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Stanols are substances that occur naturally in various plants. Their cholesterol-lowering effects were first observed in animals in the 1950s. Since then, a substantial amount of research suggests that plant stanols (modified into stanol esters) can help to lower cholesterol in individuals with normal or mildly to moderately elevated cholesterol levels. Stanols are available in margarine spreads, salad dressings, and dietary supplement tablets. Related substances called sterols and sterol esters appear to function similarly.
-------------------------------------------------------------------------------- Requirements/Sources Stanols occur naturally in wood pulp, tall oil, and soybean oil, and can also be manufactured from sterols (substances found in many foods). For incorporation into foods, stanols are processed with fatty acids from vegetable oils to form chemicals called stanol esters.3 (A similar process converts sterols to sterol esters). Stanols and sterols and their esters are added to margarine spreads and salad dressings, and are also available as dietary supplement tablets. -------------------------------------------------------------------------------- Therapeutic Dosages Typical dosages of stanol esters to lower cholesterol levels range from 3.4 to 5.1 g per day.4 One manufacturer of a commercially prepared margarine spread recommends taking 3 teaspoons (1.5 g of sitostanol ester per teaspoon) per day. The suggested use varies depending on the product and the quantity of sitostanol ester per serving. One study suggests that using stanol products once a day may be as effective as dividing up your intake throughout the day.5 It may take up to 3 months to show a substantial decrease in total cholesterol values.6 -------------------------------------------------------------------------------- Therapeutic Uses Strong evidence tells us that stanol esters and related substances can significantly improve cholesterol levels.720,54-56 -------------------------------------------------------------------------------- What Is the Scientific Evidence for Stanols? Plant stanol esters reduce serum cholesterol levels by inhibiting cholesterol absorption.21 Because they are structurally similar to cholesterol, stanols (and sterols) can displace cholesterol from the "packages" that deliver cholesterol for absorption from the intestines to the bloodstream.22 The displaced cholesterol is not absorbed and is excreted from the body; the stanols themselves are ultimately not absorbed either. Numerous double-blind, placebo-controlled studies, ranging in length from 30 days to 12 months and involving a total of more than 1,000 people, have found stanol esters and their chemical relatives effective for improving cholesterol levels.2336,54-56 The combined results suggest that these substances can reduce total cholesterol and LDL ("bad") cholesterol by about 10 to 15%. Stanol esters did not have any significant effect on HDL ("good") cholesterol or triglycerides in most of these studies.37 However, when combined with a standard cholesterol-lowering diet, use of a spread enhanced with plant sterols improved total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides as compared to a normal reduced-fat spread.38 In one of the best of the double-blind, placebo-controlled studies, 153 people with mildly elevated cholesterol were given sitostanol esters in margarine (at 1.8 or 2.6 g of sitostanol per day), or margarine without sitostanol ester, for a total of 1 year.39 The results in the treated group receiving 2.6 g per day showed improvements in total cholesterol by 10.2% and LDL cholesterol by 14.1%significantly better than the results in the control group. Neither triglycerides nor HDL cholesterol levels were affected. Other studies have found evidence that people taking statin drugs may benefit from using stanols/sterols as well.42,43,57 According to one study, if you are on statins and start taking sterol ester margarine as well, your cholesterol will improve to the same effect as if you doubled the statin dose.57 Two studies found stanols to be helpful for lowering cholesterol levels in people with type 2 (adult-onset) diabetes.40,41 -------------------------------------------------------------------------------- Safety Issues Stanols are considered safe because they are not absorbed.44,45 No adverse effects have been reported in any of the studies on lowering cholesterol, with the exception of one study that reported mild gastrointestinal complaints in a few preschool children.46 In addition, no toxic signs were observed in rats given stanol esters for 13 weeks at levels comparable to or exceeding those recommended for lowering cholesterol.47 Although concerns have been expressed that stanols might impair absorption of the fat-soluble vitamins A, D, and E, this does not seem to occur at the dosages of stanols required to lower cholesterol.48 Stanols might, however, interfere with absorption of alpha- and beta-carotene,49,50 although some studies have found no such effect.51,52 Until more is learned, it may be reasonable for people using stanol products to make sure to consume carotenoid-rich vegetables (yellow/orange and dark green vegetables).53 1. Nguyen TT. The cholesterol-lowering action of plant stanol esters. J Nutr. 1999;129:21092112. 2. Gylling H, Miettinen TA. Cholesterol reduction by different plant stanol mixtures and with variable fat intake. Metabolism. 1999;48:575580. 3. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 4. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 5. Plat J, van Onselen EN, van Heugten MM, et al. Effects on serum lipids, lipoproteins and fat soluble antioxidant concentrations of consumption frequency of margarines and shortenings enriched with plant stanol esters. Eur J Clin Nutr. 2000; 54:671677. 6. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med. 1995;333:13081312. 7. Gylling H, Miettinen TA. Serum cholesterol and cholesterol and lipoprotein metabolism in hypercholesterolaemic NIDDM patients before and during sitostanol ester-margarine treatment. Diabetologia. 1994;37:773780. 8. Gylling H, Miettinen TA. Cholesterol reduction by different plant stanol mixtures and with variable fat intake. Metabolism. 1999;48:575580. 9. Vanhanen HT, Blomqvist S, Ehnholm C, et al. Serum cholesterol, cholesterol precursors, and plant sterols in hypercholesterolemic subjects with different apoE phenotypes during dietary sitostanol ester treatment. J Lipid Res. 1993;34:15351544. 10. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 11. Nguyen TT, Dale LV, von Bergmann K, et al. Cholesterol-lowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial. Mayo Clin Proc. 1999;74:11982206. 12. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med. 1995;333:13081312. 13. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Effects of low-fat stanol ester enriched margarines on concentrations of serum carotenoids in subjects with elevated serum cholesterol concentrations. Eur J Clin Nutr. 1999;53:966969. 14. Gylling H, Siimes MA, Miettinen TA. Sitostanol ester margarine in dietary treatment of children with familial hypercholesterolemia. J Lipid Res. 1995;36:18071812. 15. Tammi A, Ronnemaa T, Gylling H, et al. Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project. J Pediatr. 2000;136:503510. 16. Gylling H, Miettinen TA. Effects of inhibiting cholesterol absorption and synthesis on cholesterol and lipoprotein metabolism in hypercholesterolemic non-insulin-dependent diabetic men. J Lipid Res. 1996;37:17761785. 17. Williams CL, Bollella MC, Strobino BA, et al. Plant stanol ester and bran fiber in childhood: effects on lipids, stool weight and stool frequency in preschool children. J Am Coll Nutr. 1999;18:572581. 18. Miettinen TA, Vanhanen H. Dietary sitostanol related to absorption, synthesis and serum level of cholesterol in different apolipoprotein E phenotypes. Atherosclerosis. 1994;105:217226. 19. Heinemann T, Leiss O, von Bergmann K. Effect of low-dose sitostanol on serum cholesterol in patients with hypercholesterolemia. Atherosclerosis. 1986;61:219223. 20. Neil HA, Meijer GW, Roe LS. Randomised controlled trial of use by hypercholesterolaemic patients of a vegetable oil sterol-enriched fat spread. Atherosclerosis. 2001;156:329337. 21. Tammi A, Ronnemaa T, Gylling H, et al. Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project. J Pediatr. 2000;136:503510. 22. Law M. Plant sterol and stanol margarines and health. BMJ. 2000;320:861864. 23. Gylling H, Miettinen TA. Serum cholesterol and cholesterol and lipoprotein metabolism in hypercholesterolaemic NIDDM patients before and during sitostanol ester-margarine treatment. Diabetologia. 1994;37:773780. 24. Gylling H, Miettinen TA. Cholesterol reduction by different plant stanol mixtures and with variable fat intake. Metabolism. 1999;48:575580. 25. Vanhanen HT, Blomqvist S, Ehnholm C, et al. Serum cholesterol, cholesterol precursors, and plant sterols in hypercholesterolemic subjects with different apoE phenotypes during dietary sitostanol ester treatment. J Lipid Res. 1993;34:15351544. 26. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 27. Nguyen TT, Dale LV, von Bergmann K, et al. Cholesterol-lowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial. Mayo Clin Proc. 1999;74:11982206. 28. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med. 1995;333:13081312. 29. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Effects of low-fat stanol ester enriched margarines on concentrations of serum carotenoids in subjects with elevated serum cholesterol concentrations. Eur J Clin Nutr. 1999;53:966969. 30. Gylling H, Siimes MA, Miettinen TA. Sitostanol ester margarine in dietary treatment of children with familial hypercholesterolemia. J Lipid Res. 1995;36:18071812. 31. Tammi A, Ronnemaa T, Gylling H, et al. Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project. J Pediatr. 2000;136:503510. 32. Hallikainen MA, Uusitupa MI. Effects of 2 low-fat stanol ester-containing margarines on serum cholesterol concentrations as part of a low-fat diet in hypercholesterolemic subjects. Am J Clin Nutr. 1999;69:403410. 33. Gylling H, Radhakrishnan R, Miettinen TA. Reduction of serum cholesterol in postmenopausal women with previous myocardial infarction and cholesterol malabsorption induced by dietary sitostanol ester margarine: women and dietary sitostanol. Circulation. 1997;96:42264231. 34. Jones PJ, Ntanios FY, Raeini-Sarjaz M, et al. Cholesterol-lowering efficacy of a sitostanol-containing phytosterol mixture with a prudent diet in hyperlipidemic men. Am J Clin Nutr. 1999;69:11441150. 35. Vanhanen HT, Kajander J, Lehtovirta H, et al. Serum levels, absorption efficiency, faecal elimination and synthesis of cholesterol during increasing doses of dietary sitostanol esters in hypercholesterolaemic subjects. Clin Sci. 1994;87:6167. 36. Neil HA, Meijer GW, Roe LS. Randomised controlled trial of use by hypercholesterolaemic patients of a vegetable oil sterol-enriched fat spread. Atherosclerosis. 2001;156:329337. 37. Nguyen TT. The cholesterol-lowering action of plant stanol esters. J Nutr. 1999;129:21092112. 38. Maki KC, Davidson MH, Umporowicz DM, 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;74:3343. 39. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med. 1995;333:13081312. 40. Gylling H, Miettinen TA. Effects of inhibiting cholesterol absorption and synthesis on cholesterol and lipoprotein metabolism in hypercholesterolemic non-insulin-dependent diabetic men. J Lipid Res. 1996;37:17761785. 41. Gylling H, Miettinen TA. Serum cholesterol and cholesterol and lipoprotein metabolism in hypercholesterolaemic NIDDM patients before and during sitostanol ester-margarine treatment. Diabetologia. 1994;37:773780. 42. Gylling H, Miettinen TA. Effects of inhibiting cholesterol absorption and synthesis on cholesterol and lipoprotein metabolism in hypercholesterolemic non-insulin-dependent diabetic men. J Lipid Res. 1996;37:17761785. 43. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 44. Blair SN, Capuzzi DM, Gottlieb SO, et al. Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy. Am J Cardiol. 2000;86:4652. 45. Moghadasian MH, Frohlich JJ. Effects of dietary phytosterols on cholesterol metabolism and atherosclerosis: clinical and experimental evidence. Am J Med. 1999;107:588594. 46. Williams CL, Bollella MC, Strobino BA, et al. Plant stanol ester and bran fiber in childhood: effects on lipids, stool weight and stool frequency in preschool children. J Am Coll Nutr. 1999;18:572581. 47. Turnbull D, Whittaker MH, Frankos VH, et al. 13-week oral toxicity study with stanol esters in rats. Regul Toxicol Pharmacol. 1999;29:216226. 48. Nguyen TT, Dale LV, von Bergmann K, et al. Cholesterol-lowering effect of stanol ester in a US population of mildly hypercholesterolemic men and women: a randomized controlled trial. Mayo Clin Proc. 1999;74:11982206. 49. Gylling H, Miettinen TA. Cholesterol reduction by different plant stanol mixtures and with variable fat intake. Metabolism. 1999;48:575580. 50. Tammi A, Ronnemaa T, Gylling H, et al. Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project. J Pediatr. 2000;136:503510. 51. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Effects of low-fat stanol ester enriched margarines on concentrations of serum carotenoids in subjects with elevated serum cholesterol concentrations. Eur J Clin Nutr. 1999;53:966969. 52. Miettinen TA, Puska P, Gylling H, et al. Reduction of serum cholesterol with sitostanol-ester margarine in a mildly hypercholesterolemic population. N Engl J Med. 1995;333:13081312. 53. Hallikainen MA, Sarkkinen ES, Uusitupa MI. Effects of low-fat stanol ester enriched margarines on concentrations of serum carotenoids in subjects with elevated serum cholesterol concentrations. Eur J Clin Nutr. 1999;53:966969. 54. Ostlund RE Jr, Racette SB, Okeke A, et al. Phytosterols that are naturally present in commercial corn oil significantly reduce cholesterol absorption in humans. Am J Clin Nutr. 2002;75:1000-1004. 55. Temme EH, Van Hoydonck PG, Schouten EG, et al. Effects of a plant sterol-enriched spread on serum lipids and lipoproteins in mildly hypercholesterolaemic subjects. Acta Cardiol. 2002;57:111-115. 56. Amundsen AL, Ose L, Nenseter MS, et al. Plant sterol ester-enriched spread lowers plasma total and LDL cholesterol in children with familial hypercholesterolemia. Am J Clin Nutr. 2002;76:338-344. 57. Simons L. Additive effect of plant sterol-ester margarine and cerivastatin in lowering low-density lipoprotein cholesterol in primary hypercholesterolemia. Am J Cardiol. 2002;90:737. |
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