As part of my business as a dietitian/nurse CDE, I will meet a patient in their favorite grocery store for a nutrition lesson. As we go through the store, I answer many questions on different kinds of foods and also on medications. For some people with diabetes over the age of 40 years, doctors may mention that they should consider consuming plant sterols and stanols that are fortified in some foods in addition to their statin medication. It is sometimes confusing as my patients are not sure why they are taking a statin medication and are also confused about the additional recommendation of adding plant sterols and plant stanols to their diet. Questions occur like: Why am I taking a statin medication? Are plant sterols and stanols a replacement for my statin medication? Where are plant sterols and plant stanols found in foods and how much is recommended? This is some of the information that we discuss on this topic.



 

What are Statins?

Statins are a class of drugs that are very effective in helping to lower cholesterol. They help the body from making excessive cholesterol and may help decrease the risk of heart attack by helping resorb the cholesterol that is built up in plaques on arteries. This may prevent the blockage in blood vessels that cause heart attack and stroke. (1) The American Heart Association has very recently updated their recommendations on statins. They included specific recommendations on the use of statins in people with diabetes and a low density lipoprotein (LDL) blood level between 70-180 mg/dl. These include:
  1.  Moderate intensity statin therapy is initiated or that it continues in adults 40-75 years-old. (2)
  2.  High intensity statin therapy in people with diabetes who are 40-75 years-old with an equal to or greater than 7.5 percent 10-year risk of Atherosclerotic cardiovascular Disease (ASCVD) unless contraindicated. (See link below marked ** to assess your cardiovascular risk.) (2)
  3. In adults less than 40 or greater than 75 years-old evaluate the potential for ASCVD benefits and potential adverse effects, to consider drug interactions and patient preferences for starting statin therapy or intensifying therapy. (2)

Statin medications available in the United States include:

Atorvastatin (Lipitor®)
Fluvastatin (Lescol®)
Lovastatin (Mevacor®, Altoprev™)
Pravastatin (Pravachol®)
Rosuvastatin Calcium (Crestor®)
Simvastatin (Zocor®) (3)

** To assess your cardiovascular risk, click here.

 

Target for LDL Cholesterol

The American Diabetes Association recommends LDL cholesterol levels be less than 100 mg/dl for most people. (4)

As of November 2013, the American College of Cardiology and the American Heart Association’s new recommendations are that there is no evidence from controlled clinical trials to recommend treatment of LDL levels to a specific target level. Instead of target levels, the new guidelines are based on the recommended levels of statin therapy suggested above under ‘What are Statins.” (5)


 

What are Sterols and Stanols?

Plant sterols and plant stanols fall under the classification of phyto-sterols that occur naturally in the oils of plants. They occur in foods such as cooking oils, margarine, peanut butter, legumes and seeds. (6)  Phyto is the Greek term for “plant”. (7) The function of a sterol in the plant kingdom is very important. They help to form the structure of the cell membrane. This is a similar that role that cholesterol has in the human. Plant stanols are not as abundant as sterols in plants. They are hydrogenation products of sterols. (6)
 

Why do some patients consider incorporating stanols and sterols in their diet?

The reason stanols and sterols may be a healthy addition to a meal plan is that when consumed as part of a diet that is low in cholesterol and saturated fat, they can help lower low density lipoprotein (LDL) levels in the blood. LDL’s are sometimes referred to as the “bad cholesterol.”  When the recommended amounts of plant stanols and sterols are added to a person’s diet who already takes a statin, LDL cholesterol levels can be lowered by as much as 14 percent. (8)

It is thought that the action of plant sterols and plant stanols is to decrease the uptake of dietary cholesterol into the body from the gut. (9) The National Cholesterol Education program recommends consuming 2 grams of phytoesterols (stanols and sterols) per day. (8)

The code of federal regulations in the United States grants permission for a health claim on foods that contain plant stanols and plant sterols. Government regulations provide the following examples of what you might see on a food label:
  • For plant sterol esters:  Foods containing at least 0.65 g per serving of plant sterol esters, eaten twice a day with meals for a daily total intake of at least 1.3 g, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. A serving of [name of the food] supplies ___grams of vegetable oil sterol esters. (10)
  • For plant stanol esters: (i) Foods containing at least 1.7 g per serving of plant stanol esters, eaten twice a day with meals for a total daily intake of at least 3.4 g, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. A serving of [name of the food] supplies ___grams of plant stanol esters.(10)

It is interesting to note that the United States government specifically states in this health claim that:
  1. The plant stanol/sterol esters should be consumed as part of a diet low in saturated fat and cholesterol. 
  2. The addition of stanol/ sterol esters “may or might” reduce the risk of “heart disease or coronary heart disease” and that there is not any degree of risk reduction to these diets. (10) 

In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) does not recommend advising patients to use plant sterols and plant stanols on a routine basis until the results of randomized control trials are proven to reduce the risk of coronary heart disease. (11) This is different than the United States government that states they “may or might” decrease the risk. (10)

Please take note that plant sterols and plant stanols should not be substituted for statins. Make sure you take your prescribed medication as ordered. (12)  Make sure you discuss consuming foods fortified with plant stanols or plant sterols with your medical team to help you decide if taking them is for you. There are contraindications to taking plant sterols and stanols including young children (under 5 years old), pregnant and lactating women and some medical conditions. (11)


If your medical team supports the use of foods fortified with plant sterols and stanols, where should you look for them in the grocery store?

You may find added sterols and stanols to foods like:
  • Margarines
  • Canola oil mayonnaise
  • Reduced-fat salad dressing
  • Chocolate
  • Butter
  • Low-fat yogurt
  • Beverages like orange juice
Breakfast barsLook on the label to see if your foods are fortified with these substances. (13, 14)

It is thought that approximately one quarter of Americans over the age of 45 years take a statin medication. With the recent new recommendations, doctors will be prescribing statins to many more people.(15) Make sure you discuss with your medical team if statins should be added to your medication profile to help you decrease the risk of heart disease. Discuss with you medical team if in addition, you should add plant stanols and sterols to your diet.
 
 
 
Article Reference Links:
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15

(Note: Reference link No. 6 is a downloadable PDF)