Management of Hypercholesterolemia Through Dietary ß-glucans–Insights From a Zebrafish Model

Consumption of lipid-rich foods can increase the blood cholesterol content. β-glucans have hypocholesterolemic effect. However, subtle changes in their molecular branching can influence bioactivity. Therefore, a comparative investigation of the cholesterol-lowering potential of two β-glucans with different branching patterns and a cholesterol-lowering drug, namely simvastatin was undertaken employing the zebrafish (Danio rerio) model of diet-induced hypercholesterolemia. Fish were allocated to 5 dietary treatments; a control group, a high cholesterol group, two β-glucan groups, and a simvastatin group. We investigated plasma total cholesterol, LDL and HDL cholesterol levels, histological changes in the tissues, and explored intestinal transcriptomic changes induced by the experimental diets. Dietary cholesterol likely caused the suppression of endogenous cholesterol biosynthesis, induced dysfunction of endoplasmic reticulum and mitochondria, and altered the histomorphology of the intestine. The two β-glucans and simvastatin significantly abated the rise in plasma cholesterol levels and restored the expression of specific genes to alleviate the endoplasmic reticulum-related effects induced by the dietary cholesterol. Furthermore, the distinct patterns of transcriptomic changes in the intestine elicited by the oat and microalga β-glucans impacted processes such as fatty acid metabolism, protein catabolic processes, and nuclear division. Oat and microalgal β-glucans also altered the pattern of lipid deposition in the liver. Our study provides insights into the effectiveness of different β-glucans to alleviate dysfunctions in lipid metabolism caused by dietary cholesterol.

Exopolysaccharides Produced by Lactic Acid Bacteria: From Biosynthesis to Health-Promoting Properties

The production of exopolysaccharides (EPS) by lactic acid bacteria (LAB) has attracted particular interest in the food industry. EPS can be considered as natural biothickeners as they are produced in situ by LAB and improve the rheological properties of fermented foods. Moreover, much research has been conducted on the beneficial effects of EPS produced by LAB on modulating the gut microbiome and promoting health. The EPS, which varies widely in composition and structure, may have diverse health effects, such as glycemic control, calcium and magnesium absorption, cholesterol-lowering, anticarcinogenic, immunomodulatory, and antioxidant effects. In this article, the latest advances on structure, biosynthesis, and physicochemical properties of LAB-derived EPS are described in detail. This is followed by a summary of up-to-date methods used to detect, characterize and elucidate the structure of EPS produced by LAB. In addition, current strategies on the use of LAB-produced EPS in food products have been discussed, focusing on beneficial applications in dairy products, gluten-free bakery products, and low-fat meat products, as they positively influence the consistency, stability, and quality of the final product. Highlighting is also placed on reports of health-promoting effects, with particular emphasis on prebiotic, immunomodulatory, antioxidant, cholesterol-lowering, anti-biofilm, antimicrobial, anticancer, and drug-delivery activities.

Development of Cholesterol-Lowering and Detox Formulations Using Bentonite and Herbal Ingredients

Detoxification enzymes involved in human metabolism works to minimize the potential xenobiotic-induced damage constantly. Studies have revealed that toxin accumulation plays an important role in the etiology of cardiovascular disease. This study has been designed to provide evidence of medicinal use of bentonite, turmeric (Curcuma longa L.), grape (Vitis vinifera L.) seed, flaxseed (Linum usitatissimum L.), and psyllium (Plantago ovata L.) as detoxification and cholesterol-lowering agents using a hypercholesterolemic model in mice. The potential hypocholesterolemic effects and detoxification ability of these ingredients were evaluated at the same time: Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, glucose, aspartate aminotransferase, alanine aminotransferase, malondialdehyde, plasma total antioxidant activity, nitric acid, leptin levels and glutathione, glutathione peroxidase, lipid peroxidation, superoxide dismutase and catalase values were measured. It was determined that GBTF group (grape seed extract, bentonite, turmeric, and flaxseed), GBTP group (grape seed extract, bentonite, turmeric, and psyllium), and GBT group (grape seed extract, bentonite, and turmeric) of the tested materials decreased the serum total cholesterol concentration by 64.8, 57.5, and 48.9%, respectively, in mice fed a high cholesterol diet. In addition, it was determined that some detoxification parameters such as superoxide dismutase, catalase, glutathione, and glutathione peroxidase were statistically significantly reversed in GBTF, GBTP, and GBT groups. Flaxseed, psyllium, and bentonite clay did not show significant effects in reducing total cholesterol; however, GBTF, GBTP, and GBT groups interventions had a significant effect in reducing total cholesterol levels. Moreover, it was observed that adding flaxseed or psyllium to the GBT group increased the cholesterol-lowering effect. Therefore, it can be thought that this significant effect is due to the synergistic effect of the raw materials. When the results obtained were evaluated, it was seen that the cholesterol-lowering and detoxification effects of the combinations were higher than from the effect of natural material used alone. As a result, combinations of some of these ingredients have a positive effect on reducing the risk of cardiovascular disease.

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651]

Background Printed educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications. Methods A pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message (“outsert”) or a longer narrative article (“insert”). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians. Results We randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings. Conclusions PEMs have no effect on physician’s adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap. Trial registration ISRCTN72772651. Retrospectively registered 21 July 2005.

463 New era in hypercholesterolemia treatment, inclisiran: early and sustained LDL-C reduction with a twice per year administration

Inclisiran is a synthetic small-interfering RNA (siRNA) that works with the RNA interference (RNAi) mechanism. SiRNA binds its target mRNA, leading to silencing the protein synthesis by the related mRNA degradation. Inclisiran is designed to bind solely PCSK9 mRNA, decreasing PCSK9 expression, thus leading to lower LDL-C level. Several chemical modifications were added to obtain a stable compound delivering a rapid effect and generally well tolerated [Khvorova A. Oligonucleotide therapeutics—a new class of cholesterol-lowering drugs. N Engl J Med 2017; 376 4–7]. High cholesterol levels and prolonged time of exposure enhance risk of new or recurrent CV events, therefore also timing became crucial for atherosclerotic cardiovascular disease (ASCVD) patients [Ference BA, Graham I, Tokgozoglu L, et al. Impact of lipids on cardiovascular health: JACC health promotion series. J Am Coll Cardiol 2018; 72 1141–1156]. Therefore, an early and effective LDL-C lowering effect is positively correlated with CV risk reduction, together with the life-long LDL-C reduction that will impact definitively on the global CV risk [Cohen JC, Boerwinkle E, Mosley TH Jr, et al. Sequence variations in PCSK9, low LDL, and protection against coronary heart disease. N Engl J Med 2006; 354 1264–1272]. The siRNA conjugation with a triantennary GalNAC leads to a specific targeted hepatic delivery therefore, the 284 mg inclisiran dose is undetectable in blood stream after 24–48 h from the subcutaneous injection [Wright RS, Collins MG, StoekenbroekRM, et al. Effects of renal impairment on the pharmacokinetics, efficacy, and safety of inclisiran: an analysis of the ORION-7 and ORION-1 studies. Mayo Clin Proc 2020; 95 77–89]. The LDL-C lowering effect starts early upon the hepatic cell entry (24–48 h) and the LDL-C level drop is already significant at 14 days post injection, and by Day 30 the mean reduction is about 50%, as shown in the ORION-1 phase II trial [Ray KK, Landmesser U, Leiter LA, et al. Inclisiran in patients at high cardiovascular risk with elevated LDL cholesterol. N Engl J Med 2017; 376 1430–1440]. Other chemical modifications at the siRNA back-bone level, protect inclisiran from degradation by liver nucleases, which may occur upon the hepatic cell uptake. In the cytoplasm, RNAi mechanism occurs by the siRNA—RISC protein complex coupling. Physiologically, this bond last for long and the inclisiran back-bone modifications further enhance the complex stability [Khvorova A. Oligonucleotide therapeutics—a new class of cholesterol-lowering drugs. N Engl J Med 2017; 376 4–7]. Moreover, one siRNA-RISC complex has an effect on multiple PCSK9 mRNA units, allowing inclisiran administration twice per year (after initial dose at baseline and 3 months), granting an early, sustained and effective LDL-C level reduction that lasts for 6 months. A pooled analysis of the 3 phase III trials (ORION-9/10/11) shows a time averaged (18 months) LDL-C reduction of 50.5% on top of therapy with statins±ezetimibe [Wright RS, Ray KK, Raal FJ, et al. Pooled patient-level analysis of inclisiran trials in patients with familial hypercholesterolemia or atherosclerosis. J Am Coll Cardiol 2021; 77 1182–1193]. Inclisiran provides effective evidence-based results on lowering LDL-C levels in different high CV risk populations (HeFH/established ASCVD/ASCVD-risk equivalent), which is demonstrated to be crucial for the reduction of patients’ CV risk. Furthermore, the twice per year administrations may positively improve adherence, thereby simplifying patient management and control during follow-up. Based on these findings, we are stepping into a new era of biologic therapeutics, where inclisiran represents the new, effective and safe therapeutic candidate for lowering LDL-C levels.

Associations Between Intake of Fermented Dairy Products and Blood Lipid Concentrations Are Affected by Fat Content and Dairy Matrix – The Tromsø Study: Tromsø7

Introduction: Dairy fat is rich in saturated fatty acids known to increase serum low-density lipoprotein cholesterol (LDL-C) concentration, an important risk factor for cardiovascular disease (CVD). However, intake of fermented dairy products has been associated with reduced CVD risk in observational studies. How intakes of different fermented dairy products are associated with blood lipid concentrations may provide a possible explanation for the suggested reduced CVD risk.Aim: To examine the associations between different types of fermented dairy products, with various fat contents and dairy matrix structures, and blood lipid concentrations in a general population.Methods: In 11,377 women and men aged between 40-99 participating in the population-based Tromsø Study 2015-2016, multivariable linear regression was used to examine associations between total intake of fermented dairy products, intake of yogurt (including regular-fat, low-fat, and semi-solid yogurt), cheese (including regular-fat and low-fat), and liquid fermented dairy, and serum concentrations of total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides. Dietary data was collected using a validated food frequency questionnaire. Analyses were adjusted for potential confounding factors, and cheese intake analyses were stratified by self-reported use of cholesterol-lowering drugs.Results: Cheese intake was positively associated with HDL-C [regression coefficient 0.02 mmol/l (95 % CI 0.01, 0.03)], and inversely associated with LDL-C [regression coefficient−0.03 mmol/l (95 % CI−0.04,−0.01)] and triglycerides [relative change −1.34 % (95 % CI: −2.29 %, −0.37 %)] per 25 g/day among non-users of cholesterol-lowering drugs, while no associations were found among users. Total intake of fermented dairy was inversely associated with triglycerides [relative change −1.11 % (95 % CI: −1.96 %, −0.24 %)] per 250 g/day, while no associations were found for yogurt intake. Intake of low-fat cheese was more favorably associated with blood lipids compared to regular-fat cheese, and semi-solid yogurt was inversely associated with LDL-C and triglycerides, while intake of liquid fermented dairy was not associated with any of the blood lipids.Conclusion: This study highlights the importance of investigating specific types of dairy products separately, based on fat content and dairy matrix, when examining effects on blood lipid concentrations, and stratifying statistical models by use of cholesterol-lowering drugs when relevant.