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Plant Sterols and Stanols: Benefits, Dangers, Foods

By Ana Aleksic, MSc Pharm

Plant sterols are fatty molecules naturally found in some vegetables and fruits. They’re
also added to margarine to trick your body into absorbing less cholesterol. What does
the research say about the potential benefits and dangers of plant sterols? Can
probiotics be combined with them or used as an alternative? Read on as we explore this
controversial topic in depth.

Disclaimer: This post is for informational purposes only. Please consult your doctor about your
health-related concerns and medications before taking any supplements.

What Are Plant Sterols and Stanols?

Overview
This post will go over the complete evidence on the pros and cons of foods and supplements
with plant sterols and stanols. We’ll highlight some controversial research that is rarely talked
about.

Pros:

● Evidence for lowering high cholesterol

● May be more effective for people who absorb cholesterol in excess than for those who
produce too much
● Possibly safe for most people
● High in some whole foods that support a healthy gut microbiome
● Added to margarine, spreads, and yogurt

Cons:

● Side effects may include gut discomfort, fatty stools, and lower nutrient levels
● Unhealthy sources of plant sterols may harm the gut microbiome
● Long-term side effects unknown
● Quality clinical trials lacking to confirm many health benefits
● Conflicting data on heart health with some studies reporting a link between plant sterols
and heart disease
Definition
Plant sterols and stanols are fatty molecules similar to cholesterol (Patel, 2008).

Exclusively plants can produce plant sterols. Many vegetables and fruits abound in them. So far,
scientists have identified over 250 plant sterols. The main ones in our diet are beta-sitosterol,
stigmasterol, and campesterol (Vezza et al., 2020).

Plant stanols are found in plants in tiny amounts, but most are artificially processed
(hydrogenated) plant sterols.

We absorb plant sterols in tiny amounts compared to cholesterol (~50% of cholesterol, <5%
plant sterols, <0.5% plant stanols from food) (Fransen et al., 2007; Patel, 2009).

Read more about the difference between cholesterol and plant sterols in general here.

How They Work

Plant sterols are absorbed by the gut in place of some cholesterol. In turn, the gut absorbs less
cholesterol, which lowers its blood levels. Levels of plant sterols in the blood, however, increase
(Weingärtner et al., 2009).

Plant stanols pass through the gut, mostly without being absorbed. They bind to
cholesterol-rich bile on the way out, removing more cholesterol from the body and lowering its
blood levels. Some fat-soluble vitamins also get flushed out, however (Weingärtner et al., 2009).

Plant sterols or stanols are usually esterified in supplements, margarine, spreads, and
yogurts. This means that they are chemically processed and joined with fatty acids into esters.
This makes them more soluble in water and increases their bioavailability (Fransen et al., 2007).

Do We Need More Data?

Ever since plant sterols were first discovered, scientists can’t seem to agree: are they essential
micronutrients or potentially harmful compounds?

Advocates claim plant sterols are mostly beneficial. They’re purported to help balance the
immune response and cholesterol levels, enhance mitochondrial and gut health, and reduce
oxidative stress and inflammation (Vezza et al., 2020).

Skeptics warn about the lack of long-term safety research and possibly detrimental effects on
heart health and nutrient status.

Regulatory health bodies across the globe are equally divided.

In 2000, the US Food and Drug Administration (FDA) allowed a health claim for reducing
the risk of coronary heart disease for foods that contain phytosterols and are low in
saturated fat and cholesterol. This is the 12th time the FDA has authorized a health claim for
a supplement ever (Weingärtner et al., 2009).

The FDA claim is valid only for esterified plant sterols and stanols. Experts wrote to the
FDA to request expanding the rule to natural (non-esterified) plant sterols. In 2010, the FDA
amended this rule to apply to all conventional foods that include mixtures of esterified and
non-esterified plant sterols derived from vegetable oils and tall oil (from Kraft wood pulping).

Yet, the FDA stuck to saying there’s not enough evidence that plant sterols can have notable
health risks. But it’s not like that in some other parts of the world.

Health Canada now allows a limited range of foods enriched with plant sterols. The
regulations eased up in 2010, after an initial ban of these foods based on a 2000 animal study
reporting the negative effects of plant sterols on heart health and red blood cells (Ratnayake et
al., 2000; Weingärtner et al., 2009).

The European Food Safety Authority states that the safety of plant sterols has not been
adequately established. They paid special attention to studies showing plant sterols may
reduce the levels of carotenoids (provitamin A) and other fat-soluble vitamins. Foods enriched
with plant sterols have to carry a label that advises children, pregnant, and breastfeeding
women to avoid them in the EU.

Potential Benefits of Plant Sterols and Stanols

Likely Effective for:

1) Lowering Cholesterol in Familial Hypercholesterolemia

Clinical studies show that plant sterols can lower total and “bad” LDL cholesterol levels in
people with familial hypercholesterolemia, a genetic condition that can cause extremely high
cholesterol.

Compared to a cholesterol-lowering diet alone, taking plant sterols additionally lowers total
cholesterol (by 12 mg/dL) and LDL cholesterol (by 23 mg/dL) in this population (Malhotra et al.,
2014).

In clinical trials, margarine spreads or yogurt with plant sterols (reaching 1.6-2.3 g/day) reduced
total cholesterol by up to 11% and LDL cholesterol by up to 14% in patients with familial
hypercholesterolemia. But, plant sterols did not reduce triglyceride levels or increase “good”
HDL cholesterol levels in most of these trials (Amundsen et al., 2004; O'Neill et al., 2005;
Guardamagna et al., 2010; Vásquez-Trespalacios & Romero-Palacio, 2014).
2) Lowering High Cholesterol in General
Similarly, clinical studies show that plant sterols (alone or with plant stanols) reduce total and
LDL cholesterol in people with high cholesterol or hypercholesterolemia.

According to clinical trials and systematic reviews, adding plant sterols to a cholesterol-lowering
diet additionally reduces total cholesterol by 3-8% and LDL cholesterol by about 5-15%
(Weststrate & Meijer, 1998; Kabral & Clein, 2017; Gylling et al., 2013).

Individualizing Supplementation
A study of 63 people revealed that plant sterols have the greatest cholesterol-lowering
effect in people who do not produce a high amount of cholesterol. These responders are
cholesterol hyperabsorbers—they have high cholesterol because they absorb it in excess.
Every fourth person is a hyperabsorber (Mackay et al., 2015).

Genetics

The above study reveals a strong genetic component to plant sterols response. Common
genetic variations (like CYP7A1-rs3808607 and APOE ε4) that increase cholesterol absorption
and bile acid production in the body have been linked to a better response to plant sterols
(Mackay et al., 2015; Mackay et al., 2015).

Another study confirmed that people with markers of low cholesterol synthesis and high
cholesterol absorption were more likely to see LDL cholesterol drops on plant sterols
(Casas-Agustench et al., 2011).

Statins Response

Interestingly, these are the same people for whom statins—the main drug therapy—are less
likely to work and more likely to trigger heart complications (Miettinen et al., 1998; the
Scandinavian Simvastatin Survival Study (4S), 1994).

Studies suggest that adding plant sterols to statins may additionally lower cholesterol levels.
However, there’s a lot we don’t know about how this therapy can be individualized and who will
respond. It’s theoretically possible that only hyperabsorbers would see a benefit (Scholle et al.,
2009).

In Combination with Zetia

Zetia (ezetimibe) is a drug alternative to statins for hyperabsorbers. It works by blocking

cholesterol absorption. In a study of 41 heart disease patients, adding plant sterols to statins
lowered LDL by ~ 17%, adding ezetimibe ~19%, while the ezetimibe-plant sterols combination
cut LDL by ~27% (Gomes et al., 2017).

Hyperabsorbers are also the same people for whom L. Reuteri NCIMB 30242 shows promise
since it was clinically investigated for lowering cholesterol absorption (Jones & Prakash, 2012).
We covered that research and how to find out if you are a hyperabsorber in a separate post.
Plant Stanols vs Sterols for Hyperabsorbers

Although one review concluded that plant sterols and stanols have similar effects on cholesterol,
some studies suggest that plant stanols might be more relevant for hyperabsobers. (Talati et al.,
2010)

Plant stanols seem to reduce plant sterol blood levels and cholesterol absorption
dose-dependently (Hallikainen & Gylling, 2014).

Plant stanols also reduced plant sterol levels in the carotid arteries in statin-treated patients
without changing the walls of the arteries. So, plant stanols might be less likely to cause side
effects to the heart and blood vessels, but more research is needed (Miettinen, 2011).

In Summary

Evidence suggests that plant sterols and stanols may help lower LDL cholesterol in
people who absorb too much cholesterol, in addition to diet and drug therapy. Plant
stanols likely block absorption better than plant sterols.

Conflicting Evidence for:

3) Heart Health
In the US, foods containing at least 0.65 g of plant sterols and foods and supplements
containing at least 1.7 g of plant stanols per serving are allowed to be labeled with a health
claim for lowering heart disease risk. These foods must also meet low saturated fat and
cholesterol requirements (fda.gov).

The health claim can say "Diets low in saturated fat and cholesterol that include two servings of
foods that provide a daily total of at least 3.4 grams of plant stanol esters may reduce the risk of
heart disease" (efcr.gov).

Yet, experts stress that lowering LDL cholesterol doesn’t equal reduced heart disease risk. It’s
more complex than that.

Studies investigating the link between plant sterol blood levels and heart health had conflicting
results. The largest trials and genome-wide association studies found an association with
increased heart disease risk. Others have reported no such association (Vergès & Fumeron,
2015).

Overall, the available data can’t confirm an increased or decreased heart disease risk
from plant sterols, nor can it rule out either. Large trials are needed to properly test this.
Likely Ineffective for:

4) Colorectal Cancer
According to limited research, eating plant sterols does not affect the risk of rectal cancer in
women or colon cancer in both men and women. One study found a link between higher dietary
plant sterols intake and an increased risk of rectal cancer in men, but more research is needed
(Normén et al., 2001).

Insufficient Evidence for:

There is not enough evidence to support the use of plant sterols for any of the conditions listed
below.

5) Stomach Cancer
In one Uruguayan study, people who ate at least 82.5 mg of plant sterols per day through food
had slightly lower odds of gastric cancer compared to those who ate less than 45.5 mg (De
Stefani et al., 2000).

6) Metabolic Syndrome
The effects of plant sterols on metabolic syndrome have been mixed.

In one clinical study, yogurt mini-drinks with plant sterols reduced total and LDL cholesterol in
108 people with metabolic syndrome on a typical Western diet (Sialvera et al., 2010).

In a smaller study of 9 men with metabolic syndrome, plant sterols in breakfast cereal and
margarine didn’t improve blood cholesterol (Ooi et al., 2007).

More research is needed.

7) Heart Attacks
According to limited research in the Swedish population, men who take in ~340 mg of plant
sterols daily have a 29% lower risk of suffering a heart attack for the first time compared to men
who take in ~150 mg daily. This association didn’t stand in women. Additional research needs to
confirm it (Klingberg et al., 2013).

8) Obesity
In one clinical study of 24 overweight people, diet and rice bran snack bars fortified with a plant
sterols and stanols mix did not improve weight loss, LDL cholesterol, or blood sugar better than
diet and unfortified snack bars (Hongu et al., 2014).

In this study, plant sterols snacks lowered total cholesterol ~10% more than regular snacks. It’s
unclear if this is meaningful.
Plant Sterols and Stanols Side Effects, Dangers & Precautions

Gut
Since plant sterols reduce cholesterol absorption, they may cause gut-specific side effects like
diarrhea and excess amounts of fat in the stool (steatorrhea).

One child also experienced abdominal discomfort in a clinical trial (Patel & Salen, 1998).

Sitosterolemia
Sitosterolemia or phytosterolemia is a rare genetic disorder that causes a massive buildup of
plant sterols in the body and blood. It affects fewer than one per 1 million people, although it
might be underdiagnosed.

Plant sterols are dangerous for people with sitosterolemia.

In sitosterolemia, a person will absorb plant sterols in extreme excess because their body can’t
tell apart cholesterol from plant sterols. Sitosterolemia is associated with fatty growths
underneath the skin, heart complications, and the breakdown of red blood cells (Patel, 2009).

Sensitivity
The FDA concluded that no cautionary statement about plant sterols sensitivity is necessary
and that consumers aware of their sensitivity should consult their medical practitioner.

However, some people may be unaware of their sensitivity, which can be subtle.

Common genetic mutations (ABCG8, ABCG5) can make people slightly sensitive to plant
sterols. A diet enriched with plant sterols will still raise their blood plant sterol levels way above
the normal range (Patel, 2009).

The consequences of high plant sterols in this population may include abnormal red blood cells,
anemia, giant platelets, increased bleeding, and adrenal and ovarian failure. Some researchers
believe that a buildup of plant sterols may disrupt hormonal balance (especially of sex and
steroid hormones), but more research is needed (Mushtaq & Wright, 2007; Patel, 2009).

Nutrient Status
An analysis of 41 trials involving over 3000 people concluded that plant sterol and stanol
intake lowers blood levels of carotenoids like beta carotene, lycopene, lutein, and
zeaxanthin. Carotenoids are antioxidants and provitamin A. They maintain immune and eye
health (Baumgartner et al., 2017).

In Europe, foods enriched with plant sterols must contain a warning about this side effect along
with a recommendation to increase fruit and vegetable intake to help maintain carotenoid levels.
Plant sterols may also reduce the absorption and blood levels of vitamin E, but it’s
uncertain to what extent. Increasing vitamin E foods is likely a good idea (Richelle et al., 2004;
Baumgartner, 2017; Tuomilehto et al., 2008).

Skin
One woman experienced allergic skin rash on the hands and feet and face swelling while taking
plant sterol supplements. The culprit isn’t completely clear, though (Hussain, & Roberts, 2008).

In another woman with high cholesterol, plant sterol-enriched margarine increased blood plant
sterols and led to fatty growths under the skin (Vergès et al., 2009).

Microcirculation
Several studies point out that plant sterols may trigger heart disease by gradually building up in
small blood vessels. They point to a link between higher blood plant sterol levels and a
narrowing of arteries that deliver oxygen-rich blood to the retina of the eye (Kelly et al., 2011).

Blockage of retinal arteries can lead to vision loss. It’s also been linked with high blood
pressure. However, additional research is needed to explore if plant sterols are part of the
problem.

Cell Studies
Stigmasterol blocked a receptor that’s important for transporting bile in liver cells (FXR) (Scolaro
et al., 2020).

Scientists are investigating whether beta-sitosterol can be toxic to cells in test tubes (Rubis et
al., 2008).

We can’t know if plant sterols will have these effects in live animals (let alone humans).

According to one theory, only mega doses of certain plant sterols have toxic potential. Natural
food sources contain a mix of plant sterols and may be less likely to cause imbalances, but this
hasn't been confirmed (Lizard, 2008).

Plant Sterols and Stanols Food List, Dosage & Probiotics Synergy

Food Sources
Here is a list of healthy foods with plant sterols (Kabral & Clein, 2017; Vezza et al., 2020;
Shin et al., 2010; Schepers et al., 2020):

● Fruits: passion fruit, orange, raspberries, bananas, cherries, plums, apricots,

 ● Vegetables: cauliflower, artichoke, avocado, green beans, broccoli, cabbage, carrots,
leeks, lettuce, chard, endive, spinach, olives

● Legumes: peanuts, chickpeas, lentils, white beans

● Nuts and seeds: pine nuts, macadamia nuts, pecans, almonds, pistachios, sunflower
seeds, cashews, walnuts

● Cereals: wheat bran, wheat grain, rice bran, corn bran, oat bran, barley

● Healthy fats: virgin olive oil, pumpkin seed oil

● Superfoods: maca powder, seaweed

Foods with plant stanols (Klingberg et al., 2008; Yang et al., 2019):

● Wheat

● Rye

● Corn oil

● Rice bran oil

● Fortified spreads

Unhealthy sources of plant sterols include:

● Refined corn, sunflower, and soybean oil

● Refined palm oil

● White bread

A typical western diet contains ~300 mg of sterols and 30 mg of plant stanols in a day.
Vegetarians tend to have a higher intake (300 - 500 mg/day) (Kabral & Clein, 2017).

The recommended daily intake of phytosterols for LDL-cholesterol reduction is ~2 g/day, but the
optimal intake is unknown (Kabral & Clein, 2017).

Safety of Widespread Fortification

Plant sterols have now been added to spreads, salad dressing, milk, soy, yogurt, cheese, fruit
drinks, and even sausages and bread. Analyses suggest that it’s very easy to take in excessive
amounts with all these new types of fortified products.

Be sure to always check the label. Children and pregnant and breastfeeding women should be
extra cautious.
Using Plant Sterols & Probiotics Together
Recent studies reveal that plant sterols can interact with the gut microbiome
(Cuevas-Tena et al., 2018; Kübeck et al., 2016).

Different sources and types of plant sterols may have different effects. Compared to olive or
safflower oil, palm oil increased weight gain, lowered microbial diversity, and increased the ratio
of “bad” to “good” probiotic bacteria (Firmicutes to Bacteroidetes) (de Wit et al., 2012).

Plant sterols may act also in symbiosis with probiotics, but clinical research is needed to
confirm this. In a rat study, probiotics were more effective at lowering total and LDL cholesterol
than plant sterols. However, their combination had the greatest effect on lowering LDL
(Awaisheh, 2013).

Increasing healthy food sources of prebiotics, probiotics, and plant sterols at the same
time is the best way to go.

Read about prebiotic and probiotic food sources here.

Probiotics as an Alternative
Lactobacillus Reuteri NCIMB 30242 is a reasonable alternative for people who want to avoid
plant sterols. In a clinical trial of 127 people, this probiotic strain reduced LDL cholesterol, total
cholesterol, and plant sterol blood levels (Jones & Prakash, 2012).

Find out how L. Reuteri affects cholesterol and plant sterols here.

Dosage
The typical plant sterols dosage for lowering cholesterol is 1.6-1.8 grams daily, usually
accomplished by eating fortified spreads.

The dosage in clinical trials varied from 200 mg to 9 g/day. Most research shows that there is no
benefit to going above 2-3 grams daily.

According to the FDA, at least 3.4 g/day of plant stanol esters or 1.3 g of plant sterol esters has
been linked with reduced heart disease risk, in addition to a low-fat, low-cholesterol diet. This
approach is controversial.

We advise caution since there is a lack of safety data on going over 3 g per day (Weingärtner et
al., 2009).

Read Next
● How L. Reuteri Affects Cholesterol & Plant Sterols
● The Difference Between Prebiotics & Probiotics
● Does Lactobacillus Reuteri Have Immune Benefits for COVID-19?