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S OY AND H EALTH 1. This activity is partially supported by educational funding received from the United Soybean Board. Printable handout available at.

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Presentation on theme: "S OY AND H EALTH 1. This activity is partially supported by educational funding received from the United Soybean Board. Printable handout available at."— Presentation transcript:

1 S OY AND H EALTH 1

2 This activity is partially supported by educational funding received from the United Soybean Board. Printable handout available at AANP CE Center. 2

3 F ACULTY Cindy Cooke MSN, NP-C, FAANP FNP - Fox Army Health Center, Huntsville, AL Joyce M. Knestrick, PhD, CRNP, FAANP Coordinator of Graduate Education- Frontier School of Midwifery and Family Nursing, Hyden, KY FNP –Primary Care Center of Mt. Morris, PA 3

4 D ISCLOSURES The faculty have no relationships to disclose. 4

5 L EARNING O BJECTIVES On completion of this activity, participants will be able to: Discuss the nutrients available in soy products. Identify sources of soy and the nutritional value of various sources Discuss ways in which soy products can be incorporated in diet Discuss recommendations and supporting evidence regarding soy as relates to specific conditions 5

6 C ONSUMERS AND NUTRITIONAL INFORMATION 88% of consumers report reviewing Nutrition Facts panel when purchasing food. 48% of consumers find nutrition information confusing. Most frequently consumers look for Calorie content (16%) Fat content (11%) United Soybean Board (2009). 16 th annual survey: Consumer attitudes about nutrition. 6

7 C ONSUMER S OY K NOWLEDGE 84% respondents rate soy products as healthy 30% reportedly seek out soy products Reported benefits: Low fat (19%) Good protein source (18%) Associated with reduced rate of heart disease (18%) Associated with lowered cholesterol (13%) 7

8 S OURCE OF S OY K NOWLEDGE Reported sources of information regarding health and nutrition information on soy: HCPs 16% Internet 42% Television 41% Magazines 40% Need for HCPs to be informed regarding soy and other dietary factors, to provide individualized instruction 8

9 S OY P RODUCTION D ETAILS US produces 42% of worlds soybeans Significant portion of US soybeans exported Soybeans account for 75% of U.S. edible fat and oil consumption Flakes remaining after oil extraction used to produce wide range of high protein products 9

10 S OY B EAN Beans generally good source of nutrients Soybeans include 47% fat energy, higher than other beans Higher in calcium and iron than other beans Lower in B vitamins, crude fiber Katcher, H., Hill, A., Lanford, J., Yoo, J., Kris-Etherton, P. (2009). Lifestyle approaches and dietary strategies to lower LDL-cholesterol and triglycerides and raise HDL-cholesterol. Endocrinology and metabolism clinics of North America, 38,

11 SOYFAT Mono and Poly unsaturated No cholesterol Omega-3 fatty acid, alpha-linolenic acid Omega-6 fatty acids, linolenic acid Important essential fatty-acids Must be obtained through diet/intake Roles in brain function, skin/hair growth, bone health, metabolism peripheral vascular function, reproduction Katcher, H., Hill, A., Lanford, J., Yoo, J., Kris-Etherton, P. (2009). Lifestyle approaches and dietary strategies to lower LDL-cholesterol and triglycerides and raise HDL-cholesterol. Endocrinology and metabolism clinics of North America, 38,

12 P ROTEIN Vegetarian source of total protein 36% of the total bean Contains all essential amino acids Staple of Asian diet In U.S. Recommendations often indicate Gm soy protein daily Katcher, H., Hill, A., Lanford, J., Yoo, J., Kris-Etherton, P. (2009). Lifestyle approaches and dietary strategies to lower LDL-cholesterol and triglycerides and raise HDL-cholesterol. Endocrinology and metabolism clinics of North America, 38,

13 C ONCENTRATED S OY S OURCES Concentrated sources of soy protein include: Soy protein powder (80-90%) Soy nuts (40%) Full-fat soy flour (35%) To consume 50 gm/dayexample: 1 soy breakfast patty, 8 oz soy milk, 3 oz tofu, 1 oz soy nuts, 2 heaping tablespoons of soy protein 13

14 S OY I NTAKE AND ISOFLAVONES Soy products vary in isoflavone content 25 G soy protein : 100 mg isoflavone Differs depending on processing, additives, etc. Estrogen-like activity through selective estrogen receptor modulator (SERM) activity Act as phytoestrogens Isoflavone pharmacokinetics: Peak 5-6 hr after ingestion Half-life 6-8 hrs Uptake is saturable, limiting benefit of large consumption Isoflavone content of foods varies between batches Setchell, K. (2001). Soy isoflavonesBenefits and risks from natures selected estrogen receptor modulators (SERMs), Journal of the American College of Nutrition, 20 (5), 354S- 362S. 14

15 C OMMON S OY P RODUCTS : G LOSSARY & N UTRITION Edamame : Large soybeans harvested while green; boiled minutes can be served as snack or vegetable; available shelled and in pods; available fresh and frozen 1 cup= 22 g protein, 12 g fat, 20 g CHO, 8 g fiber, 254 cal Soybeans : mature beans, ripened dry, varied colors. Can be roasted once soaked; often cooked in soups, stews, etc 1 cup=68g protein, 37 g fat, 56 g CHO, 14 g fiber, 776 cal (roasted) Soynuts : roasted soybeans; varied flavors available Soybean oil : natural oil extracted from soybeans; ~75% total US fat/oil consumption; also used in margarine and shortenings 1 cup=0 g protein, 218 g fat, 0 g CHO, 0 g fibre, 1664 cal 15

16 C OMMON S OY P RODUCTS : G LOSSARY & N UTRITION Soymilk : Made from soybeans soaked, ground, and strained; found in unrefrigerated section and refrigerated dairy cases; also used to make soy yogurt, soy cheese, etc 1 cup=7 g protein, 5 g fat, 8 g cho, 1 g fiber, 109 calories Tofu : Made from curdled soymilk, soft cheese-like food; bland, variety of uses 1 cup-6 g protein, 2 g fat, 2 g cho, 0 g fiber, 52 cal Tempeh : Chunky tender soybean cake, used in variety of foods 1 cup-5 g protein, 3 g fat, 3 g cho, 0 g fiber, 55 cal Miso : Condiment common to Japanese cooking; aged paste of soybean and grain 1 cup=2 g protein, 1 g fat, 5 g cho, 1 g fiber, 40 cal Soy flour : Ground roasted soybeans; 50% protein, higher protein value if defatted 1 cup=48 g protein, 0 g fat, 27 g cho, 17 g fiber, 394 cal 16

17 H EALTH E FFECTS /C LAIMS Cancer Risks Bone Health Menopause Symptoms Heart Disease Healthy eating 17

18 M R. A LLEN 42 years old weight 280 pounds; 70 inches tall Last visit 3 months ago weight 310 On a high protein diet for 3 months Eating mostly meats/salads, very little fish Becoming bored with diet Asks about adding soy products to his diet Has heard soy products high in protein and available in varied forms 18

19 M RS. C OMER 48 years old Weight 158 pounds; height 54 Concerned about her cholesterol Most recent: TC 210, HDL 35, LDL 125 Watching her diet and increasing exercise Asks about adding soy to her diet to lower cholesterol Questions: How soy works to lower cholesterol Will products be harmful or make her gain weight How much soy would need to be consumed to help lower her cholesterol. 19

20 M RS. R ICK 50 years old, with complaints of hot flashes Last pap smear normal Has not missed any periods; flow is heavier Does not want to take any medications for the hot flashes. Sister- in- law suggested use of soy milk Has been drinking the soy milk in place of cows milk for 3 weeks Has not noticed any changes in the hot flashes Would like to continue to try the soy milk She has less bloating and flatulence since drinking the soy milk Questions if the substitution of soy milk in place of cows milk will have an effect on her bones. 20

21 H OW TO R ESPOND TO PATIENTS ? As part of healthy diet, soy products considered part of nutrition/diet As part of a treatment plan to prevent or treat specific conditions, soy products best considered part of complementary therapy plan Base responses accordingly 21

22 C ONSIDERING C OMPLEMENTARY O PTIONS Rakel identifies questions to be considered in recommending complementary therapies Will the therapy result in resolution or symptom suppression? What is the evidence? What is the potential harm? What is the cost? Does the treatment fit patients culture and belief system? Rakel, D. (2006). Complementary medicine in clinical practice. Philadelphia: Elsevier. 22

23 C HALLENGES R EGARDING E VIDENCE Regarding the evidence-base for integrative or complementary measures, Rakel identifies challenges, including: Clinical trials typically measure response to one treatment, while integrative measures usually part of a package Many integrative measures are not administered in one standardized portion, but individualized Controlled studies often look at short-term outcomes rather than long-term 23

24 M ORE INFORMATION NEEDED In order to consider use of soy products as part of complementary treatment plan, must consider the evidence to help answer questions Will review summary literature regarding soy effects related to specific health conditions 24

25 R EGARDING S OY AND C ANCER 25

26 W HAT A RE E FFECTS OF S OY ON BREAST AND PROSTATE C ANCER R ISKS ? Asian diet includes soy products Asians have lower rates of breast and prostate cancers Investigations of effects of soy in cancer risk are limited 26

27 B REAST C ANCER Asian studies A Singapore and a Japan study each found soyfoods consumption associated with lower rate of BCA in pre-menopausal females, not in post-menopausal China study failed to demonstrate either relationship U.S Studies One US trial demonstrated protective relationship only in women born in Asia who migrated to U.S. Meta-analysis of 18 studies cite decreased breast cancer associated with higher soy consumption, strongest in post-menopausal women Inconclusive thus far whether positive benefits Wu, A.,et al (2008). Soy intake and breast cancer risk in Singapore Chinese Health Study. British Journal of Cancer,99: Qin, L., Xu, J., & Wan, P. (2006). Soyfood intake in the prevention of breast cancer risk in women: A meta-analysis of observational epidemiological studies. Journal of Nutritional Science, 52 (6), cited in Michelfelder 92009). Soy: A complete source of Protein, 79 (1), Trock, B., Hilakivi-Clarke, Ll, & Clarke, R. (2006). Meta-analysis of soy intake and breast cancer risk. Journal of the American Cancer Institute, 98 (7),

28 C ONCERNS R ELATED TO S OY AND E STROGEN -S ENSITIVE C ANCER Isoflavones SERM activitytheoretical concerns regarding potential role of soy/isoflavone in women at risk for estrogen-sensitive breast cancer Studies typically measure breast density and/or markers for cancer No studies have confirmed, but generally advised to counsel women regarding this risk 28

29 P ROSTATE C ANCER Limited human study Asians lower rate of prostate cancer US Asian immigrants rate similar to US rate 1989 publication: Tofu consumption associated with marked but not statistically significant decrease in PCA US study daily soymilk intake associated with decrease incidence PCA Inadequate research for conclusions Severson, R., et al (1989). A propsiective study of demgraphis, diet, and prostate cancer amon men of Japanese ancestry in Hawaii. Cancer Research, 49, Jacobsen BK et al. (1998) Does high soy milk reduce prostate cancer incidence? The Adventist Health Study (United States). Cancer Causes Control 9:

30 R EGARDING S OY AND B ONE H EALTH 30

31 S OY B ONE H EALTH Japanese women lower rate of hip fractures Lower rate could be due to anatomical differences or fall risk, as bone density similar Chinese women: higher soy intake associated with decreased fracture risk RCT demonstrated soy protein associated with decreased bone turnover markers, without density change Few human studies, which demonstrate inconsistent effects, preliminary Zhang, X., et al (2005). Prospective cohort study of soy food consumption and risk of bone fracture among postmenopausal women. Archives of Internal Medicine, 166 (16), Evans et al (2007). Effects of soy protein isolate and moderate exercise on bone turnover and bone mineral density in postmenopausal women. Menopause ,

32 R EGARDING S OY AND M ENOPAUSE S YMPTOMS 32

33 M ENOPAUSAL S YMPTOMS Estrogen-like activity of soy attributed to lessening of menopausal symptoms (SERM activity) Japanese women lower incidence of menopausal symptoms 33

34 M ENOPAUSE E VIDENCE Meta-analysis of 11 studies: mixed results in hot flash reduction Meta-analysis of 17 studies reduction in women with 10 or more hot flashes/day; no effect if <6 hot flashes/day Recent RCT soy associated with reduction in women, 4.5 hot flashes/day Other studies have demonstrated similar response to placebo Nelson, et al. (2006). Nonhormonal therapies for menopausal hot flashes: Systematic review and meta-analysis. JAMA (295 (17), Howes, L., Howes, J., & Knight, D. (2006). Isoflavone therapy for menopausal flashes: A systematic review and meta-analysis. Maturitas, 55 (3), Weity, F, et al (2007). Daidzein-rich isoflavone aglycones are potentially effective in reducing hot flashes in menopausal women. Menopause, 15 (1), Newton, K., et al (2006). Treatment of vasomotor symptoms of menopause with black cohosh, mutibotanicals, soy, hormone therapy, or placebo: A randomized trail. Annals of Internal Medicine 145 (12),

35 AHRQ Effects of soy on menopausal symptoms inconsistent, but stronger with isoflavone supplements Identified study issues include: Varied symptom scores, score intervals Decreased weekly frequency reported 7-40% No apparent effect on menstrual cycles, TSH, bone markers, glucose metabolism Soy products generally well-tolerated Balk, E. et al (2005). Effects of Soy on Health Outcomes. Evidence Report/Technology Assessment No (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No ) AHRQ Publication No. 05-E Rockville, MD: Agency for Healthcare Research and Quality. 35

36 R EGARDING S OY AND H EART E FFECTS 36

37 H YPERLIPIDEMIA FDA approved health claim: Diets low in saturated fats and cholesterol that include 25 g of soy protein a day may reduce the risk of heart disease To qualify for claim, food must contain at least 6.25 g soy protein, or 25% of RDA Statement based on review of 27 studies National Cholesterol Education Program recommends soy protein as replacement for higher-fat animal proteins 37

38 S OY & L IPIDS : B ODY OF E VIDENCE Four meta-analyses demonstrated statistically significant reduction in TC up to 9.3%, with greater effect associated with higher starting TC levels Varying results, but generally mildly positive Anderson, J., Johnstone, B., Cook-Newell, M (1999). Meta-analysis of the effects of soy protein intake on serum lipids. NEJM, 333 (5), Nies, L.,Cymbalta, A., Kasten S., et al (2006). Complementary and alternative therapies for the management of serum lipids. Annala of Pharmacotherapy, 40(11), Reynolds, K., et al (2006). A meta-analysis of the effect of soy protein supplementation on serum lipids. American Journal of Cardiology, 98 (5), Zhua, X., Melby, M., & Watanabe, S. 2004). Soy isoflavone intake lowers serum LDL cholesterol: A meta-analysis. Journal of Nutrition, 134 (9),

39 More recent meta-analyses demonstrated more modest, but favorable effects on lipids Intake of g soy protein/day associated with 3- 5% reduction in LDL-C Limited studies yet demonstrating improved long-term outcomes Only one study (Shanghai Womens Health Study) provides evidence that increased soy consumption may decrease risk of non-fatal MI and CHD or cardiac events Zhang, et al (2003). Soy food consumption is associated with lower risk of coronary heart disease in Chinese women. Journal of Nutrition, 133,

40 AHRQ M ETA - ANALYSIS 178 eligible articles Supplements (including soy milk) in 75% Soy foods (soy flour and textured soy protein) 25% Most soy protein with isoflavones 1/3 isoflavones alone Few protein alone Mean 36 g/day ( g/day) 36 g=1 # tofu Balk, E. et al (2005). Effects of Soy on Health Outcomes. Evidence Report/Technology Assessment No (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No ) AHRQ Publication No. 05-E Rockville, MD: Agency for Healthcare Research and Quality. 40

41 I SSUES RELATED TO SOY - HEART STUDIES Heterogenicity in types of soy, doses, durations, etc Lipids-small benefit on LDL (mean net change -5 mg/dl) TG (mean net change -9 mg/dL) Greater benefit associated with higher baselines and dosages No significant effect on BP No significant effect on HDL Markers of inflammation, vascular function, lipid oxidation Balk, E. et al (2005). 41

42 Greater benefit associated with higher baselines and dosages Whole soy protein greater effect than isoflavone components Lack of support for soy protein association with decreased cardiac events Michelfelder, A. (2009). Soy: A complete source of protein. American Family Physician, 79 (1)

43 R EGARDING S OY AS P ART OF HEALTHY E ATING 43

44 N UTRITIONAL C ONSIDERATIONS Vegetarian diets: Soy provides protein substitute for meat and dairy products Specific Example: Portfolio diet example Low in saturated fat, high in fiber. Designed to lower cholesterol. Includes soy, fiber, plant sterols, almonds Soy protein: 22.5 g/day Viscous fiber: 10 g/day oats, barley, psyllium-containing cereal Plant sterol & stanol esters margarine: 1 g/day Almonds: 15 nuts/day 44

45 Rakel considers the level of evidence and reported benefits for use of soy and fiber in nutritional impact on lipids, as well as potential risks/hazards. Reported benefit with limited risk, recommended Recommends soy products with both protein and isoflavones Mixed results 45

46 P OTENTIAL A DVERSE E FFECTS Soy generally well-tolerated Adverse effects include: GI symptoms/diarrhea; menstrual complaints Concern over endometrial hyperplasia, not supported by recent ROL Potential weak cytochrome P450 3A4 enzyme inducer, with one reported case lowered INR in warfarin patient related to soy milk Studies indicate addition of soy formulas decrease infant absorption of iron and thyroid supplementation Infant soy allergy rate 1% on soy formula; adult soy allergy rate 0.2% Michelfelder, A. (2009). Soy: A complete source of protein. American Family Physician, 79 (1),

47 R EVISIT S CENARIOS 47

48 M R. A LLEN 42 years old weight 280 pounds; 70 inches tall Last visit 3 months ago weight 310 On a high protein diet for 3 months Eating mostly meats/salads, very little fish Becoming bored with diet Asks about adding soy products to his diet Has heard soy products high in protein and available in varied forms 48

49 P OSSIBLE TALKING POINTS Reinforce ongoing effort and motivation Because soy is a protein, it makes you feel less hungry after eating Soy protein is low-carb. Soybeans are the only vegetable that contain more protein than carbohydrates. Soy protein has a low-glycemic index that helps with appetite and weight loss. Soy protein contains all 9 essential amino acids Comparable to meat with less fat and fewer calories. Discuss the advantages of using soy products in a high protein diet. Discuss potential ways in which soy can be incorporated into diet 49

50 S OME S OY S UGGESTIONS Tofu: Is often used in stir-fries, curries or stews. It tends to pick up the flavor of the sauce it is in. Soy nuts: Can be used as a snack similar to peanuts or sunflower seeds Soymilk: Soy milk can be substituted for cows milk Soy burgers, soy cheese, and other products can be found in many grocery stores usually in the frozen section Edamame: Sold frozen or fresh the beans can be microwaved or simmered. Tempeh: It can be used as a meat substitute, and works well in spaghetti sauce. Miso: It can be used for soup stocks or as a seasoning. 50

51 M RS. C OMER 48 years old Weight 158 pounds; height 54 Concerned about her cholesterol Most recent: TC 210, HDL 35, LDL 125 Watching her diet and increasing exercise Asks about adding soy to her diet to lower cholesterol Questions: How soy works to lower cholesterol Will products be harmful or make her gain weight How much soy would need to be consumed to help lower her cholesterol. 51

52 P OTENTIAL TALKING POINTS The studies related to the benefits of soy to lower cholesterol are mixed. Discuss the affects of Soy Products on weight loss or weight gain. The addition of Soy Products in place of animal protein can lead to a reduction of weight with decreased calorie/fat consumption An excess intake of any food can lead to weight gain. Define the amount of Soy Products that should be consumed in a healthy diet. Individualized ---- Some studies involved very large quantities of soy foods for benefit Recommended daily intake of soy products must be reasonable Soybeans offer a complete protein with nine essential amino acids; recommendation to substitute soy in place of mean/animal protein 52

53 M RS. R ICK 50 years old, with complaints of hot flashes Last pap smear normal Has not missed any periods; flow is heavier Does not want to take any medications for the hot flashes. Sister- in- law suggested use of soy milk Has been drinking the soy milk in place of cows milk for 3 weeks Has not noticed any changes in the hot flashes Would like to continue to try the soy milk She has less bloating and flatulence since drinking the soy milk Questions : Will substitution of soy milk for cows milk have an effect on her bones. Is there any evidence to support the use of soy products to alleviate her peri-menopausal symptoms? How long would she have to use the soy products before noticing a difference. 53

54 P OTENTIAL TALKING POINTS Two soy isoflavones (genistein and diadzein) believed to help the symptoms associated with peri- menopause and menopause Effects of soy on menopausal symptoms inconsistent, but decreased weekly frequency 7-40% Actions believed to related to SERM activity, blocking the negative effects of estrogen. The North American Menopause Society supports eating whole foods containing the following mg/day of isoflavones to reduce hot flashes (3- 4 glasses/day soy milk) Effects stronger with isoflavone supplements and dose related If no results at higher range, likely will not see response. Look for results after 4 weeks Ensure calcium supplementation Regarding the changes in her GI tract since switching to soy milk: may have improved some previously undiagnosed lactose intolerance. Increased amounts of soy milk could cause digestive problems similar to ingestion of other legumes. 54

55 S UMMARY Soybeans provide a high protein, low fat option Studies regarding the dietary effects of soybeans and soy products on specific conditions heterogeneous with varied results Current FDA recommendations to include 25 g of whole soy protein may decrease risk of heart disease Other potential benefits of soy products may include decreased menopausal hot flashes, maintenance of bone density, and prevention of certain malignancies 55

56 S UMMARY A large number of conditions have dietary interventions that should be considered There is a growing awareness of and interest in soy products HCPs should be prepared to discuss dietary measures with patients, using an individualized approach and reflecting relevant evidence 56

57 P OST T EST The post-test for this activity is located on the AANP CE Center. Credit earned by successful completion of the online post-test. 70% or higher score required. 57


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