Se existe algum alimento que alimenta um sem número de especulações e receios infundados é a soja. Quase toda as pessoas têm uma opinião forte sobre a ingestão de soja e os seus efeitos para a saúde. Em algumas correntes de pensamento, é responsável por vários problemas de saúde como cancro da mama e outros. No entanto, quase todas essas opiniões são pouco fundamentadas na melhor evidência científica disponível. A soja é uma das principais vedetas da nutrição pop, a nutrição das opiniões, crenças, e convicções pessoais. O facto é que embora se trate de uma leguminosa com inúmeras propriedades importantes para a saúde e nutricionalmente muito completa, a soja continua a ser alvo de muitas preocupações relacionadas com a saúde.
A soja tem sido tradicionalmente consumida ao longo de séculos pelas populações asiáticas. No Japão e na China, o consumo médio de soja é de cerca de 1,5 porções de soja por dia, podendo chegar às 3 porções, sendo que metade dessa soja é fermentada .
Os efeitos para a saúde dos produtos à base de soja têm sido abundantemente estudados ao longo dos últimos 25 anos . Interpretar corretamente os resultados desses estudos é um desafio, uma vez que isso requer um entendimento das fragilidades e vieses presentes em diferentes metodologias e modelos de estudo. Associado a isso existem correntes de pensamento que reproduzem opiniões e especulações apresentando-as como evidência. Por outro lado, um dos componentes da soja – as isoflavonas – têm suscitado dúvidas relativamente aos seus efeitos na saúde, pela sua semelhança química com o estrogénio.
Estudos in vitro e in vivo têm mostrado resultados contraditórios. No entanto, esses estudos são pouco relevantes para a saúde humana, uma vez que muitas das vezes não podem ser reproduzidos em modelo humano. O facto é que a maior parte dos animais metaboliza as isoflavonas de forma muito diferente dos humanos, pelo que os estudos em animais não permitem avaliar os efeitos das isoflavonas na saúde humana .
Além disso, por vezes nesses estudos utiliza-se soja crua, o que é desaconselhado pela presença de inibidores de tripsina e lectinas, os quais podem ser tóxicos em grandes quantidades mas são desativados quando se cozinha ou processa a soja . O facto é que, como veremos mais à frente, na grande maioria dos estudos em humanos, a soja está associada a inúmeros benefícios para a saúde e muito poucos riscos .
MAS AFINAL O QUE É A SOJA?
A soja pertence à família das leguminosas, partilhando por isso das suas propriedades nutricionais, sendo rica em proteínas, fibra, gorduras insaturadas, vitaminas, minerais e fitoquímicos. As leguminosas são dos alimentos mais importantes numa dieta de base vegetal pela sua grande concentração em nutrientes e efeitos na diminuição do risco de doenças crónicas como diabetes e doenças cardiovasculares, assim como da mortalidade . As leguminosas são igualmente dos alimentos com menor impacto ambiental, o que as torna importantes aliadas não só na saúde como no combate às alterações climáticas .
Em Portugal, a ingestão média de leguminosas são cerca de 18 gramas. Se levarmos em consideração que uma porção de leguminosas cozinhadas são cerca de 80 gramas (1/2 chávena) e que a recomendação é de ingerirmos 1 a 2 porções por dia, então claramente temos um consumo muito abaixo do adequado destes alimentos.
https://ian-af.up.pt/ingest-leguminosas-sexo
https://www.dgs.pt/ficheiros-de-upload-1/alimentacao-roda-dos-alimentos-pdf.aspx
A soja difere das outras leguminosas por ter uma concentração superior de proteína (10 a 14 g por porção) e gordura (ácidos gordos insaturados, nomeadamente ómega-6 e ómega-3). Essa proteína é considerada de grande qualidade por ter um bom equilíbrio de aminoácidos essenciais e ser de boa absorção .
A soja é também rica em ferro, sendo que este tem uma absorção muito boa, provavelmente por se encontrar na forma de ferritina, a qual é absorvida de forma mais eficaz do que outras formas de ferro não-heme .
Da mesma forma, mesmo na presença de ácido fítico e oxalato, os quais inibem a absorção de minerais, a absorção de cálcio a partir da soja é bastante boa . A absorção de cálcio a partir de bebida enriquecida de soja ou tofu é semelhante à taxa de absorção de leite de vaca .
Um dos receios em relação à soja é que alguns dos seus componentes, como o ácido fítico, oxalatos ou inibidores de protease, possam ser prejudiciais ou interferir com a absorção de minerais como ferro, zinco ou cálcio. Embora muitos alimentos tenham ácido fítico, a soja tem concentrações superiores. No entanto, como vimos antes, tanto o ferro como o cálcio presentes na soja são bem absorvidos .
O ácido fítico é uma substância orgânica que contém fósforo presente em alimentos como: cereais integrais, leguminosas, sementes, frutos secos e em menor quantidade nos vegetais. O ácido fítico é um quelante de iões de metal, especialmente ferro e zinco. Como os humanos não têm a enzima capaz de hidrolisar o ácido fítico, os minerais aos quais esteja ligado são pouco absorvidos. O fitato está presente em quase todas as células de mamíferos em pequenas quantidades, sendo importante a regular a proliferação e diferenciação celular. Processamentos como demolhar, fermentar, germinar e cozinhar com temperaturas altas diminuem os níveis de ácido fítico. Uma vez que alimentos mais ricos em ácido fítico e fibra são também mais ricos em micronutrientes, o efeito inibidor não causa carências .
Além disso, o ácido fítico pode mesmo ter efeitos benéficos para a saúde, devido às seguintes propriedades: poderoso antioxidante, inibe o crescimento das células de cancro, inibe a formação de pedras renais e diminui o colesterol .
MAS E ENTÃO A SOJA NÃO TEM ESTROGÉNIO? ISSO NÃO É PERIGOSO?
Entre os vários fitoquímicos presentes na soja, esta é particularmente rica numa subclasse de flavonoides conhecidos como isoflavonas, as quais têm uma estrutura química parecida com o estrogénio, sendo por isso também chamadas de fitoestrogénios. No entanto, as propriedades destes fitoestrogénios são muito diferentes da hormona estrogénio. Existem três tipos de isoflavonas na soja: genisteína (50%), daidzeína (40%) e gliciteína (10%). Embora tenham uma ação estrogénica fraca, estas moléculas podem ligar-se a recetores de estrogénio, imitando os efeitos do estrogénio em alguns tecidos e antagonizando-os noutros tecidos, o que significa que as isoflavonas poderão ter os benefícios associados ao estrogénio sem os seus efeitos prejudiciais. Esta ação seletiva tem sido objeto de interesse nas investigações sobre fitoestrogénios . À semelhança de alguns medicamentos, devido à forma como as isoflavonas são metabolizadas, estas podem ser classificadas como moduladores seletivos de recetores de estrogénio .
As isoflavonas ao ligarem-se aos recetores de estrogénio modificam a expressão de certos genes dessas células. Existem dois tipos de recetores de estrogénio (ERs): alfa (ERα) e beta (ERβ). Esses recetores estão distribuídos de formas diferentes pelos vários tecidos humanos e poderão ter diferentes funções. No tecido mamário, a ativação dos ERβ parece inibir os efeitos dos ERα. As isoflavonas, de um modo geral, possuem maior afinidade com os ERβ, enquanto o estradiol 17-beta tem maior afinidade com os ERα. Devido a estas características seletivas, as isoflavonas têm dessa forma efeitos estrogénicos e antiestrogénicos .
A SOJA NÃO AUMENTA O RISCO DE CANCRO DA MAMA?
Uma das razões pelas quais se começou a estudar os efeitos da soja na saúde foi a observação de que nos países onde se consome tradicionalmente soja, as taxas de incidência de cancro da mama eram muito baixos. Estudos epidemiológicos realizados nessas populações sugerem que o consumo de soja diminua cerca de 41% o risco de cancro da mama .
No entanto, vários estudos sugerem também que, para se obter a máxima proteção contra o cancro da mama, a soja deve ser consumida desde a infância. A redução no risco de cancro da mama é mais significativo quando existe um consumo de soja de forma consistente ao longo da infância e adolescência. De acordo com vários estudos de caso-controlo, consumir soja durante a infância e adolescência poderá diminuir entre 25 a 60% o risco de cancro da mama mais tarde na vida .
Um estudo que acompanhou 70578 mulheres chinesas ao longo de 13 anos, mostrou que o consumo elevado de soja durante a adolescência e idade adulta esteve associado a uma diminuição de 47% no risco de cancro da mama. No entanto, um consumo elevado apenas durante a adolescência mas baixo em idade adulta, esteve associado a uma diminuição semelhante de 44%, o que sugere que o consumo durante a infância e adolescência é mais importante do que em idade adulta .
Outro estudo prospetivo que acompanhou 73223 mulheres chinesas durante 7 anos, concluiu que aquelas que consumiram mais de 12,8 g de proteína de soja diariamente, quando comparado com um consumo de 4,9 g ou menos, tiveram uma diminuição de 59% no risco de cancro da mama antes da menopausa. O mesmo estudo sugere que se o consumo for iniciado na adolescência e representar 11,3 g de proteína de soja consumidos diariamente, o risco de cancro antes da menopausa diminui 43% .
Mais recentemente, uma meta-análise a 23 estudos prospetivos com 330826 participantes no total observou que a ingestão de produtos de soja esteve associada a uma diminuição de 12% no risco de mortalidade por cancro e 15% no risco de mortalidade por doença cardiovascular. Os participantes com uma ingestão superior de isoflavonas tiveram um risco 10% inferior de mortalidade por todas as causas. Além disso, por cada 5g/dia de proteína de soja, houve uma diminuição de 12% no risco de mortalidade por cancro da mama. O estudo conclui assim que a ingestão de soja poderá diminuir o risco de mortalidade e aumentar a longevidade .
Alguns estudos clínicos ajudam a confirmar estes resultados ao mostrarem que as isoflavonas não alteram os principais biomarcadores de risco de cancro da mama. Por exemplo, um estudo clínico duplo-cego aleatorizado com 80 mulheres mostrou que a utilização de isoflavonas durante 10 meses não teve efeitos na densidade mamária em mulheres na pós-menopausa .
MAS PARA MULHERES COM CANCRO DA MAMA, COMER SOJA AUMENTA O RISCO DE RECIDIVAS, CERTO?
Na realidade, de acordo com todos os estudos publicados até hoje, parece ser exatamente o contrário. Inúmeros estudos prospetivos com mulheres diagnosticadas com cancro da mama têm mostrado que o consumo de soja regular está associado a uma diminuição do risco de recidiva e de mortalidade da doença. Um desses estudos foi o Shanghai Breast Cancer Survival, o qual acompanhou 5042 mulheres com cancro da mama ao longo de cerca de cerca de 4 anos. Ao fim desse tempo foram observados os seguintes resultados:
- Aquelas que consumiram mais soja (>15,31 g de proteína de soja) tiveram uma diminuição de 34% no risco de recidiva e de 33% no risco de mortalidade;
- Os efeitos protetores do tamoxifen só foram observados nas mulheres que tinham um consumo baixo a moderado de soja. Entre aquelas que tinham um consumo elevado de soja (>15,31 g de proteína de soja), o tamoxifen não esteve associado a benefícios adicionais.
Estes resultados sugerem que um consumo elevado de soja pode ter efeitos semelhantes à utilização na tamoxifen na prevenção de recidivas e mortalidade. No entanto, uma vez que se trata de uma amostra pequena, estes terão de ser verificados em estudos futuros. Os benefícios associados ao consumo de soja foram observados em todos os subtipos de cancro da mama, antes ou depois da menopausa, a tomar ou não tamoxifen .
Outros estudos chegaram a conclusões semelhantes:
O estudo LACE, que incluiu 1954 mulheres diagnosticadas com cancro da mama, concluiu que as mulheres depois da menopausa tratadas com Tamoxifen que mais consumiram isoflavonas, tiveram uma diminuição de 60% no risco de recidiva .
Uma meta-análise que incluiu mais de 9500 sobreviventes de cancro da mama da China e dos EUA, concluiu que um consumo maior ou igual a 10 mg de isoflavonas por dia esteve associado a uma redução de 25% no risco de recidiva da doença .
Uma meta-análise que incluiu 5 estudos prospetivos perfazendo um total de 11206 mulheres diagnosticadas com cancro da mama, mostrou que comparativamente com aquelas que consumiam menos soja, as mulheres com maior consumo de soja depois do diagnóstico, apresentavam uma diminuição de 16% na mortalidade e a uma diminuição de 26% nas recidivas, independentemente do tipo de cancro da mama .
Mais recentemente, um estudo acompanhou 6235 mulheres com cancro da mama a viver nos EUA ao longo de 9,4 anos, tendo concluído que :
- A ingestão superior de isoflavonas (soja) esteve associada a uma diminuição de 21% na mortalidade;
- No caso daquelas que têm tumores sem recetores de estrogénio a diminuição foi de 51%;
- Entre aquelas que não fazem terapia hormonal, houve uma redução de 32%.
As organizações responsáveis por rever toda a literatura científica relacionada com prevenção do cancro (World Cancer Research Fund e American Institute for Cancer Research), concluíram que existem indicações plausíveis de que consumir soja depois de um diagnóstico de cancro da mama, juntamente com manter um peso saudável, ser fisicamente ativo, consumir alimentos ricos em fibra e limitar o consumo de gorduras saturadas, poderá aumentar as probabilidades de sobrevivência:
https://www.wcrf.org/dietandcancer/breast-cancer-survivors
https://www.aicr.org/learn-more-about-cancer/infographics/breast-cancer-survivorship.html
https://www.aicr.org/learn-more-about-cancer/infographics/what-breast-cancer-survivors-can-do.html
Um estudo transversal que incluiu 365 mulheres, sugere que consumir soja e crucíferas após um diagnóstico de cancro da mama poderá diminuir os sintomas de menopausa associados aos tratamentos assim como a fadiga. Alguns dos resultados do estudo:
- A ingestão superior a 24 g/da de soja esteve associada a uma diminuição de 49% na probabilidade de sintomas de menopausa e 57% na probabilidade de fadiga;
- A ingestão superior a 70.8 g/dia de vegetais crucíferos esteve associada a uma diminuição de 50% na probabilidade de sintomas de menopausa.
O estudo conclui assim que, nesta população, o consumo elevado de soja e crucíferas esteve associado a uma diminuição dos sintomas de menopausa induzidos pelo tratamento assim como da fadiga .
Um estudo sugere também que a ingestão de soja depois de um diagnóstico de cancro da mama poderá diminuir o risco de fraturas ósseas nas sobreviventes. Para isso foram acompanhadas 4139 mulheres com cancro da mama, 1987 das quais antes da menopausa e 2152 depois da menopausa. Ao fim de 10 anos foram observados os seguintes resultados:
- O consumo elevado de isoflavonas de soja (56mg/d) esteve associado a um risco 78% inferior de fraturas ósseas relacionadas com osteoporose entre as doentes em pré-menopausa.
- O excesso de peso esteve associado a um risco 81% superior de fraturas ósseas entre as doentes em pré-menopausa.
- O exercício físico esteve associado a um risco 44% inferior de fraturas ósseas entre as doentes em pós-menopausa.
A quantidade de isoflavonas de soja considerada elevada no estudo é o equivalente a cerca de 2 porções de soja por dia (ex.: 2 chávena de bebida de soja ou 1 chávena de tofu). O estudo concluiu que o consumo de soja antes da menopausa por sobreviventes de cancro da mama poderá diminuir o risco de fraturas ósseas relacionadas com osteoporose e que o excesso de peso poderá aumentar esse risco. Além disso, exercício físico e tomar tamoxifen poderão diminuir o risco de fraturas ósseas .
Além dos efeitos protetores das isoflavonas no cancro da mama, estas têm outras propriedades que poderão ajudar a explicar os seus benefícios na prevenção do cancro da mama e de outras doenças :
- Induzem a diferenciação, a apoptose, inibem a angiogénese e a proliferação e são anti-inflamatórias e antioxidantes;
- Inibem as tirosinas quinases, enzimas com um papel central nas vias de sinalização que estimulam a proliferação celular;
- Inibem a ação da aromatase, enzima responsável pela formação de estrogénio a partir de androgénio;
- Poderão estimular a formação de células Natural Killer, importantes na defesa contra células de cancro e agentes infecciosos.
TENHO CANCRO DA MAMA. O MEU MÉDICO ACONSELHOU-ME A NÃO COMER SOJA.
Essa recomendação, como pudemos ver mais acima, não se baseia na melhor evidência científica mas sim em receios antigos e desatualizados. Todos os estudos que foram realizados até hoje mostram que a soja depois de uma diagnóstico de cancro da mama não só parece não ser prejudicial, como poderá mesmo diminuir o risco de recidiva e aumentar a probabilidade de sobrevivência. Várias organizações de saúde deixaram de recomendar que se deixe de comer soja.
https://blogs.cancer.org/expertvoices/2012/08/02/the-bottom-line-on-soy-and-breast-cancer-risk/
https://www.mdanderson.org/publications/focused-on-health/september-2014/soy-cancer.html
(CONTINUA NA PARTE 2)
Referências:
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[…] (CONTINUAÇÃO DA PARTE 1) […]