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Does Intake of Bread Supplemented with Wheat Germ Have a Preventive Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-023662 on 17 January 2019. Downloaded from Does intake of bread supplemented with wheat germ have a preventive role on cardiovascular disease risk markers in healthy volunteers? A randomised, controlled, crossover trial. André Moreira-Rosário,1,2 Helder Pinheiro,3,4 Cláudia Marques,1,3 José António Teixeira,5 Conceição Calhau,1,3 Luís Filipe Azevedo1,2 To cite: Moreira-Rosário A, ABSTRACT Strengths and limitations of this study Pinheiro H, Marques C, Objective Intake of whole grains is associated with et al. Does intake of bread a reduced risk of cardiovascular disease (CVD). This supplemented with wheat ► This study followed the best practices for designing, evidence is also strong for bran alone, but findings about germ have a preventive role conducting and reporting clinical trials to support on cardiovascular disease risk germ are conflicting. Our aim was to elucidate the role health claims on food products, namely random al- markers in healthy volunteers? of germ in primary prevention of cardiovascular events, location, double blinding, reporting methods to mea- A randomised, controlled, and therefore, a staple food was selected for 6 g of germ sure and maximise compliance. crossover trial.. BMJ Open supplementation. This corresponds to sixfold increase in ► We used validated outcomes which are considered 2019;9:e023662. doi:10.1136/ the global mean consumption of germ, while preserving beneficial physiological effects for human health. bmjopen-2018-023662 the sensory proprieties of refined bread which is crucial for ► To the best of our knowledge, this is the largest ► Prepublication history and consumer’s acceptance. study to assess the impact of germ intake in human additional material for this Design Randomised, double-blinded, crossover, controlled subjects. paper are available online. To clinical trial with 15-week follow-up comprising a 2-week ► Although compliance was high, it is uncertain view these files, please visit run-in, two intervention periods of 4 weeks each and a whether this is due to over-reporting, since there is the journal online (http:// dx. doi. 5-week washout period. no biomarker for wheat germ intake. org/ 10. 1136/ bmjopen- 2018- A longer intervention period would be desired for http://bmjopen.bmj.com/ 023662). Setting A single centre in the north of Portugal. ► Participants 55 eligible healthy adults (mean age of 34 evaluating an effect on lipoprotein cholesterol, Received 20 April 2018 years and body mass index between 19 and 38 kg/m2) nonetheless could have a major impact on loss to Revised 27 August 2018 were randomly assigned. follow-up in this crossover study. Accepted 19 October 2018 Interventions The study consisted of two intervention periods including daily intake of refined wheat bread enriched with 6 g of wheat germ and control (non-enriched INTRODUCTIOn bread). Outcomes Changes in fasting cholesterol and Cardiovascular diseases (CVD) remain the on September 26, 2021 by guest. Protected copyright. triglycerides, fasting and postprandial glucose, insulin leading cause of mortality in the world, sensitivity and C reactive protein. having accounted for 15 million of deaths in 1 Results We observed no significant effect of daily intake 2015. Risk factors for CVD are well-identified of wheat germ on cholesterol and triglycerides levels, on and they include smoking, type 2 diabetes postprandial glucose response and on insulin sensitivity. or high glucose levels, hypertension and Incremental area under curve glucose and homeostasis elevated cholesterol levels.2 Diet is therefore model assessment for insulin resistance did not change, an important modifiable risk factor for CVD suggesting that 6 g of wheat germ have no effect on and, within the diet, some dietary components © Author(s) (or their glucose metabolism. No effect was also observed in the may have an important preventive role.3–5 In employer(s)) 2019. Re-use subgroup of participants who complied with the protocol this regard, cereal whole grains are a prom- permitted under CC BY-NC. No (n=47). commercial re-use. See rights ising protective measure due to emerging and permissions. Published by Conclusions The absence of alterations on lipid and evidence of an inverse association between BMJ. glucose profiles suggests that germ up to 6 g/day may their intake and CVD risk as shown by recent For numbered affiliations see have no preventive effect on CVD risk. However, it is systematic reviews and meta-analyses.5–8 The important to investigate other food vehicles that can end of article. role of whole grains in reducing CVD risk is accommodate higher doses of wheat germ in future broader: (1) by improving glucose metabo- Correspondence to studies. lism through better postprandial glucose and André Moreira-Rosário; Trial registration number NCT02405507. andrerosario@ med. up. pt insulin responses9; and (2) by reductions in Moreira-Rosário A, et al. BMJ Open 2019;9:e023662. doi:10.1136/bmjopen-2018-023662 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-023662 on 17 January 2019. Downloaded from plasma cholesterol levels.10 The health benefits associated through public advertisements in the University and with whole grains intake seem to be mediated by their Faculty websites and in online newspapers. The detailed high content in plant-derived redox-active compounds study protocol has been previously described.34 Briefly, that may activate antioxidant pathways and thereby have volunteers were invited to visit our Research Unit anti-inflammatory proprieties.11 (CINTESIS) for a physical examination and a brief ques- Cereal whole grains are distinguished from refined tionnaire about their medical history and background grains by the presence of bran and germ fractions. diet in order to check their eligibility to participate in the These two fractions accumulate higher amounts of study. Inclusion criteria included subjects aged 18 to 60 protective bioactive compounds, such as fibres, micro- years old, non-diabetics and non-smokers. The exclusion nutrients, vitamins and phytochemicals. CVD prevention criteria included the use of medication/dietary supple- has been associated with bran intake,7 12–15 but findings ments, potentially interfering with this trial, not willing about germ are conflicting.7 16 Recent systematic reviews to avoid prebiotics and probiotics for the duration of the addressing prospective studies reported no inverse asso- study, and change of dietary habits within the 4 week prior ciation between germ intake and CVD risk, in contrast to screening (for instance, to start a diet high in fibre). In with prior clinical trials involving high-risk groups. But the protocol manuscript, we described sample size calcu- these two types of studies report different amounts of lations. Briefly, we calculated the sample size for each germ intake. The meta-analyses of the prospective studies individually primary outcome, taking into account the reported a low germ intake (1 g/day average ranging difference in mean change from baseline and the respec- from 0.2 to 2.9 g/day),17–19 while the intervention studies tive SD. The sample size of the study was determined by used a daily supplementation of 20 or 30 g/day during the outcome that required the highest number of partici- the 4-week period. Specifically, these clinical trials showed pants. Accordingly, 40 participants were required to allow that intake of raw wheat germ can reduce cholesterol and for an 80% power and 95% confidence level.34 triglycerides in rats20–22 and also in hypercholesterolaemic The study protocol was approved, and all participants and hypertriglyceridaemic humans.23 24 provided written informed consent. The clinical trial Dietary guidelines around the world recommend 85 g was conducted from June 2015 to October 2016, in daily intake of whole grains,25 which contains nearly 2.6 g accordance with ethical principles of the Declaration of of germ. However, their daily consumption is far below Helsinki, international law and Good Clinical Practice the recommendations and consumers prefer highly guidelines. This study is registered in ClinicalTrials. gov refined products.26–28 In fact, supplementation with database, reference NCT02405507, and followed the whole-grain ingredients is therefore an elegant way to CONSORT reporting guidelines (see online supplemen- overcome consumer’s preferences while it contributes tary table S1). for public health, as long as these ingredients are indeed beneficial. Clarification of the physiological effects of Patient and public involvement http://bmjopen.bmj.com/ germ is needed. However, fortification of food products Before recruitment, volunteers that did not participate in with germ is challenging because germ becomes rancid the study were invited to be involved in the development very rapidly due to high content in unsaturated lipids of the bread formula used in this trial. They had no role together with lipases and lipoxygenases,29–31 and it also in setting the research question, the outcome measures, negatively affects the sensory properties of the final food the design or implementation of the study. We included product.32 Thus, in order to address these specificities, inputs from the participants of the study, namely any germ stabilisation33 is necessary immediately after milling burden associated with the procedures, throughout the to inhibit enzymatic rancidity, while the percentage of follow-up in order to optimise their involvement
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