The Journal of Nutrition Nutritional Epidemiology Dietary Intake of Naturally Occurring Plant Sterols Is Related to a Lower Risk of a First Myocardial Infarction in Men but Not in Women in Northern Sweden 1,2 Sofia Klingberg, 3 * Lars Ellega ˚rd, 3 Ingegerd Johansson, 4,5 Jan-Ha ˚kan Jansson, 6 Go ¨ ran Hallmans, 4 and Anna Winkvist 3 3 Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 4 Department of Public Health and Clinical Medicine/Nutritional Research, 5 Department of Odontology/Cariology, and 6 Department of Public Health and Clinical Medicine/Medicine, University of Umea ˚, Umea ˚, Sweden Abstract Dietary intake of naturally occurring plant sterols is inversely related to serum cholesterol concentrations. Elevated serum cholesterol increases the risk of myocardial infarction (MI), but it is unknown if this can be reduced by dietary intake of naturally occurring plant sterols. Our aim was to investigate if a high intake of naturally occurring plant sterols is related to a lower risk of contracting a first MI. The analysis included 1005 prospective cases (219 women, 786 men) and 3148 matched referents (723 women, 2425 men), aged 29–73 y at baseline, from the population-based Northern Sweden Health and Disease Study. A food frequency questionnaire (FFQ) was completed at baseline. Absolute plant sterol intake was inversely related to the risk of a first MI in men (OR highest vs. lowest quartile 5 0.70; 95% CI: 0.53, 0.85; P-trend 5 0.006) but not in women. After adjustment for confounders, the estimated risk was somewhat attenuated (OR highest vs. lowest quartile 5 0.71; 95% CI: 0.55, 0.92; P-trend 5 0.067), suggesting that increasing sterol intake from 150 to 340 mg/d reduces the risk of a first MI by 29%. Energy-adjusted plant sterol intake was not related to the risk of a first MI in either men or women. In conclusion, the findings of this observational study show that a high absolute intake of naturally occurring plant sterols is significantly related to a lower risk of a first MI in men in northern Sweden, whereas no significant relation was seen for energy-adjusted plant sterol intake. In women, no significant associations were found. The results from this study show that intake of plant sterols may be important in prevention of MI. J. Nutr. 143: 1630–1635, 2013. Introduction It is estimated that >17 million people died of cardiovascular disease (CVD) 7 worldwide in 2008, representing 30% of all deaths (1). In Europe, the proportion is even higher; almost one- half of all deaths are caused by CVD (2). Although the incidence of myocardial infarction (MI) has decreased by 1–2%/y during the past decade, it still affects ;40,000 people/y in Sweden and is the leading cause of death (3). However, many CVDs can be treated or prevented. There are several established risk factors for CVD, including both behavioral risk factors such as smoking, physical inactivity, and poor diet as well as medical conditions such as overweight, hypertension, elevated blood glucose, and dyslipidemia (4,5). Serum cholesterol concentrations are affected by diet and it is established that intake of saturated fat raises serum cholesterol concentrations, whereas intake of unsaturated fat and soluble dietary fiber lowers serum cholesterol concentrations (6,7). Plant sterols are bioactive compounds found in varying concentrations in vegetable foods. It has long been known that plant sterols lower serum cholesterol when consumed in large doses, i.e., 1–2 g/d from foods enriched with plant sterols (8). The mean dietary intake of naturally occurring plant sterols in European populations is only ;200–300 mg/d (9–14), an amount previously considered too low to affect serum choles- terol. However, it has been shown in small experimental studies that a plant sterol intake of 150–584 mg/d alters whole-body 1 Supported by FORMAS, the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant 22.2/2003-0655; the Swedish Research Council, grant 521-2003-3826; BBMRI.SE; and 2 grants from the Swedish Nutrition Foundation. The plant sterol analyses were supported by a grant from the Swedish government under the LUA agreement and the Swedish Cancer Foundation. The Va ¨ sterbotten Intervention Program was organized and funded by the Va ¨ sterbotten County Council and supported by Swedish Cancer Society and Europe Against Cancer Program grants. The development and maintenance of the dietary database is supported by grants from the Swedish Council for Working Life and Social Research and the Swedish Research Council. 2 Author disclosures: S. Klingberg, L. Ellega ˚ rd, I. Johansson, J.-H. Jansson, G. Hallmans, and A. Winkvist, no conflicts of interest. * To whom correspondence should be addressed. E-mail: sofia.klingberg@ nutrition.gu.se. 7 Abbreviations used: CVD, cardiovascular disease; MI, myocardial infarction; MONICA, Northern Sweden WHO Monitoring Trends and Cardiovascular Disease study; VIP, Va ¨ sterbotten Intervention Program. ã 2013 American Society for Nutrition. 1630 Manuscript received April 17, 2013. Initial review completed May 6, 2013. Revision accepted July 3, 2013. First published online August 7, 2013; doi:10.3945/jn.113.178707. by guest on October 2, 2016 jn.nutrition.org Downloaded from