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Articles

An Oat-Containing Hypocaloric Diet Reduces Systolic Blood Pressure and Improves Lipid Profile beyond Effects of Weight Loss in Men and Women¹

The Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts 02111

²To whom correspondence should be addressed at Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, 711 Washington St., Boston, MA 02111. E-mail: esaltzman{at}hnrc.tufts.edu

	ABSTRACT

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Hypertension, dyslipidemia and overweight contribute substantially to cardiovascular disease risk. One of the most effective methods for improving high blood pressure and lipid profiles is loss of excess weight. Other recommendations for reducing cardiovascular risk include changes in dietary micronutrient, macronutrient and fiber intakes. To better define a diet for reduction in cardiovascular risk, 43 adults (body mass index 26.4 ± 3.3, range 20.5–33.9 kg/m²) participated in an 8-wk study to determine the effects of two diets on weight, blood pressure, lipids and insulin sensitivity. For 2 wk, weight was maintained and all subjects consumed a control diet. For the next 6 wk, subjects consumed one of two hypocaloric diets (maintenance energy minus 4.2 MJ/d): the control diet (n = 21) or a diet containing oats [45 g/(4.2 MJ dietary energy · d), n = 22]. There was no significant difference between groups in changes in weight loss (control -4.0 ± 1.1 kg, oats -3.9 ± 1.6 kg, P = 0.8). The oats diet resulted in greater decreases in mean systolic blood pressure (oats -6 ± 7 mm Hg, control -1 ± 10 mm Hg, P = 0.026), whereas diastolic blood pressure change did not differ between the two groups (oats -4 ± 6 mm Hg, control -3 ± 5 mm Hg, P = 0.8). The oat diet resulted in significantly greater decreases in total cholesterol (oats -0.87 ± 0.47 mmol/L, control -0.34 ± 0.5 mmol/L, P = 0.003) and LDL cholesterol (oats -0.6 ± 0.41 mmol/L, control -0.2 ± 0.41mmol/L, P = 0.008). In summary, a hypocaloric diet containing oats consumed over 6 wk resulted in greater improvements in systolic blood pressure and lipid profile than did a hypocaloric diet without oats.

KEY WORDS: • weight loss • oats • blood pressure • cholesterol • humans

	INTRODUCTION

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Cardiovascular disease (CVD)³ continues to be the major cause of morbidity and death in industrialized society. Hypertension, dyslipidemia and excess body weight are among the most potent accepted risk factors for CVD. Weight loss has beneficial effects on blood pressure, lipids and glucose control, and weight loss in the range of 5–10% of initial weight can confer significant improvement in these variables (Mertens and Van Gall 2000 , National Institutes of Health 1998 , Trials of Hypertension Prevention Collaborative Research Group 1992 ,Wadden et al. 1999 ). In population studies, dietary factors, such as consumption of a vegetarian diet or a diet high in cereal fiber, fruits and vegetables, also appear to be associated with reduced risk for hypertension, dyslipidemia and CVD itself (Beilin 1994 , Dwyer 1988 , He et al. 1994 , Rimm et al. 1996 ). Identification of such factors has stimulated considerable research effort directed toward the prevention of CVD and its risk factors through diet modification. In many circumstances, dietary interventions have been shown to have salutary effects on hypertension and hyperlipidemia (Anderson et al. 2000 , Appel et al. 1997 , Stevens et al. 1993 ), but definition of the most beneficial regimens remains controversial. Despite the success observed in some of these trials due to the manipulation of specific nutrients or the provision of specific supplements, it remains likely that the benefit obtained by a complex diet cannot be reproduced through the manipulation of individual nutrients in an unhealthful diet. The recent Dietary Approaches to Stop Hypertension (DASH) report (Appel et al. 1997 ) underscores that food-based (not supplement-based) interventions can be highly effective in lowering blood pressure.

Although the benefits observed with complex diets are likely not attributable to single nutrients, it remains possible that particular classes of food or individual foods can confer particular benefit. In addition, the introduction of individual dietary classes or constituents may be preferable to broader dietary changes in terms of changing dietary behaviors. Thus, definition of the beneficial individual constituents of a complex diet is needed. One such possible constituent is oats, a whole-grain cereal that is rich in soluble fiber. The effects of oats on lipid metabolism are well documented (Ripsin 1992 ), and there is a growing body of literature to suggest that oats also lower blood pressure or help prevent CVD. Population studies suggest that diets rich in oats (He et al. 1994 ) or other foods containing soluble fiber (Pietinen et al. 1996 ) are associated with lower levels of blood pressure or rates of coronary disease. The few intervention trials examining the effect of oats on blood pressure have been inconclusive (Kestin et al. 1990 , Swain et al. 1990 ), and supplementation trials of soluble fiber have inconsistently reported beneficial effects on blood pressure (Krotkiewski 1984 , Rossner et al. 1988 , Saltzman and Roberts 1997 ). However, the amount of oats may have been inadequate in these trials to achieve the desired effect, as trials using large doses of foods or soluble fiber have more consistently demonstrated a blood pressure effect (Krotkiewski 1984 , Singh et al. 1993 ). Also, oat or oat fiber consumption has been shown to reduce postprandial glucose and insulin concentrations (Braaten et al. 1991 and 1994 ), and the reduction in insulin concentration may provide a mechanism by which blood pressure could be reduced in response to oat consumption (Tuck 1992 ).

We therefore hypothesized that a diet designed for weight loss that contained oats would produce greater improvements in blood pressure and lipid profiles than a hypocaloric diet without oats. To test this hypothesis, subjects consumed hypocaloric diets with or without oats for 6 wk and demonstrated that a diet containing oats resulted in improvements in a number of CVD risk factors compared with a control diet.

	MATERIALS AND METHODS

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Subjects.

Subjects were recruited for a trial assessing the effects of hypocaloric diets with and without oats on body weight, blood pressure and blood lipids, as well as on measures of energy regulation. Because one purpose of the trial was to measure energy regulation in healthy adults, subjects were not specifically recruited on the basis of preexisting hypertension or dyslipidemia. The weight range of subjects was limited to a body mass index (BMI) of 20–35 kg/m², which was chosen to allow a comparison of study variables in normal-weight individuals with those in overweight or mildly to moderately obese individuals. In addition, the influence of age was assessed by comparing responses in younger (age 18–30 y) and older (age 60–75 y) age groups. To ensure similar characteristics in the two diet groups, subjects were randomized on the basis of age and gender and, in younger subjects, by BMI (< or 25 kg/m²).

The subjects were 43 healthy weight-stable men and women (Table 1 ). None smoked or had a history of recent serious acute or chronic disease, and all were judged to be healthy on the basis of routine screening physical examination and blood tests. At screening, subjects had a systolic blood pressure (SBP) of <150 mm Hg and a diastolic blood pressure (DBP) of <90 mm Hg. Subjects reported habitually consuming ethanol of 30 g/d and scored 10 on a dietary restraint scale (Stunkard and Messick 1985 ) administered at screening. Subjects taking any medication known to influence body weight or blood pressure, those with a significant history of eating disorders and those who reported strenuous exercise for 1 h/d were excluded. The study was approved by the Human Investigation Review Committee of Tufts University School of Medicine and New England Medical Center, and written informed consent was obtained from all subjects.

The study was conducted at the Metabolic Research Unit (MRU) of the Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University. The 8-wk protocol was divided into a 2-wk weight-maintenance phase (phase 1) followed by a 6-wk weight-loss phase (phase 2). During both phases, all food and caloric beverages were provided to subjects at the MRU. In phase 1, all subjects consumed the same diet of usual food items (control diet), and the level of energy intake needed to maintain body weight was determined over wk 1 and held constant over wk 2. In phase 2, subjects were provided a diet calculated to contain maintenance energy needs minus 4.2 MJ/d. However, a decrease of 4.2 MJ was thought to be too severe for seven subjects whose initial maintenance requirements were low, and smaller decreases of 3.3–3.7 MJ were used. In phase 2, subjects consumed one of two study diets: the oats group received a hypocaloric diet containing oats (45 g dry weight/4.2 MJ dietary energy, roughly equivalent to 1.5 servings of oatmeal/4.2 MJ), and the control group continued to consume the same diet as in phase 1. During phase 2, a daily multivitamin containing the Recommended Daily Allowance (RDA) for most vitamins (but not containing minerals) was provided because some subjects had energy intakes that were sufficiently low to preclude intake of the RDA of vitamins from provided food.

During each phase, measures of body weight, body composition, energy expenditure, blood pressure, blood tests for metabolic variables and 24-h urine collections were conducted. Subjects slept in the MRU on nights preceding testing but were otherwise permitted to reside at home. They were encouraged to continue their usual levels of physical activity throughout the 8-wk protocol.

Diets.

All food and energy-containing beverages were provided to the subjects. Three meals and one snack were consumed each day. Subjects were required to eat at least four meals per week in the center and were given other meals for carry-out. After wk 1, subjects were required to consume all food and beverages and to rinse and scrape as well as return food containers.

For phase 1, initial energy needs were predicted using the RDA for energy (National Research Council 1989 ) with appropriate activity factors applied. Protein was provided as 1.1 g/kg body. Nonprotein energy was provided as carbohydrate (54% of total energy) and fat (35% of total energy) (Table 2 ). Total energy was adjusted daily over 1 wk to maintain weight within 500 g of d 1. The average daily energy provided over the 1st 7 d was then provided daily to subjects for the 2nd wk. During this 2nd wk, subjects were required to consume all food. In the rare event of weight changes of 500 g in phase 2, energy intake was again adjusted.

Body weight and composition.

Body weight was measured under standardized conditions with an electronic digital scale to 0.01 kg, and body height was measured by fixed-wall stadiometer. Body composition was determined by hydrodensitometry after an overnight fast: twice during phase 1 and twice during the last days of phase 2. Measurements were repeated until at least three measures of body fat were within 2% of each other, and fat-free mass was calculated according to the equations of Siri (1961 ).

Blood pressure and maximal aerobic capacity.

Blood pressure was determined each residence day and at each outpatient visit to the MRU and was measured after quiet sitting by nursing staff using a standard aneroid mercury sphygmomanometer and by noting the first and fifth Korotkoff sounds. To evaluate the effect of phase 2 diet on blood pressure, initial and final SBP and DBP were defined as averages of each in wk 2 (phase 1) and wk 8 (phase 2), respectively. Changes in blood pressure (SBP and DBP) were defined as phase 2–minus–phase 1 values.

Maximal aerobic capacity (O₂max) was determined during phase 1 with a graded exercise treadmill test using a standard Bruce protocol (Vogel et al. 1986 ) with collection of expired gases.

Metabolic parameters.

Blood was collected via venipuncture and after the placement of intravenous catheters (for metabolic tests) twice during phase 1 and again for similar measurements at the end of phase 2 (wk 8). Unless otherwise noted, all fasting samples were combined to reflect an average value for each phase.

Plasma glucose (Hexokinase/Glucose-6-Phosphate Dehydrogenase method; Roche Diagnostic Systems, Branchburg, NJ) and insulin (radioimmunoassay, DA ¹²⁵I Insulin Kit; ICN Biomedical, Costa Mesa, CA) were measured after a 12-h overnight fast twice during phase 1 and twice during the final week of phase 2 (wk 8), and values were averaged for each phase. Because changes in fasting insulin and glucose may be insensitive indicators of changes in insulin sensitivity, additional models to estimate insulin sensitivity in the fasting and fed states were used. Insulin resistance was calculated according to the homeostatic model assessment, where insulin resistance = (fasting glucose x fasting insulin)/22.5 (Matthews et al. 1985 ). In addition, a 2-h 75-g oral glucose tolerance test was performed once in phase 1 (wk 2) and once at the end of phase 2 (wk 8), and estimates of whole body insulin sensitivity were calculated according to the model of Matsuda and DeFronzo (1999 ), where insulin sensitivity = 10,000/square root of [(fasting insulin x fasting glucose) x (mean glucose x mean insulin during oral glucose tolerance test)].

Plasma lipids and lipoproteins were determined during phase 1 and phase 2 (wk 8) from fasting blood samples collected in tubes containing EDTA. HDL was prepared after precipitation of apolipoprotein B–containing lipoproteins with dextran sulfate-magnesium chloride from plasma (Warnick 1982 ). Total cholesterol and triglycerides were determined by automated methods (Abbott Spectrum CCX Analyzer; Abbott, Dallas, TX) using enzymatic reagents (Abbott A-GENT). Lipid assays were standardized through the Lipid Standardization Program of the Centers for Disease Control and Prevention, and CVs for all lipid assays between and within runs were <2.5%. LDL cholesterol was estimated by the Friedewald formula (Friedewald et al. 1972 ).

Three consecutive 24-h collections of urine were conducted in wk 5 and repeated in wk 7 or 8. Urinary sodium and potassium were analyzed by direct current plasma spectrometry (Spectra-Span VI; Beckman Instruments, Fullerton, CA); concentrations of urinary sodium and potassium were determined for each 24-h collection, and the 3 consecutive days averaged. There were no significant differences between averages for the two time points (wk 5 versus wk 7 or 8), so both were averaged to provide a single value for phase 2.

Statistical analysis.

Data are expressed as means ± SD unless otherwise noted. Student’s t test for independent samples was used to compare the two treatment groups at baseline and to compare mean change scores between the two groups. ANCOVA was used to adjust differences for age and gender and to assess interactions of treatment with diet and gender. When statistically significant interactions were found, the treatment effect was assessed separately for each treatment group by using Student’s t test for paired samples. Differences were considered statistically significant if the observed significance level was P 0.05. Statistical calculations were performed with SYSTAT Version 9 (SPSS, Chicago, IL).

	RESULTS

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Details of the subjects are given in Table 1 . There were no significant differences between the two diet groups in age, initial weight and BMI or initial percent body fat. Over phase 2, both diet groups demonstrated a similar weight change (control -4.0 ± 1.1 kg, oats -3.9 ± 1.6 kg, difference between groups P = 0.8), which was consistent with the weight loss predicted by a deficit of 4.2 MJ/d for 42 d (Saltzman and Roberts 1995 and 1996 ), suggesting that overall compliance with both diets was good. There were no significant differences between diet groups in weight change as a percentage of initial weight (control -5.3 ± 1.6%, oats -5.5 ± 2.8%, P = 0.76) or in change in fat mass (control -2.7 ± 1.6 kg, oats -2.5 ± 1.3 kg, P = 0.65). In addition, there were no effects of initial BMI, initial percent body fat, age or gender on weight loss, nor were there significant diet x age or diet x gender interactions on weight loss.

Mean baseline blood pressures were in the normotensive range (Table 1) . Within each diet group, paired t tests showed that DBP decreased significantly from phase 1 to phase 2 (DBP: control -3 ± 5 mm Hg, P = 0.013, oats -4 ± 6 mm Hg, P = 0.007, difference between oats and control P = 0.04) (Table 4 ). By similar analyses, SBP decreased significantly only in the oats group (SBP: control -1 ± 10 mm Hg, P = 0.7, oats -6 ± 7mm Hg, P < 0.0001). ANCOVA to determine the effect of diet on blood pressure in phase 2 while controlling for initial blood pressure, initial BMI and weight lost (absolute and percent initial) revealed a significant advantage of the oat diet compared with the control diet on decreases in SBP (P = 0.026) but not DBP (P = 0.8), suggesting an effect of diet on SBP independent of weight loss. There were no significant differences in urinary sodium excretion between diet groups (oats 2769 ± 814 mg/d, control 2498 ± 732 mg/d).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
The consumption of a hypocaloric diet containing oats over 6 wk resulted in greater decreases in SBP, total cholesterol and LDL cholesterol than did a similar diet without oats. Weight loss is often advocated as a first-line treatment for hypertension and hypercholesterolemia, and the identification of weight-loss diets likely to maximize the effects on blood pressure and blood lipids is of considerable importance. In this normotensive population, a hypocaloric diet containing oats was associated with a decrease in SBP of 6 mm Hg and a net advantage over the control diet of -5 mm Hg. Although it remains unclear whether similar effects would be observed in other populations, on a population-wide basis, sustained decreases in SBP of this magnitude would be likely to result in considerable prevention of CVD (Applegate 1992 ).

The magnitude of changes in SBP and DBP in this study are consistent with the range observed in other nutritional interventions to decrease blood pressure, including those designed to reduce body weight and those such as the DASH diet (Appel et al. 1997 ). These interventions have been shown to most effectively reduce blood pressure in hypertensive patients and to have less consistent effects in normotensive subjects (Mertens and Van Gall 2000 ). Thus, a hypocaloric diet containing oats consumed by hypertensive subjects may reduce blood pressure to an even greater extent than observed in this study: this hypothesis, however, remains untested. Also, the subjects in this trial had overall favorable lipid profiles, and it is possible that the inclusion of oats in a hypocaloric diet would be more effective in those with mild to moderate dyslipidemia.

Because overweight and increasing age are associated with increases in blood pressure and hyperlipidemia, it would be important to determine whether a diet such as that used in this study was effective in older populations. Unfortunately, the number of elderly subjects in this study, as well as their relatively normal blood pressures and lipid profiles, did not permit such an analysis, and further work is needed to address these issues. Systolic hypertension may be associated with increasing morbidity rates in older persons (Applegate 1992 ), so an intervention that reduces SBP, as found in the present study, may be of particular importance.

Diets rich in oats or similar foods have also been associated with lower blood pressure in epidemiologic studies (He et al. 1994 , Pietinen et al. 1996 ), but the intervention trials to date that used oats or soluble fiber have inconsistently improved blood pressure when compared with control diets (Saltzman and Roberts 1997 ). The reasons for this inconsistency remain unclear, but potential factors include the type of fiber and its viscosity, the physical form of fiber provided (as part of whole foods or as an isolate), when fiber is consumed (both the frequency and whether consumed with other food) and the dose. It should be noted that the present study incorporated soluble fiber as a whole food, in conjunction with the consumption of other food, at doses intermediate to those of existing trials and more frequently than in most prior trials.

The mechanisms by which an oat-containing diet could confer an advantage in decreasing SBP remain unclear. When the macronutrients and micronutrients considered to potentially influence blood pressure are examined, the only substantial difference between the diets was, again, in soluble fiber. However, the mechanisms underlying the effects of diet are unclear. Insulin resistance has been proposed to influence blood pressure via several means, including direct effects on sympathetic tone and effects on natriuresis. In this study, a nonsignificant trend (P = 0.09) for a greater diminution in fasting insulin was observed with the oat diet, but there was no significant correlation (data not shown) between insulin and blood pressure changes. Also, in this trial there was no significant difference in sodium excretion between diet groups.

In this study, the combination of weight loss along with the inclusion of oats appeared to have an additive influence on reducing lipid concentrations. It remains unclear whether the advantages of continued consumption of the oat diet would be associated with lipid (as well as blood pressure) benefits after weight stabilization. A review of existing data on effects of weight loss on these variables suggests that benefits occur early in weight reduction and are at least in part due to negative energy balance and that lipid-lowering effects may partially wane over time despite continued weight loss or maintenance (Mertens and Van Gall 2000 , Trials of Hypertension Prevention Collaborative Research Group 1992 , Wadden et al. 1999 ). Further investigation is required to determine whether effects on lipids and blood pressure would persist after weight stabilization.

It is important to stress that these results do not justify the recommendation of oats in an unhealthy diet as a supplement to lower blood pressure and lipids during weight loss. The inclusion of oats in a diet that is also low in fat and rich in fruit and vegetables does, however, appear to be promising in promoting improved risk factors for CVD (Rimm et al. 1996 ). The ease with which oats can be incorporated into such a diet was initially surprising to us; further, the oat diet was accepted readily and no gastrointestinal complaints were noted. The optimal dose and frequency of oat consumption are issues that will require further investigation.

In summary, a weight-loss diet containing oats was associated with favorable decreases in SBP and blood lipids compared with a control diet without oats. Further work is needed to determine whether the benefits observed here can be maintained during weight maintenance after weight loss and whether specific populations, such as those who are overweight, hypertensive or hypercholesterolemic, will respond similarly.

	ACKNOWLEDGMENTS

 
We thank the study volunteers, the staff of the MRU and the staff of the Nutritional Evaluation Laboratory of the Human Nutrition Research Center.

	FOOTNOTES

 
¹ Supported by in part by an unrestricted gift from the Quaker Oats Company (Barrington, IL), in part by National Institutes of Health Grant AG12829 and in part by U.S. Department of Agriculture contract 53-3K06-5-10.

³ Abbreviations used: BMI, body mass index; CVD, cardiovascular disease; DBP, diastolic blood pressure; MRU, Metabolic Research Unit; RDA, Recommended Dietary Allowance; SBP, systolic blood pressure.

Manuscript received August 10, 2000. Initial review completed September 3, 2000. Revision accepted January 30, 2001.

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