Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease.
OBJECTIVE
This EAS Consensus Panel critically appraised evidence relevant to the benefit to risk relationship of functional foods with added plant sterols and/or plant stanols, as components of a healthy lifestyle, to reduce plasma low-density lipoprotein-cholesterol (LDL-C) levels, and thereby lower cardiovascular risk.


RESULTS
Plant sterols/stanols (when taken at 2 g/day) cause significant inhibition of cholesterol absorption and lower LDL-C levels by between 8 and 10%. The relative proportions of cholesterol versus sterol/stanol levels are similar in both plasma and tissue, with levels of sterols/stanols being 500-/10,000-fold lower than those of cholesterol, suggesting they are handled similarly to cholesterol in most cells. Despite possible atherogenicity of marked elevations in circulating levels of plant sterols/stanols, protective effects have been observed in some animal models of atherosclerosis. Higher plasma levels of plant sterols/stanols associated with intakes of 2 g/day in man have not been linked to adverse effects on health in long-term human studies. Importantly, at this dose, plant sterol/stanol-mediated LDL-C lowering is additive to that of statins in dyslipidaemic subjects, equivalent to doubling the dose of statin. The reported 6-9% lowering of plasma triglyceride by 2 g/day in hypertriglyceridaemic patients warrants further evaluation.


CONCLUSIONS
Based on LDL-C lowering and the absence of adverse signals, this EAS Consensus Panel concludes that functional foods with plant sterols/stanols may be considered 1) in individuals with high cholesterol levels at intermediate or low global cardiovascular risk who do not qualify for pharmacotherapy, 2) as an adjunct to pharmacologic therapy in high and very high risk patients who fail to achieve LDL-C targets on statins or are statin- intolerant, 3) and in adults and children (>6 years) with familial hypercholesterolaemia, in line with current guidance. However, it must be acknowledged that there are no randomised, controlled clinical trial data with hard end-points to establish clinical benefit from the use of plant sterols or plant stanols.
Department of Medicine, Division of Internal Medicine, University of Helsinki, Biomedicum Helsinki, Finland. Electronic address: Helena.Gylling@hus.fi.
Helena
H
Gylling
Department of Human Biology, Maastricht University, The Netherlands. Electronic address: j.plat@maastrichtuniversity.nl.
Jogchum
J
Plat
Department of Internal Medicine, UT Southwestern Medical Center, Dallas, USA. Electronic address: Stephen.Turley@UTSouthwestern.edu.
Stephen
S
Turley
Irving Institute for Clinical and Translational Research, Columbia University, New York, USA. Electronic address: hng1@columbia.edu.
Henry N
HN
Ginsberg
Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy at University of Gothenburg, Sweden. Electronic address: lasse.ellegard@nutrition.gu.se.
Lars
L
Ellegård
ANZAC Research Institute, Concord Hospital, Sydney, Australia. Electronic address: wendy.jessup@gmail.com.
Wendy
W
Jessup
Richardson Centre for Functional Foods and Nutraceuticals, University of Manitoba, Winnipeg, Canada. Electronic address: Peter.Jones@umanitoba.ca.
Peter J
PJ
Jones
Institute of Clinical Chemistry and Clinical Pharmacology, University Clinics Bonn, Germany. Electronic address: Dieter.Luetjohann@ukb.uni-bonn.de.
Dieter
D
Lütjohann
Synlab Academy, Synlab LLC, Mannheim Center of Laboratory Diagnostics, Heidelberg, Germany; Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, University of Heidelberg, Germany; Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria. Electronic address: Winfried.Maerz@synlab.com.
Winfried
W
Maerz
Vascular Medicine and Metabolism Unit, University Hospital Sant Joan, IISPV, CIBERDEM, Rovira and Virgili University, Reus, Spain. Electronic address: luis.masana@urv.cat.
Luis
L
Masana
Department of Angiology, Swiss Cardiovascular Center, Inselspital, University of Bern, Switzerland. Electronic address: guenther.silbernagel@yahoo.com.
Günther
G
Silbernagel
Faculty of Pharmacy, University of Lille 2, Lille, France. Electronic address: Bart.Staels@pasteur-lille.fr.
Bart
B
Staels
Strategic Research Center, Sahlgrenska Center for Cardiovascular and Metabolic Research (CMR), University of Gothenburg, Sweden. Electronic address: Jan.Boren@wlab.gu.se.
Jan
J
Borén
Department of Pharmacological and Biomolecular Sciences, University of Milan, Italy; Multimedica IRCSS Milano, Italy. Electronic address: alberico.catapano@unimi.it.
Alberico L
AL
Catapano
Department of Public Health, University Hospital Ghent, Ghent, Belgium. Electronic address: guy.debacker@ugent.be.
Guy
G
De Backer
National Centre for Cardiovascular Prevention and Outcomes, University College London, UK. Electronic address: john.deanfield@gmail.com.
John
J
Deanfield
Lipid Clinic, Hopital de Jolimont, Haine-Saint-Paul, Belgium. Electronic address: olivierdescamps@hotmail.com.
Olivier S
OS
Descamps
Wihuri Research Institute, Helsinki, Finland. Electronic address: Petri.Kovanen@wri.fi.
Petri T
PT
Kovanen
Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy. Electronic address: riccardi@unina.it.
Gabriele
G
Riccardi
Department of Cardiology, Hacettepe University, Ankara, Turkey. Electronic address: lalet@hacettepe.edu.tr.
Lale
L
Tokgözoglu
University of Pierre and Marie Curie, Paris, France; Dyslipidaemia and Atherosclerosis Research Unit, INSERM U939, Pitié-Salpetriere University Hospital, Paris, France. Electronic address: john.chapman@upmc.fr.
M John
MJ
Chapman
D000818:Animals; D000924:Anticholesteremic Agents / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000097:blood / Q000517:prevention & control / Q000628:therapy*; D002784:Cholesterol / Q000097:blood / Q000378:metabolism; D008078:Cholesterol, LDL / Q000097:blood; D050171:Dyslipidemias / Q000628:therapy*; D006801:Humans; D007249:Inflammation / Q000188:drug therapy; D008055:Lipids / Q000097:blood; D010840:Phytosterols / Q000627:therapeutic use*; D012855:Sitosterols / Q000627:therapeutic use*; D014280:Triglycerides / Q000097:blood
D000924:Anticholesteremic Agents; D008078:Cholesterol, LDL; D008055:Lipids; D010840:Phytosterols; D012855:Sitosterols; D014280:Triglycerides; D002784:Cholesterol
Cardiovascular risk; Functional foods with added plant sterols and plant stanols; Hypercholesterolaemia; Intestinal cholesterol absorption; Phytosterols; Safety