Consistency of use of plant stanol ester margarine in Finland

Plant stanol esters are potentially cost-effective in the prevention of coronary heart disease in men: Bayesian modelling approach

BACKGROUND

Plant stanol esters in spreads have demonstrated efficacy in reducing serum cholesterol. The cost-effectiveness of plant stanol esters in the prevention of coronary heart disease, however, has remained unevaluated.

DESIGN

A Bayesian modelling approach was applied to synthesize clinical evidence and evaluate the cost-effectiveness (Euro/quality-adjusted life years) of plant stanol esters in spread in the prevention of coronary heart disease based on published FINRISK and 4S risk functions.

RESULTS

The regular use of plant stanol esters reduced total serum cholesterol by -0.362 mmol/l [95% credibility interval (CrI) -0.31 to -0.41]. The corresponding placebo-adjusted reduction attributable to stanol esters when combined with statin was -0.385 mmol/l (95% CrI -0.18 to -0.61). The cost-effectiveness estimations were assessed for men and women separately at four different initial ages at which the regular use of stanol esters was assumed to be started. The base case cost per quality-adjusted life years gained by using stanol esters regularly ranged from 7436 to 20,999 Euro in men and from 34,327 to 112,151 Euro in women based on the initial starting age. According to uncertainty analysis, there is over a 90% probability that the use of plant stanol esters is cost-effective for men inclusively and for 60-year-old and older women assuming that decision-makers' maximum willingness to pay per quality-adjusted life year is 50,000 Euro.

CONCLUSIONS

A recommendation that plant stanol ester-containing spreads be used as a part of daily diet replacing regular spread could be viewed as potentially cost-effective public health policy in the prevention of CHD in all adult men and in older age-groups of women with total serum cholesterol levels of 5 mmol/l or greater.

Materiality matters: Blurred boundaries and the domestication of functional foods

Previous scholarship on novel foods, including functional foods, has suggested that they are difficult to categorise for both regulators and users. It is argued that they blur the boundary between ‘food' and ‘drug' and that uncertainties about the products create ‘experimental' or ‘restless' approaches to consumption. We investigate these uncertainties drawing on data about the use of functional foods containing phytosterols, which are licensed for sale in the EU for people wishing to reduce their cholesterol. We start from an interest in the products as material objects and their incorporation into everyday practices. We consider the scripts encoded in the physical form of the products through their regulation, production and packaging and find that these scripts shape but do not determine their use. The domestication of phytosterols involves bundling the products together with other objects (pills, supplements, foodstuffs). Considering their incorporation into different systems of objects offers new understandings of the products as foods or drugs. In their accounts of their practices, consumers appear to be relatively untroubled by uncertainties about the character of the products. We conclude that attending to materials and practices offers a productive way to open up and interrogate the idea of categorical uncertainties surrounding new food products.

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

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 (P<0.001) and level of education (P=0.01). The usage of enriched products was more common among those following a cholesterol-lowering medication or diet (P<0.001 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.

Phytosterol-enriched products on the Irish market: examination of intake and consumption patterns

Objective

To study patterns of phytosterol intakes in the Irish population from enriched sources.

Design

An interview-assisted questionnaire, which recorded information on sociodemographics, product types, intake amounts and patterns of intake. Independent samplesttests, one-way ANOVA and cross-tabulations were used to establish significant relationships between groups of variables. The top tertile of phytosterol intakes was also calculated.

Setting

Point-of-purchase of phytosterol-enriched products in Irish supermarkets.

Subjects

Four hundred and sixty-eight consumers (186 men and 282 women) of phytosterol-enriched foods.

Results

The mean phytosterol intake from enriched sources for the sample population was 2·45 g/d. Men had greater intakes than women (2·71 g/dv. 2·29 g/d, respectively). A total of 62 % of consumers were unaware of the importance of consuming fruit and vegetables while taking these products. The majority of respondents reported that they had high cholesterol (61 %) and 22 % of consumers also took cholesterol-lowering medication (statins). In total, 23 % had phytosterol intakes >3·0 g/d and the majority of consumers (58 %) had been consuming these products for >1 year. The mean intake for respondents with phytosterol intakes >3·0 g/d was 4·1 g/d and 74 % of this subgroup had been consuming these products for >1 year.

Conclusion

In general, phytosterol intakes are within efficacious levels in the Irish population. However, there appears to be a subgroup that has been consuming these products at intakes greater than current recommendations for >1 year.

Carotid artery compliance in users of plant stanol ester margarine

OBJECTIVE

To investigate the effects of stanol ester margarine use in healthy subjects on arterial compliance, endothelial function and intima-media thickness.

DESIGN

Case-control study comparing regular stanol ester margarine users to non-users.

SETTING

Occupational health service clinic.

SUBJECTS

We recruited 50 cases and 50 controls (mean age 51+/-8, range 26-65 years). All subjects were non-smokers and the study groups were matched for age and sex. As cases, we invited subjects who had been using regularly (daily) plant stanol ester margarine for a period of 2 years or longer. Non-invasive ultrasound was used to measure carotid artery compliance, carotid intima-media thickness and brachial artery flow-mediated endothelial dependent vasodilatation.

RESULTS

The carotid artery compliance was non-significantly higher in cases compared with controls, 1.84+/-1.02 vs 1.58+/-0.76 %/10 mm Hg (P=0.13). The difference in compliance became statistically significant (P=0.04) when the unbalance between the groups in family history of coronary artery disease and years of education were taken into account. There was also a significant dose-response relationship between stanol margarine use and carotid compliance, longer use being associated with higher compliance. Serum lipoproteins, blood pressure, flow-mediated dilation and intima-media thickness values did not differ between cases and controls.

CONCLUSION

These data raise the possibility that regular stanol ester margarine use may be associated with beneficial changes in arterial compliance. Intervention studies are needed to test this hypothesis and to reveal possible mechanisms.

Exposure and effectiveness of phytosterol/-stanol-enriched margarines

BACKGROUND

Studies on effectiveness of phytosterol/-stanol-enriched margarines in the community have received low priority. For postlaunch monitoring purposes including risk-benefit analyses, it is needed to investigate both exposure and effectiveness of these margarines.

OBJECTIVE

To study the use and effectiveness of phytosterol/-stanol-enriched margarine.

DESIGN, SETTING AND SUBJECTS

The study population consisted of 2379 subjects that participated in a community intervention study ('Hartslag Limburg') aged 28-76 years. In 1998 and 2003, blood samples for total and high-density lipoprotein (HDL) cholesterol were obtained. A general questionnaire and food frequency questionnaire (FFQ) were administered. From 1999 onwards, phytosterol/-stanol-enriched margarines were introduced on the Dutch market. On the basis of 2003 data, subjects were classified in users of (a) phytosterol/-stanol-enriched margarine, (b) cholesterol-lowering drugs, (c) the combination (both enriched margarine and drugs) and (d) neither enriched margarines nor cholesterol-lowering drugs.

RESULTS

Mean (+/-s.d.) daily intake of phytosterol-enriched margarine (n=99) and phytostanol-enriched margarine (n=16) was 14+/-9 g. From 1998 to 2003, total serum cholesterol concentration changed significantly different among the four groups: in the combination users -2.04+/-1.50 mmol/l (-29%), in cholesterol-lowering drug users -1.09+/-1.17 mmol/l (-17%), in the enriched margarine users -0.24+/-0.75 mmol/l (-4%) and in non-users +0.10+/-0.72 mmol/l (+2%)(P<0.05).

CONCLUSION

Recommended doses are not consumed, but phytosterol/-stanol-enriched margarines can modestly reduce serum total cholesterol in the community. These margarines cannot equal the effect of cholesterol-lowering drugs, but may act additively. Further investigation of the health effects that may occur during simultaneous cholesterol lowering drugs and phytosterol-or -stanol-enriched margarines usage is important, as well as community education about the cholesterol lowering foods and drugs.

SPONSORSHIP

Netherlands Organization for Health Research and Development (ZonMW) (data collection of Hartslag Limburg and further data- analyses).

Effectiveness of customary use of phytosterol/-stanol enriched margarines on blood cholesterol lowering

Postlaunch monitoring of functional foods can encompass monitoring of effectiveness under conditions of customary use. To this end, the effectiveness of phytosterol/-stanol enriched margarine consumption in free-living conditions was investigated with data from the Dutch "Doetinchem cohort study". In total, 4,505 subjects (aged 26-70 years) were examined in 1994-1998 and re-examined during 1999-2003. A general and a food frequency questionnaire and non-fasting blood samples for total and HDL cholesterol determination were obtained. Subjects were stratified into phytosterol/-stanol enriched margarine users (n = 84) and non-users (n = 4,421) based on the re-examination data, as these margarines were available on the Dutch market from 1999 onwards. Mean spontaneous daily use (g +/- SD) of phytosterol-containing margarine (n = 71) was 15 +/- 8 and of phytostanol-containing margarine (n = 13) 9+/-6. After five years, total blood cholesterol had increased with 0.26 mmol/l in non-users while it had not significantly changed in users. The difference in total blood cholesterol change in users versus non-users was -0.30 mmol/l (p < 0.001). The beneficial effect of the phytosterol/-stanol enriched margarine, used under customary conditions can be characterized as a stabilization of cholesterol levels. This is the first report finding a modest beneficial effect on blood cholesterol level under customary conditions thereby partly confirming findings from clinical trials.

Plant sterols as dietary adjuvants in the reduction of cardiovascular risk: theory and evidence

Plant sterol-enriched foods are an effective dietary adjuvant in reducing cardiovascular risk by lowering total cholesterol and low density lipoprotein-cholesterol (LDL-C) in serum by up to approximately 15%. The mechanism of action of plant sterols is different from those of 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) and thus their effect is additive. Combining plant sterols with other dietary components known to reduce cholesterol in a portfolio approach has proven to be most effective for reduction of hypercholesterolemia and provide an alternative treatment option for clinicians. Plant sterol-enriched foods provides clinicians with a relatively cheap, safe, and effective way to help patients manage their cardiovascular risk.