Plant Sterol and Stanol Intake in Finland: a Comparison Between Users and Nonusers of Plant Sterol- and Plant Stanol-Enriched Foods

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ORIGINAL ARTICLE Plant sterol and stanol intake in Finland: a comparison between users and nonusers of plant sterol- and plant stanol-enriched foods

M Marttinen1, M Kosola2, M-L Ovaskainen2, M Mutanen1 and S Ma¨nnisto¨ 3

BACKGROUND/ OBJECTIVES: We evaluated plant sterol and stanol (PS) intakes from natural sources and enriched foods in the Finnish population-based national FINDIET 2007 Survey. In addition, we compared the users and nonusers of PS-enriched foods in terms of their characteristics and dietary intake. SUBJECTS/METHODS: This was a cross-sectional population-based study on 958 men and 1080 women aged 25–74. Users and nonusers of PS-enriched products were compared with respect to sex, age, education, region, cholesterol-lowering medication and cholesterol-lowering diet. Intakes of PS, energy, energy nutrients, fat composition, cholesterol and dietary ﬁbre were calculated on the basis of a 48-h dietary recall. The distribution of PS intake was assessed for the users of enriched products. RESULTS: PS-enriched foods were used by 9.5% of all subjects. The usage increased signiﬁcantly with age (Po0.001) and level of education (P ¼ 0.01). The usage of enriched products was more common among those following a cholesterol-lowering medication or diet (Po0.001 for both). Among users, the mean intake of PS was 2.2 g/d for men and 1.6 g/d for women, and among nonusers it was 363 mg/d for men and 286 mg/d for women. The majority of users received less than 2 g/d of PS from enrichment, but 20% of users obtained more than 3 g of PS per day. CONCLUSIONS: The intake of PS can reach several grams in a subgroup of subjects consuming PS-enriched foods. The manufacturers’ recommendations on PS-enriched food consumption are not consistently followed, and customer guidance needs to be improved.

European Journal of Clinical Nutrition (2014) 68, 587–591; doi:10.1038/ejcn.2014.3; published online 12 February 2014 Keywords: phytosterols; enriched foods; dietary intake; population

INTRODUCTION plant stanol-enriched products with necessary information on the Plant sterols are cholesterol-resembling compounds that are target group and intake levels of plant sterols and stanols from found in plant-based foods. Good natural sources of plant sterols enrichment (Regulation EC No 608/2004). Currently, producers are are vegetable oils, nuts, seeds, cereals, vegetables and fruit.1 advising customers to consume 2 g/d of plant sterols or stanols to According to the Finnish population-based national FINDIET 1997 attain a beneficial effect on LDL-C. Previous studies indicate that Survey the mean plant sterol intake from natural sources was the intake of plant sterols and stanols from enrichment can go 305 mg/d for men and 237 mg/d for women.2 Plant stanols are beyond the recommended level in certain subgroups; however, saturated forms of plant sterols that are less abundant in nature many of these studies included only consumers of enriched but are found mainly in commercially available functional foods. products,6,7 or the sample was not randomly selected.8 Similarly, Because of their beneficial effect on blood low-density lipoprotein simulation studies based on population dietary data have cholesterol (LDL-C), the food industry has designed functional proposed that the potential daily intake of plant sterols and foods enriched with plant sterol and stanol esters. Plant stanol stanols could exceed 8 g when conventional foods in the diet, for ester-enriched food products were brought to market first in example, margarines and yoghurts, were hypothetically replaced Finland in 1995 and later on plant sterol ester-enriched foods were with plant sterol- or stanol-enriched products.9,10 introduced to European customers. The European Food Safety The intake of plant sterols has been studied earlier in Finland in Authority has declared in their scientific opinion that a daily intake 1997; however, the users of enriched products were excluded of 3 g plant sterols or stanols lower LDL-C at similar efficacy by from analyses.2 So far, the intake of plant sterols and stanols from 11.3% and the effect is achieved when consumed for at least 2–3 enriched products has not been evaluated in the Finnish weeks.3 There seems to be some additional effect on LDL-C population. It seems likely that since 1997 the consumption of reduction when plant stanols are consumed at higher doses.4,5 plant sterol- and plant stanol-enriched foods has become more The European Food Safety Authority and the Scientific Committee common and therefore these food items could relevantly on Food state that intakes above 3 g/d should be avoided, contribute to the intake of dietary plant sterols. The main based on the scientific evidence on plant sterols and stanols and objective of this study was to evaluate the plant sterol and their blood b-carotene-decreasing effect.6 The European stanol intake from natural dietary sources and from plant sterol- Commission requires the producers to label plant sterol- and and plant stanol-enriched food items in the FINDIET 2007 Survey

1Division of Nutrition, Department of Food and Environmental Sciences, University of Helsinki, Helsinki, Finland; 2Nutrition Unit, Department of Lifestyle and Participation, National Institute of Health and Welfare, Helsinki, Finland and 3Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland. Correspondence: M Marttinen, Division of Nutrition, Department of Food and Environmental Sciences, PO Box 66 (Agnes Sjo¨bergin katu 2), FI-00014 University of Helsinki, Finland. E-mail: maija.marttinen@helsinki.fi Received 28 May 2013; revised 7 December 2013; accepted 19 December 2013; published online 12 February 2014 Plant sterol and stanol intake in Finland M Marttinen et al 588 using a 48-h dietary recall. Most importantly, we wanted to Table 1. Relationship between the use of PS-enriched food products determine how high plant sterol and stanol intakes from enriched and characteristics based on 48 h dietary recall foods are achieved when assessed using a population-based survey and whether the advised doses set by food manufacturers User (%), n ¼ 194 Nonuser (%), n ¼ 1844 P-valuea were followed by Finnish customers in the short term. Sex Men 9.2 90.8 SUBJECTS AND METHODS Women 9.8 90.2 0.65 The intake of plant sterols and stanols was calculated from the data collected by the National FINDIET 2007 Survey, which was conducted as a Age group, years part of the National FINRISK 2007 Study at the National Institute for Health 25–44 3.8 96.2 and Welfare (THL) in Finland.11 The National FINRISK Study is a cross- 45–64 11.0 89.0 sectional population survey that monitors cardiovascular risk factors at 65–74 15.3 84.7 o0.001 5-year intervals. The FINDIET 2007 Survey collected data on dietary habits b from 33% of the FINRISK 2007 Study participants by means of a 48-h Education dietary recall carried out by nutritionists trained in the method. The dietary Low 6.8 93.2 recall was completed for 2054 subjects, and dietary recall was accepted Middle 10.3 89.7 from 2038 subjects (62% of the sample). A detailed description on dietary High 11.1 88.9 0.01 data collection is described by Reinivuo et al.12 The present study included a random sample of 958 men and 1080 women aged 25–74 from five Region regions in Finland. The study was conducted according to the guidelines South 10.3 89.7 laid down in the declaration of Helsinki and all procedures involving North 9.1 91.0 0.39 participants were approved by the Ethics Committee of Helsinki and c Uusimaa hospital district. Written informed consent was obtained from all Cholesterol medication participants for field research. Yes 18.2 81.8 The abbreviation PS is used to cover both plant sterols and plant stanols, No 9.6 90.4 o0.001 and specific compounds are named when necessary. Users of plant sterol Cholesterol-lowering diet d ester margarine (n ¼ 91), plant stanol ester margarine (n ¼ 86) and users of Yes 27.4 72.6 other PS-enriched food items other than margarine (n ¼ 30) were identified from the 48 h dietary recall. There were subjects identified as No 6.8 93.2 o0.001 users in multiple aforementioned subgroups. Intakes of PS, cholesterol, aFisher’s exact test; P-values represent the significance of a characteristic energy, fat, fat composition (saturated, monounsaturated, polyunsatu- variable on the use of PS-enriched foods. bData missing from15 subjects. rated) and dietary fibre were calculated on the basis of the 48 h dietary cData missing from 379 subjects. dData missing from 59 subjects. recall using the national food composition database Fineli (version 7) at THL.12 First, users and nonusers of PS-enriched foods were compared with respect to sex, age, education, region (south and north Finland), cholesterol-lowering medication and cholesterol-lowering diet. Next, the mean daily intakes of plant sterols and stanols, energy and selected Among users, the mean intake of PS was 2.2 g/d for men and nutrients were compared between the users (n ¼ 194) and nonusers 1.6 g/d for women, of which enrichment accounted for 1.9 g/d (n ¼ 1844) of PS-enriched products. Finally, the distribution of dietary PS (86%) for men and 1.4 g/d (88%) for women (Table 2). The mean intake was assessed for the users of PS-enriched products and for users of intake of PS among nonusers (plant sterols and stanols from plant sterol- and plant stanol-enriched products separately. natural sources) was 363 mg/d for men and 286 mg/d for women. The mean intakes of energy and selected nutrients were Statistical analysis compared between the users and nonusers of PS-enriched products (Table 2). The results did not differ when adjusted for The relationship between the use of PS-enriched products and the characteristic variables was tested using Fisher’s exact test. Differences in age or for age and education (data not shown). After adjusting for nutrient intakes between users and nonusers of PS-enriched foods were age, education and the use of cholesterol-lowering medication tested using analysis of variance, adjusting for age. The analyses were also and/or cholesterol-lowering diet, percentages for fat, saturated fat conducted using education as a covariate in the model as well as using and monounsaturated fat from energy were found to be lower in cholesterol medication and/or cholesterol-lowering diet. All statistical subjects using PS-enriched products compared with nonusers, analyses were performed using the SAS statistical package version 8.2 and this was observed in both men and women (Table 2). The (SAS Institute Inc., Cary, NC, USA). percentage for polyunsaturated fat from total energy intake was not different between users and nonusers. Cholesterol intake was significantly lower in men using PS-enriched products compared RESULTS with men not using PS-enriched products. No difference in The characteristics of users of PS-enriched products are shown in cholesterol intake was found between users and nonusers among Table 1. PS-enriched margarines or other foods were used by 9.5% women after adjusting for age and education; however, when (n ¼ 194) of all participants, and the use of PS-enriched products including the use of cholesterol-lowering medication and/or was similar among men (n ¼ 88, 9.2%) and women (n ¼ 106, 9.8%). cholesterol-lowering diet as a covariate in the model, the mean The usage increased significantly with age (Po0.001) and it was intake of cholesterol was significantly lower among women using most common among subjects between 65 and 74 years of age. enriched products when compared with nonuser women. Mean The level of education was significantly associated with the use of intakes of dietary fibre did not differ between users and nonusers PS-enriched products (P ¼ 0.01), and the lowest frequency of users in either gender, although there was a trend towards a higher was among those with low education level. The use of PS-enriched density of dietary fibre in the diet (g/ MJ) in men using products was more common among subjects with cholesterol- PS-enriched products than in nonuser men after including lowering medication and diet when compared with subjects cholesterol-lowering medication and/or cholesterol-lowering diet without cholesterol-lowering medication and diet (both Po0.001). as a covariate (P ¼ 0.07). To evaluate the intake of plant sterols and stanols from natural The distribution of total dietary PS intake and plant sterol and and enriched sources, mean intakes of plant sterols and stanols plant stanol intake from enrichment among users is shown in were calculated separately for users and nonusers of PS-enriched Table 3. More than half of the users received less than 2 g/d of products (PS margarines and other PS foods combined). either plant sterol or stanol from enrichment. Among all users,

European Journal of Clinical Nutrition (2014) 587 – 591 & 2014 Macmillan Publishers Limited Plant sterol and stanol intake in Finland M Marttinen et al 589 3 g/d in 13.4% of subjects (18.6% of men and 9.3% of women). In a Table 2. Mean intake of PS, energy and selected nutrients among similar manner, the intake of plant stanol from enrichment among subjects using any PS-enriched product and subjects not using the users of plant stanol-enriched products exceeded 3 g/d in PS-enriched products (values are mean (s.d.)) 14.9% of subjects (20.8% of men and 9.4% of women). Users Nonusers P-value, P-value, adjusted 1a adjusted 2b DISCUSSION Men, n 88 870 In the present study, the mean intake of PS among the nonusers Women, n 106 974 of PS-enriched products was 363 mg/d for men and 286 mg/d for Total PS (mg) women, whereas the mean intake of PS among users was 2.2 g/d Men 2227 (1326) 363 (145) o0.001 o0.001 for men and 1.6 g/d for women. It seems that the dietary intake of Women 1627 (1123) 286 (105) o0.001 o0.001 naturally occurring plant sterols has slightly increased when compared with the estimated intakes according to the FINDIET PS from enrichment (mg) 2 Men 1892 (1290) 0 ÀÀ1997 Survey by Valsta et al., in which the mean PS intake was Women 1352 (1085) 0 ÀÀ305 mg/ d for men and 237 mg/d for women. By contrast, cholesterol intake has slightly decreased in comparison with the Energy (MJ) Men 8.19 (2.36) 8.95 (2.92) 0.15 0.24 intake in the 1997 study. The intake of plant sterols among users Women 6.16 (1.65) 6.64 (2.02) 0.53 0.59 of PS-enriched products has not been assessed earlier in the Finnish population. Plant stanol ester-enriched products were Fat (g) brought to market in Finland in 1995, and some years later Men 65.6 (25.4) 80.6 (35.4) o0.001 0.012 Women 48.8 (20.8) 56.8 (24.2) 0.038 0.020 products with plant sterol enrichment were introduced to Finnish consumers. During the data collection in 2007, several PS-enriched Fat (E%) commercial products were on market in Finland, including plant Men 29.5 (7.6) 33.0 (7.9) o0.001 0.012 sterol- and plant stanol ester-enriched margarines, yoghurt drinks, Women 28.7 (6.8) 31.2 (7.4) 0.004 0.001 o milk, sour milk, pasta and cheese-like products. Saturated fat (E%) As the LDL-C-lowering effect of plant sterols and stanols is well Men 11.2 (4.1) 14.0 (4.6) o0.001 o0.001 established, the use of PS-enriched products has become an Women 11.1 (3.6) 13.1 (4.3) o0.001 o0.001 increasingly popular treatment for lowering high serum LDL-C Monounsaturated fat (E%) levels. According to the data collected in Finland between 1996 Men 11.6 (3.7) 12.9 (3.8) 0.003 0.082 and 2000, plant stanol ester margarine was used as a bread spread Women 10.8 (3.2) 11.9 (3.5) 0.013 0.001 by 4.5% (n ¼ 1332) of subjects.13 Almost half of the plant stanol ester margarine users and one-fourth of the nonusers reported Polyunsaturated fat (E%) 13 Men 6.5 (2.2) 6.3 (2.4) 0.21 0.37 having a cardiovascular disease. In the national FINRISK 2002 Women 6.3 (2.1) 6.1 (2.3) 0.13 0.78 Study, 6% of subjects (n ¼ 588) used plant sterol- or plant stanol ester-enriched bread spread, and almost 80% of users reported Carbohydrate (g) having high or elevated blood cholesterol levels.14 The present Men 238 (78) 243 (84) 0.68 0.71 Women 184 (51) 191 (65) 0.57 0.30 data from the FINDIET 2007 Survey demonstrates that 9.5% of subjects used some PS-enriched food product including both Carbohydrate (E%) plant sterol- and plant stanol ester-enriched products. The use of Men 50.7 (8.7) 47.4 (8.8) 0.003 0.014 PS-enriched foods was more common in older people and among Women 52.4 (7.9) 50.3 (8.3) 0.025 0.004 subjects with cholesterol-lowering medication than in subjects Protein (g) without medication. However, most people on cholesterol- Men 82.5 (23.1) 87.2 (30.6) 0.76 0.45 lowering medication did not consume PS-enriched foods. The Women 63.3 (17.8) 65.8 (20.7) 1.0 0.81 use of PS-enriched foods was more common in subjects with Protein (E%) higher educational level; in general, people with higher Men 17.5 (3.1) 16.9 (3.8) 0.12 0.62 educational level are more health conscious and tend to follow Women 17.8 (3.7) 17.2 (4.0) 0.35 0.68 healthy diets than those less educated.15,16 Among the users of PS-enriched foods, the contribution of fat, saturated fat and Cholesterol (mg) Men 202 (103) 251 (148) 0.011 0.03 monounsaturated fat to energy was lower than in nonusers even Women 162 (103) 174 (89) 0.20 0.04 after adjusting for age, education and the use of cholesterol- lowering medication and/or cholesterol-lowering diet. This may be Cholesterol (mg/MJ) partly explained by the fat composition of PS-enriched Men 24.7 (9.8) 28.1 (13.0) 0.036 0.067 Women 26.3 (15.1) 26.7 (13.2) 0.29 0.047 margarines, which are low in their fat (35%, 60%) and saturated fat content; however, the users and nonusers may also differ with Dietary fibre (g) respect to other dietary behaviour. As a matter of fact, the intake Men 24.5 (12.0) 23.8 (11.0) 0.77 0.45 of cholesterol was lower in user men than in nonuser men, and Women 22.1 (8.8) 20.6 (8.9) 0.36 0.14 the difference became significant in women after adjusting for Dietary fibre (g/MJ) cholesterol-lowering medication and/or diet. Furthermore, it is Men 3.1 (1.3) 2.8 (1.2) 0.18 0.067 worth noticing that almost 73% of subjects who reported Women 3.7 (1.3) 3.2 (1.3) 0.12 0.97 following a cholesterol-lowering diet did not consume PS- aAdjusted for age. bAdjusted for age, education and cholesterol-lowering enriched foods. medication and/or cholesterol-lowering diet. Although the mean intake of PS among users of PS-enriched products is at the recommended level (2.2 g for men and 1.6 g for women), there are users who do not reach the recommended intake; on the other hand, some users consume PS at in 25% of men and 16% of women the intake of total PS was more much higher intake levels than the recommended amount. than 3 g/d. Among those subjects who used plant sterol-enriched Manufacturers producing plant sterol (Becel pro.activ, products, the intake of plant sterol from enrichment exceeded Unilever) and stanol ester-enriched foods (Benecol, Raisio Group,

& 2014 Macmillan Publishers Limited European Journal of Clinical Nutrition (2014) 587 – 591 Plant sterol and stanol intake in Finland M Marttinen et al 590 Table 3. Intakes of PS (g/d) among users of PS-enriched food products based on 48 h dietary recall

Intake of PS among users of PS products

Total dietary PSa Plant sterol from enrichmentb Plant stanol from enrichmentc

All Men Women All Men Women All Men Women

n 194 88 106 97 43 54 101 48 53 Mean (g/d) 1.9 2.2 1.6 1.4 1.7 1.2 1.7 2.0 1.5 Median (g/d) 1.6 1.9 1.3 0.94 1.3 0.90 1.4 1.9 1.2 75th percentile (g/d) 2.6 3.1 2.2 2.0 2.2 1.6 2.4 2.6 2.0 90th percentile (g/d) 3.7 4.1 3.3 3.3 3.4 2.9 3.7 3.5 3.0 95th percentile (g/d) 4.1 4.3 3.6 3.8 4.1 3.4 3.6 3.9 3.4 o2 g/d (%) 62.9 52.3 71.7 73.2 67.4 77.8 66.3 56.3 75.5 2–3 g/d (%) 17.0 22.7 12.3 14.4 16.3 13.0 18.8 22.9 15.1 43 g/d (%) 20.1 25.0 16.0 13.4 18.6 9.3 14.9 20.8 9.4 aThe intake of plant sterols and stanols from all dietary sources in all users of PS-enriched products. bThe intake of plant sterols from enrichment in the users of plant sterol ester-enriched products. cThe intake of plant stanols from enrichment in the users of plant stanol ester-enriched products.

Raisio, Finland) guide the consumers to use enriched products to of plant sterols and stanols has been evaluated by The European gain 2 g/d of plant sterol and/or stanol, and daily doses over 3 g Food Safety Authority, the long-term consumption of PS-enriched are not recommended. Consumers may, however, believe they foods has not been studied. The use of PS-enriched food items gain additional effect by increasing the daily dose of plant sterols, clearly affects the intake levels of plant sterols and stanols, and the although the evidence of the extra benefit is somewhat use and duration of enriched products needs to be assessed in controversial.17 The intake of plant sterols or stanols from the future. enriched products has been estimated earlier in Belgium in the Because the dietary intake of plant sterols and stanols was Dutch-speaking region using the food frequency questionnaire assessed using a 48-h dietary recall interview, there are (FFQ) method8 and in Ireland using an interviewer-assisted possibilities of some measurement errors in the intake values questionnaire targeting the consumers of PS-enriched foods.7 due to individuals’ subjective information on dietary intake. Among the users of PS-enriched foods, the mean intake of plant Previously, the intake of plant sterols in a Swedish population sterols and stanols was 1.5 g/d in Belgium8 and 2.5 g/d in Ireland.7 was estimated with FFQ and 24-h dietary recall methods.24 The In the Belgian study population, 23% of men and 12% of women absolute intake was estimated to be 19% higher for men and 17% had mean intakes of plant sterols more than 3 g/d, and the highest higher for women with the FFQ than with the recall method. FFQ intake for men was 6.8 g/d and that for women was 5.2 g/d.8 methodology may be useful in estimating long-term plant sterol Among the users of PS-enriched foods in Ireland, the maximum and stanol intake. However, when evaluating plant sterol and intake exceeded 9 g/d.7 In the Belgian study, 29% of the stanol intakes from enrichment, the FFQ methodology can be participating adults reported consuming PS-enriched foods, applied only if the consumption of all kinds of enriched products which seems like a very high proportion of people when is covered. Furthermore, the users of PS-enriched products compared with the results from the present study. The highest were defined as those who had reported use of PS-enriched intakes of plant sterols and stanols observed in the present data products during the previous 48-h period. However, a follow-up were higher than those in Belgium8 and the total intake of plant study on a cohort of plant stanol ester margarine users observed sterols exceeded 8 g/d in some subjects (results not shown). The that the use of enriched margarine was more often inconsistent present study supports results from simulation studies, in which than consistent.25 Therefore, the use of PS-enriched foods the consumption of conventional food products was virtually may have been occasional among those who were identified as replaced by PS-enriched products.9,10 These virtual scenarios have users in the present data. Likewise, the nonusers of this study estimated that the intake of plant sterols can exceed 8 g/d. may have been classified as users in some other investigation. Natural plant sterols and stanols originate from sources that are The duration or consistency of consumption of PS-enriched rich in other bioactive compounds, such as minerals, antioxidants, foods cannot be determined from our data. Although folate and dietary fibre. Therefore, people with the highest intakes consumption may be random in some subjects, it is likely of plant sterols from natural sources have high intakes of other that there is a subgroup of users who are long-term users of beneficial dietary factors too. When high intake of plant sterols PS-enriched foods with high total intake of plant sterols and and stanols originates from enrichment, the food matrices such as stanols as observed by Hearty et al.7 bread spreads and yoghurt alone do not provide other beneficial In conclusion, the present study shows that the intake of plant dietary compounds in similar extent and variety as compared with sterols and stanols may reach several grams when enriched foods natural sources of plant sterols and stanols. Furthermore, in are consumed, whereas daily intake of dietary plant sterols and previous epidemiological studies, the intake of natural plant stanols from natural sources remains at a few hundred milligrams. sterols, even for subjects with the highest intakes, remains at a few Our results indicate that manufacturers’ recommendations on the hundred milligrams per day.18,19 According to our results, the labels of PS-enriched products are not consistently followed, and intake of plant sterols and stanols is much higher for subjects customer guidance may need to be improved until more research consuming functional food items than for those consuming only is carried out on the long-term effects of plant sterols and stanols naturally occurring dietary plant sterols. To date, the safety of at high daily doses. plant sterols is well established, although adverse effects of plant sterols and stanols have been reported.20–22 In humans, reduced serum carotenoid concentration is a side effect that is consistently CONFLICT OF INTEREST 23 observed in clinical studies. Although the evidence on the safety The authors declare no conflict of interest.

European Journal of Clinical Nutrition (2014) 587 – 591 & 2014 Macmillan Publishers Limited Plant sterol and stanol intake in Finland M Marttinen et al 591 ACKNOWLEDGEMENTS 12 Reinivuo H, Hirvonen T, Ovaskainen ML, Korhonen T, Valsta LM. Dietary survey We thank Heli Tapanainen for her assistance in the statistical analyses. This study was methodology of FINDIET 2007 with a risk assessment perspective. Public Health funded by the Finnish Food Research Foundation and the Jenny and Antti Wihuri Nutr 2010; 13: 915–919. Foundation. The National Institute for Health and Welfare (former National Public 13 Simojoki M, Luoto R, Uutela A, Rita H, Boice Jr JD, McLaughlin JK et al. Use of plant Health Institute) in Finland is acknowledged for making the national FINDIET 2007 stanol ester margarine among persons with and without cardiovascular disease: Survey possible. early phases of the adoption of a functional food in Finland. Nutr J 2005; 4:20. 14 De Jong N, Simojoki M, Laatikainen T, Tapanainen H, Valsta L, Lahti-Koski M et al. The combined use of cholesterol-lowering drugs and cholesterol-lowering bread spreads: health behavior data from Finland. Prev Med 2004; 39: 849–855. REFERENCES 15 Boylan S, Lallukka T, Lahelma E, Pikhart H, Malyutina S, Pajak A et al. Socio- 1 Piironen V, Toivo J, Puupponen-Pimia¨ R, Lampi A-M. Plant sterols in vegetables, economic circumstances and food habits in Eastern, Central and Western Eur- fruits and berries. J Sci Food Agr 2003; 83: 330–337. opean populations. Public Health Nutr 2011; 14: 678–687. 2 Valsta LM, Lemstro¨m A, Ovaskainen M-L, Lampi A-M, Toivo J, Korhonen T et al. 16 Konttinen H, Sarlio-La¨hteenkorva S, Silventoinen K, Ma¨nnisto¨ S, Haukkala A. Socio- Estimation of plant sterol and cholesterol intake in Finland: quality of new values economic disparities in the consumption of vegetables, fruit and energy-dense and their effect on intake. Br J Nutr 2004; 92: 671–678. foods: the role of motive priorities. Public Health Nutr 2013; 16: 873–882. 3 EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA). Scientific Opinion 17 Musa-Veloso K, Poon TH, Elliot JA, Chung C. A comparison of the LDL-cholesterol on the substantiation of a health claim related to 3 g/day plant sterols/stanols and lowering efficacy of plant stanols and plant sterols over a continous dose range: lowering blood LDL-cholesterol and reduced risk of (coronary) heart disease results of a meta-analysis of randomized placebo-controlled trials. Prostagl Leukotr pursuant to Article 19 of Regulation (EC) No 1924/20061. EFSA J 2012; 10: 2693. Essent Fatty Acids 2011; 85: 9–28. 4 Gylling H, Hallikainen M, Nissinen MJ, Simonen P, Miettinen TA. Very high plant 18 Normeń AL, Brants HA, Voorrips LE, Andersson HA, van den Brandt PA, stanol intake and serum plant stanols and non-cholesterol sterols. Eur J Nutr 2010; Goldbohm RA. Plant sterol intakes and colorectal cancer risk in the Netherlands 49: 111–117. Cohort Study on Diet and Cancer. Am J Clin Nutr 2001; 74: 141–148. 5 Mensink RP, de Jong A, Lu¨tjohann D, Haenen GR, Plat J. Plant stanols dose- 19 Andersson SW, Skinner J, Ellegård L, Welch AA, Bingham S, Mulligan A et al. Intake dependently decrease LDL-cholesterol concentrations, but not cholesterol-stan- of dietary plant sterols is inversely related to serum cholesterol concentration in dardized fat-soluble antioxidant concentrations, at intakes up to 9 g/d. Am J Clin men and women in the EPIC Norfolk population: a cross-sectional study. Eur J Clin Nutr 2010; 92: 24–33. Nutr 2004; 58: 1378–1385. 6 EFSA. Consumption of food and beverages with added plant sterols. EFSA J 2008; 20 Chen Q, Gruber H, Swist E, Coville K, Pakenham C, Ratnayake WM et al. Dietary 133: 1–21. phytosterols and phytostanols decrease cholesterol levels but increase blood 7 Hearty A, Duffy E, Joyce J, O’Connor C, Gibney MJ. Phytosterol-enriched products pressure in WKY inbred rats in the absence of salt-loading. Nutr Metab (Lond) on the Irish market: examination of intake and consumption patterns. Public 2010; 7:11. Health Nutr 2009; 12: 51–58. 21 Goncalves A, Gleize B, Bott R, Nowicki M, Amiot MJ, Lairon D et al. Phytosterols 8 Sioen I, Matthys C, Huybrechts I, Van Camp J, De Henauw S. Consumption of plant can impair vitamin D intestinal absorption in vitro and in mice. Mol Nutr Food Res sterols in Belgium: consumption patterns of plant sterol-enriched foods in 2011; 55: S303–S311. Flanders, Belgium. Br J Nutr 2011; 105: 911–918. 22 Marttinen M, Païva¨rinta E, Storvik M, Huikko L, Luoma-Halkola H, Piironen V et al. 9 Kuhlmann K, Lindtner O, Bauch A, Ritter G, Woerner B, Niemann B. Simulation of Plant stanols induce intestinal tumor formation by up-regulating Wnt and EGFR

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& 2014 Macmillan Publishers Limited European Journal of Clinical Nutrition (2014) 587 – 591