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Plant stanol and sterol containing foods further lower blood cholesterol in patients treated with statin medication

  • Plant stanols/sterols work in a different way to statins and can help people who take statin medication achieve further cholesterol reduction
  • Current expert advice supports a lower the better strategy for blood cholesterol
  • Healthy diet is an important factor for reducing cardiovascular disease risk

A new systematic review of the current literature combined with a detailed meta-analysis has further confirmed that plant stanol/sterol-containing foods can add additional cholesterol lowering benefits for people already on statin therapy.

Data from a total of 500 participants was analysed from 15 suitable randomized controlled trials (RCTs) published between 1996 and December 2015. Intervention lasted from 4 to 85 weeks with a median intervention of 6 weeks. Plant sterol/stanol intake ranged from 1.8 to 6 g/d with a median intake of 2.5 g/d.

The results showed that in addition to the cholesterol lowering effect of the statin a further 0.30 mmol/l reduction in both total cholesterol and low-density lipoprotein (LDL) cholesterol could be achieved with foods containing added plant sterols/stanols. High-density lipoprotein (HDL) and triglycerides remained the same.

Overall, the results of this new meta-analysis are fully comparable to the previously reported findings from the meta-analysis by Scholle et al (Scholle et al, J Am Coll Nutr, 2009).

Plant sterols/stanols lower LDL-cholesterol by inhibiting intestinal cholesterol absorption, while statins lower serum LDL-cholesterol by inhibiting cholesterol synthesis, mainly in the liver. Because plant sterols/stanols and statins work through different, complementary mechanisms, this leads to the described additive beneficial cholesterol-lowering effect.

In line with the “lower the better” strategy advocated by leading health authorities such as the American College of Cardiology and the American Heart Association (ACC-AHA) and the European Atherosclerosis Society (EAS), such extra reduction in cholesterol may further reduce the risk of cardiovascular disease (CVD).

This meta-analysis gives important evidence of an additional benefit in terms of cholesterol reduction that can be gained from using plant sterols/stanols in combination with statin medication. This will also be useful in treating patients who fail to achieve LDL-C targets or are statin intolerant, a target population for whom plant sterols/stanols is considered as described in the EAS consensus panel paper (Gylling et al Atheroscleosis 2014). This is in keeping with current guidelines that place diet and lifestyle modification at the cornerstone of CVD risk reduction.

For further information see Han S., Jiao J., Xu J. et al. 2016 Effects of plant stanol or sterol-enriched diets on lipid profiles in patients treated with statins: systematic review and meta-analysis. Sci. Rep. 6, 31337;doi: 10.1038/srep31337.

Study shows the cholesterol-lowering efficacy of plant stanols in a new type of food supplement

  • A new study shows that a chewable food supplement with added plant stanol esters can be used to help reduce elevated blood cholesterol levels
  • Plant stanols work by reducing the absorption of cholesterol from the gut by displacing cholesterol from the mixed micelles (vehicles that carry fat, bile and cholesterol) in the gut
  • The new chewable food supplement is easy to use and no side effects were reported

Researchers in Finland have studied a new format of a supplement with added plant stanols for blood cholesterol management.

A new, sugar-free chewable and easy to swallow food supplement with added plant stanols was studied in a recent randomized, double-blind, controlled trial with results showing that it is both easy to use and effective in reducing serum total and LDL cholesterol.

This chewable supplement is based upon emulsified plant stanol esters in a gelled water matrix that allows effective release of the plant stanol esters from the product matrix and enables it to mix with emulsified fat in the stomach. In order to displace cholesterol from mixed micelles in the gut, plant stanol esters are hydrolysed by enzymes in the gut into free plant stanols. Release of bile in the upper part of the small intestine triggered by a meal is required allowing free plant stanols to displace cholesterol from the formed mixed micelles in the gut, the underlying mechanism involved in inhibiting cholesterol absorption. This process requires the plant stanol supplement to be consumed with a meal in order to be effective.

The study recruited 131 moderately hypercholesterolemic volunteers and randomised 110 of them into two study groups. The participants were asked to consume four pieces of the test supplement each day, a dose of 2g plant stanols for those in the active arm, consumed at two meals.  The participants kept a  diary on the intake of the test supplements including any symptoms.

The results showed that after four weeks of taking the supplement LDL cholesterol concentration was reduced by an average of 7.6% when compared with the control group. Total serum cholesterol was lowered by 4.9% and non-HDL cholesterol by 6.6%. HDL cholesterol and serum triacylglycerol remained unchanged.

No side effects were reported and 78% of the responders rated it easy or very easy to use this supplement. The taste of the supplement was described as good or very good by 68% of the participants making it a practical as well as a convenient solution for long term use.

This study is important because it supports the cholesterol-lowering benefit of plant stanols administered in the format of a newly developed chewable and easy to swallow food supplement. Furthermore, this new study supports the overall available evidence that food supplements with added plant stanols/sterols can play a role in lowering elevated serum cholesterol concentrations

Laitinen K, Gylling H and Kaipiainen et al Journal of Functional Foods 2017 30 119-124

Current evidence suggests plant-based diets reduce the risk of cardiovascular disease, type 2 diabetes and obesity

  • A review of the current evidence indicates that plant-based diets can reduce the risk of cardiovascular disease and type 2 diabetes by around 20-25%.
  • Plant-based diets can also help with weight management; they have a low energy density and are high in fibre. Fibre can help with feelings of fullness and thus improve satiety.
  • A move towards including more plants in the diet appears to be the most important factor for these health gains rather than trying to adhere to a totally vegetarian or even vegan diet.

Harland and Garton searched the published literature from January 2015 to August 2016 in order to understand if plant-based diets have an impact on the incidence of or risk factors for cardiovascular disease (CVD), type 2 diabetes (T2D) and obesity.  A plant-based diet is one in which there is an emphasis on plant foods rather than an exclusion of all animal products. This can include vegetarian, vegan, Mediterranean and combination diets. Recent research findings from meta-analyses, European cohort studies and randomised controlled trials (RCTs) were studied in the review.

They discovered that plant based diets are associated with a 20-25% lower risk of developing CVD or T2D. Risk factors for developing these metabolic diseases such as total cholesterol, low-density lipoprotein-cholesterol and blood pressure were lower in those on a plant based diet.

Better overall weight management was achieved with a plant based diet compared to a calorie controlled diet and a higher intake of plant-based foods is associated with a lower BMI and a smaller waist circumference.

Portfolio or combination diets are plant-based diets that further focus on specific plant foods or plant-based ingredients that have been shown to reduce blood cholesterol such as soya, nuts, soluble fibre (such as oats and psyllium) and foods with added plant stanols and stenols, Such type of diets also lower high blood pressure such as the DASH eating plan. The DASH diet is plant-based with an emphasis on vegetables, fruit, whole grain cereals, legumes, seeds and nuts. It includes low fat dairy products and lean proteins such as poultry and fish. It is low in fat, red meat and sugar-containing food and drink. Combination diets can contribute to a reduction in the risk factors for CVD and diabetes.

When compared with “Western” diets plant-based diets have higher unsaturated fats and fibre and lower saturated fats and energy density. Plant-based diets are also high in antioxidant vitamins and phytonutrients. It may be these qualities that are responsible for the health benefits found with plant based foods or it could be that eating more plants in the diet is of benefit in its own right. People with plant-based eating patterns tend to have healthier blood lipid-profiles, better glucose management, reduced blood pressure and lower biomarkers of inflammation in their body. As well as this plant-based diets are more sustainable for our environment.

Harland J and Garton L 2016 An update of the evidence relating to plant-based diets and cardiovascular disease, type 2 diabetes and overweight. Nutrition Bulletin, 41, 323-338

Diet at the heart of CVD Prevention – an e-learning module

  • A newly updated e-learning module is available to assist healthcare professionals to enable patients to make changes to their diet that will help them reduce their CVD risk
  • World leaders in the field of diet and cardiovascular risk reduction have contributed to this easy to use, practical tool
  • Extra resources to use with patients in the clinic and case studies to facilitate discussion with colleagues make it easy to translate the learning into practice

A newly updated e-learning tutorial can help primary healthcare professionals promote a healthy diet for reducing cardiovascular disease (CVD) risk. Designed and developed in collaboration with the European Atherosclerosis Society (EAS), and world leaders in the field of diet and cardiovascular health the tutorial aims to provide the knowledge required to enable people to make diet and lifestyle changes that will reduce their long-term risk of CVD. The tutorial is endorsed by the EAS.

The second updated version of the tutorial now provides a comprehensive knowledge base about the role different foods and food ingredients play on blood cholesterol management. The easy-to-read sections explain the science behind the foods that can actively reduce cholesterol. The information is presented in a way that makes it accessible not only to health care professionals but also for anyone with a keen interest in this area.

The tutorial has eight different sections covering everything from CVD risk factors, healthy dietary patterns, the role of dietary fats, plant sterols/stanols, dietary fibre and soy protein in dyslipidaemia management, other lifestyle changes for CVD prevention and motivational interviewing.  Videos and diagrams further enhance the overall learning experience.

Case studies are provided with detailed three-step approaches to help clinicians manage common problems; for example, a patient with high CVD risk who is reluctant to start statin medication. A short test can be used to check knowledge levels pre-and post-tutorial. Health care professionals can use this tutorial as part of their revalidation and the knowledge test and / or case studies could be used to help them reflect on their own practice and what changes they may make as a result of their learning. The tutorial can be used by individuals but would also lend itself well to group work and the detailed case studies could be discussed with colleagues.

Another excellent feature of this e-learning tool are the downloadable leaflets such as a foods diary, tips for healthy cooking or a “what should I eat” factsheet. This will help clinicians translate the knowledge gained into practice,

Diet at the heart of CVD prevention version 2.0 is supported by BASF, Raisio and Unilever and is freely available at

New EAS Consensus Statement:Causal role of LDL-cholesterol in atherosclerotic cardiovascular disease (ASCVD)

During the 85th EAS congress in Prague, the European Atherosclerosis Society (EAS) announced the publication of a new Consensus Statement, which confirms the causal role of LDL-cholesterol (LDL-C) in the development of atherosclerotic cardiovascular disease.

The consensus panel states that „consistent evidence from numerous and multiple different types of clinical and genetic studies unequivocally establishes that LDL causes ASCVD“. The conclusion of the panel was based on a meta-analysis of more than 200 prospective cohort studies, Mendelian randomization studies and randomized controlled trials, including in total over 2 million participants and more than 20 million person-years of follow-up and over 150 000 cardiovascular events.

With the new consensus statement, it has been confirmed that LDL is not only a biomarker, but a causal factor for CVD. There is a consistent dose-dependent log-linear association between LDL C levels and cardiovascular risk, thus it is of key importance to minimize the cumulative exposure to LDL. Lowering LDL cholesterol starting in early life will be a major opportunity to reduce the lifetime risk of a cardiovascular event.

With this message, the pivotal role of a healthy diet and lifestyle will further move to the focus of early prevention, since it is the only strategy that can be safely implemented on a population level from early life.

For more information on the new EAS Consensus Statement, please visit:

The importance of early lowering of blood cholesterol was highlighted at the 85th Congress of the European Atherosclerosis Society held in Prague, Czech Republic April 23-26, 2017

A key ‘take home’ message from the 85th EAS congress in Prague is that the lower LDL-cholesterol (LDL-C) is, the better, and that the earlier LDL-cholesterol is reduced, the better.

This message was especially emphasized in the session entitled “Progress in understanding the role of nutrition in prevention of atherosclerosis” where the key role of diet (and lifestyle) in LDL-cholesterol lowering was highlighted by three internationally renowned speakers.

Brian A Ference from the USA explained that when blood LDL-cholesterol is kept low throughout life, cardiovascular diseases (CVD) can be prevented much more effectively than when already elevated cholesterol levels are reduced later in life with e.g. cholesterol-lowering medication. Diet plays a crucial role in this early cholesterol management since a healthy diet and lifestyle are the only cholesterol-lowering means that can be safely implemented in a population from early life.

Ursula Schwab from Finland talked about the Mediterranean diet, the best-known heart-healthy dietary pattern recognized for not only improving risk factors for CVD, but also shown to reduce CVD events. Prof Schwab further talked about the Nordic diet, as another heart healthy diet pattern that utilizes healthy food items that are found locally and commonly consumed in Nordic countries.  Both diet patterns are evidence-based and they both emphasize the consumption of vegetables, fruit and berries, vegetable oils and spreads rich in unsaturated fats, fish and lean meat, whole grains, as well as fat-free or low-fat milk products.

Gabrielle Riccardi from Italy reviewed the latest dietary recommendations included in the recent European guidelines on the management of dyslipidemia (2016 EAS/ESC guidelines). He stressed the importance of following a healthy diet for individuals who have normal or mildly elevated cholesterol levels but also for patients who already need cholesterol-lowering medication. Diet and lifestyle advice should always form the foundation of CVD prevention and treatment.  As described in the European guidelines, Prof Riccardi also referred to the impact of specific dietary interventions to reduce LDL-cholesterol levels and in this context recommend foods with added plant stanols or sterols for an additional benefit above a cholesterol-lowering diet.

The 85th EAS congress gathered more than 2400 researchers, clinicians, students, and industry representatives to Prague. The role of a healthy diet and lifestyle in CVD prevention and blood cholesterol management was emphasized throughout the congress, in a plenary session and a special session on Nutraceuticals for early control of dyslipidaemia.  The role that plant sterols and stanols can play as part of a cholesterol-lowering diet was highlighted by several speakers.

For more information about the 85th EAS congress, see

2016 ESC / EAS Guidelines for CVD prevention and dyslipidaemias management published

The European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) have published respectively their 2016 European Guidelines on cardiovascular disease (CVD) prevention in clinical practice (Piepoli et al Eur Heart J 2016; doi:10.1093/eurheartj/ehw106) and their Guidelines for the management of dyslipidaemias (Catapano, Graham, deBacker, Wiklund et al. Eur Heart J 2016 (doi:10.1093/eurheartj/ehw272 and Atherosclerosis 253 (2016) 281e344)

CVD prevention is seen as effective in reducing the impact of CVD whilst the elimination of health risk behaviors would make it possible to prevent at least 80% of CVD. The guidelines consider a lifetime approach and hence people of all ages should be encouraged to adopt or sustain a healthy diet and lifestyle.

The 2016 ESC/EAS guidelines strongly emphasize the importance of CVD prevention both in the general population, by promoting healthy lifestyle behavior, and at  individual level as in those population groups at moderate to high risk of CVD or in patients with established CVD. By tackling  unhealthy lifestyles (e.g. poor-quality diet, physical inactivity, smoking) and by reducing increased levels of risk factors such as elevated blood cholesterol or blood pressure these groups can significantly benefit from reducing the risk of either developing CVD or of aggravating their existing condition.

The Guidelines reemphasize that LDL-cholesterol is the primary treatment target for CVD prevention. This affirms the IPSSAview that it is crucial for people to be aware of their blood cholesterol and in particular their LDL-cholesterol levels, a key risk factor in the development of CVD.  Blood cholesterol can be easily measured through a simple blood test (see also our related Press Release below );

Regarding a healthy diet, the guidelines recommend a diet low in saturated fat with a focus on wholegrain products, vegetables, fruit and fish. Further, the guidelines outline in detail specific diet and lifestyle interventions that reduce LDL-cholesterol levels.

The table below gives a clear picture of the impact lifestyle changes can make on LDL-cholesterol levels where more “+” mean higher efficiency of intervention in LDL-cholesterol lowering, while level of evidence A refers to data derived from multiple randomized clinical trials or meta-analyses and level of evidence B indicates data derived from a single randomized clinical trial or large non-randomized studies.


Regarding functional foods for the treatment of dyslipidaemias, the Guidelines specifically outline the role of foods with added plant sterols and stanols. Specifically, they affirm that the daily consumption of 2 g of plant sterols or stanols can effectively lower LDL-cholesterol by 7-10% in humans.

Furthermore, the Guidelines refer to target groups for whom plant sterols/stanols may be considered such as

  • individuals with high cholesterol levels at intermediate or low global CVD risk who do not qualify for drug therapy
  • as an adjunct to drug therapy in high- and very high-risk patients who fail to achieve LDL-cholesterol goals on statins or are statin intolerant
  • in adults and children (>6 years) with familiar hypercholesterolemia (FH), in line with current guidance

IPSSA has always supported that foods with added plant sterols and stanols as part of a healthy diet and lifestyle can contribute significantly to lowering  LDL-cholesterol, which constitute a major risk factor for CVD.  The cholesterol-lowering effect of plant sterols and stanols has been proven in a vast number of clinical studies, which formed the basis of authorized health claims by international regulatory bodies in many countries around the world. The cholesterol-lowering benefit is further recognized in many guidelines for the management of dyslipidaemias of leading societies such as in the recently published 2016 Guidelines of these two leading European societies.


Successful 3rd International Plant Sterols/Stanols Health and Disease Conference in Winnipeg

The 3rd international Plant Sterols/Stanols, Health and Disease Congress was held in Winnipeg, Canada, on September 29th – October 1st, 2016. The congress gathered together scientists, clinicians, and industry representatives from Europe and North America. The congress programme included several sessions addressing a range of topics including presentations on the LDL-cholesterol lowering effect and other potential beneficial health effects of plant sterols and plant stanols , plant sterol/stanol analytics, and the role of foods with added plant sterols and stanols in the management of hypercholesterolemia. Another key topic of the congress was the rare inherited condition called sitosterolemia, which was discussed both from clinical and patient perspectives. All congress presentations were of high quality and the discussion and interaction amongst conference participants were very active. IPSSA was one of the supporters of this congress. The proceedings of the congress will be published in due course.

For more details on the program and the speakers, please visit the conference homepage

New meta-analysis estimating the effects of plant sterols/stanols on plasma fat-soluble vitamins and carotenoids demonstrates that the intake of sterols/stanols is not leading to undesirable effects

The LDL-cholesterol lowering benefit of plant sterols/stanols is well established and including foods with added plant sterols/stanols into a cholesterol lowering diet is a common practice for many people. Plant sterols/stanols lower LDL-cholesterol by inhibiting cholesterol uptake (absorption) from the gut. Questions are sometimes raised whether plasma concentrations of fat-soluble vitamins and carotenoids are also affected by plant sterol/stanol consumption since their uptake follows that of cholesterol.

A new paper, ‘Plasma fat-soluble vitamin and carotenoid concentrations after plant sterol and plant stanol consumption – a meta-analysis of randomized controlled trials’
Baumgartner et al. Eur J Nutr (2016). doi:10.1007/s00394-016-1289-7 (available in open access), investigated the effect of plant sterol/stanol intake on plasma fat-soluble vitamins (i.e. vitamins A, E and D) and carotenoids concentrations (α- and β-carotene and others) to provide an up-to-date quantitated overview based on a meta-analysis of 41 randomized controlled studies including 3,306 individuals.

Plasma concentrations of vitamins A and D were not affected; neither were cholesterol-standardized concentrations of vitamin E.

Cholesterol-standardized concentrations of α- and β-carotene and lycopene decreased by 6 to 10%. Overall, the observed changes were modest and within normal ranges.

Therefore, the intake of foods with added plant sterols/stanols is not leading to undesirable effects as new evidence shows that plasma carotenoid levels remain within normal ranges after consumption of these foods.

Furthermore, the modest changes in blood carotenoid concentrations being within typical inter-individual variation are considered physiologically insignificant. A sufficient intake of fruit and vegetables as part of a healthy diet accompanying the consumption of foods with added plant sterols/stanols also prevents modest reductions in plasma carotenoid concentrations.

New review article emphasizes the role and lifestyle intervention in reducing blood LDL-cholesterol

A recent paper authored by Riccardi et al and published in the Current Cardiology Reports (July 2016 18:66) reviews the role of lifestyle modifications to control high blood LDL-cholesterol.

The article summarises the evidence of implementing lifestyle modifications such as physical activity and diet – including the role of functional foods with added plant sterols and stanols – in reducing blood LDL-cholesterol, a major risk factor for the development of cardiovascular disease (CVD) which is a significant public health threat.

The article highlights association between the consumption of foods with added plant sterols/stanols with a significant reduction in LDL-cholesterol. Therefore, plant sterols and stanols have a significant role to play in managing LDL-cholesterol levels in people whose absolute risk for developing CVD does not qualify for pharmacotherapy.

Conversely, for people with high risk for developing CVD and in need of pharmacotherapy, the research cited in the article finds that introducing plant sterols and stanols in the daily diet provides an additional beneficial effect in reducing their LDL-cholesterol levels.

Additionally, the article demonstrates that a switch to a heathy diet low in saturated fat and the addition of dietary fibre and foods with added plant sterols and stanols can lead to a reduction in LDL-cholesterol levels of 30-35% which is a substantial effect.

The abstract of the article is available for free here and here