European Journal of Clinical Nutrition (2014) 68, 587–591 & 2014 Macmillan Publishers Limited All rights reserved 0954-3007/14 www.nature.com/ejcn 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.