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Review
. 2024 Oct 21;23(1):341.
doi: 10.1186/s12944-024-02330-7.

Heart-healthy diets including phytostanol ester consumption to reduce the risk of atherosclerotic cardiovascular diseases. A clinical review

Piia Simonen  1 , Lotta Nylund  2 , Erkki Vartiainen  3 , Petri T Kovanen  4 , Timo E Strandberg  5   6 , Katariina Öörni  4 , Ingmar Wester  2 , Helena Gylling  7
Affiliations
Review

Heart-healthy diets including phytostanol ester consumption to reduce the risk of atherosclerotic cardiovascular diseases. A clinical review

Piia Simonen et al. Lipids Health Dis. .

Abstract

The risk of atherosclerotic cardiovascular diseases (ASCVDs) can be reduced by lowering low-density lipoprotein cholesterol (LDL-C) concentrations. Nevertheless, ASCVDs still cause most deaths worldwide. Here, we discuss the prevention of ASCVD and the event risk with a focus on heart-healthy diets, i.e., low intakes of saturated and trans-fatty acids and cholesterol, and high intakes of unsaturated fatty acids, viscous fibre, and dietary phytostanols as fatty acid esters, according to international dyslipidaemia treatment guidelines. Calculations based on both FINRISK and Cholesterol Treatment Trialists' Collaborators regression equations indicate that heart-healthy diets combined with phytostanol ester reduce LDL-C concentrations to such an extent that the 10-year estimated reduction in the incidence of coronary artery disease would be 23%. This information can be used, in particular, to prevent the development of subclinical atherosclerosis in healthy middle-aged populations and the progression of atherosclerosis to ASCVD. The outcome of simple and feasible dietary changes, and, when needed, combined with statins, can be significant: reduced mortality, an increased number of healthy life-years, and reduced healthcare costs.

Keywords: Atherosclerosis; Cholesterol; Cholesterol absorption; Coronary artery disease; LDL aggregation; LDL-cholesterol; Phytostanol- and phytosterol ester.

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Conflict of interest statement

P.S. and E.V. declare no conflicts of interest. L.N. and I.W. are employed by Raisio Group plc. and I.W. own shares in the company. P.T.K. has received consultancy fees, lecture honoraria, and/or travel fees from Amarin, Amgen, Novartis, Raisio Group, and Sanofi. He is also a co-inventor of a patent concerning LDL aggregation. T.E.S. has taken part in consultative work, research, and educational cooperation with several companies marketing cholesterol-lowering products. K.Ö. and P.T.K. are co-inventors of a patent concerning LDL aggregation. H.G. has taken part in educational and consultative collaboration regarding human cholesterol metabolism with Raisio Group plc. Raisio Group plc. had no role in the design or execution of the study or analysis of the data.

Figures

Fig. 1
Fig. 1
Simplified scheme of the absorption of cholesterol, phytosterols, and phytostanols Footnote: Niemann–Pick C1-Like 1 transporter takes up cholesterol, phytosterols, and phytostanols into the enterocyte, but about half of the cholesterol and most of the phytosterols, and phytostanols in particular, are driven back to the intestinal lumen via the adenosine triphosphate-binding cassette (ABC) transporters G5 and G8. Eventually, approximately 50–60% of the cholesterol, 0.5–2% of the phytosterols, and 0.04–0.15% of the phytostanols are absorbed into the body [26] Abbreviations: ABCG5/8 = adenosine triphosphate-binding cassette (ABC) transporters G5 and G8, apoB48 = apoprotein B48, CHOL = cholesterol, NPC1L1 = Niemann–Pick C1-Like 1 transporter, PS = phytosterols and phytostanols, TG = triglycerides
Fig. 2
Fig. 2
Cholesterol metabolism including cholesterol absorption from the small intestine and transport into the liver, delivery into tissues, and elimination from the body mainly via bile in individuals with high (panel A) and low (panel B) cholesterol absorption efficiency Footnote: The risk of atherosclerosis is increased in high vs. low cholesterol absorption, which can be interfered with by reducing cholesterol absorption by dietary and pharmacological means, resulting in increased cholesterol elimination from the body Abbreviations: LDL = low-density lipoprotein, HDL = high-density lipoprotein
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