Phytosterol consumption and markers of subclinical atherosclerosis: Cross-sectional results from ELSA-Brasil
Graphical abstract
Introduction
Chronic non-communicable diseases (NCD) are a global epidemic health problem and the World Health Organization (WHO) estimates that ischemic heart disease and stroke accounted for a combined 17.8 million deaths in 2017. Thirty-two percent of all global deaths predominantly occurred in low- and middle-income countries [1].
Brazil is a middle-income country that has experienced over the past decades a rapid demographic and nutrition transition, leading to increased prevalence of obesity and diabetes mellitus (DM), increased cardiovascular disease morbidity and mortality, with a direct impact on the country's productivity and health care system [2].
Early identification of risk behaviors, and clinical manifestations or risk equivalents are crucial steps in cardiovascular disease prevention. The Brazilian Cardiovascular Prevention Guideline of the Brazilian Society of Cardiology 2019 updated the strategies to address classical risk factors control and suggested new concepts for cardiovascular health prevention, including diet intervention [3]. Reduction in saturated fat and cholesterol intake combined with increase in fiber consumption are universally recommended and associated with a moderate decrease in the levels of low-density lipoprotein-cholesterol (LDL-c). Further reduction can be achieved when combined with ingestion of adequate amounts of phytosterols, soy protein, and nuts [4].
Phytosterols (PS) are plant sterols with chemical structure and biologic functions similar to those of mammalian cholesterol, but they are much less absorbed (2–5%) [5] than cholesterol (56%) [6]. These bioactive compounds cannot be synthetized by our body [5], and can be found in all plant foods, with the highest concentrations in vegetable oils. They act on the intestinal lumen reducing the incorporation of cholesterol to micelles, thus competing with cholesterol absorption, and the recirculating endogenous biliary cholesterol, an important step in cholesterol elimination. In addition, PS absorption occurs in trace amounts, not increasing phytosterol plasma levels, and plasma levels of plant sterols are around 500- to 1000-fold lower than those of cholesterol [5,7].
The usual daily consumption of PS in Western diets varies between 150 and 350 mg/day, and this amount may be two times higher for vegetarians or by the inclusion of plant sterol-enriched food products in the daily diet [8].
There is evidence of a dose–response reduction in LDL-c with increasing consumption of plant sterols [9,10], and a number of trials suggested that consumption of plant sterols supplements and enriched foods would lower cardiovascular risk based on its lipid-lowering effect. In fact, epidemiological and case–control studies are controversial in demonstrating a protective or harmful effect of usual phytosterol consumption and cardiovascular events [[11], [12], [13], [14]].
Intervention studies in humans evaluating the effect of dietary PS on measures of arterial structure or function using flow-mediated dilatation (FMD), and arterial stiffness have not shown any consistent effect on vascular or endothelial function during short and mid-term PS intake. However, there are no available studies addressing PS intake in the usual diet and markers of subclinical atherosclerosis [[15], [16], [17]].
The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) [18,19] provides a unique opportunity to analyze the phytosterols consumption in a regular diet and if there is an association of usual phytosterols consumption and markers of subclinical atherosclerosis, such as coronary artery calcium (CAC) score, carotid intima-media thickness (cIMT), and carotid-femoral pulse wave velocity (cf-PWV).
Section snippets
Study design
This is a cross-sectional study addressing the usual consumption of plant sterols in the diet and markers of subclinical atherosclerosis from the baseline of the Brazilian Longitudinal Study of Adult Health (ELSA- Brasil).
ELSA-Brasil is a cohort, multicentric and interdisciplinary study that aims to assess the complex relation of risk factors, including diet, with cardiovascular disease and type 2 diabetes mellitus (DM). The ELSA-Brasil cohort consists of 15,105 participants aged 35–74 years,
Characteristics of study population
In this study we evaluated 2560 participants, aged [median (IQR)] 48 (43–54) years, 58.4% females. Mean (SD) intake of total plant sterols was 256.08 (197.87) mg/day. Males presented higher PS consumption [mean (SD)] [323.49 (228.43) mg/day] than females [208.13 (156.38) mg/day]. Mean (SD) CAC was 22.78 (110.54) AU, cf-PWV 9.07 (1.6) m/s and cIMT 0.58 (0.12) mm. Mean values for cIMT, CAC and cf-PWV, as well as the blood pressure measured during cf-PWV were higher in males than females
Discussion
The ELSA-Brasil is an observational study that enabled the investigation of the nutrition pattern in an apparently healthy population. This cross-sectional analysis provided information on diet composition, including PS intake, markers of subclinical atherosclerosis, such as carotid intima-media thickness, carotid-femoral pulse wave velocity, and coronary artery calcium. Our main finding was that the consumption of plant sterols in a regular diet was associated with lower concentrations of
Conclusions
Our findings in this large and apparently healthy cross-sectional sample from ELSA-Brasil, have shown that usual PS consumption was associated with lower total- and LDL-cholesterol, but not with markers of subclinical atherosclerosis.
Funding
The ELSA-Brasil baseline study was supported by the Brazilian Ministry of Health (Science and Technology Department) and the Brazilian Ministry of Science, Technology and Innovation (FINEP, Financiadora de Estudos e Projetos) (grants of baseline 01 06 0010.00 RS, 01 06 0212.00 BA, 01 06 0300.00 ES, 01 06 0278.00 MG, 01 06 0115.00 SP, 01 06 0071.00 RJ) and CNPq (the National Council for Scientific and Technological Development).
TSP received a research grant from the Coordination for the
Authors' contributions
TSP participated in the study design, performed data collection, participated in data analyses and interpretation, and drafted and approved the final version of the manuscript.
HARF, FAHF, MIHF, CMM, and WTF participated in data interpretation and revised and approved the final version of the manuscript.
PAF, IMB, ACG, and MCI participated in the study conception and design, participated in data analysis and interpretation, and drafted, revised, and approved the final version of the manuscript.
Declaration of competing interest
The author(s) declare(s) that there is no conflict of interest. The authors alone are responsible for the content and writing of the paper.
Acknowledgements
We would like to thank all ELSA-Brasil participants for their valuable contribution to this study.
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