Plant sterols linked to lower cholesterol and heart disease risk in major Toronto-led review

A major review led by researchers at the University of Toronto has found that plant sterols and stanols can significantly reduce harmful cholesterol levels while delivering a range of additional cardiometabolic health benefits, reinforcing the case for more plant-forward dietary patterns.

Researchers reviewed more than 800 publications and identified 14 eligible systematic reviews and meta-analyses of randomized controlled trials for inclusion.
The analysis found that plant sterols and stanols reduced total cholesterol and low-density lipoprotein cholesterol (LDL-C) across different population groups.
Participants also experienced improvements in measures including blood pressure, inflammatory markers and apolipoprotein B (ApoB).

The study, published in Clinical Nutrition, assessed the effects of plant sterols and stanols, naturally occurring compounds found in plant cell walls that help block the absorption of cholesterol in the body.

Plant sterols are present in foods including vegetables, fruits, nuts, seeds and plant oils. They are also available through dietary supplements and fortified products such as margarine and juice.

The research was led by first author Andreea Zurbau, a postdoctoral fellow in the Department of Nutritional Sciences at the University of Toronto's Temerty Faculty of Medicine and a registered dietitian, alongside principal investigator John Sievenpiper, a professor in the departments of nutritional sciences and medicine at Temerty Medicine and a staff physician and scientist at St. Michael's Hospital, Unity Health Toronto.

According to the researchers, the findings add to a substantial body of evidence supporting dietary strategies aimed at reducing cardiovascular disease risk.

“This research helps people understand how they can improve their health through their diet,” said Zurbau.

“More than one in four Canadians are living with high cholesterol levels, and our research highlights that plant foods and supplements can be a practical and accessible way to reduce LDL-cholesterol, the key driver of heart disease risk.”

The researchers screened more than 800 publications before narrowing their analysis to 14 eligible studies. The final review focused on systematic reviews and meta-analyses of randomized controlled trials, which are generally regarded as among the strongest forms of scientific evidence.

The analysis found that consumption of plant sterols and stanols was associated with lower levels of total cholesterol and LDL cholesterol, often referred to as "bad" cholesterol because elevated levels are linked to an increased risk of cardiovascular disease.

Beyond cholesterol reduction, the researchers also identified improvements in several other cardiometabolic markers. These included some positive effects on blood pressure, inflammatory markers and apolipoproteins.

One of the markers highlighted in the study was apolipoprotein B, or ApoB, a measure that reflects the number of potentially harmful cholesterol-containing particles circulating in the bloodstream. ApoB is increasingly recognized as a strong predictor of cardiovascular disease risk.

The researchers said these findings were particularly significant given the continued global burden of coronary heart disease.

“These results are particularly important for the public and clinicians, as coronary heart disease remains the leading cause of death and disability globally, and, despite numerous medications to treat high cholesterol, we are confronted with a major treatment gap,” said Sievenpiper.

Based on the findings, the researchers pointed to dietary approaches such as the Portfolio Diet, which incorporates cholesterol-lowering foods including plant sterols and stanols as part of a broader strategy to improve heart health.

The study also explored the quantities of plant sterols needed to achieve measurable benefits. According to Zurbau, the average person consuming a typical Western diet ingests approximately 300 milligrams of plant sterols per day. That figure can rise to around 600 milligrams daily among people following vegetarian or vegan diets.

The review suggested that meaningful improvements could be achieved at relatively modest intake levels.

“We explored the best available evidence and found that daily intakes as little as half a gram of plant sterols, achievable from ordinary foods or supplements, can lower harmful cholesterol in people of all health backgrounds, including those already on cholesterol-lowering medication,” said Zurbau.

The researchers concluded that consuming between 500 milligrams and 1.0 gram of plant sterols and stanols per day could lead to clinically meaningful health benefits.

Importantly, the benefits appeared consistent regardless of how the compounds were consumed. Participants experienced reductions in LDL cholesterol whether plant sterols were obtained through fortified foods, dietary supplements, or naturally occurring food sources.

“There are many ways of consuming plant sterols, and many different people who can experience benefits as a result. We saw that whether the plant sterols were provided as part of fortified foods, or whether they were provided as food and supplements, people seemed to have clinically meaningful reductions in LDL cholesterol,” said Zurbau.

The study was funded by the Canadian Institutes of Health Research through the Canada-wide Human Nutrition Trialists' Network. The researchers noted that details of financial disclosures were available in the published paper.