Olive Oil_Fact Sheet 08

Olive Oil, Monounsaturated Fatty Acids and LDL Oxidation - latest scientific
evidence
1. Introduction
A high concentration of plasma low-density lipoprotein (LDL) cholesterol is a
dominant risk factor for the development of atherosclerosis. However, the precise
mechanisms by which LDL causes atherosclerosis, i.e. the steps between infiltration
of LDL into the arterial wall and the formation of an atherosclerotic lesion, are not
fully understood. There is increasing evidence that LDL must be modified in some
way before it can become pathogenic, and data from biochemical and animal studies
strongly support the hypothesis that oxidative modification of LDL plays a crucial
and causative role in atherogenesis. The susceptibility of LDL to become oxidised is
determined by a variety of endogenous and exogenous factors. Among the latter,
nutritional factors are of outstanding importance, particularly the types of dietary
fatty acids and antioxidant vitamins. The present paper outlines the oxidation
hypothesis of atherosclerosis and the role dietary fat quality could play in modulating
this process.
2. The role of LDL oxidation in atherogenesis
According to the so-called oxidation hypothesis, one of the initial steps in
atherogenesis is the oxidative modification of LDL and the uptake of the modified
lipoprotein particles by macrophages, which in turn become lipid laden cholesterolrich cells, so-called foam cells1. An accumulation of foam cells in the arterial wall is
the first visible sign of atherosclerosis and is termed fatty streak 2. Although the
relevance of the oxidation hypothesis has not been fully established, much supportive
data has been generated in the last decade. LDL has been shown to be oxidised in
vivo3, autoantibodies to oxidised LDL have been found in humans 4, and LDL
extracted from human atherosclerotic lesions demonstrates many of the physical,
chemical and biological properties of in vitro oxidised LDL5. Furthermore, the
measurement of the susceptibility of LDL to oxidation has been shown to correlate
independently with the extent of atherosclerosis6.
It is well known that oxidation of LDL can be initiated in vitro by incubating isolated
LDL particles with cells (macrophages, lymphocytes, smooth muscle cells, or
endothelial cells), metal ions (copper or iron), enzymes, oxygen radicals, or UVlight7-9. However, less is known about the mechanisms by which LDL becomes
oxidised in vivo. There is evidence that LDL is protected against oxidation in plasma
by water-soluble antioxidative substances, such as ascorbic acid, ureic acid, or
bilirubin. Thus, it is likely that the majority of oxidative modification of LDL occurs
in the artery wall, where LDL is largely isolated from the plasmatic antioxidants.
Recent evidence suggests, that metal ions (copper or iron) and the enzymes
myeloperoxidase and lipoxygenase play major parts in the modification of LDL10.
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If LDL is exposed to pro-oxidative conditions, it becomes depleted of its

antioxidants. The oxidation of the LDL polyunsaturated fatty acids (PUFA) to lipid
hydroperoxides starts when most of the antioxidant defence has been lost. The
decomposition of PUFA leads to a lot of further modifications in the LDL-particle,
e.g. oxidation of cholesterol or modifications of apo B 7; 11. These modifications have
two major effects. First, molecules with high biological potential are generated.
These include substances that are chemotactic for monocytes and lymphocytes,
cytotoxic or that directly alter gene expression of arterial wall cells (Table 1).
Second, the modifications of apo B lead to changes in the receptor specificity of the
LDL particle and increase its affinity to the so-called scavenger receptors. Native
LDL mainly binds to the LDL-receptor. Because the number of LDL-receptors on
cells is regulated by intracellular free cholesterol content, cells can only take up
limited amounts of LDL by means of these receptors. On the other hand, scavenger
receptors, a family of structurally heterogenous proteins located on the surface of
endothelial cells, monocytes and macrophages12, are not feedback-regulated by
intracellular cholesterol content. By means of scavenger receptors the cells can take
up modified LDL in an unregulated manner and accumulate huge amounts of
cholesterol and cholesterol esters. Because these features of modified LDL promote
atherosclerosis it should be a lingering concern to minimise the susceptibility of LDL
to oxidation.
Table 1: Atherogenic properties of ox-LDL (reviewed in 11; 13; 14).

Ox-LDL shows an enhanced uptake by macrophages leading to cholesteryl

ester enrichment and foam cell formation
Ox-LDL is chemotactic for monocytes and T-lymphocytes
Ox-LDL inhibits the motility of macrophages in the artery wall
Ox-LDL is cytotoxic
Ox-LDL alters gene expression, inducing the production of cytokines and
adhesion molecules
Ox-LDL induces smooth muscle cell proliferation
Ox-LDL is immunogenic and can elicit autoantibody formation
Ox-LDL is more susceptible to aggregation, which independently leads to
enhanced macrophage uptake
Ox-LDL can adversely alter coagulation pathways, such as alteration of
platelet aggregation
Ox-LDL can adversely alter vasomotor properties of coronary arteries

3. Olive oil and oxidative processes

There is no doubt that nutrition is of great importance in LDL oxidisability. In
particular, the quality of fat as well as the content of antioxidative components in the
diet affect the susceptibility of LDL and cells to oxidative damage. There are several
potential ways by which dietary fatty acids may influence the atherogenicity of LDL.
First of all, the amount and composition of dietary fat affects the amount of LDL
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particles present in the artery wall. Replacement of dietary saturated fatty acids with
either MUFA or PUFA lowers total and LDL cholesterol levels (for details see fact
sheet 1). Dietary fatty acids may also directly influence LDL susceptibility to
oxidation by changing its fatty acid composition. Furthermore, dietary fatty acids
may change the fatty acid composition of the artery wall cells, thus altering their prooxidant activity and their response to oxidative stress11; 9.
Due to its high MUFA content olive oil seems to have protective properties with
regard to LDL oxidation. Additionally, olive oil may further provide some protection
by supplying LDL with potent antioxidants, such as Vitamin E and polyphenolic
compounds. These protective effects of antioxidants will be detailed in a separate fact
sheet "Antioxidative Constituents of Olive Oil and LDL Oxidation".
3.1 Effects of dietary fatty acids from olive oil on LDL oxidation
Several investigators have compared the influence of dietary MUFA and PUFA on
LDL oxidation. It could first be shown in rabbits that oleate-rich LDL particles are
remarkably resistant to oxidative modification15.
One of the first studies investigating this question in humans was done by Reaven et
al.16, who provided their study participants with high-fat liquid formula diets which
had a MUFA content of about 80% of total fatty acids or a PUFA content of about
60%. After these diets extremely enriched in MUFA (derived from high-oleic
sunflower oil) or PUFA (derived from sunflower oil) the fatty acid composition of
isolated LDL particles reflected the fatty acid composition of the diet, and the fatty
acid distribution was similar in the different lipid fractions of the LDL-particle. The
linoleic acid (C18:2) content of LDL was strongly related to the rate and the extent of
oxidation, whereas the amount of oleic acid (C18:1) in the LDL-particles was
inversely correlated with the extent of oxidation.
Several other studies were conducted with solid food diets in healthy 17-23,
hyperlipidemic24; 25 and diabetic subjects26. These studies consistently show, that diets
rich in MUFA lead to LDL that is more resistant to oxidative modifications when
compared to PUFA-rich diets. For instance, Bonanome et al. 17 compared a grapeseed
oil-enriched diet (45 % fat; 5 % MUFA, 30 % PUFA) to a diet enriched in olive oil
(45% fat; 30% MUFA, 5% PUFA) in 12 healthy subjects. Again, the rate of LDL
oxidation during the PUFA diet was higher compared to the MUFA diet.
Although these results are unambiguous, several questions remain open. On the basis
of the studies conducted so far, it is not clear whether only the decrease in easily
oxidisable linoleic acid in LDL is responsible for the decrease in lipid peroxidation
after a MUFA-rich diet, or whether this decrease is due to direct antioxidant
properties of oleic acid. Or, are both mechanisms together involved in reducing the
susceptibility of LDL to oxidation? Do PUFA enhance or do MUFA decrease LDL
oxidation?
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Until now, there are only two studies dealing with these questions: Aviram and Eias 27
compared the effects of an olive oil supplement (50g/day) to the baseline diet (30%
fat, 50% carbohydrates). It could be demonstrated, that the LDL obtained after one
and two weeks of the olive oil rich diet showed a reduced susceptibility to oxidation
as well as reduced cellular uptake by macrophages. Thus, it can be suggested that
MUFA supplementation can cause an absolute decrease in LDL susceptibility to
oxidation. Berry et al.28 confirmed these results in their study in which they compared
a MUFA-rich diet (17% of energy, total fat: 33 % of energy) with a carbohydrate-rich
diet (65% of energy; MUFA: 7%), keeping the PUFA content constant in both diets.
The MUFA-diet led to a significant reduction in the susceptibility of LDL to
oxidative stress. These data support the concept, that oleic acid enriched diets may
reduce LDL oxidation both through intrinsic anti-oxidant properties of MUFA, as
well as by reducing the content of linoleic acid in LDL11.
3.2 Effects of dietary fatty acids on cellular pro-oxidant activity and cellular
susceptibility to oxidative stress
Dietary fatty acids can also have effects on cellular pro-oxidant activity. Several
investigators have demonstrated that dietary supplementation with different types of
fatty acids leads to changes in the fatty acid composition of the monocyte membrane
composition and that this influences the production of oxygen radicals, particularly
superoxide anion, in monocytes and macrophages. The production of superoxide
anion by these cells undoubtedly contributes to LDL oxidation. In a comparison of
the effects of dietary supplementation with MUFA, n-3-, or n-6-PUFA on superoxide
anion generation a decrease in superoxide production was only observed after n-3
fatty acid supplementation, while the monocytes from the MUFA or n-6-PUFA
supplemented groups showed no change or had increased superoxide anion levels 29.
The mechanism by which n-3 fatty acids may reduce the oxygen radicals is not
known, and other studies could not confirm these effects. Further investigation is
needed to exactly evaluate the role of the different fatty acids on cellular pro-oxidant
activity11.
Furthermore, dietary fatty acids can influence the susceptibility of cells to oxidative
stress, probably also by changing cell membrane fatty acid composition. Cells
enriched with MUFA have been shown to be less susceptible to oxidative damage,
whereas n-6 PUFA increased the susceptibility to oxidative damage. Oxidative
damage of cells of the artery wall can contribute to the progression of atherosclerotic
lesions. For instance, oxidation-induced injury to endothelial cells may increase the
likelihood of plaque rupture and clot formation 11. Additionally, dietary MUFA from
virgin olive oil have been shown to protect mitochondrial membranes from rat heart
cells against ageing-related peroxidative damage30.
3.3 The impact of olive oil on the atherogenicity of oxidised LDL
As described above, oxidatively modified LDL exerts several atherogenic properties.
Tsimikas and colleagues23 have investigated the effect of dietary MUFA and PUFA on
the ability of mildly oxidised LDL to induce monocyte adhesion and chemotaxis.
They found an inverse correlation between the oleic acid content of LDL and
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stimulation of monocyte adhesion and chemotaxis and a positive correlation between

the LDL linoleic acid content and these parameters. This suggests, that a higher
amount of oleic acid in LDL not only renders the LDL particle less oxidisable, but
also reduces its biological activity with regard to atherosclerotic processes. Similar
results with regard to monocyte adhesion were reported by Mata et al.19.
4. Summary and conclusions
There is extensive evidence that oxidative modification of LDL plays a crucial and
causative role in the pathogenesis of atherosclerosis. Oxidation of LDL begins with
peroxidation of PUFA in the LDL particle. Thus, LDL fatty acid composition
undoubtedly contributes to the process of LDL oxidation. The fatty acid composition
of LDL is influenced by dietary fatty acids, and, as a consequence, the amount and
type of fat in the diet also affects the susceptibility of LDL to oxidative damage.
Diets rich in MUFA render LDL more resistant to oxidative modifications compared
to diets rich in PUFA, due to an enrichment of LDL particles with oleic acid instead
of linoleic acid. In addition, the fatty acid composition of cell membranes is dietdependent, and MUFA-rich diets also lead to a higher MUFA content of cell
membranes, and therefore to a higher cellular resistance to oxidative damage.
Furthermore, an increase in dietary MUFA does not only reduce the susceptibility of
LDL to oxidation, but also reduces the atherogenic features of the LDL once it is
oxidised.
Until several years ago attention to the benefits of the Mediterranean diet has been
focused on its favourable effects on hyperlipidaemia and other established
cardiovascular risk factors. Now more and more evidence emerges that the high
intake of MUFA in the Mediterranean diet due to the olive oil consumption combines
the advantages of lowering cholesterol levels and decreasing LDL and cell
susceptibility to oxidation as well as reducing the atherogenic properties of the LDL
particle.