Effect of moderate and regular consumption of Cinco Jotas acorn‐fed 100% Iberian ham on overall cardiovascular risk: A cohort study

Abstract Objective To evaluate the impact that the moderate and regular consumption of Cinco Jotas acorn‐fed 100% Iberian ham has on overall cardiovascular risk, lipid parameters, blood pressure, and weight. Methods A longitudinal, analytical, and quasi‐experimental clinical study with repeated measures was carried out with 100 randomly selected individuals in primary care. The sample population included men and women (64%) between the ages of 25 and 55 (42.08, SD 9.6) who were not diagnosed with any cardiovascular illness or diabetes, were not undergoing antihypertensive treatment, nor taking lipid‐lowering drugs. There were four visits during a 2‐week washout period for the first of three phases. Phases 2 and 3 included an 8‐week habitual diet phase followed by an 8‐week intervention phase when participants consumed 40 g daily of acorn‐fed 100% Cinco Jotas Iberian ham. Measurements of cardiovascular risk factors were taken following the SCORE table. These included total cholesterol, high‐density lipoproteins cholesterol (HDL‐c), low‐density lipoproteins cholesterol (LDL‐c), triglycerides (TG), and weight. Results The average vascular risk (SCORE) was 0.20 (SD 0.49) before the consumption phase and 0.18 (SD 0.48) at the end of the study (p > 0.05). An increase in HDL‐c of 5 mg/dl was observed while there was a decrease in LDL‐c and TG of 10 mg/dl (p < 0.05). There were no differences in total cholesterol levels, blood pressure, or weight; nor were differences observed in average consumption of calories, protein, lipids, carbohydrates, or alcohol (p > 0.05). Conclusions The daily consumption of 40 g of Cinco Jotas acorn‐fed 100% Iberian ham does not increase the risk of cardiovascular disease and has a favorable impact on lipid levels without affecting blood pressure or weight.


| INTRODUC TI ON
Scientific evidence has proven the beneficial effect that some foods have on cardiovascular diseases (CVD), some forms of cancer, and other degenerative diseases (Deleuze Isasi, 2006), but it must also confirm that these foods do not contribute to the appearance of cardiovascular risk factors like increased cholesterol total (TC), highdensity lipoproteins cholesterol (HDL-c), low-density lipoproteins cholesterol (LDL-c), triglycerides (TG), and blood pressure.
Cinco Jotas acorn-fed 100% Iberian ham, produced principally in southwest Spain and considered a red meat, is a popular part of Spanish cuisine. This ham, made from the hind quarters of Iberian pigs nourished primarily on grass and acorns, is cured, seasoned with salt, and exposed to a range of favorable environmental conditions and habitats (Deleuze Isasi, 2006;Jiménez-Colmenero, Ventanas, & Toldrá, 2010). The Cinco Jotas curing cellars have the right conditions to ensure proper maturation of the hams by naturally maintaining just the right temperature and humidity levels, allowing the performance of proteases found naturally in meat. This process instils in the ham certain nutritional characteristics such as high-biologicalvalue proteins and elevated levels of iron, zinc, and B vitamins.
Importantly, its 5% fat content is rich in unsaturated fatty acids, of which between 67% and 68% (Ortega, López-Sobaler, Requejo, & Andrés, 2003) is composed of oleic acid. The ham is also rich in polyphenols and amino acids which are released by the proteolysis that occurs during the curing process (De la Hoz, Lopez, Hierro, Cambero, & Ordonez, 1996).
Several studies have confirmed the cardiovascular health benefits of the Mediterranean diet and, specifically, the consumption of olive oil and other monounsaturated fats (Deleuze Isasi, 2006) associated with a lower incidence of CVD, cancer, high blood pressure, obesity, and osteoporosis (Jiménez-Colmenero et al., 2010).
Similarly, different components of this diet have been associated with providing varying degrees of protection against these same diseases (Martínez-González & Sanchez-Villegas, 2004;Ruiz-Canela López et al., 2009).
The objectives of this study were primarily to evaluate the impact that the moderate and regular consumption Cinco Jotas acornfed 100% Iberian ham has on overall cardiovascular health and, secondarily, on lipid parameters (TC, TG, HDL-c, and LDL-c), blood pressure, weight, and waist circumference (WC).

| MATERIAL AND ME THODS
This clinical study was designed to be longitudinal, analytical, and quasi-experimental with pre-and postrepeated measures. With a level of significance of 5%, assuming that the proportion in the reference group is 80.00%, and the proportion in the experimental group is 90.00%, and that the superiority limit is 2.00%, we needed to include 97 subjects in the study. Estimating a 9% dropout rate, a recruit total of 106 participants was deemed appropriate. The software Ene 3.0 was used to estimate the size of the sample population. The participants were randomly selected from patients who had visited the Health Centre during the last three weeks of June 2016 using numbers randomly generated from Microsoft Excel. Six subjects were selected from the daily roster of patients for each doctor. If they met the criteria for inclusion, they were invited to participate in the study. Approximately 60 subjects were recruited each week.
The inclusion criteria were as follows: (a) individuals of both sexes between the ages of 25 and 55 years old; (b) absence of any documented CVD (including stroke, transient ischemic attack, acute myocardial infarction, acute coronary syndromes, stable ischemic cardiopathy, or peripheral arterial disease); (c) individuals who have provided written informed consent; (d) individuals whose caloric intake was between 80 and 105% of the daily amount recommended for their profile and met the nutritional objectives for the general adult population regarding macronutrients. The criteria for exclusion were as follows: (a) pregnant or breastfeeding women; (b) individuals whose pathological situation could interfere with the development of the study(e.g., acute stroke, acute myocardial infarction or cancer); (c) individuals who  The results of a nutritional study based on 54 samples are shown in Table 1.
The 40-g portions of ham were sent by courier weekly from the slicing and packing room of the producer in Jabugo to the health center, where they were collected by the subjects. The portions did not require refrigeration because they were delivered within 5 days of consumption. The cured ham was provided sliced, in 40-g portions, in thermoforming vacuum packaging, without identifying the brand on the packaging.
There were four visits, the initial visit and three follow-up visits at 2, 10, and 18 weeks. During the initial screening visit, criteria were reviewed to confirm subject eligibility, participants were fully briefed, both orally and in print form, and they signed in-  (0) Note. Data were expressed as an average and standard deviation (SD).
was administered both at the beginning and at the end of the study.

| RE SULTS
A total of 148 subjects were evaluated, of which 105 were recruited.
Forty-three individuals were excluded from the study; 22 were over the age of 55 (17 women and five men), one was pregnant, three women and two men presented multiple pathologies, three women declined to participate, and 12 presented with high blood pressure, diabetes, or dyslipidemia under pharmacological treatment (seven women and five men).
Of the 105 subjects eventually selected, 100 completed the study: one subject moved away from the area, two did not want to repeat the periodic visits to the center for analysis, and two cited family problems that prevented them from continuing. The final sample was composed of 64 women (64%) and 36 men (36%) with a global average age of 42.08 (SD 9.6) years.
The compliance with the daily intake of ham was 92%. The remaining 8% reported that although they had discarded the packaging,

| D ISCUSS I ON
Based on the results obtained, it can be concluded that Cinco Jotas acorn-fed 100% Iberian ham can be consumed daily without any risk to cardiovascular health since it did not increase the risk in individuals consuming a daily portion of 40 g, a portion that can be considered regular and acceptable. No significant changes were observed in the creatinine (CR), blood pressure, TC levels, glycemie, CRP, weight, and WC; values that did not change throughout the study.
These results coincide with those obtained by Maciá Botejara et al. (2005), who observed an improvement in the atherothrombotic profile, and those of Mayoral et al. (2003), who observed a drop in blood pressure, increase in antioxidants, and decrease in lipid peroxidation after a period of 6 weeks consuming cured ham made from acorn-fed 100% Iberian pigs.
Significant differences have been observed in the composition of some fatty acids in pigs due to differences in the feeding plan  neither of them produced weight gain, nor did they modify the lipid profile. Moderate decreases in blood pressure were also observed.
These results support those found in this current study.
Multiple studies have identified natural peptides with antihypertensive effects generated during the curing process of Spanish where effective therapeutic treatments are scarce. However, more evidence is necessary.

ACK N OWLED G M ENTS
We want to thank the professionals of the La Orden Health Center of Huelva, for its collaboration in the research. involved in drafting the article or revising it critically for important intellectual content. All authors: involved in final approval of the version to be submitted.

CO N FLI C T O F I NTE R E S T
There is no conflict of interest. The authors declare that they have no conflict of interests in the research. The study was sponsored through a research grant from Osborne Wineries that financed the samples of Iberian ham (Osborne Wineries had no role in the design, analysis, or writing of this article). The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported. The reporting of this work is compliant with STROBE guidelines. The lead author affirms that no important aspects of the study have been omitted and that any discrepancies from the study as planned.

E TH I C A L S TATEM ENT
This study was performed in accordance with the ethical principles laid down in the Declaration of Helsinki for human subjects.
This study was evaluated, reviewed, and approved by the Ethical Committee of Juan Ramón Jiménez Hospital of Huelva (Spain).
Written informed consent was obtained from all study participants.