Six Months of Isoflavone Supplement Increases Fat-Free Mass in Obese–Sarcopenic Postmenopausal Women: a Randomized Double-Blind Controlled Trial

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SHORT COMMUNICATION Six months of isoflavone supplement increases fat-free mass in obese–sarcopenic postmenopausal women: a randomized double-blind controlled trial

M Aubertin-Leheudre2, C Lord, A Khalil3 and IJ Dionne1,2

1Research Centre on Aging, Sherbrooke, Que´bec, Canada; 2Faculty of Physical Education and Sports, Sherbrooke, Que´bec, Canada and 3Department of Medicine, University of Sherbrooke, Sherbrooke, Que´bec, Canada

Objective: The aim of this study was to verify if six months of isoflavone supplementation could increase fat-free mass (FFM) and muscle mass index (MMI ¼ appendicular FFM/height2) in obese–sarcopenic postmenopausal women. Design: Double-blind randomized study. Subject: Eighteen sarcopenic–obese women completed the study (12 on isoflavones and six on placebo). Body composition was measured by dual-energy X-ray absorptiometry. Subjects ingested 70 mg of isoflavones per day (44 mg of diadzein, 16 mg glycitein and 10 mg genestein) or a placebo for 24 weeks. Results: The isoflavone group increased significantly appendicular (P ¼ 0.034), leg (P ¼ 0.016) FFM and MMI (P ¼ 0.037), but not the placebo group. Conclusion: Six months of isoflavone supplementation increased FFM and MMI in obese–sarcopenic postmenopausal women. European Journal of Clinical Nutrition (2007) 61, 1442–1444; doi:10.1038/sj.ejcn.1602695; published online 21 February 2007

Keywords: menopause; sarcopenia; muscle mass; phytoestrogens; appendicular fat-free mass; muscle mass index

Introduction et al., 2001; van der Schouw et al., 2005). Metabolic studies have found that soy, which contains isoflavones, exerts a Menopause is associated with a decrease in muscle mass, also lipid-lowering effect (Hermansen et al., 2001), favours known as sarcopenia (Beaufrere and Morio, 2000), which is vasodilatation and arterial compliance (Walker et al., 2001) significantly associated with functional limitations and and contributes to regulate fasting glucose and insulin levels physical disability (Tanko et al., 2002). Hormonal replace- in humans (Crisafulli et al., 2005). In addition, phytoestro- ment therapy (HRT) has been shown to promote the gens by their estrogenic properties may favourably affect maintenance or increase total fat-free mass (FFM) (Haarbo muscle mass. Nevertheless, it is unknown if isoflavone et al., 1991; Greeves et al., 1999; Skelton et al., 1999). As such, supplementation could increase FFM. The aim of this study estrogens may have a direct effect on muscle via its estrogen was to verify if 6 months of isoflavone supplementation receptors (Lemoine et al., 2003). However, the Women’s could increase FFM in obese–sarcopenic postmenopausal Health Initiative study revealed that estrogens combined women compared to a placebo. with progesterone increased cardiovascular morbidity and mortality risks in postmenopausal women (Rossouw et al., 2002). Hence, the use of HRT has thus become controversial. In contrast, phytoestrogens are structurally comparable to Methods 17b-estradiol that have shown estrogenic properties (Hsu Subjects Fifty postmenopausal women aged between 50 and 70 years Correspondence: Dr IJ Dionne, Research Centre on Aging, 1036 Belve´de`re (5875 years) were recruited for a larger trial by the use ´ Sud, Sherbrooke, Quebec, Canada. of advertisements in local newspaper. To be included in E-mail: [email protected] Received 10 August 2006; revised 6 December 2006; accepted 22 December the trial, women had to meet the following criteria: 2006; published online 21 February 2007 overweight or obese (body mass index 428 kg/m2 and waist A randomized double-blind controlled trial M Aubertin-Leheudre et al 1443 circumference 488 cm), healthy, without major physical Body composition measurements incapacity, without HRT (women had never been on HRT or Overall. Body weight was determined by using an electronic off HRT for at least 1 year), sedentary, weight stable (72 kg) scale (kg70.2; SECA707, Hambourg, Germany). Height was for the last 6 months, non-smoker, moderate drinker (15 g of measured using a tape measure fixed to the wall with the alcohol/day maximum, the equivalent of one alcoholic subject in stocking feet. Determination of FM and FFM was beverage/day), no medication that could influence glucose assessed in a supine position, by the use of dual-energy X-ray or lipid metabolism and absence of menses for the past absorptiometry (GE Prodigy Lunar, Madison, WI, USA). In 12 months. A phone interview was conducted to screen for our laboratory, the coefficients of variations for repeated the aforementioned inclusion criteria. After subjects were measures of FM and FFM in 10 adults (measured 1 week apart) thoroughly explained of the nature and goals of the study, are 0.9 and 0.4%, respectively (Aubertin-Leheudre et al., they provided written informed consent. Women were 2005). FFM is herein defined as the mass of tissue represent- randomly assigned to one of two groups (isoflavone (ISO) ing soft tissue exclusively (mineral body mass excluded). vs placebo (PLA)) to compare the effect of 6 months of isoflavone supplementation on body composition and cardiovascular disease risk factors. Subjects received either Muscle mass index four soy capsules or four identical placebo capsules daily for MMI is generally used as an index of sarcopenia and is 6 months in a double-blind fashion. Each capsule contained calculated as follows: 325 mg of soy extract with 17.5 mg of isoflavones (total dose Appendicular FFM ðkgÞ=height ðmÞ2 of isoflavones was 70 mg/day which was divided into 44 mg of diadzein, 16 mg glycitein and 10 mg genestein). Identical Class I sarcopenia is considered as a MMI between one or active and placebo capsules were supplied by Arkopharma more standard deviations below the values of young adults Ltd (France). To be included in this analysis, all subjects had from a reference population (Baumgartner et al., 1998; Janssen to be sarcopenic and obese. Sarcopenia was defined as a et al., 2002). In our laboratory, women were considered 2 muscle mass index (MMI) 6.87 kg appendicular FFM/m 2 o sarcopenic when MMI was o6.87 appendicular FFM kg/m . and obesity as a fat mass (FM) 440% (Baumgartner et al., These criteria were established based on a reference sample of 2004). At baseline, among the 50 women, 24 were consi- 30 healthy women aged between 20 and 35 years. dered sarcopenic–obese (14 on ISO vs 10 on PLA), of whom 18 completed the study (12 on ISO vs 6 on PLA) and constitute the women included in the present study. The Statistical analyses percentage of withdrawal (25%) is in accordance with the Results are presented as means7s.d. A one-way analysis of literature (Fox et al., 1996). The reasons for dropping out variance was used to verify the difference between groups at were personal reasons or lack of time (two in ISO vs four in baseline and at 6 months. Furthermore, a paired t-test was PLA). None reported adverse effect to the treatment. All performed to verify the difference in each group between the procedures were approved by the Ethics Committee of the measures at baseline and at 6 months. Finally, an analysis of Geriatric Institute of University of Sherbrooke. covariance (Univariate General linear model) was used to

Table 1 Body composition before and after 6 months of phytoestrogen or placebo

Variables Phytoestrogen Phytoestrogen Placeb Placebo P-values baseline for 6 months Baseline for 6 months

Weight (kg) 73747275757874760.618 BMI (kg/m2)297 12872307229720.589 Waist circumference (cm) 92710 92789876 100760.155 Total FM (kg) 31.5374.07 30.6174.65 34.6377.88 34.1776.61 0.439 Abdominal FM (kg) 15.7173.50 15.1173.81 16.9974.23 17.7574.01 0.082 Total FFM (kg) 38.0571.94 38.3472.43 38.1572.15 37.2773.01 0.053 Arms FFM (kg) 3.4570.26 3.6970.39 3.6270.49 3.4370.43 0.180 Legs FFM (kg) 13.4271.05 13.7171.29 13.2871.20 12.6671.35 0.034 Appendicular FFM (kg) 16.877 1.18 17.4071.40* 16.8771.42 16.0971.47 0.016 MMIa 6.5170.32 6.7770.36* 6.6970.10 6.4270.61 0.037

Abbreviations: ANCOV, analysis of covariance; BMI, body mass index; FFM, fat-free mass; FM, fat mass; MMI, muscle mass index. Means7s.d. P-values obtained by ANCOVA; Po0.05 significant treatment effect. aMMI (appendicular FFM (kg)/height (m2)). *Po0.05 significant different from baseline values (paired t-test). Bold indicates statistically significant values.

European Journal of Clinical Nutrition A randomized double-blind controlled trial M Aubertin-Leheudre et al 1444 verify the effect of the isoflavone treatment after 6 months Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield on body composition. P-values of p0.05 were considered SB, Ross RR et al. (1998). Epidemiology of sarcopenia among the Am J Epidemiol statistically significant. Analyses were performed using SPSS elderly in New Mexico. 147, 755–763. Beaufrere B, Morio B (2000). Fat and protein redistribution with 11.0 program (Chicago, IL, USA). aging: metabolic considerations. Eur J Clin Nutr 54 (Suppl 3), S48–S53. Crisafulli A, Altavilla D, Marini H, Bitto A, Cucinotta D, Frisina N Results et al. (2005). Effects of the phytoestrogen genistein on cardiovascular risk factors in postmenopausal women. Menopause 12, 186–192. No difference was found at baseline and at 6 months Dragan I, Stroescu V, Stoian I, Georgescu E, Baloescu R (1992). Studies regarding the efficiency of Supro isolated soy protein in Olympic between groups for all variables (Table 1). We observed a athletes. Rev Roum Physiol 29, 63–70. significant difference for the isoflavone group between Fox AA, Thompson JL, Butterfield GE, Gylfadottir U, Moynihan S, baseline and 6 months for appendicular FFM (P ¼ 0.006) Spiller G (1996). Effects of diet and exercise on common and MMI (P ¼ 0.002), but not in the placebo group. More- cardiovascular disease risk factors in moderately obese older over, we observed a significant treatment effect of isoflavone women. Am J Clin Nutr 63, 225–233. Greeves JP, Cable NT, Reilly T, Kingsland C (1999). Changes in muscle supplementation on appendicular (P ¼ 0.016), leg (P ¼ 0.034) strength in women following the menopause: a longitudinal FFM and MMI (P ¼ 0.037). assessment of the efficacy of hormone replacement therapy. Clin Sci (Lond) 97, 79–84. Haarbo J, Marslew U, Gotfredsen A, Christiansen C (1991). Discussion Postmenopausal hormone replacement therapy prevents central distribution of body fat after menopause. Metabolism 40, 1323–1326. Hermansen K, Sondergaard M, Hoie L, Carstensen M, Brock B (2001). The aim of this study was to examine if 6 months of Beneficial effects of a soy-based dietary supplement on lipid levels isoflavone supplementation could increase FFM in obese– and cardiovascular risk markers in type 2 diabetic subjects. sarcopenic postmenopausal women compared to a placebo. Diabetes Care 24, 228–233. Our results demonstrated that 6 months of isoflavone Hsu CS, Shen WW, Hsueh YM, Yeh SL (2001). Soy isoflavone supplementation has a beneficial effect on FFM and MMI supplementation in postmenopausal women. Effects on plasma lipids, antioxidant enzyme activities and bone density. J Reprod in obese–sarcopenic postmenopausal women and specifically Med 46, 221–226. on appendicular FFM which is recognized to be responsible Janssen I, Heymsfield SB, Ross R (2002). Low relative skeletal muscle for locomotion and physical independence (Sowers et al., mass (sarcopenia) in older persons is associated with functional 2005). One explanation about this effect could be that impairment and physical disability. J Am Geriatr Soc 50, 889–896. Lemoine S, Granier P, Tiffoche C, Rannou-Bekono F, Thieulant ML, skeletal muscle is an important site of estrogen receptors a Delamarche P (2003). Estrogen receptor alpha mRNA in human (ERa) and -b (ERb) and that phytoestrogens are known to skeletal muscles. Med Sci Sports Exerc 35, 439–443. have estrogenic properties. In this sense, it has been demon- Moeller LE, Peterson CT, Hanson KB, Dent SB, Lewis DS, King DS strated previously that soy protein supplementation has an et al. (2003). Isoflavone-rich soy protein prevents loss of hip lean mass but does not prevent the shift in regional fat distribution in effect on hip lean mass in perimenopausal women 40 g/day for perimenopausal women. Menopause 10, 322–331. 24weeks (Moeller et al., 2003); and on lean body mass in elite Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, athletes, 1.5 g/kg/day for 8 weeks (Dragan et al., 1992). Stefanick ML et al. (2002). Risks and benefits of estrogen plus However, our study supports the fact that this effect was not progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. solely because of an increase in dietary protein intake but JAMA 288, 321–333. likely to the beneficial effect of isoflavones on muscle tissue. Skelton DA, Phillips SK, Bruce SA, Naylor CH, Woledge RC (1999). As such, our results are concordant with those of Wu et al. Hormone replacement therapy increases isometric muscle (2004), who found a significant increase in FFM in ovariecto- strength of adductor pollicis in post-menopausal women. Clin Sci (Lond) 96, 357–364. mized mice after an isoflavone supplementation. Hence, Sowers MR, Crutchfield M, Richards K, Wilkin MK, Furniss A, although the increase in FFM that was observed was not Jannausch M et al. (2005). Sarcopenia is related to physical sufficient to counteract sarcopenia totally, further research is functioning and leg strength in middle-aged women. J Gerontol needed to understand by which mechanism isoflavone A Biol Sci Med Sci 60, 486–490. Tanko LB, Movsesyan L, Mouritzen U, Christiansen C, Svendsen OL supplementation could influence FFM metabolism and if a (2002). Appendicular lean tissue mass and the prevalence of greater duration of intervention could counteract sarcopenia. sarcopenia among healthy women. Metabolism 51, 69–74. van der Schouw YT, Kreijkamp-Kaspers S, Peeters PH, Keinan-Boker L, Rimm EB, Grobbee DE (2005). Prospective study on usual dietary References phytoestrogen intake and cardiovascular disease risk in Western women. Circulation 111, 465–471. Aubertin-Leheudre M, Audet M, Goulet ED, Dionne IJ (2005). HRT Walker HA, Dean TS, Sanders TA, Jackson G, Ritter JM, Chowienczyk provides no additional beneficial effect on sarcopenia in physi- PJ (2001). The phytoestrogen genistein produces acute nitric cally active postmenopausal women: a cross-sectional, observa- oxide-dependent dilation of human forearm vasculature with tional study. Maturitas 51, 140–145. similar potency to 17beta-estradiol. Circulation 103, 258–262. Baumgartner RN, Wayne SJ, Waters DL, Janssen I, Gallagher D, Wu J, Wang X, Chiba H, Higuchi M, Nakatani T, Ezaki O et al. (2004). Morley JE (2004). Sarcopenic obesity predicts instrumental Combined intervention of soy isoflavone and moderate exercise activities of daily living disability in the elderly. Obes Res 12, prevents body fat elevation and bone loss in ovariectomized mice. 1995–2004. Metabolism 53, 942–948.

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