1. ROLE OF PLANT STEROLS AND STANOLS IN A CHOLESTEROL LOWERING DIET
This presentation ‘The role of plant sterols and stanols in a cholesterol lowering diet’ is the fourth presentation in the series of RCN accredited presentations. This presentation looks at the benefits of plant sterols/stanols, their cholesterol lowering properties and also includes a case study to help keep your audience engaged.
Allow about minutes for this presentation if using the slide set as it is presented here including the case study exercise.
The case study exercise is:
Slide 11 allow 10 – 15 minutes for the case study. This exercise can be moved to any point within the presentation.

2. OUTLINE What are plant sterols/stanols? Mechanism of action
What is the evidence for plant sterols/stanols in cholesterol lowering?
An additive cholesterol lowering effect to lipid-lowering medication
The ‘Portfolio diet’
Dietary guidelines

3. LDL-cholesterol lowering
Reference: Adapted from Jenkins et al. Mayo Clin Proc 2003
No food ingredient is more effective than plant sterols/ stanols for lowering cholesterol

4. Plant sterols are natural components of the human diet
Major sources of plant sterols:
fat and oils
bread and cereals
fruits and vegetables
nuts
Reference : International Atherosclerosis Society, 2003; NCEP III Expert Panel, JAMA 2001
Average daily plant sterol intake of adults
mg/day
Recommended intake of
plant sterol-enriched foods
for a significant
cholesterol-lowering effect
2g/day*

5. Plant sterols and stanols have similar structures to cholesterol
ß-Sitosterol
Campesterol
ß-Sitostanol
Sterols and stanols are thought to work by displacing cholesterol molecules in the gut due to their similar structure.
This slide demonstrates the structure of dietary cholesterol compared to that of other plant sterols and stanols. The key differences in structure are highlighted in the red circles.
It clearly shows how structurally similar sterols and stanols are with cholesterol. It also shows how similar sterols and stanols are to one another. The difference being that plant sterols have no double bonds, indeed plant stanols are the saturated form of plant sterols.

6. Plant sterols and cholesterol absorption
The cholesterol-lowering effect of plant sterols cannot be accounted for by just one single effect, but rather to a complex set of consecutive and/or interacting events.
Plant sterols interfere with the absorption of cholesterol in the gut, but the exact details of how they do this are not fully understood. Several mechanisms have been suggested by which plant sterols reduce the uptake of cholesterol into the blood.
It is proposed that:
Cholesterol and plant sterols compete with each other, due to their similar structure. Plant sterols therefore displace cholesterol from the micelles formed in the gut that play a vital role in cholesterol absorption. Reducing the amount of cholesterol in the micelles thus reduces the amount that is presented to the lining of the gut wall in a form that can be absorbed.
Plant sterols may also compete with cholesterol for access to cholesterol transporters at the gut wall.
As a result of consuming plant sterols the absorption of cholesterol is reduced by 30-40%.
Cholesterol that isn’t incorporated into the micelles is subsequently excreted.
Reference: Trautwein et al. Eur J Lipid Sci Technol 2003
More cholesterol absorbed = Less cholesterol absorbed =
Higher blood cholesterol levels Lower blood cholesterol levels

7. Clinical studies performed
Cholesterol-lowering effects of plant sterols have been known since the early 1950s
Over 170 studies have been carried out on plant sterols
Subjects involved in the studies included:
Healthy adults and those with hypercholesterolaemia (men and women)
Those on normal Western diets and those on low-fat diets
Those with increased risk: diabetes, familial hypercholesterolaemia
Children: familial hypercholesterolaemia.
The cholesterol lowering effect of plant sterols has been known since the 1950’s. Hundreds of studies have now been conducted on plant sterols in a variety of different subjects.

8. Overview of clinical trials assessing efficacy of plant sterols
A plethora of independent studies have been undertaken using plant sterol-enriched foods, the effect is shown with the orange points. Katan and collaborators (32 experts in all) performed a meta-analysis of the data from 41 clinical trials, as shown in the green bars.
2-2.5g of plant sterols daily significantly reduces LDL-cholesterol by approximately 10%. After this point the effect levels off, so increasing intake beyond 2-2.5g achieves little further reduction in cholesterol.
Reference: Katan et al. Mayo Clin Proc 2003

9. Quantity of regular foods required to provide 2g plant sterols
2g plant sterols can be obtained by eating:
425 tomatoes
210 carrots
150 apples
83 oranges
70 slices of wholemeal bread
11 cups of peanuts.
To get the optimal amount of plant sterols from regular foods would be extremely difficult
Plant sterol enriched foods facilitate the consumption of the recommended intake of 2g of plant sterols/day.

10. Plant sterol enriched foods Plant sterol enriched foods
Plant sterols have an additive cholesterol-lowering effect with lipid lowering medication %
Healthy diet
Healthy diet
Healthy diet
Plant sterol enriched foods
-10
Statin treatment
-20
-30
Plant sterol enriched foods
When used in combination with statins, plant sterols provide an additional lowering effect which could help patients reach their target cholesterol levels. The graph shows the additive effect of plant sterols on lipid-lowering medication.
Reference: Katan et al Mayo Clin Proc 2003; Based on Edwards & Moore BMC Family Practice 2003
-40

11. CASE STUDY– INTERACTIVE EXERCISE 1
Mr Jones, 56 years and has smoked 20 cigarettes a day since the age of 18
Total cholesterol 7.0mmol/L, HDL 1.1mmol/L, LDL 3.5mmol/L, TGs 2.3mmol/L
Typical diet:
Breakfast: cereal with semi-skimmed milk & two slices toast with spread
Lunch: shop-bought sandwich and bag of crisps
Dinner: ready meal most nights, takeaways once a week
Alcohol: units per week.
Interactive exercise
Break into groups to discuss suggested ways to lower lipid levels?
This case study will help to keep your audience engaged. We suggest you get your audience to break into groups to do this. You should leave approximately minutes for the exercise (time to do the case study, feedback and for you to comment on the feedback).
Example answer:
Discuss concept of a healthy diet i.e. increase fruit and vegetable intake, reduce salt, reduce portion sizes etc
Reduce intake of saturated fat
Use of plant sterol enriched foods

12. A dietary portfolio effectively reduces LDL- cholesterol levels
Week 0
Week 2
Week 4 -5
-8.5%
-10
-15
Control diet
LDL cholesterol (% change )
Control diet + statin
-20
Dietary portfolio#
-25
-29.6%*
-30
This study compared, in the same subjects, the cholesterol-lowering potential of a dietary portfolio that included plant sterols, soya protein and viscous fibre, with pharmaceutical intervention (early generation statins).
The trial involved 34 hyperlipidaemic adults, who underwent all three treatments:
a control diet that was very low in saturated fat
the same diet plus lovostatin (control diet plus statin)
diet high in plant sterols (1.0g/1000 kcal), but also containing soya protein foods and viscous fibres.
LDL-cholesterol decreased by 8.5%, 33.3% and 29.6% in the control, statin and portfolio diets respectively.
Although the absolute difference between the portfolio and statin diets was significant at 4 weeks, 9 participants achieved their lowest LDL concentration with the portfolio diet.
It is worth noting that the statin and portfolio diets did not differ significantly in their ability to reduce LDL-cholesterol below the 3.4mmol/L primary prevention cut-off.
For further information please visit
Reference: Jenkins et al. AJCN 2005
-33.3%*
-35
34 adults
4 week interventions
# Dietary portfolio = plant sterols, soya protein, viscous fibre, almonds
* Significantly different from control (low saturated fat diet)

13. Longer term effects of portfolio diet in hypercholesterolaemia
12 month study involving 66 participants, of which 55 completed the trial
Prescribed diets high in:
plant sterols (1.0g/1000 kcal)
soya protein (22.5g/1000kcal)
viscous fibre (10g/1000 kcal)
whole almonds (23g/1000 kcal)
Results at 3 and 12 months: Mean LDL-cholesterol reduced by 14% & 12.8% respectively
32% of participants had LDL-cholesterol reductions of > 20%.
A further study was conducted to investigate the effects of the portfolio diet over a longer period – over 12 months. The results show that the cholesterol lowering effect of the ‘Portfolio diet’ is sustained on a longer term.
The findings of the ‘Portfolio studies’ reinforce the view that a diet-based approach can markedly lower cholesterol levels.
Reference: Jenkins et al Am J Clin Nutr 2006

14. Most effective way to lower cholesterol with dietary change is to include plant sterols or stanols
Dietary component
Dietary change
Approximate LDL-cholesterol reduction in %
Plant sterols and stanols
2-2.5g/day 10
Saturated fat
<7% of energy
5-10
Beta-glucan
3g/day
(3 bowls of porridge)
2-5
Soya protein
25g/day
(4 portions)
3-5
Body weight maintenance
Lose ~ 5kg 5
Many dietary factors affect LDL-cholesterol levels. Making positive dietary changes including replacing saturated fats with polyunsaturates and keeping intakes of trans fats to a minimum are well known to lower LDL-cholesterol.
However, the single most effective way to lower LDL-cholesterol with dietary change is to include plant sterols or stanols. Eating g of plant sterols daily, can lower LDL-cholesterol by 10-15% when moving to a healthy diet and lifestyle.
Plant sterols should always be included as part of a healthy diet and lifestyle (a healthy diet is the same as a cholesterol-lowering diet) and not instead of.
References:
Jenkins et al., Curr Opin Lipidol.
Weggemans & Trautwein, Eur J Clin Nutr.
Katan MB, Grundy SM, Jones P, Law M, Miettinen T, Paoletti R; Stresa Workshop Participants. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Mayo Clin Proc 2003 Aug; 78(8): Review
Clarke R, Frost C, Collins R, Appleby P, Peto R. Dietary lipids and blood cholesterol: quantitative meta-analysis of metabolic ward studies. BMJ 1997; 314(7074): 14

15. International health authorities approve and support plant sterol-enriched foods
EU regulations – Novel Foods
FDA GRAS (Generally Regarded as Safe), US
Australia New Zealand Food Authority approved
Bundesamt fur Gesundheitswesen, Switzerland
Ministry of Agriculture, Brazil
Directorate of Food Control, South African
FOSHU, Japan
Plant sterols are natural components of a normal diet. Plant sterols are known to be safe through a long history of consumption. The safety of consuming high intakes of plant sterols to lower has been extensively studied since the 1950’s and reviewed by independent experts and regulatory authorities internationally.
References:
Safety of long-term consumption of plant sterol esters-enriched spread. Hendriks HFJ et al; Eur J of Clin Nutr. 2003; 57(5):
Noakes et al Am J Clin Nutr 2002

16. Dietary Guidelines
Many International and National organisations now include consumption of 2g of plant sterols (or stanols) daily in their recommendations for cholesterol management.

17. Dietary Guidelines - NCEP ATP III
Therapeutic Lifestyle Changes
Weight reduction
Increase physical activity
Total fat intake: 25-35% of energy
Reduce saturated fat intake (<7% of energy)
Reduce cholesterol intake (<200 mg/day)
Additional options for LDL-cholesterol lowering
Plant sterols/stanols (2g/day)
Soluble fibre (10-25g/day).
The Recommendations of the US National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) and its update are well recognised guidelines for the management of cholesterol in adults. Plant sterols and stanols are included in their guidelines.
Reference: NCEP Expert Panel, JAMA 2001 and CIRC 2004

18. Dietary Recommendations – IAS
Reduce saturated fats to <7% of total energy
Keep intakes of trans fatty acids low
Maintain n-3 fatty acid intake (in the form of alpha-linolenic acid) to at least 1% of total energy (2-3g/day)
Fish oil supplements for high risk patients are optional (EPA+DAH of 1g/day)
Reduce dietary cholesterol to <200mg/day
Increase viscous fibre, if possible to 10g/day
Consume at least five servings of fruits and vegetables daily
Ensure adequate intake of folic acid ( mg/day)
Avoid excess intake of alcohol. Limit consumption to no more than 20-30g/day (men) and 10-20g/day (women)
Consider adding plant sterol/stanol (2g/day) for elevated LDL-cholesterol.
Plant sterols and stanols are included in the International Atherosclerosis Society Guidelines
Reference: International Atherosclerosis Society, 2003

19. Summary of cholesterol-lowering of plant sterols
Reproducible, robust effects
Sustained with longer-term use
Independent of the background diet (typical Western or low-fat)
Proven compliance and efficacy in free-living populations (adults and familial hypercholesterolemia children)
Additive effect to low saturated fat, low cholesterol lipid-lowering diet
Additive effect to lipid-lowering medication (statins and fibrates)
HDL-cholesterol not lowered
Included in dietary guidelines.

20. Thank you Questions?