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Plant sterols and stanol esters

This HEART UK Nutrition Academy webpage has been funded by Novartis Pharmaceuticals UK Ltd who have had no input into the content or development of this material.
 

Foods fortified with plant sterols or stanol esters can lower LDL cholesterol by 7% to 12.5%. We take a closer look at the evidence.

Take home messages

  • Plant sterols and stanol esters are naturally found in plant foods in very small quantities. Over the course of a day, plant foods will provide up to 24mg of plant stanol esters and 600mg of sterols.
  • Higher concentrations of 1.5g to 3g daily have been proven to lower blood LDL cholesterol by 7% to 12.5%.
    • The beneficial effect can be seen within two weeks.
  • Foods fortified with plant sterols and stanol esters such as spreads, yogurts and yogurt drinks provide a convenient and familiar format for consumers to easily achieve the effective dose.
  • Fortified products should be taken with meals to optimise their effect.
  • Contraindications include those without hyperlipidaemia, children under the age of five and pregnant or breast feeding women who are not under close medical supervision.

The clinical evidence for plant sterols and stanol esters is very strong. Over a hundred randomised placebo controlled trials have consistently shown a significant drop in total and LDL cholesterol following a daily intake of plant sterols or stanol esters over a period of at least two weeks1–3.

The wealth of evidence has led to both a US FDA- and EFSA-approved health claim for foods fortified with plant sterols or stanol esters4–6. The cholesterol-lowering benefit has been demonstrated alongside statin use1,7.

Plant sterols and stanol esters are naturally present in various plant-based foods, including whole grains, vegetable oils, seeds and nuts. In their natural state, these compounds are present in relatively small amounts, with an average daily intake from plant sources ranging from approximately 17-24mg for plant stanol esters and 2-600mg for sterols8,9. These quantities are too low to have any appreciable effect on blood lipids. For this, considerably higher daily intakes of 1.5-3g (equivalent to 1,500-3,000mg) of sterols or stanol esters are needed.

The evidence

  • The most recent meta-analysis found a dose-dependent reduction in serum cholesterol levels with an average intake of 2.1g of plant sterols or stanol esters. Data from 124 RCTs were included9. Daily doses below 1g yielded an average 5.7% reduction in LDL cholesterol, while the highest intakes of 3-4g daily resulted in a 12.4% reduction.
  • A 2011 meta-analysis was conducted on 113 RCTs with a mean daily intake of 2.6g of plant sterols and 1.8g of plant stanol esters over four weeks2. The variation in dose was linked to corresponding impacts on lipid profiles, with plant sterols leading to a 10.3% reduction in LDL cholesterol and plant stanol esters resulting in a 7.7% reduction. Overall, a daily intake of 2g of sterols or stanol esters was associated with an 8.2% and a 9.3% reduction in LDL cholesterol, respectively.
  • An earlier meta-analysis of 84 RCTs found similar results. A total of 6,805 participants ate an average of 2.15g of sterols or stanol esters over periods ranging from three weeks to six months10. Overall, sterols and stanol esters lowered LDL cholesterol by 8.8%. The reductions in LDL cholesterol were more pronounced in people with higher baseline cholesterol levels and when the dose was distributed across multiple servings.
  • These results were consistent with those from a 2003 meta-analysis of 41 RCTs, which demonstrated that an average intake of 2g of plant sterols or stanol esters resulted in a 10% reduction in LDL cholesterol7. Notably, when used in conjunction with statin therapy, they had the potential to lower cholesterol to a degree equivalent to doubling the statin therapy dose.

Mechanism of action

Plant sterols and stanol esters interfere with the process of transporting dietary and biliary cholesterol from the gut into the body31,33,37,39.

Since fats and cholesterol are not water soluble, they require a specific transport mechanism for absorption from the gut into the bloodstream. This mechanism involves the formation of micelles that incorporate cholesterol and fat into their core.

Because plant sterols and stanol esters share a similar chemical structure to cholesterol, they can compete for space within the micelles, displacing some cholesterol. Cholesterol outside the micelles cannot be absorbed and is expelled through faeces.

The formation of micelles in the gut is initiated by bile acids, released only when food is consumed. Consequently, plant sterols and stanol ester-fortified foods are most effective when consumed with meals.

Foods fortified with plant sterols or stanol esters

Most studies have incorporated plant sterols and stanol esters within fat-containing foods and drink, usually dairy products, spreads and mayonnaise. A few studies incorporated sterols and stanol esters into bakery products, orange juice and cereals2,9,10.

Approved health claims

The European food and safety authority has approved health claims for 1.5 to 3g plant sterols or stanol esters daily as an effective dose to lower blood cholesterol. Manufacturers of yellow fat spreads, dairy products, mayonnaise or salad dressings with added plant sterols or stanol esters can make reference to magnitude of impact using the following statements4,6:

  • For foods that provide a daily intake of 1.5-2.4g plant sterols/stanol esters, blood cholesterol can be reduced by 7% to 10%

OR

  • For foods that provide a daily intake of 2.5-3 g plant sterols/stanol esters, blood cholesterol can be reduced by 10% to 12.5%

An additional statement can be added that these effects can be achieved within two to three weeks of consuming the products.

The effective dose: 1.5-3g plant sterols or stanol esters daily

Achieving 1.5-3g a day

Most products can provide this dose in one serving.

Foods fortified with plant sterols or stanol esters should be taken with meals for the greatest effect.

One a day options: products that provide 2g of plant sterols or stanol esters per serving
Product Single serving How to incorporate into the diet

Mini yogurt drinks

Dairy or plant-based varieties

67.5–100g bottles

retail or brand

Quick shot drink with breakfast or any main meal.
Flavoured yogurts

115g individual pot

OR

175g serving from a big pot

Have as a dessert after a main meal or use instead of milk with cereal.
Fat spreads – three servings a day. Each 10g/2tsp serving providing 0.54g-0.7g sterols or stanol esters
Fat spreads 10g (2tsp) Spread on bread or toast or use in cooking.*

* plant sterols and stanol esters fortified fat spreads should not be used for frying/sauteeing as the esters can stick to the pan and are not available

How to take plant sterols and stanol esters fortified products

  • they can be taken alongside statin therapy
  • they should only be consumed by people with high cholesterol 
  • daily intake should not exceed 3g in 24 hours 
  • they should be taken with a main meal to optimise impact
  • women who are pregnant or breast-feeding and children under five years old should only use these products after discussing them with their medical team or a specialised lipid dietitian.

Watch our CPD e-module: The four cholesterol lowering foods

Go

Read about the other cholesterol-lowering foods 

Nuts Oats and barley Soya

References 

  1. Trautwein EA, Vermeer MA, Hiemstra H, Ras RT. LDL-Cholesterol Lowering of Plant Sterols and Stanols—Which Factors Influence Their Efficacy? Nutrients. 2018;10(9):1262. doi:10.3390/nu10091262
  2. Musa-Veloso K, Poon TH, Elliot JA, Chung C. A comparison of the LDL-cholesterol lowering efficacy of plant stanols and plant sterols over a continuous dose range: Results of a meta-analysis of randomized, placebo-controlled trials. Prostaglandins, Leukotrienes and Essential Fatty Acids. 2011;85(1):9-28. doi:10.1016/j.plefa.2011.02.001
  3. Gylling H, Plat J, Turley S, et al. Plant sterols and plant stanols in the management of dyslipidaemia and prevention of cardiovascular disease. Atherosclerosis. 2014;232(2):346-360. doi:10.1016/j.atherosclerosis.2013.11.043
  4. European Commission. Commission Regulation (EU) No 376/2010 of 3 May 2010 amending Regulation (EC) No 983/2009 on the authorisation and refusal of authorisation of certain health claims made on food and referring to the reduction of disease risk and to children’s development and health - Plant stanol and sterols. OJ L. 2011;111:3-4.
  5. FDA. Commission Regulation (EU) No 384/2010 of 5 May 2010 on the authorisation and refusal of authorisation of certain health claims made on foods and referring to the reduction of disease risk and to children’s development and health-Plant Stanols and Sterols. OJ L. 113:6-9.
  6. COMMISSION REGULATION (EU) No 686/2014 - of 20 June 2014 - amending Regulations (EC) No 983/2009 and (EU) No 384/2010 as regards the conditions of use of certain health claims related to the lowering effect of plant sterols and plant stanols on blood LDL-cholesterol -.
  7. Katan MB, Grundy SM, Jones P, Law M, Miettinen T, Paoletti R. Efficacy and Safety of Plant Stanols and Sterols in the Management of Blood Cholesterol Levels. Mayo Clinic Proceedings. 2003;78(8):965-978. doi:10.4065/78.8.965
  8. Klingberg S, Andersson H, Mulligan A, et al. Food sources of plant sterols in the EPIC Norfolk population. Eur J Clin Nutr. 2008;62(6):695-703. doi:10.1038/sj.ejcn.1602765
  9. Ras RT, Geleijnse JM, Trautwein EA. LDL-cholesterol-lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. British Journal of Nutrition. 2014;112(2):214-219. doi:10.1017/S0007114514000750
  10. Demonty I, Ras RT, van der Knaap HCM, et al. Continuous Dose-Response Relationship of the LDL-Cholesterol–Lowering Effect of Phytosterol Intake. The Journal of Nutrition. 2009;139(2):271-284. doi:10.3945/jn.108.095125
  11. Jones PJH, Shamloo M, MacKay DS, et al. Progress and perspectives in plant sterol and plant stanol research. Nutrition Reviews. 2018;76(10):725-746. doi:10.1093/nutrit/nuy032

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