέτες έχουν παρατηρήσει μείωση των επιπέδων λιπόφιλων αντιοξειδωτικών, όπως τα καροτενοειδή και τις τοκοφερόλες, μετά από κατανάλωση τροφών που περιέχουν φυτικές στερόλες και στανόλες, ο δευτερεύων στόχος της παρούσας μελέτης ήταν να εξετάσει την επίδραση των φυτοστερολών, στη συνολική αντιοξειδωτική ικανότητα του πλάσματος. Σύμφωνα με τα αποτελέσματα, δεν παρατηρήθηκαν διαφορές στις προσλήψεις μακρο- και μίκρο- θρεπτικών συστατικών μεταξύ των 2 ομάδων και των παρεμβάσεών τους. Η συνολική αντιοξειδωτική ικανότητα πλάσματος, μετά από 2 μήνες παρέμβασης δεν άλλαξε σημαντικά μεταξύ και εντός των ομάδων παρέμβασης και ελέγχου, είτε με τη χρήση μέτρησης της FRAP (Ferric Reducing Antioxidant Power of plasma), είτε με την ORAC(Oxygen Radical Absorbance Capacity).Από όσο γνωρίζουμε, αυτή είναι η πρώτη κλινική μελέτη η οποία παρατήρησε μείωση επιπέδων των μικρών και πυκνών LDL σωματιδίων μετά την προσθήκη φυτοστερολών σε ασθενείς με μεταβολικό σύνδρομο. Αν και δεν υπάρχουν ακόμη άμεσα διαθέσιμες αποδείξεις για την ικανότητα των φυτοστερολών να μειώνουν την επίπτωση της καρδιαγγειακής νόσου, η καλά τεκμηριωμένη και εδραιωμένη υπολιπιδαιμική τους δράση αποτελεί τη βάση για τις συστάσεις, ώστε να τις περιλαμβάνουν στις στρατηγικές για τη μείωση των επιπέδων της LDL-χοληστερόλη

Small dense low-density lipoprotein particles: priority as a treatment target in type 2 diabetes?

During the past two decades, the importance of the quality of low-density lipoprotein (LDL) particles – in addition to its quantity – has become of increasing interest. The risk of cardiovascular events was recognized to be closely linked to a predominance of small, dense LDL particles. In addition, in patients with Type 2 diabetes mellitus, the disease itself and its severity (in particular the degree of insulin resistance) is associated with this subclass of LDL particles. Lipid lowering as well as antihyperglycemic drugs have been evaluated in many studies concerning their effect on LDL particle size. It has increasingly been recognized that a reduction of LDL quantity is not necessarily associated with a beneficial effect on LDL quality. Advances in the understanding of alterations in LDL quality may therefore influence the choice of the therapeutic regimen in patients with diabetes in the future

Micronutrient dietary intakes and their food sources in adults: the Hellenic National Nutrition and Health Survey (HNNHS)

Background: The present study aimed to assess micronutrient intake among Greek adults and to identify the main food sources that contribute to it. Methods: Food consumption data from 2389 participants in the Hellenic National Nutrition and Health Survey (HNNHS), collected with 24-h recalls, was used to calculate micronutrient intakes. Usual nutrient intake was estimated according to the National Cancer Institute method. Nutrient adequacy was estimated using the estimated average requirement (EAR) cut-point method, when available, or adequate intake otherwise. The probability approach was used to determine iron intake adequacy in females of reproductive age. Food group contribution for each nutrient assessed was derived to identify their main food sources. Results: Almost all individuals had vitamin D intake below EAR, whereas vitamins A, E, K and C, as well as potassium intake, were also insufficient in a considerable percentage of the population (>70% in most age groups). Calcium intake was substantially below the EAR for females aged >50 years and males >70 years; the same for magnesium in males >70 years. Furthermore, 50% of females, including those of reproductive age, had intake of folate below EAR. More than 50% of the population (to 79%) exceeded the upper tolerable limit for sodium (2300 mg day−1). Food contribution analysis revealed that most vitamins were derived from low-quality foods (i.e. fast-food). Conclusions: A significant proportion of adults residing in Greece have low nutrient intake and poor food selections. These results provide guidance to public health policy makers for developing strategies to improve the dietary quality in Greece. © 2021 The British Dietetic Association Ltd

Dietary patterns and lifestyle characteristics in adults: results from the Hellenic National Nutrition and Health Survey (HNNHS)

Objectives: The objective of this study was to identify and describe different dietary patterns in a nationally representative sample of Greek adults and to assess potential associations with lifestyle characteristics. Study design: This was a cross-sectional study. Methods: Dietary patterns were derived by principal component analysis using individual dietary data (24-h recall) of 3552 participants of the Hellenic National Nutrition and Health Survey (HNNHS). Analysis of variance and chi-squared test were used to determine the lifestyle characteristics of the participants following each pattern. Results: Three dietary patterns were identified explaining 16.5% of variance; a traditional pattern, loading positively on olive oil, non-starchy vegetables, and cheese; a Western pattern, loading positively on refined grains, processed meats, and animal fats; and a prudent pattern, loading positively on fruits, whole grains, and yoghurt and negatively on fast food. A fourth, snack-type pattern, loading positively on sweets, salty snacks, and nuts, was identified in women. Primary crude results revealed an association between dietary patterns and socio-economic status. In multivariate analysis, highest adherence to the prudent pattern was associated with higher protein and unsaturated fat intake and lower energy and saturated fat intake (all P ≤ 0.05); the Western and traditional patterns were associated with higher energy and total and saturated fat intake. The traditional pattern was additionally associated with higher monounsaturated fatty acids intake, whereas the Western pattern, with higher alcohol intake (all P ≤ 0.001). Conclusions: These findings are valuable for understanding the dietary behaviors of adults in Greece and enabling more focused public health policies for the promotion of healthier food behaviors in the future. © 2019 The Royal Society for Public Healt

Dietary patterns and cardiovascular disease in Greek adults: The Hellenic National Nutrition and Health Survey (HNNHS)

Background and aims: Empirically-derived dietary patterns have been shown to have both positive and adverse associations with cardiovascular disease (CVD). Yet, such associations remain unclear in the Greek population. The aim of this study was to investigate the association between empirically-derived dietary patterns and the presence of CVD and CVD-related medical conditions in a nationally representative sample of Greek adults. Methods and results: Adult participants (≥20 years old) of the Hellenic National Nutrition and Health Survey (HNNHS) were included (N = 3552; 41.2% men; 43.7 years, SD: 18.1). Dietary patterns were derived by principal component analysis using 24-h recall data. The presence of dyslipidemia (elevated cholesterol and/or triglycerides), hypertension, coronary heart disease, and total CVD, was defined according to the International Clinical Diagnosis (ICD)-10 codes. Odds ratios of CVD outcomes were estimated across dietary patterns using multivariable logistic regression analysis. Three dietary patterns -Traditional (proxy Mediterranean), Western, and Prudent-were identified explaining 16.5% of the total variance in consumption. Logistic regression analysis, adjusted for age, sex, total caloric intake, sociodemographic characteristics, and other CVD risk factors, showed an inverse association between the Traditional dietary pattern and CVD presence (OR: 0.53; 95% CI: 0.30–0.95), and a positive association between the Western pattern and dyslipidemia (1.52; 1.02–2.26). No association was found between the Prudent pattern and CVD outcomes. Conclusion: The variability of food intake combinations in the Greek population seem to be associated with the presence of CVD and CVD related conditions. Such findings are imperative for national monitoring and informed priority setting. © 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II Universit

The recalibrated HellenicSCORE based on newly derived risk factors from the Hellenic National Nutrition and Health Survey (HNNHS); the HellenicSCORE II

Background: Because of the increased burden of cardiovascular disease (CVD), country specific risk prediction models to forecast future CVD events and mortality are recommended, for primary prevention. The aim of this study was to recalibrate the HellenicSCORE, to accurately estimate the 10-year risk CVD mortality of Greek adults. Methods: Data from the Hellenic National Nutrition and Health Survey (HNNHS) were used (N = 1012; 37.9% males). Information on age, smoking, systolic blood pressure (SBP), and total blood cholesterol from adults >40 years of age were derived following validated health survey protocols. Individual scores were calculated using these data and beta-coefficients derived from ESC SCORE. Results: Both updated HellenicSCORE II charts had lower risk estimates compared to the older version and were closer to the ESC SCORE charts, particularly at the extremes. No significant age difference by sex was observed (mean 59.5 (SD 13.1) years in total) in the population. Women had a significant higher mean total cholesterol compared to men [212.9 (39.5) vs 204.6 (41.2) mg/dl, respectively; p = 0.0343], but smoking prevalence and mean SBP was significantly higher in men [p for all, <0.001]. The mean population HellenicSCORE II score level was between 5.6% (0.2) and 7.9% (3.2) depending on the chart used, with no significant sex differences. Conclusion: Although the HellenicSCORE II charts were lower, the mean population score was moderately high. This is of great importance because according to ESC guidelines, lifestyle intervention, and drug treatment should be based on an individuals’ total cardiovascular risk. © 2020 Hellenic Society of Cardiolog