4.3.1. Traditional Pharmacopeia
Soy polyphenol content has been studied thoroughly. So, soybean is known to contain many functional substances such as phenolic acids, flavonoids, IFs, stilbenes, saponins [
26] or the peptide lunasin. According to Baraibar Norberg and Deutsh [
7] soybean appeared first in the traditional Chinese pharmacopeia. The oldest treaties reporting soy medicinal properties still available is the
Shiliao bencao (Compendium of Diet Therapy [Materia Dietetica]), which was written by Meng Shen in 670 CE. It can be read there that “
soybeans boiled into a liquid form, can eradicate poisons from the system and cure gastric fever, paralysis, pains, difficulty in passage of urine and other bladder troubles. It can also improve circulation of the blood, improper heart, liver, kidneys and stomach function and even remedy the chills” [
7,
30]. It should be noted that none of these health effects rely on estrogenic properties. This observation suggests that IFs were not present in these preparations confirming that traditional processes tended to eliminate them. By comparison, kudzu roots which contains GEN, DAI and puerarin among other substances, were known to induce some estrogenic and antipyretic effects. The latter are now attributed to IFs [
31] and suggest that the traditional preparation of kudzu preserved GEN and DAI levels [
31]. These facts put together with data obtained on IFs content of soy-foods prepared following traditional recipes, strongly suggest that the exposure to IFs was low in pre-industrialized period. It most probably increased in Human populations with industrial processing.
4.3.2. Toxic Effects and Reference Doses
The reprotoxic effects of soy IFs and their methoxylated parents from clover were first documented in the 1940’s when ewes were affected by the clover disease [
32]. Within four years the herds’ fertility was reduced from 80% to less than 5% and many farmers stopped their activities. Veterinaries then understood that IFs reduced the pituitary hormones FSH and LH which themselves were decreased due to an impairment of GnRH production at hypothalamic level [
33]. Such mechanism is known to be used pharmacologically in contraceptive pills based on the synthetic estrogen: ethynyl-estradiol [
34]. This impairment of pituitary hormones was then observed in premenopausal women who had 45 mg dietary IFs per day [
35]. More recently it was shown that an exposure to 50 mg IFs per day significantly increases the risk of luteal deficiency [
36] and infertility [
37] in American women. An exposure of baby-girls to soy IFs via soy-based infant formulas was shown to increase the incidence of fibrosis, endometriosis, menstrual pains and bleedings [
38,
39,
40,
41]. These impairments were also observed in women with an over-consumption of soy-based products [
42]. Moreover, a case of hypogonadism, gynecomastia and reduced libido was observed in a Japanese man over-consuming soy-milk for four years [
43]. Finally, in five studies, soy IFs in biological fluids were associated to reduced quality and quantity of semen in men [
44,
45,
46,
47,
48].
In addition, a controversy remains about the effects of IFs on breast cancers. An obvious discrepancy is observed between two data sources. On one hand, there are data obtained in vitro on recognized cell models [
3,
49], in animals implanted with these cancer cells [
3,
50], in healthy pre-menopausal women under IFs oral supplementation [
3,
51], and in women with breast cancer supplemented with soy and IFs [
3,
52]. On the other hand there are epidemiological studies [
3,
53] and review of randomized controlled trials (RCTs) [
3,
54]. The population studies tend to show a reduction of breast cancer risk in Asian women in an Asian environment (including green tea polyphenols intake) but this protection is not clearly observed in Western women in a Western environment [
3,
55]. Many biases including genetic, dietary and environmental parameters, make it difficult to reach a definitive conclusion on the effects of IFs on breast cancer incidence in Western menopausal women. The reviews including RCTs concluded that there was no increased risk of breast cancer in women taking soy or food supplements based on soy IFs [
3,
56]. However, the subjects recruited for these RCTs were selected on health criteria and did not represent the real population. Moreover, the RCTs were not designed to study the incidence of breast cancers and thus the conclusions of these analyses should be considered cautiously.
Still in humans, there are now enough evidences that soy-IFs can interact with thyroid function. On top of mechanistic arguments [
3], clinical cases [
57,
58], observation studies [
59,
60] and intervention studies [
61] confirm that soy IFs have slight anti-thyroid effects and can worsen the status of hypothyroid patients.
Beside these effects directly reported in human beings, the USA NTP showed that GEN was reprotoxic in sprag Dawley rats in a multi-generational study published in 2008 [
4]. The study showed that some reproductive parameters including anogenital distance in pups and litter size were altered at a GEN dose of 35 mg/kg/day in males. According to the general toxicology rules, the NTP study can be used to define a Reference Dose in human, by applying safety factors to the level defined. Indeed, an amount of 35 mg.kg
-1day
-1 is a LOAEL (Lowest Observed Adverse Effect Level) and no effect were recorded on reproductive parameters at the dose of 7 mg.kg
-1.day
-1. When a LOAEL is available, the safety factors to apply should be 10 for interspecific differences between rat and human, 10 for intraspecific differences i.e. interindividual differences between human beings and 1.8 or 3 for conversion of LOAEL to NOAEL. If the last factor is fixed at 1.8, the Reference Dose for GEN appears to be about 20 mg.day
-1 for an adult of 60 kg. In addition, as GEN is usually present in food with DAI, both IFs should be considered. Unfortunately, there is neither LOAEL nor NOAEL for DAI in rats. Also, even if DAI is less estrogenic than GEN, it can be converted into Equol which may be more active than GEN on certain tissues [
3]. Consequently, it would be relevant to consider the limit concentration of both GEN and DAI to be set at 20 mg.day
-1 for an adult of 60 kg. The present study show that the IFs levels reached in tofu, tempeh, miso and soy-juice are below this limit after water treatments meanwhile this is not the case in the corresponding industrial products. For textured proteins, the treatments allowed to decrease IFs concentrations from 35 to 22 mg/100g depending on protein sizes. This is higher than the potential reference dose. However, textured proteins are usually used with other ingredients and at a percentage ranging from 45 to 20%. Therefore, the final concentration in a 100g portion is lower than 20 mg. This dose is about half that which was shown to have a physiological effect in humans and seems to correspond to exposure levels in Asian populations following traditional soy-food preparation processes. Finally, these various doses discussed here correspond to median modern exposures in China and Japan [
15,
16]. To our knowledge, thy did not induce deleterious effects in the past.
To conclude this part, excess IFs should be avoided by populations which should not be exposed to estrogens. These are infants, children, premenopausal women, pregnant women, hypothyroid patients and men. Concerning women with breast cancer, it seems difficult to advice soy-consumption considering the estrogenic effects of IFs. The latter may prevent from breast cancer occurrence but their actions on an established breast cancer dependent on estrogens are still a subject of debate.
4.3.3. Beneficial Health Effects for a Restricted Population
If IFs should be carefully monitored it is because they seem to be active in human beings at dietary levels. Their beneficial estrogenic effects are restricted to certain categories of populations. Indeed, the most studied effect is the reduction of menopausal symptoms. The last meta-analysis which analyzed the effects of IFs on vasomotor symptoms and criteria showed only modest effects [
62]. However other meta-analyses reported a decrease in hot-flushes occurrence [
63]. In some studies, the effects appeared to be restricted to some natural compounds such as Equol [
64] while in others, only some preparation-types were found to be active [
65]. Nevertheless, while latest studies tend to show that vasomotor symptoms equally affect Asian and Western peri- and post-menopausal women [
66] in accordance with an Asian exposure to IFs lower than 50 mg/day, IFs are the most popular substances used world-wide to reduce hot-flushes.
Besides menopausal symptoms, there are evidences that IFs doses >80 mg /day can prevent Bone Mineral Density (BMD) decrease in menopausal women [
67]. Equol is also considered to have a specific beneficial effect on BMD during menopause when administered as supplement [
68]. In the latter study, a RCT gathered 76 menopausal women between 50 and 55 years-old, the treatment lasted one year and the supplement contained 80 mg IFs aglycone, 10 mg of Equol and 25 mg Resveratrol as an antioxidant. In these specific conditions the BMD was preserved significantly in the treated group compared to the placebo group.
To conclude, there are enough data showing that IFs may be useful for menopausal women when there is no thyroid or estrogen-dependent diseases.