Impact of Supplementation with Flax Seed Powder and Flax Seed Oil on the Lipid levels of Patients with Dyslipidemia

Cardiovascular diseases (CVD) are the most prevalent cause of death and disability in both developed as well as developing countries (Chaturvedi and Bhargava, 2007). According to National Commission on Macroeconomics and Health (NCMH), there would be around 62 million patients with CAD by 2015 in India and out of these 23 million would be patients younger than 40 years of age (Indrayan, 2006). Cardiovascular diseases are due to atherosclerosis of large and medium sized arteries and dyslipidemia has been found to be one of the most important contributing factors of CAD (NCEP-ATP III, 2001). Dyslipidemia describes a number of abnormality in lipoprotein homeostasis including elevated total cholesterol (≥200 mg/dl), low density lipoprotein cholesterol (≥130 mg/dl), triglycerides (≥150 mg/dl) and low levels of high density lipoprotein (≤40 mg/dl) (NCEP,ATP III, 2002). Alternative to hypolipidemic drugs, plant seeds and dietary supplements provided a potential source of lowering blood lipid profile and are widely used in several traditional systems of medicines. Flax seed (linseed, Linum Usitatissimum), an edible oil seed/grain and one of the oldest crops, was acknowledged as a functional food (Thompson, 2003). Flax seed has gained much attention because of its unique nutrient components and potential effect on the prevention of CVD (Bloedon, 2004).

Cardiovascular diseases (CVD) are the most prevalent cause of death and disability in both developed as well as developing countries (Chaturvedi and Bhargava, 2007). According to National Commission on Macroeconomics and Health (NCMH), there would be around 62 million patients with CAD by 2015 in India and out of these 23 million would be patients younger than 40 years of age (Indrayan, 2006). Cardiovascular diseases are due to atherosclerosis of large and medium sized arteries and dyslipidemia has been found to be one of the most important contributing factors of CAD (NCEP-ATP III, 2001). Dyslipidemia describes a number of abnormality in lipoprotein homeostasis including elevated total cholesterol (≥200 mg/dl), low density lipoprotein cholesterol (≥130 mg/dl), triglycerides (≥150 mg/dl) and low levels of high density lipoprotein (≤40 mg/dl) (NCEP,ATP III, 2002). Alternative to hypolipidemic drugs, plant seeds and dietary supplements provided a potential source of lowering blood lipid profile and are widely used in several traditional systems of medicines. Flax seed (linseed, Linum Usitatissimum), an edible oil seed/grain and one of the oldest crops, was acknowledged as a functional food (Thompson, 2003). Flax seed has gained much attention because of its unique nutrient components and potential effect on the prevention of CVD (Bloedon, 2004).
The current chapter presents relevant review in the area of present research under the following headings: The results indicated that the prevalence of hypercholesterolemia and hypertension was 47% and 30%, respectively.
One another study was conducted by Margaret One another study was conducted in Mumbai, India among 1805 urban dwellers of age group ≥ 40 years. It was summarized from the study that the prevalence of dyslipidemia was higher in males than in females. Among participants having total cholesterol concentration ≥ 200 mg/dl, 38.7% were males and 23.3% were females. High density lipoprotein cholesterol was abnormally low in 64.2% males and 33.8% in females. The prevalence of hypercholesterolemia and hyper-triglyceridemia was more prominent in 31-40 years of age group than in ≤ 30 years of age group (Sawant et al., 2008).
Coronary heart disease is increasing in Indian subjects residing in urban areas and lipid abnormalities are important risk factors.  The principal component of flaxseed is its oil, 39 g 100 g, Cotyledons are the tissue in which oil is mainly stored, containing the highly sought-after α-linolenic, linoleic and oleic acids. One of the most interesting characteristics of flaxseed is its content of complex phenols, such as lignans. The most remarkable one is secoisolariciresinol (SDG), although isolariciresinol, pinoresinol, mataresinol and other derivatives of ferulic acid are also present (Daun et al., 2003). Phenolics are plant derived compounds that have many different functions. Flax contains at least three types of phenolics as phenolic acids (about 1%), flavonoids (35-70 mg/ 100 g) and lignans. Lignans are found in amounts ranging from 1 mg/g of seed to nearly 26 mg/g of seed (Muir, 2006). Flax contains 75 to 100 times more lignans than any other plant source. Flaxseed contains several water and fat-soluble vitamins as ascorbic acid thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, folic acid and biotin. Flax seed also contain minerals as calcium, copper, iron, magnesium, manganese, phosphorus, potassium, sodium and zinc.

Role of flax seed in management of dyslipidemia
A recent study by Bolla and Santhi, 2016 showed significant reduction in the lipid profile by the supplementation of flax seeds for a period of 3 months. A total of 75 dyslipidemic subjects of age group 40-60 years were recruited and advised to take 25 gram of flax seeds in their diets for 3 months. It was found from the data that the mean reduction in body weight was 2.89% and the mean difference in the values of total cholesterol, triglycerides, HDL, LDL and VLDL were 16.19%, 13.9%, 4.94%, 19.93% and 17.94%, respectively. Regular intake of flax seed also brought about a significant fall in the blood pressure. of flax seeds in mitigation of dyslipidemia. The study included 50 dyslipidemic subjects. Subjects were divided into two group as control group and experimental groups. Subject in the experimental group received 30 g of roasted flax seeds powder for 3 months.
After supplementation there was remarkable improvement in anthropometric measurement, blood pressure and lipid profile in the experimental group. Body weight and body index of the experimental were significantly reduced. A lowering of systolic and diastolic blood pressure was also recorded in the dyslipidemic subject. A highly significant reduction in total cholesterol, triglycerides, low density lipoprotein cholesterol and very low density lipoprotein levels simultaneous elevation in high density lipoprotein cholesterol was observed. Improvement in lipid profile resulted in reduction of atherogenic indices. Therefore, it was summarized from the study that the supplementation of roasted flax seed powder for three months improved the body mass index, blood pressure and lipid profile of dyslipidemic subjects, thus exhibiting cardio protective effect.
Flax seeds are a rich source of unsaturated fatty acids, antioxidants and fibres, known to have anti-atherogenic activities. Hence, a study was conducted by Katare and Saxena, (2013) to evaluate the effect of flax seeds on serum lipid profile of dyslipidaemic patients. A total of 75 patients were selected for the study and patients were divided into 3 groups each comprising of 25 patients. Patients of group E-I were administered roasted flaxseeds chutney powder (RFCP) 30 g and group E-II were administered to soya nuts (SN) 30 g for twelve weeks. The control group was not provided with any supplementation. The results indicated that control group exhibited mean lowering of 1.81% in total serum cholesterol level followed by 16.19% and 3.79% drop in group E1 and E2. A highly significant reduction in triglyceride levels was noted in groups E-I and E-II with a mean lowering of 13.99% and 11.73%, respectively. Elevation of 4.94% and 3.21% in high density lipoprotein cholesterol level was seen. Low density lipoprotein cholesterol values were also significantly lowered in group E-I and E-II with a mean change of 19.93% and 3.92%. It was abstracted from the study that 12 weeks supplementation with roasted flax seed chutney powder brought about a remarkable improvement in anti-atherogenicity indices (Katare and Saxena, 2013).
Extensive studies have indicated that nutritional therapy plays a pivot role in the controlling of many diseases. Several functional foods have been shown to possess hypolipidemic properties. Flax seed (FS) is a functional food that is rich in omega 3 fatty acids and antioxidants and is low in carbohydrates. So a study on the effect of flax seed powder supplementation in the management of dyslipidemia was conducted by Mani et al., (2011). Twenty nine subjects were included in the study. Subjects were assigned to the experimental group (n=18) and the control group (n=11). The experimental group's diet was supplemented daily with 10g of flax seed powder for a period of 1 month. The control group received no supplementation. A favorable reduction in total cholesterol (14.3%), triglyceride (17.5%), low density lipoprotein cholesterol (21.8%) increased high density lipoprotein cholesterol (11.9%) were noticed. The observation of the study indicated the therapeutic potential of flax seeds in the management of dyslipidemia.
One another study was conducted by Kristensen et al., 2012 to examine the effect of flax seed dietary fiber in different food matrics on blood lipids among 17 subjects. Three different diets were tested-a low fiber control diet (control group), a diet with flax seed fiber drink(3 drinks/day) and a diet with flax seed fiber bread(3day). The results indicated that flax drink lowered fasting total cholesterol and LDL cholesterol by 12% and 15%, respectively. Flax bread also lowered total cholesterol and LDL cholesterol by 7% and 9%, respectively. Viscous flax seed fiber may be a useful tool for lowering blood cholesterol.
A study on flax seed powder suggested statistically significant reduction in blood glucose levels and blood lipid profile. The processed flax seed powder was incorporated at levels of 5%, 10% and 15% in standardized recipes such as idli powder, bread, sesame powder boli (south Indian sweet dish) and biscuits. A total of 50 type II diabetic subjects were selected for supplementation and divided into two groups of 25 subjects each. Experimental group was supplemented with 5 g of flax seeds incorporated bread for a period of 90 days as evening snack. The findings showed that the mean values for lipid profile were decreased from 224.3 to 167.5mg/dl for total cholesterol, from 178.8 to 150.9mg/dl for serum triglyceride from 157.2 to 128.8 mg/dl for low density lipoprotein cholesterol and the mean values increased significantly from 36.5 to 52.1 mg/dl for high-density lipo-protein cholesterol. The findings had revealed that the use of flax seed powder had immense therapeutic potential (Nazni et al., 2006).

Role of Flax Seed Oil in Management of dyslipidemia-
Flax seed oil is mainly considered as a healthy food. Fatty acid composition of regular flax seed oil is different from other commercial oils because of the very good composition of, alpha linolenic acid usually above 50%. To compare the effect of hempseed oil (HO) and flax seed oil (FO) on the profile of serum lipids and fasting concentration of serum total and lipoprotein lipids, plasma glucose and insulin in healthy humans. Schwab et al. (2006) had conducted a study. Fourteen healthy volunteers participated in the study. The subjects were asked to consume hempseed oil and flax seed oil 30 ml/day for 21 weeks each. The periods were separated by a four week wash-out period. The data revealed that the hempseed oil period resulted in a lower total of HDL cholesterol ratio compared with the flax seed oil period (p=0.065). The effect of HO and FO on the profile of serum lipid was found to be different significantly, with only minor effects on concentration of fasting serum total or lipoprotein lipids, and no significant changes in concentration of plasma glucose or insulin (Schwab et al., 2006). day), examined to see the effect on blood pressure of dyslipidaemic patients. Diet of control group (n=28) was supplemented with safflower oil, containing the equivalent n 6 fatty acids (11g/day) linoleic acid. After 12 weeks supplementation with ALA resulted in the significantly lower systolic and diastolic blood pressure levels compared with LA (p=0.016 and p=0.011, respectively).
In conclusion, dietary supplementation with 8g/day ALA for 12 weeks lowered both SBP and DBP in dyslipidaemic men. The magnitude of hypotensive effect (5mm/hg or 3-6 %) was certainly clinically relevant, and is expected to considerably reduce the overall CVD risk in the patients (Paschos et al., 2007).
Recently, novel dietary oils with modified fatty acid profiles have been manufactured to improve fatty acid intakes and to reduce cardiovascular diseases risks. A study by Gillingham et al. (2011) was conducted to evaluate the efficacy of novel high oleic rapeseed (canola) oil (HOCO), alone or blended with flax seed oil (FXCO), on circulating lipids and inflammatory biomarkers over a typical western diet (WD). A total of thirty six hypercholesterolemic subjects were included in the study and asked to consume three isoenergetic diets for 28 days. Experimental diets were designed as typical western diet contained 50% energy as carbohydrate, 15% as protein and 35% as fat, of which 70% was provided with experimental oil. The study was designed as three phases with 28 days per phase separated by 4-8 weeks wash-out periods. Subjects consumed three isoenergetic diets. Each contained approximately 36% energy from fat, of which 70% was provided by HOCO, FXCO or WD. The results of the study indicated that the total cholesterol was reduced by 11% (p=0.001) with flax seed oil and 3.5% reduction was found in HOCO group. After 28 days compared with WD, LDL cholesterol was reduced 15.1% with FXCO and 7.4% with HOCO group. In conclusion, consumption of novel HOCO alone or blended with flax seed oil is cardioprotective through lipid lowering effects (Gillingham et al., 2011). Kawakami et al. (2015) investigated the effect of 12 week supplementation with flax seed oil (FO), which is a rich source of alpha linolenic acid (ALA), on cardiovascular risk factors such as serum small dense low-density lipoprotein concentration. A total of 15 subjects were included in the study. The subjects were instructed to take 10 g of flax seed oil or corn oil for 12 weeks using spoon provided, once with dinner. Supplements of 10 g of flax seed oil and corn oil contained 5.49 and 0.09 g of ALA, respectively. Subjects were instructed to maintain their habitual diet throughout the study. Subjects were also instructed to avoid intake of anti-inflammatory drugs vitamins or other dietary supplements throughout the intervention period. The data revealed that the flax seed oil supplementation reduced low density lipoprotein cholesterol concentration by 25.8% and 21.2% at 4 and 12 weeks, respectively. Although, corn oil supplementation had no effect on LDL concentrations. It was also abstracted from the study that serum total cholesterol, LDL-cholesterol, HDL-cholesterol were significantly lowered in the flax seed oil supplementation (Kawakami et al., 2015).