Baumgartner 2013 To compare the effects of plant sterols with stanols on oxyphytosterol levels 47 healthy subjects (38% male, 18-70y), 43 completed study. Mean baseline LDL-C concentrations was 3.5 mmol/L. Subjects consumed 20g margarine per day containing either no PS, 3g plant sterols or 3g plant stanols. PS were esterified with rapeseed oil fatty acids. 3x 4wk periods with 4wk washout. Dietary intake by validated FFQ at end of each intervention period. Compliance by return of unused product. Blood lipid measured enzymatically with LDL calculated. ANOVA analysis with Bonferroni post-hoc testing. Minimised by cross-over design and similarity of dietary intakes between intervention periods. Significant decrease in total and LDL cholesterol in both sterol and stanol periods. No differences between sterol and stanol period. No change in HDL levels. Power calculation performed for oxyphytosterol levels. Government funded. Buyuktuncer 2013 Parallel To assess the effects of plant stanol intake in yoghurt in a Turkish population 70 subjects with untreated mild to moderate (27% male, 35 participants in each group, withdrawals not reported. Participants consumed 115g yogurt with or without 1.9g plant stanol esters with lunch each day. 2wk run-in, 4wk intervention. Dietary intake by 3d diet diary in run-in and week 4. Compliance by patient interview and return of unopened and uneaten product. Blood lipids by standard techniques with LDL calculated. Analysis by general linear model repeated measures procedure. Groups well matched at baseline and dietary intakes similar during intervention. Significant decrease in total and LDL cholesterol. No significant change in HDL cholesterol. Industry funded.
Gagliardi 2010 Parallel To compare the effects of butter, trans fat free margarine and plant sterol enriched margarine on blood lipids, lipoproteins, inflammation and endothelial function. 75 subjects with metabolic syndrome were randomised, 53 completed the trial (37% male, mean age 47y). Subjects continued regular diet and exercise and consumed either 18g butter, 36g trans fat free margarine or 30g plant sterol margarine per day. 5wk trial. Compliance by telephone monitoring. subjects excluded. Dietary intake by 3x 1d food diaries. Blood lipids measured enzymatically, including LDL-C. RMANOVA Margarine well matched on baseline clinical characteristics. Median saturated fat intake was higher in plant sterol group at baseline, but difference was not significant. Changes reported as median not mean. No significant difference in total, LDL or HDL cholesterol, but there was a median decrease of 11.3% in LDL-C in the plant sterol group. The butter group was not considered as the trans fat free margarine was considered the appropriate control for this review. Government funded study. Goncalves 2007 Parallel To test the efficacy and safety of phytosterols in milk in healthy and subjects 22 healthy (not considered in review) and 34 subjects (32% male, 40-72y) randomised. subjects received placebo or phytosterol enriched milk (2g per day) for 30d. Compliance unclear. Dietary intake not assessed. Method of blood lipid analysis not detailed. Statistical analysis by Student’s t-test only. Not well controlled. Baseline characteristics not reported, except difference in gender distribution (20% male in control, 42% male in phytosterol group). A significant reduction in total and LDL cholesterol is reported, but similar albeit reductions were observed in placebo group. Had the change between groups been compared it would be unlikely to be significant. No adverse effects were reported from analysis of various blood parameters. The intervention in healthy subjects was not considered for the review as no placebo groups was used. Industry funded
2011 Parallel To compare the effects of consuming PS in low fat milk in subjects with and without metabolic syndrome 48 subjects with moderate (18-76y, 44% male, 24 with metabolic syndrome). Same intervention as Bañuls 2010 Same methods as Bañuls 2010 Dietary intake for study not reported, but reference to an earlier trial was included. Significant reduction in total and LDL cholesterol in subjects without metabolic syndrome. No significant change in cholesterol concentrations in subjects with metabolic syndrome. Government funded. Khandelwal 2009 Parallel To assess the independent and interactive effects of plant sterols and fish oil on blood lipids 200 subjects with mildly elevated lipid levels (total cholesterol between 5.0-8.0mmol/L) were randomised, 178 completed trial (89% male, 35-55y). Note: 4-arm trial, 2 arms considered for review: control and plant sterol only arms. Subjects consumed normal diet with placebo or plant sterol yoghurt drink, and placebo (safflower oil) or fish oil capsules. Control group (placebo yoghurt drink and safflower oil capsules) and plant sterol only group (2g per day plant sterol yogurt drink and safflower oil capsules) were considered. 2wk run-in prior to randomisation, then 4wk trial. Compliance by daily recording of intake, return of unused and empty test products and phone call follow ups. Dietary intake by 2d, validated recall questionnaire. Blood lipids measured in certified laboratory. ANCOVA analysis of “quasi” Despite randomisation the plant sterol group had significantly lower baseline LDL-C concentrations. ANCOVA showed a significant decrease in total and LDL cholesterol. However, unadjusted data showed no effect of plant sterols on LDL-C in the test group, with an increase observed in the control group. Power calculation performed for LDL-C and triglycerides. Funding source unclear.
Ruiu 2009 To assess the effects of a daily single dose of plant sterols on lipoprotein metabolism 15 patients with were enrolled and completed the trial (67% male, mean age 54y) Subjects consumed a controlled diet under the guidance of a dietitian, with a daily placebo or plant sterol yoghurt drink (100mL, with or without 1.6g plant sterol esters) consumed in the morning. 2x 4wk periods with a 3wk washout (diet continued during washout). Food intake diary to monitor diet adherence, but intakes not quantified. Assessment of compliance unclear. Blood lipids measured enzymatically, LDL isolated by ultracentrifugation but quantification unclear. ANCOVA and t-test analysis. Minimised by cross-over design and dietary advice. Significant decrease in total and LDL cholesterol and increase in HDL cholesterol by t-test. Change in LDL and HDL cholesterol remained significant with ANCOVA. Unclear funding source. Shaghaghi 2014 To compare the effects of a new formulation of (WD) plant sterols with that of plant sterol esters on blood lipids and fat soluble vitamins. 53 subjects with mild to moderate were recruited, 47 completed trial (53% male, 19-75y). Subjects consumed their regular diet and attended the study centre once a day to consume 100g control or test yoghurt, containing 2g plant sterols (as esters or as 3x 29d treatment periods, with 4wk wash-out. Subjects consumed yoghurt in study centre. No dietary intake assessment. Blood lipids measured by automated techniques, with LDL calculated. Analysis by ANOVA with Dunnett’s multiple comparison test. Minimised by cross-over design. Lack of dietary assessment risks confounders not being identified. Both sterol preparations significantly reduced total and LDL cholesterol concentrations. No adverse effects observed. Power calculation performed for LDL-C. Industry funded study. sterols).
Weidner 2008 Parallel To assess the lipid-lowering effects of plant sterols in a soy 50 subjects with untreated moderate were randomised, 49 completed trial (38% male, 19-65y). Subjects consumed 200mL soy drink each morning, with or without added plant sterols (2.6g sterol esters, equivalent to 1.6g free 2wk run-in then 8wk intervention. Dietary recommendations during run-in and trial to avoid plant sterol enriched foods. Compliance by counting empty packets. Dietary intake by food survey at baseline and of intervention Blood lipid analysis methods not reported, LDL-C calculated. Intention to treat analysis used. Dietary intake analysis not reported. Groups generally well matched at baseline. Significant reduction in total and LDL cholesterol. No change in HDL cholesterol or triglyceride levels. Power calculation for LDL-C performed. No difference in adverse effects between groups. Funding source unclear. Abbreviations used: AHA; American Heart Association, ANCOVA; analysis of covariance, ANOVA; analysis of variance, HDL; high density lipoprotein, LDL-C; low-density lipoprotein cholesterol, RMANOVA; repeated measures ANOVA Appendix 3 – Risk of bias assessment Reference Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessors (detection bias) Incomplete outcome data (attrition bias) >20% = high Selective reporting (reporting bias) Other Allen 2008 ? Matched on age, total cholesterol, BMI, but method not described low Numbered codes, investigators blinded low Double- blind low Investigators blinded until after analysis low 10% attrition low Expected outcomes reported low Banuls 2010 ? Unclear method of randomisation ? Not described high Not blinded ? Not described low No attrition low Expected outcomes reported low
Banuls 2011 ? Unclear method of randomisation ? Not described high Not blinded ? Not described low 7% attrition ? Dietary intake data not reported low Baumgartner 2013 low sequence ? Not described low ? Not described low 9% attrition low Expected outcomes reported low Buyuktuncer 2013 Low Randomisation list in blocks ? Not described low ? Not described ? Not described low Expected outcomes reported low Chen 2009 ? Unclear method of randomisation ? Not described low Double- blind low Investigators blinded until after analysis low 4% attrition low Expected outcomes reported low Dulalia 2011 low sequence low Opaque envelopes low low Blinded low 1% attrition low Expected outcomes reported low Gagliardi 2010 ? Unclear method of randomisation ? Not described low Participants but not personnel blinded high Not blinded high 29% attrition low Expected outcomes reported low Goncalves 2007 ? Unclear method of randomisation ? Not described low Participants but not personnel blinded ? Not described ? Not reported low Expected outcomes reported high No control group for healthy subjects Gylling 2009 low Frequency matched for gender ? Not described low ? Not described low 5% attrition low Expected outcomes reported low Gylling 2013 low sequence ? Not described low low Blinded low 2% attrition low Expected outcomes reported low Hallikainen 2013 low Performed by independent statistician ? Not described low ? Not described low 8% attrition low Expected outcomes reported low 2011 ? Unclear method of randomisation ? Not described high Not blinded ? Not described low no attrition ? Dietary intake data not low
reported Khandelwal 2009 low sequence low Sealed envelopes low low Blinded low 11% attrition low Expected outcomes reported high Difference in baseline LDL-C between groups Ruiu 2009 ? Unclear method of randomisation ? Not described low Participants but not personnel blinded high Not blinded low No attrition low Expected outcomes reported low Shaghaghi 2014 ? Unclear method of randomisation ? Not described ? Not described ? Not described low 11% attrition low Expected outcomes reported low Sialvera 2012 ? Unclear method of randomisation ? Not described low Participants but not personnel blinded high Not blinded low No attrition low Expected outcomes reported high Difference in protocol between arms. Soderholm 2012 low Stratified for total chol. and gender ? Not described low ? Not described low 7% attrition low Expected outcomes reported low Weidner 2008 ? Unclear method of randomisation ? Not described low ? Not described low 2% attrition high Dietary intake data not reported low Appendix 4 – GRADE summary of findings table GRADE evidence profile of FSANZ’s updated systematic review Question: What is the effect of phytosterol intake on blood cholesterol concentrations in adults? Source: FSANZ update of Demonty et al. 2009 and Ras et al 2013 systematic reviews.