Garlic

Overview

Garlic has been used for centuries for its reported benefits in promoting heart health and preventing infection. For more than 5,000 years, humans have been cultivating garlic for use as a spice and a medicine and records document its medicinal use from Egyptian pharaohs to Chinese emperors to Middle Age and World War II soldiers where garlic juice was known as “Russian penicillin” for its antibiotic effects in wound healing.

Modern-day usage of garlic as a dietary supplement generally centers around promotion of heart health by reducing serum lipid levels (total cholesterol, LDL, triglycerides), lowering blood pressure, and inhibiting blood clotting. The cardioprotective benefits associated with garlic are generally attributed to the various sulfur compounds that can be isolated from the raw clove. These compounds, which include alliin, allicin, S-allyl-cysteine, and S-methyl-cysteine are found in varying concentrations in garlic, chives, leeks, shallots and onions, but the chemical composition may vary considerably depending on processing methods and are generally highest in garlic compared to other plants in the allium family. The chemical responsible for the pungent smell of garlic, allicin, is produced from alliin (an odorless amino acid derivative) via the action of alliinase and is thought to contribute to many of the health effects associated with garlic supplements.

Comments

A major concern with all garlic supplements is the total level of sulfur-containing compounds or total allicin potential of commercial products. Raw garlic is more potent than cooked garlic, and fresh garlic is more potent than old garlic. De-odorized and aged garlic supplements typically contain only a fraction of the alliin found in fresh garlic. Because alliin is converted to the active allicin form (the source of garlic’s unique odor) in the body, and because the precise mechanism by which garlic helps lower cholesterol is unknown, it is prudent to select a product with high allicin potential. General considerations for dosing are that each milligram of alliin yields approximately 50% of that amount as allicin – so 500mg of a garlic extract standardized to 1% alliin would yield approximately 2,500mcg allicin (compare this to a clove of fresh garlic, approximately 4 grams with 1% alliin, yielding about 20,000mcg allicin). Due to differences in strength and preparations of various commercial garlic supplements, consumers should pay attention to the “allicin potential” of a particular product.

Scientific Support

Garlic is mostly used for its antihyperlipidemic and antihypertensive effects. It also has been reported to possess antibacterial, antiviral, antifungal effects, but these are generally confined to topical applications. In patients with hyperlipidemia, garlic might lower cholesterol level by acting as a mild HMG-CoA reductase inhibitor. Garlic is thought to protect vascular endothelial cells from injury by reducing oxidative stress and inhibiting low density lipoprotein (LDL) oxidation. Garlic has also shown to have antithrombotic activity by increasing fibrinolytic activity and decreasing platelet aggregation. For hypertension, garlic is thought to reduce blood pressure by causing smooth cell relaxation and vasodilation by activating production of nitric oxide.

The health benefits of garlic supplements are a controversial area. Although there would appear to be quite a large number of studies indicating a beneficial cardiovascular effect of garlic supplements, the most well-controlled studies generally suggest a lack of any beneficial effects (Arora et al. 1981, Buck et al. 1979) – or suggest benefits only at high doses (Breithaupt-Grogler et al. 1997, Fogarty 1993). For example, a study of children with elevated blood cholesterol and triglycerides, 8 weeks of garlic supplementation (900mg/day) produced no significant effect on total cholesterol, triglycerides LDL or HDL (Jepson et al. 2000). It is possible that these children, who had severe cases of familial hyperlipidemia, did not respond to the garlic supplements because their medical condition was too advanced for treatment with a mild approach such as dietary supplementation. In support of this “non-effect,” however, is a multi-center study carried out over 12 weeks (also using 900mg/d) also found no significant lipid or lipoprotein changes following garlic supplementation (Jepson et al. 2000). The Food and Drug Administration (FDA) has gone so far as to issue a ruling to prohibit the use a claim on dietary supplements relating to the relationship between garlic, decreased serum cholesterol, and the risk in adults of cardiovascular disease.

The lack of effect in the above studies may have been due to the dose used – with 900mg per day being too low. Larger doses of garlic (4-10 grams per day) have been more consistently associated with beneficial effects. For example, a study of 30 patients with coronary artery disease (Simons et al. 1995), garlic supplements (4 capsules per day equivalent to 4 grams of raw garlic) showed a significant reduction in serum cholesterol and triglyceride levels as well as an inhibition of platelet aggregation (reduced blood clotting). Further supporting the cardiovascular benefits in humans is a well-controlled study which compared the effect of aged garlic extract on blood lipids in a group of 41 men with moderately elevated cholesterol levels (Chutani and Bordia 1981). Each subject received about 7 grams of garlic extract per day over the course of 6 months. The major findings were a reduction in total serum cholesterol of approximately 7% and a drop in LDL of 4-5%. In addition, there was a 5.5% decrease in systolic blood pressure and a modest reduction of diastolic blood pressure in response to aged garlic extract. The overall conclusion of the study was that “dietary supplementation with aged garlic extract has beneficial effects on the lipid profile and blood pressure of moderately hypercholesterolemic subjects” – but this dose of garlic would certainly pose numerous practical issues such as compliance.

Safety/Dosage

Adverse side effects associated with garlic supplements are rare. Occasionally, mild gastrointestinal symptoms such as heart burn and nausea may occur with high intakes. In some cases, high doses of garlic may potentiate the anti-thrombotic (blood-thinning) effects of anti-inflammatory medications such as aspirin and dietary supplements such as vitamin E and fish oil. The German Commission E monographs recommend a dose of 4 grams of fresh garlic per day to lower blood lipids. This amount of garlic would be equivalent to approximately 18,000 mcg (18 mg) of alliin (9 mg of allicin) and 500 mcg of S-allyl cysteine.

References

1.Arora RC, Arora S, Gupta RK. The long-term use of garlic in ischemic heart disease--an appraisal. Atherosclerosis. 1981 Oct;40(2):175-9.

2.Breithaupt-Grogler K, Ling M, Boudoulas H, Belz GG. Protective effect of chronic garlic intake on elastic properties of aorta in the elderly. Circulation. 1997 Oct 21;96(8):2649-55.

3.Buck C, Simpson H, Willan A. Ischaemic heart-disease and garlic. Lancet. 1979 Jul 14;2(8133):104-5.

4.Chutani SK, Bordia A. The effect of fried versus raw garlic on fibrinolytic activity in man. Atherosclerosis. 1981 Feb-Mar;38(3-4):417-21.

5.Fogarty M. Garlic's potential role in reducing heart disease. Br J Clin Pract. 1993 Mar-Apr;47(2):64-5.

6.Jepson RG, Kleijnen J, Leng GC. Garlic for peripheral arterial occlusive disease. Cochrane Database Syst Rev. 2000;(2):CD000095.

7.Randerson K. Cardiology update. Garlic and the healthy heart. Nurs Stand. 1993 Apr 14-20;7(30):51.

8.Simons LA, Balasubramaniam S, von Konigsmark M, Parfitt A, Simons J, Peters W. On the effect of garlic on plasma lipids and lipoproteins in mild hypercholesterolaemia. Atherosclerosis. 1995 Mar;113(2):219-25.

EDITOR'S NOTE: This monograph can be found in The Health Professional's Guide to Dietary Supplements (Lippincott, Williams & Wilkins) by Shawn M. Talbott, PhD and Kerry Hughes, MS.

Fiber

Overview

Fiber is found in the stems, seeds and leaves of plants. Fiber is made up of long chains of sugar, but as humans, we lack the digestive enzymes to break down these complex polysaccharides (although a small amount of ingested fiber can be partially broken down by enzymes produced by bacteria in the intestines). Most of the fiber, however, is not broken down and exits the body in the feces. “Fiber” is a very broad term. More precise terms are soluble and insoluble fiber. Soluble fiber dissolves in water and can be broken down by bacterial enzymes, while insoluble fiber cannot. The distinction is important because the solubility of the fiber determines its health benefit. Fiber found in food is usually a mixture of both types of fiber, while purified fiber supplements may contain just one type of fiber.

Dietary sources of fiber are plentiful. Fruits, vegetables, seeds and legumes (dried peas and beans such as lentils, split peas, red beans and pinto beans) contain both types of fiber. Barley, oats, oat bran and rye contain predominantly soluble fiber. Wheat bran, brown rice and whole grains (grains that have not been refined) are excellent sources of insoluble fiber.

Supplemental sources of fiber include psyllium, methylcellulose or polycarbophil as well as fiber extracted from fruits, vegetables and grains. Psyllium is a concentrated source of fiber from the husks of the psyllium plant. Methylcellulose and polycarbophil are chemically altered forms of cellulose (the cell wall of many plants). The chemical alterations make them resistant to bacterial breakdown. The United States Food and Drug Administration (FDA) has approved health claims for 2 dietary fibers, beta-glucan (0.75g/serving) and psyllium (1.78g/serving), based on evidence that 4 servings/day can reduce cardiovascular disease risk – reducing total cholesterol by an average of 2% and overall cardiovascular disease risk by about 4% (Jenkins et al. 2002).

General health recommendations call for a daily consumption of 20-40 grams of fiber, but the average American consumes less than 15 grams. Although the amount of soluble and insoluble fiber is not specified, it is assumed that people will receive both types of fiber. In general, claims made for supplemental forms of dietary fiber are based on scientific evidence showing that soluble fiber reduces the risk of heart disease (by lowering total and LDL cholesterol levels) and that insoluble fiber reduces the risk of colon cancer (by reducing the concentrations of fecal bile acids).

Comments

There is no question that adequate fiber is necessary for good health. Consumption of 20 to 40 grams of fiber per day is possible from food sources alone – but this entails a high consumption of legumes and whole grains. However, it is recognized that in the U.S., the average fiber intake is less than 15 grams per day. In light of average intake, fiber supplements are often recommended and warranted.

Scientific Support

Soluble Fiber and Heart Disease Risk

Hundreds of studies have been conducted to examine the role of soluble fiber in reducing the risk of heart disease by lowering cholesterol levels. Although it is difficult to compare the studies because of differences in the type and amount of soluble fiber, the number of people studied and the initial cholesterol levels of the subjects, some general conclusions can be drawn. It is generally accepted by nutrition scientists that approximately 2-10 grams of soluble fiber daily appears to reduce blood cholesterol and LDL cholesterol (Jenkins et al. 1993, Jenkins et al. 2001, Jenkins et al, 2002). The reduction is small, but makes a substantial contribution to reducing heart disease risk. The source of the fiber (oats, pectin found in fruits or psyllium) seems to make little difference, as all types have been shown to be effective (Jenkins et al. 2002, Lampe et al. 1992). The inclusion of soluble fibers in the diet is both practical and safe as long as the individual is not allergic to the source of the fiber.

Soluble fiber reduces the risk of heart disease by lowering cholesterol and LDL (Jenkins et al. 1993, Jenkins et al. 2001). Although the mechanism is not entirely known, soluble fiber is thought to decrease the absorption of bile. Bile, which contains cholesterol, is necessary for the digestion of fat. It is secreted into the intestine in response to food intake and most is reabsorbed after digestion is complete. When soluble fiber is present in the digestive tract, not as much bile is reabsorbed and more must be made by the liver. Some of the cholesterol that would have circulated in the blood is used to make the bile. In addition, soluble fiber can be partially broken down by intestinal bacteria which produce fatty acids that keep the liver from making cholesterol. It is generally accepted by nutrition scientists that soluble fiber intake can help reduce cholesterol levels. In one study, a high-fiber fruit and vegetable diet was shown to reduce LDL cholesterol levels by 33% within 1 week (Jenkins et al. 2001) – and a number of studies have shown that the drop in total and LDL cholesterol from a diet high in fiber is nearly 50% greater than would be predicted by differences in dietary fat and cholesterol (Haack et al. 1998, Jenkins et al. 1993, Jenkins et al. 1997).

Insoluble Fiber and Colon Cancer Risk

For nearly 30 years, researchers have been studying the effect of fiber on colon cancer. People who consume diets high in fiber tend to also consume diets that are low in total fat, low in animal fat and high in fruits and vegetables – all of which are factors that might reduce colon cancer risk. Fiber is also a vehicle for other compounds, such as phytic acid, an antioxidant thought to prevent colon cancer. Researchers are trying to determine whether fiber should be considered an independent factor in reducing colon cancer risk or whether the effect of fiber is due to a combination of other factors. Results of human studies have been mixed but a number of recent large studies suggest that fiber is not protective against colon cancer (Hung et al. 2004, McCullough et al. 2003, Michels et al. 2000, Sellers et al. 1998). In particular, McCullough (2003) and Michels (2000) looked at very large populations (cohorts from the 62,609-men and 70,554-women Cancer Prevention Study II Nutrition Cohort, the 88,764-women Nurses Health Study and the 47,325-men Health Professionals Follow-up Study) – finding that higher intakes of plant foods or fiber were not related to lower risk of colon cancer (but that low intakes were related to a higher cancer risk).

There are, however, numerous studies that have suggested that diets high in insoluble fiber reduce the risk of colon cancer (Alberts et al. 1996, Kesaniemi et al. 1990, Lampe et al. 1992) – but not all studies have supported these findings (McCullough et al. 2003, Michels et al. 2000). If, and how, fiber reduces the risk of cancer is not completely known and is undoubtedly complicated. The theory that supports the role of a high fiber diet in the prevention of colon cancer is controversial. It is suggested that insoluble fiber may work by helping to excrete bile from the body. Bile, which is necessary for the digestion of fat, is also thought to promote tumor growth. Insoluble fiber may bind with the bile – thus preventing it from being a promoter. Insoluble fiber also reduces the amount of time that fecal material is in the colon. Exposure to potential cancer-causing compounds is reduced because the fiber binds and removes these compounds quickly. Researchers who question whether or not insoluble fiber actually reduces colon cancer risk do so because they are not convinced that the fiber itself is responsible. They suggest that foods that contain insoluble dietary fiber also contain substances such as antioxidants, folate or dozens of other phytonutrients that protect the body from colon cancer (McCullough et al. 2003, Slattery et al. 1997, Voorrips et al. 2000). They argue that it is these compounds, rather than the dietary fiber, that help to protect against colon cancer.

Constipation

Constipation is a condition where bowel movements (feces) are hard and dry. The strain of trying to pass the hard, dry feces may result in hemorrhoids (swollen veins in the rectum). Adequate fiber, fluid and exercise help prevent constipation. Both soluble and insoluble fibers help the feces stay moist because fiber attracts water. Insoluble fiber also has a laxative effect and helps speed up the time it takes for feces to move out of the body. This theory is well accepted. Scientific studies support the role of dietary fiber to relieve constipation. Fluid and exercise are also mentioned as important factors. Both dietary fiber and fiber supplements are beneficial.

Safety/Dosage

The intake of dietary fiber or fiber supplements within the recommended doses (see below) is considered safe. To prevent dehydration, adequate fluid must be consumed. Side effects such as excessive gas or bloating may occur. Some individuals may be allergic to the source of the fiber, for example, wheat or psyllium.

Total daily fiber consumption should be within the range of 20-40 grams – with supplemental sources of fiber advised when dietary sources (fruits, vegetables, whole grains, legumes, and nuts) are below recommended levels. Popular fiber supplements (all with 8 ounces of water) may include, psyllium (7 grams – up to 3 times daily), methylcellulose (10 grams – up to 3 times daily), and polycarbophil (1 gram – up to 4 times daily).

References

1.Alberts DS, Ritenbaugh C, Story JA, Aickin M, Rees-McGee S, Buller MK, Atwood J, Phelps J, Ramanujam PS, Bellapravalu S, Patel J, Bextinger L, Clark L. Randomized, double-blinded, placebo-controlled study of effect of wheat bran fiber and calcium on fecal bile acids in patients with resected adenomatous colon polyps. J Natl Cancer Inst. 1996 Jan 17;88(2):81-92.

2.Anderson JW, Smith BM, Gustafson NJ. Health benefits and practical aspects of high-fiber diets. Am J Clin Nutr. 1994 May;59(5 Suppl):1242S-1247S.

3.Correa P. Epidemiological correlations between diet and cancer frequency. Cancer Res. 1981 Sep;41(9 Pt 2):3685-90.

4.Dietary fiber and health. AMA council on Scientific Affairs. Conn Med. 1989 Sep;53(9):529-34.

5.Haack VS, Chesters JG, Vollendorf NW, Story JA, Marlett JA. Increasing amounts of dietary fiber provided by foods normalizes physiologic response of the large bowel without altering calcium balance or fecal steroid excretion. Am J Clin Nutr. 1998 Sep;68(3):615-22.

6.Hung HC, Joshipura KJ, Jiang R, Hu FB, Hunter D, Smith-Warner SA, Colditz GA, Rosner B, Spiegelman D, Willett WC. Fruit and vegetable intake and risk of major chronic disease. J Natl Cancer Inst. 2004 Nov 3;96(21):1577-84.

7.Jacobs DR Jr, Meyer KA, Kushi LH, Folsom AR. Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women: the Iowa Women's Health Study. Am J Clin Nutr. 1998 Aug;68(2):248-57.

8.Jenkins DJ, Kendall CW, Popovich DG, Vidgen E, Mehling CC, Vuksan V, Ransom TP, Rao AV, Rosenberg-Zand R, Tariq N, Corey P, Jones PJ, Raeini M, Story JA, Furumoto EJ, Illingworth DR, Pappu AS, Connelly PW. Effect of a very-high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function. Metabolism. 2001 Apr;50(4):494-503.

9.Jenkins DJ, Kendall CW, Vuksan V, Vidgen E, Parker T, Faulkner D, Mehling CC, Garsetti M, Testolin G, Cunnane SC, Ryan MA, Corey PN. Soluble fiber intake at a dose approved by the US Food and Drug Administration for a claim of health benefits: serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial. Am J Clin Nutr. 2002 May;75(5):834-9.

10.Jenkins DJ, Popovich DG, Kendall CW, Vidgen E, Tariq N, Ransom TP, Wolever TM, Vuksan V, Mehling CC, Boctor DL, Bolognesi C, Huang J, Patten R. Effect of a diet high in vegetables, fruit, and nuts on serum lipids. Metabolism. 1997 May;46(5):530-7.

11.Jenkins DJ, Wolever TM, Rao AV, Hegele RA, Mitchell SJ, Ransom TP, Boctor DL, Spadafora PJ, Jenkins AL, Mehling C, et al. Effect on blood lipids of very high intakes of fiber in diets low in saturated fat and cholesterol. N Engl J Med. 1993 Jul 1;329(1):21-6.

12.Kesaniemi YA, Tarpila S, Miettinen TA. Low vs high dietary fiber and serum, biliary, and fecal lipids in middle-aged men. Am J Clin Nutr. 1990 Jun;51(6):1007-12.

13.Kritchevsky D. The role of dietary fiber in health and disease. J Environ Pathol Toxicol Oncol. 1986 Mar-Apr;6(3-4):273-84.

14.Lampe JW, Slavin JL, Melcher EA, Potter JD. Effects of cereal and vegetable fiber feeding on potential risk factors for colon cancer. Cancer Epidemiol Biomarkers Prev. 1992 Mar-Apr;1(3):207-11.

15.McCullough ML, Robertson AS, Chao A, Jacobs EJ, Stampfer MJ, Jacobs DR, Diver WR, Calle EE, Thun MJ. A prospective study of whole grains, fruits, vegetables and colon cancer risk. Cancer Causes Control. 2003 Dec;14(10):959-70.

16.Michels KB, Edward Giovannucci, Joshipura KJ, Rosner BA, Stampfer MJ, Fuchs CS, Colditz GA, Speizer FE, Willett WC. Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers. J Natl Cancer Inst. 2000 Nov 1;92(21):1740-52.

17.Sandler RS, Lyles CM, Peipins LA, McAuliffe CA, Woosley JT, Kupper LL. Diet and risk of colorectal adenomas: macronutrients, cholesterol, and fiber. J Natl Cancer Inst. 1993 Jun 2;85(11):884-91.

18.Sellers TA, Bazyk AE, Bostick RM, Kushi LH, Olson JE, Anderson KE, Lazovich D, Folsom AR. Diet and risk of colon cancer in a large prospective study of older women: an analysis stratified on family history (Iowa, United States). Cancer Causes Control. 1998 Aug;9(4):357-67.

19.Slattery ML, Potter JD, Coates A, Ma KN, Berry TD, Duncan DM, Caan BJ. Plant foods and colon cancer: an assessment of specific foods and their related nutrients (United States). Cancer Causes Control. 1997 Jul;8(4):575-90.

20.Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000 Jul 6;343(1):16-22.

21.Voorrips LE, Goldbohm RA, van Poppel G, Sturmans F, Hermus RJ, van den Brandt PA. Vegetable and fruit consumption and risks of colon and rectal cancer in a prospective cohort study: The Netherlands Cohort Study on Diet and Cancer. Am J Epidemiol. 2000 Dec 1;152(11):1081-92.

22.Wolk A, Manson JE, Stampfer MJ, Colditz GA, Hu FB, Speizer FE, Hennekens CH, Willett WC. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA. 1999 Jun 2;281(21):1998-2004.

EDITOR'S NOTE: This monograph can be found in The Health Professional's Guide to Dietary Supplements (Lippincott, Williams & Wilkins) by Shawn M. Talbott, PhD and Kerry Hughes, MS.