How can sterol stanols be used to manage cholesterol levels?

Plant Sterols/Stanols for Cholesterol Management

Plant sterols and stanols at 2-3 grams per day should be used as an adjunctive therapy to lower LDL cholesterol by 9-20%, particularly in patients with elevated LDL who need additional cholesterol reduction beyond diet modification or in combination with statin therapy. 1

Mechanism and Efficacy

Plant sterols and stanols work by blocking cholesterol absorption in the intestine, interfering with uptake of both dietary and biliary cholesterol. 2 This mechanism leads to:

• LDL cholesterol reduction of 10-15% at doses of 2-3 grams daily 3, 4
• Maximum effect at 2 grams per day, with intakes exceeding 3 grams providing no additional benefit 1
• No meaningful effect on HDL cholesterol or triglycerides 1

Both sterol esters and stanol esters have comparable efficacy, though stanols are virtually unabsorbable, making them theoretically more ideal agents. 4

Clinical Application Algorithm

First-Line Use

• Add plant sterols/stanols (2 g/day) when LDL goals are not achieved after 6 weeks of dietary modification (saturated fat <7% of calories, cholesterol <200 mg/day) 3
• Re-evaluate LDL response after another 6 weeks 3

Combination Therapy

• Plant sterols/stanols are additive with statins: adding 2-3 g/day of sterols/stanols to statin therapy is more effective than doubling the statin dose 5
• The International Atherosclerosis Society recommends plant sterols as adjunctive therapy if LDL goals are not achieved with diet, maximally tolerated statins, and ezetimibe 1
• Dietary changes plus plant sterols can reduce LDL by 20% when combined 5

Treatment Position

According to current guidelines, plant sterols fit into the treatment algorithm as: 1

1. First-line: Maximally tolerated statins ± ezetimibe/bempedoic acid + heart-healthy diet
2. Second-line adjunctive: Add plant sterols/stanols 2-3 g/day if LDL goals not met
3. Third-line: PCSK9 inhibitors if still not at goal

Delivery Forms and Practical Use

Plant sterols/stanols are available in: 3

• Margarines and spreads (most studied form)
• Fortified orange juice and other beverages
• Soft gel capsules
• Various fortified foods

Critical point: These products must be consumed daily, just like lipid-lowering medication, to sustain LDL reductions. 3

Target Populations

Adults with Hypercholesterolemia

The American Heart Association recommends plant sterols/stanols specifically for adults requiring LDL cholesterol lowering due to hypercholesterolemia or for secondary prevention after an atherosclerotic event. 1

Patients with Diabetes

Plant sterols show similar efficacy in patients with diabetes compared to those without diabetes, and the Academy of Nutrition and Dietetics recommends 2-3 g/day as part of a cardioprotective diet for individuals with dyslipidemia. 1

Familial Hypercholesterolemia

Plant sterols are particularly useful as part of comprehensive management in patients with familial hypercholesterolemia, including children. 1

Safety Considerations and Caveats

Fat-Soluble Vitamins

• Beta-carotene levels decline with plant sterol/stanol use, though adverse health outcomes are not expected 5
• Vitamins A and D levels are not affected 5
• Alpha-carotene, lycopene, and vitamin E remain stable relative to LDL 5
• The American Heart Association notes concerns about potential decreases in fat-soluble vitamins and antioxidants 1

Plasma Plant Sterol Levels

• Plant sterols (but not stanols) are absorbed in small amounts (0.02-3.5%) and increase plasma plant sterol levels 6
• While patients with homozygous phytosterolemia have markedly increased atherosclerosis, the small increases from dietary plant sterols are believed to pose largely hypothetical risk that is offset by LDL reduction 5

Caloric Content

Important practical consideration: Choose delivery vehicles based on caloric content—fortified beverages or capsules may be preferable to margarine for patients managing weight. 3

Limitations

There is currently no direct evidence that plant sterols reduce coronary heart disease mortality, despite their proven cholesterol-lowering effects. 1 The benefit is inferred from LDL reduction, which is an established surrogate marker for cardiovascular risk.

Children

Plant sterols have been studied in children with familial hypercholesterolemia, showing LDL reductions of approximately 8% with 20 g/day of plant sterol-containing margarine. 3 However, formal recommendations for routine use in children await additional clinical trial data, and caution is advised regarding fat-soluble vitamin absorption. 3