Commentary on Phytosterol-added Foods

Focus on lifestyle: EAS Consensus Panel Position Statement on Phytosterol-added Foods

Lifestyle underpins the prevention of cardiovascular disease (CVD). The escalating burden of obesity and diabetes provides impetus for further emphasis on lifestyle preventive measures. Diet is clearly critical; indeed, new data from the Nurses’ Health Study and Health Professionals Follow-up Study provide support for the value of nut consumption in the diet (see below).1

However, are there possibilities for improving the CV risk profile with inclusion of innovative nutritional strategies, so-called functional foods, in the diet? Interest has focused on the role of foods with added plant sterols or plant stanols (often referred to as phytosterols), given the consistent evidence that inclusion of these foods in the diet can lower plasma levels of low-density lipoprotein cholesterol (LDL C) by 8-10%.2-4 The European Atherosclerosis Society (EAS) recently convened a Consensus Panel to appraise evidence for the benefit to risk relationship of foods with added plant sterols and/or plant stanols, as components of a healthy lifestyle, to reduce plasma LDL-C levels, and potentially lower CV risk. The Consensus Statement is now published online in Atherosclerosis,5 with key findings summarised here.

What are plant sterols and plant stanols?

Plant sterols/stanols are natural components of the diet. The main sources of plant sterols are vegetable oils, spreads and margarines, breads, cereals, vegetables and to a lesser extent fruit. The average daily intake of plant sterols is 300 mg; the daily intake of plant stanols is much lower (17-24 mg), mainly from cereals.6 These levels are insufficient for any significant LDL-C lowering effects.

Why do foods with added plant sterols/stanols lower LDL-C?

Plant sterols and plant stanols are metabolised in the small intestine via a 3-step process involving 1) a solubilisation step, essential for entry of sterols into the absorptive cell; 2) uptake into the enterocyte, facilitated by the general sterol transporter protein Niemann-Pick C1-Like1 (NPC1L1); and 3) transport back into the gut lumen via the ATP-binding cassette co-transporters G5 and G8 (ABCG5/ABCG8). The plant sterols and stanols can compete with cholesterol (dietary and biliary) for absorption by the small intestine at each the first two steps; the third step allows for excretion of plant sterols and stanols, thereby maintaining very low levels of each in blood and tissues. Understanding of this process provides the rationale for consumption of foods with added gram quantities of plant sterols/stanols (~2 g/day). At these recommended intakes, there is significant inhibition of cholesterol absorption and lowering of plasma LDL-C levels by 8-10%. Similar lowering of plasma LDL-C levels was observed in trials of children with familial hypercholesterolaemia (FH).7-10

Benefit versus risk considerations

Do plant sterols/stanols accumulate in tissues?

A key issue addressed by the Consensus Panel was the benefit versus risk for inclusion of foods with added gram quantities of plant sterols/stanols in the diet. The available evidence suggests that in healthy human subjects following consumption of these supplemented foods the relative proportions of cholesterol versus sterol/stanol levels are similar in plasma and tissues; levels of sterols/stanols are 500-/10,000-fold lower than those of cholesterol both in plasma and tissues. These data are also consistent with the absence of preferential accumulation or retention in tissues. However, the Panel recognises the need for further study to exclude the possibility that consumption of dietary plant sterols/stanols might result in accumulation in arterial tissues.

Are plant sterols/stanols atherogenic?

The EAS Consensus Panel appraised multiple lines of evidence to address this issue.

In animal models of atherosclerosis, protective effects of supplemental plant sterols and stanols were observed, including reduction in arterial lipid accumulation, and inhibition of lesion formation and progression, despite increases (up to 10-fold) in plasma plant sterol/stanol concentrations (reviewed by Kritchevsky and Chen, 2005).11 However, the Panel does recognise the limitations of such models, in particular the use of high intakes for short duration and recommends the need for studies using physiological intakes. Furthermore, on the basis of limited cell-based data, the Panel cannot exclude the possibility that plant sterols affect the function of cells involved in the development of atherosclerosis, such as endothelial cells, monocytes and macrophages under resting and ’activated‘ conditions in vitro, ex vivo and in vivo, or have significant effects on biochemical surrogate markers of atherosclerosis.

Studies in humans have shown no significant, consistent effects on vascular or endothelial function during short and mid-term plant sterol or plant stanol intake. It is, however, important to bear in mind that the these studies were limited by small numbers of subjects, short duration of intake, and that several studies included individuals at low CV risk with normal vascular function at baseline. Taken together, the data provide no indication that dietary supplementation with plant sterols/stanols is associated with either benefit or harm to vascular function.

Mendelian randomisation studies do not provide evidence of harm associated with circulating plasma levels of plant sterols. Alleles in the ABCG8 gene, which are associated with moderate elevations of circulating plant sterols, showed a positive association with prevalent coronary artery disease.12,13 However, the increase in risk was explained by the association of these ABCG8 variants with increased intestinal cholesterol absorption, as reflected by circulating cholestanol levels, and with increased LDL-C plasma concentration, rather than circulating levels of plant sterols.14,15

Finally, issues have been raised about the possible atherogenicity of plant sterols/stanols given the link between phytosterolaemia, a condition involving severe loss of function mutations in genes coding for the ABCG5/ABCG8 transporters resulting in marked elevation in plasma plant sterol/stanol levels, and premature atherosclerosis. However, it is important to note that manifestation of atherosclerosis in these individuals is variable, and not all patients develop atherosclerosis (E. Bruckert, privileged communication). Indeed, evidence suggests that the presence of premature atherosclerosis in these individuals may depend on whether there is co-existing severe hypercholesterolaemia. Finally, it should be emphasised that this rare genetic disease is beyond the scope of recommended intake of added plant sterols/stanols (2 g/day) as part of a healthy diet for prevention of CVD.

In conclusion, there is a gap in the current evidence-base due to the lack of randomised, controlled clinical trials of sufficient duration with hard end-points. These are needed to definitively evaluate the effects of foods with added plant sterols or plant stanols on CVD outcomes.

Are plant sterols/stanols safe in the long-term?

At the recommended daily intake of 2 g/day, the available evidence does not suggest any adverse effect associated with long-term intake. Rather, evidence from animal and cell studies suggests a protective role of plant sterol intake and risk of certain cancers.16,17 Epidemiological data also associate reduced risk of certain cancers with plant sterol intakes (e.g., stomach and lung cancer).18,19

Modest suppression of plasma carotenoid levels (by 10%) observed during consumption of foods with added plant sterols/stanols can be countered by increasing consumption of fruits and vegetables.20

As mentioned above, long-term randomised, controlled clinical trial data are needed to definitively establish the safety of foods with added plant sterols or plant stanols.

Do plant sterols/stanols have other lipid effects?

There is some evidence that consumption of foods with added plant sterols/stanols (2 g/day) also modestly lower triglycerides (by 6-9%) in subjects with elevated triglycerides,21 although further study is needed.

What role do foods with plant sterols/stanols have in clinical practice?

The key recommendations of the EAS Consensus Panel are summarised in Table 1.

Table 1.
Key recommendations of EAS Consensus Panel on Phytosterols
Daily consumption of foods with added plant sterols and/or plant stanols (up to 2 g/day) lowers plasma LDL-C levels by up to 10%. Therefore inclusion of these foods may be considered as an adjunct to lifestyle in the following groups:

• Subjects with high cholesterol levels at intermediate or low global CV risk who do not qualify for pharmacotherapy

• 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

• Adults and children (>6 years) with FH, in line with current guidance. The recent EAS Statement on FH states that functional foods known to lower LDL-C, such as plant sterols and stanols, may be considered as part of lifestyle management.22

However, the cost of these products is also relevant when considering their use. Data from the UK (2005) indicate that the cost/kg of foods with added plant sterols can be 1.3- to 4-fold higher than that of their conventional counterparts,23 which can be a deterrent to their use. Indeed, data from the PrediMed study24 show that economic difficulties in Southern Europe appear to have a detrimental effect on adherence to a Mediterranean diet. Clearly, the cost issue warrants discussion between practising physicians and their patients.

Outstanding issues

It is clear that that we need a well-designed and adequately powered study of the effects of foods with added plant sterols/stanols on CVD outcomes. While the EAS Consensus Panel recognises that there are considerable practical issues, it is clear that only the conduct of such a study, with associated pharmacoeconomic analyses, will fully resolve outstanding questions regarding the role of these foods in CVD prevention. This Consensus view is also consistent with that of the Joint European Society of Cardiology/EAS guidelines for management of dyslipidemia.25

The reader is referred to the Full Position Statement (in press) which is available at

More evidence for eating nuts

There is accumulating evidence for the benefits of nut consumption as part of a healthy diet. Nuts contain a number of bioactive substances, including unsaturated fatty acids, fibre, vitamins, minerals, phenolic antioxidants and phytosterols.26 Thus, by virtue of their unique composition, nuts may beneficially impact health, potentially via effects on blood cholesterol, hyperglycaemia, insulin resistance, oxidative stress, inflammation or endothelial dysfunction.27-31 Regular nut consumption has also been associated with a reduced risk of type 2 diabetes mellitus or metabolic syndrome.32,33

A key question, therefore, is whether such effects may translate to reduction in mortality? Recently published findings from the Nurses’ Health Study and Health Professionals Follow-up Study now provide some insights into this challenging issue.1

This report evaluated data from these two studies including 76,464 women (Nurses’ Health Study) followed over the period 1980–2010, and 42,498 men (Health Professionals Follow-up Study), followed over the period 1986–2010. Subjects with a history of cancer, heart disease, or stroke were excluded from analyses. The studies evaluated nut consumption at baseline and every 2 to 4 years using validated food-frequency questionnaires. In 1980 and 1984 (Nurses’ Health Study) subjects were also asked how often each week they had consumed 1 oz of nuts (one serving), and this was later modified to include information on peanuts versus other nuts.

The primary endpoint of the study was death from any cause. There were 16,200 deaths over 30 years of follow-up of women in the Nurses’ Health Study and 11,229 deaths over 24 years of follow-up of men in the Health Professionals Follow-up Study. In both studies, there was a significant, dose-dependent inverse association between nut consumption and total mortality, after adjusting for potential confounders. Notably, daily consumption of nuts was associated with 20% reduction in all-cause death (pooled multivariate hazard ratio versus subjects who did not eat nuts 0.80, 95% CI, 0.73 to 0.86, p<0.0.001 for trend). Eating nuts at least 5 times per week also significantly reduced the risk of CV death by 25% (p<0.001) (Table 2).

While the authors acknowledge that the observational nature of these studies does not permit definitive conclusions regarding cause and effect, they highlight the strengths of the report. These include prospective design, large sample size, long duration of follow-up with low dropout rates and repeated assessment of diet and lifestyle. Additionally, while the food-frequency questionnaire was self-reported and therefore potentially subject to measurement error, nut consumption was relatively constant for individuals over the follow-up period.

Table 2.
Key implications of the Nurses’ Health Study and Health Professionals Follow-up Study
• Data from these two prospective cohort studies involving a large number of men and women and extended duration of follow-up showed significant inverse associations of nut consumption with all-cause and cause-specific mortality, including CV death.

• Added to an accumulating evidence-base, these findings suggest a role for including a small serving of nuts (1 oz or ~30 g) in the daily diet, as part of a healthy lifestyle.

Finally, the findings of this study are broadly consistent with those from the PrediMed study which showed that for high-risk primary prevention patients, a Mediterranean diet supplemented with ~1 oz nuts (15 g of walnuts, 7.5 g of hazelnuts and 7.5 g of almonds) significantly reduced the risk of CV events by 28% (p=0.03), almost entirely due to an effect of stroke.34

Taken together, these findings reinforce the critical role of dietary intervention, as part of a healthy lifestyle, as the fundamental first step in preventing CVD. The EAS Consensus Panel on Phytosterols Position Statement also suggests a potential role for functional foods across the spectrum of CV risk, although there is clearly a need for randomised controlled clinical trial data for definitive conclusions.


  1. Bao Y, Han J, Hu FB et al. Association of nut consumption with total and cause-specific mortality. N Engl J Med 2013;369:2001-11.
  2. Katan MB, Grundy SM, Jones P et al. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Mayo Clin Proc 2003;78:965-78.
  3. Demonty I, Ras RT, van der Knaap HC et al. Continuous dose-response relationship of the LDL-cholesterol-lowering effect of phytosterol intake. J Nutr 2009;139:271-84.
  4. Musa-Veloso K, Poon T H, Elliot JA, Chung C. A comparison of the LDL-cholsterol efficacy of plant stanols and plant sterols over a continuous range: Results of a meta-analysis of randomized, placebo-controlled trials. Prostaglandins Leukot Essent Fatty Acids 2011;85:9-28.
  5. Gylling H, Jogchum Plat, Turley S, Ginsberg HN, Ellegård L, Jessup W, Jones PJ, Lütjohann D, Maerz W, Masana L, Silbernagel G, Staels B, Borén J, Catapano AL, De Backer G, Deanfield J, Descamps OS, Kovanen PT, Riccardi G, Tokgözoglu L, Chapman MJ for the European Atherosclerosis Society Consensus Panel on Phytosterols. Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis Epub 22 November 2013 [In Press, Accepted Manuscript].
  6. Valsta LM, Lemström A, Ovaskainen ML et al. Estimation of plant sterol and cholesterol intake in Finland: quality of new values and their effect on intake. Br J Nutr 2004;92:671-8.
  7. Becker M, Staab D, von Bergmann K. Treatment of severe familial hypercholesterolemia in childhood with sitosterol and sitostanol. J Pediatr 1993;122:292-6.
  8. Gylling H, Siimes MA, Miettinen TA. Sitostanol ester margarine in dietary treatment of children with familial hypercholesterolemia. J Lipid Res 1995;36:1807-12.
  9. Amundsen AL, Ose L, Nenseter MS, Ntanios FY. Plant sterol ester-enriched spread lowers plasma total and LDL cholesterol in children with familial hypercholesterolemia. Am J Clin Nutr 2002;76:338-44.
  10. Vuorio AF, Gylling H, Turtola H, Kontula K, Ketonen P, Miettinen TA. Stanol ester margarine alone and with simvastatin lowers serum cholesterol in families with familial hypercholesterolemia caused by the FH-North Karelia mutation. Arterioscler Thromb Vasc Biol 2000;20:500-6.
  11. Kritchevsky D, Chen SC. Phytosterols – health benefits and potential concerns: a review. J Nutr Res 2005;25:413-28.
  12. Teupser D, Baber R, Ceglarek U et al. Genetic regulation of serum phytosterol levels and risk of coronary artery disease. Circ Cardiovasc Genet 2010;3:331-9.
  13. CARDIoGRAMplusC4D Consortium, Deloukas P, Kanoni S, Willenborg C et al. Large-scale association analysis identifies new risk loci for coronary artery disease. Nat Genet 2013;45:25-33.
  14. Kathiresan S, Willer CJ, Peloso GM et al. Common variants at 30 loci contribute to polygenic dyslipidemia. Nat Genet 2009;41:56-65.
  15. Silbernagel G, Chapman MJ, Genser B et al. High intestinal cholesterol absorption is associated with cardiovascular disease and risk alleles in ABCG8 and ABO: evidence from the LURIC and YFS cohorts and from a meta-analysis. J Am Coll Cardiol 2013;62:291-9.
  16. Baskar AA, Ignacimuthu S, Paulraj GM, Al Numair KS. Chemopreventive potential of beta-sitosterol in experimental colon cancer model – an in vitro and in vivo study. BMC Complement Altern Med 2010;10:24.
  17. Woyengo TA, Ramprasath VR, Jones PJ. Anticancer effects of phytosterols. Eur J Clin Nutr 2009;63:813-20.
  18. De Stefani E, Boffetta P, Ronco AL et al. Plant sterols and risk of stomach cancer: a case-control study in Uruguay. Nutr Cancer 2000;37:140-4.
  19. Mendilaharsu M, De Stefani E, Deneo-Pellegrini H, Carzoglio J, Ronco A. Phytosterols and risk of lung cancer: a case-control study in Uruguay. Lung Cancer 1998;21:37-45.
  20. Noakes M, Clifton P, Ntanios F, Shrapnel W, Record I, McInerney J. An increase in dietary carotenoids when consuming plant sterols or stanols is effective in maintaining plasma carotenoid concentrations. Am J Clin Nutr 2002;75:79-86.
  21. Demonty I, Ras RT, van der Knaap HC et al. The effect of plant sterols on serum triglyceride concentrations is dependent on baseline concentrations: a pooled analysis of 12 randomised controlled trials. Eur J Nutr 2013;52:153-60.
  22. Nordestgaard BG, Chapman MJ, Humphries SE et al. Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: Consensus Statement of the European Atherosclerosis Society. Eur Heart J. 2013 Sep 12. [Epub ahead of print].
  23. European Food Safety Authority. A report from the data collection and exposure unit in response to a request from the European Commission. EFSA Journal 2008;133:1-21.
  24. Bes-Rastrollo M. Costs of Mediterranean and Western dietary patterns and their relationship with prospective weight change. EuroPRevent 2013;Abstract 610.
  25. Catapano AL, Reiner Z, De Backer G et al. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis 2011;217:3-46.
  26. Ros E. Health benefits of nut consumption. Nutrients 2010;2:652–82.
  27. Sabaté J, Oda K, Ros E. Nut consumption and blood lipid levels: a pooled analysis of 25 intervention trials. Arch Intern Med 2010;170:821-7.
  28. Jenkins DJ, Kendall CW, Josse AR, et al. Almonds decrease postprandial glycemia, insulinemia, and oxidative damage in healthy individuals. J Nutr 2006;136:2987-92.
  29. Jiang R, Jacobs DR Jr, Mayer-Davis E, et al. Nut and seed consumption and inflammatory markers in the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 2006;163:222-31.
  30. Casas-Agustench P, López-Uriarte P, Bulló M et al. Effects of one serving of mixed nuts on serum lipids, insulin resistance and inflammatory markers in patients with the metabolic syndrome. Nutr Metab Cardiovasc Dis 2011;21:126-35.
  31. Ma Y, Njike VY, Millet J et al. Effects of walnut consumption on endothelial function in type 2 diabetic subjects: a randomized controlled crossover trial. Diabetes Care 2010;33:227-32.
  32. Jiang R, Manson JE, Stampfer MJ et al. Nut and peanut butter consumption and risk of type 2 diabetes in women. JAMA 2002;288:2554-60.
  33. Fernández-Montero A, Bes-Rastrollo M, Beunza JJ et al. Nut consumption and incidence of metabolic syndrome after 6-year follow-up: the SUN (Seguimiento Universidad de Navarra, University of Navarra Follow-up) cohort. Public Health Nutr 2013;16:2064-72.
  34. Estruch R, Ros E, Salas-Salvadó J et al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279-90.