A psyllium-enriched cereal for the treatment of hypercholesterolemia in children: a controlled, double-blind, crossover study

Cholesterol-Lowering Bioactive Foods and Nutraceuticals in Pediatrics: Clinical Evidence of Efficacy and Safety

Long-term exposure to even slightly elevated plasma cholesterol levels significantly increases the risk of developing cardiovascular disease. The latest evidence recommends an improvement in plasma lipid levels, even in children who are not affected by severe hypercholesterolemia. The risk-benefit profile of pharmacological treatments in pediatric patients with moderate dyslipidemia is uncertain, and several cholesterol-lowering nutraceuticals have been recently tested. In this context, the available randomized clinical trials are small, short-term and mainly tested different types of fibers, plant sterols/stanols, standardized extracts of red yeast rice, polyunsaturated fatty acids, soy derivatives, and some probiotics. In children with dyslipidemia, nutraceuticals can improve lipid profile in the context of an adequate, well-balanced diet combined with regular physical activity. Of course, they should not be considered an alternative to conventional lipid-lowering drugs when necessary.

Physiologic Effects of Isolated or Synthetic Dietary Fiber in Children: A Scoping Review

Background

Fiber is an integral part of a healthy diet. Studies have shown that the fiber intake in children is below adequate amounts, leading to adverse health outcomes.

Objectives

This study aimed to perform a scoping review to assess the available evidence for the impact of isolated and synthetic dietary fiber on children's health outcomes.

Methods

A systematic literature search was conducted in Ovid Medline, Ovid Global Health, Embase, and Cochrane Library via Wiley to identify randomized controlled trials (RCTs) in healthy children aged 1-18 y at baseline who consumed added, isolated, or synthetic dietary fiber. The outcomes of interest were categorized based on the Food and Drug Administration's guidance for industry on nondigestible carbohydrates and the Vahouny Fiber Symposium criteria, which included reduced fasting blood, glucose, total and/or LDL cholesterol concentrations, attenuation of postprandial glycemia/insulinemia, increased fecal bulk/laxation, reduced transit time, weight loss/reduction in adiposity, reduced energy intake from food consumption, increased satiety, bone health/enhanced mineral absorption, and blood pressure. We also cataloged additional reported outcomes.

Results

Of 3837 randomized controlled parallel or crossover trials screened at the abstract level, 160 were eligible for full-text review, and 32 included for data extraction. This scoping review presents analysis of data from 32 RCTs in children who were healthy, overweight/obese or had mild hypercholesterolemia. Inulin-type fructans (41%) and psyllium (22%) were the most frequently administered fiber types, with weight/adiposity, markers of lipid metabolism (41%), and bone-related markers (38%) being the most frequently reported health outcomes. Only a few RCTs have investigated the effects of laxation (9%), and none specifically studied the impact of fiber on reducing postprandial glycemia/insulinemia.

Conclusions

This scoping review demonstrates sufficient evidence for conducting systematic reviews and meta-analyses for several outcomes. Evidence gaps remain on the impact of isolated fibers on outcomes such as laxation, colonic transit time, and postprandial glycemia/insulinemia in children.

Evaluation and Management of Lipids and Lipoproteins in Children and Adolescents

Cardiovascular disease (CVD) is the leading cause of mortality in the United States. Universal screening in all children aged 9 to 11 years and 17 to 21 years, and targeted screening in children with high-risk factors, can help in early identification and treatment of dyslipidemia during the youth, significantly reducing clinical CVD risk in adult life. Lifestyle modifications with heart-healthy diet and moderate-vigorous activity are fundamental in the management of pediatric dyslipidemia. Pharmacotherapy has been evolving in children, and statins, bile acid sequestrants, ezetimibe and PCSK9 inhibitors, fibrates, niacin, and omega-3 fish oils are available for use in pediatric population.

Synthesis and characterization of arabinoxylan-bis[2-(methacryloyloxy)ethyl] phosphate crosslinked copolymer network by high energy gamma radiation for use in controlled drug delivery applications

Keeping in view the therapeutic important dietary fiber psyllium, herein this research report its potential has been explored for the formation of sterile hydrogel by high energy radiation induced copolymerization of arabinoxylan-poly bis[2-(methacryloyloxy)ethyl] phosphate (BMEP) for use as drug delivery carrier. The polymeric network structure was characterized by ¹³C NMR, FTIR, TGA/DTG and DSC, XRD and AFM techniques. Release profile of a drug cefuroxime and best fit kinetic model were determined. The blood -polymer interaction, mucosal-polymer adhesion, antioxidant and mechanical properties were also evaluated. The radiation dose influenced the crosslink density and the mesh size of the hydrogel network. Release profile of a drug cefuroxime followed non-Fickian diffusion and best fitted to first order kinetic model. The grafted product was sterile, porous, antioxidant and mucoadhesive in nature and could be explored for controlled and sustained GIT drug delivery applications.

Nutraceuticals in Paediatric Patients with Dyslipidaemia

Coronary heart disease (CHD) is the main cause of death and morbidity in the world. Childhood is a critical period during which atherosclerosis may begin to develop; in the presence of familial hypercholesterolaemia (FH), the lifelong elevation of LDL cholesterol levels greatly accelerates atherosclerosis. Lowering LDL-C levels is associated with a well-documented reduction in cardiovascular disease risk. Current guidelines support the dietary and lifestyle approach as the primary strategy of intervention in children and adolescents with FH. Nutraceuticals (functional foods or dietary supplements of plant or microbial origin) are included in the EU guidelines as lifestyle interventions and may provide an additional contribution in reducing LDL levels when pharmacological therapy is not yet indicated. Meta-analyses of randomised clinical trials have demonstrated that the same nutraceuticals improve lipid profile, including lowering LDL-C, total cholesterol and triglyceride levels. In this narrative review, starting from current scientific evidence, we analyse the benefits and limitations of the nutraceuticals in children and adolescents with dyslipidaemia, and we try to evaluate their use and safety in clinical practice.

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

Background

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

Methods

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

Results

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

Conclusion

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

Effect of psyllium (Plantago ovata) fiber on LDL cholesterol and alternative lipid targets, non-HDL cholesterol and apolipoprotein B: a systematic review and meta-analysis of randomized controlled trials

Background

Studies have identified viscous dietary fiber as potentially attenuating cholesterol, including psyllium, which reduces LDL cholesterol and thus may complement cardiovascular disease (CVD) treatment.

Objectives

The aims of this study were to update evidence on the effect of psyllium on LDL cholesterol and to provide an assessment of its impact on alternate markers: non-HDL cholesterol and apolipoprotein B (apoB).

Design

Medline, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched through 3 October 2017. Independent reviewers extracted relevant data and assessed risk of bias. We included randomized controlled trials with a duration of ≥3 wk that assessed the effect of psyllium on blood lipids in individuals with or without hypercholesterolemia. Data were pooled by using the generic inverse variance method with random-effects models and expressed as mean differences (MDs) with 95% CIs. Heterogeneity was assessed by Cochran's Q statistic and quantified by the I2 statistic. Overall quality of the evidence was assessed by using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

Results

We included 28 trials in our analysis (n = 1924). Supplementation of a median dose of ∼10.2 g psyllium significantly reduced LDL cholesterol (MD = -0.33 mmol/L; 95% CI: -0.38, -0.27 mmol/L; P < 0.00001), non-HDL cholesterol (MD = -0.39 mmol/L; 95% CI: -0.50, -0.27 mmol/L; P < 0.00001), and apoB (MD = -0.05 g/L; 95% CI: -0.08, -0.03 g/L; P < 0.0001). Effect estimates for LDL cholesterol and non-HDL cholesterol were graded as moderate quality on the basis of downgrades for inconsistency and graded as high quality for apoB.

Conclusion

Psyllium fiber effectively improves conventional and alternative lipids markers, potentially delaying the process of atherosclerosis-associated CVD risk in those with or without hypercholesterolemia. This trial is registered at www.clinicaltrials.gov as NCT03346733.

Knowns and unknowns in the care of pediatric familial hypercholesterolemia

Familial hypercholesterolemia (FH) is a common genetic disorder that causes elevated LDL cholesterol levels from birth. Untreated FH accelerates atherosclerosis and predisposes individuals to premature coronary artery disease (CAD) in adulthood. Mendelian randomization studies have demonstrated that LDL cholesterol has both a causal and cumulative effect on the risk of CAD. This supports clinical recommendations that children with FH commence pharmacological treatment from the age of 8 to 10 years, to reduce the burden of hypercholesterolemia. Worldwide, the majority of children with FH remain undiagnosed. Recent evidence suggests that the frequency of FH is at least 1 in 250 and this constitutes a public health issue. We review and identify the knowns and unknowns concerning the detection and management of pediatric FH that impact on the developing model of care for this condition.

Familial hypercholesterolemia in childhood and adolescents: A hidden reality

Familial hypercholesterolemia (FH) is the most common genetic disorder in childhood, but in most cases is not detected. High levels of low-density lipoprotein cholesterol are present since the child's birth and this fact will suppose silent development of early atherosclerosis. In cases of homozygous FH, the coronary disease will appear before 20s and in cases of heterozygous FH will occur in middle age. Despite published data, there is not agreement about how and when perform the screening. Familial history of early cardiovascular disease plus presence of hypercholesterolemia in parents is crucial for detection and diagnosis. Actually, it is topic of discussion that it is necessary to achieve therapeutic goals from an early age to improve prognosis. Lifestyle changes are the first line therapy. Statins are the lipid-lowering drugs of choice but the optimal age to start therapy it is still controversial. In this article, current recommendations of expert consensus guidelines about the management and new line therapies of child and adolescents are reviewed.

An update on the assessment and management of metabolic syndrome, a growing medical emergency in paediatric populations

In the last decades the increasing rate of obesity in children and adolescents worldwide has led to the onset in paediatric age of metabolic syndrome, a disease commonly associated to adulthood. Central obesity, dyslipidaemia, hyperglycaemia, and hypertension are typical features of metabolic syndrome that seem to hesitate often in type 2 diabetes, cardiovascular disease, non-alcoholic fatty liver disease, and many other clinical conditions. Thus preventing and curing metabolic syndrome in paediatric patients is becoming an urgent need for public health. While diagnostic criteria and therapy of metabolic syndrome in adults are very well defined, there is no consensus on the definition of metabolic syndrome in children and adolescents as well as on healing approaches. The aim of this review is to describe the recent advances on the pathogenesis and clinical outcomes of paediatric metabolic syndrome. We then detail the therapeutic strategies (i.e. dietary regimens, physical exercise, nutraceuticals, and medications) employed to manage the disease. Finally, we analyse the safety profile of the drugs used in children and adolescents by performing a retrospective review of paediatric adverse reactions reported in the FDA's Adverse Event Reporting System database.

Familial hypercholesterolaemia in children and adolescents: gaining decades of life by optimizing detection and treatment

Familial hypercholesterolaemia (FH) is a common genetic cause of premature coronary heart disease (CHD). Globally, one baby is born with FH every minute. If diagnosed and treated early in childhood, individuals with FH can have normal life expectancy. This consensus paper aims to improve awareness of the need for early detection and management of FH children. Familial hypercholesterolaemia is diagnosed either on phenotypic criteria, i.e. an elevated low-density lipoprotein cholesterol (LDL-C) level plus a family history of elevated LDL-C, premature coronary artery disease and/or genetic diagnosis, or positive genetic testing. Childhood is the optimal period for discrimination between FH and non-FH using LDL-C screening. An LDL-C ≥5 mmol/L (190 mg/dL), or an LDL-C ≥4 mmol/L (160 mg/dL) with family history of premature CHD and/or high baseline cholesterol in one parent, make the phenotypic diagnosis. If a parent has a genetic defect, the LDL-C cut-off for the child is ≥3.5 mmol/L (130 mg/dL). We recommend cascade screening of families using a combined phenotypic and genotypic strategy. In children, testing is recommended from age 5 years, or earlier if homozygous FH is suspected. A healthy lifestyle and statin treatment (from age 8 to 10 years) are the cornerstones of management of heterozygous FH. Target LDL-C is <3.5 mmol/L (130 mg/dL) if >10 years, or ideally 50% reduction from baseline if 8–10 years, especially with very high LDL-C, elevated lipoprotein(a), a family history of premature CHD or other cardiovascular risk factors, balanced against the long-term risk of treatment side effects. Identifying FH early and optimally lowering LDL-C over the lifespan reduces cumulative LDL-C burden and offers health and socioeconomic benefits. To drive policy change for timely detection and management, we call for further studies in the young. Increased awareness, early identification, and optimal treatment from childhood are critical to adding decades of healthy life for children and adolescents with FH.

Effects of psyllium on LDL-cholesterol concentrations in Brazilian children and adolescents: a randomised, placebo-controlled, parallel clinical trial

The present study investigated the LDL-cholesterol (LDL-C)-lowering effects of psyllium in Brazilian dyslipidaemic children and adolescents. A total of fifty-one individuals (6–19 years) with mild-to-moderate hypercholesterolaemia were evaluated by conducting a randomised, double-blind, placebo-controlled, parallel clinical trial. Over an 8-week trial period, the participants were randomly allocated to one of two groups (control:n25 and psyllium:n26) using a computer-generated random number sequence. Fasting blood samples, dietary records and anthropometric data were collected. Both groups were treated with the National Cholesterol Education Program Step 2 diet for 6 weeks before randomisation. After this run-in period, a daily supplement of 7·0 g psyllium was given to the intervention group, while an equivalent amount of cellulose was given to the control group. Statistically significant changes between the control and intervention groups over time were observed for total cholesterol (7·7 %; − 0·39 mmol/l;P= 0·003) and LDL-C (10·7 %; − 0·36 mmol/l;P= 0·01). None of the participants reported any aversion to the smell, taste, appearance or texture of psyllium. No serious adverse effects were reported during the study. In addition to causing a significant reduction in LDL-C concentrations, psyllium therapy was found to be both safe and acceptable for the treatment of hypercholesterolaemic children and adolescents.

Impact of increasing adiposity in hyperlipidemic children

Despite lifestyle management, children with high-risk hyperlipidemias may become overweight, and this may further adversely impact their lipid profile. Regression analysis was used to determine changes over time in adiposity and their association with lipid profiles and other risk factors for hyperlipidemic children followed in a lipid disorder clinic. 184 patients were included. Median age at presentation was 7 years (2-17 years), and median duration of follow-up was 9 years (5-20 years). Mean initial total cholesterol was 6.9+/-1.6 mmol/L, low-density lipoproteins were 5.2+/-1.7 mmol/L, high-density lipoproteins were 1.2 +/- 0.4 mmol/L, triglycerides were 1.1+/-0.8 mmol/L, and body mass index z score was +0.4+/-1.0. A significant increase in body mass index z score (+0.032/year, P< .001) was observed. There was an associated significant increase in total cholesterol and triglyceride levels and decrease in high-density lipoprotein levels over time. Worsening adiposity is prevalent in hyperlipidemic children and adversely affects their lipid profiles and cardiovascular risk.

Clinical and laboratory assessment of cardiovascular risk in children: Guidelines for screening, evaluation, and treatment

The early lesions of atherosclerosis begin in childhood and are related to antecedent cardiovascular disease (CVD) risk factors. Environmental and genetic factors (eg, diet, obesity, exercise, and certain inherited dyslipidemias) influence progression of such lesions. Identification of youth at risk for atherosclerosis includes an integrated assessment of these predisposing factors. Treatment starts with a diet low in total and saturated fat and cholesterol, use of water-soluble fiber, plant stanols and plant sterols, weight control, and exercise. Drug therapy, for example, with inhibitors of hydroxymethylglutaryl-CoA reductase, bile acid sequestrants, and cholesterol absorption inhibitors, can be considered in those with a positive family history of premature CVD and low-density lipoprotein cholesterol >160 mg/dL after dietary and hygienic measures. Candidates for drug therapy often include those with familial hypercholesterolemia, familial combined hyperlipidemia, the metabolic syndrome, polycystic ovarian syndrome, type 1 diabetes, and the nephrotic syndrome. Such dietary and drug therapy appears safe and efficacious. Early identification and treatment of youth with CVD risk factors and dyslipidemia are likely to retard the atherosclerotic process. Optimal detection and treatment of high-risk children either from the general population or from families with premature CVD will require a comprehensive universal screening and evaluation program.

Elevated atherogenic lipoproteins in childhood: Risk, prevention, and treatment

Elevated low-density lipoprotein cholesterol (LDL-C) level in childhood is an increasing problem, mainly due to a rising prevalence secondary to the childhood obesity epidemic and better recognition and screening. Vascular changes and impaired endothelial function associated with elevated LDL-C are apparent even in early childhood. Secondary adiposity-related cases are at higher risk due to the clustering of risk factors besides overweight, such as the atherogenic lipid triad, change in the atherogenic properties of the LDL-C particle itself, and the presence of insulin resistance. Prevention should focus on maintaining a healthy lifestyle, including a restricted fat and cholesterol diet, encouraging physical activity, and decreasing sedentary pursuits to maintain an appropriate weight in children. For children and adolescents found to have elevated LDL-C, management should focus on the pursuit of a healthy lifestyle mirroring that for prevention for at least 6 months. Additional dietary therapy, such as plant stanol and sterol esters, have also been shown to modestly reduce LDL-C levels. If the adoption of a healthy lifestyle is not sufficient to reduce LDL-C, lipid-lowering drugs should be considered in selected patients. Current drugs of choice are statins and potentially ezetimibe. Long-term treatment with statins has been shown to markedly reduce carotid intima-media thickness in children and adolescents, particularly when started early. Current evidence supports early and efficient treatment for affected children.

Beneficial health properties of psyllium and approaches to improve its functionalities

Psyllium is an excellent dietary source for both soluble and insoluble fibers and has been used in supplemental and food products for its beneficial health effects. The strong water-absorbing and gelling capacities have made it a great challenge to incorporate psyllium in foods at the level needed to claim health benefits on the label. This review is focused on the approaches to improve the functionality, sensory property, and bioactivity of psyllium. Also included is a brief summary of the health beneficial effects of psyllium, along with its possible adverse effects. The information may be useful for those in psyllium research and functional food development.

Screening and treatment for lipid disorders in children and adolescents: systematic evidence review for the US Preventive Services Task Force

OBJECTIVE

This was a systematic evidence review for the US Preventive Services Task Force, intended to synthesize the published evidence regarding the effectiveness of selecting, testing, and managing children and adolescents with dyslipidemia in the course of routine primary care.

METHODS

Literature searches were performed to identify published articles that addressed 10 key questions. The review focused on screening relevant to primary care of children without previously identified dyslipidemias, but included treatment trials of children with dyslipidemia because some drugs have only been tested in that population.

RESULTS

Normal values for lipids for children and adolescents are defined according to population levels (percentiles). Age, gender, and racial differences and temporal trends may alter these statistical cut points. Approximately 40% to 55% of children with elevated total cholesterol and low-density lipoprotein levels will continue to have elevated lipid levels on follow-up. Current screening recommendations based on family history will fail to detect substantial numbers (30%-60%) of children with elevated lipid levels. Drug treatment for dyslipidemia in children has been studied and shown to be effective only for suspected or proven familial monogenic dyslipidemias. Intensive dietary counseling and follow-up can result in improvements in lipid levels, but these results have not been sustained after the cessation of the intervention. The few trials of exercise are of fair-to-poor quality and show little or no improvements in lipid levels for children without monogenic dyslipidemias. Although reported adverse effects were not serious, studies were generally small and not of sufficient duration to determine long-term effects of either short or extended use.

CONCLUSIONS

Several key issues about screening and treatment of dyslipidemia in children and adolescents could not be addressed because of lack of studies, including effectiveness of screening on adult coronary heart disease or lipid outcomes, optimal ages and intervals for screening children, or effects of treatment of childhood lipid levels on adult coronary heart disease outcomes.

Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing

Despite compliance with lifestyle recommendations, some children and adolescents with high-risk hyperlipidemia will require lipid-lowering drug therapy, particularly those with familial hypercholesterolemia. The purpose of this statement is to examine new evidence on the association of lipid abnormalities with early atherosclerosis, discuss challenges with previous guidelines, and highlight results of clinical trials with statin therapy in children and adolescents with familial hypercholesterolemia or severe hypercholesterolemia. Recommendations are provided to guide decision-making with regard to patient selection, initiation, monitoring, and maintenance of drug therapy.

The release dynamics of model drugs from the psyllium and N-hydroxymethylacrylamide based hydrogels

In order to utilize the psyllium husk, a medicinally important natural polysaccharide, for developing the novel hydrogels for the controlled drug delivery device, we have prepared psyllium and N-hydroxymethylacrylamide based polymeric networks by using N,N'-methylenebisacrylamide (N,N'-MBAAm) as crosslinker. The polymeric networks thus formed were characterized with scanning electron micrography (SEM), FTIR and thermogravimetric analysis (TGA) techniques to study various structural aspects of the networks and also with the swelling response of the polymeric networks as a function of time, temperature, pH and [NaCl]. Equilibrium swelling has been observed to depend on both structural aspects of the polymers and environmental factors. Maximum P(s) 748.3 was observed at 13.0 x 10(-3)mol/L of [N,N'-MBAAm] in 0.5M NaOH solution. The release dynamics of model drugs (salicylic acid and tetracycline hydrochloride) from hydrogels has also been discussed, for the evaluation of the release mechanism and diffusion coefficients. The effect of pH on the release pattern of tetracycline has been studied by varying the pH of the release medium. In release medium of pH 7.4 buffer the release pattern of tetracycline drastically changes to the extent that mechanism of drug diffusion shifted from non-Fickian diffusion to Fickian diffusion. It has been observed that diffusion exponent "n" have 0.71, 0.67 and 0.52 values and gel characteristic constant 'k' have 1.552 x 10(-2), 2.291 x 10(-2) and 5.309 x 10(-2) values in distilled water, pH 2.2 buffer and pH 7.4 buffer, respectively, for tetracycline release. In solution of pH 7.4 buffer, the rate of polymer chain relaxation was more as compare to the rate of drug diffusion from these hydrogels and it follows Fick's law of diffusion. The value of the initial diffusion coefficient for the release of tetracycline hydrochloride was higher than the value of late time diffusion coefficient in each release medium indicating that in the start, the diffusion of drug from the polymeric matrix was fast as compare to the latter stages.

Psyllium decreased serum glucose and glycosylated hemoglobin significantly in diabetic outpatients

Psyllium is a bulk-forming laxative and is high in both fiber and mucilage. The beneficial effect of dietary fiber in the management of type II diabetes, has not been totally demonstrated. The purpose of this study was to determine the plasma-lowering effects of 5.1g b.i.d. of psyllium husk fiber, as an adjunct to dietary and drug therapy on lipid and glucose levels, in patients with type II diabetes. Patients were randomly selected from an outpatient clinic of primary care to participate in a double-blind placebo-controlled study in which Plantago ovata Forsk., or placebo was given in combination with their anti-diabetic drugs. Forty-nine subjects were included in the study that were given diet counseling before the study and then followed for 8 weeks in the treatment period. Fasting plasma glucose (FBS) was measured every 2 weeks, and total plasma cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), triglyceride (TG), and insulin levels were measured every 4 weeks. Glycosylated hemoglobin (HbA1c) was also measured at the beginning and ending of the study. The test products (psyllium or placebo) were supplied to subjects in identically labeled foil packets containing a 5.1g dose of product, to consume two doses per day, half an hour before breakfast and dinner. Both products were well tolerated, with no serious adverse events related to treatment was reported in either. Better gastric tolerance to metformin was recorded in the psyllium group. FBS, and HbA1c, showed a significant reduction (p<0.05), whereas HDL-C increased significantly (p<0.05) following psyllium treatment. LDL/HDL ratio was significantly decreased (p<0.05). Our results show that 5.1g b.i.d. of psyllium for persons with type II diabetes is safe, well tolerated, and improves glycemic control.

Adverse events of herbal food supplements for body weight reduction: systematic review

Herbal weight-loss supplements are marketed with claims of effectiveness. Our earlier systematic review identified data from double-blind, randomized controlled trials for a number of herbal supplements. The aim of this systematic review was to assess all clinical evidence of adverse events of herbal food supplements for body weight reduction for which effectiveness data from rigorous clinical trials exist. We assessed Ephedra sinica, Garcinia cambogia, Paullinia cupana, guar gum, Plantago psyllium, Ilex paraguariensis and Pausinystalia yohimbe. Literature searches were conducted on Medline, Embase, Amed and The Cochrane Library. Data were also requested from the spontaneous reporting scheme of the World Health Organization. We hand-searched relevant medical journals and our own files. There were no restrictions regarding the language of publication. The results show that adverse events including hepatic injury and death have been reported with the use of some herbal food supplements. For herbal ephedra and ephedrine-containing food supplements an increased risk of psychiatric, autonomic or gastrointestinal adverse events and heart palpitations has been reported. In conclusion, adverse events are reported for a number of herbal food supplements, which are used for reducing body weight. Although the quality of the data does not justify definitive attribution of causality in most cases, the reported risks are sufficient to shift the risk-benefit balance against the use of most of the reviewed herbal weight-loss supplements. Exceptions are Garcinia cambogia and yerba mate, which merit further investigation.

Antithrombic and anti-atherogenic effects of partially defatted flaxseed meal using a laser-induced thrombosis test in apolipoprotein E and low-density lipoprotein receptor deficient mice

Atherothrombosis can be regarded as a 'life-style related disease' of which diet is one of the important risk factors. The prophylactic effect of partially defatted flaxseed meal (PDFM) on atherothrombosis has not yet been studied. The aim of this study was to assess the effect of PDFM and a lignan from flaxseed, secoisolariciresinol diglucoside (SDG), on thrombosis and atherogenesis. An earlier developed test, the quantitative assessment of laser-induced thrombus formation in the carotid artery of apolipoprotein E and low-density lipoprotein receptor deficient mice was used in this study. Thrombotic and atherosclerotic status was assessed in mice kept on a high-fat diet for 8 weeks (40% in energy). The diet contained 0.05% cholesterol alone (control) or the same cholesterol with added PDFM (5% w/w; 8.3 g/kg body weight per day) or SDG (0.06% w/w; 100 mg/kg body weight per day). PDFM showed antithrombotic (P < 0.01) and anti-atherogenic effect (P < 0.01). SDG did not affect either atherogenesis or thrombosis. This study suggests that dietary intake of PDFM can be beneficial in reducing the risk of high-fat-induced atherothrombosis.

Psyllium fibre and the metabolic control of obese children and adolescents

In children and adolescents from developed countries, obesity prevalence has strongly increased in the last decades and insulin resistance and impaired glucose tolerance are frequently observed. Some dietary components such as low glycemic index foods and dietary fibre could be used in order to improve glucose homeostasis in these children. Psyllium or ispaghula husk (the husk of the seeds of Plantago ovata) is a mixture of neutral and acid polysaccharides containing galacturonic acid with a ratio of soluble/insoluble fibre of 70/30. Some foods could potentially be enriched with psyllium, like breads, breakfast cereals, pasta and snack foods. The aim of this review was to assess the usefulness of psyllium in the management of obese children and adolescents with abnormalities of carbohydrate and lipid metabolism. After psyllium supplementation, the percentage change in postprandial glucose in type 2 diabetes patients, ranged from -12.2 to -20.2%. In hypercholesterolemic children, the effect of psyllium in LDL-cholesterol serum concentrations ranged from 2.78 to -22.8%; the effect in HDL-cholesterol from -4.16 to 3.05%; and the effect on triglycerides from 8.49 to -19.54%. The reviewed evidence seems to show that psyllium improves glucose homeostasis and the lipid and lipoprotein profile; however, more well controlled trials and further studies are needed to clarify it's effects and the mechanisms involved.

Management of hypercholesterolaemia in postmenopausal women

Increased rates of coronary heart disease (CHD) occur with advancing age in both sexes, although CHD rates in women lag behind those of men by about 10 years. There is a sharp increase in CHD rate among women after approximately 50 years of age. The reasons for this are not completely understood and are undoubtedly multifactorial. Cross-sectional data from large-scale population studies suggest that around the time of the menopause, low-density lipoprotein (LDL)-cholesterol levels increase by approximately 15 to 25%. Because this increase is larger than that observed in men over the same age span and closely approximates that observed in women after oophorectomy, it is likely that reduced circulating estrogen levels associated with menopause play a role in the adverse changes in both blood lipid levels and CHD incidence. There is clear evidence that treating hypercholesterolemia reduces cardiovascular risk in women, as well as in men. In the US National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines, diet and other lifestyle changes are recommended as first-line therapy. If the treatment goals cannot be achieved through non-pharmacological measures, drug therapy should be added. Of the available lipid-lowering agents, HMG CoA reductase inhibitors (statins) are the clear choice to decrease LDL-cholesterol levels. However the favourable effects of statins on high-density lipoprotein (HDL)-cholesterol and triglyceride levels are more modest, and statins are not known to decrease lipoprotein (a) [Lp(a)] levels. Estrogen or hormone replacement therapy (ERT/HRT) and nicotinic acid improve LDL- and HDL-cholesterol levels and also decrease Lp(a) levels. However, ERT/HRT is no longer recommended as first-line therapy for decreasing CHD risk. Nicotinic acid is particularly useful for decreasing triglyceride levels (as are fibrates) and raising HDL-cholesterol levels. Bile-acid sequestrants reduce LDL-cholesterol and slightly increase HDL-cholesterol levels. Both bile acid sequestrants and ERT/HRT tend to raise triglyceride levels, therefore they should be used cautiously in women with hypertriglyceridaemia. Treatment should be individualised for each patient. It is important to evaluate the primary form of dyslipidaemia, other CHD risk factors, comorbidities, and the extent of lipid improvement needed in order to reach treatment goals. The effects of each type of therapy and potential adverse effects should also be considered.

Cholesterol lowering with high-viscosity hydroxypropylmethylcellulose

Hydroxypropylmethylcellulose (HPMC) is a food gum having several structural and functional properties in common with hypocholesterolemic soluble fibers. The safety and cholestero-lowering efficacy of HPMC, incorporated into a National Cholesterol Education Program Step I diet, was compared with placebo in patients with mild to moderate hypercholesterolemia. After an 8-week National Cholesterol Education Program Step I dietary lead-in phase, 160 patients with low-density lipoprotein (LDL) cholesterol between 130 and 200 mg/dl and triglycerides <300 mg/dl were randomized to placebo, 2.5, 5.0, or 7.5 g/day of HPMC for a 6-week treatment period. Patients returned to the clinic every 2 weeks for lipid measurements and safety assessments. HPMC significantly lowered total, LDL, and non-high-density lipoprotein (HDL) cholesterol. LDL cholesterol concentrations (average of weeks 4 and 6) decreased by 3.0% (4.9 mg/dl), 5.9% (10.3 mg/dl), 12.1% (20.4 mg/dl), and 11.7% (20.3 mg/dl) from baseline levels in the placebo and 2.5, 5.0, and 7.5 g/day HPMC treatment groups, respectively. Statistically significant (p<0.05) reductions in LDL cholesterol were observed in the 5.0 and 7.5 g/day HPMC groups compared with placebo and 2.5 g/day HPMC treatment groups. Total and non-HDL cholesterol responses paralleled those of LDL cholesterol. There were no significant differences between the treatment groups in HDL cholesterol or triglyceride responses, incidence of adverse experiences, or gastrointestinal-related adverse experiences. These results suggest that HPMC is a well-tolerated and effective adjunct to diet for lowering LDL cholesterol in patients with mild to moderate hypercholesterolemia.

Health aspects of partially defatted flaxseed, including effects on serum lipids, oxidative measures, and ex vivo androgen and progestin activity: a controlled crossover trial

BACKGROUND

Currently there is considerable interest in the potential health benefits of oil seeds, such as soy and flaxseed, especially in relation to cardiovascular disease and cancer.

OBJECTIVE

We therefore evaluated health aspects of partially defatted flaxseed in relation to serum lipids, indicators of oxidative stress, and ex vivo sex hormone activities.

DESIGN

Twenty-nine hyperlipidemic subjects (22 men and 7 postmenopausal women) completed two 3-wk treatment periods in a randomized, crossover trial. Subjects were given muffins that contributed approximately 20 g fiber/d from either flaxseed (approximately 50 g partially defatted flaxseed/d) or wheat bran (control) while they consumed self-selected National Cholesterol Education Program Step II diets. Both muffins had similar macronutrient profiles. Treatment phases were separated by > or = 2 wk.

RESULTS

Partially defatted flaxseed reduced total cholesterol (4.6+/-1.2%; P = 0.001), LDL cholesterol (7.6+/-1.8%; P < 0.001), apolipoprotein B (5.4+/-1.4%; P = 0.001), and apolipoprotein A-I (5.8+/-1.9%; P = 0.005), but had no effect on serum lipoprotein ratios at week 3 compared with the control. There were no significant effects on serum HDL cholesterol, serum protein carbonyl content, or ex vivo androgen or progestin activity after either treatment. Unexpectedly, serum protein thiol groups were significantly lower (10.8+/-3.6%; P = 0.007) at week 3 after the flaxseed treatment than after the control, suggesting increased oxidation.

CONCLUSIONS

These data indicate that partially defatted flaxseed is effective in lowering LDL cholesterol. No effects on lipoprotein ratios, ex vivo serum androgen or progestin activity, or protein carbonyl content were observed. The significance of increased oxidation of protein thiol groups with flaxseed consumption requires further investigation.

Cookies enriched with psyllium or oat bran lower plasma LDL cholesterol in normal and hypercholesterolemic men from Northern Mexico

BACKGROUND

Psyllium and oat bran have been shown to lower plasma LDL cholesterol levels in different populations. Hypercholesterolemia is prevalent in the Northern part of Mexico and might be associated to dietary habits and sedentary lifestyle.

METHODS

Sedentary normal (cholesterol<200 mg/dL) (n=36) and hypercholesterolemic (cholesterol>220 mg/dL) (n=30) men from the Northern part of Mexico aged 20 to 45 years of age participated in an 8-week study to determine the effects of dietary soluble fiber, either psyllium or oat bran, in lowering plasma LDL cholesterol in this population. Fiber was administered by feeding the subjects an amount of cookies (100 g) equivalent to 1.3 or 2.6 g/day of soluble fiber from psyllium or oat bran, respectively. Subjects were randomly allocated to three groups: a control group consuming cookies with wheat bran, a known source of fiber with no cholesterol lowering effects, psyllium, or oat bran.

RESULTS

Food frequency questionnaires indicated that subjects from the three groups had similar intakes of foods classified as hypercholesterolemic (p>0.05). Plasma LDL cholesterol concentrations were reduced by an average of 22.6 and 26% in the psyllium and oat bran groups (p<0.001) while a non-significant reduction of 8.4% was observed in the hypercholesterolemic individuals from the control group. No effects on plasma HDL or triglycerides levels were observed among the three dietary treatments except for hypercholesterolemic individuals supplemented with oat bran where a 28% reduction in plasma triglycerides was observed after 8 weeks (p<0.01).

CONCLUSION

These results indicate that psyllium and oat bran are efficacious in lowering plasma LDL cholesterol in both normal and hypercholesterolemic individuals from this population.

A low-viscosity soluble-fiber fruit juice supplement fails to lower cholesterol in hypercholesterolemic men and women

This study was designed to determine whether a soluble dietary fiber supplement containing gum arabic and pectin in apple juice would lower serum lipids in 110 hypercholesterolemic men and women. Subjects were stabilized on an American Heart Association Phase I Diet for 8 wk. Those with elevated low density lipoprotein cholesterol levels, despite dietary modification, continued to follow the diet and were randomly assigned to receive 720 mL/d of apple juice containing 0 (control), 5, 9 or 15 g of gum arabic and pectin (4:1 ratio) for 12 wk, followed by a 6-wk apple juice-only washout phase. Serum lipid profiles, body weight and 3-day diet records were collected at 3-wk intervals. No significant differences among groups were observed in serum lipid responses during treatment or washout. During the treatment phase, mean serum total cholesterol and triglyceride concentrations increased by 3.5 and 28.5%, respectively (all groups combined, P < 0.0001). The high density lipoprotein cholesterol level did not change significantly from baseline in any group. During washout, mean total cholesterol concentration rose by an additional 2.4% (P < 0.05) compared with the value at the end of the treatment period, suggesting that the apple juice used to deliver the fiber supplement may have contributed to the adverse changes observed in the serum lipid profile. These findings do not support the hypothesized hypocholesterolemic effect of the gum arabic/pectin (4:1) mixture studied, but do underline the importance of selecting appropriate vehicles for delivery of dietary fiber mixtures.

Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis

We conducted a meta-analysis to determine the effect of consumption of psyllium-enriched cereal products on blood total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C) levels and to estimate the magnitude of the effect among 404 adults with mild to moderate hypercholesterolemia (TC of 5.17-7.8 mmol/L) who consumed a low fat diet. Studies of psyllium cereals were identified by a computerized search of MEDLINE and Current Contents and by contacting United States-based food companies involved in psyllium research. Published and unpublished studies were reviewed by one author and considered eligible for inclusion in the meta-analysis if they were conducted in humans, were randomized, controlled experiments, and included a control group that ate cereal providing </=3 g soluble fiber/d. Eight published and four unpublished studies, conducted in four countries, met the criteria. Analysis of a linear model was performed, controlling for sex and age. Female subjects were divided into two groups to provide a rough estimate of the effect of menopausal status (premenopausal = <50 y, postmenopausal = >/=50 y) on blood lipids. The meta-analysis showed that subjects who consumed a psyllium cereal had lower TC and LDL-C concentrations [differences of 0.31 mmol/L (5%) and 0.35 mmol/L (9%), respectively] than subjects who ate a control cereal; HDL-C concentrations were unaffected in subjects eating psyllium cereal. There was no effect of sex, age or menopausal status on blood lipids. Results indicate that consuming a psyllium-enriched cereal as part of a low fat diet improves the blood lipid profile of hypercholesterolemic adults over that which can be achieved with a low fat diet alone.

A rational approach to treating hypercholesterolaemia in children. Weighing the risks and benefits

Because atherosclerosis is a continuous process throughout life, expert panels have suggested guidelines to reduce the risk of cardiovascular disease, starting from childhood. The guidelines focus on population-based measures and on treating hypercholesterolaemia in individual children. Low-fat diets in children have been widely debated. There is little evidence that growth is stunted or that nutritional deficiencies arise if the energy that is lost by limiting fat intake is substituted with other nutrients. Dietary fibre, plant sterols and fish oils have been used to modify lipid levels in children; however, the efficacy of these dietary adjuncts is limited. Bile acid-binding resins are the only approved drugs to lower cholesterol levels in children and appear to be well tolerated. However, compliance with resins is low because of unpalatability, so low dosages are preferred and vitamin supplementation is prudent. Data on HMG CoA reductase inhibitors and fibrates are insufficient to recommend these drugs at present. Drug treatment should be restricted to children who are at exceptionally high risk of disease, usually those with genetic dyslipidaemias.