INSIDE THIS ISSUE: Page 2 - Letter to theEditor - Transitions; WeAsked an Expert - Vision Page 3 - An Introductionto Pelvic Floor Health Page 4 - CollaborativeEfforts to Provide Free Safe for your Baby? Car Seats to Syrian and of itself. A current prevailing hypothesis to O ver the last decade been an explosive
Soy nutritional profile and health impact ades.pdf
balanced diet promotes more than good body function, it is an important way to provide
vitality and well-being. A good variety of foods should deliver all the nutrients necessary for
Aa healthy body in a practical, delicious and creative way. vzv A healthy and fun diet is important
for everybody, but particularly those who experience the stress of modern life and lack of time. The increasing knowledge provided by nutrition science motivates the population to adopt balanced diets and healthier habits. There are many sources of inspiration for a healthy diet: nutrition guidelines, research into eating habits and new food products whose development is based on the latest scientiﬁc insights. Aligned with this trend, Unilever has a team of professionals and specialists, including food engineers, dietitians and biologists, dedicated to the development of its products and the communication of their beneﬁts. AdeS® is a result of their commitment. As a synonym for the soymilk category in Latin America, AdeS®
has been offering the beneﬁts of soy for 20 years.
AdeS® is a line of soy-based beverage that, in addition to being naturally lactose and cholesterol free,
offers delicious ﬂavors and nutrients that can contribute to the family diet throughout the day.
This material contains important information about soy, including its nutritional characteristics and health beneﬁts. Enjoy! AdeS® team
The Nutritional Profile of Soy
Although soy and soy products are beneﬁcial for cardiovascular and overall health due to their The Nutritional Profile of Soy
high content of protein, polyunsaturated fats, ﬁber, vitamins and minerals and low saturated fat content, the consumption of soy remains low. Potential reasons to explain this low consumption are a lack of knowledge of the nutritional beneﬁts of soy, the soy-based products available in the market and the delicious and creative ways that soy can be included in the diet1.
Amino acid profile of soy protein
Protein accounts for approximately 45% of the composition of soybeans1. Soy is a source of vegetable protein with a high biological value. The method established by the World Health Organization (WHO) to measure the protein quality - the Protein Digestibility Corrected Amino Acid Score (PDCAAS) - is based on human amino acid requirements and corrected for the protein's digestibility.1,2,3. When the PDCAAS is one (1), the highest score possible, it means that the protein contains sufﬁcient quantities of all the essential amino acids and has an adequate digestibility, like many animal proteins2,4. Soy protein has an adequate amino acid proﬁle and digestibility, i.e., the PDCAAS score is 12. When compared to other vegetable proteins, the quality of soy protein is superior as it has an optimal balance of essential amino acids. It can be considered the only vegetable food with a complete protein, whose quality is equivalent to that of egg albumin, the gold standard protein2,3,4. In addition to Protein
Soybeans contain 18 - 20% of lipids of which 23% are monounsaturated fatty acids, 58% polyunsaturated and 15% saturated1.
Carbohydrates contribute 35% of the nutritional value of the seed as insoluble carbohydrates from the hull (cellulose, hemi-cellulose and lignin) and soluble carbohydrates (fructose, sucrose, pectin and oligo-saccharides such as stachyose and rafﬁnose - also known as galacto-oligosaccharides or GOS). GOS have been associated with symptoms such as bloating and ﬂatulence due to the lack of the enzyme galactosidade in the human body5. Consequently GOS are not digested in the small intestine and arrive intact in the large intestine, where they are metabolized by microorganisms present in the intestinal ﬂora. As a result of this process gases, such as carbon dioxide, hydrogen, nitrogen and methane are produced, which has a direct relationship with the food supply of the intestinal microﬂora3,5. Therefore, oligossacharides, which were previously criticized for inducing gas production, are today included among prebiotic substances, associated with functional improvement of the digestive system5,6.
Soy also contains a signiﬁcant quantity of minerals, such as calcium, iron, copper, phosphorus and zinc1, and vitamins, particularly the vitamin-B complex3. The bioavailability of these micronutrients is affected by the presence of phytate, which acts as an anti-nutrient. However, it is not present in fermented soy foods and it's effects reduced in mineral fortiﬁed products6.
How to consume soy
Soy can be consumed in many ways, such as cooked beans, in salads or stews, in delicious dishes made with textured soy protein (TSP) such as soy burger, ﬁlled vegetables, strogonoff and lasagna. Other delicious and practical ways to include soy in daily diet are tofu, miso and soy beverages. The production of soy beverages
The industrial process to obtain soy extract starts with the selection of soybeans, which are then ground in water before the soluble nutrients and part of the fat are separated from the other parts of the seed in a centrifuge. The liquid obtained is soy "extract", which is then thermally treated to preserve the protein content and give the product a good ﬂavor.
During the manufacturing of AdeS®, other ingredients, such as water, fruit pulp or cacao, are mixed with the soy extract. The products are then enriched with vitamins and minerals. Before being packed, the product is homogenized and ultra-pasteurized where it is subjected to high temperatures for a few seconds followed by immediate cooling to destroy microorganisms.7,8. Because of the increase in life expectancy, modern society today faces an increasing prevalence of chronic diseases such as cardiovascular disease, diabetes, obesity, osteoporosis and cancer, which can be inﬂuenced by both by diet and lifestyle9. Evidence from various epidemiological studies associates the consumption of vegetables with the low incidence of chronic diseases. Studies have detected the presence of bioactive compounds (phytochemicals) in vegetables associated with beneﬁcial health effects6,10.
Isoﬂavones are phytochemicals that are part of a larger group, the ﬂavonoids, which are found in a large range of vegetable-based foods, particularly soy6,10. The content of isoﬂavones in soybeans is approximately 1 mg/g, but can range from 0.4 – 2.4 mg/g10.
Since their discovery in 1982, various epidemiological studies have shown that populations that consume higher quantities of soy-based foods (50 – 200 mg of isoﬂavone/day)10, such as Asian populations, present a lower risk for cardiovascular diseases, osteoporosis and some types of cancer compared to Western populations, who consume less soy (approximately 5 mg In animals, isoﬂavones can have important biological effects such as vasidilatation, reduction of blood cholesterol and inhibition of atherosclerosis11,12. The three principal types of isoﬂavones found in soy are genistein, daidzein and glycitein. The amounts of these isoﬂavones can vary depending on the type of preparation and process used13,14. For example, the use of alcohol to extract isolated protein, or other soy-derived product, can remove a signiﬁcant amount of isoﬂavones15. Isoﬂavones are found as glycosides bound to a sugar molecule (inactive form) or as aglycones (active form) 6,16.
Genistin, daidzin and glycitin. Genistein, daidzein and glycitein.
Isoﬂavones are consumed as glucosides and are later hydrolyzed to the active aglycone form by bacteria present in the small intestine. These bacteria can also metabolize the other forms of isoﬂavones: equol (low estrogenic activity) and 0-desmethylangolensin (no estrogenic activity).
Isoﬂavones are heterocyclic phenols structurally similar to the estrogenic steroids. In order to have estrogenic action, the diphenolic inactive structures of genistein (4', 5', 7' – trihydroxy-isoﬂavone - ) and daidzein (4', 7' – dihydroxy-isoﬂavone - ) are essential because the hydroxy groups and the aromatic rings of the molecules are recognized by the estradiol receptor and can produce agonist or antagonist estrogenic responses. The afﬁnity of the estrogenic receptor for genistein is 100 - 10,000 times lower than its afﬁnity for human estradiol17. Although the afﬁnity is low, it has been the subject of much research, particularly in relation to the symptoms of menopause and cancer17,18. As they function as weak estrogens, isoﬂavones may act as antiestrogens by competing with the more potent and naturally-occurring endogenous estrogens such as 17b-estradiol for binding to the estrogen receptor.
This may be the reason for the reduced risk of estrogen-dependent cancer in Asian populations that regularly consume signiﬁcant amounts of soy17,18. To cause effects in the body, isoﬂavone concentrations in the plasma need to be from 10,000 to 20,000 times higher than the level of circulating estradiol17. To date there is no evidence that the level of isoﬂavones absorbed by the human body during the normal consumption of soy affects estrogen-dependent processes. It is also unlikely that a normal consumption of soy affects the fertility of human beings or produces any adverse effect on pregnant women and the fetus18.
Less known, but also important, is the enzymatic inhibition mechanism of isoﬂavones. There is evidence that genistein may inhibit some of the enzymes that participate in steroid metabolism, such as estrogen synthetase (aromatase), tyrosine-kinase, sulfatase, sulphotransferase, 5-a reductase, 17-beta hydroxysteroid dehydrogenase and 3-beta hydroxysteroid dehydrogenase19. Results from some scientiﬁc studies show genistein to be a potential anticarcinogen due to its antioxidant and tyrosine-kinase inhibition properties20. However, the majority of these studies show tumor reduction only with very high doses of this phytochemical (10-50 μM). Therefore, further studies are required to prove its effect20.
With respect to antioxidant action, some studies have shown that isoﬂavones neutralize free radicals therefore reducing oxidation, principally of LDL - cholesterol21. Despite this, the evidence for the beneﬁts of isoﬂavones on cardiovascular health is still not conclusive. Around 19 studies with isoﬂavones showed no effect on LCL - cholesterol and other risk factors for cardiovascular diseases15. The beneﬁts of soy on cardiovascular health may be due to soy protein rather than isoﬂavones.
Although there is some evidence associating isoﬂavones with health beneﬁts, the American Heart Association does not recommend the consumption of isoﬂavone supplements because the efﬁcacy and safety of isoﬂavones in the prevention or treatment of different types of cancer, such as breast, endometrium and prostate cancer, have not been established yet. The reduction in risk factors for cardiovascular desease and menopause symptoms are still not conﬁrmed15. Soy and Health
The health effects of soy have gained considerable attention from the scientiﬁc community, especially for its potential role in improving the blood lipid proﬁle, one of the important risk factors for cardiovascular disease. There are also other interesting results linking soy to potential beneﬁts for diabetes, obesity, osteoporosis, cancer, menopause and lactose intolerance. Cardiovascular disease is the number one cause of death globally and is projected to remain the leading cause of death. An estimated 17.5 million people died from cardiovascular disease in 2005, representing 30% of all global deaths. The overall number of deaths caused by CVD has been increasing and if appropriate action is not taken, by 2015, an estimated 20 million people will die from cardiovascular disease every year, mainly from heart attacks and strokes23,24.
According to the World Health Organization, lifestyle changes associated with urbanization, industrialization and globalization are the key causes of this situation. Amongst the main risk factors identiﬁed by epidemiological studies is dyslipidemia. Nutritional therapy can play an important role in the prevention and/or treatment of dyslipidemia23. Anderson et al. conducted a meta-analysis of 38 studies that showed a signiﬁcant reduction in total cholesterol (9.3%) , LDL - cholesterol (12.9%) and triglycerides (10.5%) in patients whose diets contained soy protein in place of animal protein25.
Meta-analysis of 38 studies with soy25
Soy and Health
Source: Adapted from Anderson et. al., 1995.
Based on this data, the Food and Drug Administration (FDA)26 in the United States approved a labeling claim that foods containing soy protein can protect against coronary heart disease. The FDA based this decision on clinical studies showing that at least 25 g per day of soy protein lowered total and LDL cholesterol as part of a diet reduced in saturated fat and cholesterol26. In a more recent meta-analysis, Anderson et. al. showed that 2 or 3 servings of soy products throughout the day seem to be more effective than a single dose27.
The results of recent studies on which component of soy is responsible for its health effects are conﬂicting, demonstrating the importance of continued investigations into soy and its role in cardiovascular health29. Weggemans & Trautwein published a meta-analysis in 2003 that concluded that the beneﬁcial changes in the LDL and HDL - cholesterol proﬁles associated with soy consumption do not depend on isoﬂavone content29.
However, a 2005 meta-analysis of 23 studies evaluated by Zahn30, showed that the consumption of soy protein with isoﬂavones improves lipid proﬁle with signiﬁcant reductions in total cholesterol, LDL - cholesterol and triglycerides and an increase in HDL - cholesterol. Nevertheless, the positive effects of soy on lipid proﬁle and consequently, its protective effect on the cardiovascular system are attributed mainly to soy protein rather than isoﬂavones15,31.
In 2006, after assessing 22 randomized trials, the American Heart Association (AHA), in a position statement, did not rule out beneﬁts of soy on cardiovascular and general health based on the nutritional proﬁle of soy as a whole: vegetable protein, polyunsaturated fatty acids, ﬁbers, vitamins, minerals and low of saturated fat content15. In Brazil, a clinical trial conducted by the Federal University of São Paulo and the Dante Pazzanese Institute of Cardiology and published in 2004, examined the inﬂuence of AdeS® Original Light, a beverage made with soy extract, compared with skimmed cow's milk32. Sixty hypercholesterolaemic patients following a diet based on the AHA recommendations, i.e., up to 30% total fat and 10% saturated fat, were evaluated. The diet with the soy beverage resulted in the best lipid proﬁle, with a decrease in LDL - cholesterol and an increase in HDL - cholesterol, in addition to reduced lipid peroxidation32.
P<0.05 Source: Adapted from Bricarello et al., Nutrition, 200432.
Furthermore, interesting, although inconclusive, data suggests that soy can promote coronary beneﬁts independent of its effect on lipid concentrations.
There is some evidence that soy reduces the size of LDL - cholesterol particles, improves the endothelium function, reinforces arterial elasticity and inhibits the oxidation of LDL - cholesterol27. The Rotterdam study33 indicated that the consumption of soy protein could be associated with the enhancement of arterial elasticity, as opposed to the stiffness characteristic of atherosclerosis. Three-hundred hypertensive Chinese who consumed 40 g of soy protein daily for 12 weeks showed a reduction in blood pressure33. The latest review published by Anderson27 indicates that the effects of soy on the cardiovascular system, including the lower oxidation of LDL - cholesterol and triglycerides, lower platelet aggregation and less inﬂammation, could be mediated by peptides produced during protein hydrolysis in the intestine27. As cardiovascular disease can be asymptomatic and many individuals ignore their blood cholesterol and triglycerides levels, it is worth emphasizing that including foods with soy protein in the diet can improve the lipid proﬁle of the population23, 27, 29, 30, 32, 33.
Lactose intolerance and cow's milk allergy
Intolerance to lactose (the sugar present in of cow's milk) is characterized by the deﬁciency of the intestinal enzyme lactase34,35. Individuals with lactose intolerance present symptoms such as abdominal cramps, vomiting and diarrhea, which are relieved with the withdrawal of dairy products34. The mechanisms involved in cow's milk allergy are different from those found in lactose intolerance.
Various proteins can cause allergy, but those from milk and eggs are the most common. They cause greater problems for young children due to the increased production of immunoglobulins against the different allergenic sites in these proteins. There is a wide range of symptoms, including gastrointestinal, respiratory, ocular, neurological and skin problems. 36, 37. Soy-based beverages can be a dietary alternative for both lactose intolerance and cow's milk allergy for children, as long as they follow clinical and nutritional recommendations for adequate energy and nutrient intake38. Surveys conducted in Latin American and Caribbean countries in 2002 found that 50 - 60% of adults and 7 - 12% of children under 5 years of age were overweight or obese. In Argentina, Colombia, Mexico, Paraguay, Peru and Uruguay, more than half of the population is overweight and over 15% obese. Between now and 2015, the prevalence of overweight in the Americas is expected to increase in both men and women39. Some clinical trials that studied the impact of soy-based foods in place of conventional foods indicated weight loss in both animals and humans40. In 2006, an estimated 35 million people in the Americas were diabetic—a number that is projected to increase to 64 million by 202539. Diet can play an important role in the prevention and management of the disease. For individuals with diabetes, the inclusion of soy protein compared to a diet based exclusively on the recommendations of the American Diabetes Association promoted increased weight loss42.
Beneﬁcial changes were also observed in the glycaemic proﬁle, showing that a diet based on soy protein could be an interesting strategy for weight loss and blood glucose management42. One study showed that, when compared to the milk protein casein, soy protein enhanced insulin sensitivity and glucose effectiveness43.
A randomized study that examined the lipid proﬁle and the renal function of patients with diabetes type 2 and nephropathy showed that the consumption of soy milk resulted in a decrease in total cholesterol, LDL - cholesterol and triglycerides, in addition to improving the levels of urea and proteinuria44. The inclusion of soy in the diet modiﬁed the risk factors for Coronary Artery Disease (CAD) and improved renal function in these patients44. Populational and experimental studies suggest that soy can have a positive impact on the reduction of bone mass after menopause45. Various studies have shown a strong association between the high consumption of soy and bone density in women due to the decreased urinary excretion of calcium caused by either the reduced presence of sulphur-containing amino acids in soy protein or unknown mechanisms related to isoﬂavones46, 47, 48.
A study with more than 24,000 Chinese women in the perimenopause showed a decreased fracture risk49. Another study which evaluated 500 Japanese children for ﬁve consecutive years (from 10 to 15 years of age) also showed a positive effect of soy consumption on bone density50. However, the duration and sample size of these two studies were not sufﬁcient to give conclusive results45,51.
The hypothesis that the consumption of soy has an impact on the prevalence of breast and endometrium cancer is based on their low incidence in Asian women and because soy isoﬂavones demonstrated beneﬁts in animal models52,53. To date, epidemiological evidence is not conclusive - some studies suggest a lower incidence of breast cancer in populations that consume diets rich in soy protein whereas other studies did not ﬁnd an association52, 54, 55, 56. The exact mechanism of this potential protective effect still needs to be clariﬁed, but isoﬂavones are probably involved49, 57, 58, 59.
Contrary to this, some scientists have suggested that the estrogenic effect of isoﬂavones increases the risk for breast and endometrial cancer57, 58. However, only one out of 15 recently published clinical trials that studied the effect of isoﬂavones on endometrial tissue showed a relationship with an increased risk of endometrial cancer57. This study investigated the effects of isoﬂavone supplements on endometrial tissue and not soy-based foods, so the observed effects may not necessarily apply to foods. Therefore, there is no contra-indication for the consumption of soy products by women who present risk for breast cancer or by women who already have this disease, according to the results from studies in humans and animals58, 59, 60. In conclusion, the beneﬁts of soy in relation to cancer are not proven and further studies are required15.
Soy and Balanced Diet
Soy has been grown in China and Korea for more than 2,000 years. Although Western countries are the major producers and are responsible for meeting the demand of Eastern countries, the consumption of soy is still low in the West compared to Asian countries61. However, soy has really been appreciated since the beginning of this century as science has started to show that it has a good nutritional proﬁle, especially due to the beneﬁts associated with its optimal protein proﬁle.62 - as has been shown in the previous chapters. With the introduction of new growing techniques, the reduction of the characteristic soy taste after processing and, consequently, the introduction of new soy products in the market, soy has started to be consumed in other countries, contributing to the promotion of a more balanced diet61. Most part of the protein consumed in western diets comes from animal sources, such as meat, milk and eggs, and has a high biological value because it contains all the amino acids essential for our health - unlike vegetable proteins. However, the content of saturated fat in foods of animal origin is high and this is associated with increased LDL - cholesterol62,63,64.
Soy has some advantages compared to foods of animal origin and compared to legumes, like beans and lentils, because, unlike other vegetable foods, it contains protein with a high biological value comparable to animal protein65, but with a lipid proﬁle characteristic of grains: a high level of polyunsaturated and monounsaturated fat and low level of saturated fat, with no cholesterol.
For this reason, the American Heart Association considers soy as a food with good nutritional proﬁle for cardiovascular health15.
Furthermore, studies that show a relation between the consumption of soy protein and a decrease in LDL - cholesterol and increase in HDL - cholesterol32 also encourage the inclusion of soy in the diet. On the other hand, although soy isoﬂavones have been extensively studied15, research on their role is still inconclusive. This is why the inclusion of soy in the diet is recommended for the beneﬁts associated with its protein and its content of mono and polyunsaturated fat. Soy and Balanced Diet
Because it combines these unique features in its nutritional proﬁle, soy and soy products have been considered an ally of physicians and dietitians in their recommendations for a balanced diet. The combination of soy with other foods with an appropriate nutritional proﬁle may produce effects that enhance the overall health beneﬁts, particularly with respect to cardiovascular health. Clinical trials have shown that soy combined with viscous ﬁber, plant sterol and almonds as part of a balanced diet decreased LDL - cholesterol and optimized the already proven effects of margarine with phytosterols66. In order to meet the current needs of society, nutrition science has progressed. Today it is known that a balanced diet with a variety of different coloured vegetable foods that are sources of vitamins, minerals, ﬁbers and phytochemicals64 can improve several body functions, such as decrease LDL - cholesterol levels64,68 and consequently help to reduce the risk of some chronic diseases64. These foods provide much more than just energy and macronutrients such as protein or fat because they provide unique bioactive compounds that make them functional foods28. This is the case for soy protein, phytosterols, and possibly isoﬂavones.
Anyhow, the habit of including foods with a better nutritional proﬁle such as soy beans and soy products should not be an isolated action, but rather be part of a balanced diet that takes the culture and social life of individuals into consideration, i.e., nutrition combined with eating pleasure. Knowing how to introduce soy in the diet is the ﬁrst step in increasing its consumption: • At breakfast and as snacks: soy beverage is a nutritious drink option. A 200-mL glass provides 6.25g of soy protein, 25% of the daily quantity recommended to help to reduce LDL - cholesterol levels. • At main meals with all the family, soy can be consumed in many different ways: soy beverage can be used as a culinary ingredient in different recipes such as dressings, ﬁllings, doughs and desserts. When cooked, soybeans can be used to prepare a more nutritious salad or soup. As textured soy protein, soy can replace ground beef in traditional recipes such as kibbe, stuffed eggplant or sauces for pasta and lasagna. Soy meat cubes are often used in vegetarian dishes such as strogonoff and feijoada (a typical Brazilian dish with meat, pork and black beans).
Soy beverages can be an option to treat both cow's milk allergy and lactose intolerance in adults and children over than two years of age, with appropriate clinical and nutritional guidance regarding the adequate intake of energy and the other nutrients70. For healthy individuals, the inclusion of soy-based foods in the diet should not exclude milk or meat-based foods. On the contrary, it is a way to balance the amount of good fat, vitamins, minerals and ﬁbers in the diet15.
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Current Concepts age of 40 years10 and are increasingly seen in youngchildren.11 Eating disorders are more prevalent inindustrialized societies than in nonindustrialized so-cieties and occur in all socioeconomic classes and major ethnic groups in the United States.12-14 Thedisorders appear to be caused by a combination of ANNE E. BECKER, M.D., PH.D., STEVEN K. GRINSPOON, M.D., ANNE KLIBANSKI, M.D.,