E. J.
Simpson
*a,
B.
Mendis
b and
I. A.
Macdonald
a
aUniversity of Nottingham, School of Life Sciences, Queen's Medical Centre, Nottingham, NG7 2UH, UK. E-mail: liz.simpson@nottingham.ac.uk
bNottingham Universities Hospital NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
First published on 8th March 2016
Data from epidemiological and in vitro studies suggest that orange juice (OJ) may have a positive impact on lipid metabolism. However, there have been reports in the media claiming detrimental consequences of 100% juice consumption, including weight-gain and adverse effects on insulin sensitivity and blood lipid profile. The effect of daily OJ consumption was assessed using a randomised, placebo-controlled, single-blinded, parallel group design. Thirty-six overweight, but otherwise healthy men (40–60 years; 27–35 kg m−2) with elevated fasting serum cholesterol (5–7 mmol l−1), were recruited from the general UK population. None were using nutritional strategies or medication to lower their cholesterol, nor were regular consumers of citrus products. Assessment of BMI, HOMA-IR, and circulating lipid (total cholesterol, low-density lipoprotein, high-density lipoprotein, non-esterified fatty acids, triacylglycerol, apolipoprotein-A1 and apolipoprotein-B) concentrations, was made when fasted before (V1) and after a 12-week intervention (V2), during which participants consumed 250 ml per d of OJ or an energy and sugars-matched orange-flavoured drink (control). The two groups were matched at V1 with respect to all parameters described above. Although triacylglycerol concentration was similar between the groups at both visits, a trend for the change in this variable to differ between groups was observed (P = 0.060), with those in control exhibiting a significant increase in triacylglycerol at V2, compared with V1. In OJ, those with the highest initial triacylglycerol concentration showed the greatest reduction at V2 (R2 = 0.579; P < 0.001), whereas there was no correlation between these variables in controls (R2 = 0.023; P = 0.548). Twelve weeks consumption of 250 ml per d of OJ did not adversely affect insulin sensitivity, circulating lipids or body weight.
Regular consumption of soda drinks containing high-fructose corn syrup and sucrose has been suggested as a risk factor in the development of obesity in children3 and some researchers have expressed concern that a high dietary intake of 100% juice may also contribute to the development of obesity and the metabolic syndrome in adults, the latter perhaps due to increased fructose consumption.4 However, a relationship between 100% juice consumption and adverse metabolic consequences is not universally accepted,5,6 with epidemiological surveys, such as the NHANES, suggesting that consumption of fruit juice is associated with lower BMI and reduced indices of the metabolic syndrome, including circulating total cholesterol concentration.7,8 Despite the sugars content of 100% juice, it is proposed that characteristics of fruit juice, not found in sweetened beverages, in particular phenolic compounds and flavonoids, may be protecting individuals from adverse metabolic effects. Indeed, lower fasting total and Low Density Lipoprotein (LDL) cholesterol, and Apolipoprotein B (Apo-B) have been observed in daily consumers of orange juice compared with non-consumers.9
In vitro studies, using isolated liver cells, have shown that citrus flavonoids can reduce net Apo-B secretion, by inhibiting synthesis of the cholesterol esters required for LDL production.10 This LDL lowering effect of purified citrus flavonoids is supported by in vivo supplementation studies in rodents,11–13 rabbits,14 and humans,15 and the presence of these flavonoids in orange juice (the most commonly consumed 100% juice in the US) may contribute to the observation of reduced serum total cholesterol concentration measured in epidemiological studies.8 However, prospective data from humans supplementing their diet with 100% orange juice are limited and equivocal. Short-term, high-dose consumption (750 ml d−1 for 4–8 weeks), in hypercholesterolemic patients, has been shown to lower serum LDL concentrations16 or have no effect on this parameter,17 with high-density lipoprotein cholesterol (HDL) concentration in these patients being unaffected by supplementation in the former study16 but increased in the latter.17 However, the above studies were potentially compromised by the lack of blinding, supplementation in conjunction with other dietary advice, and the absence of a placebo control drink. Moreover, supplementing the diet with 750 ml of orange juice per day, is equivalent to adding 5 UK recommended portions of 100% juice,18 and provides approximately 60 g of sugars plus an extra 1 MJ in dietary energy intake. Increasing dietary intake of sugars, when in positive energy balance, has been associated with detrimental changes to the circulating lipid profile in humans.19 It is therefore important for any lipid-modifying effects of orange juice consumption to be assessed prospectively at a daily intake which is more representative of UK consumption guidelines. Kurowska et al. did not observe any statistical improvement in blood lipid profile after a month's supplementation with 250 ml of orange juice a day.17 However, a 5% increase in circulating HDL concentration was observed, which may be further increased over a longer time frame.
The current study investigated the effect of 3 month's daily consumption of 250 ml of orange juice on lipid profile, body weight and fasting insulin sensitivity in overweight men with elevated serum total cholesterol concentration. A sugars- and energy-matched control drink was used to standardise for any potential confounding effect of increasing dietary sugars and energy intake on variables, and to investigate any positive effects that may be associated with orange juice consumption.
OJ (n = 18) | CON (n = 18) | |||
---|---|---|---|---|
Pre-intervention | Change at week 12 | Pre-intervention | Change at week 12 | |
Body weight (kg) | 96.3(9.91) | −0.32(2.85) | 94.9(8.19) | −0.13(1.76) |
Waist circumference (cm) | 105.1(6.16) | 0.06(2.80) | 104.1(4.47) | −0.44(3.17) |
Hip circumference (cm) | 109.8(5.36) | 0.39(5.03) | 108.8(4.59) | −0.03(2.76) |
Waist![]() ![]() |
0.96(0.05) | −0.003(0.04) | 0.96(0.04) | −0.005(0.03) |
Total body fat (kg) | 26.39(5.86) | −0.19(2.24) | 28.82(4.94) | −0.39(1.78) |
Total body fat (%) | 33.36(5.37) | −0.14(1.55) | 33.78(4.05) | −0.44(1.54) |
Median HOMA-IR | 3.5(2.4–4.3) | 0.0(−1.3–0.63) | 3.2(2.6–4.4) | 0.0(−0.7–0.9) |
OJ (n = 18) | CON (n = 18) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Pre-intervention | Change at week 12 | Pre-intervention | Change at week 12 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
a P < 0.05 compared to control group at pre-intervention. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
PYY (pg ml−1) | 86.8 (77.8–107.6) | 6.7 (−9.5–13.7) | 99.1 (71.0–118.8) | 0.7 (−7.9–12.6) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ghrelin (pg ml−1) | 797.9 (722.7–1096.8) | −9.1 (−62.5–117.3) | 933.7 (763.7–1056.9) | 25.0 (−103.9–62.4) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
GLP-1 (pmol l−1) | 2.24 (1.94–4.00) | −0.14 (−0.77–0.43) | 2.32 (1.16–3.49) | −0.02 (−0.43–0.56) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Leptin (ng ml−1) | 7.88 (6.81–14.36) | −0.58 (−1.99–0.57) | 8.23 (6.88–12.62) | 0.32 (−1.03–1.85) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CRP (pg ml−1) | 0.91a (0.48–1.77) | 0.13 (−0.21–0.66) | 1.86 (1.08–3.74) | 0.01 (−1.29–0.90) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
IL-6 (pg ml−1) | 3.93 (2.23–5.94) | 0.00 (−0.94–0.82) | 2.33 (2.09–3.27) | 0.00 (−0.95–1.01) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TNFα (pg ml−1) | 3.24a (2.34–3.88) | −0.06 (−0.84–0.41) | 2.22 (1.69–3.01) | 0.00 (−0.99–0.89) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mean UA (μmol l−1) | 376.7(72.54) | 15.6(47.10) | 387.1(68.07) | −3.4(60.93) |
OJ (n = 18) | CON (n = 18) | |||
---|---|---|---|---|
Pre-intervention | Change at week 12 | Pre-intervention | Change at week 12 | |
Total cholesterol (mmol l−1) | 5.62 (5.22–6.53) | 0.02 (−0.54–0.36) | 6.21 (5.78–6.63) | 0.23 (−0.32–0.33) |
LDL (mmol l−1) | 3.64 (3.38–4.24) | 0.04 (−0.33–0.33) | 4.20 (3.65–4.53) | −0.01 (−0.41–0.22) |
HDL (mmol l−1) | 1.11 (1.03–1.34) | −0.02 (−0.11–0.08) | 1.17 (1.04–1.37) | −0.02 (−0.05–0.03) |
NEFA (mmol l−1) | 0.39 (0.32–0.56) | −0.08 (−0.19–0.02) | 0.44 (0.31–0.55) | −0.02 (−0.18–0.08) |
Apo-A1 (g l−1) | 1.23 (1.10–1.28) | 0.06 (−0.04–0.09) | 1.22 (1.10–1.32) | 0.01 (−0.04–0.08) |
Apo-B (g l−1) | 1.08 (1.04–1.26) | 0.06 (−0.10–0.10) | 1.27 (1.10–1.36) | 0.02 (−0.11–0.07) |
TAG (mmol l−1) | 1.52 (0.93–2.30) | −0.11 (−0.68–0.53) | 1.47 (1.04–2.60) | 0.29 (−0.07–0.72) |
Although median TAG concentration of both groups was comparable at V1 (P = 0.839) and V2 (P = 0.613), there was a trend for the change in this variable to be different between the groups after the intervention period (P = 0.060), with fasting TAG being significantly higher at V2 in controls (P < 0.05). Although median TAG was numerically lower in the OJ group at V2, compared with V1, this was not statistically significant or notable in terms of a trend. However, in the OJ group, those with the highest initial triacylglycerol concentration pre-intervention, showed the greatest reduction after 12 weeks supplementation, whereas there was no correlation between these variables in the control group (Fig. 1). There were also no significant associations observed between the change in dietary carbohydrate, total sugars or energy intake after 12 weeks supplementation, and the change in serum TAG concentration, in either group. Spearman's rho was 0.345 (P = 0.227), 0.213 (P = 0.464), and 0.165 (P = 0.573) respectively in the OJ participants, and 0.016 (P = 0.957), −0.066 (P = 0.831) and −0.462 (P = 0.112) respectively in the control group. Indeed, the trend for the change in TAG to be different, between the groups, after the intervention period, remained when sugars intake at V1 was used as a covariate (P = 0.076). However, when either dietary energy or carbohydrate intake at V1 were used as a covariate, this trend was no longer present (P = 0.110 and P = 0.103, respectively).
OJ (n = 17) | CON (n = 16) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Pre-intervention | Change at week 11 | Pre-intervention | Change at week 11 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
a P < 0.05 compared to control group pre-intervention. b P < 0.05 compared to control group, for change at week 11. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Median protein intake (g) | 103.0 (78.5–121.1) | −7.4 (−21.7–8.9) | 92.2 (77.7–106.3) | −8.6 (−14.4–9.5) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fat intake (g) | 131.3(35.2) | −10.2(32.2) | 119.6(36.4) | −10.7(34.6) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CHO intake (g) | 348.9(72.9)a | −33.1(72.9)b | 257.9(60.7) | 23.1(63.9) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Total sugars intake (g) | 144.2(52.7)a | −5.4(54.6) | 99.0(38.5) | 8.57(37.7) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Total energy intake (MJ) | 13.1(2.86)a | −1.32(2.39) | 10.9(2.70) | −0.53(2.14) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Median % total energy (E) derived from protein | 13.6 (11.3–14.8) | 0.7 (−0.55–1.95) | 14.8 (13.7–15.9) | 0.2 (−2.98–1.95) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
% E from fat | 37.8(6.42) | 1.13(5.11) | 40.9(5.13) | −1.94(6.98) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
% E from CHO | 42.2(7.16) | −0.14(4.13)b | 37.7(6.31) | 5.08(8.14) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
% E from sugars | 18.6(4.88)a | −0.07(4.21) | 14.3(4.22) | 1.81(5.17) |
Strengths of the current study were the use of an energy and sugars matched control drink (to isolate any difference between 100% juice and a sweetened beverage) and a single-blinded study design (to identify any placebo effect of participating in the study). Participants were not aware that 100% juice was being investigated and did not know whether they had been randomised to the drink containing citrus flavonoids or no citrus flavonoids. In previous studies examining the effect of OJ consumption on lipid parameters, participants were not blinded to the drink being consumed, which may have altered their health behaviours and had an impact on outcomes. However, in the current study, 12 weeks daily supplementation of the diet with the control drink did not result in significant increases in body weight, insulin resistance, or circulating cholesterol. It is therefore not possible to determine whether phenolic compounds and flavonoids found in fruit juice can protect individuals from these purported adverse metabolic effects of consuming drinks containing sugars.
In the present study, components within orange juice may have mitigated the negative effect of regular sweet drink consumption on circulating TAG concentration, and may have promoted a reduction in this variable in those who demonstrated hypertriacylglycerolemia at V1. Although the observed effects of interventions on circulating TAG are statistically underpowered, the impact that OJ consumption could be having on TAG concentration in the current study supports findings from rodent and human studies which have supplemented the diet with purified flavonoids.13,24 However, observations are not consistent with other human in vivo studies supplementing with whole juice, which have observed no change in TAG concentration after 4 weeks when up to 500 ml per d of orange juice have been provided,17,22 but an increase when participants consumed 750 ml d−1.17 Our data and that of Miwa et al.24 suggest that the lowering effect of orange juice, or citrus flavonoid, supplementation on circulating TAG is not observed where plasma TAG concentration is within the healthy range, and might explain why improvements in TAG concentration were not seen in normotriacylglycerolemic individuals in the Morand study.22
A criticism of the current study is that despite a randomised design, the OJ group reported greater carbohydrate, total sugars and dietary energy intake than the control group before the intervention began, and covariate analysis suggested that carbohydrate and/or energy intake at V1 may have had an impact on the subsequent response of circulating TAG to the interventions. Increasing the proportion of carbohydrate in the diet has been associated with a rise in plasma TAG concentration,25 and in the current study the change in dietary carbohydrate intake at week 11 of supplementation in the OJ group, compared with that in controls, may have contributed to the observed trend for the change in circulating TAG to be different at V2 between groups. Furthermore, although there appears to be a genetic component to this observation, overfeeding energy has also been shown to increase plasma TAG concentration26 and the reduction in dietary energy intake observed in the OJ group may have had an impact on this variable. However, overfeeding is generally accompanied by modifications to other lipid measures, such as increased LDL and ApoB, and decreased HDL,26 and changes to these variables were not observed. Indeed, changes in reported energy intake were not reflected in any significant alterations to body weight in these cohorts, and it is possible that recording dietary intake over 3 days was not sufficient to truly reflect the habitual diet, as has been reported by others.27 Further investigation, with more detailed dietary intake measures, is required to determine the potential confounding effect of macronutrient composition and energy balance on the TAG modifying effects of orange juice supplementation.
Previous studies have reported a LDL-lowering effect of orange juice and citrus flavonoid supplementation in man,15,24,28 but this is not a universal finding.17,29 Indeed, no change in LDL concentration was observed in the current study. Data from in vitro research suggest that the LDL modifying ability of citrus juices is mediated through their flavonoid components.10 It is therefore possible that the failure to improve LDL profile in the current investigation was due to the amount of flavonoids provided being too low; studies reporting improvements in LDL concentration with daily intake of purified flavonoids, have supplemented the diet of participants with approximately 0.7 mmol of glucosyl hesperidin or naringin (naringenin 7-O-rhamnoglucoside),15,24 whereas the amount provided by the orange juice in the present study was approximately 0.22 mmol of hesperidin and 0.03 mmol of narirutin (naringenin-7-O-rutinoside) per day. However, data in the literature do not provide evidence for this supposition. The reported quantity of flavonoids provided by daily consumption of 750 ml of orange juice, in a study which induced a reduction in LDL concentration, was of a similar magnitude to that provided in the current study (0.14 mmol hesperitin and 0.02 mmol naringin),16 and daily supplementing the diet with greater amounts (1.3 mmol hesperidin or 0.86 mmol naringin) did not result in any improvements to circulating lipids in those with elevated cholesterol.29 It is therefore difficult to identify a clear explanation for the differences in LDL response to citrus juice and purified citrus flavonoid supplementation seen in the in vivo human studies, but statistical power, variability in study design (including absence of placebo control), quantity of juice or flavonoids used, supplementation durations, character of participant cohorts, habitual diet, fibre content, or the forms of citrus flavonoids being used (glycoside vs. aglycone), may all play a part. Further investigation of these confounding factors may help to clarify any potential health benefit of citrus consumption.
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the University of Nottingham Medical School Ethics Committee. Written informed consent was obtained from all subjects, and the protocol was registered at http://www.clinicaltrials.gov reference NCT01350843.
Participants were asked to consume 250 ml of either orange juice (as frozen concentrate orange juice; FCOJ, provided by Florida State Department of Citrus, USA, and diluted 1 part concentrate to 3 parts water before consumption; FCOJ was 42° Brix and reconstituted OJ was 11.8° Brix), or an energy and sugars matched, orange-flavoured control drink (MPBioscience Ltd, Derby, UK), once a day for 12 weeks. Participants in the OJ group were provided the FCOJ, a measuring jug and storage vessel for the reconstituted drink. Instructions on how to reconstitute the juice before consumption and how to store both the frozen and reconstituted drink were also provided. The quantity consumed was chosen to reflect the average volume of 100% juice portions available commercially in the UK (which range from 200 ml–330 ml), and allow comparison with previous studies. A sugars matched control was selected to identify any confounding effects that supplementing the diet with additional sugars and energy may have. The composition of the drinks is shown in Table 5, and the citrus flavonoids contained in the orange juice reflect their natural abundance in the product.
Orange juice | Control drink | |
---|---|---|
Sucrose (g) | 10.78 | 11.66 |
Fructose (g) | 5.60 | 5.87 |
Glucose (g) | 5.25 | 4.95 |
Vitamin C (mg) | 137 | 90 |
Hesperidin (mg) | 135.4 | 0 |
Narirutin (mg) | 15.5 | 0 |
The 12 week supplementation period began on the day after the first study visit. In all documentation and interaction with participants, the products were described as an ‘orange flavoured drink’ which was either rich in citrus polyphenols or low in these compounds. The study was therefore single blinded; those providing drink supplies to participants knew which product participants received, but participants and those executing the biochemical analysis were blinded. Weekly telephone contact with the study participants was maintained over the dosing period to improve compliance. No problems with the supplementation protocol or the palatability of the drinks were reported by participants.
Individuals were asked to complete a further 3-day diet diary (as previously described) in the week before the second study visit (week 11), to assess any changes in macronutrient or energy intake which may have occurred as a consequence of the intervention. Household measures were used to estimate portion size, and diaries were subsequently analysed using a food composition database (WISP V2, Tinuviel Software UK 2003). To calculate habitual diet composition, a mean daily intake was obtained from all 3 days of each recording period, and macronutrient composition was expressed as a percentage of total energy intake. These data were combined to produce group means.
IAM is on Scientific Advisory Boards for Nestlé, Ikea and Mars Inc.
The work was supported by an infrastructure award from MRC/ARUK to establish a centre of excellence in musculoskeletal ageing research (Grant No. MR/K00414X/1 and 19891 2012–2017).
This journal is © The Royal Society of Chemistry 2016 |