Contenido Contexto El ester de estanol vegetal ester y la reduccion del colesterol LDL Respuesta a la alta ingesta diaria de éster de estanol vegetal.

Presentación del tema: "Contenido Contexto El ester de estanol vegetal ester y la reduccion del colesterol LDL Respuesta a la alta ingesta diaria de éster de estanol vegetal."— Transcripción de la presentación:

0 La ciencia del ester de estanol vegetal

1 Contenido Contexto El ester de estanol vegetal ester y la reduccion del colesterol LDL Respuesta a la alta ingesta diaria de éster de estanol vegetal Planta estanol ester se recomienda ampliamente para el colesterol como parte de una dieta

2 ¿Por qué bajar el colesterol LDL?
Reducir el colesterol LDL es el objetivo principal en el tratamiento de la dislipidemia y prevención de enfermedades cardiovasculares Dieta y otros cambios de estilo de vida siempre constituyen la base para el tratamiento

3 Éster de estanol vegetal reduce el colesterol LDL
Reduce el Colesterol LDL en un promedio de 10% No afecta el colesterol HDL 2 DE ESTANOLES VEGETALES POR DÍA REDUCE EL COLESTEROL LDL EN 10 % EU commission has approved in 2009 the following health claim to be used in plant stanol ester containing products: ” Plant stanol esters have been shown to lower/reduce blood cholesterol. High cholesterol is a risk factor in the development of coronary heart disease.” This is the strongest type of a health claim possible to get in EU, an Art health claim for reducing a risk factor for a disease. In order to bear the claim, the product must also provide on its labeling the following information to consumers: “Information to the consumer that the beneficial effect is obtained with a daily intake of 1,5-2,4 g plant stanols. Reference to the magnitude of the effect may only be made for foods within the following categories: yellow fat spreads, dairy products, mayonnaise and salad dressings. When referring to the magnitude of the effect, the entire range '7 to 10 %' and the duration to obtain the effect 'in 2 to 3 weeks' must be communicated to the consumer.” Read more at: FDA has approved a health claim for “Plant sterol/stanol esters and Risk of Coronary Heart Disease”. Suggested wording for the claim is “Diets low in saturated fat and cholesterol that include two servings of foods that provide a daily total of at least 3.4 grams of plant stanol esters in two meals may reduce the risk of heart disease. A serving of [name of food] supplies __ grams of plant stanol esters.” Read more at:

4 Eficacia Comprobada Plant stanol ester has been granted strong health claims by the Comision de la Union Europea FDA E.U.A Guias de organismos oficiales estan recomendando el consumo de alimentos funcionales con estanoles vegetales para la reduccion del riesgo de ECV.

5 Estructura Molecular: Colesterol, estanoles y esteroles
Phytosterols (i.e. plant stanols and plant sterols) are a group of compounds that are found in plant-based foods like cereals and vegetable oils. The amounts of phytosterols found naturally in foods are too small to produce significant reductions in human serum cholesterol levels. However, foods enriched with phytosterol esters have been shown to effectively lower serum cholesterol levels. Plant stanols are esterified with vegetable oil fatty acids in order to ensure their bioavailability and the good quality of the end food product. 2 g of plant stanols weight about 3.4 g when they are esterified into plant stanol esters. Plant stanols and plant sterols differ from each other by molecular structure (plant stanols are saturated forms of plant sterols), which leads to differences in their absorbtion efficacy, serum levels, metabolism, excretion and efficacy at intakes above 2 g/d. The absorption rate of plant sterols is roughly ten times higher than the absorption rate of corresponding plant stanols: the absorption rate of plant sterols is approximately 0.5-2% and the absorption rate of plant stanols is approximately % (Ostlund et al. 2002). Consumption of plant stanol ester reduces the absorption of both cholesterol and plant sterols, resulting in reduced serum levels of both cholesterol and plant sterols. Apposed to that, consumption of plant sterol ester only reduces the absorption of cholesterol and leads to increased serum levels of plant sterols (Hallikainen et al. 2000). On a normal diet, serum concentrations of plant stanols are low, typically 10 – 15 μg/dl (Hallikainen et al. 2000) A daily intake of 2 g plant stanols (as plant stanol ester) increases serum plant stanol concentrations to 20 – 30 μg/dl. Serum levels of plant stanols remains at low levels even with high daily intake of plant stanols (up to 9 g/d), (Gylling et al. 2010a, Mensink et al. 2010) On a normal diet, serum concentrations of plant sterols are typically much higher than those of plant stanols, namely 350 – 800 μg/dl. A daily intake of 2 g plant sterols (as plant sterol ester) increases blood plant sterol concentrations to 500 – 1000 μg/dl (Hallikainen et al. 2000). Plant stanols are stable molecules that are not metabolized in the body (Lütjohann et al. 1993). Plant sterols can be metabolized by intestinal microbes to secondary metabolites (Weststrate et al. 1999). Plant stanols are more effectively eliminated from the body than the corresponding plant sterols. Ostlund et al studied the decay of intravenously injected dideuterated tracers and found that the half-life (t½) of plant stanols was consistently shorter than that for corresponding plant sterols. Consumption of plant stanols dose-dependently reduces serum cholesterol levels even at intakes higher than around 2 g/d (Gylling et al. 2010b, Mensink et al. 2010, Musa-Veloso et al. 2011, Musa-Veloso and Poon 2011). Apposed to that, higher intakes of plant sterols than around 2 g/d have not been shown to result in enhanced cholesterol-lowering efficacy (Davidson et al. 2001, Hendriks et al. 1999, Musa-Veloso et al. 2011, Musa-Veloso and Poon 2011, Noakes et al. 2005).

6 Mecanismo de accion El Ester de Estanol Vegetal Reduce la Absorcion del Colesterol en el Intestino Delgado SIN ESTANOL VEGETAL ~50% del colesterol se absorbe CON ESTANOL VEGETAL ~20% of colesterol se absorbe Colesterol Ester de Estanol Vegetal Plant stanol ester works by inhibiting the absorption of cholesterol in the small intestine. In the intestine, plant stanol ester is hydrolyzed into plant stanol, the bioactive ingredient, and fatty acid. Fatty acids are digested normally. Plant stanol is able to replace cholesterol in mixed micelles due to similar molecular structure. Cholesterol that is not solubilized into a mixed micelle can not be absorbed, and significantly more cholesterol is excreted from the body. Apart from this rather simple, mechanistical mechanism, plant stanols are believed to affect other mechanisms related to cholesterol absorption. As a single-dose of plant stanols a day has been found to be as effective as the same dose divided over several meals a day, there must be some longer affecting mechanism also playing role. It has been suggested that plant stanols may induce ATP binding cassette transporter A1 (ABCA1) expression, which indicates that within the enterocyte, plant stanols increase the ABCA1 -mediated cholesterol efflux back into the intestinal lumen. Other, more recent finding is that plant stanols may stimulate cholesterol excretion via non-biliary route, the trans intestinal cholesterol excretion (TICE) (Brufau, 2011). TICE was discovered in in vivo-studies when it was suggested that the hepatobiliary cholesterol secretion might not be the only route for cholesterol excretion into the intestinal lumen. It has been demonstrated that cholesterol is secreted throughout the entire length of the small intestine (van der Velde 2007). These findings are very preliminary, however.

7 Dieta Normal + ester de estanol vegetal (3 g/d)
Absorcion Reducida del Colesterol Éster de estanol vegetal reduce la absorción de colesterol en el intestino. Cholesterol absorption (mg/day) in postmenopausal women with coronary artery disease Absorción de colesterol biliar Absorción de colesterol de la dieta mg/d dieta Normal Dieta Normal + ester de estanol vegetal (3 g/d) Fecal elimination and the absorbtion efficiency of cholesterol was measured as a part of a double-blind, randomized, cross-over intervention study on postmenopausal women with previous myocardial infarction (n=22) who used margarine containing 3 g/d plant stanols as plant stanol esters and placebo margarine for 7 weeks each. Elimination of cholesterol from the body and cholesterol absorption efficiency were measured once in each period from the 3-day stool collections. Cholesterol absorbtion efficiency was calculated by the altered 14C/3H ratio in stools as compared with the fed ratio. Fecal cholesterol as fecal neutral sterols, bile acids and plant sterols were quantitated by gas-liquid chromatography. Dietary intake of fatty acids and cholesterol were determined from the 7-day diaries by a computer method applied to the country’s dietary ingredients. Compared to control period, intervention with plant stanol ester spread containing 3 g/d plant stanols decreased the cholesterol absorption efficacy by 45%. Plant stanol ester increased the fecal elimination of both biliary and dietary cholesterol. This resulted in 15 % reduction in LDL-cholesterol compared to placebo period. Adapted from Gylling et al. Circulation 1997; 96:

8 Ester de Estanol Vegetal y la Reduccion del Colesterol LDL

9 Descenso rápido de colesterol LDL
Reducción de colesterol LDL rápida y eficiente con éster de estanol vegetal. Esparcible Control n=50 Dieta Mediterranea diet n=50 Esparcible con ester de estanol vegetal (2 g/d) n=50 CAMBIO EN EL COLESTEROL LDL * % Meses *p <0.01 vs. control Serum LDL cholesterol reduces fast once plant stanol ester consumption is started. 2 grams of plant stanol a day as plant stanol ester lowers LDL cholesterol on average by 10 % within 1 to 2 weeks. When the consumption is maintained daily, the effect is lasting. In the study by Athyros et al. 150 mildly hypercholesterolemic subjects (TC 5.2 – 6.4 mmol/L; mg/dl) were randomized after a run-in period of 4 weeks into three categories for 4 months; one using regular spread (placebo) (n=50); one adviced to consume Mediterranean diet (n=50) and one using plant stanol ester containing spread (2 g/d of plant stanols) (n=50). During the run-in period subjects were advised to follow step I hypolipidemic diet. Those subjects who were using either placebo spread or plant stanol ester spread continued on this diet throughout the study. Compared to the control group, the subjects using the plant stanol ester spread had their LDL cholesterol reduced by 16 % already after the 1st month of intervention. The reduction sustained on this level throughout the study. The improvements in the diets of those subjects who followed the mediterranean diet resulted in significant 7 % reduction in LDL cholesterol compared to control, but only after 4 months of intervention. Athyros et al. Nutr Metab Cardiovasc Dis 2011; 21(3):

10 NIVELES DE CAMBIO DEL COLESTEROL TOTAL EN SUERO
Eficacia sostenible con el uso diario .El efecto del descenso de colesterol LDL de éster de estanol vegetal se mantiene con el uso diario. Esparcible con ester de estanol vegetal (1.8 g/dia estanol egetal ) n=51 Esparcible Control n=51 Esparcible de ester de estanol vegetal (2.6 g/dia n=51 NIVELES DE CAMBIO DEL COLESTEROL TOTAL EN SUERO * Cholesterol (mg/dl) Meses Intervencion *p<0.05 compared to the control group * * * * The landmark study by Miettinen et al. from 1995 was the first long-term study done with a food product containing plant stanol ester. It showed that using spread with added plant stanol ester reduced LDL-cholesterol significantly and that the effect was sustained throughout the study. The study was an one-year, randomized, double-blind study with 153 mildly hypercholesterolemic subjects. 51 consumed control margarine with no plant stanols and 102 consumed intervention margarine with 2.6 g plant stanols as plant stanol ester for six months, after which the plant stanol ester margarine group was further randomized to either continue with the margarine with 2.6 g of plant stanols/day (n=51) or change to margarine with 1.8 g of plant stanols/day for the remaining 6 months. Subjects were not to change their habitual western diet apart from the substitution of their regular spread with the test margarines (24 g/d in each group). With 2.6 g/day of plant stanols as plant stanol ester, LDL-cholesterol reduced by 13 % compared to the control at 12 months. Miettinen et al. New Engl J Med 1995; 333:

11 Una vez al día es suficiente
La eficacia de éster de estanol vegetal es independiente de la frecuencia de consumo. PLANTA ESTANOL ESTER ES TAN EFECTIVO DIVIDIDOS EN VARIAS COMIDAS COMO TOMANDOLO UNA VEZ AL DÍA Periodo Control Ester de estanol vegetal (2,5 g/d ) 1 X Dia Ester de estanol vegetal (2,5 g/d 3 X Dia *p<0.001 comparado con el periodo de control LDL-cholesterol (mmol/l) * * Plat et al. studied if the efficacy of daily plant stanol ester intake was dependent on the consumption frequency. A randomized, double-blind, placebo-controlled, cross-over study with 39 healthy normo- or mildly hypercholesterolemic subjects. Each consumed in a random order: no plant stanols; 2.5 g plant stanols at lunch; and 2.5 g plant stanols divided over the three meals (0.42 g at breakfast, 0.84 g at lunch and 1.25 g at dinner: proportional to dietary cholesterol intake). Each period lasted for 4 weeks. Food containing the added plant stanols as plant stanol ester were margarines and/or shortenings. Using plant stanol ester containing food products once a day reduced LDL cholesterol significantly by 9.4 % whereas using them three times a day reduced LDL cholesterol by 10.4 %. The difference between the different usage pattern was not significant. Thus effective LDL cholesterol lowering can be achieved when plant stanol ester containing products are used once a day with a meal. Plat et al. Eur J Clin Nutr 2000; 54:

12 Vegetal EN USUARIOS DE ESTATINAS
Efecto Aditivo al de las Estatinas Elefecto del ester de estanol vegetal es aditivo alefecto reductor del colesterol de las estatinas. Esparcible Control n=72 * Efecto incremental en la reduccion del COLESTEROL LDL I con el ester de estanol tal Vegetal EN USUARIOS DE ESTATINAS Esparcible con ester de estanol vegetal (3 g/d estanol) vegetal ) n=69 Cambio en c- LDL (%) Semanas 10 % Efecto atribuido al ester de estanol vegetal *=p<0.001, grupo con el ester de estanol vegetal vs. grupo control Blair et al. wanted to compare the effect of plant stanol ester spread with a placebo spread on serum cholesterol in patients taking statin therapy, but who still had elevated LDL-cholesterol. Randomized, double-blind, placebo-controlled clinical trial. N=167, baseline LDL-chol >130 mg/dl (>3,33 mmol/l), subjects had been on a stable dose of statin drug for at least 90 days. Subjects consumed either plant stanol ester spread with 3 g/d plant stanols or placebo spread (divided into 3 servings/d) for 8 weeks. At 8 weeks, plant stanol ester spread reduced LDL cholesterol by 17% compared with a 7 % reduction in the placebo group. When used together with stable statin medication, plant stanol ester was able to reduce LDL cholesterol further by 10%. That degree of reduction is somewhat greater than can be expected with doubling the dose of a statin, which generally produces an additional reduction of about 6%. Blair et al. Am J Cardiol 2000; 86:

13 EFICAZ COMO PARTE DE UNA DIETA DE COLESTEROL
Efecto adicional al de una dieta saludable El efecto del ester de estanol vegetal es adicional al efecto reductor del colesterol de una dieta saludable. EFICAZ COMO PARTE DE UNA DIETA DE COLESTEROL 'ESTRICTA' Dieta para bajar el Colesterol n=17 C- LDL Dieta para bajar el colesterol + ester de estanol vegetal (2.3 g/d estanol vegetal) n=18 Cambio % en c- LDL l *Efecto especifico al ester de estanol vegetal; a= significativamente diferente de semana 0 p<0.01; b= significativamente diferente de semana 0 p<0.001; significativamente diferent vs. control p<0.01 The first clinical studies done with plant stanol ester had proven the efficacy of the ingredient as a part of normal, western diet often high in saturated fat and cholesterol. The study by Hallikainen et Uusitupa was conducted to study whether plant stanol ester is effective as a part of a healthy, low-fat, low-cholesterol diet as well. In a parallel, double-blind, randomized study 35 hypercholesterolemic subjects were assigned after a 4-wk high-fat diet (baseline) to either a group consuming control margarine or a group consuming plant stanol ester (2.3 g plant stanol/d as plant stanol ester) containing margarine for 8 weeks. During the intervention period, all subjects consumed a diet resembling that of the National Cholesterol Education Program’s Step II diet. During run-in, subjects diet contained about 40 E% of fat and 17 E% saturated fat. During the experimental period, about 26 % of subjects’ energy came from fat and 7 % from saturated fat. This change in diet resulted in about 10 % reduction in LDL-cholesterol in the subjects using placebo spread. The LDL-cholesterol of the subjects using plant stanol ester containing spread reduced by about 24 %, of which about 14 % was plant stanol ester specific effect. The study showed that plant stanol ester effectively lowers cholesterol also as a part of a healthy cholesterol-lowering diet. Hallikainen and Uusitupa. Am J Clin Nutr 1999; 69:

14 Tan eficaz como la dieta mediterránea
El ester de estanol vegetal es tan efectivo como la adopción de la dieta mediterránea para el riesgo estimado de enfermedad coronaria . EFFECTIVE REDUCTION IN THE ESTIMATED RISK OF CORONARY ARTERY DISEASE (CAD) Control spread A change in the estimated CAD risk during the following 10 years (Framingham risk engine) Mediterranean diet Plant stanol ester spread (2 g of plant stanols / day) Months *=p<0.05 vs. control * * * * * (More results from the Athyros et al. study presented in the slide 6.) In the study by Athyros et al. 150 mildly hypercholesterolemic subjects (TC 5.2 – 6.4 mmol/L; mg/dl) were randomized after a run-in period of 4 weeks into three categories for 4 months; one using regular spread (placebo) (n=50); one adviced to consume Mediterranean diet (n=50) and one using plant stanol ester containing spread (2 g/d of plant stanols) (n=50). During the run-in period subjects were advised to follow step I hypolipidemic diet. Those subjects who were using either placebo spread or plant stanol ester spread continued on this diet throughout the study. The fast and efficient LDL-cholesterol lowering achieved with the use of plant stanol ester spread resulted in fast reduction in the estimated CAD risk during the following 10 years as estimated with Framingham risk engine. Adopting a heart-healthy Mediterranean diet resulted in similar reduction after 4 months, when several small improvements in the over-all heart health were combined. Athyros et al. Nutr Metab Cardiovasc Dis 2011; 21(3):

15 La respuesta dependiente a dosis del ester de estanol vegetal a consumos diarios de altas dosis

16 Mejor eficacia a dosis mas altas
Reduccion adicional del colesterol con 8.8 g de estanoles vegetales al dia. Cambio (%) Control (n=24) Ester de Estanol Vegetal (8.8 g/d estanol vegetal) (n=25) CAMBIOS COLESTEROL DURANTE UN ESTUDIO DE 10- SEMANAS Colesterol Total LDL Colesterol * *p<0.01 Based on the early studies typically done with 2-3 g of plant stanols a day, it was believed that the maximal cholesterol lowering efficacy of plant stanols could be achieved with these daily intakes. In this high-dose study by Gylling et al. it was first indicated that higher daily intake of plant stanols does indeed reduce LDL-cholesterol further. In this randomized, double-blind, placebo-controlled study the intervention (n=25) and control (n=24) groups consumed spread and drink enriched or not with plant stanol esters for 10 weeks. Subjects had serum total cholesterol concentrations between 4.5 to 7.5 mmol/l. Study products were 20 g/d vegetable-oil based spread and 2.5 dl/d oat-based drink containing 8.8 g/d plant stanols as plant stanol ester or placebo. Subjects were advised to continue their habitual diet, which was monitored with 3-day food records kept at baseline and at the end of the study (week 10). Fasting blood samples were taken at weeks 0,9,10 and on week 14 (4 weeks after the intervention on regular home diet). Serum LDL-cholesterol reduced by 17.1% in plant stanol ester group compared to control group. Gylling et al. Clin Nutr 2010; 29:

17 Reduccion dependiente a Dosis
La reduccion del colesterol LDL es dependiente de dosis a altos consumos de ester de estanol vegetal. Cambio en colesterol LDL (mmol/l) Comparad o a linea de base Consumo de Estanol Vegetal (g/dia) It was studied by Mensink et al. if the cholesterol lowering efficacy of higher than 2-3 grams of plant stanols/d truly was dose-responsive. Randomized, double-blind, placebo-controlled parallel study. Healthy subjects (n=93) with moderately elevated serum total cholesterol ( mmol/l) received after a 3-week run-in period, control products or products (margarine 20 g/d and soy-based yogurt 2x150 mL /d) providing 3 g, 6 g or 9 g plant stanols as plant stanol ester for 4 weeks. Compared to control group, LDL-cholesterol reduced by 7.5% in the 3 g group, by 12.0 % in the 6 g group and by 17.4% in the 9 g group. Mensink et al. Am J Clin Nutr 2010; 92:

18 Estanoles/Esteroles (g/dia)
Mejor eficacia maxima Significativamente mejor eficacia maxima con éster de estanol vegetal Ester de esterol vegetal Estanoles/Esteroles (g/dia) Ester de Estanol vegetal Reduccion c-LDL (%) Accumulating data from plant stanol ester high-dose studies, and the fact that similar data is not available on plant sterols prompted Musa-Veloso et al. to conduct a meta-analysis of available plant stanol and sterol studies to see if there is a difference in the two substances cholesterol-lowering ability. A comprehensive and transparent literature search for the meta-analysis was conducted for the first time in May 2009 and updated for the last time in November 2010 to ensure that the data were current. Major scientific literature databases were searched for high-quality, randomized, controlled, clinical human studies. Study inclusion and exclusion criteria were pre-defined and applied to all of the studies identified. Out of 3456 publications initially identified, 113 publications with 182 data sets met the inclusion criteria. In 137 of these data sets, plant stanols or plant sterols were administered in ester form. The data from the studies were collected individually by two investigators as double data entry ensures accuracy in the transcription of study data. Numerous statistical analyses were conducted to characterise the plant stanol (ester) and plant sterol (ester) data sets and to confirm the analytical results obtained. The meta-analysis showed that plant stanols and plant sterols do have differences in their cholesterol-lowering efficacy. The meta-analysis does not contradict previous findings that the effects of plant sterols and stanols are practically similar at the currently recommended level of 2 g/d. However, the analysis showed that the estimated maximal LDL-cholesterol reduction was 18.2% for plant stanol ester but only 9.1% for plant sterol ester. This difference in favour of plant stanol ester was statistically significant. The results demonstrated that, as the intake of plant stanol ester increased, LDL-cholesterol is reduced in a dose-dependent way. In contrast, this dose-response was not seen for plant sterols. Exclusion of high-dose studies (> 4 g plant stanols/sterols per day) from the analysis did not change the results. Additional analyses also showed that the efficacy of plant stanol ester was not affected by the fat content of the diet, or by the type of food in which it was served. Musa-Veloso et al. Prostag Leukotrien Ess Fatty Acids 2011.

19 El ester de estanol vegetal se recomienda ampliamente para la reduccion del colesterol como parte de una dieta saludable

20 Cuerpos de expertos recomiendan el uso de estanoles vegetales
European Society of Cardiology, 2012 National Heart, Lung, and Blood Institute & National Institutes of Health & American Academy of Pediatrics, 2011 European Society of Cardiology & European Atherosclerosis Society, 2011 The Australian Heart Foundation, 2009 American Academy of Pediatrics, 2008 American Diabetes Association, 2008 American Diabetes Association & American College of Cardiology, 2008 American Heart Association & American College of Cardiology, 2006 Joint British Societies, 2005 International Atherosclerosis Society, 2005 Joint WHO/FAO Expert Consultation, 2003 International Lipid Information Bureau, 2003 National Cholesterol Education Program & National Institute of Health, 2002 European Society of Cardiology (ESC): European Guidelines on cardiovascular disease prevention in clinical practice,   National Heart, Lung, and Blood Institute (NHLBI) & National Institutes of Health (NIH) & American Academy of Pediatrics (AAP): Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, 2011. ESC & European Atherosclerosis Society (EAS): ESC/EAS Guidelines for the management of dyslipidemias, 2011. The Australian Heart Foundation: Position statement on phytosterol/stanol enriched foods, 2009. AAP: Lipid Screening and Cardiovascular Health in Childhood, 2008. American Diabetes Association (ADA): Nutrition Recommendations and Interventions for Diabetes, 2008. ADA & American College of Cardiology (ACC): Lipoprotein Management in Patients With Cardiometabolic Risk, 2008. American Heart Association (AHA) / ACC: Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease, 2006. Joint British Societies: JBS 2: Guidelines on prevention of cardiovascular disease in clinical practice, 2005. International Atherosclerosis Society (IAS): Harmonized Guidelines on Prevention of Atherosclerotic Cardiovascular Diseases, 2005. Joint WHO/FAO Expert Consultation: Diet, nutrition, and the prevention of chronic diseases, 2003. International Lipid Information Bureau: Dyslipidemia and Coronary Heart Disease - The ILIB Lipid Handbook for Clinical Practice, 2003. NCEP & NIH: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, Evaluation and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III, 2002. In addition to these guidelines mentioned, there are several local national guidelines recommending the use of plant stanols.

21 ESC/EAS directrices para el manejo de dislipidemias, 2011
La magnitud del efecto de los alimentos funcionales enriquecidos con fitoesteroles es graduada lo más alto posible y el nivel de evidencia de clase 'A‘ +++: "Basada en la evidencia disponible, los alimentos enriquecidos con fitoesteroles (1-2 g/día) pueden ser considerados para individuos con valores elevados de CT y C- LDL, en los cuales la evaluación del riesgo CV total no justifica el uso de drogas para colesterol.“ The Task Force for the management of dyslipidemias of the European Society of cardiology (ESC) and the European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidemias. Atherosclerosis 2011; 217S1: S1-S44.

22 ESC, 2012 European Guidelines on cardiovascular disease prevention in clinical practice ' Alimentos funcionales que contienen fitoesteroles (esteroles y estanoles vegetales) son eficaces en la disminución de los niveles de colesterol LDL hasta en un 10% de la media, cuando se consume en cantidades de 2 g/día. El efecto reductor del colesterol es adicional al obtenido con una dieta baja en grasa o al del uso de estatinas. Algunas investigaciones recientes indican que, especialmente para la reducción de colesterol, se pueden obtener reducciones mas altas pueden con dosis más altas estanoles. ' Eur Heart J; doi: /eurheartj/ehs092.

23 Paso Importante antes del medicamento
El uso del Ester de Estanol Vegetal se recomienda antes de empezar medicamento Cambios Terapeuticos del Estilo de Vida (CTEV) Si la meta de colesterol LDL no se logra con CTEV en 6 semanas, agregar Ester de Estanol Vegetal Si la meta de colesterol LDL no se logra con CTEV en 6 semanas, agregar: Medicamentos Monitorizar adherencia a los CTEV y dieta despues de 4-6 meses National Cholesterol Education Program, National heart, Lung and Blood Institute and National Institutes of Health. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, Final report.) (NIH Publication No September 2002, updated 2004.) NCEP ATPIII, 2002.

24 Cambios Terapeuticos del Estilo de Vida
Eficacia comprobada cuando se combina con estatinas Para pacientes que ya estan tomando estatinas agregar el Ester de Estanol Vegetal disminuye el colesterol LDL en un 10% adicional Cambios Terapeuticos del Estilo de Vida Medicamentos Ester de Estanol Vegetal The Task Force for the management of dyslipidemias of the European Society of cardiology (ESC) and the European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidemias. Atherosclerosis 2011; 217S1: S1-S44. Eur Heart J; doi: /eurheartj/ehs092. National Cholesterol Education Program, National heart, Lung and Blood Institute and National Institutes of Health. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, Final report.) (NIH Publication No September 2002, updated 2004.) Blair et al. Am J Cardiol 2000; 86: De Jong et al. Br J Nutr 2008; 100:

25 El ester de estanol vegetal es la opción dietética más eficaz en reducir el colesterol
The graph: 1. Plant stanols (0,8 g/day), e.g. less than half a bottle of Benecol 2. Plant stanols (2 g/day), e.g. 1 bottle of Benecol 3. Plant stanols (3 g/day), e.g. 1,5 bottles of Benecol 4. Soluble fibre (5-15 g/day), e.g bananas 5. Soy protein (25 g/day), e.g. 1 l of soy milk 6. Replacing saturated fats with mono- & polyunsaturated fats, e.g. switching from 25 g of butter/day to 20 g of vegetable oil/day 7. Beta-glucan (3 g/day), e.g. 3 bowls of oatmeal porridge, 2 dl each 8. Omega-3 from fish oil (2 g/day), e.g. 150 g of salmon 25