EAS recommendations for the use of plant sterols and stanols

Plants sterols and stanols are recommended by the EAS as a part of lifestyle intervention in the management of dyslipidemia1,2.

The EAS consensus panel papers 2,10,11 recommend that food with added plant sterols and stanols may be considered for:

  • Individuals with high cholesterol levels at low/intermediate global CVD risk who do not need cholesterol-lowering drugs;
  • In combination to cholesterol-lowering drugs (i.e. statins) in high and very high CVD risk patients who do not achieve LDL-cholesterol targets or are statin intolerant;
  • In adults and children from the age of 6 years with familial hypercholesterolemia (FH);
  • In patients with statin-associated muscle symptoms (SAMS);

Foods containing plant sterols and stanols may be used either alone or in combination with statins or other cholesterol-lowering drugs (see below).

For patients with familial hypercholesterolemia (FH), cholesterol-lowering treatment is necessary. Next to drug treatment, diet and lifestyle interventions play an important role, especially in children with FH10. The benefits of reducing LDL-cholesterol are greater if action is taken early in life rather than later in life2.

Early management of elevated LDL-cholesterol can reduce CVD burden1,12.
CVD prevention, through dietary and lifestyle change13, should start as soon as possible.

Plant sterols and stanols combined with statins

The EAS consensus panel advocates combining plant sterols and stanols with statins to maximize the potential for reaching LDL-cholesterol goals to manage overall CVD risk2. Due to their distinct mechanism of action, plant sterols and stanols (i.e. inhibitors of cholesterol absorption) are expected to have an additive effect when combined with a statin (i.e. inhibitors of cholesterol synthesis)2. In fact, in clinical studies, dietary plant sterols and stanols have been shown to further increase LDL-cholesterol reduction by 7-10% when used in addition to statin therapy - a result superior to that achieved by doubling the statin dose (6%) 2,14,15 (see Table 10).

If experiencing statin-associated muscle symptoms (SAMS), which may require interruption of the use of statins, including foods with added plant sterols and stanols may help to reach LDL-cholesterol targets, next to other lipid-lowering therapies11. Furthermore, according to the EAS Consensus Panel, the Portfolio diet approach may be appropriate in patients with SAMS11, as well as dietary patterns that include foods low in saturated fats and high in viscous fibre in addition to foods with added plant sterols and stanols.

Table 10: Approximate and cumulative LDL-cholesterol reduction achievable by dietary modification
Ways to further lower cholesterol Dietary Change Approximate LDL-cholesterol reduction
In combination with statins
Doubling statin dose - 6%
Adding plant sterol/Stanols 1.5-2.4g/day 7 - 10%

Table adapted from ESC/EAS Guidelines, 20111 and Gylling et al., 20142.

Plant sterols and stanols and Ezetimibe

Consumption of plant sterols and stanols and treatment with ezetimibe both reduce cholesterol absorption in the intestine, although the exact mechanisms of action differ2. Very limited data are currently available about the combined use of plant sterols and stanols and ezetimibe.

The results from one clinical study indicate that adding plant sterols on top of ezetimibe has no therapeutic

benefit over ezetimibe alone in hypercholesterolemic individuals16. On the other hand, a significant further reduction in intestinal cholesterol absorption has been shown in another study during administration of ezetimibe plus plant sterols (2 g/day) which resulted in an additional 7 % reduction in LDL-cholesterol compared to ezetimibe alone17.