Impact of Supplementation with Flax Seed Powder and Flax Seed Oil on the Lipid levels of Patients with Dyslipidemia
Dyslipidemia, Flax Seed Powder, Flax Seed Oil, Supplementation, Lipid Levels.
Dyslipidemia, Flax Seed Powder, Flax Seed Oil, Supplementation, Lipid Levels
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:
• Prevalence of dyslipidemia
• Chemical composition of flax seed
• Role of flax seeds powder in management of dyslipidemia
• Role of flax seed oil in management of dyslipidemia
Prevalence of Dyslipidemia:
Hypercholesterolemia and hypertension are important modifiable
risk factors for cardiovascular disease. A study was conducted by
Wong et al., 2006 in United States among 2,864 subjects from the
National Health and Nutrition Examination Survey 2001 to 2002.
The results indicated that the prevalence of hypercholesterolemia
and hypertension was 47% and 30%, respectively.
One another study was conducted by Margaret, 2009 among 3,810
United States adults, participating in the National Health and
Nutrition Examination Survey 1999-2004. It was concluded from
the results that the overall prevalence of dyslipidemia was 60.3%.
Dyslipidemia has become one of the important health risk factor
in the Chinese population. Zhao et al., 2007 had conducted a
study to investigate the prevalence of dyslipidemia in the Chinese
population. Plasma lipid profile was analyzed by using the data
obtained during the Chinese National Nutrition and Health Survey
(CNHS) in 2002 which involved 14,252 participants of age 18 years
or older. The mean levels of total cholesterol (TC), triglycerides
(TG) and high density lipoprotein cholesterol (HDL-C) were found
to be 3.81 mmol/L, 1.10 mmol/L and 1.30 mmol/L, respectively.
The results indicated that the prevalence of hypercholesterolemia,
hypertriglyceridemia and low HDL-cholesterol was 2.9%, 11.9%
and 7.4%, respectively.
Wong et al. (2011) also analyzed the prevalence of dyslipidemia
among 2951 Chinese individuals and found that the prevalence
of dyslipidemia was 56% and the factors likely associated with
dyslipidemia were higher age, female gender, urban region, higher body mass index, higher income, higher diastolic blood pressure,
higher blood concentration of glucose and smoking.
Hypercholesterolemia, hypertriglyceridemia and abnormally low
high density lipoprotein cholesterol had increased considerably
over the past 20 years in professional population in Beijing (Zhiyan
et al., 2005). The study included 14,963 individuals (8572 males
and 6391 females) of 20-90 years of age. It was concluded from
the study that hypercholesterolemia was found in 6% of males and
2.8% of females in the younger age group (20-39 years) and in
20.2% of males and 38.7% of females in the older age group (>60
years). High density lipoprotein cholesterol was abnormally low
in 7% of males and 1.6% of females. The increase was found to be
higher in the middle age group (40-59 years) (Zhiyan et al., 2005).
The prevalence of dyslipidemia among Korean population of age ≥
20 years increased from 32.4% in 1998 to 42.6% in 2001 and 44.1%
in 2005. Compared with the Korea National Health and Nutrition
Survey (KNHANES) in 1998, the prevalence of dyslipidemia was
47%, higher in 2001 and 61% higher in 2005. In 2005, only 9.5%
of people with dyslipidemia were aware of the disease, 5.2% used
lipid lowering medication and 33.2% of patients with treatment,
reached treatment goals. It was summarized from the data that the
prevalence of dyslipidemia in Korea gradually increased between
1998 and 2005 (Lee et al., 2012).
A study by Chatlert et al. (2006) in Thailand demonstrated the
effect of an urban life style on dyslipidemia by comparing the
lipid profile. A total of 916 subjects (595 urban and 321 rural)
between the age group 20 and 88 years were selected for the
study. The results indicated that in both men and women the mean
total cholesterol and low density lipoprotein cholesterol were
significantly higher in urban v/s rural subjects. Total cholesterol
values were 207 v/s 169 mg/dl for men and 204 v/s 192 mg/dl
for women and low density lipoprotein cholesterol levels were
120 v/s 87 mg/dl for men and 122 v/s 110 mg/dl for women. The
study demonstrated a significant difference between the urban and
rural subject’s lipid profile and the prevalence of dyslipidemia.
Migration to urban centers and adopting an urban life style was
related to the rising lipid profile and prevalence of dyslipidemia
(Chartlert et al., 2006).
Hyperlipidemia and obesity have been traditionally considered
as diseases of affluence. Mishra et al. (2001) had shown the
results of a study that the prevalence of dyslipidemia was very
high in urban slum population of northern India. A total of 532
subjects (170 males and 362 females) were included in the study.
Hypercholesterolemia was observed in a high number in both males
(26.8%) and females (27.5%) and similarly equally high number
of subjects had high low density lipoprotein cholesterol levels.
However hypertriglyceridemia was found to be more prevalent
in males, although, the difference was not statistically significant.
Further, low level of high density lipoprotein cholesterol was
found to be 15.8% males and 16.7% female subjects (Mishra et al., 2001).
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.
Gupta et al. (2008) had conducted studies in western India in urban
locations. The studies evaluated adults of ≥ 20 years of age for
multiple coronary risk factors (JHW-1- 1993-94; n=2212, JHW-
2- 1999-2001; n=1123, JHW-3- 2002-2003; n=458 and JHW-4-
2004-2005; n=1127). The data showed that the mean levels of
various lipoproteins increased from JHW-1 to JHW-2 and then
gradually in JHW-3 and JHW-4. Age adjusted mean values (mg/dl)
in JHW-1, JHW-2, JHW-3 and JHW-4 studies showed a significant
increase in total cholesterol as 174.9, 196.0, 187.5 and 193.5 mg/
dl, respectively. The levels of low density lipoprotein cholesterol
were 106.2, 127.6, 122.6 and 119.2 mg/dl. Triglycerides levels
were 125.6, 144.5, 130.1 and 158.7 mg/dl. Hence, it was concluded
from the study that there was a high prevalence of various forms
of lipoprotein abnormalities in Indian urban subjects (Gupta et al.,
Estari et al. (2009) investigated serum lipids and the prevalence
of dyslipidemia in urban adult population in Warangal district of
Andhra Pradesh. A total of 1496 individuals of age group 20-29
years of age were included in the study. The results of the study
indicated that 52.7% of males and 42.9% of females had at least one
abnormal lipid concentration. High density lipoprotein cholesterol
was abnormally low in 7% of males and in 1.6% of females. The
prevalence of hypercholesterolemia, Hypertriglyceridemia and
low levels of high density lipoprotein cholesterol were found to be
higher in all age groups.
A cross sectional community based study was conducted in an
urban community in Tenali, Andhrapradesh between July 2009 and
October 2009 to assess the prevalence and risk factors for CAD by
Murthy et al., 2012. A total of 534 subjects of age ≥20 years were
investigated. The overall prevalence rate of CAD was 5.4%. Out
of 29 cases of CAD, 11 cases were found to have dyslipidemia.
A study was conducted by The Indian Council of Medical Research,
India Diabetes (ICMR-INDIAB) in the representative population
of three states of India (Tamil Nadu, Maharashtra and Jharkhand)
and one union territory (Chandigarh). The study included a
total of 16,607 people of age group ≥ 20 years using stratified
multistage sampling design. The findings of the study suggested
that out of the subjects studied, 13.9% had hypercholesterolemia,
29.5% had hyper-triglyceridemia, 72.3% had low high density
lipoprotein cholesterol, 11.8% had high low density lipoprotein
cholesterol levels and 79% had abnormalities in one of the lipid parameters. Regional disparity existed with the highest rates of
hypercholesterolemia observed in Tamil Nadu (18.3%), highest
rates of hypertriglyceridemia in Chandigarh (38.6%), highest rates
of low high density lipoprotein cholesterol in Jharkhand (76.8%)
and highest rates of high low density lipoprotein cholesterol in
Tamil Nadu (15.8%). Low high density lipoprotein cholesterol was
the most common lipid abnormality (72.3%) in all the four regions
studied. It was observed that the risk factors for dyslipidemia are
obesity, diabetes and dysglycaemia (Joshi et al., 2014).
To determine the levels of cholesterol lipoproteins and prevalence
of dyslipidemia in urban Asian Indians. Guptha et al., 2014
performed a study at eleven cities located in all regions of India. A
total of 6123 subjects were reviewed. The cities were in Northern
(Jammu, Chandigarh, Karnal, Bikaner), Western (Ahmadabad,
Jaipur), Eastern (Lucknow, Patna, Dibrugarh), Southern (Madurai,
Hyderabad, Belgaum) and Central(Indore, Nagpur) regions of
India. The data revealed that the age adjusted prevalence in men and
women were, total cholesterol 25.1% and 24.9%, LDL-cholesterol
16.3% and 15.1% and HDL-cholesterol 33.6% and 52.8% and
triglycerides were 42.1% and 32.9%, respectively. It was concluded
from the study that cholesterol level was significantly greater in
subjects with better economic status, body mass index and waist
circumference while triglycerides were found to be more among
those with high socioeconomic status, fat intake, body mass index
and waist circumference.
A study was carried out by Gupta et al., 2009 in two North Indian
cities, Jaipur and Delhi to determine the prevalence of various
cardiovascular risk factors in adolescents and young adults. A total
of 2051 subjects (male 1009, female 1042) of age group 15-39
years were selected for the study. The results of the study indicated
that high LDL cholesterol was observed in 9.4% and 8.9% in
males and females, respectively. Whereas low HDL cholesterol
was observed in 16.2% and 49.7%, hypertriglyceridemia was
observed in 9.7% and 6% in males and females, respectively. It
was summarized from the study that there was low prevalence
of multiple cardiovascular risk factors (smoking, hypertension,
dyslipidemia, diabetes and metabolic syndrome) in adolescents
and rapid escalation of these risk factors by age of 30-39 years was
noted in urban Asian Indians.
One more study demonstrated the high prevalence of dyslipidemia
in young Indian population (Sawant et al., 2008). A total of 1805
subjects (1128 males and 677 females) subjects of age ≥40 years
were selected from P.D.Hinduja Hospital, Mumbai, India. The
prevalence of dyslipidemia was observed to be higher in males
then in females. High level of total cholesterol was found in
38.7% males and 23.3% in females. High density lipoprotein
cholesterol was abnormally low in 64.2% males and 33.8% in
females. The increase of prevalence of hypercholesterolemia
and hypertriglyceridemia was more prominent in 31-40 years
of age group than in ≤30 years of age group. It was concluded
from the study that the low percentage of adults with controlled
lipid concentrations suggests that there is a need for awareness
programs for the prevention and control of dyslipidemia.
Chemical composition of flax seed:
Flax (Linum usitatissimum) is an annual plant of the linaceae
family. This plant grows to a height up to 60 cm, with slender
and very fibrous stems. The fruit contains a seed known as
flaxseed or linseed (Pradhan et al., 2010). Flax is considered a
functional food or source of functional ingredients, because it
contains alpha-linolenic acid (Bozan and Temelli, 2008), lignans
and polysaccharides, all of which have positive effects in disease
prevention. The seed contains approximately 40% lipids, 30%
dietary fiber and 20% protein.
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. Flaxseed oil is
mainly found as triacylglycerols (98%) with lower contents of
phospholipids (0.9%) and free fatty acids (0.1%) (Mueller et al.,
2010). The average protein content in flaxseed is 22 g 100 g of
seed. In flax, globulins are the main proteins; they make up 18.6%
of the total protein, while albumin content represents 17.7% of the
total protein. Flax protein is relatively rich in arginine, aspartic
acid and glutamic acid, and the limiting amino acids are lysine,
methionine and cysteine (Chung et al., 2005). Total fiber accounts
for about 28% of the weight of full-fat flax seeds. Flax contains
both soluble and insoluble dietary fiber. Dietary fiber acts as a
bulking agent in the gut.
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
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.
Saxena and Katare (2014) had reported the therapeutic potential 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,
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).
Alpha linolenic acid (ALA) is the natural precursor of cardio
protective long chain n=3 fatty acids. Paschos et al. (2007) had
conducted a study to examine the effect of increased ALA intake
on blood pressure in middle aged dyslipidemic men. The dietary
supplementation of flax seed oil rich in alpha linolenic acid (8 g/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).
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