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CONSENSuS POSITION PAPEr ON PlANT STErOlS AND PlANT STANOlS IN ThE MANAgEMENT OF DYSlIPIDAEMIA AND PrEVENTION OF CArDIOVASCulAr DISEASE.



Objective this eAS consensus Panel critically appraised evidence relevant to the benefit to risk relationship of functional foods with added plant sterols and/or plant stanols, as components of a healthy lifestyle, to reduce plasma low-density lipoprotein-cholesterol (LDL-c) levels, and thereby lower cardiovascular risk.
Methods and results plant sterols/stanols (when taken at 2 g/ day) cause significant inhibition of cholesterol absorption and lower LDL-c levels by between 8 and 10%. the relative proportions of cholesterol versus sterol/ stanol levels are similar in both plasma and tissue, with levels of sterols/stanols being 500-/10,000-fold lower than those of cholesterol, suggesting they are handled similarly to cholesterol in most cells.
Despite possible atherogenicity of marked elevations in circulating levels of plant sterols/stanols, protective effects have been observed in some animal models of atherosclerosis.
higher plasma levels of plant sterols/stanols associated with intakes of 2 g/day in man have not been linked to adverse effects on health in longterm human studies. importantly, at this dose, plant sterol/stanol-mediated LDL-c lowering is additive to that of statins in dyslipidaemic subjects, equivalent to doubling the dose of statin.
the reported 6–9% lowering of plasma triglyceride by 2 g/day in hypertriglyceridaemic patients warrants further evaluation.
Conclusion based on LDL-c lowering and the absence of adverse signals, this eAS consensus Panel concludes that functional foods with plant sterols/stanols may be considered 1) in individuals with high cholesterol levels at intermediate or low global cardiovascular risk who do not qualify for pharmacotherapy, 2) as an adjunct to pharmacologic therapy in high and very high risk patients who fail to achieve LDL-c targets on statins or are statin- intolerant, 3) and in adults and children (>6 years) with familial hypercholesterolaemia, in line with current guidance.
however, it must be acknowledged that there are no randomised, controlled clinical trial data with hard endpoints to establish clinical benefit from the use of plant sterols or plant stanols.

AuthOrS

Helena GyllinGe, JoGcHum Plat, StePHen turley, Henry n. GinSberG, larS elleGård, Wendy JeSSuP, Peter J. JoneS, dieter lütJoHann, Winfried maerz, luiS maSana, GüntHer SilbernaGel, bart StaelS, Jan borén, alberico l. cataPano, Guy de backer, JoHn deanfield, olivier S. deScamPS, Petri t. kovanen, Gabriele riccardi, lale tokGözoGlu, m. JoHn cHaPman, euroPean atHeroScleroSiS Society conSenSuS Panel on PHytoSterolS



https://www.escardio.org/static_file/Escardio/Guidelines/publications/DYSLIPguidelines-dyslipidemias-FT.pdf

guIDElINES FOr ThE MANAgEMENT OF DYSlIPIDEMIAS



Dietary Supplements and functional foods active on plasma lipid innovative nutritional strategies to improve dyslipidemias have been developed; they are based either on changing some ‘risky’ dietary components or on encouraging the consumption of specifically targeted ‘healthy’ functional foods and/ or dietary supplements; these so-called ‘nutraceuticals’ can be used either as alternatives or in addition to lipid-lowering drugs.
nutritional evaluation of functional foods includes not only the search for the clinical evidence of beneficial effects relevant to improved health or reduction of disease risk, but also the demonstration of good tolerability and the absence of major undesirable effects. the substantiation of health claims relevant for each food should be based on results from intervention studies in humans that are consistent with the proposed claims.
Overall, the available evidence on functional foods so far identified in this field is lacking; the major gap is the absence of diet-based intervention trials of sufficient duration to be relevant for the natural history of dyslipidemia and cvD.

Phytosterols
the principal phytosterols are sitosterol, campesterol, and stigmasterol, and they occur naturally in vegetable oils and, in smaller amounts, in vegetables, fresh fruits, chestnuts, grains, and legumes. the dietary intake of plant sterols ranges between an average of 250 mg/day in northern europe to 500 mg/day in Mediterranean countries. Phytosterols compete with cholesterol for intestinal absorption, thus modulating tc levels.
Phytosterols have been added to spreads and vegetable oils (functional margarine, butter, and cooking oils) as well as yoghurt and other foods; however, food matrices do not significantly influence the cholesterol-lowering efficacy of phytosterols at equivalent doses. the daily consumption of 2 g of phytosterols can effectively lower tc and LDL-c by 7–10% in humans, with little or no effect on hDL-c and tG levels when consumed with the main meal.
currently there are no data available indicating that cholesterol lowering through plant sterol ingestion results in prevention of cvD. Long-term surveillance is also needed to guarantee the safety of the regular use of phytosterol-enriched products. the possible decrease in carotenoid and fat-soluble vitamin levels by sterols/ stanols can be prevented with a diet rich in these nutrients.

Soy protein
Soy protein has a modest LDL-c-lowering effect. Soy foods can be used as a plant protein substitute for animal protein foods high in SfAs, but expected LDL-c lowering may be modest (3–5%) and most likely in subjects with hypercholesterolemia.


Dietary fibre
Available evidence consistently demonstrates a tc- and LDL-c-lowering effect of water-soluble fiber from oat bran, b-glucan, and psyllium. foods enriched with these fibers are well tolerated, effective, and recommended for LDL-c lowering at a daily dose of 5–15 g/day soluble fiber.


n-3 unsaturated fatty acids
Supplementation with 2–3 g/day of fish oil (rich in long chain n-3 fatty acids) can reduce tG levels by 25–30% in both normo-lipidaemic and hyperlipidemic individuals. A-Linolenic acid (a medium chain n-3 fatty acid present in chestnuts, some vegetables, and some seed oils) is less effective on tG levels. Long chain n-3 PufAs also reduce the postprandial lipaemic response. Long chain n-3 PufAs, at doses of 3 g/ day given as supplements, may increase LDL-c by 5% in severely hypertriglyceridaemic patients.85 however, a low dose supplementation of a margarine with n-3 PufAs (400 mg/day) or a-linolenic acid (2 g/day) did not significantly reduce tG levels in an rct involving 4837 post-Mi patients; neither did this supplementation reduce the rate of major cv events.


Policosanol and red yeast rice
Policosanol is a natural mixture of long chain aliphatic alcohols extracted primarily from sugarcane wax. 93 Studies show that policosanol from sugarcane, rice, or wheat germ has no significant effects on LDL-c, hDL-c, tG, apo b, Lp(a), homocysteine, hs-crP, fibrinogen, or blood coagulation factors.
‘red yeast rice’ (ryr) is a source of fermented pigment used in china as a food colorant and flavor enhancer for centuries.
Possible bioactive effects of ryr are related to a statin-like mechanism [inhibition of hydroxymethylglutaryl-coenzyme A (hMG-coA) reductase]. Different commercial preparations of ryr have different concentrations of monacolins, the bioactive ingredients, and lower tc and LDL-c,71 but the long-term safety of the regular consumption of these products is not fully documented. in one rct from china in patients with cAD, a partially purified extract of ryr reduced recurrent events by 45%.


CONCLUSION
treatment with red yeast chinese rice has reduced the cardiovascular events and the death rate by 30% and 33%, and need for coronary revascularization has lowered to one third of the original rate. the therapy has reduced the level of LDL and tG but with an increase of hDL.

AuthOrS

67. abumWeiS SS, barake r, JoneS PJ. Plant SterolS/StanolS aS cHoleSterol loWerinG aGentS: a meta-analySiS of randomized controlled trialS. food nutr reS 2008;52: doi:10.3402/fnr. v52io.1811.
69. Sirtori cr, Galli c, anderSon JW, arnoldi a. nutritional and nutraceutical aPProacHeS to dySliPidemia and atHeroScleroSiS Prevention: focuS on dietary ProteinS. atHeroScleroSiS 2009;203:8–17.
71. becker dJ, Gordon ry, Halbert Sc, frencH b, morriS Pb, rader dJ. red yeaSt rice for dySliPidemia in Statin-intolerant PatientS: a randomized trial. ann intern med 2009;150:830–839.
72. lu z, kou W, du b, Wu y, zHao S, bruSco oa, morGan Jm, caPuzzi dm, li S; cHineSe coronary Secondary Prevention Study GrouP. effect of XuezHikanG, an eXtract from red yeaSt cHineSe rice, on coronary eventS in a cHineSe PoPulation WitH PreviouS myocardial infarction. am J cardiol 2008;101:1689–1693. 85. liu S, manSon Je, StamPfer mJ, HolmeS md, Hu fb, HankinSon Se, Willett Wc. dietary Glycemic load aSSeSSed by food-frequency queStionnaire in relation to PlaSma HiGH denSity-liPoProtein cHoleSterol and faStinG PlaSma triacylGlycerolS in PoStmenoPauSal Women. am J clin nutr 2001;73:560–566.
88. PaSSclaim. ProceSS for tHe aSSeSSment of Scientific SuPPort for claimS on foodS: conSenSuS on criteria. eur J nutr 2005;44:i/5 – i/30.
89. lea lJ, HePburn Pa. Safety evaluation of PHytoSterol-eSterS. Part 9: reSultS of a euroPean PoSt-launcH monitorinG ProGramme. food cHem toXicol 2006;44: 1213 – 1222.
90. deWell a, Hollenbeck Pl, Hollenbeck cb. a critical evaluation of tHe role of Soy Protein and iSoflavone SuPPlementation in tHe control of PlaSma cHoleSterol concentrationS. J clin endocrinol metab 2006:91:772–780.
91. rideout tc, HardinG Sv, JoneS PJ, fan mz. Guar Gum and Similar Soluble fiberS in tHe reGulation of cHoleSterol metaboliSm: current underStandinGS and future reSearcH PrioritieS. vaSc HealtH riSk manaG 2008;4:1023–1033.
92. kromHout d, Giltay eJ, GeleiJnSe Jm for tHe alPHa omeGa trial GrouP. n-3 fatty acidS and cardiovaScular eventS after myocardial infarction. n enGl J med 2010; 363:2015 – 2026.
93. maS r, caStano G, illinait J, fernández l, fernández J, alemán c, PontiGaS v, leScay m. effectS of PolicoSanol in PatientS WitH tyPe ii HyPercHoleSterolemia and additional coronary riSk factorS. clin PHarmacol tHer 1999;65:439–447.
94. reiner z, tedeScHi-reiner e, romic á z. effectS of rice PolicoSanol on Serum liPo- ProteinS, HomocySteine, fibrinoGen and c-reactive Protein in HyPercHoleStero- laemic PatientS. clin druG inveStiG 2005;25:701–707.


https://www.escardio.org/static_file/Escardio/Guidelines/publications/DYSLIPguidelines-dyslipidemias-FT.pdf

MONACOLIN
EFFECT OF XuEzhIkANg, AN EXTrACT FrOM rED YEAST ChINESE rICE, ON COrONArY EVENTS IN A ChINESE POPulATION wITh PrEVIOuS MYOCArDIAl INFArCTION.



treatment with red yeast chinese rice has reduced the cardiovascular events and the death rate by 30% and 33%, and need for coronary revascularization has lowered to one third of the original rate. the therapy has reduced the level of LDL and tG but with an increase of hDL.

AuthOrS
zonGlianG lu, md, PHda, WenronG kou, mda, baominG du, mdb, yanGfenG Wu, mde, SHuiPinG zHao, md, PHdd, oSvaldo a. bruSco, mde, JoHn m. morGan, mdf, and david m. caPuzzi, md, PHdf on beHalf of tHe cHineSe coronary Secondary Prevention Study GrouP


https://www.escardio.org/static_file/Escardio/Guidelines/publications/DYSLIPguidelines-dyslipidemias-FT.pdf