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*
Department of Community and Family Medicine, Chinese University of Hong Kong, Lek Yuen Health Centre, Shatin, N.T., Hong Kong;
Department of Medicine and Therapeutics, Chinese University of Hong Kong;
**
private practice;
Department of Community Medicine, Hong Kong University and
Clinical Biochemistry Unit, Hong Kong University, Hong Kong
2To whom correspondence should be addressed.
 |
ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • soy products • plasma cholesterol • humans • Chinese population •
|
INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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, Potter et al. 1998
) and the reduction in hormone-dependent diseases
or conditions such as menopausal symptoms and cycles
(Adlercreutz et al. 1992
), breast cancer and possibly
prostate cancer and osteoporosis (Potter et al. 1998
).
Interpopulation comparisons have indicated the lower incidences of many
of these diseases or conditions in populations who consume soy, such as
the Japanese and Chinese (Messina et al. 1994
). Soy is
the major source of isoflavones in the human diet (Knight et al. 1995
). Evidence is accumulating that many of the beneficial
effects of soy are related to this form of phytoestrogen.
Although soy is a component of traditional Asian food, many of the
studies on soy consumption have been conducted in Caucasian
populations, among whom soy intake is rather low or almost nil
(Adlercreutz 1990
, Anderson et al. 1997
).
This report describes the pattern of soy intake in the Hong Kong
Chinese population, the amount of soy protein intake in this population
and its association with plasma lipid levels.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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A dietary survey was conducted from August 1995 to September 1996 as
part of a territory-wide population-based cardiovascular risk
factor study. Approval was obtained from the University Ethics
Committee to conduct the study. The sampling method and characteristics
of the study population have been reported previously (Woo et al. 1997
and 1998
). In brief, subjects were contacted through a
random telephone survey and invited to a hospital for a physical
examination and blood tests. Ninety-nine percent of the households
in Hong Kong have telephones. The response rate for the telephone
interview was 78%, and of the respondents, 2900 (37%) came to the
hospital for more detailed assessments. Dietary assessment was carried
out consecutively for those who came to the hospital until >100
subjects were recruited into each of the four 10-y age groups (<34,
35–44, 45–54 and >55 y) and sex groups. A total of 500 men and 510
women completed the dietary intake study. The sample closely matched
the Hong Kong general population (Hong Kong Census and Statistics Department 1996
). There were no significant
differences in physical or laboratory variables among subjects
recruited from the various regions or between those who received the
dietary assessment and those who did not. The mean ± SD age of the study sample was 45.6 ± 11.7 y,
and the age range was 24–74 y.
Dietary survey.
The dietary survey consisted of two parts: a dietary practice
questionnaire based on the Singapore Ministry of Health 1993 Food
Consumption Study (Food and Nutrition Department, Ministry of Health 1994
) and a semiquantitative food frequency
questionnaire that consisted of 253 food items. The items chosen were
the most frequently consumed foods selected from the results of
previous local surveys. The items also included some items from the
questionnaire used in the Australian Chinese Dietary Survey
(Hsu-Hage et al. 1992
). The questionnaire included 10
soy items commonly consumed by the Hong Kong Chinese population:
soybean, canned soybean, soft tofu, firm tofu, deep fried tofu,
tofu-pop (dried tofu), bean curd skin, bean curd sheet, soy milk
and Vitasoy [a common brand of soymilk (Vitasoy Inc., Hong Kong)
consumed by the Hong Kong population].
Whenever possible, subjects were asked to briefly record their diet for the week that preceded the interview. During the interview, subjects were asked to complete the questionnaire, supplying the portion size and frequency of consumption per day or week for each food. Portion size was explained with a catalogue of pictures of each food item, as well as portions, using bowls with a volume of 240 mL and plates with a diameter of 17.5 cm.
Other covariates.
Other covariates included sociodemographic variables, sex, age, marital status and level of education. Education was broadly categorized into primary, secondary and above. Primary education is the first 6 y of formal schooling, equivalent to grades 1–6, whereas secondary school would be equivalent to grades 7–12 in most countries.
Estimation of nutrients and isoflavones.
We quantified the nutrients based on food tables compiled from McCance
and Widdowson (Holland et al. 1992
) and two food tables
used in China (Institute of Health, Chinese Academy of Medical Sciences 1985
, Tsang et al. 1991
). Isoflavone
content in soy products was estimated on the basis of published data
(Anderson 1997
, Dwyer et al. 1994
,
Franke et al. 1994
, Reinli et al. 1996
,
Wang et al. 1994
).
Plasma lipid analysis.
All participants were asked to eat normally during the period before
their attendance and to fast for 12 h before their visit. Blood
(15 mL) was collected from fasting subjects and placed into tubes with
EDTA (9 mL) for lipid and lipoprotein analysis. Cholesterol was
determined with the Hitachi 717 analyzer (Hitachi Instruments, San
Jose, CA) according to the cholesterol oxidase method (coefficient of
variation of 2.9% at 3.3 mmol/L and 2.5% at 7.0 mmol/L). HDL
cholesterol was measured on the Hitachi 717 analyzer after
precipitation of VLDL and LDL with polyethylene glycol PEG-6000
(coefficient of variation of 4.2% at 1.64 mmol/L). LDL cholesterol was
calculated according to the Friedewald equation (Friedewald et al. 1972
) provided total triglycerides did not exceed 4.0
mmol/L. The calibration materials were supplied by
Boehringer-Mannheim Biochemica (Mannheim, Germany).
Statistical analysis.
Descriptive statistics are presented for the frequency and amount
of soy protein intake by sex and age groups. The 
2 test
was used to test the association between soy intake and
sociodemographic status variables, i.e., sex, age, marital status and
education. The Student’s t test was used to compare
differences in mean dietary soy, dietary lipid intake and plasma
cholesterol concentrations between sexes and between age groups. The
contribution of soy to the various dietary nutrients was estimated.
Multiple logistic regression analysis was used to test for the
association between sociodemographic status and the likelihood of being
in the top quartile of soy protein intake. Univariate analyses and
stepwise backward multivariate analyses (F-to-remove
= 0.05) were used to investigate the relation between soy protein
intake and plasma lipid concentrations, with other social, lifestyle
and dietary confounders taken into account. The analyses were repeated
for estimated amount of soy isoflavone intake. All analyses were
conducted with SPSS software Version 7.5. An 
-value of 0.05 was used
as the level of significance. The association between lipid and soy was
further tested in women, who were stratified into two age groups: <50
y and 
50 y old. The cutoff was to capture the potential differences
in the association between soy intake and lipid concentrations among
premenopausal and postmenopausal women. Because we did not obtain
information on menopausal status, this arbitrary cutoff is based on
previous studies that show the mean age of menopause is 
50 y in Hong
Kong Chinese women (S. C. Ho, unpublished data). Values are means
± SD.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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3 soy products. Most of the intake was
in the form of tofu, with about half of the population consuming it
once or twice per week. Among those who consumed any of the soy
products, their mean frequency of intake ranged from 1.0 to 1.9
times/wk (Table 1
). Subjects with tofu/soy milk intake had a mean intake of 400–500
g/wk. Different forms of tofu (including fried tofu and tofu-pop)
contributed to 80% of the total soy protein or isoflavone intake,
whereas soy milk and Vitasoy accounted for 9%. In this population,
soy products contributed to 5.7 ± 5.5% of the overall dietary
protein, 12.4 ± 11.1% of calcium intake and 7.2 ± 7.4% of
iron intake (table not shown).
|
Men had a higher intake of soy protein plus isoflavones and dietary
fats than did women of all ages (Table 2
), but the values were similar after adjustment for energy intake. The
adjusted values for soy protein were 4.5 ± 4.45 g/MJ in both men
and women. The respective values for soy isoflavones were 9.9 ± 9.8 and 10.1 ± 11.0 mg/MJ. Men had significantly higher plasma
LDL cholesterol (P < 0.01) and lower HDL cholesterol
(P < 0.001) concentrations than women. Women <50 y
old had significantly lower plasma total cholesterol and LDL
cholesterol concentrations than women 50 y old (P < 0.001) (Table 2)
.
|
). We observed a significant negative linear relation between soy
protein intake and plasma total cholesterol (r = -0.09, P = 0.04) as well as LDL cholesterol
(r = -0.11, P = 0.02) in men. The
respective values in women <50 y were r = -0.11,
P = 0.04 and r = -0.11, P
= 0.05. Soy protein and age were retained in the final models from
the multivariate analyses that included age, smoking, dietary fats,
cholesterol and saturated fatty acids. However, we did not observe an
association between soy protein intake and plasma lipids in women aged
50 y. We also did not observe an association between soy protein and
HDL cholesterol (data not shown). The observed results were quite
consistent when soy isoflavones instead of soy protein were used in the
analyses (data not shown).
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|
DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Many researchers have noted lower rates of mortality for breast
cancer and heart disease and a lower prevalence of menopausal symptoms
among Asians than in the Western population (Boulet et al. 1994
, Cancer Facts and Figures 1992
,
Donnan et al. 1994
, Ho et al. 1999
,
Yu et al. 1995
). The age-standardized heart disease
mortality rates ranged from 214 and 88 per 100,000 in men and women in
the United States to 191 and 63 in the Netherlands and 100 and 69 in
urban China, respectively (World Health Statistics Annual 1998
). Researchers suggested that the higher consumption of soy
or phytoestrogens in the Asian populations may in part explain the
observed disease variations (Messina et al. 1994
).
Studies have reported a graduation of isoflavone consumption that
ranges from 15 to 200 mg in the various Asian populations
(Adlercreutz et al. 1992
, Knight et al. 1995
), whereas limited data revealed that the intake in the
United States is probably <3 g of soy/d or <5 mg of isoflavones/d
(Anderson 1997
, Kurzer et al. 1997
).
Urinary excretions of isoflavones, a reflection of dietary soy intake,
were observed to be 100 to 1000 times higher in Japanese than in
Caucasian women (Adlercreutz et al. 1993
). Roach et al. (1998)
reported a total urinary isoflavone excretion of
5.36 µmol/d in the Hong Kong Chinese postmenopausal women, and the
concentration was lower than that observed in the Japanese population
(Adlercreutz et al. 1993
). In this study, we found that
the amount of soy product intake in the Hong Kong Chinese population is
only moderate, with a mean intake of 50 g of soy protein/wk and 100
mg of soy isoflavones/wk among those who consumed soy. The usual
frequency of intake was around once or twice per week. The most
frequently consumed soy products were different types of tofu and soy
milk. Although men had a higher intake of soy, no sexual differences
existed after adjustment was made for total energy intake. However, a
higher level of education was related to a higher level of soy intake.
Soy provided 12% of dietary calcium intake in our study population
and 15% in Japan but only 1% in the United Status (Anderson 1997
).
Soy intake and lipid levels.
The beneficial effects of soy protein include a reduction of plasma
cholesterol levels. A recent meta-analysis based on 38 clinical
trials has revealed that an intake of 17–25 g of soy protein would
have a meaningful effect on plasma cholesterol levels (Anderson et al. 1995
). The proposed mechanisms for the soy–cholesterol
effect include the stimulation of bile acid excretion and an increase
in liver LDL cholesterol receptor activities that produce increased
bile acids and their excretion (Potter et al. 1998
). Soy
isoflavones may also have an estrogenic effect in the reduction in LDL
cholesterol and increase in HDL cholesterol concentrations. It is still
unclear what component of soy produces the beneficial effects on plasma
lipids, but studies have suggested that 60–70% of the effect is
probably related to soy isoflavones (Anderson et al. 1995
).
In a population study, Nagata et al. (1998)
compared the
total cholesterol concentrations in Japanese subjects who were in the
highest quartile with those in the group who ate the least amount of
soy. They found that as soy protein intake increased, total cholesterol
concentrations decreased.
We observed in our cross-sectional study the increased
association between soy protein intake and cholesterol and cholesterol
LDL concentrations in men and women <50 y old. Possibly a higher
intake is required in older and postmenopausal women for the soy–lipid
effect to be observed. Because a 1% cholesterol reduction could be
translated to a 2% reduction in heart disease (Anderson et al. 1995
), the soy effect on cholesterol concentrations could have
a potential impact on the reduction in cardiovascular diseases in our
population (Janus 1997
). Although the
age-standardized mortality rates for ischemic heart disease in Hong
Kong have declined from 60.7 per 100,000 in 1977 to 46.4 in 1996 in men
and from 33 to 26.5 in women, the reduction was slower than that
experienced in Western countries (Yu et al. 1995
). As
such, an overall increase in the mean soy intake to the level of the
current top intake quartile may be a powerful strategy to improve the
cardiac health of the population. Many intervention studies
(Anderson et al. 1995
) conducted in Western populations
have demonstrated the effectiveness of soy protein in lowering plasma
cholesterol levels. More epidemiological and controlled clinical trials
in our setting would help to confirm the optimal amount required for
the prevention and treatment of hyperlipidemia as well as for the
reduction of other disease end points such as menopausal symptoms,
cancer and osteoporosis.
Our population-based cross-sectional study has shown that soy
intake in the Hong Kong population is only moderate and is lower than
of the Japanese population. The 1997 dietary guideline recommended by
the China Nutrition Association included a daily intake of 40 g of
soybean (China Nutritional Association 1997
). Such an
intake is equivalent to 250 g of tofu or 650–800 g of soy milk,
providing 60–75 mg of total isoflavones. Thus the Hong Kong
population may have to increase their intake by at least twofold to
threefold to meet the guideline.
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FOOTNOTES |
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Manuscript received December 28, 1999. Revision accepted June 26, 2000.
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