Stanol Research Articles

Response to comments on the Scientific Opinion on the substantiation of a health claim related to 3 g/day plant stanols as plant stanol esters and lowering blood LDL‐cholesterol and reduced risk of (coronary) heart disease pursuant to Article 14 of Regulation (EC) No 1924/2006

EFSA Supporting PublicationsVolume 9, Issue 9 333E Technical reportOpen Access Response to comments on the Scientific Opinion on the substantiation of a health claim related to 3 g/day plant stanols as plant stanol esters and lowering blood LDL-cholesterol and reduced risk of (coronary) heart disease pursuant to Article 14 of Regulation (EC) No 1924/2006 European Food Safety Authority (EFSA), Search for more papers by this author European Food Safety Authority (EFSA), Search for more papers by this author First published: 04 September 2012 https://doi.org/10.2903/sp.efsa.2012.EN-333 Published date: 4 September 2012 Question number: EFSA-Q-2012-00732 AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Volume9, Issue9September 2012333E ReferencesRelatedInformation

The influence of plant stanol (β-sitostanol) on inner leaflet of human erythrocytes membrane modeled with the Langmuir monolayer technique

The presence of dietary phytocompounds – plant sterols and stanols – in human plasma and membranes raises the question on their influence on membrane properties. A good way to get an insight into interactions of these biomolecules with membranes at molecular level is to perform experiments on artificial systems, e.g. Langmuir monolayers, composed of membrane lipids. In this paper the influence of plant stanol – β-sitostanol – on monolayers imitating the inner leaflet of human membrane, composed of phosphatidylethanolamine (POPE)/phosphatidylserine (POPS)/cholesterol (Chol) was studied. Two effects have been investigated and compared, namely the systematic increase of plant stanol (β-sitostanol) content in the mixed film as well as the replacement of cholesterol by β-sitostanol in POPE/POPS/Chol monolayer. The analysis of the collected data evidenced that the plant stanol strongly influences the condensation and interactions in POPE/POPS/Chol film. BAM images taken for the studied monolayers demonstrated that the presence of β-sitostanol in the mixture leads to the formation of 3D crystallites within the film, which seems to result from a limited solubility of plant stanol in phospholipids environment. All these effects have got intensified upon systematic elimination of cholesterol and its replacement by plant stanol in the mixed monolayer. The obtained results evidence that the presence of plant stanol may significantly alter organization of the inner leaflet of human membrane.

Plant stanol ester consumption did not interfere with serum vitamin D level in humans

Plant stanol ester consumption did not interfere with serum vitamin D level in humans

P02.88. Powdered Red Yeast Rice and Plant Stanols and Sterols to lower cholesterol

P02.88. Powdered Red Yeast Rice and Plant Stanols and Sterols to lower cholesterol

Effects of plant sterols and stanols on intestinal cholesterol metabolism: Suggested mechanisms from past to present

Plant sterols and stanols are natural food ingredients found in plants. It was already shown in 1950 that they lower serum low-density lipoprotein cholesterol (LDL-C) concentrations. Meta-analysis has reported that a daily intake of 2.5 g plant sterols/stanols reduced serum LDL-C concentrations up to 10%. Despite many studies, the underlying mechanism remains to be elucidated. Therefore, the proposed mechanisms that have been presented over the past decades will be described and discussed in the context of the current knowledge. In the early days, it was suggested that plant sterols/stanols compete with intestinal cholesterol for incorporation into mixed micelles as well as into chylomicrons. Next, the focus shifted toward cellular processes. In particular, a role for sterol transporters localized in the membranes of enterocytes was suggested. All these processes ultimately lowered intestinal cholesterol absorption. More recently, the existence of a direct secretion of cholesterol from the circulation into the intestinal lumen was described. First results in animal studies suggested that plant sterols/stanols activate this pathway, which also explains the increased fecal neutral sterol content and as such could explain the cholesterol-lowering activity of plant sterols/stanols.

Scientific Opinion on the substantiation of a health claim related to 3 g/day plant stanols as plant stanol esters and lowering blood LDL-cholesterol and reduced risk of (coronary) heart disease pursuant to Article 14 of Regulation (EC) No 1924/2006

Following an application from Raisio Nutrition Ltd, submitted pursuant to Article 14 of Regulation (EC) No 1924/2006 via the Competent Authority of Finland, the Panel on Dietetic Products, Nutrition and Allergies was asked to deliver an opinion on the scientific substantiation of a health claim related to 3 g/day plant stanols as plant stanol esters per day and lowering blood LDL-cholesterol by 12 % and reduced risk of (coronary) heart disease. The applicant has further requested that the minimum duration to obtain the effect be stated to be one to two weeks, and that the claims be authorised for an extended range of foods, including yellow fat spreads, dairy products, cheese, rye bread, oatmeal, fermented soy milk based products (drinkable and spoonable yoghurt-type products), and oat based milk drinks. The applicant provided an unpublished meta-analysis with 18 randomised, controlled human studies on the LDL-lowering efficacy of plant stanol esters at intakes between 2.7 to 3.3 g per day plant stanols. On the basis of the data presented, the Panel concludes that plant stanol esters at a daily intake of 3 g plant stanols (range 2.7 g to 3.3 g) in matrices approved by Regulation (EC) No 376/2010 (yellow fat spreads, dairy products, mayonnaise and salad dressings) lowers LDL-cholesterol by 11.4 % (95% CI: 9.8 – 13.0), that the minimum duration required to achieve the maximum effect of plant stanol esters on LDL-cholesterol lowering is two to three weeks, and that while plant stanol esters added to foods such as margarine-type spreads, mayonnaise, salad dressings, and dairy products such as milk, yoghurts including low-fat yoghurts, and cheese have been shown consistently to lower blood LDL-cholesterol levels, the size of the cholesterol-lowering effect of plant stanols added to other food formats is less well established.

Scientific Opinion on the substantiation of a health claim related to 3 g/day plant sterols/stanols and lowering blood LDL-cholesterol and reduced risk of (coronary) heart disease pursuant to Article 19 of Regulation (EC) No 1924/2006

Following an application from Unilever PLC and Unilever NV, submitted pursuant to Article 19 of Regulation (EC) No 1924/2006 via the Competent Authority of the United Kingdom, the Panel on Dietetic Products, Nutrition and Allergies was asked to deliver an opinion on the scientific substantiation of an application to modify the conditions of use of an authorised Article 14 claim related to 1.5 – 3.0 g plant sterols/stanols per day and lowering blood LDL-cholesterol by 7 – 12 % and reduced risk of (coronary) heart disease. The applicant has further requested that the minimum duration to obtain the effect be one to two weeks. The applicant provided a published systematic review and meta-analysis that evaluated the comparative efficacy of plant sterols and plant stanols for lowering blood LDL-cholesterol in healthy and hypercholesterolaemic subjects and an unpublished meta-analysis on 27 randomised controlled human studies on the LDL-lowering efficacy at a dose range between 2.6 and 3.4 g per day. On the basis of the data presented, the Panel concludes that plant sterols and stanol esters at daily intakes ranging from 1.5 to 3.0 g plant sterols/stanols in matrices approved by Regulation (EC) No 376/2010 (yellow fat spreads, dairy products, mayonnaise and salad dressings) have a similar efficacy on blood LDL-cholesterol lowering, that plant sterols and stanol esters at a daily intake of 3 g (range 2.6 g to 3.4 g) plant sterols/stanols in matrices approved by Regulation (EC) No 376/2010 lower LDL-cholesterol by 11.3 % (95 % CI: 10.0 – 12.5), and that the minimum duration required to achieve the maximum effect of plant sterols and stanols on LDL-cholesterol lowering is two to three weeks.

Powdered Red Yeast Rice and Plant Stanols and Sterols to Lower Cholesterol

ABSTRACTElevated low-density lipoprotein (LDL) cholesterol is a significant risk factor for cardiovascular disease. It is estimated that 42% of females and 34% of males in the USA have elevated total cholesterol. The current mainstay of lipid-lowering therapy utilizes 3-hydroxy-3-methylglutaryl-coezyme A (HMG-CoA) reductase inhibitor (i.e., statin) medications that lower total cholesterol and LDL cholesterol by an average of 20% and 28%, respectively. However, due to the significant side effects of statin medications, many patients seek alternative therapies to help manage their hypercholesterolemia. Red yeast rice (Monascus purpureus) has been used as a food and as an herbal medication in China for centuries. Phytosterols are foods that are similar in structure and function to animal cholesterol. Both of these compounds have been shown in clinical studies to significantly lower LDL cholesterol. We report on a case series of 18 patients with hypercholesterolemia despite therapeutic lifestyle change through diet and exercise who took a proprietary product combining red yeast rice and phytosterols as a powdered shake in an effort to improve their cholesterol indices. Statistically significant reduction (p < .05) in the following mean variables was seen: total cholesterol 19% (46 mg/dL) and LDL 33% (53 mg/dL) after 6 weeks using the blend. There was no significant difference in body mass index (BMI), triglyceride, high-density lipoprotein (HDL) cholesterol levels, or systolic and diastolic blood pressure over the same period. This magnitude of reduction in LDL cholesterol is significantly greater than the 28% reduction observed in the 1999 Journal of the American Medical Association (JAMA) meta-analysis on the average effectiveness of statin medications in lowering cholesterol levels. None of the participants in our study reported any muscle pains, and no abnormal liver function tests were seen while taking the product. Though this case series is limited by small sample size, study duration, and lack of control group, the product's significant reduction in LDL cholesterol without severe side effects indicates that this product may be a clinically effective and well tolerated alternative treatment to using statin medications to treat hypercholesterolemia.

Dietary intake of plant sterols stably increases plant sterol levels in the murine brain

Plant sterols such as sitosterol and campesterol are frequently administered as cholesterol-lowering supplements in food. Recently, it has been shown in mice that, in contrast to the structurally related cholesterol, circulating plant sterols can enter the brain. We questioned whether the accumulation of plant sterols in murine brain is reversible. After being fed a plant sterol ester-enriched diet for 6 weeks, C57BL/6NCrl mice displayed significantly increased concentrations of plant sterols in serum, liver, and brain by 2- to 3-fold. Blocking intestinal sterol uptake for the next 6 months while feeding the mice with a plant stanol ester-enriched diet resulted in strongly decreased plant sterol levels in serum and liver, without affecting brain plant sterol levels. Relative to plasma concentrations, brain levels of campesterol were higher than sitosterol, suggesting that campesterol traverses the blood-brain barrier more efficiently. In vitro experiments with brain endothelial cell cultures showed that campesterol crossed the blood-brain barrier more efficiently than sitosterol. We conclude that, over a 6-month period, plant sterol accumulation in murine brain is virtually irreversible.

Lipase-mediated synthesis of water-soluble plant stanol derivatives in tert-butanol

The effects of solvents with different log P values, and of lipases on the synthesis of water-soluble plant stanol derivatives were investigated. Results showed that conversion in solvents with log P<0.37 was mainly controlled by the hydrophobicity of the solvent and subsequent complete or partial deactivation of the enzyme. The solubility of substrate was the leading factor for the conversion in solvents with log P>0.37. Lipozyme RM IM and tert-butanol was the most suitable biocatalyst and solvent, respectively. The highest yield (>51%) of plant stanyl sorbitol succinate was obtained under the selected conditions: 50μmol/mL plant stanyl hemisuccinate, 1:3molar ratio of plant stanyl hemisuccinate to d-sorbitol, 80mg/mL 3Å molecular sieves and 100mg/mL Lipozyme RM IM in tert-butanol, 150r/min and 55°C. Fourier transform infrared spectroscopy, mass spectroscopy and nuclear magnetic resonance spectroscopy were adopted to determine the structure of product, suggesting that water-soluble plant stanol derivatives were successfully synthesized.

Alteration of lipids and the transcription of lipid-related genes in myelodysplastic syndromes via a TP53-related pathway

Myelodysplastic syndromes (MDS) are clonal stem cell diseases of the bone marrow characterized by abnormalities in maturation of hematopoietic cells of all lineages. MDS patients frequently have lower lipids and high rates of apoptosis and p53 (TP53) expression. An association between the reduced lipids in MDS and the expression of lipid-related genes was sought. We further evaluated whether 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGcoAR) and low-density lipoprotein receptor (LDL-R) are regulated by TP53 invivo and invitro. Gene expression was measured using real-time reverse transcription polymerase chain reaction on RNA extracted from bone marrow and peripheral blood from eight newly diagnosed MDS patients and eight controls and from mice livers. Serum lipid profile was measured using colorimetric enzymatic procedures. Total- and LDL cholesterol were lower in MDS patients in comparison to controls (p = 0.04 and p = 0.01, respectively). HMGcoAR messenger RNA increased in peripheral blood and bone marrow of MDS patients compared to controls (p = 0.04 and p = 0.01, respectively). LDL-R messenger RNA was higher only in the peripheral blood of MDS patients (p = 0.05). Comparable results were obtained invivo. The transcription of these genes correlates with TP53 activation as documented by p21 messenger RNA elevation, a surrogate for TP53 activation and by using TP53 temperature-sensitive cells treated with adriamycin. To conclude, an association between reduced lipids in MDS and expression of HMGcoAR and LDL-R genes was documented. The transcription of these genes can be regulated by TP53.

Enhanced low density lipoprotein-cholesterol lowering efforts by consuming plant stanols as part of a low saturated fat diet

Enhanced low density lipoprotein-cholesterol lowering efforts by consuming plant stanols as part of a low saturated fat diet

Plant sterols and stanols as dietary factors reducing hypercholesterolemia by inhibiting intestinal cholesterol absorption

The review is focussed on the mechanisms of action, lipid-lowering activity, structural characteristics, and safety of plant sterins and stanols. Phytosterins and phytostanols inhibit intestinal cholesterol (CH) absorption, therefore decreasing plasma CH levels. The emphasis is put on prospective epidemiological studies of representative samples, which demonstrated that plasma concentrations of phytosterins and phytostanols in patients with coronary heart disease (CHD) are substantially lower than in CHD-free participants. A two-fold increase in serum sytosterin concentration was associated with a reduction in relative risk of CHD by 22 %. Plant sterin and sterol esters could be regarded as effective and safe dietary ingredients decreasing blood levels of CH — one of the major cardiovascular disease risk factors.

Phytosterols in human nutrition: Type, formulation, delivery, and physiological function

AbstractPhytosterols are a family of compounds similar to cholesterol which have been shown to lower cholesterol levels when supplemented in the diet. A daily dose of 2–3 g of phytosterols has been shown to reduce LDL‐cholesterol levels by 5–15%. Phytosterol supplementation can be undertaken using phytosterol enriched functional foods or nutraceutical preparations. The type of phytosterol supplemented, such as plant sterol or saturated plant stanol appear to be equally effective in lowering cholesterol levels. Phytosterols, whether in esterified or free form have both been shown to lower cholesterol levels, with esterified phytosterol formulations having a greater number of clinical trials demonstrating efficacy. The functional food or nutraceutical matrix which is used to deliver supplemental phytosterols can significantly affect cholesterol lowering efficacy. Effective cholesterol lowering by phytosterols depends on delivery of phytosterols to the intestine in a form which can compete with cholesterol for absorption. New phytosterol functional food and nutraceuticals products should always be tested to demonstrate adequate delivery of phytosterol dose and effective total and LDL‐cholesterol lowering. Phytosterol products which do not effectively lower cholesterol will negatively impact the perception and use of phytosterols, and must not be allowed on the marketplace.

A Review of the Rationale for Additional Therapeutic Interventions to Attain Lower LDL-C When Statin Therapy Is Not Enough

Statins alone are not always adequate therapy to achieve low-density lipoprotein (LDL) goals in many patients. Many options are available either alone or in combination with statins that makes it possible to reach recommended goals in a safe and tolerable fashion for most patients. Ezetimibe and bile acid sequestrants reduce cholesterol transport to the liver and can be used in combination. Niacin is very effective at lowering LDL, beyond its ability to raise high-density lipoprotein and shift LDL particle size to a less atherogenic type. When statins cannot be tolerated at all, red yeast rice can be used if proper formulations of the product are obtained. Nutrients can also be added to the diet, including plant stanols and sterols, soy protein, almonds, and fiber, either individually or all together as a portfolio diet. A clear understanding of how each of these strategies works is essential for effective results.

Lipid-altering effects of a dietary supplement tablet containing free plant sterols and stanols in men and women with primary hypercholesterolaemia: a randomized, placebo-controlled crossover trial

This randomized, placebo-controlled, crossover trial assessed the lipid-altering efficacy of a dietary supplement (tablet form) providing 1.8 g/day free (non-esterified) plant sterols and stanols versus placebo for 6 weeks as part of a therapeutic lifestyle changes (TLC) diet in 32 men and women with primary hypercholesterolaemia. Mean ± SE baseline (end of a 5-week TLC diet lead-in) lipid concentrations (mmol/l) were total cholesterol (TC), 5.88 ± 0.08; non-high-density lipoprotein cholesterol (non-HDL-C), 4.71 ± 0.09; low-density lipoprotein cholesterol (LDL-C), 4.02 ± 0.08; HDL-C, 1.17 ± 0.06 and triglycerides (TGs), 1.51 ± 0.12. Differences from control in responses (plant sterol/stanol − control) were significant (p < 0.05) for LDL-C ( − 4.9%), non-HDL-C ( − 3.6%) and TC ( − 2.8%). HDL-C and TG responses were not significantly different between treatment conditions. These results indicate that 1.8 g/day free plant sterols/stanols administered in a tablet produced favourable lipoprotein lipid changes in men and women with hypercholesterolaemia.

Functional foods and cardiovascular disease risk

To review the concept of functional foods and to summarize recent evidence on functional foods and cardiovascular disease (CVD) risk. Recent studies have examined the use of antioxidant vitamins and found no support for a beneficial effect on CVD risk, lipid levels or blood pressure. The evolving data also provide little support for a cardioprotective effect of soy protein. The role of soluble fiber in cardiovascular health has been of interest for many years and new studies support important beneficial effects on lipids as well as total CVD risk. In addition, the benefits of fish intake and nut consumption have been recently affirmed. Two promising areas of investigation from a functional food perspective are studies of phytosterols and milk-derived tripeptides. Plant stanol esters have been shown to have strong lipid-lowering effects, whereas milk-derived tripeptides directly benefited blood pressure. The functional food market has grown exponentially in recent years. Our understanding of the health benefits of foods and nutrients is continually evolving. Careful attention to the strength of the scientific evidence will help to ensure that it is used appropriately to guide the development of the next generation of health-promoting functional foods.

Serum and lipoprotein sitostanol and non-cholesterol sterols after an acute dose of plant stanol ester on its long-term consumption

Chronic inhibition of cholesterol absorption with large doses of plant stanol esters (staest) alters profoundly cholesterol metabolism, but it is unknown how an acute inhibition with a large staest dose alters the postprandial serum and lipoprotein cholesterol precursor, plant sterol, and sitostanol contents. Hypercholesterolemic subjects, randomly and double-blind divided into control (n = 18) and intervention groups (n = 20), consumed experimental diet without and with staest (plant stanols 8.8 g/day) for 10 weeks. Next morning after a fasting blood sample (0 h), the subjects had a breakfast without or with staest (4.5 g of plant stanols). Blood sampling was repeated 4 h later. Lipoproteins were separated with ultracentrifugation, and sterols were measured with gas-liquid chromatography. In 0-h chylomicrons and VLDL, plant sterols were lower in staest than in controls. Postprandially, cholestenol (cholesterol synthesis marker) was reduced in chylomicrons in staest compared with controls (-0.13 ± 0.04 μg/dL vs. 0.01 ± 0.08 μg/dL, P < 0.05). Staest decreased postprandially avenasterol in chylomicrons (P < 0.05 from 0 h). Sitostanol was high at 0 h by chronic staest in serum and VLDL but not in chylomicrons. Postprandial sitostanol was increased by staest in VLDL only. Chronic cholesterol absorption inhibition with large amount of plant stanol esters decreases plant sterols in triglyceride-rich lipoproteins. Acute plant stanol ester consumption increases sitostanol content in triglyceride-rich lipoproteins but suggests to decrease the risk of plant sterol and plant stanol accumulation into vascular wall by chylomicrons.

Properties of β-sitostanol/DPPC monolayers studied with Grazing Incidence X-ray Diffraction (GIXD) and Brewster Angle Microscopy

Although the influence of structurally modified sterols on artificial membranes has been intensively investigated, studies on the properties of stanols, which are saturated analogs of sterols, are very rare. Therefore, we have performed Grazing Incidence X-ray Diffraction (GIXD) experiments aimed at studying in-plane organization of a plant stanol–β-sitostanol monolayer and its mixtures with 1,2-dipalmitoyl- sn-glycero-3-phosphocholine – DPPC at the air/water interface. The collected GIXD data, resulting in-plane parameters and BAM images provide information on molecular organization and in-plane ordering of the investigated films. It was found that the lateral organization of β-sitostanol/DPPC monolayers depends on their composition. The oblique structure of the in-plane lattice of tilted hydrophobic region of molecules, found for DPPC film, is maintained at 10 mol% of stanol in the system. However, at 30 and 90 mol% of stanol in the mixture, the arrangement of molecules is hexagonal and they are oriented perpendicularly to the interface. With the addition of stanol the extend of the in-plane order of the monolayers decreases. Moreover, in mixtures the ordered domains consist of both monolayer’s components. Additionally, β-sitostanol film is of similar in-plane organization as the corresponding sterol monolayer (β-sitosterol) and stanol induces condensing effect on DPPC.

Phytosterol ester processing in the small intestine: impact on cholesterol availability for absorption and chylomicron cholesterol incorporation in healthy humans

Phytosterols (plant sterols and stanols) can lower intestinal cholesterol absorption, but the complex dynamics of the lipid digestion process in the presence of phytosterol esters (PEs) are not fully understood. We performed a clinical experiment in intubated healthy subjects to study the time course of changes in the distribution of all lipid moieties present in duodenal phases during 4 h of digestion of meals with 3.2 g PE (PE meal) or without (control meal) PE. In vitro experiments under simulated gastrointestinal conditions were also performed. The addition of PE did not alter triglyceride (TG) hydrolysis in the duodenum or subsequent chylomicron TG occurrence in the circulation. In contrast, cholesterol accumulation in the duodenum aqueous phase was markedly reduced in the presence of PE (-32%, P < 0.10). In vitro experiments confirmed that PE reduces cholesterol transfer into the aqueous phase. The addition of PE resulted in a markedly reduced presence of meal-derived hepta-deuterated cholesterol in the circulation, i.e., in chylomicrons (-43%, PE meal vs. control; P < 0.0001) and plasma (-54%, PE meal vs. control; P < 0.0001). The present data show that addition of PE to a meal does not alter TG hydrolysis but displaces cholesterol from the intestinal aqueous phase and lowers chylomicron cholesterol occurrence in humans.