Plant Sterols / Stanols / Phytosterols
Brief description
Plant sterols or stanols are collectively known as phytosterols. They are naturally found in plant-based foods, including vegetable oils and grain products (breads, seeds, nuts, legumes, fruits and veg). A typical healthy diet will provide around 200-400mg.
“As part of our normal digestion, cholesterol-rich bile is emptied into the gut by the gall bladder and aids digestion by emulsifying the fat from our food. This cholesterol from the bile is normally reabsorbed into the blood further down the gut(1)”.
Phytosterols have a chemical structure like cholesterol. They bind to a structure in the gut (micelle) which block cholesterol absorption(2).
You can achieve 2g per day of plant stanol and sterol by consuming(3):
One plant stanol or sterol fortified mini yoghurt drink (one bottle) or yoghurt (one pot) per day which contains all the 2g recommended OR,
Two to three portions of foods with at least 0.8g of added plant sterol/stanol per day such as:
Two teaspoons (10g) fortified spread.
One fortified yoghurt
One glass (250ml) fortified milk.
Evidence base
Cholesterol: Multiple systematic reviews (SR) and meta-analyses reported plant sterols were able to significantly reduce LDL-C(4-8).
In the most recent (2023) SR of 125 studies(4), PS were able to reduce LDL-C by 0.55mmol/L (95%CI: 10.82-12.67). A greater reduction in LDL-C was found with higher doses of PS.
Another SR (2023), found PS also reduced total cholesterol (Weight Mean Difference (WMD) [95% CI] = -0.37 [-0.41, -0.34], p < 0.001), but not HDL or triglycerides(6).
In the earlier SR (2022), authors suggested PS to be effective for LDL-C concentrations >140mg/dL and with a dose of >2g/day(5).
Findings appeared to also extend to children and adolescents, hinting at the possibility hereditary high cholesterol could be in-part treated with PS. Authors found supplementation was able to reduce LDL levels by 10% with higher reductions >10% after 8-12 weeks. There was no change in HDL or triglycerides(9).
Recommended serving & duration.
Research has found doses higher than 2g per day convey the greatest reduction in LDL-C.
Safety & tolerability
Cholesterol is a controversial topic; you should seek advice from your healthcare professional regarding not opting for traditional approaches such as a statin. Studies have noted that in those with familial hypercholesterolaemia, it is necessary to combine diet with a statin. Risks of heart disease/stroke are much higher in this cohort.
These products are safe for individuals taking cholesterol-lowering drugs e.g. statins and fibrates. As those medications work in different ways, plant sterols can complement them.
If you’re taking Ezetimibe (Ezetrol) cholesterol-lowering medication, you should discuss with your doctor whether there is any additional cholesterol-lowering benefit for you to take stanols and sterols.
References
Plant sterols and stanols 2024 [Available from: https://www.heartuk.org.uk/healthy-living/flora-proactiv-2.
Kris-Etherton PM, Ohlson M, Bagshaw D, Stone NJ. CHAPTER 19 - Dietary Patterns for the Prevention and Treatment of Cardiovascular Disease. In: Ballantyne CM, editor. Clinical Lipidology. Philadelphia: W.B. Saunders; 2009. p. 217-31.
Stanols and Sterols 2024 [Available from: https://www.bda.uk.com/resource/food-facts-plant-stanols-and-sterols.html.
Fontané L, Pedro-Botet J, Garcia-Ribera S, Climent E, Muns MD, Ballesta S, et al. Use of phytosterol-fortified foods to improve LDL cholesterol levels: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis. 2023;33(8):1472-80.
Turini E, Sarsale M, Petri D, Totaro M, Lucenteforte E, Tavoschi L, et al. Efficacy of Plant Sterol-Enriched Food for Primary Prevention and Treatment of Hypercholesterolemia: A Systematic Literature Review. Foods. 2022;11(6).
Gao Y, Xun R, Xia J, Xia H, Sun G. Effects of phytosterol supplementation on lipid profiles in patients with hypercholesterolemia: a systematic review and meta-analysis of randomized controlled trials. Food Funct. 2023;14(7):2969-97.
Lôbo IMB, Bordallo COS, Sacramento JM, Leite LO, Santana PDS. Phytosterol supplementation in capsules or tablets as adjunctive treatment for hypercholesterolemia: A systematic review of randomized controlled trials. Clin Nutr ESPEN. 2023;57:718-29.
Barkas F, Nomikos T, Liberopoulos E, Panagiotakos D. Diet and Cardiovascular Disease Risk Among Individuals with Familial Hypercholesterolemia: Systematic Review and Meta-Analysis. Nutrients. 2020;12(8).
Mantovani LM, Pugliese C. Phytosterol supplementation in the treatment of dyslipidemia in children and adolescents: a systematic review. Rev Paul Pediatr. 2020;39:e2019389.
