Plant Sterol/Stanol Recommendation for High Cholesterol
For managing high cholesterol, consume 2 grams per day of plant sterols or 3.4 grams per day of plant stanols, taken with meals, which will lower LDL cholesterol by approximately 10%. 1
Recommended Dosing Based on FDA-Approved Claims
The FDA has established specific intake recommendations that differ between plant sterols and stanols 1:
- Plant sterol esters: At least 0.65 g per serving, consumed twice daily with meals for a total daily intake of at least 1.3 g 1
- Plant stanol esters: At least 1.7 g per serving, consumed twice daily with meals for a total daily intake of at least 3.4 g 1
The American College of Cardiology and American Heart Association recommend 1-3 g per day consumed with meals, either once daily or in divided doses 1. The optimal dose for maximal LDL-lowering is 2 g/day, which achieves a 5-15% reduction in LDL cholesterol 1, 2.
Expected LDL Cholesterol Reduction
- 2 g/day: Reduces LDL cholesterol by 5-15% (most commonly cited as 10%) 1, 2, 3, 4
- Doses above 3 g/day: Provide no additional benefit, as the LDL-lowering effect plateaus 1, 2
- Higher doses (8.8 g/day): May achieve up to 17% LDL reduction, but this is not routinely recommended 5, 6
Clinical Application Algorithm
Step 1: Initial dietary modification 1, 2, 7
- Reduce saturated fat to <7% of total calories
- Limit cholesterol to <200 mg/day
- Eliminate trans fats
Step 2: Add plant sterols/stanols 1, 2, 7
- Start 2 g/day with meals as part of a heart-healthy diet
- Available in fortified margarines, spreads, orange juice, beverages, or soft gel capsules 2, 7
Step 3: Reassess after 6-12 weeks 2, 7
- Measure LDL cholesterol response
- If goals not achieved, escalate to statin therapy while continuing plant sterols 2, 7
Important Clinical Caveats
Drug interactions: Separate plant sterol/stanol consumption from bile acid sequestrants by 2-4 hours to avoid binding in the gut 1, 7.
Contraindication: Do not use in patients with phytosterolemia (sitosterolemia), a rare genetic disorder of plant sterol metabolism 1.
Side effects: Generally well tolerated with GRAS (Generally Recognized as Safe) status; may cause mild bloating, diarrhea, or constipation 1. Plant sterols may decrease fat-soluble vitamin and carotenoid absorption, so ensure adequate fruit and vegetable consumption 1, 7, 4.
Additive effects with statins: The LDL-lowering effect of plant sterols is additive to statins and often exceeds the benefit of doubling the statin dose 3.
Delivery Vehicle Selection
Choose based on caloric content and patient needs 2, 7:
- Fortified beverages or capsules: Preferred for patients managing weight
- Fortified margarines/spreads: Acceptable if caloric intake is not a concern
- Must be consumed daily to sustain LDL reductions 2, 7
Lack of Cardiovascular Outcomes Data
While plant sterols effectively lower LDL cholesterol, no randomized controlled trials have demonstrated reduction in cardiovascular morbidity or mortality 1, 2, 8. This contrasts with statins, which have robust cardiovascular outcomes data. Therefore, plant sterols should be viewed as adjunctive therapy, not a replacement for proven pharmacotherapy when indicated 2, 7.