Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225

Contents lists available at ScienceDirect

Journal of Steroid Biochemistry & Molecular Biology

journal homepage: www.elsevier.com/locate/jsbmb

Full article

Plant sterol ester diet supplementation increases serum plant sterols

and markers of cholesterol synthesis, but has no effect on total
cholesterol levels
Oliver Weingärtner, M.D.a,c,d,* , Ivan Bogeskie,h,1, Carsten Kummerowe,h,1,
Stephan H. Schirmerb , Constanze Huschef , Tim Vanmierlof,g, Gudrun Wagenpfeila,b,c,d,e,f ,
Markus Hothe,h , Michael Böhmb , Dieter Lütjohannf,1, Ulrich Laufsb
a
Abteilung für Kardiologie, Klinikum Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky Universität, Oldenburg, Germany
b
Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Germany
c
Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
d
Institut für Medizinische Biometrie, Epidemiologie und Medizinische Informatik, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
e
Abteilung für Biophysik, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
f
Institut für klinische Chemie und klinische Pharmakologie, Universitätsklinikum Bonn, Bonn, Germany
g
Dept. of Immunology and Biochemistry, BIOMED, Hasselt University, Hasselt, Belgium
h
Department of Biophysics Faculty of Medicine CIPMM, Building 48, D-66421 Homburg, Germany

A R T I C L E I N F O A B S T R A C T

Article history:
Received 14 January 2016 This double-blind, randomized, placebo-controlled, cross-over intervention-study was conducted in
Received in revised form 23 July 2016 healthy volunteers to evaluate the effects of plant sterol ester supplemented margarine on cholesterol,
Accepted 26 July 2016 non-cholesterol sterols and oxidative stress in serum and monocytes. Sixteen volunteers, average age 34
Available online 27 July 2016 years, with no or mild hypercholesterolemia were subjected to a 4 week period of daily intake of 3 g plant
sterols per day supplied via a supplemented margarine on top of regular eating habits. After a wash-out
Keywords: period of one week, volunteers switched groups. Compared to placebo, a diet supplementation with plant
Cholesterol sterols increased serum levels of plant sterols such as campesterol (+0.16  0.19 mg/dL, p = 0.005) and
Plant sterol
sitosterol (+0.27  0.18 mg/dL, p < 0.001) and increased markers of cholesterol synthesis such as
Margarine
desmosterol (+0.05  0.07 mg/dL, p = 0.006) as well as lathosterol (+0.11  0.16 mg/dL, p = 0.012).
Monocyte
Oxidation Cholesterol serum levels, however, were not changed significantly (+18.68  32.6 mg/dL, p = 0.052).
These findings could not be verified in isolated circulating monocytes. Moreover, there was no effect on
monocyte activation and no differences with regard to redox state after plant sterol supplemented diet.
Therefore, in a population of healthy volunteers with no or mild hypercholesterolemia, consumption of
plant sterol ester supplemented margarine results in increased concentrations of plant sterols and
cholesterol synthesis markers without affecting total cholesterol in the serum, activation of circulating
monocytes or redox state.
ã 2016 Elsevier Ltd. All rights reserved.

1. Introduction have demonstrated that a diet supplementation with 2% of plant

sterols or plant stanols confers a plasma LDL-cholesterol (LDL-C)
Hypercholesterolemia is a risk factor for cardiovascular diseases lowering of about 10% [3,4]. Cater and colleagues showed that a
and therefore a major target for primary and secondary prevention daily intake of 2, 3, and 4 g of plant stanols as their esters reduce
[1,2]. Plant sterols have been added in different food matrixes to LDL cholesterol by 12, 13, and 14% [5]. However, clinical
serve as cholesterol lowering agents for many years. Clinical trials interventions show a significant inter-individual variability in
the extent of cholesterol reductions and some studies show that
not all individuals respond to an equal degree to standard doses of
* Corresponding author at: Klinik für Kardiologie, Klinikum Oldenburg, European plant sterols [6,7]. This heterogeneity of responsiveness appears to
Medical-School Oldenburg-Groningen, Carl von Ossietzky Universität Oldenburg, be patient-specific, with individuals showing consistency of lipid
Rahel-Straus-Str. 10, 26133 Oldenburg, Germany.
level response to a diet supplementation with plant sterols across
E-mail address: oweingartner@aol.com (O. Weingärtner).
1
These authors contributed equally to the manuscript. repeated challenges.

http://dx.doi.org/10.1016/j.jsbmb.2016.07.016
0960-0760/ã 2016 Elsevier Ltd. All rights reserved.
220 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225

Table 1
Study design. Sixteen volunteers were randomized either to a 4 week period to a pre-packed margarine supplemented with 3 g of plant sterols (red lable) a day or alternatively
to a placebo-margarine (green lable). After a wash-out period of 1 week volunteers switshed groups.

consumption of functional foods were exclusion criteria. The

Table 2
Volunteers characteristics. volunteers’ characteristics and their baseline laboratory values are
outlined in Table 2. The study was a prospective, randomized,
Age 34.20
double-blind, placebo-controlled, crossover study. The volunteers
BMI 25. 10
mean (n = 16) female (n = 8) male (n = 8) were on their usual diet throughout the entire study period.
Volunteers were randomized to margarine with plant sterol esters
GC–MS
cholesterol 202  41 194  33 210  49 or placebo for a time period of 4 weeks. A detailed lipid
sitosterol 0.23  0.13 0.27  0.17 0.20  0.08 composition of the margarines is provided in Table 3. After a
campesterol 0.31  0.15 0.35  0.20 0.27  0.09 wash out period of one week, volunteers switched groups. The
cholestanol 0.29  0.06 0.30  0.07 0.29  0.05 margarines were provided by RAISIO (Turku, Finland). Routine
lathosterol 0.39  0.20 0.34  0.25 0.44  0.13
laboratory measurements were taken to ensure normal health
desmosterol 0.19  0.07 0.16  0.08 0.21  0.05
before entry. Both at baseline and after 4 weeks, routine laboratory
Enzymatic measurements, total cholesterol, LDL-C, HDL-C, TGs, non-choles-
Cholesterol 205  42 194  45 216  38 terol sterols and monocyte subpopulations in serum were
LDL-C 121  40 102  38 141  34
determined. Moreover, total cholesterol, non-cholesterol sterols
HDL 66  18 77  18a 55  11
Triglycerides 118  51 100  39 136  58
and oxidative stress were assessed in circulating monocytes.

Volunteer characteristics are displayed in Table 2.

a 2.2. Sterol and oxysterol extraction from monocytes
Difference p < 0.05.

The cells were diluted in 200 ml phosphate-buffered saline.

In this prospective study we enrolled healthy volunteers with
Fifteen microliters were taken for protein analysis. Ten ml
no or only mild hypercholesterolemia who were not on any lipid-
epicoprostanol (stock solution: 100 mg/mL in ethanol) and 25 ml
lowering medications. We analysed concentrations of sterols in
5a-cholestane (stock solution: 1 mg/mL in ethanol) were added to
serum and in circulating monocytes before and after a diet
the remaining cell solution prior to alkaline hydrolysis. Free sterols
supplementation with 3 g of plant sterol esters and assessed the
were extracted by cyclohexane and derivatized to trimethylsilyl
effects on monocyte activation, subpopulations and redox state.
ethers as described previously [8,9].
2. Materials and methods
2.3. Sterol and oxysterol analysis in serum and in monocytes
2.1. Study population and study design
Serum sterols were extracted and derivatized to trimethylsilyl
ethers as described previously [8,9]. Serum cholesterol was
The protocol was registered at Clinical-Trials.gov (Identifier
quantified using gas chromatography-flame ionization detection
NCT00928616) and approved by the ethics committee of the
(GC-FID) and non-cholesterol sterols such as plant sterols and
Saarland, Germany (number 159/07). Sixteen subjects (8 males, 8
cholesterol precursors as well as cholesterol in monocytes by GC-
females) with normal or only mildly elevated serum cholesterol
mass spectrometry-selected ion monitoring [8,9]. Moreover, total
levels were included in the study. See also Table 1 “Study design”.
cholesterol, LDL-C, HDL-C and triglycerides were determined
The presence of angina pectoris, inflammatory gastrointestinal
enzymatically.
disease, diabetes mellitus, lipid-lowering medication, or

Table 3
Margarine composition.

[mg/mg] [mg/mg] [mg/mg] [mg/mg] [mg/mg] [mg/mg]

cholestanol campesterol campestanol stigmasterol sitosterol sitostanol
green-labeld 0,017 0,944 0,011 0,020 1,482 0,027
margarine
red-labeled margarine 0,020 24,162 3,752 0,472 102,602 30,463

Detailed lipid composition of placebo and plant sterol margarine.

 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225 221

2.4. Monocyte isolation from blood samples 2.5. Fluorescence activated cell sorting (FACS)

Peripheral blood mononuclear cells (PBMCs) were separated From 5 ml of blood drawn at each time point, flow cytometric
from the blood samples by a Ficoll density gradient centrifugation. analysis of monocyte activation and composition was performed.
The cells were placed in 50 ml Falcon tubes and separated using Blood was processed within 20 min after blood drawing to avoid
centrifugation at 450  g for 30 min. The separated leukocyte phase ex-vivo activation. Whole blood was stained using monoclonal
was transferred to a new reaction tube and washed in HBSS buffer antibodies against CD14, CD11b, CD16 (all Serotec, Düsseldorf,
(250  g, 15 min). Remaining erythrocytes and thrombocytes in the Germany) at 4 for 45 min. Following red blood cell lysis and
leukocyte pellet were removed by erythrocyte lysis (2 ml washing, samples were subjected to fluorescence-activated cell
Erythrocyte-lysis-buffer) for two minutes followed by gentle sorting (FACS) analysis in a FACSCalibur (BD Biosciences, Heidel-
centrifugation (RT, 130  g, 10 min). CD14+ monocytes were berg, Germany).
isolated from PBMCs (in PBS + 0.5% BSA) by negative isolation
using the Dynabeads1 UntouchedTM Human Monocytes System 2.6. Single cell ROS measurements
following the manufacturer instructions. Part of the cells was
frozen at 80  C and used for mass spectrometry analysis. The rest Intracellular ROS was determined on a single cell level by the
of the isolated monocytes were cultured in RPMI medium + 10% fluorescent dye 5-(and-6)-carboxy-2, 7-difluorodihydrofluores-
FCS at 37  C with 5% CO2. cein diacetate (H2-DCFDA) (ex.485/em.535). Cells were loaded
with H2-DCFDA (1 mM) for 30 min and imaged on a fluorescent

Fig. 1. Effects on serum cholesterol and non-cholesterol sterols.

Difference in mean values between plant sterol margarine (PSE) and placebo margarine (A–E).
222 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225

microscope (BD Pathway 855). Data was analyzed using AttoVision (cholesterol 9.43  19.91 mg/dL, p = 0.08; LDL-C 8.21  24.58 mg/dL
software. p = 0.20; HDL-C 1,74  13,14 mg/dL p = 0.60, triglycerides 18,71
 65.07 mg/dL, p = 0.27). Data not shown.
2.7. Statistics
3.3. Effects on monocyte cholesterol and non-cholesterol sterols
For statistical evaluation a paired, two-sided standard student
T-test was applied and significance indicated at p < 0.05. Addition- Because of their important role in the pathogenesis of
ally we calculated for the outcome variables of each of the patients atherosclerosis we determined the levels of cholesterol and plant
differences between follow-up and baseline value. Due to the sterols in monocytes isolated from the peripheral blood of
crossover design, we used the t-test for two dependent samples to volunteers as outlined above. Analysing the differences between
compare the differences in the sterol versus placebo group. In all subjects on placebo and all subjects on a plant sterol diet
addition we give mean values with respective 95% confidence supplementation, the plant sterols sitosterol and campesterol in
intervals as well as standard deviations for differences in the monocytes did not increase (sitosterol 0.04  0.18 mg/mg, p = 0.38;
outcome between placebo and sterol intake. The local two-sided campesterol 0.02  0.09 mg/mg; p = 0.31). Lathosterol as a marker
significance level was set at alpha = 0.05. For statistical analysis we of cholesterol synthesis and total monocyte cholesterol content
used IBM-SPSS version 23. were also not affected (lathosterol 0.01  0.03 mg/mg, p = 0.33,
cholesterol 0.10  9.20 mg/mg, p = 0.97). Desmosterol content
3. Results was not measureable in most monocytes, therefore no data are
available. Data not shown.
3.1. Effects on serum cholesterol and non-cholesterol sterols
3.4. Effects on oxidative stress in monocytes
Analysing the differences between all subjects on placebo and
all subjects on a plant sterol diet supplementation, the plant sterols Moreover, we also quantified the levels of reactive oxygen
sitosterol and campesterol increased in the serum (sitosterol species (ROS) in circulating monocytes from all 16 volunteers.
0.27  0.18 mg/dL, p < 0.001; campesterol 0.15  0.18 mg/dL, Comparing the intergroup differences between placebo and plant
p = 0.005). Markers of cholesterol synthesis such as lathosterol sterol group, there was no significant effect on ROS levels (Fig. 2).
and desmosterol were also increased (lathosterol 0.11  0.16,
p = 0.012; desmosterol 0.05  0.07 mg/dL, p = 0.006). Total serum 3.5. Effects on monocyte activation
cholesterol did not increase significantly in serum
(18.68  32.6 mg/dL, p = 0.052). See also Fig. 1A–E. Monocyte subpopulation distribution (CD16+CD14low and
CD16+CD14high) remained unchanged following sterol supplemen-
3.2. Effects on serum total cholesterol, LDL-C, HDL and triglycerides tatio. Expression of CD11b (part of monocyte Mac1 receptor for
endothelial adhesion to intercellular adhesion molecule (ICAM)-1)
Analysing the difference between all subjects on placebo and on increased significantly demonstrating enhanced monocyte activa-
a plant sterol diet supplementation enzymatically, total serum tion following sterol supplementation (by 31 15%, p = 0.024)
cholesterol, LDL-C, HDL-C and triglycerides were not affected when comparing all subjects before and after a plant sterol diet

Fig. 2. Effects on monocyte ROS levels.

Intergroup differences in ROS levels after plant sterol diet vs. placebo margarine.
 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225 223

Fig. 3. Effects on monocyte activation.

Monocyte CD11b expression on circulating monocytes as determined by flow cytometry following PSE.

supplementation (data not shown). However, this effect was not design for statistical analysis to identify inter-individual variations
significant when comparing differences for each outcome variable in dietary response as volunteers undergo both treatment and
and each of the patients (10.6  40.8%; ns) See also Fig. 3. control phases and consequently serve as their own control [12].
Using controlled study designs, three types of individuals may be
4. Discussion characterized to cholesterol lowering response: “responders” with
significant reductions in serum cholesterol levels; “non-respond-
The purpose of this study was to evaluate the effect of a daily ers” who exhibit no response or a suboptimal cholesterol-
diet supplementation with 3 g of plant sterol esters in margarine in lowering; and “adverse-responders” who respond with an increase
a young and healthy population on cholesterol, non-cholesterol in serum cholesterol levels to cholesterol-lowering interventions
sterols, monocyte activation and oxidative stress in monocytes. [13]. Previously, Rideout and colleagues have reported two clinical
After a 4-week period on 3 g plant sterol ester per day via studies that adeptly demonstrate response, non-response, and
supplemented margarine, serum levels of plant sterols increased. adverse response to a dietary approach with plant sterol
Interestingly, in this specific population serum levels of lathosterol consumption in mildly hypercholesterolemic patients [6]. A study
and desmosterol, both indicators of cholesterol synthesis, also conducted with low-fat soymilk included more non-responders
demonstrated an increase, even though the increase in serum total than a study with moderate-fat soy beverages. In fact, in the low-
cholesterol levels did not reach statistical significance. Moreover, fat soymilk study LDL-C changes ranged from 33% to + 37%, with 9
there was no significant increase in cholesterol and non- out of 33 subjects displaying increased LDL-C following a diet
cholesterol sterols in isolated monocytes. Of note, enzymatic supplementation with plant sterols. Interestingly, also in that
measurements of total serum cholesterol, confirmed these findings study total cholesterol (203 mg/dL) and LDL-C (123 mg/dL) at
obtained with GC–FID measurements and did not reveal an effect baseline was comparable to our study at baseline with total
of a plant sterol diet supplementation on these blood lipids. Finally, cholesterol levels of 205 mg/dL and LDL-C levels of 121 mg/dL. Even
FACS analysis revealed no significant increase in monocyte thought other studies have predicted a significant decrease in
activation and there was no significant increase in regard to redox cholesterol lowering with plant sterol esters in normocholester-
state or monocyte subpopulations. olemic or mildly hypercholesterolemic individuals [4], it can be
Clinical trials have demonstrated a considerable inter-individ- speculated that the findings in our study add to the notion that
ual heterogeneity in responsiveness of blood lipids to a wide especially in populations with normal blood cholesterol levels, the
spectrum of diet based therapies [10]. One reason for this is the blood cholesterol responsiveness of plant sterols cannot be
large variability in blood lipid outcomes that are reported between accurately predicted. Clearly, further research will be required to
clinical studies for any given dietary therapy. These inter-study elucidate on this.
inconsistencies in responsiveness can often be explained by It has been previously demonstrated that the effectiveness of
differences in study population, dietary background, and treat- blood cholesterol lowering of statins (inhibitors of endogenous
ment dose and duration. Extreme inter-study lipid responsiveness cholesterol synthesis) as well as ezetimibe and plant sterols/plant
can generate uncertainty within the research community, a stanols (inhibitors of cholesterol absorption) depends on individ-
situation illustrated recently by the ambiguous low-density ual differences in cholesterol metabolism reflected as a sum of both
lipoprotein cholesterol (LDL-C)-lowering action of policosanols cholesterol synthesis and cholesterol absorption [14–17]. There-
[11]. Moreover, there is inter-individual heterogeneity of lipid fore, we have suggested the “Oldenburg lipid therapy pathway” as a
responsiveness that is most often observed in randomized model for an “individualized” lipid lowering strategy for drug
crossover studies. Of note, the crossover study is the most robust treatment in patients with elevated serum cholesterol levels [18].
224 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225

Moreover, we asked for a re-evaluation of the IMPROVE-IT trial clarify the controversy over plant sterols and their role in
according to individual differences in cholesterol metabolism [19] cardiovascular prevention [33–36].
as demonstrated previously for statin treatment by Mettinen and To provide most effective lipid-lowering therapeutic outcomes,
colleagues in the 4S Study [15]. Interestingly, another study by future clinicians will need to “get personal” in their counselling
Rideout and colleagues further adds to this concept in which they and prescription of lipid-lowering agents [19]. Just like drugs such
have examined basal cholesterol synthesis as a possible metabolic as statins and ezetimibe, plant sterols show a variation with regard
factor contributing to the considerable heterogeneity of lipid to effectiveness. The fact that some individuals on a plant sterol
responsiveness to plant sterol consumption [7]. In a retrospective supplemented diet demonstrate a “paradoxical increase” in
analysis of three controlled feeding plant sterol interventions cholesterol levels in serum, suggests that future approaches in
employing stable isotope methodology (deuterium incorporation) lipid-lowering therapy call for “individualized” concepts. To
to directly measure fractional cholesterol synthesis rate, they establish such concepts, individual differences in cholesterol
identified 47 non-responders (3.73  1.1% change in LDL-C) and 66 metabolism and their reactions to lipid-lowering therapies will
responders ( 15.2  1.0% change in LDL-C) to a diet supplementa- need increased scrutiny and investigation.
tion with 2 g of plant sterols a day. Basal fractional cholesterol
synthesis was 23% higher (P = 0.003) in non-responders compared Acknowledgements
with responders to plant sterol supplementation. These findings
suggest that humans with high basal cholesterol synthesis are This work is supported by the Medical Faculty of Saarland
unresponsive to cholesterol absorption inhibition by a diet (HOMFOR excellent research grant to OW and IB) and by the
supplementation with plant sterols. As obese individuals exhibit following DFG grants: SFB1027 project C4 to IB and BO3643/3-1 (to
higher cholesterol synthesis compared with non-obese individuals IB) and HO2190/4-1 (to MH). Furthermore, this work was
[20], it has been speculated previously, that body weight may be supported by an unrestricted research grant from RAISIO Nutrition
predictive in the LDL-C lowering response to a diet supplementa- (Turku, Finland) to OW.
tion with plant sterols [21]. However, our study population
exhibits an average body mass index (25.2 kg/m2) and direct References
comparisons between lean and obese has not been conducted yet
[8]. Although stable isotope assessment of cholesterol synthesis is [1] J. Shepherd, S.M. Cobbe, I. Ford, et al., Prevention of coronary heart disease
with pravastatin in men with hypercholesterolemia. West of Scotland
not a feasible option in routine clinical practice, indirect analysis of Coronary Prevention Study Group, N. Engl. J. Med. 333 (1995) 1301–1307.
sterol biomarkers that accurately reflect cholesterol synthesis can [2] Randomised trial of cholesterol lowering in 4444 patients with coronary heart
be accomplished through inexpensive routine gas-chro- disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 344 (1994)
1383–1389.
matographic analysis [6] and may prove to be a practical tool to [3] T.A. Miettinen, P. Puska, H. Gylling, et al., Reduction of serum cholesterol with
assess whether plant sterols would be an effective therapy in sitostanol-ester margarine in a mildly hypercholesterolemic population, N.
patients with elevated serum cholesterol levels in future “individ- Engl. J. Med. 333 (1995) 1308–1312.
[4] J.A. Weststrate, G.W. Meijer, Plant sterol-enriched margarines ad reduction of
ualized” lipid-lowering therapy.
plasma total-and LDL-cholesterol concentrations in normalcholesterolemic
At present there are inconclusive results in regard to triglycer- and mildly hypercholesterolaemic subjects, Eur. J. Clin. Nutr. 52 (1998) 334–
ide concentrations, but some animal [22,23] and some clinical 343.
[5] N.B. Cater, A.B. Garcia-Garcia, G.L. Vega, S.M. Grundy, Responsiveness of
investigations [24,25] have reported consistent yet variable
plasma lipids and lipoproteins to plant stanol esters, Am. J. Cardiol. 96 (2005)
reductions in triglycerides in response to a diet supplementation 23D–28D.
with plant sterols. Moreover, a recent meta-analysis supports the [6] T.C. Rideout, Y.M. Chan, S.V. Harding, P.J. Jones, Low and moderate-fat plant
notion that plant sterols reduce triglycerides [26], even thought sterol fortified soymilk in modulation of plasma lipids and cholesterol kinetics
in subjects with normal to high cholesterol concentrations: report on two
others have failed to establish this relationship [27,28]. Two recent randomized crossover studies, Lipids Health Dis. 8 (2009) 45.
studies suggest that patients with high baseline plasma trigly- [7] T.C. Ridout, S.V. Harding, D. Mackay, et al., High basal fractional cholesterol
cerides respond with enhanced triglyceride reductions to plant synthesis is associated with nonresponse of plasma LDL cholesterol to plant
sterol therapy, Am. J. Clin. Nutr. 92 (2010) 41–46.
sterol diet supplementation compared to patients with low [8] D. Lutjohann, A. Brzezinka, E. Barth, et al., Profile of cholesterol-related sterols
triglycerides [12,14]. Of note, in our study with mean triglycerides in aged amyloid precursor protein transgenic mouse brain, J. Lipid Res. 43 (7)
at baseline of 118 mg/dL, we did not observe any triglyceride- (2002) 1078–1085.
[9] D.S. Mackay, P.J. Jones, S.B. Myrie, J. Plat, D. Lutjohann, Methodological
lowering effect. Again, these findings suggest that both elevated considerations for the harmonization of non-cholesterol sterol bio-analysis, J.
serum cholesterol levels and elevated triglyceride levels are a Chromatogr. B Anal. Technol. Biomed. Life Sci. 957 (2014) 116–122, doi:http://
prerequisite for a lipid lowering effect of a diet supplementation of dx.doi.org/10.1016/j.jchromb.2014.02.052.
[10] D. Lairon, C. Defoort, J.C. Martin, et al., Nutrigenetics: links between genetic
plant sterols. background and response to the Mediterranean-type diet, Publ. Health Nutr.
We have previously reported that a diet supplementation with 12 (2009) 1601–1606.
plant sterols increases plant sterol concentrations in serum and in [11] C.P. Marinangeli, P.J. Jones, A.N. Kassis, M.N. Eskin, Policosanols as
nutraceuticals: fact of fiction, Crit. Rev. Food Sci. Nutr. 50 (2010) 259–267.
aortic valve cusps [29]; Miettinen and colleagues have demon-
[12] A.M. Zivkovic, M.M. Wiest, U. Nguyen, et al., Assessing individual metabolic
strated that plant sterol levels in serum correlate with plant sterol responsiveness to a lipid challenge using a targeted metabolic approach,
concentrations in the arterial wall [30] and we have reported only Metabolomics 5 (2009) 209–218.
recently that plant sterols and their oxides correlate between [13] R.G. Bach, Heterogeneity of response to lipid-lowering therapy, J. Am. Coll.
Cardiol. 38 (2001) 2136–2137.
serum and aortic valve cusps [31]. Interestingly, patients with [14] O. Weingärtner, D. Lütjohann, M. Böhm, U. Laufs, Relationship between
increased deposition of plant sterols and their oxides in vascular cholesterol synthesis and intestinal absorption is associated with
tissue were characterized by a significantly higher incidence of cardiovascular risk, Atherosclerosis 210 (2010) 362–365.
[15] T.A. Miettinen, H. Gylling, T. Strandberg, S. Sarna, Baseline serum cholestanol
coronary artery disease [32]. Due to a wide variability of sterol as predictor of recurrent events in subgroup of Scandinavian simvastatin
concentrations in monocytes in our placebo group and a too short survival study. Finnish 4S Investigators, BMJ 316 (1998) 1127–1130.
wash out period in between the groups we could not demonstrate [16] M. Farnier, M. Averna, L. Missault, et al., Lipid-altering efficacy of ezetimibe/
simvastatin 10/20 mg compared with rosuvastatin 10 mg in high-risk
a significant increase of sterols in circulating monocytes. Moreover, hypercholesterolaemic patients inadequately controlled with prior statin-
there was no significant increase in regard to redox state in monotherapy—the IN-CROS study, Int. J. Clin. Pract. 63 (2009) 547–559.
circulating monocytes between placebo and plant sterol diet [17] S.C. Thuvula, M. Igel, U. Giesa, et al., Ratio of lathosterol to campesterol in
serum predictsthe cholesterol-lowering effect of sitostanol-supplemented
supplementation. Therefore, further studies are needed to better margarine, Int. J. Clin. Pharmacol. Ther. 43 (2005) 305–310.
 O. Weingärtner et al. / Journal of Steroid Biochemistry & Molecular Biology 169 (2017) 219–225 225

[18] O. Weingärtner, D. Lütjohann, T. Plösch, A. Elsässer, Individualized lipid- cholesterol and triacylglycerol concentrations, J. Am. Coll. Nutr. 27 (2008) 117–
lowering therapy to further reduce residual cardiovascular risk, J. Steroid 126.
Biochem. Mol. Biol. 169 (2017) 198–201, doi:http://dx.doi.org/10.1016/j. [27] S.S. Albumweis, R. Barake, P.J. Jones, Plant sterols/stanols as cholesterol-
jsbmb.2016.05.016. lowering agents: a meta-analysis of randomized controlled trials, Food Nutr.
[19] O. Weingärtner, D. Lütjohann, A. Elsässer, Personalize and optimize lipid- Res. 52 (2008) 8.
lowering therapies, J. Am. Coll. Cardiol. 68 (2016) 325–326. [28] A. Berger, P.J. Jones, S.S. Albumweis, Plant sterols: factor affecting their efficacy
[20] P.P. Simonen, H. Gylling, T.A. Miettinen, Body weight modulates cholesterol and safety as functional food ingredients, Lipids Health Dis. 3 (2004) 5.
metabolism in noninsulin dependent type 2 diabetics, Obes. Res. 10 (2002) [29] O. Weingärtner, D. Lütjohann, S. Ji, et al., Vascular effects of a diet
328–335. supplementation with plant sterols, J. Am. Coll. Cardiol. 51 (2008) 1551–1561.
[21] T.C. Rideout, Getting personal: considering variable interindividual [30] T.A. Miettinen, M. Railo, M. Lepantalo, H. Gylling, Plant sterols in serum and
responsiveness to dietary lipid-lowering therapies, Curr. Opin. Lipidol. 1 atherosclerotic plaques of patients undergoing carotid endarterectomy, J. Am.
(2011) 37–42. Coll. Cardiol. 45 (2005) 1794–1801.
[22] T.C. Rideout, S.V. Harding, P.J. Jones, Consumption of plant sterols reduces [31] H.F. Schött, A. Luister, C. Husche, et al., The relationships of phytosterols and
plasma and hepatic triglycerides and modulates the expression of lipid oxyphytosterols in plasma and aortic valve cusps in patients with severe aortic
regulatory genes and de novo lipogenesis in C57BL/6J mice, Mol. Nutr. Food stenosis, Biochem. Biophys. Res. Commun. 446 (2014) 805–810.
Res. 54 (2010) S7–S13. [32] A. Luister, H.F. Schött, C. Husche, et al., Increased plant sterol deposition in
[23] L. Calpe-Berdiel, J.C. Escola-Gil, V. Ribas, et al., Changes in intestinal and liver vascular tissue characterizes patients with severe aortic stenosis and
global gene expression in response to a phytosterol-enriched diet, concomitant coronary heart disease, Steroids 99 (2015) 272–280.
Atherosclerosis 181 (2005) 75–85. [33] O. Weingärtner, T. Teupser, S.B. Patel, The atherogencicity of plant sterols: the
[24] J. Plat, G. Brufau, G.M. Dallinga-Thie, et al., A plant stanol yoghurt drink alone or evidence from genetics to clinical trials, J. AOAC Int. 98 (2015) 742–749.
combined with a low-dose statin lowers serum triacylglycerol and non-HDL [34] O. Weingärtner, M. Böhm, U. Laufs, Controversial role of plant sterol esters in
cholesterol in metabolic syndrome patients, J. Nutr. 139 (2009) 1143–1149. the management of hypercholesterolaemia, Eur. Heart J. 30 (2009) 404–409.
[25] P.J. Jones, M. Raeini-Sarjaz, F.Y. Ntanios, et al., Modulation of plasma lipid levels [35] H. Gylling, J. Plat, S. Turley, et al., Plant sterols and plant stanols in the
and cholesterol kinetics by phytosterol versus phytostanol esters, J. Lipid Res. management of dyslipidaemia and preventon of cardiovascular diseases,
41 (2000) 697–705. Atherosclerosis 232 (2014) 346–360.
[26] E. Naumann, J. Plat, A.D. Kester, R.P. Mensink, The baseline serum lipoprotein [36] O. Weingärtner, R. Baber, D. Teupser, Plant sterols in food: no consensus in
profile is related to plant stanol induced changes in serum lipoprotein guidelines, Biochem. Biophys. Res. Commun. 446 (2014) 811–813.