The Heart Health Benefits of Dietary Fiber

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Conclusions. Heart disease continues to be one of the most factors for cardiovascular disease, including blood pressure, weight, widespread health problems in the United States. Fortunately, it is and glucose levels. Not all fibers provide the same cardiovascular ™ also among the most preventable health problems. To that end, benefits; however, and differences among the various types of fibers Expert Views Americans are encouraged to adopt heart-healthy habits, which should be appreciated when choosing a fiber supplement. Psyllium include a healthy diet and regular exercise.7 In addition to being an and oat fibers are the only fibers that have been recognized by the GI Health & Wellness | issue four | february 2011 important part of a healthy diet, dietary fibers provide a number of FDA for their cholesterol-lowering and cardiovascular benefits, while cardiovascular benefits. The cholesterol-lowering benefits of certain other fibers such as calcium polycarbophil are indicated for their fibers (psyllium and oat fibers) as adjunct to a low-fat diet are well- laxation effects. An understanding of these differences should allow features: the heart health benefits of recognized and have been demonstrated in numerous well-controlled physicians and patients to tailor their choice of dietary fiber and fiber trials. Further, dietary fibers have beneficial effects on other key risk supplements to better meet their individual health goals. One dietary fiber CHD Prevalence February is American Heart Health Month Cholesterol Lowering Benefits Heart disease remains the leading cause of death in the United States, with someone dying from a Two heart-related event every 34 seconds.1 Cardiovascular disease accounts for over 20% of reported cases of Postprandial Glucose chronic diseases in America, surpassing other major chronic diseases such as pulmonary conditions (17.4%), Weight Control diabetes (4.9%), mental disorders (10.7%), and cancer (3.7%).2 Nine out of ten patients with heart disease Daily Fiber Requirements have at least one risk factor for heart disease, with about 1 in 6 Americans reported to have high cholesterol (ie, hypercholesterolemia: meta-analysis of 8 controlled trials. Am J Clin Nutr. total cholesterol >240 mg/dL)3 and 1 in 3 having high blood pressure.4 In addition, obesity—a major risk factor 2000;71:472-479. Three references for heart disease—has increased dramatically during the past 20 years in the United States, with only two states 1. Centers for Disease Control and Prevention. Heart disease fact sheet. 13. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber with Not All Fibers Are Created Equal currently having a prevalence less than 20%.5 Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_ simvastatin in lowering cholesterol. Arch Intern Med. 2005;165:1161-1166. Health Benefits Vary By Fiber disease.htm. Accessed November 7, 2010. 14. Moreyra AE. Personal communication. Practical Considerations In an effort to raise awareness about heart disease and encourage Americans to adopt healthier lifestyles, 2. Milken Institute. The economic burden of chronic disease on the United 15. Anderson JW, Davidson MH, Blonde L, et al. Long-term cholesterol- For Fiber Supplementation February has been proclaimed American Heart Month.6,7 In keeping with these goals, dietary fibers are lowering effects of psyllium as an adjunct to diet therapy in the treatment of States. Available at: http://www.chronicdiseaseimpact.com. Accessed Four increasingly recognized for their heart-healthy benefits, which include proven cholesterol-lowering effects as well November 30, 2010. hypercholesterolemia. Am J Clin Nutr. 2000;71:1433–1438. as beneficial effects on key risk factors such as weight and glucose levels.8,9 3. Centers for Disease Control and Prevention. Cholesterol fact sheet. Available 16. Ziai SA, Larijani B, Akhoondzadeh S, et al. Psyllium decreased serum Conclusions The insights of Abel Moreyra, MD, Professor of Medicine, Division of Cardiology at UMDNJ-Robert Wood at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm. glucose and glycosylated hemoglobin significantly in diabetic outpatients. Johnson Medical School of New Brunswick, New Jersey are featured in this publication. Accessed November 7, 2010. J Ethnopharmacol. 2005;102:202–207. 4. Centers for Disease Control and Prevention. Blood pressure fact sheet. 17. Landin K, Holm G, Tengborn L, Smith U. Guar gum improves insulin Dr. Moreyra is a Fellow of the American College of Physicians and the American College of Cardiology and he Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_ sensitivity, blood lipids, blood pressure, and fibrinolysis in healthy men. is a member of the American Heart Association. He has authored over 70 peer-reviewed publications, and has bloodpressure.htm Accessed November 7, 2010. Am J Clin Nutr. 1992;56:1061-1065. conducted research using fiber supplementation in the management of hyperlipidemia. 5. Centers for Disease Control and Prevention. US obesity trends. Available 18. Position of the American Dietetic Association: Health implications of at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm. dietary fiber. J Am Diet Assoc. 2002;102:993-1000. Accessed November 7, 2010. 19. Institute of Medicine of the National Academies. Dietary reference intakes: dietary fiber and cardiovascular health 6. American Heart Association. American Heart Month. Available at: macronutrients. Available at: http://iom.edu/Reports/2002/Dietary-Reference- http://www.americanheart.org/presenter.jhtml?identifier=4441. Accessed Intakes-for-Energy-Carbohydrate-Fiber-Fat-Fatty-Acids-Cholesterol-Protein- CHD Prevalence. Epidemiologic studies over the past several decades have associated high levels of dietary November 23, 2010. and-Amino-Acids.aspx. Accessed November 24, 2010. fiber intake with a lower prevalence of coronary heart disease (CHD).9 A review of seven prospective cohort 7. The White House. Office of the Press Secretary. Presidential 20. United States Department of Agriculture. Dietary Guidelines Advisory studies demonstrated that the prevalence of CHD was 29% lower among persons with the highest dietary fiber proclamation-American Heart Month. Available at: http://www.whitehouse.gov/ Committee. Report of the Dietary Guidelines Advisory Committee on the intake compared with those with the lowest intake.9 the-press-office/presidential-proclamation-american-heart-month. Accessed Dietary Guidelines for Americans, 2010. Appendix E-1: Major conclusions: November 24, 2010. Section 1: Energy balance and weight management. Available at: Faculty Cholesterol Lowering Benefits.Recognizing low-density lipoprotein (LDL)-cholesterol, and serum 8. Anderson JW, Allgood LD, Turner C, Oelgten PR, Daggy BP. Effects of http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/ Abel Moreyra, MD the scientific evidence supporting the cholesterol- ratios of apolipoprotein (apo) B to apo A-I beyond psyllium on glucose and serum lipid responses in men with type 2 diabetes E-Appendix-E-1-Conclusions.pdf. Accessed November 30, 2010. lowering benefit of viscous soluble fibers, the U.S. reductions seen with low-fat diet only.12 Psyllium and hypercholesterolemia. Am J Clin Nutr. 1999;70:466–473. 21. Park Y, Hunter DJ, Spiegelman D, et al. Dietary fiber intake and risk of Professor of Medicine 9. Anderson JW, Baird P, Davis RH, et al. Health benefits of dietary fiber. colorectal cancer: a pooled analysis of prospective cohort studies. JAMA. Division of Cardiology Food and Drug Administration (FDA) has authorized did not significantly lower high-density lipoprotein Nutr Rev. 2009;67:188-205. 2005;294:2849-2857. UMDNJ-Robert Wood Johnson the use of a health claim in the labeling of foods and (HDL)-cholesterol or triglycerides. Similar reductions 10. Food and Drug Administration, US Department of Health and Human 22. Anderson JW. All fibers are not created equal. J Med. 2009;2:87-91. Medical School dietary supplements containing psyllium (and oat) in cholesterol have been found in high-quality Services. Code of Federal Regulations, Title 21, Volume 2, Section 101.81. 23. National Fiber Council. Fiber and your heart. Available at: New Brunswick, New Jersey fibers regarding the potential for these fibers to controlled studies with oat fibers.8,9 In one 12-week, Health claims: Soluble fiber from certain foods and risk of coronary heart http://www.nationalfibercouncil.org. Accessed November 23, 2010. reduce the risk of heart disease.10 Indeed, many controlled study, the addition of psyllium to a low disease (CHD). Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ 24. Pastors JG, Blaisdell PW, Balm TK, Asplin CM, Pohl SL. Psyllium fiber dose of simvastatin (10 mg) achieved the same LDL- reduces rise in postprandial glucose and insulin concentrations in 13 patients short-term (4-8 week) controlled trials have shown that cfcfr/CFRSearch.cfm?fr=101.81. Accessed November 23, 2010. Supported by 11. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol lowering effects with non-insulin-dependent diabetes. Am J Clin Nutr. 1991;53:1431-1435. dietary fiber intake, in conjunction with low-fat diets, cholesterol and apo B-lowering effects as doubling the 25. Sierra M, Garcia JJ, Fernandez N, et al. Therapeutic effects of psyllium 11,12 simvastatin dose in 68 patients who met the National of dietary fiber: a meta-analysis. Am J Clin Nutr. 1999;69:30–42. Personal Health Care reduces serum cholesterol. A meta-analysis of 8 12. Anderson JW, Allgood LD, Lawrence A, et al. Cholesterol-lowering in type 2 diabetic patients. Eur J Clin Nutr. 2002;56:830-842. randomized, controlled trials (RCTs) found that psyllium Cholesterol Education Program Adult Treatment Panel effects of psyllium intake adjunctive to diet therapy in men and women with 26. Data on file. Procter & Gamble. fiber significantly lowered total cholesterol, III criteria for drug treatment of hyperlipidemia and dietary intervention.13 Commenting on these results, Dr. Moreyra added that “instead of Not All Fibers Are Created Equal. The many types of available Psyllium and oat bran fibers reduce cholesterol, maintain a “While statins are very effective medications, patients escalating the statin dose, the ability to achieve similar cholesterol- fiber supplements differ in their chemical properties, processes healthy blood glucose level by modulating postprandial glycemia, may be resistant to taking medications and look for lowering effects by adding fiber was very appealing to patients.”14 used to extract their ingredients, and their physiologic effects (Table and help maintain healthy weight.22 In contrast, because wheat alternative strategies. Certainly, adding fiber as an Longer-term studies suggest that fiber can play an important role 1). Fibers can be classified as soluble fibers, which dissolve in water dextrin does not form a gel and trap cholesterol or waste to any alternative to escalating the dose of a statin was very in sustaining cholesterol-lowering benefits, with the use of psyllium and are readily fermented in the colon into gases; and insoluble significant extent, it does not affect cholesterol, blood pressure, appealing to patients.” -Dr. Moreya shown to maintain LDL-cholesterol reduction for up to 6 months fibers, which do not dissolve in water, are only fermented to a limited weight, or laxation..22 Other fibers provide selective benefits, such (Figure 1).15 extent and move quickly through the colon, and absorb water to as prebiotic/immune-enhancing effects with inulin and laxation increase stool bulk.9,23 Soluble fibers can be further divided into effects with calcium polycarbophil.9,22 Figure 1. Mean (± SEM) percentage change from baseline in serum lipid concentrations during treatment with diet alone (weeks -8 to -1) viscous (ie, gel-forming) or nonviscous types. Soluble viscous fiber 15 followed by diet plus psyllium (------) or placebo (——). supplements are typically made from psyllium or ispaghula husk, Practical Considerations For Fiber Supplementation. while soluble nonviscous fibers are typically composed of inulin Recognizing the different properties and health benefits of various TotalTotal cholesterol TotalCholesterol cholesterol LDLLDL-Cholesterol cholesterolLDL cholesterol methylcellulose, partially hydrolyzed guar gum, wheat dextrin, or fibers, individual health goals should be considered when choosing 8 8 10 10 acacia. Most dietary fibers in fruits, vegetables and whole grains a fiber supplement. Owing to their cholesterol-lowering properties,

6 6 8 8 are not exclusively soluble or insoluble, however, but rather are a psyllium or oat fibers are good choices to promote cardiovascular mixture of both types. health. When beginning a fiber supplement regimen, patients 6 6 4 4 should be counseled to expect some bloating, gas, and changes in 4 4 Health Benefits Vary By Fiber. The physiologic effects—and bowel function. 2 2 health benefits—vary among different fibersTable ( 1). Viscosity and 2 2 0 0 fermentability are associated with cardiovascular benefits due to Diets low in saturated fat and cholesterol that include 7 0 0 their ability to form a gel-like substance that helps trap sugars, fats, grams of soluble fiber per day from psyllium, as found in -2 -2 and cholesterols in the upper intestine and transport them through ® -2 -2 Metamucil , may reduce the risk of heart disease by lowering Change from baseline (%) Change from baseline (%) Change from Change from baseline (%) Change from baseline (%) Change from 22,23 the gastrointestinal tract. 10 -4 -4 cholesterol. -4 -4

-6 -6 -6 -6 -12 -8 -12-4 -80 -44 0 8 412 816 1220 1624 2028 24 28 -12 -8 -12-4 -80 -44 0 8 412 816 1220 1624 2028 24 28 Time (wk)Time (wk) Time (wk)Time (wk) Permission obtained from Am J Clin Nutr. 2000;71:1433-1438. Table 1. Comparison of Heart Health Benefits of Fiber Supplements9,22,26

Postprandial Glucose. Increasing evidence suggests that dietary daily fiber intake that are based on age, gender, and energy intake.19,20 Active Ingredient (Common Brand Names) fiber may help maintain a healthy blood glucose level by modulating Based on the recommended daily intake of 14 g fiber per 1,000 postprandial glycemia. Several prospective controlled studies have kcalories of food consumed, adult women (aged 19-50 years) should Property Psyllium husk Inulin Partially Methylcellulose Calcium Wheat ® ® demonstrated that the addition of a fiber supplement to a standard receive 25 g/day fiber and adult men (19-50 years) should receive (Metamucil ) hydrolyzed (Citrucel ) polycarbophil dextrin guar (FIberCon®, (Benefiber®) diet improves postprandial8 and fasting16 glucose levels compared 38 g/day.19,20 Unfortunately, Americans consume less than half of the Equalactin® , recommended daily fiber amount,21 a problem considered a substantial with placebo in patients with type 2 diabetes and normal healthy Fiberlax®) subjects.17 public health concern..20 In order to increase their fiber intake, Americans are encouraged Soluble 70-80% 100% 100% 100% 0% 100% Weight Control. In conjunction with reducing cholesterol, lifestyle to eat a well-balanced diet containing fiber-rich foods. Dietary fiber has Forms a gel Yes No No No Yes No changes that promote weight control are important in reducing the been defined as “the nondigestible carbohydrates and lignin (a complex Traps bile acids Yes No data No Yes No data No risk of heart disease. To that end, high fiber food consumption appears polymer) present in plants and isolated nondigestible carbohydrates Heart Health Benefits to have a beneficial role in weight management. In addition to creating that have physiologic effects in humans.”22 Good dietary sources a sense of fullness, high-fiber foods tend to take longer to eat, delay of fiber include fruits (eg, dried figs, pears, strawberries, apples, Helps lower Yes† No No Minimal No No gastric emptying, and bring a feeling of satiety sooner than low-fiber bananas); vegetables (eg, peas, lentils, beans, spinach); and whole blood cholesterol foods.9,18 A meta-analysis of 16 RCTs using fiber supplements in grains (eg, brown rice, oatmeal, shredded wheat, wheat bran flakes), Helps maintain Possibly No data No data No data No data No data doses ranging from 4.5 to 20 g/day demonstrated significant reduction and nuts.18 healthy weight in weight compared with placebo at 4 weeks (P=0.0063) and 8 weeks Although dietary sources of fiber also contribute vitamins, Helps modulate Yes* No data Yes No data No data Uncertain (P=0.0088).9 minerals, water, and other phytonutrients, fiber supplements can play postprandial an important role in persons who find it difficult to meet their daily blood glucose Daily Fiber Requirements. The Institute of Medicine of the National fiber intake through diet alone.9 A number of fiber supplements are Helps lower the Yes† No data No data No data No data No Academy of Science and the U.S. Department of Agriculture recognizes available over-the-counter, and these products are available in various risk of heart fiber as an important part of a healthy diet and has issued guidelines for formulations including powdered fiber, capsules, and caplets.9 disease †Diets low in saturated fat and cholesterol that include 7 grams of soluble fiber per day from psyllium husk may reduce the risk of heart disease by reducing cholesterol10 *Emerging science suggests that psyllium may modulate postprandial blood glucose levels8,16,24,25 Conclusions. Heart disease continues to be one of the most factors for cardiovascular disease, including blood pressure, weight, widespread health problems in the United States. Fortunately, it is and glucose levels. Not all fibers provide the same cardiovascular ™ also among the most preventable health problems. To that end, benefits; however, and differences among the various types of fibers Expert Views Americans are encouraged to adopt heart-healthy habits, which should be appreciated when choosing a fiber supplement. Psyllium include a healthy diet and regular exercise.7 In addition to being an and oat fibers are the only fibers that have been recognized by the GI Health & Wellness | issue four | february 2011 important part of a healthy diet, dietary fibers provide a number of FDA for their cholesterol-lowering and cardiovascular benefits, while cardiovascular benefits. The cholesterol-lowering benefits of certain other fibers such as calcium polycarbophil are indicated for their fibers (psyllium and oat fibers) as adjunct to a low-fat diet are well- laxation effects. An understanding of these differences should allow features: the heart health benefits of recognized and have been demonstrated in numerous well-controlled physicians and patients to tailor their choice of dietary fiber and fiber trials. Further, dietary fibers have beneficial effects on other key risk supplements to better meet their individual health goals. One dietary fiber CHD Prevalence February is American Heart Health Month Cholesterol Lowering Benefits Heart disease remains the leading cause of death in the United States, with someone dying from a Two heart-related event every 34 seconds.1 Cardiovascular disease accounts for over 20% of reported cases of Postprandial Glucose chronic diseases in America, surpassing other major chronic diseases such as pulmonary conditions (17.4%), Weight Control diabetes (4.9%), mental disorders (10.7%), and cancer (3.7%).2 Nine out of ten patients with heart disease Daily Fiber Requirements have at least one risk factor for heart disease, with about 1 in 6 Americans reported to have high cholesterol (ie, hypercholesterolemia: meta-analysis of 8 controlled trials. Am J Clin Nutr. total cholesterol >240 mg/dL)3 and 1 in 3 having high blood pressure.4 In addition, obesity—a major risk factor 2000;71:472-479. Three references for heart disease—has increased dramatically during the past 20 years in the United States, with only two states 1. Centers for Disease Control and Prevention. Heart disease fact sheet. 13. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber with Not All Fibers Are Created Equal currently having a prevalence less than 20%.5 Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_ simvastatin in lowering cholesterol. Arch Intern Med. 2005;165:1161-1166. Health Benefits Vary By Fiber disease.htm. Accessed November 7, 2010. 14. Moreyra AE. Personal communication. Practical Considerations In an effort to raise awareness about heart disease and encourage Americans to adopt healthier lifestyles, 2. Milken Institute. The economic burden of chronic disease on the United 15. Anderson JW, Davidson MH, Blonde L, et al. Long-term cholesterol- For Fiber Supplementation February has been proclaimed American Heart Month.6,7 In keeping with these goals, dietary fibers are lowering effects of psyllium as an adjunct to diet therapy in the treatment of States. Available at: http://www.chronicdiseaseimpact.com. Accessed Four increasingly recognized for their heart-healthy benefits, which include proven cholesterol-lowering effects as well November 30, 2010. hypercholesterolemia. Am J Clin Nutr. 2000;71:1433–1438. as beneficial effects on key risk factors such as weight and glucose levels.8,9 3. Centers for Disease Control and Prevention. Cholesterol fact sheet. Available 16. Ziai SA, Larijani B, Akhoondzadeh S, et al. Psyllium decreased serum Conclusions The insights of Abel Moreyra, MD, Professor of Medicine, Division of Cardiology at UMDNJ-Robert Wood at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm. glucose and glycosylated hemoglobin significantly in diabetic outpatients. Johnson Medical School of New Brunswick, New Jersey are featured in this publication. Accessed November 7, 2010. J Ethnopharmacol. 2005;102:202–207. 4. Centers for Disease Control and Prevention. Blood pressure fact sheet. 17. Landin K, Holm G, Tengborn L, Smith U. Guar gum improves insulin Dr. Moreyra is a Fellow of the American College of Physicians and the American College of Cardiology and he Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_ sensitivity, blood lipids, blood pressure, and fibrinolysis in healthy men. is a member of the American Heart Association. He has authored over 70 peer-reviewed publications, and has bloodpressure.htm Accessed November 7, 2010. Am J Clin Nutr. 1992;56:1061-1065. conducted research using fiber supplementation in the management of hyperlipidemia. 5. Centers for Disease Control and Prevention. US obesity trends. Available 18. Position of the American Dietetic Association: Health implications of at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm. dietary fiber. J Am Diet Assoc. 2002;102:993-1000. Accessed November 7, 2010. 19. Institute of Medicine of the National Academies. Dietary reference intakes: dietary fiber and cardiovascular health 6. American Heart Association. American Heart Month. Available at: macronutrients. Available at: http://iom.edu/Reports/2002/Dietary-Reference- http://www.americanheart.org/presenter.jhtml?identifier=4441. Accessed Intakes-for-Energy-Carbohydrate-Fiber-Fat-Fatty-Acids-Cholesterol-Protein- CHD Prevalence. Epidemiologic studies over the past several decades have associated high levels of dietary November 23, 2010. and-Amino-Acids.aspx. Accessed November 24, 2010. fiber intake with a lower prevalence of coronary heart disease (CHD).9 A review of seven prospective cohort 7. The White House. Office of the Press Secretary. Presidential 20. United States Department of Agriculture. Dietary Guidelines Advisory studies demonstrated that the prevalence of CHD was 29% lower among persons with the highest dietary fiber proclamation-American Heart Month. Available at: http://www.whitehouse.gov/ Committee. Report of the Dietary Guidelines Advisory Committee on the intake compared with those with the lowest intake.9 the-press-office/presidential-proclamation-american-heart-month. Accessed Dietary Guidelines for Americans, 2010. Appendix E-1: Major conclusions: November 24, 2010. Section 1: Energy balance and weight management. Available at: Faculty Cholesterol Lowering Benefits.Recognizing low-density lipoprotein (LDL)-cholesterol, and serum 8. Anderson JW, Allgood LD, Turner C, Oelgten PR, Daggy BP. Effects of http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/ Abel Moreyra, MD the scientific evidence supporting the cholesterol- ratios of apolipoprotein (apo) B to apo A-I beyond psyllium on glucose and serum lipid responses in men with type 2 diabetes E-Appendix-E-1-Conclusions.pdf. Accessed November 30, 2010. lowering benefit of viscous soluble fibers, the U.S. reductions seen with low-fat diet only.12 Psyllium and hypercholesterolemia. Am J Clin Nutr. 1999;70:466–473. 21. Park Y, Hunter DJ, Spiegelman D, et al. Dietary fiber intake and risk of Professor of Medicine 9. Anderson JW, Baird P, Davis RH, et al. Health benefits of dietary fiber. colorectal cancer: a pooled analysis of prospective cohort studies. JAMA. Division of Cardiology Food and Drug Administration (FDA) has authorized did not significantly lower high-density lipoprotein Nutr Rev. 2009;67:188-205. 2005;294:2849-2857. UMDNJ-Robert Wood Johnson the use of a health claim in the labeling of foods and (HDL)-cholesterol or triglycerides. Similar reductions 10. Food and Drug Administration, US Department of Health and Human 22. Anderson JW. All fibers are not created equal. J Med. 2009;2:87-91. Medical School dietary supplements containing psyllium (and oat) in cholesterol have been found in high-quality Services. Code of Federal Regulations, Title 21, Volume 2, Section 101.81. 23. National Fiber Council. Fiber and your heart. Available at: New Brunswick, New Jersey fibers regarding the potential for these fibers to controlled studies with oat fibers.8,9 In one 12-week, Health claims: Soluble fiber from certain foods and risk of coronary heart http://www.nationalfibercouncil.org. Accessed November 23, 2010. reduce the risk of heart disease.10 Indeed, many controlled study, the addition of psyllium to a low disease (CHD). Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/ 24. Pastors JG, Blaisdell PW, Balm TK, Asplin CM, Pohl SL. Psyllium fiber dose of simvastatin (10 mg) achieved the same LDL- reduces rise in postprandial glucose and insulin concentrations in 13 patients short-term (4-8 week) controlled trials have shown that cfcfr/CFRSearch.cfm?fr=101.81. Accessed November 23, 2010. Supported by 11. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol lowering effects with non-insulin-dependent diabetes. Am J Clin Nutr. 1991;53:1431-1435. dietary fiber intake, in conjunction with low-fat diets, cholesterol and apo B-lowering effects as doubling the 25. Sierra M, Garcia JJ, Fernandez N, et al. Therapeutic effects of psyllium 11,12 simvastatin dose in 68 patients who met the National of dietary fiber: a meta-analysis. Am J Clin Nutr. 1999;69:30–42. Personal Health Care reduces serum cholesterol. A meta-analysis of 8 12. Anderson JW, Allgood LD, Lawrence A, et al. Cholesterol-lowering in type 2 diabetic patients. Eur J Clin Nutr. 2002;56:830-842. randomized, controlled trials (RCTs) found that psyllium Cholesterol Education Program Adult Treatment Panel effects of psyllium intake adjunctive to diet therapy in men and women with 26. Data on file. Procter & Gamble. fiber significantly lowered total cholesterol, III criteria for drug treatment of hyperlipidemia and dietary intervention.13