Fat-modified diets influence serum concentrations of cholesterol precursors and plant sterols in hypercholesterolemic subjects

The effects of canola and olive oils consumption compared to sunflower oil, on lipid profile and hepatic steatosis in women with polycystic ovarian syndrome: a randomized controlled trial

BACKGROUND

Polycystic Ovarian Syndrome (PCOS) is one of the most common endocrinopathies and metabolic disorders in women during their reproductive years. It is often associated with dyslipidemia and other risk factors of cardiovascular diseases (CVD). This study was aimed to evaluate dietary intervention effects with canola and olive oils compared to sunflower oil on lipid profile and fatty liver severity among women with PCOS.

METHOD

This study was a 10-week intervention including 72 women with PCOS. Patients were randomly assigned to three groups for receiving 25 g/day canola, olive, or sunflower oils for 10 weeks. The primary and secondary outcomes were to assess changes in lipid profile and in fatty liver severity, respectively.

RESULT

At the end of the study, 72 patients with a mean age of 29.31 were analysed. Canola oil consumption resulted in a significant reduction in serum levels of TG (P = 0.002) and TC/HDL (P = 0.021), LDL/HDL (P = 0.047), and TG/HDL (P = 0.001) ratios, however, there was no significant reduction in lipid profile following olive oil consumption. Canola (P < 0.001) and olive oils (P = 0.005) could significantly reduce the fatty liver grade. Moreover, HOMA-IR in both canola (P < 0.001) and olive (P = 0.004) groups was significantly decreased.

CONCLUSION

In total, compared to olive and sunflower oils, significant improvements in lipid profile, liver function, and HOMA-IR were observed following canola oil consumption in women with PCOS.

TRIAL REGISTRATION

IR.MUI.

RESEARCH

REC.1397.315. Registered 30 JUNE 2019 - Retrospectively registered, https://www.irct.ir/trial/38684.

ω-6 Polyunsaturated Fatty Acids and Cardiometabolic Health: Current Evidence, Controversies, and Research Gaps

The 2015 Dietary Guidelines for Americans recommend limiting the intake of saturated fatty acids (SFAs) to <10% of energy/d and replacing dietary SFAs with unsaturated fatty acids. A Presidential Advisory from the American Heart Association recently released its evaluation of the relation between dietary fats and cardiovascular disease (CVD), and also recommended a shift from SFAs to unsaturated fatty acids, especially polyunsaturated fatty acids (PUFAs), in conjunction with a healthy dietary pattern. However, the suggestion to increase the intake of PUFAs in general, and omega-6 (n-6) PUFAs in particular, continues to be controversial. This review was undertaken to provide an overview of the evidence and controversies regarding the effects of ω-6 PUFAs on cardiometabolic health, with emphasis on risks and risk factors for CVD (coronary heart disease and stroke) and type 2 diabetes mellitus (T2D). Results from observational studies show that higher intake of ω-6 PUFAs, when compared with SFAs or carbohydrate, is associated with lower risks for CVD events (10-30%), CVD and total mortality (10-40%), and T2D (20-50%). Findings from intervention studies on cardiometabolic risk factors suggest that ω-6 PUFAs reduce concentrations of LDL cholesterol and non-HDL cholesterol in a dose-dependent manner compared with dietary carbohydrate, and have a neutral effect on blood pressure. Despite the concern that ω-6 fatty acids increase inflammation, current evidence from studies in humans does not support this view. In conclusion, these findings support current recommendations to emphasize consumption of ω-6 PUFAs as a replacement of SFAs; additional randomized controlled trials with cardiometabolic disease outcomes will help to more clearly define the benefits and risks of this policy.

Effects of Canola Oil Consumption on Lipid Profile: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

Hyperlipidemia is a well- known risk factor of cardiovascular disease. A healthy diet containing vegetable oils such as canola oil (CO) may help to reduce serum lipids. This study aimed to quantify the effects of CO on lipid parameters using a systematic review and meta-analysis of randomized controlled trials. PubMed, Web of Science, Scopus, ProQuest, and Embase were systematically searched until December 2017, with no time and design restrictions. Also, a manual search was performed to find extra relevant articles. Lipid parameters including total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglycerides (TG), apolipoprotein A1 (Apo A1), and apolipoprotein B (Apo B) were entered the meta-analysis. Weighed mean difference (WMD) and 95% confidence interval (CI) were stated as the effect size. Sensitivity analyses and prespecified subgroup were conducted to evaluate potential heterogeneity. Twenty-seven trials, comprising 1359 participants, met the eligibility criteria. Results of this study showed that CO consumption significantly reduced TC (-7.24 mg/dl, 95% CI, -12.1 to -2.7), and LDL (-6.4 mg/dl, 95% CI, -10.8 to -2), although it had no effects on HDL, TG, Apo B, and Apo A1. Effects of CO on TC and LDL significantly decreased after CO consumption in subgroups of >50 years of age participants and >30 intervention duration subgroup. Moreover, CO decreased LDL and TC compared to sunflower oil and saturated fat. This meta-analysis suggested that CO consumption improves serum TC and LDL, which could postpone heart disease progression. Key Teaching Points CO consumption could decrease serum TC and LDL, although it had no effects on other blood lipids. There was an overall significant effect of canola oil on TC and LDL compared to sunflower oil and saturated fats. CO could have beneficial effects on serum TC and LDL just when consumed longer than 30 days. CO consumption improved lipid profiles in participants older than 50 years.

Determining the mechanisms of dietary turnip rapeseed oil on cholesterol metabolism in men with metabolic syndrome

We have earlier reported the reduction of total cholesterol, low-density lipoprotein (LDL) cholesterol and oxidized LDL caused by short-term modification of diet with cold-pressed turnip rapeseed oil (CPTRO) instead of butter. The aim of this supplementary study was to determine whether the beneficial effects resulted from altered cholesterol metabolism during the intervention.Thirty-seven men with metabolic syndrome (MetS) completed an open, randomized and balanced crossover study. Subjects' usual diet was supplemented with either 37.5 g of butter or 35 mL of CPTRO for 6-8 weeks. Otherwise normal dietary habits and physical activity were maintained without major variations. Serum non-cholesterol sterols were assayed with gas-liquid chromatography and used as surrogate markers of whole-body cholesterol synthesis and absorption efficiency. Serum proprotein convertase subtilisin/kexin type 9 (PCSK9) concentration was analyzed with Quantikine ELISA Immunoassay. Serum cholesterol synthesis markers and serum cholestanol (absorption marker), all as ratios to cholesterol, did not differ between the periods. Serum campesterol and sitosterol ratios to cholesterol were significantly increased after the administration of CPTRO resulting from the increased intake of 217 mg/day of plant sterols in CPTRO. Serum PCSK9 concentration did not differ between CPTRO and butter periods.The reduction in serum cholesterol by 7.2% after consumption of rapeseed oil could not be explained by changes in cholesterol absorption, synthesis or PCSK9 metabolism in MetS.ClinicalTrials.gov NCT01119690.

Omega 6 fatty acids for the primary prevention of cardiovascular disease

BACKGROUND

Omega 6 plays a vital role in many physiological functions but there is controversy concerning its effect on cardiovascular disease (CVD) risk. There is conflicting evidence whether increasing or decreasing omega 6 intake results in beneficial effects.

OBJECTIVES

The two primary objectives of this Cochrane review were to determine the effectiveness of:1. Increasing omega 6 (Linoleic acid (LA), Gamma-linolenic acid (GLA), Dihomo-gamma-linolenic acid (DGLA), Arachidonic acid (AA), or any combination) intake in place of saturated or monounsaturated fats or carbohydrates for the primary prevention of CVD.2. Decreasing omega 6 (LA, GLA, DGLA, AA, or any combination) intake in place of carbohydrates or protein (or both) for the primary prevention of CVD.

SEARCH METHODS

We searched the following electronic databases up to 23 September 2014: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (Issue 8 of 12, 2014); MEDLINE (Ovid) (1946 to September week 2, 2014); EMBASE Classic and EMBASE (Ovid) (1947 to September 2014); Web of Science Core Collection (Thomson Reuters) (1990 to September 2014); Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database, and Health Economics Evaluations Database on the Cochrane Library (Issue 3 of 4, 2014). We searched trial registers and reference lists of reviews for further studies. We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions stating an intention to increase or decrease omega 6 fatty acids, lasting at least six months, and including healthy adults or adults at high risk of CVD. The comparison group was given no advice, no supplementation, a placebo, a control diet, or continued with their usual diet. The outcomes of interest were CVD clinical events (all-cause mortality, cardiovascular mortality, non-fatal end points) and CVD risk factors (changes in blood pressure, changes in blood lipids, occurrence of type 2 diabetes). We excluded trials involving exercise or multifactorial interventions to avoid confounding.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted the data, and assessed the risk of bias in the included trials.

MAIN RESULTS

We included four RCTs (five papers) that randomised 660 participants. No ongoing trials were identified. All included trials had at least one domain with an unclear risk of bias. There were no RCTs of omega 6 intake reporting CVD clinical events. Three trials investigated the effect of increased omega 6 intake on lipid levels (total cholesterol, low density lipoprotein (LDL-cholesterol), and high density lipoprotein (HDL-cholesterol)), two trials reported triglycerides, and two trials reported blood pressure (diastolic and systolic blood pressure). Two trials, one with two relevant intervention arms, investigated the effect of decreased omega 6 intake on blood pressure parameters and lipid levels (total cholesterol, LDL-cholesterol, and HDL-cholesterol) and one trial reported triglycerides. Our analyses found no statistically significant effects of either increased or decreased omega 6 intake on CVD risk factors.Two studies were supported by funding from the UK Food Standards Agency and Medical Research Council. One study was supported by Lipid Nutrition, a commercial company in the Netherlands and the Dutch Ministry of Economic Affairs. The final study was supported by grants from the Finnish Food Research Foundation, Finnish Heart Research Foundation, Aarne and Aili Turnen Foundation, and the Research Council for Health, Academy of Finland.

AUTHORS' CONCLUSIONS

We found no studies examining the effects of either increased or decreased omega 6 on our primary outcome CVD clinical endpoints and insufficient evidence to show an effect of increased or decreased omega 6 intake on CVD risk factors such as blood lipids and blood pressure. Very few trials were identified with a relatively small number of participants randomised. There is a need for larger well conducted RCTs assessing cardiovascular events as well as cardiovascular risk factors.

Effect of different fat-enriched meats on non-cholesterol sterols and oxysterols as markers of cholesterol metabolism: Results of a randomized and cross-over clinical trial

BACKGROUND AND AIM

Different kinds of fatty acids can affect the synthesis, absorption, and elimination of cholesterol. This study was carried out to assess the associations of cholesterol metabolism with the intake of two meats with different fatty acid composition in healthy volunteers.

METHODS AND RESULTS

The study group was composed of 20 subjects (12 males and eight females; age, 34.4 ± 11.6 years; body mass index (BMI), 23.5 ± 2.3 kg/m(2); low-density lipoprotein (LDL) cholesterol, 2.97 ± 0.55 mmol/l; high-density lipoprotein (HDL) cholesterol, 1.61 ± 0.31 mmol/l; triglycerides (TG), 1.06 ± 0.41 mmol/l) who completed a 30-day randomized and cross-over study to compare the cholesterol metabolism effect of 250 g of low-fat lamb versus 250 g of high-fat lamb per day in their usual diet. Cholesterol absorption, synthesis, and elimination were estimated from the serum non-cholesterol sterol and oxysterol concentrations analyzed by a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). No changes in weight, plasma lipids, or physical activity were observed across the study. Cholesterol intestinal absorption was decreased with both diets. Cholesterol synthesis and elimination decreased during the low-fat lamb dietary intervention (ρ = 0.048 and ρ = 0.005, respectively).

CONCLUSION

Acute changes in the diet fat content modify the synthesis, absorption, and biliary elimination of cholesterol. These changes were observed even in the absence of total and LDL cholesterol changes in plasma.

REGISTRATION NUMBER FOR CLINICAL TRIALS

ClinicalTrials.gov PRS, NCT02259153.

Evidence of health benefits of canola oil

Canola oil-based diets have been shown to reduce plasma cholesterol levels in comparison with diets containing higher levels of saturated fatty acids. Consumption of canola oil also influences biological functions that affect various other biomarkers of disease risk. Previous reviews have focused on the health effects of individual components of canola oil. Here, the objective is to address the health effects of intact canola oil, as this has immediate practical implications for consumers, nutritionists, and others deciding which oil to consume or recommend. A literature search was conducted to examine the effects of canola oil consumption on coronary heart disease, insulin sensitivity, lipid peroxidation, inflammation, energy metabolism, and cancer cell growth. Data reveal substantial reductions in total cholesterol and low-density lipoprotein cholesterol, as well as other positive actions, including increased tocopherol levels and improved insulin sensitivity, compared with consumption of other dietary fat sources. In summary, growing scientific evidence supports the use of canola oil, beyond its beneficial actions on circulating lipid levels, as a health-promoting component of the diet.

Cholesterol-absorber status modifies the LDL cholesterol-lowering effect of a Mediterranean-type diet in adults with moderate cardiovascular risk factors

LDL-cholesterol (LDL-C) reduction may be achieved by various types of prudent diets, but their effects on surrogate markers of cholesterol absorption and synthesis have not been well studied in humans. We aimed to assess whether the extent of cholesterol absorption or synthesis, and cholesterol concentrations, are modified in adults when they shift from a Western-type diet (WD) to a combined low-fat, low-cholesterol/Mediterranean-type diet (LFCMD). Cholestanol and sitosterol, as well as desmosterol and lathosterol, surrogate markers of cholesterol absorption or synthesis, respectively, were quantified in the serum of 125 fasting, middle-aged participants at moderate cardiovascular risk. They habitually consumed a WD and then consumed a LFCMD during the 3-mo intervention. The group was stratified by serum cholestanol concentration and classified as high, intermediate, or low absorbers of cholesterol. When they consumed the WD, participants had comparable total and LDL-C concentrations, independent of absorber group and sex. After 3 mo of consuming the LFCMD, absorption and synthesis did not change or changed only slightly. The cholestanol concentration increased in low absorbers by 18% (P < 0.02) and decreased in high absorbers by 14% (P < 0.001), but these variations did not change the high- or low-absorber status. In male and female low absorbers, plasma total (-7%) and LDL-C (-9%) concentrations decreased after the 3-mo intervention and changes were 2.3- and 2.4-fold greater, respectively, than in high absorbers, independent of sex. Cholesterol synthesis/absorption status was not markedly altered by diet, but the decrease in plasma LDL-C due to the Mediterranean-type diet occurred only in low absorbers of cholesterol. This should be considered during further dietary interventions.

Dietary modeling shows that the substitution of canola oil for fats commonly used in the United States would increase compliance with dietary recommendations for fatty acids

OBJECTIVE

To examine the effect of substituting canola oil for selected vegetable oils and canola oil-based margarine for other spreads on energy, fatty acid, and cholesterol intakes among US adults.

DESIGN

Twenty-four-hour food recall data from the 1999-2002 National Health and Nutrition Examination Survey (NHANES) were used to calculate the effect of substituting canola oil for dietary corn, cottonseed, safflower, soybean, and vegetable oils described as "not further specified" and of canola oil-based margarine for other spreads at 25%, 50%, and 100% replacement levels.

SUBJECTS

Adult participants aged>or=20 years (n=8,983) of the 1999-2002 NHANES.

STATISTICAL ANALYSIS

Sample-weighted mean daily intake values and the percentage of subjects meeting dietary recommendations were estimated at the various replacement levels. Standard errors of the means and percentages were estimated by the linearization method of SUDAAN.

RESULTS

Significant (P<0.05) changes compared to estimated actual intakes included: saturated fatty acid intake decreased by 4.7% and 9.4% with 50% and 100% substitution, respectively. Complete substitution increased monounsaturated fatty acid and alpha-linolenic acid intakes by 27.6% and 73.0%, respectively, and decreased n-6 polyunsaturated fatty acid and linoleic acid intakes by 32.4% and 44.9%, respectively. The ratio of n-6 to n-3 fatty acids decreased from 9.8:1 to 3.1:1 with 100% replacement. Energy, total fat, and cholesterol intakes did not change.

CONCLUSIONS

Substitution of canola oil and canola oil-based margarine for most other vegetable oils and spreads increases compliance with dietary recommendations for saturated fatty acid, monounsaturated fatty acid, and alpha-linolenic acid, but not for linoleic acid, among US adults.

Omega 3 fatty acids for prevention and treatment of cardiovascular disease

BACKGROUND

It has been suggested that omega 3 (W3, n-3 or omega-3) fats from oily fish and plants are beneficial to health.

OBJECTIVES

To assess whether dietary or supplemental omega 3 fatty acids alter total mortality, cardiovascular events or cancers using both RCT and cohort studies.

SEARCH STRATEGY

Five databases including CENTRAL, MEDLINE and EMBASE were searched to February 2002. No language restrictions were applied. Bibliographies were checked and authors contacted.

SELECTION CRITERIA

RCTs were included where omega 3 intake or advice was randomly allocated and unconfounded, and study duration was at least six months. Cohorts were included where a cohort was followed up for at least six months and omega 3 intake estimated.

DATA COLLECTION AND ANALYSIS

Studies were assessed for inclusion, data extracted and quality assessed independently in duplicate. Random effects meta-analysis was performed separately for RCT and cohort data.

MAIN RESULTS

Forty eight randomised controlled trials (36,913 participants) and 41 cohort analyses were included. Pooled trial results did not show a reduction in the risk of total mortality or combined cardiovascular events in those taking additional omega 3 fats (with significant statistical heterogeneity). Sensitivity analysis, retaining only studies at low risk of bias, reduced heterogeneity and again suggested no significant effect of omega 3 fats. Restricting analysis to trials increasing fish-based omega 3 fats, or those increasing short chain omega 3s, did not suggest significant effects on mortality or cardiovascular events in either group. Subgroup analysis by dietary advice or supplementation, baseline risk of CVD or omega 3 dose suggested no clear effects of these factors on primary outcomes. Neither RCTs nor cohorts suggested increased relative risk of cancers with higher omega 3 intake but estimates were imprecise so a clinically important effect could not be excluded.

REVIEWERS' CONCLUSIONS

It is not clear that dietary or supplemental omega 3 fats alter total mortality, combined cardiovascular events or cancers in people with, or at high risk of, cardiovascular disease or in the general population. There is no evidence we should advise people to stop taking rich sources of omega 3 fats, but further high quality trials are needed to confirm suggestions of a protective effect of omega 3 fats on cardiovascular health. There is no clear evidence that omega 3 fats differ in effectiveness according to fish or plant sources, dietary or supplemental sources, dose or presence of placebo.

Evidence that leptin contributes to intestinal cholesterol absorption in obese (ob/ob) mice and wild-type mice

In the present study, the effect of leptin on intestinal cholesterol absorption was investigated in C57 BL/6 OlaHsd Lep(ob)/Lep(ob) obese (ob/ob) mice and lean C57 BL/6 (wild-type) mice. Animals were treated either with or without recombinant leptin for 2 wk. Cholesterol absorption was measured by the constant isotope feeding method and indirectly by the ratio of campesterol to cholesterol in serum. In ob/ob mice, cholesterol absorption was significantly higher compared to wild-type mice [83.4 +/- 2.3% (SD) vs. 77.6 +/- 1.5%, P < 0.01]. Treatment with leptin significantly reduced cholesterol absorption in both ob/ob and wild-type mice by 8.5 (P < 0.001) and 5.2% (P < 0.05), respectively. Serum concentrations of campesterol and the ratio of campesterol to cholesterol in ob/ob mice were significantly higher compared to wild-type mice (2.2 +/- 0.3 mg/dL vs. 1.2 +/- 0.3 mg/dL, P< 0.001; and 36.8 +/- 2.8 microg/mg vs. 28.0 +/- 3.3 microg/mg, P < 0.001). After treatment of ob/ob mice with leptin, concentrations of campesterol and its ratio to cholesterol were significantly lower (2.2 +/- 0.3 mg/dL vs. 1.0 +/- 0.2 microg/mg, P < 0.001; and 36.8 +/- 2.8 microg/mg vs. 13.2 +/- 2.2 microg/mg, P < 0.001, respectively). In wild-type mice, the ratio of campesterol to cholesterol in serum was also significantly lower after treatment with leptin (28.0 +/- 3.3 microg/mg vs. 22.6 +/- 5.0 microg/mg, P < 0.05). A significant positive correlation (r = 0.701, P < 0.01) between cholesterol absorption and the ratio of campesterol to cholesterol in serum was found. It is concluded that leptin contributes to intestinal cholesterol absorption in ob/ob mice and lean wild-type mice.

Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project

OBJECTIVE

To investigate cholesterol-lowering efficacy and safety of plant stanol ester margarine in healthy 6-year-old children already consuming a low-saturated-fat, low-cholesterol diet.

STUDY DESIGN

Eighty-one intervention children from the STRIP project, a randomized prospective trial aimed at reducing exposure of young children to the known environmental atherosclerosis risk factors, were recruited to this double-blind crossover study at 6 years of age. In randomized order the families were advised to replace daily 20 g of the child's dietary fat intake with plant stanol ester margarine or control margarine for 3 months. The washout period lasted 6 weeks. Statistical analysis was performed according to intention-to-treat principle with analysis of variance for crossover design.

RESULTS

The mean daily plant stanol ester margarine consumption was 18.2 g (1.5 g plant stanol). The well-tolerated plant stanol ester margarine reduced serum total and low-density lipoprotein cholesterol concentrations by 5.4% and 7.5%, respectively (P =.0001 for both). The serum high-density lipoprotein cholesterol and triglyceride concentrations and alpha-tocopherol to low-density lipoprotein cholesterol ratio remained unchanged. The serum beta-carotene to low-density lipoprotein cholesterol ratio decreased by 19% (P =.003).

CONCLUSION

Plant stanol ester margarine significantly diminishes serum total and low-density lipoprotein cholesterol concentration without adverse clinical effects in healthy children who already consume a low-saturated-fat, low-cholesterol diet but decreases the serum beta-carotene to low-density lipoprotein cholesterol ratio.

Effects of 2 low-fat stanol ester-containing margarines on serum cholesterol concentrations as part of a low-fat diet in hypercholesterolemic subjects

BACKGROUND

Full-fat sitostanol ester-containing margarine reduces serum total and LDL cholesterol, but the effect of plant stanol ester-containing margarine as part of a low-fat, low-cholesterol diet has not been studied.

OBJECTIVE

We investigated the cholesterol-lowering effects of 2 novel, low-fat stanol ester-containing margarines as part of a low-fat diet recommended for hypercholesterolemic subjects.

DESIGN

In a parallel, double-blind study, 55 hypercholesterolemic subjects were randomly assigned after a 4-wk high-fat diet (baseline) to 3 low-fat margarine groups: wood stanol ester-containing margarine (WSEM), vegetable oil stanol ester-containing margarine (VOSEM), and control margarine (no stanol esters). The groups consumed the margarines for 8 wk as part of a diet resembling that of the National Cholesterol Education Program's Step II diet. The daily mean total stanol intake was 2.31 and 2.16 g in the WSEM and VOSEM groups, respectively.

RESULTS

During the experimental period, the reduction in serum total cholesterol was 10.6% (P < 0.001) and 8.1% (P < 0.05) greater and in LDL cholesterol was 13.7% (P < 0.01) and 8.6% (P = 0.072) greater in the WSEM and VOSEM groups, respectively, than in the control group. Serum campesterol concentrations decreased 34.5% and 41.3% (P < 0.001) in the WSEM and VOSEM groups, respectively. Serum HDL cholesterol, sitostanol, campestanol, beta-carotene, and fat-soluble vitamin concentrations did not change significantly from baseline.

CONCLUSIONS

We conclude that the low-fat, plant stanol ester-containing margarines are effective cholesterol-lowering products in hypercholesterolemic subjects when used as part of a low-fat, low-cholesterol diet. They offer an additional, clinically significant reduction in serum cholesterol concentrations to that obtained with a low-fat diet alone.

Inhibition of cholesterol absorption by plant sterols for mass intervention

Plant sterols and stanols lower serum cholesterol by inhibiting intestinal absorption of cholesterol. Because of their safety and efficacy, their application for mass intervention is promising. The use of fatty acid esters of stanols is particularly helpful because stanols readily mix with dietary fats in this form and their hypocholesterolemic efficacy is greater than in the free form.