Functional Foods
 …functional foods, including whole foods and
fortified, enriched, or enhanced foods, have a
potentially beneficial effect on health when consumed
as part of a varied diet on a regular basis, at effective
levels.
JADA 1999;99:1278-128
 adjunctive to dietary goals
 soluble fiber
 plant stanols/sterols
 soy protein
 -3 fatty acids
Soluble Fiber
 Viscous fibers from legumes, pectin, B-glucan from
barley, oats, guar gum and psyllium husk
 Inverse association between soluble fiber, IHD
mortality and MI (Jacobs DR; Am J Clin Nutr. 1998;68:248-257)
 Diet + soluble fiber
 Cholesterol  11%
 LDL-C  14% (in hypercholesterolemic
subjects)
 LDL-C  10% (in normolipemic subjects)
(Glore SR; J Am Diet Assoc. 1994;94:425-436)
(Ripsin CM et al. JAMA 1992;267(24):3317-3325)
Soluble fiber in foods
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Oat bran, 1/2 cup
Oatmeal, 1/2 cup
Cheerios, 1 1/2 cups
Apple, 1 medium
Banana, 1 medium
Broccoli, 1 cup
Baked potato w/skin, 1 small
Kidney beans, 1/2 cup
Split peas, 1/2 cup
Psyllium seed husks, 3 tsp.
3.6 g
2.0 g
1.5 g
1.0 g
0.7 g
2.8 g
1.0 g
2.8 g
1.1 g
10 g
(Psyllium data: Bell LP; JAMA 1989;261:3419-3423)
Soluble fiber: mechanisms
 Depletion of bile acid pool
 Inhibition of hepatic cholesterol synthesis by
short-chain FA produced by colonic
fermentation
 Increased LDL-c catabolism
  Sat. fat and cholesterol intake due to lower
fat choices higher in soluble fiber
(Glore SR; J Am Diet Assoc. 1994;94:425-436)
Summary Notes:
Soluble Fiber
 Appears to lower LDL by up to 8%
 Adjunctive to other dietary and
pharmacological measures to lower LDL
 Recommended as therapeutic option by
ATP III: 10 to 25 g/day
Plant sterols/stanols
 Structurally resemble cholesterol; not synthesized by
humans
  Serum cholesterol: inhibit absorption of dietary and
biliary cholesterol from small intestine by up to 65%
 Present in normal diet but not in therapeutic amounts
 Sitostanol (saturated sterol) most effective
 Commercial spreads: Benecol® (stanol) and Take
Control® (sterol)
(Hallikanienen M and Uustupa MI; Am J Clin Nutr. 1999;69:403-10)
(Lichtenstein AH et al; Circulation 2001;103(8):1177-9)
(Neils HAW et al. Atherosclerosis 2001;156:329-37)
Plant sterol-containing margarines
Plant stanol margarines
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Randomized, double-blind
153 subjects w/mild hypercholesterolemia
3g x 6 mo., then 2g sitostanol per day vs. control
Dose:response relationship
12-mo. maximum:
 total cholesterol 10.2%; LDL-c 14.1%
 no change in HDL or triglycerides
 Values returned to baseline after 2 months
(Miettinen TA et al. N Engl J Med. 1995;333:1308-12)
Plant stanol margarines
Hallikainen MA et al. J Nutr. 2000:130:767-776.
Dose
Choles
P Value
LDL-C
P Value
0.8
2.8%
0.384
1.7%
0.892
1.6
6.8
<0.001
5.6
<0.05
2.4
10.3
<0.001
9.7
<0.001
3.2
11.3
<0.001
10.4
<0.001
(g/d)
(%)
(%)
Investigators conclude: Differences between 1.6 vs. 2.4 and 3.2 g/d not
significant (P=0.054-0.516).ApoB  sig. At 0.8 g (P<0.001).  dose not
clinically important.
Randomised controlled trial of use by
hypercholesterolemic patients of a vegetable oil
sterol-enriched fat spread
Neil HAW et al. Atherosclerosis 2001;156:329-37
 Double-blind, placebo-controlled crossover (2 periods x 8
weeks)
 30 w with familial hypercholesterolemia on statins; 32
w/type IIa not on drug therapy
 Usual diet + 2.5 g plant sterols
 Significant reduction in total and LDL-cholesterol (10%)
after 8 weeks
 No difference in response between patients on statins and
those not on drug therapy
 Well tolerated and effective as an additive therapy in
statin-treated familial hypercholesterolemia
Plant stanol-containing
margarines: 2-3 TB per day
1 TBSP
Stanol ester (stanol)
Benecol® Light Benecol® Regular
1.7 g (1 g)
1.7 g (1 g)
Calories
45
80
Total fat
5g
9g
Sat. fat/Trans fat
0.5 g/0 g
1 g/<1 g
PUFA/MUFA
2 g/2.5 g
3 g/4 g
Cholesterol
0 mg
0 mg
Omega-3 Fatty Acids
 No recommendations by ATP III
 Populations with diets high in fish and other marine
animals suggest high intakes of n-3 FA: low
incidence of CVD
 Intake of EPA (C20:5n-3) and DHA (C22:6n-3)
from seafood: may platelet aggregation and
coronary spasm; accumulation of myocardial
cytosolic calcium during ischemia
(Siscovick DS et al. JAMA 1995;274(17):1363-67)
(Drevon, CA Nutr Reviews 1992;50(4):38-45)
Omega-3 Fatty Acids
 Lyon Diet-Heart Study: risk cardiac death by 76%
w/diet enriched in -linolenic acid (18:3) (in some
nuts, canola oil, flaxseed)
(de Lorgeril M, et al. Circulation 1999;99:779-85)
 DART: 2033 men, post-MI add 300g fish per
week (3 sv.)  29%  in 2-year all-cause mortality;
33%  in IHD mortality
(Burr ML et al. Eur Heart J. 1992;13(2):166-70)
 Others find no association between fish intake and
incidence of CHD
(Ascherio A, et al. N Engl J Med. 1995;332:977-82; Gualler
E, et al. J Am Coll Cardiol. 1995;25:287-94)
Omega-3 Fatty Acids
 Case-control study: Are dietary long-chain n-3 PUFAs linked to
 vulnerability to life-threatening arrhythmias?
 Assessed intake of 35 types of seafood; estimated dietary EPA
and DHA; and dietary fat
 Assayed RBC membrane FA levels (biomarker)
 Intake of 2.9 g n-3 PUFA (2 fish meals per month): 30%
reduction in risk of primary cardiac arrest (OR 0.7; CI 0.6-0.9)
 Intake of 5.5 g n-3 PUFA (1 fish meals per week): 50%
reduction in risk of primary cardiac arrest (OR 0.5; CI 0.4-0.8)
 May decrease vulnerability to ventricular fibrillation
(Siscovick DS et al. JAMA 1995;274(17):1363-67)
Omega-3 Fatty Acids
% Change
Subjects
LDL-C
TG
n
Normal
+0.03
25.2
596(14)
n-3/day
(g)
5.3
Type IIa
+2.3
20.3
37(3)
4.9
Type IIb
+5.6
38.0
194(12)
6.4
Type IV/V
+29.9
52.2
101(12)
8.0
(# studies)
5 – 8 g equivalent to 1-2 fish meals/day or 12 to 20 1-g fish oil capsules.
Adapted from Harris WS. Am J Clin Nutr. 1997;65(suppl):1645S-1654S
Summary notes:
Omega-3 Fatty Acids
 Not addressed by ATP III, possibly due to
equivocal data
 Most powerful effect is on triglycerides
 Food sources (fish and seafood, certain oils)
most often preferable to supplements
 May reduce risk for coronary events or
mortality
Soy protein
 High quality protein, low in saturated FA
 Good source of phytoestrogens: isoflavones
believed to be most active
 Substitute soy for animal protein: cholesterol 
 ? Protective mechanisms:
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Inhibition of LDL oxidation
Maintenance of blood vessel flexibility
Prevention of thrombosis
(Platt R. Prev Cardiol. 2000;3:83-87)
Soy protein: LDL by 5%
Goal: 25 to 30 g soy protein/day
Product
Soy burger
Tofu, 1/3 block
Tempeh, ½ cup
Soy milk, 1 cup
Soybeans, ½ cup
Protein (g)
18
15
15.7
6.6
14.3
Sample Eating Pattern
(1500 kcals, 23% fat, 50% CHO,
11 g soluble fiber, 3.4 g stanol esters)
 Breakfast
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1 cup oatmeal
1 TB Benecol® Light
1 oz. raisins
4 oz. Skim milk
1 small orange
 Lunch
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2 oz. Harvest Burger® (soy)
2 tsp. Mayonnaise
2 leafs romaine lettuce
2 slices wholegrain bread
1 small apple
3 oz. Baby carrots
4 oz. Skim milk
 Dinner
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3 oz. Filet of sole
½ cup brown rice
1 cup broccoli
2 tsp. canola oil
1 cup strawberries
 Snack
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1 slice wholegrain bread
1 TB Benecol® Light
8 oz. Skim milk
Summary
 Cardioprotective changes through individualized eating
patterns can be achieved
 Most successful with team/behavioral approach
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Nutrition professional facilitates translation of clinical
recommendations into changes in eating behavior by fully
assessing risk factors and tailoring to fit medical and lifestyle
needs; other behavioral/activity professionals have key roles
 Nutritional + other lifestyle changes alone may be sufficient
to normalize lipids; approaches are adjunctive to
pharmacological rx, when needed, and may allow lower dose
 More investigation needed on ratio of CHO:fat and type(s) of
fat to optimize risk reduction
 Selected functional foods are promising