Women’s Health Update

by Tori Hudson, ND

Cardiovascular Tidbits

For Your Heart: Don’t Forget the Flaxseeds

Because the incidence of cardiovascular disease significantly increases in postmenopausal women, alternative and conventional options to improve lipid profiles, lower blood pressure and lower other cardiovascular risk factors are on the minds of clinicians and health-conscious women. Among the many functional foods that have been evaluated for their affects on improving lipids, reducing insulin resistance, lowering blood pressure and reducing atherogenic properties, flaxseed has shown some optimistic potential for its ability to reduce the progression of atherosclerotic lesions. It’s source of lignans, alpha-linolenic acid, and soluble fiber all have positive influences. Flaxseeds have been shown to reduce serum cholesterol in humans.^1,2

A flaxseed supplement consisting of three slices of flaxseed-containing bread and 15 g of ground flaxseed was studied in 15 hyperlipidemic patients and total and low-density lipoprotein cholesterol levels were reduced significantly, 18 mg/dL and 19 mg/dL respectively. Triglycerides fell only slightly.³ A study specifically in postmenopausal women found that 40 g/day of flaxseeds resulted in a small reduced serum total cholesterol and increased high density lipoproteins greater than that compared to the same amount of wheat germ.⁴ In another study, 55 Native American postmenopausal women were divided into 3 groups over 3 months. Group 1 was the control group, group 2 received 30 g/day of flaxseeds, and group 3 30 g/day of flax plus additional oat-bran fiber. Dietary flaxseed supplementation lowered total cholesterol by approximately 7% and low-density lipoprotein cholesterol by approximately 10%.⁵

Not all results are positive when it comes to flaxseeds and lipids. In 2002, 40 g/day of flaxseeds did not improve the cholesterol profile in hypercholesterolemic menopausal women although it did improve mild menopausal symptoms and lowered glucose and insulin levels.⁶ Not all is positive when it comes to flaxseeds and lipids. .A study in postmenopausal women demonstrated no effect of a flaxseed component on lipids or any antioxidant properties.⁷

However, a recent animal study also showed that a diet of 15% and 22.5% flaxseeds significantly reduced lipoprotein (a) and ApoB.⁸ In other research, 13.7 g/day of flaxseed in health individuals significantly reduced inflammatory markers, including tumor necrosis factor-alpha, interleukin-1 beta, thromboxane B5, and prostaglandin E5.⁹ Other studies have shown a reduction of inflammatory markers and adhesion molecule production, which suggests some antioxidant properties of flaxseeds.^10–12

Overall, it seems like there is enough evidence that including flaxseeds into the diet can modify cholesterolemia. This is especially important in postmenopausal women, as their lipid levels begin to change in an unfavorable direction due to the decline in endogenous estrogen, and their cardiovascular risks increase.

Red Yeast Rice: Still a Player

Red yeast rice formulations have been a common strategy to improve lipids among alternative-minded practitioners, as well as consumers in self treatment. This approach, along with lifestyle changes, has provided a reasonable solution for those who have mild to moderate abnormal lipids. Red yeast rice is produced by culturing the yeast Monascus purpureus on rice. This results in a mixture of monacolins that inhibit hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase, which then inhibits the synthesis of cholesterol in the liver. Monacolin K is identical to lovastatin in its chemical structure. While these red yeast rice products are widely available as a dietary supplement, the monacolin levels per gram of active product are not standardized and this variability leads to variability in efficacy of products.

In the current study, physicians and spouses were study participants in a randomized, double-blind, placebo-controlled trial. Those with a total cholesterol >200 mg/dl were randomly assigned to receive red yeast rice (RYR) extract or placebo for 8 weeks. Participants were excluded if they were on statins, had a triglyceride level >400 mg/dL, or had changes in medications or food supplements that are known to affect lipid levels. A product was used that contained 1.5% monacolin K (5025 mg of monacolin K per capsule) along with coenzyme Q10 30 mg, procyanidins 20 mg, and lecithin 100 mg. A dose of 2 capsules per day of active product or placebo were given each evening for 8 weeks to the 54 participants, with 31 in the active group and 23 in the placebo group.

In the active group, low density lipoproteins (LDL) was lowered by 36 mg/dL (22%) and total cholesterol by 37 mg/dL (15%), a statistically significant effect compared to no reduction was seen in total cholesterol and LDL in the placebo group. There were no reported side effects.

Comment

: The study dose of 10,050 mg of monacolin K is a higher dose than most commercially available RYR products. Given the political and legal climate of dietary supplements, and the particular history of RYR products in this regard, it can be very difficult to get a good answer from a supplement company on the precise amount of monacolin K in their products. This makes prescribing RYR challenging. The manufacturer of this particular product used in this study added coenzyme Q10 to the formulation with the purpose of aiming to reduce myalgia side effects. Coenzyme Q10 deficiency has been proposed to have a role in HMG-CoA reductase–inhibitor induced myopathies that can be seen with prescription statins, and occasionally RYR as well.

Lowering total cholesterol and LDL is one thing, but reducing cardiovascular disease is another. This can be seen as an advantage of the prescription statins by some, due to studies that have been done with cardiovascular disease outcomes. However, there is also some evidence regarding RYR and secondary prevention from a large multicenter, randomized, double blind placebo-controlled study in almost 5000 Chinese patients with a history of myocardial infarction and moderate hypercholesterolemia.^13,14 Over a duration of 4.5 years, a one-third reduction in cardiovascular deaths and the need for coronary revascularization was seen, and in those with diabetes and hypertension, a reduction in coronary events was also seen.

Verhoeven V, Hartmann M, Remmen R, et al. Red yeast rice lowers cholesterol in physicians-a double-blind, placebo controlled randomized trial. BMC Comp and Altern Med. 2913;13:178

Lowering Lipids in Women: How Effective Is It in Treating Heart Disease?

One of the most important issues to be reminded of in the common focus on addressing lipids, is that over 50% of patients who have heart attacks did not have any prior known risk factors. For women, the first symptom of coronary heart disease (CHD) is in fact, a heart attack. Treating cholesterol numbers reduces CHD by about 50%, but targeting regular exercise, good nutrition with a Mediterranean diet, weight reduction, smoking cessation and perhaps even a little red wine can reduce cardiovascular disease by about 80%. New guidelines from the American Heart Association and the American College of Cardiology, have in my mind, basically admitted that lipid targeted strategies are limited in risk reduction. The new guidelines have changed the focus from LDL and total cholesterol levels, to focusing on other risk factors, with the only lipid number still relevant for the indication of a cholesterol lowering medication being an LDL > 190 mg/dL.

Women have significantly different mechanisms underlying their CHD symptoms. Symptoms in women are more related to microvascular angina and stress cardiomyopathy and are more likely to be upper back pain or neck pain, dyspnea, palpitations, indigestion and/or fatigue. Women also are most likely to have the symptom of sweating if they are having a heart attack.

Approximately 40% of women have no chest pressure, discomfort or pain. Using statins in women is also less effective than in men.

In addition, the usual treadmill test is not very useful in women, especially in whose women who are under 50 years old. It is more predictive of women >65 years old. (68%), but overall, in all ages, it is only a predictive value of 51%. A stress echo and nuclear medicine testing are more helpful tests in most women.

For women, a specific tool can define a woman’s risk for coronary heart disease. It is a scoring system developed by physicians at the University of Texas Southwestern Medical Center, and published in the American Journal of Cardiology in 2013. A scoring system of seven independent factors predictive of CAD in women is used in those with abnormal stress test findings:

• 55 years old or older

• body mass index > 30 kg/m²

• smoking

• low HDL

• family history of premature CAD

• lateral abnormality on stress imaging

• exercise capacity

One point is assigned for each variable. A score under 2 indicates little risk of CAD; a score of over 2 signals concern. If the score is <2, then the treadmill stress test has a negative predictive value of 80%.¹⁵

For women, it is important to really understand the lesser role of lipid lowering, and incorporate strategies that address vascular health, heart muscle health, circulation, inflammation, blood pressure, blood pressure, insulin resistance, and body weight.

Notes

1. Arjmandi B, Khan D, Juma S, et al. Whole flaxseed consumption lowers serum LDL-cholesterol and lipoprotein (a) concentrations in postmenopausal women. Nutr Res. 1998;18:1203–1214.

2. Lucas E, Lightfoot S, Hammond L, et al. Flaxseed reduces plasma cholesterol and atherosclerotic lesion formation in ovariectomized Golden Syrian hamster. Atherosclerosis. 2004;173:223–229.

3. Bierenbaum M, Reichstein R, Watkins T. Reducing atherogenic risk in hyperlipemic humans with flax seeds supplementation: a preliminary repot. J Am Coll Nutr. 1993;12(5):501–504.

4. Dodin S, Lemay H, Jacques F, et al. The effects of flaxseed dietary supplement on lipid profile, bone mineral density, and symptoms in menopausal women : a randomized, double-blind, wheat germ placebo-controlled clinical trial. J Clin Endocrinol Metab. 2005;90:1390–1397.

5. Patade A, Devareddy L, Lucas E, et al. Flaxseed reduces total and LDL cholesterol concentrations in Native American postmenopausal women. J Womens Health. 2008;17(3):355–365.

6. Lemay A, Dodin S, Kadri N, et al. Flaxseed dietary supplement versus hormone replacement therapy in hypercholesterolemic menopausal women. Ob Gyn. 2002;100:495–504.

7. Hallund J, Ravn-Haren G, Bugel S, et al. A lignan complex isolated from flaxseed does not affect plasma lipid concentration or antioxidant capacity in healthy postmenopausal women. J Nutr. 2006;136:112–116.

8. Campbell S, Bakhshalian N, Sadaat R, et al. Flaxseed reverses atherosclerotic lesion formation and lowers lipoprotein (a) in ovarian hormone deficiency. Menopause. 2013 Nov;20(11):1176–1183. doi:10.1097/GME.0b013e31828cef8d.

9. Caughey G, Mantzioris E, Gibson R, Cleland L, James M. The effect on human tumor necrosis factor alpha and interleukin 1 beta production of diets enriched in n-3 fatty acids from vegetable oil or fish oil. Am J Clin Nutr. 1996;63:116–122.

10. Wang Y, Li D, Haake E, Brown J. A three-point Dixon method for water and fat separation using 2D and 3D gradient-echo techniques. J Magn Reson Imaging. 1998;8:703–710.

11. Abouhamed M, Reichenberg S, Robenek H, Plenz G. Tropomysin 4 expression is enhanced in dedifferentiating smooth muscle cells in vitro and during atherogenesis. Eur J Cell Biol. 2003;82:473–482.

12. Campbell G, Campbell J. The phenotypes of smooth muscle expressed in human atheroma. Ann NY Acad Sci. 1990;598:143–158.

13. Lu Z, Kou W, Du B, et al. Effects of Xuezhikang, an extract from red yeast Chinese rice, on coronary events in a Chinese population with previous myocardial infarction. Am J Cardiol. 2008;101:1689–1693.

14. Li J, Lu Z, Kou W, et al. Chinese coronary secondary prevention study group. Beneficial impact of Xuezhikang on cardiovascular events and mortality in elderly hypertensive patients with previous myocardial infarction from the China Coronary Secondary Prevention Study. J Clin Pharmacol. 2009;49:947–956.

15. Lo M et al. A risk score for predicting coronary artery disease in women with angina pectoris and abnormal stress test finding. Am J Cardiol. 2013;111(6):781–785.

Dr. Tori Hudson graduated from the National College of Naturopathic Medicine (NCNM) in 1984 and has served the college in many capacities over the last 28 years. She is currently a clinical professor at NCNM and Bastyr University; has been in practice for over 28 years; and is the medical director of the clinic A Woman’s Time in Portland, Oregon, and director of research and development for Vitanica, a supplement company for women. She is also a nationally recognized author, speaker, educator, researcher, and clinician.