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Noncommunicable diseases are long-lasting and slowly progressive and are the leading causes of death and disability. They include cardiovascular diseases (CVD) and diabetes mellitus (DM) that are rising worldwide, with CVD being the leading cause of death in developed countries. Thus, there is a need to find new preventive and therapeutic approaches. Polyphenols seem to have cardioprotective properties; among them, polyphenols and/or minor polar compounds of extra virgin olive oil (EVOO) are attracting special interest. In consideration of numerous sex differences present in CVD and DM, in this narrative review, we applied “gender glasses.” Globally, it emerges that olive oil and its derivatives exert some anti-inflammatory and antioxidant effects, modulate glucose metabolism, and ameliorate endothelial dysfunction. However, as in prescription drugs, also in this case there is an important gender bias because the majority of the preclinical studies are performed on male animals, and the sex of donors of cells is not often known; thus a sex/gender bias characterizes preclinical research. There are numerous clinical studies that seem to suggest the benefits of EVOO and its derivatives in CVD; however, these studies have numerous limitations, presenting also a considerable heterogeneity across the interventions. Among limitations, one of the most relevant in the era of personalized medicine, is the non-attention versus women that are few and, also when they are enrolled, sex analysis is lacking. Therefore, in our opinion, it is time to perform more long, extensive and lessheterogeneous trials enrolling both women and men.
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Review Article
Is Extra Virgin Olive Oil an Ally for Women’s and Men’s
Cardiovascular Health?
Flavia Franconi,
1
Ilaria Campesi ,
1
,
2
and Annalisa Romani
3
,
4
1
Laboratorio Nazionale sulla Farmacologia e Medicina di Genere, Istituto Nazionale Biostrutture Biosistemi, 07100 Sassari, Italy
2
Dipartimento di Scienze Biomediche, Universit`
aDegli Studi di Sassari, 07100 Sassari, Italy
3
Laboratorio PHYTOLAB (Pharmaceutical, Cosmetic, Food Supplement Technology and Analysis),
DiSIA Universit`
aDegli Studi di Firenze, 50019 Florence, Italy
4
Laboratorio di Qualit`
aDelle Merci e Affidabilit`
adi Prodotto, Universit`
aDegli Studi di Firenze, 59100 Florence, Italy
Correspondence should be addressed to Ilaria Campesi; icampesi@uniss.it
Received 3 February 2020; Accepted 4 March 2020; Published 24 April 2020
Academic Editor: Hangang Yu
Copyright ©2020 Flavia Franconi et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Noncommunicable diseases are long-lasting and slowly progressive and are the leading causes of death and disability. ey include
cardiovascular diseases (CVD) and diabetes mellitus (DM) that are rising worldwide, with CVD being the leading cause of death in
developed countries. us, there is a need to find new preventive and therapeutic approaches. Polyphenols seem to have
cardioprotective properties; among them, polyphenols and/or minor polar compounds of extra virgin olive oil (EVOO) are
attracting special interest. In consideration of numerous sex differences present in CVD and DM, in this narrative review, we
applied “gender glasses.” Globally, it emerges that olive oil and its derivatives exert some anti-inflammatory and antioxidant
effects, modulate glucose metabolism, and ameliorate endothelial dysfunction. However, as in prescription drugs, also in this case
there is an important gender bias because the majority of the preclinical studies are performed on male animals, and the sex of
donors of cells is not often known; thus a sex/gender bias characterizes preclinical research. ere are numerous clinical studies
that seem to suggest the benefits of EVOO and its derivatives in CVD; however, these studies have numerous limitations,
presenting also a considerable heterogeneity across the interventions. Among limitations, one of the most relevant in the era of
personalized medicine, is the non-attention versus women that are few and, also when they are enrolled, sex analysis is lacking.
erefore, in our opinion, it is time to perform more long, extensive and lessheterogeneous trials enrolling both women and men.
1. Introduction
e Mediterranean diet (MedDiet) includes high con-
sumption of legumes, cereals, fruits, and vegetables; mod-
erate fish and wine consumption; and low consumption of
red meat ([1] and cited literature). e MedDiet also in-
cludes the consumption of 25–50 ml/day of extra virgin olive
oil (EVOO), which seems to have health benefits [2, 3].
Cardiovascular diseases (CVD) are the main cause of
deaths, accounting for >17 million deaths annually [4]. e
beneficial effect of MedDiet on CVD is suggested by several
randomized clinical trials, although some recent papers
stated that the evidence is still uncertain [5, 6]. For example,
the Oslo Diet-Heart Study and the Finnish Mental Hospital
Study [7–9] tested the effectiveness of low-cholesterol diets,
enriched in polyunsaturated fatty acids, showing a decrease
in coronary heart diseases (CAD) and blood cholesterol
(Chol). Moreover, the Seven Countries Study, enrolling
11,579 middle-aged men from eight nations of seven
Mediterranean and non-Mediterranean countries, shows a
lower mortality from ischemic heart disease (IHD) in
Mediterranean populations compared to those of Northern
Europe and America [10]. PREDIMED study proves that
EVOO is linked to lower risk of cardiovascular (CV) events
[11]. However, a Cochrane Systematic Review proves that
elevation in polyunsaturated fatty acids (PUFA) assumption
has a small effect, if any, on all-cause mortality or CV deaths
although it slightly decreases Chol and probably triglycerides
Hindawi
Cardiovascular erapeutics
Volume 2020, Article ID 6719301, 33 pages
https://doi.org/10.1155/2020/6719301
(TG), leaving practically unaltered high density lipoprotein
(HDL) [12].
Beneficial effects of EVOO are also associated with the
presence of minor polar compounds (MPCs) that have
antioxidant, anti-inflammatory, anti-aggregating, and anti-
microbial activities and regulate serum insulin/glucose re-
sponse [13–21]. A claim of the European Food Safety
Authority (EFSA) declared that “consumption of olive oil
polyphenols contributes to the protection of blood lipids
from oxidative damage” at a daily dose of 5 mg of
hydroxytyrosol (HTyr) and its derivatives (e.g., oleuropein
complex and tyrosol) [22].
Actually, botanicals are largely used [23, 24], especially
by women [25, 26], but rigorous findings regarding their
efficacy and safety profiles are still lacking [27]. Besides, the
influence of sex on botanicals including EVOO, VOO, OO,
and MPCs is also lacking; nevertheless, the individual’s sex
and gender is one of the most important modulators of CV
health [28–39] and the numerous sex and gender differences
at CV level are summarized in Table 1. Previously, we
reviewed the sex-gender effect on polyphenols of various
origins [25, 26]; here we focus on EVOO and its MPCs
because, as already mentioned, EFSA declares their utility in
ameliorating low-density lipoproteins (LDL) oxidation and
their importance in MedDiet [22].
2. MedDiet and Sex Differences
e Mediterranean Region includes about 20 nations with
different ethnic, historical, and cultural backgrounds; reli-
gions (Muslims, Orthodox Christians, Catholic Christians,
Jews); and economic status [56], and the UNESCO declared
that MedDiet is an intangible cultural heritage [57]. Im-
portantly, MedDiet also includes social aspects (social in-
tegration) and a peculiar way of life (sleeping and nutrition)
that may play a role in reducing age-related diseases [58, 59].
However, the transferability of the benefit of MedDiet
outside of Mediterranean Region decreases the importance
of social aspects [60, 61]. In particular, it has been found that,
in US women who are adherent to MedDiet, the CV risk
reduced by about 25% over 12 years, having a reduction in
myocardial and cerebral infarcts and vascular death [62].
Mediterranean populations have the lowest prevalence
of chronic inflammatory disease and have very high life
expectancy [63]. Actually, adherence to this diet is decreased
[56] nevertheless many authors declare that adherence to the
MedDiet has beneficial effects on diabetes mellitus (DM),
obesity, and CVD [11, 64–70].
High adherence to the MedDiet reduces the overall
mortality [71–73] and the risk of CVD (10%) and neoplastic
diseases (4%) [71]. Adherence to MedDiet induces small
favorable changes in some risk factors for CVD, but its effect
on hematic lipids is generally weak [74]. Low-carbohydrate
MedDiet reduces glycosylated haemoglobin (HbA1c) levels
and delays the use of oral antidiabetic drugs when compared
with a low-fat diet [75–77]. Recently, it has been shown that
MedDiet can influence the genetics. However, there is not
univocal data on health benefits [5, 6]. Importantly, in-
vestigating the rs7903146 polymorphism in the transcription
factor 7-like 2 gene, Corella and coworkers [78] proved that
in the homozygotes the hypercholesterolemia and hyper-
triglyceridemia are reduced by MedDiet.
Low adherence to MedDiet and smoking are inde-
pendent predictors of 10-year CV events in women and in
men, respectively [79]. e adherence to the MedDiet,
nonsmoking, normal weight, and regular physical activity
reduce the mortality in men and in women, but the sta-
tistical significance is reached only in women [72, 73, 80].
However, the response to the MedDiet seems to be greater
in men than in premenopausal women when car-
diometabolic changes are considered [8184]. MedDiet
ameliorates plasma lipid profile and diastolic blood pres-
sure (DBP) without impacting on leptin levels and the
leptin-to-adiponectin ratio in both sexes [84]. Only in men,
it ameliorates the insulin homeostasis and redistribution of
LDL subclasses from smaller to larger LDL, while an op-
posite trend is observed in women [81]. Finally, MedDiet
increased telomere length, a marker of biological age, in
women [85], although no consensus is found about this
effect [86]. Finally, men are less adherent to MedDiet than
women [87].
3. EVOO, VOO, OO, and MPC
OO is produced from the fruits of Olea europaea L. ever-
green trees, a plant cultivated worldwide, but it is typical
cultivation of the Mediterranean area [88]. It mainly con-
tains monounsaturated fats (98-99% of total weight of
EVOO), such as oleic acid, followed by a low amount (1-2%)
of phenols, phytosterols, tocopherols, and squalene [89].
Importantly, in EVOO only, fatty acids are stabilized by
MPCs, with antioxidant activities [90].
EVOO composition and concentration in MPCs are
extremely variable either qualitatively or quantitatively
(200–600 mg/kg) [91]. MPCs are dependent on the tree
cultivar, the climate, growing, and production procedure
[92]. e phenolic cluster of EVOO can be subdivided into
several subclasses. In particular, EVOO contains saponifi-
able compounds (triacylglycerol, partial glycerides, esters of
fatty acids or free fatty acids, and phosphatides) and
unsaponifiable compounds (hydrocarbons (squalene),
phytosterols (β-sitosterol, stigmasterol, and campesterol),
tocopherols, carotenoids, pigments (chlorophylls), aliphatic
and triterpenic alcohols, triterpenic acids (oleanolic acid),
volatile compounds, and polyphenols) [93].
In general, secoiridoids are the most representative
followed by phenolic alcohols such as Tyr and HTyr, fla-
vonoids, lignans, and phenolic acids [89, 92]. In general,
HTyr, Tyr, and conjugated forms of secoiridoids like
oleuropein (which are hydrolyzed to HTyr and Tyr in the
stomach) are the most representative [94]. HTyr also
originates by the hydrolysis of oleuropein during olive
ripening or/and during the storage and elaboration of table
olives [95]. It can be found in a free form, such as acetate
form, or as part of oleacein, verbascoside, and oleuropein
[93]. Also ligstroside, oleacein, and oleocanthal are sources
of HTyr and Tyr [96].
2Cardiovascular erapeutics
Some of MPCs such as HTyr,Tyr, and their secoiridoid
derivatives (oleuropein, oleuropein aglycone, and elenolic
acid dialdehydes) are hydrophilic [97], while other MPCs
are lipophilic [89]. Lignans belong to the family of phy-
toestrogen [98] and in general the predominant lignan is
(+)-1-acetoxypinoresinol [98]. e leaves of the Olea
Europaea L. contain higher concentrations of phenols
than the olive fruit and derived oils [99101]. e pre-
dominant MPCs in the leaves are verbascoside, apigenin-
7-glucoside, luteolin-7-glucoside, HTyr, Tyr, and oleur-
opein [102]. Notably, a single MPC may possess distinct
biological activity [103, 104]. us, it is impossible to
extrapolate the result of the single EVOO, VOO, and OO
to another. For example, Chetoui and Blanqueta cultivars
(rich in linoleic acid) induce higher total triacylglycerol
(TAG) incorporation into THP-1 cells than Buldiego and
Picual (rich in oleic acid), promoting foam cells formation
[104]. Further, extracts of Taggiasca and Seggianese,
which have different amounts and composition of MPCs,
have a different antioxidant activity being higher in
Seggianese extract [103].
4. Pharmacokinetics of MPCs and
Influence of Sex
e influence of sex and gender on pharmacokinetics of
phenols was recently reviewed [25]. Briefly, in humans,
MPCs are well adsorbed (40%–95%, using HTyr and Tyr as
proxy) [105, 106]. It is important to recall here that, in
humans, there is an endogenous synthesis of HTyr during
the metabolism of dopamine with its formation being fa-
vored by ethanol [107]. In addition, HTyr is a product of
oleuropein hydrolysis that can occur in the stomach. Besides,
gut microbiota generates HTyr from oleuropein [108].
In the intestinal tract (both ileum and colon), more than
40% of HTyr is absorbed by bidirectional passive transport
[108], which depends on numerous factors such as food
matrix or vehicle. e absorption of HTyr and Tyr is higher
when administered as an OO solution than as aqueous
solution [108]. In the gastric and intestinal tract MPCs are
hydrolyzed [109], with some exceptions. In particular,
oleuropein is degraded by the colon microbiota to HTyr that
is then absorbed [109]. HTyr bioavailability seems to be
Table 1: Examples of sex and gender differences in CVD and risk factors.
Diseases or risk factors Sex differences References
Myocardial infarction
Women are 10 years older than males and have higher mortality in younger ages
and have more atypical symptoms. Women have less anatomical obstructive CAD
than men; it is estimated a 20% or greater excess of normal or nonobstructive
arteries in women vs men
[40–42]
Heart failure
Lower incidence in women but the prevalence is similar in both sexes, with
diastolic heart failure being more common in women. Lower mortality rate in
women than in men
[40, 41]
Hypertension Lower incidence in premenopausal women [40]
Cardiac hypertrophy Premenopausal women are better protected than men; men have more cardiac
hypertrophy [40, 43]
Ischemia-reperfusion injury Studies evidenced that females have lower ischemia-reperfusion injury [40]
Diabetes Higher increased risk of CVD in women vs men [40]
Endothelial dysfunction More frequent in women vs men [44, 45]
HDL Higher levels in women vs men; the difference declines with age [46]
TG Higher increased risk of CVD in women vs men. In women, they increase after
menopause [47]
Chol Levels rise in menopausal transition period [47]
LDL Levels rise in menopausal transition period [46]
Lp (a) Levels rise in menopausal transition period [46]
Smoking Less women smoke vs men, but smoking has more negative effects on women [48]
Social economicus status In women, it is inversely associated with increased risk of CAD, stroke, and CVD.
In particular, for CHD, it is associated with lower education [49]
Psychological factors Women had higher contributions from psychosocial risk factors (45.2% vs 28.8%
in men) [50, 51]
Unique for women
Gestational diabetes, pre-eclampsia,
syndrome of polycystic ovary Higher increased risk of CVD in women [48, 52]
Oral contraceptives
A large cohort study (1.6 million of women, 15 to 49 years old) shows that
ethinylestradiol (20 μg or 30 to 40 μg) is associated with an increased risk of MI.
e risk is not significantly varied by progestin
[53]
OC should not be prescribed for women over the age of 35 years and smokers
(American College of Obstetricians and Gynecologists) and should be prescribed
with caution in case of CV risk factors such as hypertension, diabetes, and
dyslipidemia
[54]
Hormone replacement therapy A large cohort study shows that ethinylestradiol is associated with an increased
risk of MI that is not significantly changed with progestins [55]
Cardiovascular erapeutics 3
influenced by sex [110]. e maximum plasmatic concen-
tration of HTyr is reached 5–30min after administration of
EVOO and VOO [108]. HTyr and its derivatives cross the
blood brain barriers [111]. Finally, HTyr is incorporated in
HDL, which is higher in women than in men [108].
HTyr and Tyr are extensively metabolized by phase I
enzymes, such as CYP2D6 and CYP3A4, and by phase II
enzymes both at intestinal and hepatic levels [108, 112].
Numerous phase I and II enzymes present numerous sex
differences both in animals and in humans [33]. us, the
metabolism of MPCs can be sex divergent at least in rats [110].
In humans, the biotransformation of HTyr and Tyr mainly
occurs through glucuronidation and sulphation, and the main
circulating metabolites are both HTyr sulfate and HTyr ac-
etate [108]. HTyr is also metabolized by catechol-O-methyl
transferases that are more expressed in men than in women
[33] forming 3-hydroxy-4-methoxyphenyl ethanol (homo-
vanillyl alcohol) [113]. Globally, HTyr and Tyr have lower
bioavailability than their metabolites [107]. Inside the cells,
the conjugated forms can be deconjugated and thus HTyr and
Tyr metabolites can be reformed. Finally, the intestinal mi-
croorganisms metabolize HTyr into hydroxylated phenyl-
acetic acid, acetic acid, and benzoic acid [114]. In plasma and
urine, 98% of HTyr is recovered as glucuronide form and only
2% is free [115]. Usually, the complete elimination of HTyr
and metabolites occurs approximately in 4 and 6 h in rats and
humans, respectively [116]. HTyr is mainly excreted by the
renal route where it is present both in conjugated and
nonconjugated form [108]. Urinary HTyr levels (adjusting for
ethyl glucuronide) are higher in men than in women [107]. In
addition, through the biliary route they reach the small in-
testine where they can be retransformed and reabsorbed
[116]. Despite the enterohepatic recycling, a small amount
(about 5%) of total HTyr is excreted by feces [116] and the
consumption of MPC-rich OO elevates the free HTyr levels in
feces of men [114]. Notably, Tyr, HTyr acetate, 3,4-dihy-
droxyphenylacetic acid, and homovanillyl alcohol adminis-
tration changes urinary excretion of catecholamines
(dopamine, normetanephrine, norepinephrine, and 3-
methoxytyramine) in male and female rats, with the excretion
being significantly higher in male than in female rats [110].
Oleocanthal constitutes about 10% of the olive’s MPCs
(100–300mg/kg EVOO) [117]. Oleocanthal, as other MPCs,
is stable at acid pH and at 37°C and it is biotransformed by
phase I and II enzymes, with glucuronidation being the
prevalent way [117]. Oleocanthal and other secoiridoids and
their metabolites are mainly eliminated by renal route and
they are found in human urine 2–6 h after the intake [117].
Little and nonunivocal data are available on sex influence
on bioavailability of chlorogenic acids ([118] and cited lit-
erature) and lignans. After long flaxseed lignan secoisolar-
iciresinol diglycoside exposure, female rats have higher
lignan concentrations in heart and thymus than male rats
[119]. A strong association between dietary lignan intake
and prevalent obesity exists only for boys [120].
Importantly, pharmacokinetic interactions with other
botanicals and prescription drugs have been described. For
example, bioavailability of HTyr is enhanced when co-ad-
ministered with the thyme extracts [121].
Considering the role of gut microbiota in sex healthcare
paradigm [122, 123] and their ability to expand metabolic
activity of the host [124], it important to recall that they
could be a modifier of the activity and kinetic of all com-
pounds present in olive and leaves and other matrixes [125].
In turn, OO derivatives may influence the gut microbiome.
For example, the dialdehydic form of decarboxymethyl
oleuropein aglycone, oleocanthal, HTyr, and Tyr may inhibit
the growth of bacteria [126], including the beneficial ones
[127]. Sex-gender differences in the microbiota are recently
reviewed by Kim et al. [128]. Here, it is important to recall
that microbiota modifications may participate in the
pathophysiology of CVD [129]. For example, some me-
tabolites of gut microbiota such as short-chain fatty acids
and trimethylamine N-oxide may participate in the mod-
ulation of blood pressure through G protein receptors [129].
Further gut microbiota may inhibit HDL-coordinated re-
verse cholesterol transport [129].
Globally, the effects of MPCs on microbiota appear to be
compound and sex specific, and in consideration of sex
differences that characterize the human microbiota, its ef-
fects on MPC fate and activity should be accurately studied.
5. Effect of EVOO, VOO, OO, Leaf Extracts, and
MPCs on Endothelial Dysfunction:
Influence of Sex
Endothelial function is a barometer of vascular health [130] and
it is a predictor and a pathogenic mechanism of atherosclerosis
[131], being also related to the prognosis and severity of CVD
[50, 132]. Endothelial dysfunction is more precocious than
atherosclerotic plaques and it is a more prominent risk factor in
women than in men (Table 1). It is related to oxidative stress,
inflammation, platelet activity, an alteration of glucose meta-
bolism, and uric acid levels [133136], and all these processes
present sex differences [34, 136140].
5.1. Effect of EVOO, VOO, OO, Leaf Extracts, and MPCs on
Oxidative Stress: Influence of Sex. e influence of sex on
oxidative stress is widely reviewed [34, 137]. However, no
univocal results are obtained and this could depend on
species, tissues, and cells used and on donor age. For ex-
ample, Brunelli et al. [141] report no differences in the
plasma antioxidant barrier, although women present a
higher oxidative status than men. Moreover, they suggest
that premenopausal and postmenopausal women are similar
[141]. By contrast, Vassalle and coworkers [47] report that
menopause is a condition that elevates oxidative stress.
Further, young men have lower levels of malondialdehyde
(MDA) in comparison to fertile women and older men [142].
After correction for body weight (BW), both pre- and
postmenopausal women have higher amounts of carbony-
lated proteins vs men of similar age [142]. Others show that
lipid and protein oxidation are increased in peri- and
postmenopausal women, whereas superoxide dismutase
(SOD) and catalase (CAT) activities are decreased and in-
creased in postmenopause and in perimenopausal women,
respectively [143]. Glutathione (GSH) and glutathione
4Cardiovascular erapeutics
peroxidase (GPx) are lower in women aged 32–39 years than
in women aged 20–25 years. Meanwhile, 20–25-year old
men have higher GSH and lower glutathione disulfide
(GSSG) than women of the same age. e SOD and CAT
activities are higher in women aged 32–39 years than in men
and women of younger age [144]. Moreover, women with
CAD seem to have higher oxidative stress than men [145].
Another study shows that African American women with
symptomatic peripheral artery disease produce more ROS
than men, while Caucasian men and women do not diverge
indicating that ethnicities could play a role in sex and gender
differences [146–150]. Others report the opposite trend and
others do not find any significant sex difference [151–153].
e antioxidant activity of EVOO, VOO, and MPCs is
extensively reviewed [154, 155] (Table 2). It is based on their
scavenger, chain breaking, and chelating activities [116].
Moreover, they favor the resistance over oxidation [266].
High dose of oleuropein and HTyr may exert prooxidant
activity [267, 268], and this paradoxically could be one of the
mechanisms of their antioxidant activity because it can
activate the translocation of nuclear factor E2-related factor
2 (Nrf2) to the nucleus [269] in a sex-specific manner
[270, 271] that leads to modifications of proteins expression
and activity such as c-glutamylcysteine ligase, which is
expressed less in female rat livers than in male ones [272].
After trauma and hemorrhage, HTyr elevates liver Nrf2
modulating heme oxygenase-1 (OH-1) especially in rat fe-
males (proestrous phase) compared to males [273]. rough
Nrf2, MPCs can also activate phase II detoxifying enzymes
and mitochondrial biogenesis, two critical pathways in re-
ducing the negative effect of oxidative stress [271]. Oleur-
opein and HTyr seem to be scavengers of HOCl [274], which
starts LDL lipid peroxidation and oxidizes the apolipo-
protein (Apo) B-100 [275]. However this is not a univocal
result [213]. Finally, in animals and in humans, HTyr may
interact with several microRNAs [218, 276] that regulate
numerous cellular function including DICER function that
is relevant to the redox state [277, 278].
5.2. Effect of EVOO, VOO, OO, Leaf Extracts, and MPCs on
Inflammatory Response: Influence of Sex. e effect of sex on
inflammatory response has been recently reviewed
[138, 139, 279]. Women and men have a different immune
system [281] and arachidonic acid (AA) cascade [281]. is
last generates numerous compounds with proinflammatory
and anti-inflammatory activities. Interestingly, females seem
to be protected against endothelial dysfunction induced by
systemic inflammation [282]. In particular, COX2 and
COX1 female knockout mice have less inflammatory edema
and joint destruction than male mice [283]. Consistently,
expression of COX2 is more elevated in male than in female
cells [284]. More PGE
2
is produced by human male neu-
trophils vs female ones [284]. In male coronary rat arteries,
PGF
2
αexerts a major contraction in male arteries than in
female ones for the presence of more PG receptors [285].
Also the lipoxygenase (LOX) system presents some sexual
dimorphism. 5-LOX and its 5-lipoxygenase-activating
protein (FLAP) are downregulated by androgens [286].
us, the bigger production of leukotrienes in monocytes
and neutrophils of women is not surprising [286]. In human
neutrophils and monocytes, the synthesis of lipoxin A
4
(LXA
4
), a proresolving molecule [287], is reduced by es-
tradiol [281]. Further, a positive and a negative correlation
exist between age and aspirin triggered 15-epi-LXA
4
in
women and men, respectively [288]. Resolvins, protectins,
and maresins activities may be influenced by sex [289]. For
example, D-resolvin is higher in women exudate whereas
chemoattractant leukotriene B
4
is higher in men [282]. e
precursors of oxylipins are higher in the female urine than in
male one [290].
Also the nuclear factor-kappa b (NF-kB) pathway,
which is crucial for inflammatory response [291], is sex-
dependent with its activation being mediated by the
adaptor molecule MyD88, which interacts with cytoplasmic
estrogen receptor-α[292]. e NF-kB activation is higher
in female human umbilical cord vein endothelial cells
(HUVEC) than in male ones, under hyperoxic conditions
[293]. Also the tumor necrosis factor-α(TNF-α) pathway
exhibits sex differences. For example, the human female
adult cardiac progenitor cells appear to be more responsive
to TNF-αwhen migration and cell cycle progression are
considered [294]. Young men have lower levels of TNF-α
when compared to fertile women [142]. Also the inter-
leukin systems present some sex differences, with IL-6
being significantly higher in postmenopausal women than
in premenopausal women [142], and in young women with
CAD either in basal condition or after stress than men
[295]. e anti-inflammatory effects of OO and its deriv-
atives are summarized in Tables 2 and 3. In general, female
animals and women are less studied and OO with a high
content of MPCs is more active in the control inflam-
mation, redox status, and lipid metabolism than OO with
low content of MPCs. For example, EVOO with high MPCs
reduces peripheral blood mononuclear cells (PBMC) ac-
tivation of the CD40/CD40 ligand (CD40L) and LDLox and
modifies numerous genes [313]. Some MPCs like HTyr
exert anti-inflammatory activity with multiple mechanisms
attenuating iNOS, COX2, and IL-1βexpression and TNF-α
and inhibiting the activation of granulocytes and mono-
cytes [116]. Also oleocanthal and Tyr inhibit COX
[246, 360].
5.3. Effects of EVOO, VOO, OO, Leaf Extracts, and MPCs on
Platelets Function: Influence of Sex. Human platelets are
sexually divergent; women have more platelets, longer
bleeding time, and more activatable glycoprotein IIb/IIIa
than men whereas platelet spreading and adherence are
higher in men than in women [135]. e already described
sex differences in AA pathways may induces sex differences
in platelet aggregation. Adenosine diphosphate (ADP) and
collagen-induced aggregation are higher in women, and
women and men respond differently to antiaggregating
agents [135, 361]. Both preclinical and clinical studies
(Tables 2 and 3) show that EVOO and some of its MPCs
(HTyr, oleuropein aglycone, luteolin, and oleocanthal) re-
duce platelet aggregation [13, 180], interfering either with
Cardiovascular erapeutics 5
Table 2: Some CV effects of EVOO, VOO, OO, leaf extracts, and MPCs.
EVOO, VOO, OO, leaf extracts, and MPCs Activity References
Acetoxypinoresinol Using DPHH test, it exerts antioxidant effects [156]
Caffeic acid
It inhibits 5-LOX and exerts an antioxidant effects in male rat peritoneal leukocyte triggered by calcium ionophore
and PMA [157]
It decreases IL-1βin human blood cultures (sex not reported) stimulated with LPS [158]
EVOO
In healthy men, EVOO reduces urinary excretion of urinary 8-oxo-deoxyguanosine by 13% [159]
In 30 hamster males, it reduces atherosclerosis [160]
In ApoE deficient mice (14 females and 22 males), the antiatherogenic effect of EVOO is reduced by dietary
cholesterol [161]
In ApoE deficient mice (54 females), EVOO from different cultivars reduces atherosclerotic lesions, plaque size,
and macrophage recruitment if compared to diets containing palm oil. EVOO also induces a cholesterol-poor,
ApoA-IV-enriched lipoparticles with enhanced arylesterase and antioxidant activities
[162]
In male STZ-diabetic rats, it raises BW and HDL and decreases glycaemia, TG, Chol, being ineffective in healthy
rats [163]
In STZ-diabetic rats (sex not reported), it elevates HDL and reduces Chol, TG, and LDL [164]
In human platelets obtained from 3 male and 2 female healthy subjects, it reduces NOX2 activation and H
2
O
2
production [165]
In vitro, it inhibits ACE, α-glucosidase, and α-amylase being more active vs α-glucosidase; the richest MPC EVOO
is also the most active [166]
Seggianese EVOO extract (rich in secoiridoids) is more active in preventing human LDL oxidation than Taggiasca
EVOO extract (rich in lignans) (sex not reported)[103]
In vitro, Spanish EVOO inhibits α-glucosidase, α-amylase, and 5-LOX [167]
LDL and HDL obtained from treated healthy 14 women and 10 men are less oxidizable and are more resistant to
lipid peroxidation. Both EVOO and EVOO extract enhance the Chol efflux [168]
In male hypertensive rats, EVOO + olive + leaf rich in HTyr, 3,4 dihydroxyphenylglycol, and oleuropein decreases
BP, angiotensin II, and endothelin-1 vs low MPC oil. ere are no significant differences in plasma Na
+
, urea, HDL,
and LDL
[169]
In an acellular model, HTyr rich extracts have a higher antioxidant and antimutagenic activity than Tyr-rich
extract. In HELA cells, the Tyr-rich extract is more effective in increasing GSH whereas ROS levels are not changed
by tested EVOO extracts. All extracts upregulate Keap1/Nrf2 pathway
[170]
In male mice, high-fat EVOO diet improves glycaemia, insulinemia, glucose tolerance, insulin sensitivity, and
insulin secretion. It reduces β-cell apoptosis and normalizes islet glucose metabolism vs high fat lard diet [171]
EVOO extract inhibits p50 and p65 NF-kB translocation in both stimulated and unstimulated PMA-challenged
human monocytes and monocyte-derived macrophages (sex not reported)[172]
In ECV304 cells (sex not reported), EVOO extract partially prevents the increase of NO/ET-1 levels induced by high
glucose/FFA [173]
In male rats, a bolus of EVOO changes the phospholipids of HDL [174]
Serum obtained from 6 healthy males and 6 females treated with EVOO extract rich in oleuropein and ligstroside
reduces the VEGF-stimulated increase in NOX, Nox4, and MMP-9 activities, migration, and invasiveness. It also
regulates VEGF-induced morphological differentiation capacity of HUVEC (sex not reported) into capillary-like
structures. In human microvascular endothelial cell line, it reduces the VEGF-induced angiogenesis
[175]
In male rats, subacute administration of both EVOO rich in MPC and native EVOO with low MPCs reduces ADP
platelet aggregation, but acutely only MPC-rich extract reduces ADP induced aggregation [176]
In vitro unfiltered EVOO extract with peptide of low molecular weight inhibits ACE angiotensin converting
enzymes in vitro, and in hypertensive male rats, it reduces SBP and DBP [177]
In ApoE deficient mice (sex not reported), extracts (EVOO vs EVOO + polyphenols green tea) enhance
macrophage Chol efflux but only EVOO + polyphenols green tea reduces lipid peroxidation [178]
In vitro, Galician EVOO with high level of oleuropein and ligstroside derivatives inhibits the α-amylase and
α-glucosidase, being more effective in inhibiting α-glucosidase than acarbose [167]
EVOO vs sunflower oil, sunflower oil + oleic acid, MPC-deprived EVOO, sunflower oil
enriched with the MPC of EVOO, and sunflower oil + oleic acid + MPC of EVOO
In all male rats fed with a high-Chol diet, GSH and IL-6 do not vary. EVOO, sunflower oil+ MPC of EVOO, and
sunflower oil +oleic acid + MPC of EVOO decrease the elevation in MDA and TNF-αlevels induced by high-Chol
diet
[179]
OC-rich EVOO with 1 : 2 oleacein/oleocanthal, 2 : 1 (D2
i
2) rich in Tyr; EVOO 1 : 2 oleacein/
oleocanthal (D2
i
0.5) rich in Tyr
In healthy men (20 and 50 years), 40 ml of enriched EVOO for one week reduces collagen-stimulated platelet
aggregation [180]
OO
In ApoE deficient mice (77 males 63 females), all treatments reduce TG being ineffective versus Chol and vs the
number of lesions; however, their dimensions are reduced in females by palm and olive II oils [181]
In 40 male new Zeeland rabbits, dietary supplementation with 15% OO reduces the thrombogenic factors and
elevates antithrombotic factors [182]
In male rats, OO reduces and prevents the growth of urinary stones [183]
VOO
In 24 male new Zeeland rabbits, it reduces atherosclerosis [184]
In 40 male new Zeeland rabbits, it reduces atherosclerosis [182]
In human PBMC (sex not reported) and HL60 cells (sex not reported), it inhibits H
2
O
2
and PMA induced DNA
damage, being HTyr and Tyr, respectively (extract without verbascoside) [185]
Extract of olive cake vs extract of thyme and vs extract of olive cake + thyme extract In male rats, single oral administration of the three extracts regulates plasma antioxidant status (DPPH and FRAP)
in a time and extract dependent way. In red cells, extracts decrease SOD but increase GPx and CAT [186]
6Cardiovascular erapeutics
Table 2: Continued.
EVOO, VOO, OO, leaf extracts, and MPCs Activity References
HTyr
In vitro experiments, HTyr and many other phenolic compounds added to standard cell culture media (such as
DMEM, MEM, or RPMI) produce H
2
O
2
in the one- to three-digit micromolar range [187, 188]
In alloxan-diabetic male rats, it lowers glycaemia, TG, Chol, alkaline phosphatases, AST and ALT, aspartate and
lactate transaminases, lipid peroxidation, total and direct bilirubin, creatinine, urea and increases HDL and hepatic
and renal SOD, CAT, and GPx
[189]
In alloxan-diabetic male rats, it decreases glycaemia, Chol, and oxidative stress [190]
In STZ-diabetic male rats, it reduces plasma lipid peroxidation, nerve conduction velocity, and thermal
nociception and attenuates the decline of sciatic nerve Na
+
K
+
ATPase activity [191]
In STZ-diabetic male rats, it lowers oxidative, nitrosative, and inflammatory biomarkers and platelet aggregation [192]
In STZ-diabetic male rats, it reduces retinopathy, lipid peroxidation, nitrosative stress, TBX2, 6-keto-PGF1α, and
IL-β1[193]
In STZ-diabetic male rats, it lowers retinal ganglion cell number, retinal thickness, and cell size [193]
In STZ-diabetic male rats, it reduces brain lipid peroxidation and inflammation, nitrosative stress, cell death, IL-1β,
PGE
2
[194]
In STZ-induced diabetic and triton WR-1339 induced hyperlipidemic male mice, it reduces plasma glucose, TG,
Chol, lipid peroxidation, TNF, CRP and elevates, glucose tolerance, antioxidants, and atherosclerotic index [195]
It prevents metabolic syndrome and inhibits the hepatic and muscular SREBP-1c/FAS pathway reducing oxidative
stress and mitochondrial abnormalities and improving lipid and glucose metabolism in db/db C57BL/6J male mice [196]
In the brain of diabetic db/db C57BL/6J male mice, it activates AMPK, SIRT1, and PPARccoactivator-1αand
reduces oxidative stress [197]
In LPS-stimulated human monocytic cells (sex not reported), it suppresses NO release and attenuates the
transcription and expression of TNF-α, iNOS, and COX2 in a dose-dependent way [198]
In HUVEC (sex not reported), HTyr and its metabolites suppress TNF-α-induced phosphorylation of NF-κB, ROS
production, depletion of GSH, adhesion molecules and downregulate genes encoding antioxidant enzymes. ey
also reduce the adhesion of human monocytes (cell line) to HUVEC. Finally, they reduce carrageenan induced paw
edema and TPA-induced ear edema in male mice
[199]
e HTyr pretreatment of HUVEC (sex not reported) suppresses inflammatory angiogenesis induced by PMA and
ameliorates mitochondrial function [200]
In male mice, it ameliorates the impact on body adiposity induced by the obesogenic diet [201]
In male rats fed fed with high-fat diet, it reduces AST, ALT, Chol, liver inflammation, and nitrosative/oxidative
stress. It improves glucose tolerance, insulin sensitivity, and intestinal barrier integrity and functions and increases
hepatic PPARαand its downstream-regulated genes
[202]
In male mice fed with diet-induced obesity, it improves glucose homeostasis, insulin signaling markers, chronic
inflammation, hepatic steatosis, and endoplasmic reticulum stress [203]
In male rats fed with a diet-induced metabolic syndrome, it reduces adiposity and ameliorates impaired glucose,
insulin tolerance, and endothelial dysfunction. It also decreases SBP, left ventricular fibrosis, and resultant diastolic
stiffness and markers of liver damage. Notably, the diet used for induction of metabolic syndrome alters HTyr
metabolism
[204]
In endothelial cells obtained from porcine pulmonary arteries (sex not reported), it increases AMPK, CAT
activities, forkhead transcription factor, and cytoprotection against TNF-α-induced damage through the
suppression of caspase-3 and NF-kB activation. It also promotes wound healing via Nrf2 synthesis and stabilization
[205, 206]
In rat aorta VSMC (sex not reported), it exerts a proapoptotic effect through NO production and protein
phosphatase 2A activation with subsequent inactivation of AKT [207]
In male rat peritoneal leukocytes triggered by calcium ionophore, it inhibits 5-LOX and exerts antioxidant effects
in leukocytes triggered by PMA [157]
In a female mice model for accelerated aging, it induces the expression of SIRT1 [208]
In vitro, it inhibits human platelet (sex not reported) aggregation induced by ADP and collagen being more active
than other MPCs and TBX2 production induced by collagen and thrombin [209]
In pooled human liver microsomes (sex not reported), it inhibits androstenedione 6β-hydroxylase and reductive
17β-HSD activity, whereas it is inactive vs oxidative 17β-HSD [210]
In white adipose of male mice fed with high-fat diet, it reduces the increase in oxidative stress, lipid, and protein
oxidation and increases the antioxidant defenses [211]
In adult male rats, it reduces myocardial infarction area, necrosis and apoptosis, the release of LDL and CPK,
probably through upregulation of PI3K/AKT pathway [212]
It is a scavenger of hydroxyl radicals, with peroxynitrite and O
2
being inactive vs HOCl and H
2
O
2
. It protects LDL
against oxidation but is not effective vs the oxidation of LDL isolated from humans after HTyr intake (sex not
reported)
[213]
It inhibits α-glucosidase and α- amylase, being more effective vs α-glucosidase [214]
In human aortic endothelial cells (sex not reported) stimulated with TNF-α, it significantly reduces the secretion of
P-selectin, ICAM-1, VCAM-1, and MCP-1 [215]
In human HUVEC (sex not reported), it reduces the stimulated tube-like differentiation and the stimulated
locomotion, MMP-9 secretion induced by PMA, PMA-stimulated COX2 activity and expression. Pretreatment
with HTyrbefore PMA decreases intracellular ROS and nuclear translocation of the p65 NF-κB subunit and NF-κB
transactivation
[216]
In male rats, HTyr, 3,4-DHPEA-EA and 3,4-DHPEA-EDA reduce the increase in intracytoplasmic Ca
2+
induced
by vasopressin. Further, higher concentration of HTyr exerts an endothelium-independent effect. 3,4-DHPEA-EA
and 3,4-DHPEA-EDA exert an endothelium-dependent vasodilation in aorta increasing the production of NO
[217]
It regulates expression of numerous miRNA in the mice gut (sex not reported) being less effective in other tissues.
HTyr administration increases TG [218]
In male mice, it lowers Chol [219]
In human monocytes (sex not reported) stimulated with PMA, it reduces the expression of mRNA and protein of
COX2 decreasing PGE
2
and O
2
-production and increases TNF-αproduction. In human neutrophils (sex not
reported) stimulated with PMA, or chemotactic peptide FMLP or opsonized zymosan particles, it does not
influence the production of O
2
and NOX activity whereas it inhibits the production of H
2
O
2
[220]
In human PBMC (sex not reported) and in human monocytic cell line U937 stimulated with PMA, it reduces the
secretion of MMP-9, PGE
2
production, COX2 protein expression, and COX2 mRNA without modifying COX1. It
inhibits both PGE
2
and MMP-9 release from human monocyte-derived macrophages. It suppresses NF-κB
activation in human monocytoid cells and reduces PKCαand PKCβ1 activation. Notably, it does not affect MMP-9
and COX2 in basal conditions
[221]
In LPS-stimulated human monocytic THP-1 cells (sex not reported), it reduces LPS-stimulated NO and ROS
formation in a concentration-dependent way, increases GSH levels, and suppresses the of NF-kB activation [222]
In young male C57BL/6 mice treated with MPC does not modify BW, food intake, and TG but it lowers plasma
Chol, leptin. In murine 3T3-L1 preadipocytes, it positively modulates the glutathione-driven antioxidant
enzymatic machinery reducing GSSG/GSH ratio, through the modulation of genes related to oxidative stress
[223]
In male rats with diet-induced metabolic syndrome, it decreases glucose tolerance, lipids, ALT, AST activity,
insulin, weight gain, fat mass, liver steatosis, and ventricular fibrosis [204]
It prevents COX2, TNF-α, DNA damage, and oxidative stress in Balb/c mice treated with LPS (sex not reported) [224]
It increases the TNF-αmRNA level in LPS-activated human monocytes (sex not reported) [225]
HTyr, oleuropein, EVOO extract, homovanillyl alcohol
In HUVEC (sex not reported), EVOO extracts decrease cell surface expression and mRNA of ICAM-1 and VCAM-
1. Olea and HTyr are the main actors for these effects. Homovanillyl alcohol inhibits cell surface expression of
adhesion molecules, but the effects on mRNA are small
[226]
Cardiovascular erapeutics 7
Table 2: Continued.
EVOO, VOO, OO, leaf extracts, and MPCs Activity References
HTyr
HTyr- acetate (HTyr-Ac)
HTyr ethyl hydroxytyrosol ether (HTyr-Et)
In male rats fed with high-fat diet, the compounds improve glucose, insulin, leptin levels, lipid peroxidation, and
antioxidant capacity status, with HTyr-Ac being the most active. ey also reduce the release of inflammatory
biomarkers. HTyr-Ac and HTyr-Et improve adipose tissue distribution and adipokine production, decreasing
MCP-1 and IL-1βlevels
[227]
HTyr and homovanillic alcohol In PBMC obtained by healthy men and women, they inhibit the increase of IL-1β, MIF, and RANTES induced by
oxysterols [228]
HTyr-acetate (HTyr-Ac) In TNF-α- stimulated HUVEC (sex not reported), it reduces the inflammatory response partly through the
TNFRSF1A/SIRT6/PKM2-mediated signaling pathway [229]
HTyr and oleuropein
Both compounds inhibit oxidative burst in human granulocytes and monocytes obtained from healthy individuals
(sex not reported) stimulated with PMA. HTyr attenuates the generations of NO and PGE
2
. In LPS triggered
RAW264.7, it reduces NRf2 nuclear translocation and miR-146a expression
[230]
HTyr and HTyr-NO
In vascular ring obtained from male rats, it releases NO while HTyr is ineffective. HTyr NO decreases Chol, TG,
lipid peroxidation and increases SOD and NO in the serum of STZ-diabetic male mice. Both HTyr-NO and HTyr
upregulate SIRT1 expression in the thoracic aorta of male diabetic mice. In HUVEC triggered by hyperglycaemia
(sex not reported), HTyr-NO increases cell viability and reduces oxidative stress trough SIRT1
[231]
HTyr, dialdehydic form of elenolic acid linked to HTyr, oleuropein aglycon, oleuropein, Tyr,
the dialdehydic form of elenolic acid linked to Tyr, caffeic acid, and verbascoside In human PBMC and HL60 cells (sex not reported), they inhibit H
2
O
2
-induced DNA damage [185]
HTyr+ nicotinate It inhibits α-glucosidase, and in healthy male mice fed with high-fat diet, it has hypoglycemic, antioxidant, and
hypolipidemic activities [232]
HTyr+ eicosapentaenoic acid (EPA) In male mice fed a with high-fat diet, it reduces the steatosis and elevates the hepatic levels of eicosapentaenoic acid
(EPA), docosahexaenoic acid (DHA), resolvins and attenuates proinflammatory markers [233]
Leaf extract
In INS-1 cells (sex not reported), leaf ethanolic extract and oleuropein improve the damage induced by H
2
O
2
. e
leaf extract is more potent than oleuropein in preventing the cytotoxic effects and only leaf extract preserves GPx [234]
In STZ-diabetic male rats, the extract ameliorates diabetic alterations [235]
In STZ-diabetic male rats, it decreases glycaemia and HbA1c and increases insulin. It also inhibits α-amylase and
α-glucosidase [236]
In acellular model, it inhibits DPPH radical generation. In STZ-diabetic male rats, the extract increases CAT
activity, GSH and lowers lipid peroxidation, Chol, TG, histological pancreas, and hepatic damage [237]
In male alloxan-diabetic rats, it shows a hypoglycemic effect and reduces the damage of islets of langerhans [238]
In cultured neonatal rat cardiomyocytes of both sexes, it decreases maximum I (Ca,L) in a reversible manner [239]
Male rats fed with a high-fat diet develop signs of metabolic syndrome. Comparing rats with high-fat diet vs those
with high-fat + leaf extract enriched with MPCs, it emerges that leaf extract improves the signs of metabolic
syndrome and decreases MDA and uric acid while it is not effective on BP
[240]
In human coronary artery endothelial cells (sex not reported) stimulated with serum amyloid A, it reduces the
release of IL-6, IL-8, mRNA expression of E-selectin, the phosphorylation of p65 of NF-κB, DNA damage and
stabilizes microRNA-146a and let-7e
[241]
In male rats, leaf extract containing 20% of HTyr decreases the paw edema induced by carrageenan and IL-1βand
TNF-αrelease. It does not affect the anti-inflammatory cytokine IL-10 [242]
In diet-induced hypercholesterolemic male rats, olive leaf extracts enriched with oleuropein enzymatic and acid
hydrolysates rich in oleuropein aglycone and HTyr decrease Chol, TG, and LDL and elevate HDL and serum
antioxidant potential. In livers, hearts, kidneys, and aorta lipid peroxidation decreases while liver CAT and SOD
increase
[243]
Luteolin It is antioxidant in chemical test and prolongs the lag phase of LDL oxidation. It protects the cells against H
2
O
2
induced damage but it is ineffective vs platelet aggregation (sex not reported)[209]
Oleacein In vitro, it inhibits angiotensin converting enzyme [244]
It stabilizes atherosclerotic plaque in samples obtained from 20 hypertensive individuals of both sexes [245]
Oleocanthal
It is a nonselective inhibitor of COX1 and 2 and attenuatesiNOS and human recombinant 5-LOX, being ineffective
vs 15-LOX. Regarding 5-LOX, it is less active than oleuropein and oleacein. In addition, it inhibits TNF-α, IL-1β,
IL-6, and GM-CSF
[117, 246,
247]
In rat and mouse trigeminal ganglia (females and males used in equal ratio), it acts as agonist of TRPA1 [248, 249]
In male adult rats, it decreases the traumatic injury reducing the inflammatory response by reducing the eNOSand
iNOS [250]
In murine chondrogenic ATDC-5 cells and in mouse macrophage J774A.1, it inhibits the LPS-mediated
upregulation of NOS2 and LPS induced release of cytokines (sex not reported)[251]
In human monocytes (sex not reported), it reduces the release of O
2
, PGE
2
and the expression of COX2 and
inhibits NAPH-oxidase [220]
Oleuropein
In vitro, it inhibits α-glucosidase and α- amylase [214]
In C2C12 cells (sex not reported), it protects against H
2
O
2
induced damage; further it increases glucose
consumption and the phosphorylation of AMPK/ACC and MAPK, but not PI3 kinase/Akt. It improves the insulin
sensitivity via insulin-dependent (PI3 kinase/Akt) and insulin independent (AMPK/ACC)
[252]
In bovine VSMC (sex not reported), it inhibits cell proliferation in the G1-S phase probably by inhibition of ERK1/2 [253]
In caco cells (sex not reported), it inhibits maltase, human sucrose, glucose transport across Caco-2 monolayers,
and uptake of glucose by GLUT2 in Xenopus oocytes; it is a weak inhibitor of human α-amylase [254]
In vitro, it inhibits platelet aggregation being less active than HTyr. In whole blood,collagen platelet aggregation is
not modified (sex not reported)[209]
It is antioxidant both in chemical assay and in the lag phase prolonging of LDL oxidation. However it is less active
than homovanillic alcohol [255]
In samples of pooled human liver microsomes (sex not reported), it inhibits CYP3A [256]
J774A.1 cells (sex not reported) and in peritoneal macrophages from male mice, it increases the production of NO
that is blocked by NOS inhibitor [257]
In male rat peritoneal leukocytes triggered by calcium ionophore, it inhibits 5-LOX and exerts antioxidant effects
when leukocytes are stimulated by PMA [157]
In human HUVEC (sex not reported), oleuropein and HTyr reduces the stimulated tube-like differentiation and
stimulates locomotion, the increase in MMP-9 secretion induced by PMA without affecting tissue inhibitors of
MMP, with this activity being mediated by pretranslation process. It inhibits PMA-stimulated COX2 activity and
expression. HTyr before decreases intracellular ROS and nuclear translocation of the p65 NF-κB and its
transactivation
[216]
In pooled human liver microsomes (sex not reported), they inhibit androstenedione 6β-hydroxylase and 17β-HSD [210]
Oleuropein glycoside In diluted human blood cultures (sex not reported) stimulated with LPS, it decreases IL-1β[158]
Oleuropein, caffeic acid, Tyr HTyr In acellular models, they scavenger reactive nitrogen species, with Tyr being the less active; however they do not
inhibit the nitrergic transmission in the nerve-stimulated anococcygeus preparation of male rats [258]
Oleuropein-containing supplement OPIACE In DM2 model (Tsumura Suzuki obese diabetes male) mice, the diet attenuates hyperglycaemia and impairs
glucose tolerance and oxidative stress but has no effect on obesity [259]
Olive water methanol extract
In normotensive anaesthetized and atropinized rats (sex not reported), the intravenous administration of extract
reduces the BP. In isolated atria of Guinea pig of both sexes, it reduces the spontaneous beating. In isolated thoracic
artery of male and female rabbits it reduces K
+
and/or phenylephrine induced contraction
[260]
Pinoresinol Using DPHH test, it exerts antioxidant effects being more active than acetoxypinoresinol [156]
In PMA-stimulated RAW 264.7 macrophages (sex not reported), Tyr decreases the O
2
and H
2
O
2
generation
induced by PMA and scavenges the O
2
. ese effects seem to be linked with the impairment of (3H)AA release,
COX2 expression, PGE
2
/B4 synthesis, and NO release
[261]
8Cardiovascular erapeutics
AA pathways [362] or with other mechanisms such as
calcium mobilization and attenuating iNOS activity
[247, 363]. In hypercholesterolemic patients, MPCs decrease
platelet aggregation inhibiting procoagulant factors, such as
plasminogen activator inhibitor-1 and factor VII [364].
Small crossover trial proves that oleocanthal is the most
active in inhibiting collagen-induced aggregation at least in
men [180], probably because it is a nonselective inhibitor of
COX. HTyr antiaggregant activity seems to be agonist
specific [209]. However, in vivo, it remains difficult to
discriminate EVOO associated effects of specific MPCs and
phenols. Tables 2 and 3 show that, globally, the majority of
the studies are performed on males and even when females
are recruited no sex analysis is performed.
5.4. Effect of EVOO, VOO, OO, Leaf Extracts, and MPCs on
Glucose Metabolism: Influence of Sex. eir effects are
summarized in Tables 2 and 3. Briefly, the antidiabetic actions
may reside in the inhibition of α-amylase and α-glucosidase
[166, 167, 214, 365], which might lead to less effective ab-
sorption of glucose [366]. Some authors suggest that HTyr is a
better inhibitor of α-amylase than of α-glucosidase [214]. Also
oleuropein inhibits these enzymes [214]. Beyond the inhi-
bition of these enzymes, other mechanisms have been pro-
posed for the antidiabetic activity including antioxidant and
anti-inflammatory action (see above) and activation of AMP-
activated protein kinase and of incretin release
[197, 205207, 341]. In particular, the antidiabetic activity of
HTyr and oleuropein is recently reviewed [367, 368]. Again it
emerges that the antidiabetic activity has been mainly studied
in males; nevertheless, it clearly shows that DM presents
numerous sex differences [39], including the relative risk for
CVD associated with hyperglycaemia that is higher in women
than in men (Table 1).
5.5. Effects of EVOO, VOO, OO, Leaf Extracts, and MPCs on
Uric Acid: Influence of Sex. It is related to CV events both in
women and in men [140, 369, 370], but it is a higher risk in
women [371]. However, these are not univocal data because
others sustain that this association is present only in women
[372–374], who have lower plasma levels that men [375].
Leaf extracts of olive tree and HTyr inhibit xanthine oxidase
reducing uric acid synthesis [376]. In male rats, HTyr also
regulates transcription of some renal transporters that favor
uric acid excretion [377].
6. Clinical Studies
Results of clinical studies are summarized in Table 3. e
beneficial aspects of regular use of OO on CVD has been
suggested by numerous authors [2, 154, 306, 310, 378–380],
through the biological activities discussed above and sum-
marized in Table 2. However, clinical studies have common
limitations: (a) despite the numerosity of studies, the size of
samples is very small and they do not take into account the
high interindividual variability; (b) they are relatively limited
or of questionable quality; (c) with some exceptions they are
very short in duration; (d) they are mainly performed on
Mediterranean populations; (e) they have heterogeneous
designs, with variation in control diets and in the type of oil
used. erefore, to overcome these limitations we focus on
meta-analyses.
Schwingshackl and Hoffmann [381] reported that the
use of OO is associated with a 20–40% lower risk of stroke
and CHD. Another meta-analysis of case-control, pro-
spective cohort studies and randomized controlled trials
proves a negative relationship between OO consumption
and stroke (and stroke and CHD combined), but the as-
sociation is not significant for CHD [348]. A successive
meta-analysis proves that high EVOO MPCs ameliorate
surrogate end points such as lipid peroxidation, oxLDL,
Chol, and HDL [382]. In addition, the subgroup analysis
indicates an improvement in inflammatory biomarkers and
in BP [382]. After pooling oil interventions, PCR and IL-6
are lowered compared to baseline [380]. Others show that
the regular dietary intake of OO reduces CRP, IL-6, and
TNF-α[383]. e comparison of the effect of different types
of OO (refined, mixed, low, and high MPC EVOO) shows no
significant effects on Chol, HDL, TG, or DBP [3]. However,
in secondary analyses, EVOO may reduce oxLDL vs refined
OO in a dose-dependent manner. Finally, one meta-analysis
that includes 1089 participants shows that OO increases
HDL reducing LDL and TG, while ApoA1 and ApoB are not
significantly changed [384].
Table 2: Continued.
EVOO, VOO, OO, leaf extracts, and MPCs Activity References
In RAW 264.7 macrophages (sex not reported), triggered by oxLDL-stimulated Tyr reverts H
2
O
2
generation and
the AA release and PGE
2
production [262]
In human monocytes (sex not reported) stimulated with PMA, it reduces the production of O
2
and the expression
of mRNA and protein of COX2, dose-dependently decreasing PGE
2
production [220]
Tyr In RAW 264.7 macrophages (sex not reported), it reduces the activation of iNOS and COX2 gene expression, NF-
κB, interferon regulatory factor-1 (IRF-1), and activator of transcription-1α(STAT-1α) induced by gliadin + IFN-c[263]
In male rat peritoneal leukocytes triggered by calcium ionophore, it inhibits 5-LOX and exerts antioxidant effects
when leukocytes are stimulated by PMA [157]
In human PBMC (sex not reported) and HL60 cells, it inhibits H
2
O
2
-induced DNA damage [185]
In PBMC obtained by healthy men and women, it inhibits the increase of IL-1β, MIF, and RANTES induced by
oxysterols [228]
Tyr, Tyr glucuronate (Tyr-GLU), and sulfate (Tyr-SUL)
In TNF-αtreated-HUVEC (sex not reported), Tyr and Tyr-SUL prevent ROS generation and GSH decrease and
downregulate GPx-1, GCL, and OH-1 genes. Tyr-SUL, Tyr, and Tyr-GLU prevent the phosphorylation of NF-κB
signaling proteins. Tyr-GLU and Tyr-SUL prevent the increase of genes and proteins expression and secretion of
adhesion molecules. In vivo, Tyr and Tyr-SUL,in a dose-dependent manner, ameliorate plantar and ear edemas in
male mice
[264]
Tyr, oleuropein, and olive pomace
In anoxic EA.hy926 human endothelial cell line (sex not reported), both Tyr and oleuropein attenuate anoxia-
induced expression of MMP-9 and MMP-2. Tyr is more efficient than oleuropein in reducing TNF-α. e olive
pomace ameliorates all the above parameters and induces time-dependent phosphorylation of p38 MAPK and
ERK1/2, and inhibits anoxia-induced NF-κB activation.
[265]
Verbascoside In PBMC (sex not reported) and HL60 cells, it inhibits H
2
O
2
induced DNA damage. [185]
Cardiovascular erapeutics 9
Table 3: Clinical studies on the effect of EVOO, VOO, OO, leaf extracts, and MPCs.
Compounds Individuals Design Main data References
High MPC EVOO vs moderate
and low MPC EVOO 200 healthy men Multicenter RC
crossover design
e negative association
between the oleic/linoleic
acid ratio and biomarkers of
oxidative stress and
improvement of LDL fatty
acid profile
[296]
EVOO vs saturated fat diet 18 healthy postmenopausal women Prospective,
longitudinal, study
EVOO decreases the risk to
develop the metabolic
syndrome and CAD
[297]
EVOO vs soya oil 41 adult women with excess body
fat
Double-blinded RC vs
placebo
EVOO increases fat loss and
reduces DBP and some
biochemical parameters
[298]
High MPC EVOO vs low MPC
EVOO
9men and 11 women with
metabolic syndrome
RC sequential
crossover design
After EVOO-based
breakfast, numerous
inflammatory genes
involved in factor NF-κB,
AP-1, MAPK, and AA
pathways are repressed in
PBMC
[299]
High MPC VOO vs intermediate
and low VOO
19 men and 30 women with
metabolic syndrome RC, crossover design
High MPC VOO-based
breakfast attenuates plasma
LPS, TLR4, and SOCS3
proteins, activation of NF-
κB and the IL-6 vs low and
intermediate oil. In PBMC,
postprandial expression of
IL-1B, IL-6, and CXCL1 is
reduced especially by high
MPC VOO
[300]
High MPC EVOO vs low MPC
EVOO
6 healthy men and 6 healthy
women; 6 men and 6 women with
metabolic syndrome
Paired study
Acute high MPC EVOO
transiently improves
glycaemia and insulin
sensitivity. It directly
modifies the miRNA of
PBMC. Acute EVOO poor
in MPC is less effective
[278]
EVOO vs ROO 14 healthy and 14
hypertriacylglycerolemia men
Blind RC crossover
design
EVOO has postprandial
anti-inflammatory effects [301]
EVOO 26 male and 34 female DM2
patients RC trial
Both atorvastatin and EVOO
reduce plasma lipids and
increase HDL with a higher
activity of atorvastatin
[302]
EVOO 17 males and 13 females with
impaired fasting glucose
Blind RC crossover
design
After EVOO meal, glucose,
TG, ApoB-48, and DPP4
activity decrease, whereas
insulin and GLP-1 increase
vs meal without EVOO.
Chol and HDL do not
change after EVOO meal vs
meal without EVOO
[303]
EVOO vs coconut oil vs unsalted
butter
Healthy women (67%) and men
(33%) RC trial
No changes in BW, BMI,
central adiposity, fasting
blood glucose, SBP, and DBP
for all diets. Butter increases
LDL; coconut increases HDL
[304]
EVOO vs VOO 41 males and females (overweight
or obese) Single-blinded RC
EVOO decreases SBP and
increases anti-CD3/anti-
CD28 stimulated T cell
proliferation vs VOO
[305]
10 Cardiovascular erapeutics
Table 3: Continued.
Compounds Individuals Design Main data References
VOO rich in MPC vs ROO
11 women at stage 1 of essential
hypertension or 13 with normal-
high BP
Double-blind RC
crossover design
VOO rich in MPC decreases
SBP, DBP, CRP, LDL,
ADMA and increases
nitrites/nitrates and
hyperemic area after
ischemia
[306]
Diet enriched with VOO,
walnuts, or almonds
9 female and 9 male
hypercholesterolemic patients RC crossover design
e VOO, walnut, and
almond diets reduce LDL;
ey reduce LDL, Chol, and
LDL/HDL ratio. Other lipid
fractions, oxidation, and
inflammatory biomarkers do
not change
[307]
OO rich in MPC vs OO + EGCG
Patients with endothelial
dysfunction, OO rich in MPC (13
men and 15 women) OO + EGCG
(10 men and 14 women)
Double-blinded RC
ey reduce endothelial
dysfunction, but only OO
reduces inflammatory
biomarkers, white blood
cells, monocytes, and
lymphocytes
[308]
OO enriched with oleanolic acid
(OA) vs OO
176 individuals of both sexes with
impaired fasting glucose and
impaired glucose tolerance
Multicenter double-
blind RC trial
e intake of OO rich in OA
reduces the risk of
developing DM in
individuals with impaired
fasting glucose and impaired
glucose tolerance
[309]
MedDiet + EVOO vs
MedDiet + nut vs control
7447 old participants of
PREDIMED (43% men and 57%
women) at risk for CVD
Observational study in
primary prevention
Long intake of
MedDiet + EVOO and
MedDiet + nut reduces
primary CV events
[11]
High MPC EVOO vs moderate
and low MPC VOO 18 healthy men Double-blind RC,
crossover design
High PMC EVOO reduces
SBP vs basal values and low
PMC VOO. It maintains
DBP values compared to low
MPC VOO. Further, it
reduces ACE and NR1H2
gene expressions vs basal
and IL-8RA vs low PMC
MPC
[310]
MeDiet + EVOO vs
MeDiet + washed EVOO vs
habitual diet
26 healthy men and 64 healthy
women RC crossover design
In plasma, MedDiet +
EVOO reduces oxidative
and inflammatory status. In
PBMC, it reduces oxidative
stress, the gene expression of
INF-c, Rho GTPase-
activating protein 15, IL-7
receptor, adrenergic β2
receptor and polymerase
(DNA-directed) k. ese
effects with the exception of
polymerase (DNA-directed)
κare more elevated when
EVOO rich in polyphenols
was added
[311]
High MPC EVOO vs low MPC
EVOO
46 healthy subjects (14 men and 32
women) RC crossover design No effect on fasting plasma
lipids, oxLDL, and LPO [106]
EVOO vs refined OO 24 men RC crossover design
Only EVOO rich in MPCs
lowers oxLDL being
ineffective vs plasma lipids
[312]
Cardiovascular erapeutics 11
Table 3: Continued.
Compounds Individuals Design Main data References
High MPC VOO vs moderate
and low MPC VOO 18 healthy men RC crossover design
High MPC VOO reduces
oxLDL MPC-1, CD40L, IL-
23A, IL-7R, IL-8RA,
ADRB2, and OLR1 genes,
whereas IFNG, IL-7R, IL-
23A, CD40L, MCP-1, and
IL-8RA decrease with low
MPC VOO
[313]
High MPC VOO + triterpenes
(OVOO) vs OVOO + higher
MPC and triterpenes (FOO) vs
low MPC and triterpenes (VOO)
27 healthy men and 26 healthy
women
Double-blind RC,
crossover design
Urinary 8-hydroxy-2-
deoxyguanosine, plasma IL-
8, and TNF- αdecrease more
after FOO vs OVOO
[314]
High MPC VOO + triterpenes
(OVOO) vs OVOO + higher
amounts of MPC and triterpenes
(FOO) vs low MPC and
triterpenes (VOO)
27 healthy men and 26 healthy
women
Double-blind RC,
crossover design
After OVOO, HDL increases
only in females. Chol
increases after FOO and TG
after VOO and OVOO. SBP
decreases after the VOO and
increases after the FOO.
DBP and pulse pressure do
not vary as well as LDL,
sICAM-1, and sVCAM-1.
Plasma ET-1 decreases after
the VOO, OVOO, and FOO
[315]
VOO, VOO + MPC (FVOO),
VOO + MPC + yme phenols
(FVOOT)
Hypercholesterolemic men and
women
Double-blind RC
crossover design
Acute and sustained intake
of VOO and FVOO
attenuate PON1 protein and
increase PON1-associated
specific activities, while
FVOOT has opposite effects.
Only VOO increases PON3
protein
[316]
VOO vs VOO + MPC (FVOO)
vs VOO + MPC + yme
phenols (FVOOT)
Hypercholesterolemic volunteers:
5 women and 7 men
Double-blind RC,
crossover design
FVOOT reduces serum
oxLDL and elevates gut
bifidobacteria vs VOO.
FVOO does not change
blood lipids and microbial
populations but elevates the
coprostanone vs FVOOT
[317]
VOO vs VOO + MPC (FVOO)
VOO + MPC + yme phenols
(FVOOT)
Hypercholesterolemic volunteers:
19 men and 14 women
Double-blind, RC
crossover design
Urinary HTyr sulfate and
thymol sulfate increase after
FVOO or after FVOOT,
respectively. FVOO and
FVOOT do not change
glycaemia, TG, LDL, HDL,
ApoAI, and ApoB100 vs
VOO with the exception of
LDL that decreases after
FVOO. FVOO and FVOOT
change the lipoprotein
subclasses profile and
decrease insulin resistance
index. BP and BMI do not
change
[318]
VOO vs VOO + MPC (FVOO)
Prehypertensive or stage 1
hypertension participants
(7 men and 6 women)
Double-blind RC
crossover design
FVOO decreases ischemic
reactive hyperemia, oxLDL,
postprandial glycaemia, TG,
PAI-I, and CRP vs VOO
[319]
12 Cardiovascular erapeutics
Table 3: Continued.
Compounds Individuals Design Main data References
VOO vs VOO + MPC and
VOO + yme
8 men and 14 women
hypercholesterolemic subjects
Double-blind, RC
crossover design
In PBMC, the intake of
enriched VOO and
VOO + thyme increases the
expression of proteins
involved in Chol efflux and
nuclear receptor-related
genes
[320]
VOO vs VOO + MPC (FVOO)
and VOO + yme (FVOOT)
Hypercholesterolemic subjects: 19
men and 14 women
Double-blind, RC
crossover design
e 2 enriched oils elevate
antioxidants in HDL,
whereas α-tocopherol is
elevated only after FVOOT
[321]
VOO vs VOO + MPC vs
VOO + MPC + yme phenols
19 hypercholesterolemic men and
14 women
Double-blind RC
crossover design
eir consumption of each
oil affects the HDL proteome
in a cardioprotective mode
[322]
Diets with VOO and refined OO
vs sunflower or corn oil during
washout period
24 young women with high-normal
BP or stage 1 essential
hypertension
Double-blind RC
crossover design
Only VOO decreases SBP
and DBP, serum asymmetric
dimethylarginine, oxLDL,
and CRP. It increases the
plasma nitrites/nitrates ratio
and hyperemic area after
ischemia
[306]
High MPC OO enriched
breakfast vs low MPC OO
breakfast
5 hypercholesterolemic men and
16 women
RC design sequential
crossover
After the high MPC
breakfast, FVIIa increases
less and PAI-1 activity
decreases more than after
the low MPC breakfast
[169]
OO rich in MPC vs refined OO 69 healthy participants of both
sexes
Double-blind RC
parallel design
Both OO improve the
urinary proteomic CAD
score but not chronic kidney
disease or DM proteomic
biomarkers. No differences
are measured between the
two OO
[99]
OO with high vs OO with
moderate MPC
pre/hypertensive patients 17 men
and 6 women RC crossover design
In white blood cells, high
MPC OO increases gene
expression of ATP binding
cassette transporter-A1,
scavenger receptor class B
type 1, PPARα, PPARc,
PPAR δ, and CD36 vs
moderate MPC OO
[323]
High MPC OO vs moderate
MPC and low MPC OO 30 healthy subjects of unknown sex
Double-blind RC vs
placebo- crossover
design
e consumption of oil rich
in MPCs increases MPCs in
LDL-C and decreases oxLDL
[324]
High MPC OO vs moderate and
low MPC OO 12 healthy male subjects Double-blind RC,
crossover design
All OO promote
postprandial increase in F2-
isoprostanes whereas the
LDL oxidation is inversely
linked with MPCs
[325]
High MPC OO vs moderate and
low MPC OO 200 healthy men RC crossover design
HDL and Chol increase and
decrease linearly with the
MPC amounts, respectively.
OxLDL and MPC amount
are inversely related. TG
decrease is not influenced by
MPC amount
[325]
Cardiovascular erapeutics 13
Table 3: Continued.
Compounds Individuals Design Main data References
High MPC OO vs low MPC OO 10 menopausal healthy women RC design crossover
MPC-rich OO diet reduces
DNA damage vs low MPC
OO whereas plasma
antioxidant capacity does
not diverge
[326]
High MPC OO vs moderate and
low MPC OO 12 male healthy subjects Double-blind, RC
crossover design
Short-term consumption of
MPC-rich OO decreases
plasma oxLDL, urinary 8-
oxo-dg and increases plasma
HDL and GPx vs moderate
and low MPC OO
[327]
High MPC OO
Patients with polymorphism in
NOS3 Glu298Asp (rs1799983) of
eNOS (22 men, 35 women)
RC sequential
crossover design
Single administration seems
to reduce the deleterious
effect of the T allele carrier’s
condition
[328]
High MPC OO vs moderate and
low MPC OO
30 healthy men from a religious
center RC, crossover design
MPC-rich OO is more
effective in protecting LDL
oxidation and in raising
HDL than OO with lower
quantities of MPCs
[15]
High MPC OO vs low MPC OO 22 mildly dyslipidemic subjects RC crossover design
MPC-rich OO lowers
plasma TXB
2
and elevates
plasma antioxidant capacity
vs low MPC OO. Urinary
F2-isoprostanes and plasma
lipids do not diverge
between the two groups
[329]
High MPC OO vs low MPC OO
enriched breakfast
21 hypercholesterolemic subjects
(5 men and 16 postmenopausal
women)
RC crossover design
High MPC OO protects
against postprandial
endothelial dysfunction and
decreases lipid peroxide and
F2-isoprostanes vs low MPC
OO
[330]
High MPC OO vs low phenolic
OO
28 individuals with CHD (sex not
reported)
Double-blind RC
placebo-controlled,
crossover design
Enriched OO decreases IL-6
and CRP being ineffective on
soluble sICAM-sVCAM-1
and lipid profile
[331]
High MPC OO vs low MPC OO
vs corn oil 12 healthy men e study has a Latin
square design
Enriched OO decreases
TXB2 and LTB4 and
increases plasma antioxidant
capacity
[332]
High MPC OO vs low MPC OO 40 men with stable CID RC crossover design
MPC-rich OO decreases
oxLDL and LPO and
increases GPx
[333]
OO vs sunflower-seed vs and
rapeseed 18 healthy men Double-blind RC
crossover design
Postprandial lipid and
lipoprotein concentrations
are not greatly affected
versus rapeseed and
sunflower-seed oil, while
rapeseed and OO diets have
the same effect on LDL
oxidation
[334]
OO 18 healthy men RC crossover design
OO may attenuate the acute
procoagulant effects of fatty
meals
[335]
OO 8 men and 5 women with type DM2 Single-blinded RC
crossover design
It increases in GLP-1 and
GIP [336]
14 Cardiovascular erapeutics
Table 3: Continued.
Compounds Individuals Design Main data References
OO (unrefined) 23 hypertensive patients of both
sexes
Double-blind RC
crossover design
Resting SBP and DBP are
significantly lower at the end
of the MUFA diet vs the
PUFA diet. e cold pressor
test and isometric exercise
are similar. Daily drug
dosage is significantly
reduced during the MUFA
vs PUFA diet
[337]
High MPC OO vs low MPC OO Healthy smokers: 11 men and 14
women
Single-blind RC
crossover design
Plasma antioxidant capacity
and oxLDL do not differ
significantly between the
rich and low MPC OO
[18]
High MPC OO (HPCOO); low
MPC VOO low-MPCOO
(LPCOO), refined OO
25 healthy men RC parallel, crossover,
design
HPCOO decreases ApoB-
100 and small LDL particles
vs baseline and LPCOO.
LPCOO increases previous
parameters. HPCOO
increases the lag time of LDL
oxidation, which is not
affected by LPCCO. LPL
gene expression is not
significantly changed by
both OO
[338]
High MPC OO (HPCOO); VOO
low MPC OO (LPCOO); refined
OO
47 healthy men RC crossover design
HPCOO increases HDL
cholesterol efflux capacity vs
the LPCOO and
incorporation of MPC and
their metabolites in HDL
and HDL2. HPCOO intake
decreases HDL3 and the
HDL core becomes TG-
poor, and HDL fluidity
increased
[339]
HTyr Healthy subjects (12 men and 16
women)
Double-blinded, RC
crossover design
Regular intake of HTyr
improves the antioxidant
defense and decreases nitrate
and MDA
[340]
HTyr 21 healthy volunteers (sex not
reported)
Double-blinded, RC
crossover design
In PBMC, it induces miR-
193a-5p, which leads to the
generation of anti-
inflammatory molecules
[218]
Oleuropein 24 healthy participants (sex not
reported)
Double-blind RC Latin
square design
No effect on postprandial
glucose derived from bread,
but in solution it attenuates
postprandial blood glucose
after 25 g sucrose, but has no
effect after 50 g of sucrose or
glucose
[254]
Oleuropein Healthy 10 men and 10 women Double-blind RC
crossover study
Its intake lowers glycaemia,
DPP-4 activity, soluble
NADPH oxidase-derived
peptide activity, 8-iso-
PGF2α, platelet p47
phox
phosphorylation and
elevates insulin and GLP-1
[341]
Low-fat diet vs high in saturated
fat (butter) vs high in
monounsaturated fat (EVOO)
diets
8women and 5 men with type 1
DM RCT crossover design
e addition of EVOO
attenuates the early
postprandial glucose
response
[342]
Cardiovascular erapeutics 15
Table 3: Continued.
Compounds Individuals Design Main data References
Lunch + EVOO 17 men and 13 women patients
with impaired fasting glucose RCT crossover design
Lunch + EVOO reduces
glucose, TG, ApoB-48, and
DPP4 activity and increases
insulin and GLP1. Chol and
HDL do not change
[303]
Lunch + EVOO 12 healthy men and 13 healthy
women RC crossover design
Lunch + EVOO decreases
postprandial glucose and
LDL
[343]
Lunch + EVOO vs lunch + corn
oil
Healthy subjects (12 men and 13
women) RCT crossover design
Lunch + EVOO ameliorates
postprandial oxidative stress
and endothelial dysfunction
being lunch + corn oil
ineffective
[344]
Lunch + EVOO 30 patients with impaired fasting
glucose RC crossover design
Lunch+EVOO attenuates
the increase of oxidative
stress and in LPS
[345]
Lunch + EVOO
Subgroup of the PREDIMED
study, 110 women with metabolic
syndrome
Multicenter, controlled
parallel group
MedDiet + EVOO decreases
urinary 8-oxo-7,8-dihydro-
2-deoxyguanosine and
prostanoids
[346]
MedDiet + EVOO vs
MedDiet + nuts vs MedDiet with
advice to use low fat
7477 individuals (57% women) at
high CV risk
Randomized
multicenter
PREDIMED study
testing the MedDiet in
primary CV prevention
MedDiet + EVOO and
MedDiet + nuts reduce the
incidence of major CV
events by approximately
30% vs the control diet
[347]
MedDiet + EVOO vs
MedDiet + nuts vs MedDiet with
advice to use low fat
2292 (1343 women) patients with
high CV risk
2210 (1200 women)
2203 (1323 women)
Post hoc analysis of the
PREDIMED study
MedDiet + EVOO reduces
the risk of atrial fibrillation [348]
MedDiet + EVOO vs
MedDiet + nuts vs MedDiet with
advice to use low fat
351 men and women with DM2 or
CV risk 3
A subgroup of
PREDIMED study
MedDiet + EVOO decreases
the BW and changes fat
distribution
[349]
MedDiet + EVOO vs
MedDiet + nuts vs MedDiet with
advice to use low fat
Men and women (3541 patients) at
high CV risk PREDIMED study
e MedDiet + EVOO
reduces DM2 risk among
persons with high CV risk
[350]
MedDiet + EVOO vs
MedDiet + nuts vs MedDiet with
advice to use low fat
3230 men and women with DM2 PREDIMED study
MedDiet + EVOO may delay
the introduction of glucose-
lowering medications
[351]
MedDiet + EVOO vs
MedDiet + nuts, low-fat diet Old men and women PREDIMED study
MedDiet especially if
supplemented with EVOO
changes the transcriptomic
response of genes related to
CV risk
[352]
MedDiet + EVOO vs
MedDiet + nuts, low-fat diet Old men and women PREDIMED study
Both diets decrease IL-6, IL-
8, MCP-1, and MIP-1β.
MedDiet + EVOO decreases
IL-1β, IL-5, IL-7, IL-12p70,
IL-18, TNF-α, IFNc, GCSF,
GM-CSF, ENA78, E-
selectin, and sVCAM-1 vs
the MedDiet + nuts group
[353]
16 Cardiovascular erapeutics
Another crucial risk factor for CVD is hypertension
[385], a condition that presents numerous sex differences
[386]. After 4 years of follow-up, results of interventional
and randomized PREDIMED study show no significant
variations in systolic blood pressure (SBP), whereas DBP is
decreased in EVOO and EVOO + nuts MedDiet [387]. e
1-year trial that examines 235 subjects (56.5% women)
proves that MedDiet supplemented with either EVOO or
mixed nuts reduces SBP and DBP [388]. A meta-analysis,
which includes primary and secondary prevention trials
proves that high MPC OO slightly reduces SBP and oxLDL
compared to low MPC OO, leaving Chol, TG, MDA, and
DBP unchanged [389]. A very small decrease in blood
pressure is observed in MedDiet + EVOO or nut vs a low-fat
control group [390]. Finally, the meta-analysis of RTC of
PREDIMED shows that the MedDiet lowers SBP by 3.02 mm
Hg and DBP by 1.99 mm Hg [391]. Importantly, a systemic
review that includes primary prevention proves the im-
portance of pharmaceutical form because only liquid oil but
not capsule with oil significantly reduces DBP [392].
OO impacts on glucose metabolism, two meta-analyses,
which include cohort and interventional studies in prevention
and care of DM2 [380, 393], prove that there is a 16% risk
reduction in people that consume more OO with high
Table 3: Continued.
Compounds Individuals Design Main data References
MedDiet + EVOO vs
MedDiet + nuts, low-fat diet
160 (74 men and 86 women) with
high CV risk
PREDIMED study
subgroup
Both diets reduce CRP, IL-6,
TNF-α, and MCP-1. After 3
years, both reduce CD49d
and CD40 expressions in T
lymphocytes and monocytes
and increase HDL but
decrease Chol, LDL, TG, and
BP. At 5 y, low-fat diet
increases glucose and
glycated hemoglobin
[354]
MedDiet vs MedDiet + EVOO
MedDiet + corn oil 12 men and 13 women RC crossover design
EVOO but not corn oil
counteracts the upregulation
of NOX2 protecting from
postprandial oxidative stress
[344]
MedDiet rich in OO
805 patients (sex not reported) with
CHD, who had their last coronary
event more than 6 months before
enrolment, stratified in diabetes
and prediabetes
Prospective,
randomized, single-
blind, controlled trial
(CORDIOPREV)
MedDiet rich in OO
improves endothelial
function in patients with
prediabetes and DM vs low-
fat diet
[355]
Leaf extract 60 prehypertensive men Double-blind, RC
crossover design
It reduces plasma TC, LDL,
TAG, HDL, Chol/HDL ratio,
IL-8. It does not affect
oxLDL, CRP, adiponectin,
ICAM-1, VCAM-1, P-
selectin, E-selectin, IL-6, IL-
10, IL-1β, TNF-α, fasting
glucose, insulin,
fructosamine or calculated
HOMA-IR or QUICKI
indices, nitrites. It reduces
SBP and DBP
[356]
Leaf extract 9 male and 9 female healthy
volunteers
Double-blind, RC
crossover design
It modulates positively
vascular functions and IL-8
production
[357]
Leaf extract 46 participants (sex not reported) Double-blinded RC,
placebo-controlled trial
It improves insulin secretion
and sensitivity and increases
IL-6, IGFBP-1, and IGFBP-
2. It does not affect IL-8,
TNF-α, CRP, lipid profile,
BP, body composition,
carotid intima-media
thickness, or liver function
[358]
Leaf extract
152 patients with stage-1
hypertension (85.4% and 87.6%
women in OO and captopril
groups, respectively)
Double-blind RC
Leaf extract and captopril
reduce SBP and DBP in a
similar manner. Only leaf
extract reduces TG
[359]
Cardiovascular erapeutics 17