Plant sterols and NICE advice

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Kentoldlady

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Hello, DUK.
Quick question. Recently dx t2d and am reading everything. Having cholesterol results next week and I know it will not be good news. As I dont want statins I have been looking at dietary measures instead.
On this site the use of plant sterols added to food ( yoghurts, spread etc ) is actively encouraged in one of your useful articles.
However the nice guidelines specifically state that t2d should use them. In big bold letters it says " do not recommend". Not that we should not use them with statins, or instead of statins, but they should NOT be recommended.
Do you know why they are not recommended?
And do you know why DUK has not followed this guideline?
I would much rather follow your advice and use them and ignore nice.
Really grateful for you help. This is all very confusing and your site is very helpful.
Thank you.
 
Kentoldlady are you referring to a post on this forum, or on the Diabetes UK website?
 
Ralph-YK said:
Kentoldlady are you referring to a post on this forum, or on the Diabetes UK website?
Click to expand...
Hello ralph. I read an article on Duk site about the use of plant sterols. Not the forum, although from what I have read on the forum no one seems to think they are a bad idea.
However, it is nice that say they arenot recommend for t2d.
 
Kentoldlady said:
Hello, DUK.
Quick question. Recently dx t2d and am reading everything. Having cholesterol results next week and I know it will not be good news. As I dont want statins I have been looking at dietary measures instead.
On this site the use of plant sterols added to food ( yoghurts, spread etc ) is actively encouraged in one of your useful articles.
However the nice guidelines specifically state that t2d should use them. In big bold letters it says " do not recommend". Not that we should not use them with statins, or instead of statins, but they should NOT be recommended.
Do you know why they are not recommended?
And do you know why DUK has not followed this guideline?
I would much rather follow your advice and use them and ignore nice.
Really grateful for you help. This is all very confusing and your site is very helpful.
Thank you.
Click to expand...

Hi, Kentoldlady
I think it is a question of semantics, where the "NOT" is placed - NICE are telling HCPs not to recommend them, perhaps because they think there is no evidence of their benefit, rather than recommending you should not use them because they will harm you. This is a relatively recent addition to the NICE guidelines, so the DUK article may well have been written before this.
 
Hi squirrel. That is a possibility, but lots of things will neither help or harm us, but there are no blanket recommendations about them. There are studies to show that these products help and I did not find any to show harm. It is a puzzle.
 
The earlier version of the guidelines did tell HCPs to recommend them.
 
Thank you, secret. So you are saying they have decided to stop recommending them because they have no benefit? Just to us or everyone?
 
Hello DUK. Is anyone able to answer my question ? Many thanks.
 
Kentoldlady said:
Thank you, secret. So you are saying they have decided to stop recommending them because they have no benefit? Just to us or everyone?
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Sorry, @Kentoldlady, missed your reply. I am just guessing, but think the answer would be no proven benefit, or not enough benefit for them to actively recommend them.
@everydayupsanddowns is more practised at interpreting NICE guidelines, he might have a more informed take on this!
 
Hello @Kentoldlady @silentsquirrel

NICE's position is here - plant stanols and sterols make their 'do not do' list for people with diabetes of any type and whether or not you have had a heart disease event.
https://www.nice.org.uk/donotdo/do-...ionpeople-who-are-being-treated-for-secondary

Basically everyone.

I had a vague recollection that I had read something about this a few years ago.

My recollection was that although cholesterol can be shown to be lowered - that is essentially meaningless unless there is also a reduction in heart disease risk. With plant stanols/sterols the opposite appears to be true. Or at least there is some evidence that suggests an increase in risk of CVD or CHD when you eat them. They lower your cholesterol, but make heart disease more likely.

So at the very least the evidence is mixed.

Here are a few links that do not support stanols/sterols

http://www.drbriffa.com/2013/08/01/...-are-good-for-cholesterol-but-bad-for-health/

http://thescipub.com/abstract/10.3844/ojbsci.2014.167.169

There also seems to be some evidence that eating plant stanols/sterols promotes atherosclerosis (plaques) though again the evidence is not very clear.
 
Well, if NICE have said Do Not Use, that suggests to me that it is not simply that they do not work, but that there could be evidence of possible harm

Hopefully @Hannah DUK or @Stefan Diabetes UK can respond with DUK's position and explain why their advice is different to NICE - it may simply be that the DUK pages have not been reviewed since NICE published 'Do Not Use' advice.

Edited following subsequent conversation.
 
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Am I then being over-pedantic thinking there is a difference between "do not advise to take" and "advise not to take"?
 
silentsquirrel said:
Am I then being over-pedantic thinking there is a difference between "do not advise to take" and "advise not to take"?
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That's a really interesting question. I wish I knew the answer. I wonder if I could find that out?
 
Hannah DUK said:
Hello @Kentoldlady - Please could you post a link to the article you are referring to so that I can see the informaiton.

Thank you 🙂
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I found this, when I was discussing the point with the OP, which I found by searching on the DUK main website, I assume this is the article referred to.
https://www.diabetes.org.uk/Guide-t...-medical-conditions/Cholesterol-and-diabetes/

( I feel a bit of responsibility here, as it was I who suggested Kentoldlady posed the question on the 'Ask Diabetes UK' thread!)
 
everydayupsanddowns said:
Well, if NICE have said Do Not Use, that suggests to me that it is not simply that they do not work, but that there is significant evidence of possible harm - just not quite enough to get them banned outright

Hopefully @Hannah DUK or @Stefan Diabetes UK can respond with DUK's position and explain why their advice is different to NICE - it may simply be that the DUK pages have not been reviewed since NICE published 'Do Not Use' advice.
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I think if NICE had found 'significant evidence of possible harm' and hadn't publicised this, it would be criminally irresponsible. There just isn't significant evidence of harm. The article by Dr John Briffa, in typical fashion, quotes from a few reputable journals and a collection of non peer reviewed sources. There simply isn't any reliable evidence of harm. And you cannot infer that from the NICE advice. NICE, perfectly reasonably, don't advise these products because they are unregulated, and impossible to advise at any particular 'dose'. There is reliable evidence that plant stanols work, and do the same job as statins. Is this why vegans suffer less heart disease?
 
mikeyB said:
I think if NICE had found 'significant evidence of possible harm' and hadn't publicised this, it would be criminally irresponsible. There just isn't significant evidence of harm. The article by Dr John Briffa, in typical fashion, quotes from a few reputable journals and a collection of non peer reviewed sources. There simply isn't any reliable evidence of harm. And you cannot infer that from the NICE advice. NICE, perfectly reasonably, don't advise these products because they are unregulated, and impossible to advise at any particular 'dose'. There is reliable evidence that plant stanols work, and do the same job as statins. Is this why vegans suffer less heart disease?
Click to expand...

Yes, quite right @mikeb I think I worded that poorly. Maybe 'some' ? Or at the very least, no evidence of positive effect?

Plant stanols/sterols only ever advertise their cholesterol lowering effects. I'm not sure they have ever been trialled for their effect (positive or otherwise) on CHD/CVD itself. I'll have to look at the 'evidence to recomendations' and see if anything is mentioned.

I can't think of another reason why NICE would review the evidence and put them on the 'Do not do' list. Can you?
 
Found the full 'Lipid modification' guideline here: https://www.nice.org.uk/guidance/cg...ification-update-full-guideline-pdf-243786637

The recommendation is on page 124
45. Do not advise any of the following to take plant stanols or sterols for the prevention of CVD:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes. [new 2014]
Click to expand...

The reasoning seems to be 'no information of any benefit'.

"Critical outcomes were all-cause mortality, CV mortality, non-fatal MI, stroke and quality of life."

"No benefit was found for CV outcomes."

"However, the clinical review found no evidence regarding the effectiveness of this intervention in reducing CV events. It is hence impossible to say whether the intervention is cost effective. The GDG noted that any recommendation to people to use stanol or sterol supplementation would impose additional costs on the individual. As these costs would have to be paid for from within an unchanged personal disposable income, this may lead to changes in the individual’s other shopping choices, which could impact upon the balance and healthiness of the individual or family’s diet as a whole."
 
Thanks for that, Mike. That's what I suspected their thinking was. No mention of any harm, then, other than the cost to the patient, and the possibility of fad eating affecting the balance of household food and the effect on health for that reason. Seems to me to be a suck it and see situation.
 
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