The Effect of Soya Beverage Fortified With Plant Sterol on Major Serum Lipids in Normocholesterolemic, Healthy Southern Chinese Individuals
Phase: NA
Conditions: Dyslipidemia
Sponsor: The University of Hong Kong

Page 1 
 
 
The Effect of Soya Beverage Fortified with Plant 
Sterol on Major Serum Lipids in 
Normocholesterolemic, Healthy Southern 
Chinese Individuals 
Brief Title: The Effect of 3-Week Consumption of Soya Beverage Enriched With Plant 
Sterols on Serum LDL-C 
 
ClinicalTrials.gov ID: NCT02881658 
Protocol Number: CTC1521 
Principal Investigator: Professor Cheung Bernard Man Yung 
Co-Investigator: Dr. Cheung Ching-Lung  
Dated: 17/5/2016  
 
 
 
 
 
 
 
 

Page 2 
 
1 LIST OF ABBREVIATIONS 
AE 
Adverse Event 
ANCOVA 
Analysis of Covariance 
BMI 
Body Mass Index 
CRF 
Case Report Form 
CTC 
Clinical Trial Centre 
CVD 
Cardiovascular Disease 
eCRF 
Electronic Case Report Form 
DMP 
Data Management Plan 
EDC 
Electronic Data Capture 
EU 
European Union 
GCP 
Good Clinical Practice 
HDL-C 
High-Density Lipoprotein Cholesterol 
HKU 
The University of Hong Kong 
ICH 
The International Council on Harmonisation of Technical 
Requirements for Registration of Pharmaceuticals for Human Use 
IRB 
Institutional Review Board 
ITT 
Intention-to-Treat 
LDL-C 
Low-Density Lipoprotein Cholesterol 
PI 
Principal Investigator 
PP 
Per-Protocol 
TAG 
Triglycerides 
TC 
Total Cholesterol 
UP 
Unanticipated Problems 
US FDA  
United State Food and Drug Administration  

Page 3 
 
2 TABLE OF CONTENTS 
PAGE 
1 
LIST OF ABBREVIATIONS ................................................................................................ 2 
2 
TABLE OF CONTENTS ..................................................................................................... 3 
3 
PROTOCOL SYNOPSIS .................................................................................................... 5 
4 
SCHEMATIC OF STUDY DESIGN ..................................................................................... 9 
5 
SCHEDULE OF STUDY ASSSSMENTS / PROCEDURES .............................................. 10 
6 
INTRODUCTION .............................................................................................................. 11 
6.1 
Background Information ........................................................................................ 11 
6.1.1 Disease Background Relevant to Clinical Study ........................................ 11 
6.1.2 Investigational Product Background Relevant to Clinical Study ................. 12 
6.2 
Study Rationale .................................................................................................... 13 
6.3 
Potential Risks and Benefits ................................................................................. 15 
6.3.1 Potential Risks .......................................................................................... 15 
6.3.2 Potential Benefits ...................................................................................... 15 
7 
OBJECTIVES ................................................................................................................... 16 
7.1 
Study Objectives ................................................................................................... 16 
8 
STUDY DESIGN .............................................................................................................. 17 
9 
STUDY POPULATION ..................................................................................................... 18 
9.1 
Inclusion Criteria ................................................................................................... 18 
9.2 
Exclusion Criteria .................................................................................................. 18 
9.3 
Subject Withdrawal ............................................................................................... 20 
9.3.1 Reasons for Withdrawal ............................................................................ 20 
9.3.2 Handling of Subject Withdrawals or Subject Discontinuation of Study 
Intervention ............................................................................................... 20 
9.4 
Premature Termination or Suspension of Study .................................................... 21 
10 
GROUP ASSIGNMENT PROCEDURES .......................................................................... 22 
10.1 
Subject Number .................................................................................................... 22 
10.2 
Randomization Schemes ...................................................................................... 22 
10.3 
Group Allocation ................................................................................................... 22 
10.4 
Masking ................................................................................................................ 23 
10.5 
Emergency Unblinding .......................................................................................... 23 
11 
INVESTIGATONAL AND CONTROL PRODUCT ADMINISTRATION .............................. 24 
11.1 
Product Description .............................................................................................. 24 
11.1.1 Acquisition ................................................................................................. 24 
11.1.2 Formulation, Packaging, and Labeling....................................................... 24 
11.1.3 Product Storage and Stability .................................................................... 24 
11.2 
Dosage, Preparation and Administration of Study Products .................................. 24 
11.3 
Accountability Procedures for the Study Products ................................................. 24 
12 
STUDY SCHEDULE AND PROCEDURE ......................................................................... 25 
12.1 
Study Visit ............................................................................................................. 25 
12.1.1 Screening and Enrollment/Baseline (Visit 1, Day 0)................................... 25 
12.1.2 End of Study (Visit 2, Day 21 ± 5) .............................................................. 25 

Page 4 
 
12.1.3 Early Withdrawal ....................................................................................... 26 
12.2 
Procedures and Evaluations ................................................................................. 26 
12.2.1 Clinical Laboratory Evaluations ................................................................. 26 
12.2.2 Special Assays or Procedures ................................................................... 26 
13 
STUDY MEASUREMENTS AND VARIABLES ................................................................. 27 
13.1 
Efficacy Measurements ......................................................................................... 27 
13.1.1 Primary Endpoint ....................................................................................... 27 
13.1.2 Secondary Endpoints ................................................................................ 27 
13.2 
Safety Measurements ........................................................................................... 27 
13.2.1 Adverse Events ......................................................................................... 27 
13.3 
Demographic Information ...................................................................................... 28 
13.4 
Medical History ..................................................................................................... 28 
13.5 
Dietary Information ............................................................................................... 28 
13.6 
Study Product Compliance ................................................................................... 28 
13.7 
Prior/Concomitant Medications ............................................................................. 29 
13.8 
Protocol Deviations ............................................................................................... 29 
14 
STATISTICAL SECTION .................................................................................................. 30 
14.1 
Sample Size Rationale .......................................................................................... 30 
14.2 
Data Set Analyzed ................................................................................................ 30 
14.3 
Handling of Missing or Invalid Data ....................................................................... 30 
14.4 
Demographics and Baseline Characteristics ......................................................... 30 
14.5 
Primary Efficacy analysis ...................................................................................... 31 
14.6 
Secondary Efficacy analyses ................................................................................ 31 
14.7 
Safety Analysis ..................................................................................................... 31 
14.8 
Compliance of the study products ......................................................................... 31 
14.9 
Concomitant Medications ...................................................................................... 31 
14.10 Interim Analyses ................................................................................................... 31 
15 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS .................. 32 
15.1 
Source Documents ............................................................................................... 32 
16 
DATA HANDLING AND RECORD KEEPING ................................................................... 33 
16.1 
Data Management Responsibilities ....................................................................... 33 
16.2 
Data Capture Methods .......................................................................................... 33 
16.3 
Study Records Retention ...................................................................................... 33 
17 
ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................................. 34 
17.1 
Ethical Standard ................................................................................................... 34 
17.2 
Institutional Review Board .................................................................................... 34 
17.3 
Informed Consent Process ................................................................................... 34 
17.4 
Subject Confidentiality .......................................................................................... 35 
17.5 
Future Use of Stored Specimens and Other Identifiable Data ............................... 35 
18 
PUBLICATION/DATA SHARING POLICY ........................................................................ 36 
19 
LITERATURE REFERENCES .......................................................................................... 37 

Page 5 
 
3 PROTOCOL SYNOPSIS 
Title: 
The Effect of Soya Beverage Fortified with Plant Sterol on Major 
Serum Lipids in Normocholesterolemic, Healthy Southern 
Chinese Individuals 
Phase: 
Phase II 
Study Site: 
Queen Mary Hospital, The University of Hong Kong 
Study Design: 
This is a local, single-center, two-arm, randomized, double-
blind, placebo-controlled study that examine the effect of the 
consumption of a soya beverage enriched with plant sterol for 3 
weeks. Subject will be randomly assigned to receive either the 
investigational or control product. The randomization will be 
stratified by both gender (male and female) and age group (18-
40 years and >40 years). 
Blood specimens will be collected at the baseline and at the end 
of the consumption period, which will be subjected to laboratory 
analysis. 
Study Objectives: 
 
Primary Objective:  To examine the effect of the consumption 
of a plant sterols fortified soya beverage on serum LDL 
cholesterol in healthy, free-living normocholesterolemic 
individuals 
 
Secondary Objective: To examine health-benefits by 
consuming the plant sterols fortified soya beverage in terms of 
serum total triglyceride, total and HDL cholesterol, other 
cardiometabolic risk factors and musculoskeletal-related traits. 
Study Population: 
Two hundred (200) Southern Chinese male or female in Hong 
Kong who aged 18 or above with good general health will be 
recruited in this study. 
Investigational and 
Control Product 
Administration: 
The investigational product is a soya drink fortified with 2g plant 
sterols per pack and the control product is the same soya drink 
except without plant sterols. 
Subjects will be asked to consume 1 pack of either 
investigational or control product daily for 3 consecutive weeks, 
each pack consumed once with main meal. Subjects consuming 
test product will therefore consume 2 g of plant sterols daily. 
 

Page 6 
 
Study Duration: 
This study is estimated to last for 12 months (from subject 
enrollment until completion of data analyses) 
Subject 
Participation 
Duration: 
3 weeks 
Estimated Time to 
Complete 
Enrollment: 
9 months 
Study Endpoints: 
The primary endpoint is the mean serum LDL-C at the end of 
week 3 after the consumption of plant sterols fortified soya 
beverage or control product. 
The secondary endpoints include the changes of serum LDL-
C, HDL-C, total cholesterol, triglycerides (TAG), serum 
creatinine, fasting blood glucose, other cardiometabolic risk 
factors and musculoskeletal-related traits from baseline to week 
3. 
Statistical 
Analysis: 
Sample size rationale: 
The sample size calculation is based on ANCOVA with baseline 
serum LDL-C as independent covariate. According to a previous 
study (36), the standard deviation of LDL-C at week 4 is 
approximately 0.85 mmol/l and the estimated correlation 
coefficient between the outcomes measured at baseline and 
week 4 is about 0.7. In addition, a minimum difference of 0.28 
mmol/l in LDL-C between the groups is considered clinically 
important.  
By using PASS 12 for the sample size calculation, a power of 
0.8 and a 5% of the maximum tolerable false positive rate, 75 
subjects per group is required to detect the minimum difference 
between the mean values of LDL-C. 
Considering an attrition rate of 25%, a total of 200 subjects will 
be recruited. 
 
 
 
 
 

Page 7 
 
Data set analyzed: 
The intention-to-treat (ITT) population is consisted of all 
randomized subjects. The per-protocol (PP) population includes 
all eligible subjects who have 80% of study product compliance, 
efficacy data collected within the pre-specified allowable visit 
window, and no protocol violation that is clinically significant.    
Handling of missing or invalid data: 
No data imputation will be performed to replace missing or 
invalid data. 
Efficacy Analysis: 
Primary Efficacy Analysis:  
ANCOVA will be carried out to compare the serum LDL-C level 
at week 3 between the groups. The baseline of the response 
outcome will be used as a covariate to control for initial group 
differences. A log transformation will be performed if the 
normality assumption for the ANCOVA model is violated. And if 
the normality assumption is still not sustained, non-parametric 
approach might be performed. The primary efficacy analysis will 
be performed on both the ITT and the PP populations. 
Secondary Efficacy Analyses: 
Stratified analysis for the primary endpoint will be performed 
using the ANCOVA model adjusted for gender and age group. 
Subjects will be classified to one of the following strata: 
1. Male, aged 18-40 years 
2. Male, aged >40 years 
3. Female, aged 18-40 years 
4. Female, aged >40 years 
The changes of the following response outcomes from baseline 
to week 3 will be summarized by descriptive statistics:  
 Blood Tests: LDL-C, HDL-C, total cholesterol, TAG, 
creatinine and fasting glucose.  
 Cardiometabolic risk factors: blood pressure, body 
temperature, weight, BMI, waist and hip circumferences. 
 Musculoskeletal-related traits: handgrip strength, peak 
expiratory flow rate, bio-impedance, gait speed and body 
balance 
The secondary efficacy analyses will be performed on the ITT 
population only. 

Page 8 
 
 
 
Safety Analysis: 
 
The incidence of AE such as nausea, abdominal cramps, 
vomiting, diarrhea, and flatulence will be summarized by 
frequency tables per study group. Data listings will be reported. 
 

Page 9 
 
4 SCHEMATIC OF STUDY DESIGN 
 
Prior to  
Enrolment 
 
 
 
 
 
 
 
 
 
Visit 1 
(Day 0) 
 
 
 
 
 
 
 
 
 
 
 
Visit 2 
 
(Day 21±5) 
 
 
 
 
Remarks 
Subjects will be asked to refrain from drinking 2 alcoholic or caffeinated beverages per day and 
advised to maintain their typical diet and physical activity levels. They will also be asked to 
report any changes in diet or physical activity and symptoms or changes in health and 
medications throughout the trial. 
Total Planned Number of Subjects = 200; 
Screen potential subjects by inclusion and exclusion criteria 
 
Follow-up assessments of outcome measures and safety 
Collect dietary information; 
Collect peripheral blood specimen; 
Perform physical examination;  
Measure cardiometabolic risk factors; 
Record concomitant medications; 
Record adverse events; 
Stratified Randomization 
→Investigational Group  
Or 
→Control Group  
Dispense study products 
Obtain informed consent; 
Obtain documents of medical and medication history 
Baseline assessments 
Collect demographic information; 
Collect dietary information 
Collect peripheral blood specimen; 
Perform physical examination;  

Page 10 
 
5 SCHEDULE OF STUDY ASSSSMENTS / PROCEDURES 
Assessments / Procedures 
Screening & 
Baseline 
(Day 0) 
End of Study 
(Day 21 ± 5) 
 Early 
Withdrawal 
Informed Consent Form Signed 
X 
 
 
Eligibility Criteria 
X 
 
 
Demographic Information 
X 
 
 
Medical History 
X 
 
 
Physical Examination 
X 
X 
X 
Cardiometabolic Risk Factors 1 
X 
X 
X 
Blood Test 2 
X 
X 
X 
Concomitant Medications 
X 
X 
X 
Dispensing Study Product 
X 
 
 
Adverse Events 
 
X 
X 
Study Product Compliance 
 
X 
X 
Dietary Information 
X 
X 
X 
 
Remarks: 
1. Cardiometabolic risk factors include blood pressure, body temperature, body height 
and weight, waist and hip circumferences. Body height will be measured at the 
baseline only. 
2. Blood tests include:  
 
Lipid profile: Serum level of LDL-C, HDL-C, total cholesterol and TAG 
 
Serum creatinine, fasting blood glucose 
3. Physical examination includes measurement of bioimpedance. Participants with 
metal implant will be excluded from this measurement.  

Page 11 
 
6 INTRODUCTION 
6.1 
Background Information 
6.1.1 
Disease Background Relevant to Clinical Study 
 
The Relationship Between Cardiovascular Disease (CVD) and Low-Density Lipoprotein 
Cholesterol (LDL-C) 
 
A cardiovascular disease (CVD) is a major health problem as the third leading causes of 
mortality in Hong Kong (3). A number of CVD risk factors have been identified, such as 
hypertension, obesity, tobacco exposure and physical inactivity. Among these risk 
factors, elevated plasma LDL-C levels play a significant role in CVD development. The 
deposition of cholesterol in the arterial wall by the infiltration of LDLs is a key step in the 
development of atherosclerotic CVD such as coronary artery disease, stroke and 
peripheral vascular disease. The consensus of LDL as the major proatherogenic 
lipoproteins in the circulation provides a valuable parameter for assessing CVD risk (4). 
Indeed, blood LDL-C level is also one of the predictors in the Framingham Risk Score, a 
risk assessment tool widely used in clinical setting for estimating of 10-year 
cardiovascular risk of an individual (5).  
 
The blood cholesterol level is controlled by cholesterol absorption from the diet and by 
endogenous cholesterol synthesis that occurs through a series of pathways. The main 
strategy of conventional lipid lowering therapy is to interfere with some of these 
pathways by pharmacological agents and dietary components (6). For example, statins 
are a class of highly effective cholesterol-lowering drugs by inhibiting the enzyme HMG-
CoA reductase, which plays a central role in the production of cholesterol in the liver (7). 
Despite the various lipid lowering agents for the management of hyperlipidemia, a 
significant number of patients do not reach their LDL-C target goals due to various 
reasons such as low drug compliance and resistant to lifestyle change (7-8). The often 
poor achievement of LDL-C goals among high risk patients warrants the need of other 
cholesterol lowering measures with higher efficacy and patient acceptance. 

Page 12 
 
 
6.1.2 
Investigational Product Background Relevant to Clinical Study 
Plant Sterols and their Physiological Characteristics 
Plant sterols are the naturally occurring functional equivalent of mammalian cholesterol. 
The most common plant sterols include sitosterol, campensterol, and sigmasterol. Plant 
sterols differ structurally from cholesterol by a methyl or ethyl group in their side chains 
and are not synthesized by the human body. These structural differences render them 
minimally absorbable in the intestine, of the fraction of 0.5-2% for plant sterols (9). As a 
result of low absorption and efficient excretion after uptake by the liver, circulating levels 
are low, varying from 0.3-1.0 mg/dL for plant sterols. Phytosterol-enriched foods and 
dietary supplements have been marketed for decades. The main food sources of plant 
sterols are vegetable oils, margarines, breads, cereals, and vegetables, contributed 50-
80% of the daily plant sterol intake (11-12). 
 
Lipid-Modifying Effect of Plant Sterols 
The cholesterol lowering effect of plant sterols were demonstrated more than 50 years 
ago (13). Earlier studies demonstrated that pure plant sterol supplementation lowered 
both total serum cholesterol and LDL-C in individuals with hypercholesterolemia (14). A 
number of clinical trials have been examined the efficacy of plant sterols/stanols as a 
cholesterol lowering agent when incorporated into low fat foods including yoghurt, bread 
and cereal (15). Results from several epidemiological studies consistently reported that 
dietary incorporation of plant sterols/stanols (1.5-2 g/day) reduces serum LDL-C levels 
5% to 15% with minimal adverse events (16-18). In addition, the impact of the 
consumption of plant sterols/stanols-enriched foods is relatively consistent in both 
normolipidemic and dyslipidemic individuals including those treated with lipid-lowering 
agents, regardless of background diet and that there is little or no effect on high-density 
lipoprotein (HDL) cholesterol or triglyceride (TAG) levels (19-20). It has now been 
recognized by the United States Federal Drug Administration (US FDA) and the 
American Heart Association that dietary incorporation of plant sterols is recommended 
for blood cholesterol reduction and thereby reducing the risk of CVD (21-22). 
 
 

Page 13 
 
Potential Mechanisms of Action of Plant Sterols 
Several studies have investigated the mechanism of action of phytosterols on reducing 
serum LDL-C level (23-24). The initial stage of intestinal handling of phytosterols from 
diet is essentially similar to the absorption of cholesterol, involving emulsification, 
hydrolysis and micellar transport (25). However, most of plant sterols/stanols are 
pumped back into the gut lumen via the ATP-biding cassette co-transporters G5 and G8 
(ABCG5/ABCG8), resulting in the minimal entry of these plant-derived molecules into 
the circulation. The hypochoelsterolemic effects of plant sterols/stanols is explained by 
an inhibition of cholesterol absorption, which is ascribed to a competition with intestinal 
cholesterol for incorporation into mixed micelles (26), although other possible 
mechanistic explanation have been proposed (27). 
 
Clinical Significance 
The goal of this study is to determine the efficacy of regular consumption of plant 
sterols-enriched soya beverage in reducing serum LDL-C level among Southern 
Chinese individuals. The hypocholesterolemic effects of plant sterols with soya milk as 
carrier has only been investigated in few studies, the beneficial effects of soya beverage 
fortified with plant sterols on Southern Chinese individuals are not well-understood and 
necessitate investigation. Results from this study will have important clinical implications 
in the control and management of blood LDL-C level among normolipidemic individuals 
and will promote further development of novel soya beverage or related products 
containing plant sterols for future use in cholesterol-lowering initiatives. In addition to a 
role in primary prevention in the general population, functional food enriched with plant 
sterols may provide additional LDL-C lowering benefit in dyslipidaemic patients at high 
CV risk as an adjunct to traditional pharmacologic therapy.  
 
6.2 
Study Rationale 
Eligible Southern Chinese in Hong Kong aged 18 or above with good health condition 
will be asked to consume 2g of plant sterols orally per day for 3 consecutive weeks as 
provided by one pack of plant sterols-containing soya beverage, each pack consumed 
during the main meal every day. The dosage regime is designed in accordance with the 
recommendations from European Union (EU) Register of Nutrition and Health claims as 
well as previous clinical trials and epidemiological studies regarding the same study 
ingredient (13-18). It is hypothesized that daily consumption of 2g of plant sterols in a 
soya beverage results in a significant reduction of serum LDL-C.  
Result from this study encourages further development of novel soya beverage or 
related products containing plant sterols for future use in cholesterol-lowering initiatives 

Page 14 
 
among Chinese population.

Page 15 
 
Potential Risks and Benefits 
6.2.1 
Potential Risks 
 
This study does not involve any pharmacological intervention. Pre-clinical and 
previous clinical trials (13-18) indicated that the study product is generally safe 
and will not affect the health status of the subjects. Therefore, additional risk 
will be minimal.  
 
Blood samples will be taken at the start and the end of the study by a 
registered nurse. Venipuncture may result in pain or bruises. The chance of 
infection associated with venipuncture is very low.  
6.2.2 
Potential Benefits 
 
Subjects will receive an assessment of their current health status and they will 
be informed if any test result shows a potential risk to their health condition. 
 
Previous studies have demonstrated that regular consumption of plant sterols 
may reduce total blood cholesterol and LDL-C level. Reduction of LCL-C 
levels has been demonstrated to significantly reduce CVD morbidity and 
mortality (13-18).  
 
While it is possible, however, that subjects may not obtain any direct benefits 
in this clinical study, the information obtained from this study maybe useful to 
scientific community to examine the efficacy of plant sterols for future use in 
cholesterol-lowering initiatives and prevention of cardiovascular disease. 

Page 16 
 
7 OBJECTIVES 
7.1 
Study Objectives 
 
The primary objective of this study is to assess the efficacy of daily 
consumption of 2g plant sterols as provided by one pack of 250 ml soya 
beverage product each taken during the main meal for 3 consecutive weeks, 
in lowering the blood LDL-C level among Southern Chinese. 
 
The secondary objective is to examine if there is other health-benefits by 
consuming the plant sterols-enriched soya beverage, such as glucose and 
TAG lowering effect. 

Page 17 
 
8 STUDY DESIGN 
The study is a 3-week, single-center, double-arm, randomized, double-blind clinical 
study. Healthy, normocholesterolemic Southern Chinese in Hong Kong will be recruited 
and screened by the inclusion and exclusion criteria.  
Two hundred (200) eligible and consented subjects will be assigned to consume either 
the investigational or control product by stratified randomization, according to the 
instructions as follows: 
 
Investigational Group: Daily consumption of 2g of plant sterols as provided by one 
pack of the plant sterols-enriched  soya beverage for 3 consecutive weeks, each 
pack consumed during the main meal 
 
Control Group: Daily consumption of one pack of the soya beverage without plant 
sterols  for 3 consecutive weeks, each pack consumed during the main meal 
The randomization will be stratified by both gender (male and female) and age group 
(18-40 years and >40 years). 
Subjects will be invited to attend a baseline visit (Day 0), after which study products will 
be administered for 21 days. A follow-up assessment (Day 21±5) at the end of the study 
intervention will be performed for outcome assessment. Clinical data and blood 
specimen will be obtained by trained personnel in both visits. All blood specimens will 
be analyzed in a centralized and certified clinical laboratory.  
Subjects will be asked to refrain from drinking 2 alcoholic or caffeinated beverages per 
day and advised to maintain their typical diet and physical activity levels. They will also 
be asked to report any changes in diet or physical activity and symptoms or changes in 
health and medications throughout the trial. 
 

Page 18 
 
9 STUDY POPULATION 
9.1 
Inclusion Criteria 
In order to be eligible to participate in this study, an individual must meet all of the 
following criteria: 
 Southern Chinese male or female ≥ 18 years. 
 In good general health as evidenced by medical history 
 Have the ability to understand the requirements of the study, provide written 
informed consent, including consent for the use and discloser of research-related 
health information, and comply with the study data collection procedures. Provide 
signed and dated informed consent form 
9.2 
Exclusion Criteria 
An individual who meets any of the following criteria will be excluded from participation 
in this study: 
 Subject with familial hypercholesterolemia (31) 
 On regular medication(s) which affect gastrointestinal functions and blood lipids level 
for the past 3 months, such as, but not limited to: 
o Antibiotics of >1 week duration 
o GI related medications such as antacids 
 Having blood lipid lowering medications such as statins, selective cholesterol 
absorption inhibitors (e.g. ezetimibe), fibrates, niacin, resins, omega- 3 
 Heavy-smokers (more than 1 pack per day) 
 Subject with heavy alcohol intake (>40 g/day for men ; >30 g/day for women) (32), or 
having history of alcohol abuse within 12 months prior to the study 
 Subjects with taste aversion to placebo/intervention soya beverages 
 Subject refusing to stop the consumption of plant sterols-enriched products if any 
during the study (other than the studied product) or having regular consumption of 
sterols/stanols cholesterol-lowering supplements/functional foods or other related 
products such as: 
o Sterol/ Stanol - containing margarines, milk, yoghurt drink and soya 
beverages 
o Sterol / Stanol supplements 
o Fish oils & omega-3 supplements 
 Subject receiving systemic treatment or topical treatment likely to interfere with 
evaluation of the study parameters 

Page 19 
 
 Subject currently involved in a clinical trial or in an exclusion period following 
participation in another clinical trial 
 Pregnancy or lactation 
 Having soy allergy 
 Being a vegan 
 Being an athlete 
 Concurrently participating in weight management or dietary program  
 On diet pills, such as, but not limited to chitosan and dulcolax 
 With history of sitosterolemia 
 Having history of hypercholesterolemia, diabetes, thyroid disease, severe kidney 
diseases, cardiovascular diseases, chronic gastrointestinal disorders, cancers and 
AIDs 
 Having history of malabsorption syndrome arising from diseases such as, but not 
limited to celiac disease, short bowel syndrome, cystic fibrosis, pancreatitis, 
diseases of gall-bladder, liver or pancreas, intestinal infection, injury, surgery and 
radiotherapy 
 Taking over-the-counter Chinese medications or supplements with 
cholesterol/lipidlowering and related claims 
 High blood cholesterol at screening [Total cholesterol level ≥6.22mmol/L] 
 High LDL cholesterol [LDL cholesterol level ≥4.15mmol/L] 
 High blood triglyceride at screening [TG ≥3.39mmol/L] 
 Anything that would place the individual at increased risk or preclude the individual’s 
full compliance with or completion of the study.  
 

Page 20 
 
9.3 
Subject Withdrawal 
9.3.1 
Reasons for Withdrawal 
Subjects are free to withdraw from participation in the study at any time upon request. 
Withdrawal from this study will not affect subjects’ ability to receive normal medical care 
and will not lose any benefits to which they would otherwise be entitled. 
An investigator may terminate a study subject’s participation in the study if: 
 Any clinical adverse event (AE), laboratory abnormality, or other medical 
condition or situation occurs such that continued participation in the study 
would not be in the best interest of the subject. 
 The subject meets an exclusion criterion (either newly developed or not 
previously recognized) that precludes further study participation. 
 The subject do not follow instructions regarding to the study 
 The research investigators or ethic committee(s) stop this research project due 
to any reasons 
For subjects meeting violation of exclusion criteria for baseline laboratory values (i.e. 
lipid profiling) after randomization, subjects’ participation will be continued at the 
discretion of the investigator. 
9.3.2 
Handling of Subject Withdrawals or Subject Discontinuation of Study 
Intervention 
Effort will be made to collect the safety and efficacy outcome measures of the 
withdrawn subjects or subjects who discontinue study intervention by undertaking safety 
follow-up visit to capture adverse events (AEs), unanticipated problems (UPs), and to 
collect biological specimens for laboratory evaluations. The participation of the 
withdrawal visit is entirely voluntary.  
Since 25% dropout rate is assumed in the calculation of sample size, no replacement of 
subjects who withdraw or discontinue early will be made. 
 

Page 21 
 
9.4 
Premature Termination or Suspension of Study 
This study may be suspended or prematurely terminated if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to the study 
investigators and regulatory authorities.  If the study is prematurely terminated or 
suspended, the principal investigator will promptly inform the IRB and will provide the 
reason(s) for the termination or suspension.  
Circumstances that may warrant termination include, but are not limited to: 
 Determination of unexpected, significant, or unacceptable risk to subjects. 
 Insufficient adherence to protocol requirements. 
 Data that is not sufficiently complete and/or evaluable.  
 Determination of futility. 
 

Page 22 
 
10 GROUP ASSIGNMENT PROCEDURES 
10.1 
Subject Number 
Prior to study intervention at Day 0 (Screening / Baseline visit), the investigator assigns 
a uniquely identified subject number to each eligible subject chronologically (e.g. 001, 
002, etc). The subject number will not be reused. The actual subject number allocated 
will be recorded on a subject number allocation log. 
10.2 
Randomization Schemes 
The Data Management and Medical Statistics unit in CTC, HKU, will define 
randomization specifications and generating the randomization codes, prior to the start 
of the study.  
Block randomization with varying block sizes will be performed separately within each 
stratum to maintain approximately 1:1 allocations of the two study groups.  
Four strata are constructed as follows: 
Strata: 
1. Male, aged 18-40 years 
2. Male, aged >40 years 
3. Female, aged 18-40 years 
4. Female, aged >40 years 
10.3 
Group Allocation 
A web-based randomization system will be developed by CTC, HKU to carry out the on-
line group allocation. 
At Day 0 visit, each subject who fulfils all the eligibility criteria will be given a subject 
number by the Investigator. The Investigator will prescribe the study intervention 
according to the subject number by completing a prescription form to the unblinded 
personnel. Once the unblinded personnel receive the prescription form for the subject 
number, the unblinded personnel will login the web-based randomization system and 
randomize the subject using the particular subject number. The information about the 
group assignment to the subject will be printed out [Group Allocation Sheet] from the 
system as a source document.   
 
 

Page 23 
 
10.4 
Masking 
This clinical trial is double-blinded in which neither the subjects nor the investigators 
know which of the subjects belong to the control group or the investigational group. The 
product manufacturer will help to ensure the products are packaged, coded and labelled 
in a manner that will not make reference to group allocation. 
The whole process of group allocation, study product preparation and dispensing will 
only be carried out by the designated personnel with privilege of using the web-based 
randomization system. The blinding of the trial will be maintained throughout the trial 
until all data entry and processing are complete and the database has been locked. 
10.5 
Emergency Unblinding 
Breaking of randomization codes will be performed in a medical emergency where 
knowledge of the blinded treatment is necessary, for the treatment of a safety event, or 
requested by the PI. In the event of a code break, the person requesting the code 
break, subject number, reasons for unblinding, date and time should be documented. 

Page 24 
 
11 INVESTIGATONAL AND CONTROL PRODUCT ADMINISTRATION 
11.1 
Product Description 
11.1.1 Acquisition 
The investigational and control products will be supplied by VITASOY International 
Holdings Ltd. 
11.1.2 Formulation, Packaging, and Labeling 
The investigational product is a plant sterols-enriched soya beverage packed in cartons 
and the control product is the same soya beverage except without plant sterols. 
All study products will be labeled with a subject number, bar code, manufacturer, 
instructions for administration, contact information of study staff, caution statements 
indicating the product is strictly for subject’s use and product storage. 
11.1.3 Product Storage and Stability 
The study products have to be stored in cool (around room temperature) and dry place.  
11.2 
Dosage, Preparation and Administration of Study Products 
Investigational Group: Subjects will orally consume 2g of plant sterols daily as provided 
by one pack of the soya beverage for 3 consecutive weeks, each pack consumed 
during the main meal.  
Control Group: Subjects will orally consume one pack of the soya beverage except 
without plant sterols for 3 consecutive weeks, each pack consumed during the main 
meal.  
Subjects will be advised to consume the products immediately once the package is 
opened and store the products in cool place. 
11.3 
Accountability Procedures for the Study Products 
Study products will be distributed to subjects during their screening and baseline visit 
(Day 0).  
All unused products have to be returned to the study staff in the final visit (Day 21 ±5) 
which will be used as a count of subject’s compliance with the study products. 
 
 

Page 25 
 
12 STUDY SCHEDULE AND PROCEDURE 
12.1 
Study Visit 
12.1.1 Screening and Enrollment/Baseline (Visit 1, Day 0) 
 Obtain and document signed informed consent form 
 Review medical history to determine eligibility based on inclusion/exclusion criteria 
 Review and record medications history to determine eligibility based on 
inclusion/exclusion criteria 
 For eligible subject, perform medical examinations 
 For eligible subject, collect detailed demographic information, dietary information, 
medical history, medication history, alcohol, and tobacco use history 
 For eligible subject, collect fasting blood specimen and cardiometabolic risk factors 
 Schedule follow-up visit for subject who is eligible and available for the duration of 
the study 
 Provide subject with instructions of the administration of study products 
 Provide subject with instructions needed to prepare for follow-up study visit; For 
instance, return the excess product as a measure of product compliance 
12.1.2 End of Study (Visit 2, Day 21 ± 5) 
 Perform physical examinations 
 Record adverse events as reported by subject or observed by investigator 
 Record concomitant medications as reported by subject 
 Collect fasting blood specimen and cardiometabolic risk factors 
 Record subject’s compliance with the study product 
 

Page 26 
 
12.1.3 Early Withdrawal  
If subject withdraws early or investigator terminates subject’s participation, following 
evaluations will be offered to the subject:  
 Perform physical examinations 
 Record adverse events as reported by subject or observed by investigator 
 Record concomitant medications as reported by subject 
 Collect fasting blood specimen and cardiometabolic risk factors 
 Record subject’s compliance with the study product 
12.2 
Procedures and Evaluations 
12.2.1 Clinical Laboratory Evaluations 
42ml peripheral blood sample will be collected from all subjects. The following 
laboratory assessments will be assessed at baseline and after the 3-week study period. 
Biological specimens will be stored under the subject’s consent for any genetic and cell 
analysis related to risk factors of cardiometabolic disease in the future. 
12.2.2 Special Assays or Procedures 
Fasting lipid profile 
Blood will be collected into EDTA-coated tubes and the plasma levels of total 
cholesterol (TC), low density lipoprotein (LDL-C), high density lipoprotein (HDL-C) and 
triglycerides will be measured automatically by electrophoresis (Architect ci8200 
analyzer; Abbott Diagnostics, Wiesbaden, Germany) at the certified Clinical Laboratory. 
 

Page 27 
 
13 STUDY MEASUREMENTS AND VARIABLES 
13.1 
Efficacy Measurements 
13.1.1 Primary Endpoint 
 The primary endpoint is the mean serum LDL-C at the end of the week 3 after the 
consumption of plant sterols fortified soya beverage or control product. 
13.1.2 Secondary Endpoints 
The secondary endpoints include the changes of serum LDL-C, HDL-C, total 
cholesterol, triglycerides (TAG), serum creatinine, fasting blood glucose, other 
cardiometabolic risk factors and musculoskeletal-related traits from baseline to week 3. 
Blood Tests: 
 
Serum LDL-C, HDL-C, total cholesterol, and triglycerides (TAG) 
 
Serum creatinine and fasting blood glucose 
Cardiometabolic risk factors: 
 
Blood pressure, body temperature. body height and weight, waist and hip 
circumferences 
Musculoskeletal-related traits: 
 
Handgrip strength, peak expiratory flow rate, bio-impedance, gait speed and body 
balance 
13.2 
Safety Measurements 
13.2.1 Adverse Events 
An adverse event (AE) is any untoward or unfavorable medical occurrence in a human 
subject, including any abnormal sign (for example, abnormal physical exam or 
laboratory finding), symptom, or disease, temporally associated with the subject’s 
participation in the research, whether or not considered related to the subject’s 
participation in the research. 
The relationship of each AE to the study product is defined as below: 
 
Unrelated: There is no temporal sequence of the AE onset relative to the 
administration of study product, and /or there is evidence of other cause such as 
concurrent medication or illness contributed to the event. 

Page 28 
 
 
Possibly related: A temporal sequence of the AE onset relative to the 
administration of trial treatment is not clear, alternative causes are also possible. 
 
Probably related: There is a clear temporal sequence of the AE onset relative to 
the administration of study product, and potential alternative etiology is not 
apparent. 
 
Definitely related: There is a clear temporal sequence of the AE onset relative to 
the administration of study product, and no other possible cause. 
The severity of each AE will be assessed as described below: 
 
Mild: The AE is transient and easily tolerated by the subject. 
 
Moderate: The AE causes the subject discomfort and interrupts the subject’s 
usual activities. 
 
Severe: The AE causes considerable interference with the subject’s usual 
activities and may be incapacitating or life threatening. 
13.3 
Demographic Information 
Demographic information including age, sex and socioeconomic status will be collected 
during the baseline visit. 
13.4 
Medical History 
Medical history including medical and medications history,  alcohol, and tobacco use 
history will be obtained by interview or from medical records during the screening and 
baseline visit. 
13.5 
Dietary Information  
Structured dietary habit questionnaire will be used to evaluate the dietary habit within 
one month before the screening and end of study visit. 
13.6 
Study Product Compliance 
At the end of the study intervention period, subjects need to return all the excess soya 
beverage packs for counting the measure of compliance. 
The study product compliance is calculated by the following equation: 
 
%
100
 
(%)
 
Compliance
uct 
Study Prod


onsumption
Expected C
onsumption
Observed C
 
 
Observed consumption =  Pack of soy milk dispensed – Pack of soy milk returned 
 
Expected consumption =  (Expected daily consumption  Number of treatment 
days) 

Page 29 
 
 
13.7 
Prior/Concomitant Medications 
Complete medications history of prescription and over-the-counter medications within 3 
months before the screening and baseline visit will be collected. 
Detailed information regarding to subject’s concomitant medication records including 
medication name and total dosage will be collected during the baseline and follow-up 
visit. Any subject receiving the following medications will be excluded from the study: 
 
On diet pills, such as chitosan and dulcolax 
 
Ingestion of over-the-counter Chinese medications or supplements with 
cholesterol/lipidlowering and related claims 
 
On medications which affect gastrointestinal functions and blood lipids level for 
the past 3 months, such as, 
 
Antibiotics of >1 week duration 
 
GI related medications such as antacids 
 
Blood lipid lowering medications such as statins, selective cholesterol 
absorption inhibitors (e.g. ezetimibe), fibrates, niacin, resins, omega- 3 
13.8 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical study protocol, Good Clinical 
Practice, or manual of procedures requirements.  The noncompliance may be on the 
part of the subject, the investigator, or study staff. All deviations from the protocol will be 
recorded in the study subject source documents. 

Page 30 
 
14 STATISTICAL SECTION 
14.1 
Sample Size Rationale 
The primary endpoint is the mean serum LDL-C at the end of the 3-week treatment 
period. The sample size calculation is based on ANCOVA with baseline serum LDL-C 
as independent covariate.  
According to a previous study (36), the standard deviation of LDL-C at week 4 is 
approximately 0.85 mmol/l and the estimated correlation coefficient between the 
outcomes measured at baseline and week 4 is about 0.7. In addition, a minimum 
difference of 0.28 mmol/l in LDL-C between the groups is considered clinically 
important. 
By using PASS 12 for the sample size calculation, a power of 0.8 and a 5% of the 
maximum tolerable false positive rate, 75 subjects per group is required to detect the 
minimum difference between the mean values of LDL-C. 
Considering an attrition rate of 25%, a total of 200 subjects will be recruited. 
14.2 
Data Set Analyzed 
The intention-to-treat (ITT) population is consisted of all the cases that are randomized.  
The per-protocol (PP) population includes all eligible subjects who have: 
 80% of study product compliance 
 Primary efficacy data collected within the pre-specified allowable visit window 
 No protocol violation that is clinically significant.    
14.3 
Handling of Missing or Invalid Data 
No data imputation will be performed to replace missing or invalid data. 
14.4 
Demographics and Baseline Characteristics 
Demographics data and other baseline characteristics including medical history, dietary 
information, physical examination and prior medication will be summarized by 
appropriate descriptive statistics. 
 

Page 31 
 
14.5 
Primary Efficacy analysis 
ANCOVA will be carried out to compare the serum LDL-C level at week 3 between the 
groups. The baseline of the response outcome will be used as a covariate to control for 
initial group differences. A log transformation will be performed if the normality 
assumption for the ANCOVA model is violated. And if the normality assumption is still 
not sustained, non-parametric approach might be performed. 
The primary efficacy analysis will be performed on both the ITT and the PP populations. 
14.6 
Secondary Efficacy analyses 
Stratified analysis for the primary endpoint will be performed using the ANCOVA model 
adjusted for gender and age group. Subjects will be classified to one of the following 
strata: 
1. Male, aged 18-40 years 
2. Male, aged >40 years 
3. Female, aged 18-40 years 
4. Female, aged >40 years 
The changes of the following response outcomes from baseline to week 3 will be 
summarized by descriptive statistics:  
 Blood Tests: LDL-C, HDL-C, total cholesterol, TAG, creatinine and fasting glucose.  
 Cardiometabolic risk factors: Blood pressure, body temperature, weight, BMI, waist and hip 
circumferences. 
 Musculoskeletal-related traits: Handgrip strength, peak expiratory flow rate, bio-impedance, gait 
speed and body balance 
The secondary efficacy analyses will be performed on the ITT population only. 
14.7 
Safety Analysis 
The incidence of AE such as nausea, abdominal cramps, vomiting, diarrhea, and 
flatulence will be summarized by frequency tables per treatment group. Data listings will 
be reported. 
14.8 
Compliance of the study products 
The compliance of the study products will be summarized by descriptive statistics per 
study group. 
14.9 
Concomitant Medications 
Data listing of concomitant medications will be reported per study group. 
14.10 
Interim Analyses  
No interim analyses will be planned for this study. 

Page 32 
 
15 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS 
15.1 
Source Documents 
The Investigators will maintain source documents for each subject in the study.  
Source documents are defined as original documents, data and records.  This may 
include hospital records, clinical and office charts, laboratory data/information, subjects’ 
diaries or evaluation checklists, pharmacy dispensing and other records, recorded data 
from automated instruments, microfiches, photographic negatives, microfilm or 
magnetic media, and/or x-rays. The Investigator could create source data worksheets 
and document information that are not available on the hospital records.  
Designated investigator staff will document all the information required by the protocol. 
It is the investigator’s responsibilities to ensure the compliance of protocol and the 
completeness and accuracy of collected data. Investigator will only instruct qualified site 
personnel to make any required corrections or additions of collected data. All source 
documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.   
The Investigator(s)/institution(s) will permit any trial-related monitoring, audit, IEC/IRB 
review, and regulatory inspection(s), providing direct access to source data documents. 

Page 33 
 
16 DATA HANDLING AND RECORD KEEPING 
16.1 
Data Management Responsibilities 
Data management will be carried out by data management personnel at CTC, HKU. A 
data management plan (DMP) will be developed to outline all works related to data 
management activities, including but not limited to Electronic-Case report forms (eCRF) 
design, data collection, data cleaning and data storage. 
However, data collection and accurate documentation are the responsibility of the study 
staff under the supervision of the principal investigator.  All source documents and 
laboratory reports must be reviewed by the study team and data entry staff, who will 
ensure that they are accurate and complete.  Unanticipated problems and adverse 
events must be reviewed by the investigator or designee.   
16.2 
Data Capture Methods 
An Electronic Data Capture (EDC) system will be setup by CTC, HKU. eCRFs will be 
developed and to collect information for this study. All information on the eCRFs must 
also be reflected in the subject source documents. The principal investigator will review 
the eCRFs for completeness and accuracy of eCRFs.  
Data entered by the site personnel on the web-based EDC system will be submitted and 
stored securely in the study database. The data management personnel could access 
and review the study database for completeness and logical consistency. A 
comprehensive validation check program is built in the system for identifying missing 
data, out-of-range data and other data inconsistencies. The data management 
personnel will also perform regular validation check to generate discrepancy reports and 
individual data query to investigators for solution of data.  
Once all the study data are cleaned, the data manager will lock the study database. 
Once the database is locked, the randomization codes will be unblinded and the data is 
made available for data analyses. 
16.3 
Study Records Retention 
Study documents should be retained for a minimum of 25 years after the end of the 
study.  No records will be destroyed without the written consent of the sponsor-
investigator, if applicable.   
The study database will be retained in CTC, HKU for retrieval for at least three years 
from the date of the clinical study report is submitted to sponsor-investigator.  
 

Page 34 
 
17 ETHICS/PROTECTION OF HUMAN SUBJECTS 
17.1 
Ethical Standard 
The investigator will ensure that this study is conducted in full conformity with the 
principles set forth in The Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research, as drafted by the US National Commission 
for the Protection of Human Subjects of Biomedical and Behavioral Research (April 18, 
1979) and codified in 45 CFR Part 46 and/or the ICH E6.  
17.2 
Institutional Review Board 
The protocol, informed consent form(s), recruitment materials, and all subject materials 
will be submitted to the IRB for review and approval.  Approval of both the protocol and 
the consent form must be obtained before any subject is enrolled.  Any amendment to 
the protocol will require review and approval by the IRB before the changes are 
implemented in the study.   
17.3 
Informed Consent Process 
Informed consent is a process that is initiated prior to the individual agreeing to 
participate in the study and continues throughout study participation.  Extensive 
discussion of risks and possible benefits of study participation will be provided to 
subjects and their families, if applicable.  A consent form describing in detail the study 
procedures and risks will be given to the subject.  Consent forms will be IRB-approved, 
and the subject is required to read and review the document or have the document read 
to him or her.  The investigator or designee will explain the research study to the subject 
and answer any questions that may arise.  The subject will sign the informed consent 
document prior to any study-related assessments or procedures.  Subjects will be given 
the opportunity to discuss the study with their surrogates or think about it prior to 
agreeing to participate.  They may withdraw consent at any time throughout the course 
of the study.  A copy of the signed informed consent document will be given to subjects 
for their records.  The rights and welfare of the subjects will be protected by 
emphasizing to them that the quality of their clinical care will not be adversely affected if 
they decline to participate in this study. 
The consent process will be documented in the clinical or research record.   

Page 35 
 
17.4 
Subject Confidentiality 
Subject confidentiality is strictly held in trust by the sponsor-investigator, study staff, and 
their agents.  This confidentiality is extended to cover testing of biological samples and 
genetic tests in addition to any study information relating to subjects. 
The study protocol, documentation, data, and all other information generated will be 
held in strict confidence.  No information concerning the study or the data will be 
released to any unauthorized third party without prior written approval of the sponsor-
investigator. 
The study monitor or other authorized representatives of the sponsor-investigator may 
inspect all study documents and records required to be maintained by the investigator, 
including but not limited to, medical records (office, clinic, or hospital) for the study 
subjects.  The clinical study site will permit access to such records. 
17.5 
Future Use of Stored Specimens and Other Identifiable Data 
Subjects can choose freely if they agree to the future use of his/her specimens for any 
genetic or cell analysis related to risk factors of cardiometabolic disease in the future. 
Residual specimens and personal data will be maintained for at least 25 years after the 
study is completed only under subject’s consent.  All data collected and written 
assignment for this study will be stored in a secured server. The server will then be 
locked in a cabinet in a locked room. Only principal investigator (Professor Cheung 
Bernard Man Yung) and his delegates will have access to this locked cabinet. 
Confidentiality will be protected as all specimens will be coded and anonymized. All 
data will be destroyed after the storage period.  
 
 
 
 

Page 36 
 
18 PUBLICATION/DATA SHARING POLICY 
The clinical trials registration policy will be adopted for this study. Before the start of the 
study, registration will be done in an acceptable public trials registry such as 
ClinicalTrials.gov. 
Vitasoy International Holdings Ltd. and the University of Hong Kong are the legal co-
owners of the data. Vitasoy International Holdings Ltd. is free to use the data and/or any 
results derived from the data or publications based on that data for marketing purposes, 
scientific purposes, internal or educational uses. 
Publications describing study results must be submitted to Vitasoy International 
Holdings Ltd at least 30 days before planned manuscript submission and at least 14 
days prior to planned abstract submission. If the Vitasoy International Holdings Ltd has 
no objection to publication requests within the review-period, the submission for 
publication will proceed. 
 
 
 

Page 37 
 
19 LITERATURE REFERENCES 
1. 
Miettinen TA & Vanhanen H. Dietary sitostanol related to absorption, synthesis 
and serum level of cholesterol in different apolipoprotein E phenotypes. 
Atherosclerosis. 1994;105, 217–226. 
2. 
Hallikainen MA & Uusitupa MIJ. Effects of 2 low fat stanol ester containing 
margarines on serum cholesterol concentrations as part of a low fat diet in 
hypercholesterolemic subjects. Am. J. Clin. Nutr. 1999;69, 403–410. 
3. 
Centre for Health Protection, HKSAR. 2014. No-communicable diseases and 
risk factor. Retrieved from http://www.chp.gov.hk/en/content/9/25/57.html 
4. 
Jialal I & Remaley AT. Measurement of low-density lipoprotein cholesterol in 
assessment and management of cardiovascular disease risk. Clin Pharmacol 
Ther. 2014;96(1):20-2. 
5. 
D'Agostino RB.; Sr., Vasan, RS, Pencina, MJ, Wolf, PA, Cobain, M, Massaro, 
JM, Kannel, WB. General cardiovascular risk profile for use in primary care: the 
Framingham Heart Study. Circulation. 2008;117(6): 743–753. 
6. 
Ros E. Intestinal absorption of triglyceride and cholesterol. Dietary and 
pharmacological inhibition to reduce cardiovascular risk. Atherosclerosis. 
2000;151, 357–379. 
7. 
Gitt AK, Drexel H, Feely J, et al. Persistent lipid abnormalities in statin-treated 
patients and predictors of LDL-cholesterol goal achievement in clinical practice 
in Europe and Canada. Eur J Prev Cardiol. 2012;19:221-30. 
8. 
Kotseva K, Wood D, De Backer G, et al. Cardiovascular prevention guidelines 
in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight 
European countries. Lancet. 2009;373:929-40. 
9. 
Ostlund Jr RE, McGill JB, Zeng C-M, et al. Gastro-intestinal absorption and 
plasma kinetics of soy D5-phytosterols and phytostanols in humans. Am J 
Physiol Endocrinol Metab; 2002;282:E911-6. 
10. Björkhem I, Boberg KM, Leitersdorf E. Inborn errors in bile acid biosynthesis 
and storage of sterols other than cholesterol. In: Scriver CR, Beaudet AL, Sly 
WS, Valle D, editors. The metabolic and molecular bases of inherited disease. 
8th ed. New York: McGraw-Hill; 2001. pp. 2961--88 
11. Klingberg S, Andersson H, Mulligan A, et al. Food sources of plant sterols in 
the EPIC Norfolk population. Eur J Clin Nutr. 2008;62:695-703. 
12. Piironen V, Lampi AM. Occurrence and levels of phytosterols in foods. In: Dutta 
PC, editor. Phytosterols as functional food components and nutraceuticals. 
New York: Marcel Dekker, Inc; 2004. pp. 1-32 
13. Peterson, DW. Effect of soybean sterols in the diet on plasma and liver 
cholesterol in chicks. Proc. Exp. Biol. Med. 1951;78, 
14. Farquhar JW, Smith RE, Dempsey ME. The effect of beta sitosterol on the 
serum lipids of young men with arteriosclerotic heart disease. Circulation. 

Page 38 
 
1956;14:77-82. 
15. Clifton PM, Noakes M, Sullivan D, Erichsen N, Ross D, Annison G, Fassoulakis 
A, Cehun M, Nestel P. Cholesterol lowering effects of plant sterol esters differ 
in milk, yoghurt, bread and cereal. Eur J Clin Nutr 2004;58:503-9. 
16. Andersson SW, Skinner J, Ellegård L, et al. Intake of plant sterols is inversely 
related to serum cholesterol concentration in men and women in the EPIC 
Norfolk population: a cross-sectional study. Eur J Clin Nutr 2004;58:1378-85. 
17. Klingberg S, Ellegård L, Johansson I, et al. Inverse relation between naturally 
occurring dietary plant sterols and serum cholesterol in northern Sweden. Am J 
Clin Nutr. 2008;87:993-1002. 
18. Wang P, Chen YM, He LP, et al. Association of natural intake of dietary plant 
sterols with carotid intima-media thickness and blood lipids in Chinese adults: a 
cross-section study. PLoS ONE 2012;7:-32736. 
 
19. Demonty I, Ras RT, van der Knaap HC, et al. The effect of plant sterols on 
serum triglyceride concentrations is dependent on baseline concentrations: a 
pooled analysis of 12 randomised controlled trials. Eur J Nutr. 2013;52:153-60. 
20. Plat J, Mensink RP. Plant stanol esters lower serum triacylglycerol 
concentrations via a reduced hepatic VLDL-1 production. Lipids. 2009;44:1149-
53. 
21. FDA (2000): Food labeling: health claims; plant sterol/stanol esters and 
coronary heart disease. Food and Drug Admin. Fed. Reg. 65, 54686–54739  
22. Lichtenstein AH & Deckelbaum RJ. AHA Science Advisory. Stanol/sterol ester-
containing foods and blood cholesterol levels. A statement for healthcare 
professionals from the Nutrition Committee of the Council on Nutrition, Physical 
Activity, and Metabolism of the American Heart Association. Circulation. 2001. 
103,1177–1179. 
23. Berge KE, von Bergmann K, Lutjohann D, Guerra R, Grundy SM, Hobbs HH & 
Cohen JC. Heritability of plasma noncholesterol sterols and relationship to DNA 
sequence polymorphism in ABCG5 and ABCG8. J. Lipid Res. 2002. 43, 486–
494. 
24. Plat J & Mensink RP. Increased intestinal ABCA1 expression contributes to the 
decrease in cholesterol absorption after plant stanol consumption. FASEB J. 
2002;16, 1248–1253. 
25. Lu K, Lee M & Patel SB. Dietary cholesterol absorption; more than just bile. 
TRENDS Endocrinol. Metab. 2001;12, 314–320. 
26. Ikeda, I., Tanabe, Y., and Sugano, M. (1989) Effects of sitosterol and sitostanol 
on micellar solubility of cholesterol. J. Nutr. Sci. Vitaminol. 35, 361–369 
27. De Smet E, Mensink RP, Plat J. Effects of plant sterols and stanols on 
intestinal cholesterol metabolism: suggested mechanisms from past to present. 
Mol Nutr Food Res. 2012;56:1058e72. 

Page 39 
 
28. Abumweis SS, Barake R, Jones PJ. Plant sterols/stanols as cholesterol 
lowering agents: A meta-analysis of randomized controlled trials. Food Nutr 
Res. 2008;52 
29. Salen G, von Bergmann K, Lütjohann D, et al., Multicenter Sitosterolemia Study 
Group. Ezetimibe effectively reduces plasma plant sterols in patients with 
sitosterolemia. Circulation 2004;109:966-71. 
30. Calkin AC, Tontonoz P. Liver x receptor signaling pathways and 
atherosclerosis. Arterioscler Thromb Vasc Biol. 2010 Aug;30(8):1513-8. 
31. Consumer Reports; Drug Effectiveness Review Project (2013). "Evaluating 
statin drugs to treat High Cholesterol and Heart Disease: Comparing 
Effectiveness, Safety, and Price". Best Buy Drugs (Consumer Reports): 9. 
32. Thomsen AB, Hansen HB, Christiansen C, Green H, Berger A. Effect of free 
plant sterols in low-fat milk on serum lipid profile in hypercholesterolemic 
subjects. Eur J Clin Nutr. 2004 Jun;58(6):860-70.  
33. Navazesh M. Methods for collecting saliva. Ann N Y Acad Sci. 1993; 694:72-7. 
34. Evans AM, DeHaven CD, Barrett T, et al. Integrated, nontargeted ultrahigh 
performance liquid chromatography/electrospray ionization tandem mass 
spectrometry platform for the identification and relative quantification of the 
small-molecule complement of biological systems. Anal Chem 2009;81:6656-
6667. 
35. Ohta T, Masutomi N, Tsutsui N, et al. Untargeted metabolomic profiling as an 
evaluative tool of fenofibrate-induced toxicology in Fischer 344 male rats. 
Toxicol Pathol 2009;37:521-535. 
36. ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 
2000 Feb 29 - . Identifier NCT02541201, The Effect of a Plant Sterols-Enriched 
Low-Fat Milk on Lipid Profile in Healthy Southern Chinese (COME-PASS); 
2015 Aug 26. Available from: http://clinicaltrials.gov/ct2/show/NCT02541201