Phytosterols, Cholesterol Control, and Cardiovascular Disease

Abstract

The use of phytosterols (or plant sterols) for the control of plasma cholesterol concentrations has recently gained traction because their efficacy is acknowledged by scientific authorities and leading guidelines. Phytosterols, marketed as supplements or functional foods, are formally classified as food in the European Union, are freely available for purchase, and are frequently used without any health professional advice; therefore, they are often self-prescribed, either inappropriately or in situations in which no significant advantage can be obtained. For this reason, a panel of experts with diverse medical and scientific backgrounds was convened by NFI-Nutrition Foundation of Italy-to critically evaluate and summarize the literature available on the topic, with the goal of providing medical doctors and all health professionals useful information to actively govern the use of phytosterols in the context of plasma cholesterol control. Some practical indications to help professionals identify subjects who will most likely benefit from the use of these products, optimizing the therapeutic outcomes, are also provided. The panel concluded that the use of phytosterols as supplements or functional foods to control Low Density Lipoprotein (LDL) cholesterol levels should be preceded by the assessment of some relevant individual characteristics: cardiovascular risk, lipid profile, correct understanding of how to use these products, and willingness to pay for the treatment.

Keywords: cardiovascular disease; cholesterol; functional foods; phytosterols; plant sterols; supplements.

Figure 1

Main metabolic pathways of cholesterol and phytosterol in enterocytes. P, phytosterols.; C, cholesterol; CE, cholesteryl esters; ACAT, acylCoA cholesterol acyltransferase; NPC1L1, Niemann-Pick C1-Like 1; ABCG5, ATP-binding cassette G5; ABCG8, ATP-binding cassette G8; TG, triglycerides; B48, Apolipoprotein B-48. Modified from [18] and [19].

Figure 2

Flowchart A. Patient <40 years old or >40 years old, but with global cardiovascular risk <1%. This flow-chart is not appropriate for patients with genetic disorders of lipoprotein metabolism or with manifest cardiovascular disease, who need to be treated according to the Guidelines.

Figure 3

Flowchart B. Patient ≥40 years old with global cardiovascular risk 1–5%. This flow-chart is not appropriate for patients with genetic disorders of lipoprotein metabolism or with manifest cardiovascular disease, who need to be treated according to the Guidelines.

Figure 4

Combination of phytosterols with other food supplements or drugs active on plasma cholesterol levels. Blue (continuous) arrows: appropriate combination. Red (dotted) arrows: less appropriate combinations.