Effect of plant sterols in combination with other cholesterol-lowering foods☆
Introduction
The National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines have emphasized the principle of maximal therapy for the management of low-density lipoprotein cholesterol (LDL-C) through adding viscous fibers and plant sterols to the original advice on reduction of saturated fat, dietary cholesterol, and body weight as the dietary prescription [1]. With these dietary changes, it has been estimated that 25% to 35% reductions in LDL-C can be achieved [2], [3]. The importance of maximizing cholesterol reduction has been further stressed in the ATP III update that, based on the success of statin trials in reducing coronary heart disease (CHD), advocates treating to a new optional target for LDL-C of less than 100 mg/dL (1.8 mmol/L) in high-risk subjects [4]. The United States Food and Drug Administration has also encouraged the development of cholesterol-lowering functional foods by allowing CHD risk reduction health claims for products containing plant sterols, viscous fibers, soy protein, and nuts [5], [6], [7], [8], [9]. Diets containing these elements have confirmed predicted lipid-lowering effects of 28% to 35% in LDL-C when they are combined in the same diet in what has been termed a dietary portfolio[10], [11], [12], [13].
However, it is not clear what cholesterol reduction each functional food component contributes to the overall cholesterol reduction observed and whether all ingredients have to be present.
We have therefore taken the opportunity to remove one element, plant sterols, from the diets of individuals who have been taking the combination diet (dietary portfolio) for 1 year to determine its effects on the previously observed reduction in serum cholesterol. Plant sterols were selected because they represent the component with possibly the largest effect, with 2 g resulting in 9% to 14% reduction in LDL-C [14], and for which more data are available than the other components.
Section snippets
Participants
Fifty-five subjects completed a 1-year ad libitum dietary portfolio study and were asked to forgo consumption of plant sterol–enriched margarine for 10 weeks, after which they were asked to continue for a further 18 weeks with plant sterol–enriched margarine reinstated in their diets. Forty-nine subjects were enrolled in the present study. Forty-two provided data on and off plant sterols, of whom 18 followed the protocol with no deviation in terms of complete attendance and diet records. Data
Results
For the 42 subjects, compliance for plant sterol–enriched margarine was 65.8% ± 4.3%, whereas for the non–plant sterol components (ie, viscous fiber, soy protein, and almonds), the combined compliance was 52.0% ± 3.7%. No significant change in the compliance of the non–plant sterol components was seen when plant sterol margarine was removed from the diet (combined compliance after plant sterol elimination was 49.9% ± 4.0%, P = .281). In the 18 subjects who adhered most completely to the study
Discussion
Plant sterol withdrawal from a cholesterol-lowering diet resulted in a reduction in the overall cholesterol-lowering effect of the diet of similar magnitude to that ascribed to plant sterols when administered as the sole cholesterol-lowering component. However, in compliant subjects, even when not consuming plant sterol–enriched margarine, substantial reductions in serum cholesterol can still be achieved through good adherence to the other components of the dietary portfolio.
Meta-analyses and
Acknowledgments
The authors wish to thank Mrs Kathy Galbraith for her assistance on this project and the study participants for their enthusiasm and attention to detail. This study was supported by the Canada Research Chair Endowment of the Federal Government of Canada; the Canadian Natural Sciences and Engineering Research Council of Canada; Loblaw Brands Limited; the Almond Board of California; and Unilever Canada and Unilever Research & Development, Vlaardingen, the Netherlands.
Authors’ contributions—Study
References (57)
- et al.
A dietary portfolio approach to cholesterol reduction: combined effects of plant sterols, vegetable proteins, and viscous fibers in hypercholesterolemia
Metabolism
(2002) - et al.
The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia
Metabolism
(2003) - et al.
Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia
Am J Clin Nutr
(2006) - et al.
Plant sterols as cholesterol-lowering agents: clinical trials in patients with hypercholesterolemia and studies of sterol balance
Atherosclerosis
(1977) - et al.
Cholesterol-lowering efficacy of a sitostanol-containing phytosterol mixture with a prudent diet in hyperlipidemic men
Am J Clin Nutr
(1999) - et al.
Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels
Mayo Clin Proc
(2003) - et al.
Effects of phytosterol ester–enriched margarine on plasma lipoproteins in mild to moderate hypercholesterolemia are related to basal cholesterol and fat intake
Metabolism
(2002) - et al.
Phytosterols mixed with medium-chain triglycerides and high-oleic canola oil decrease plasma lipids in overweight men
Metabolism
(2006) - et al.
Plant sterols are efficacious in lowering plasma LDL and non-HDL cholesterol in hypercholesterolemic type 2 diabetic and nondiabetic persons
Am J Clin Nutr
(2005) - et al.
Lipid responses to plant-sterol–enriched reduced-fat spreads incorporated into a National Cholesterol Education Program Step I diet
Am J Clin Nutr
(2001)
Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis
J Nutr
Long-term cholesterol-lowering effects of psyllium as an adjunct to diet therapy in the treatment of hypercholesterolemia
Am J Clin Nutr
Soybean-protein diet in the treatment of type-II hyperlipoproteinaemia
Lancet
Long-term intake of soy protein improves blood lipid profiles and increases mononuclear cell low-density–lipoprotein receptor messenger RNA in hypercholesterolemic, postmenopausal women
Am J Clin Nutr
Nuts and their bioactive constituents: effects on serum lipids and other factors that affect disease risk
Am J Clin Nutr
Almonds and almond oil have similar effects on plasma lipids and LDL oxidation in healthy men and women
J Nutr
Serum lipid response to the graduated enrichment of a Step I diet with almonds: a randomized feeding trial
Am J Clin Nutr
Effect of citrus pectin on blood lipids and fecal steroid excretion in man
Am J Clin Nutr
Soy sterol esters and beta-sitostanol ester as inhibitors of cholesterol absorption in human small bowel
Am J Clin Nutr
Plasma sitosterol elevations are associated with an increased incidence of coronary events in men: results of a nested case-control analysis of the Prospective Cardiovascular Munster (PROCAM) study
Nutr Metab Cardiovasc Dis
Relationships of serum plant sterols (phytosterols) and cholesterol in 595 hypercholesterolemic subjects, and familial aggregation of phytosterols, cholesterol, and premature coronary heart disease in hyperphytosterolemic probands and their first-degree relatives
Metabolism
Plasma levels of plant sterols and the risk of coronary artery disease: the prospective EPIC-Norfolk Population Study
J Lipid Res
Vegetable oils high in phytosterols make erythrocytes less deformable and shorten the life span of stroke-prone spontaneously hypertensive rats
J Nutr
Effect of a very–high-fiber vegetable, fruit, and nut diet on serum lipids and colonic function
Metabolism
Dietary fibre in food and protection against colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study
Lancet
Colonic-rectal cancer: fiber and other dietary factors
Am J Clin Nutr
Diabetes mellitus and dietary fiber of starchy foods
Am J Clin Nutr
Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
JAMA
Cited by (49)
Sustainability, nutrition, and scientific advances of functional foods under the new EU and global legislation initiatives
2023, Journal of Functional FoodsResistant starch type 2 from lotus stem: Ultrasonic effect on physical and nutraceutical properties
2021, Ultrasonics SonochemistryCitation Excerpt :Apart from these factors, hydrolysis of starch by enzymes is also governed by amylose content, gelatinization enthalpy relative crystallinity and gelatinization temperature [72]. The classification of foods on the basis of GI includes low GI food (GI of 55), medium GI food (GI of 56–69) and high GI foods (GI of 70) [73]. For RS the low GI values can be an important nutritional property as studies have reported that low GI/ high RS foods prevents cardiovascular and cerbrovascular diseases, regulates blood glucose level, decreases insulin resistance, and improves lipid metabolism [74].
Dietary fiber and the microbiota: A narrative review by a group of experts from the Asociación Mexicana de Gastroenterología
2021, Revista de Gastroenterologia de MexicoYoghurt and curd cheese addition to wheat bread dough: Impact on in vitro starch digestibility and estimated glycemic index
2021, Food ChemistryCitation Excerpt :The lowest HI and eGI was recorded at higher levels of Yg and Cc (25%, w/w) tested, with eGI of 65.7 and 58.2, representing a reduction of 31.0% (Yg) and 38.4% (Cc), respectively. GI of foods can vary between ≤ 55, and 56–69 and ≥ 70, that are classified as low, medium, and high GI, respectively (Atkinson et al., 2008; Jenkins et al., 2008). According to this classification, the dairy breads developed with maximum incorporations (25%, w/w) can be classified in medium GI (Yg25%) and almost low GI (Cc25%).
Phytosterols and phytostanols
2018, Encyclopedia of Food ChemistryStarch digestibility and predicted glycemic index in the bread fortified with pomelo (Citrus maxima) fruit segments
2017, Food ChemistryCitation Excerpt :The lowest HI and pGI was recorded in brown breads that ranged between 62.41 and 53.13%. According to Jenkins et al. (2008), foods with GI of ≤55, 56–69 and ≥70 are classified as low, medium and high GI, respectively. The observation of low pGI in this study could be attributed to high fraction of RS among samples.
- ☆
Clinical Trial Identifier: NCT00438893