**1. Introduction**

Cardiovascular disease (CVD) is a global health problem and a leading cause of death [1]. CVD risk factors are associated with poor lifestyle, including smoking, physical inactivity, obesity, unhealthy diet, and excessive alcohol consumption, leading to hypertension, hyperglycemia, and high LDL cholesterol [2,3]. Studies indicate a link between CVD and diabetes [3,4].

Type 2 diabetes mellitus (T2DM) predisposes patients to cardiovascular disease and cardiovascular mortality [5]. The development and progression of T2DM are strongly influenced by diet, physical inactivity, and increased body weight; therefore, intensive lifestyle modification is recommended for T2DM [6]. In patients with diabetes, the addition of soluble dietary fiber and phytosterols is recommended as a primary measure to prevent CVD before considering non-statin therapy [7].

Phytosterols (plant sterols and plant stanols) are natural bioactive plant substances with a structure similar to cholesterol. In the intestine, phytosterols and cholesterol com-

**Citation:** Witkowska, A.M.; Wa´skiewicz, A.; Zujko, M.E.; Cicha-Mikołajczyk, A.; Miro ´nczuk-Chodakowska, I.; Drygas, W. Dietary Plant Sterols and Phytosterol-Enriched Margarines and Their Relationship with Cardiovascular Disease among Polish Men and Women: The WOBASZ II Cross-Sectional Study. *Nutrients* **2022**, *14*, 2665. https://doi.org/10.3390/ nu14132665

Academic Editor: Arrigo Cicero

Received: 3 June 2022 Accepted: 24 June 2022 Published: 27 June 2022

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pete for the same absorption mechanisms [8]. As a result, phytosterols can affect blood cholesterol concentrations by reducing the amount of cholesterol available for absorption. Studies have shown that consumption of 0.6–3.3 g of plant sterols per day reduces serum LDL-C concentrations by approximately 6–12%, and this effect was dose-dependent [9].

The diet typically provides 150–400 mg of plant sterols [10–15]. The phytosterols found in the highest amounts in plant-based foods, and, thus, in the human diet, are β-sitosterol, campesterol, and stigmasterol [16]. Food sources with the highest plant sterol content are vegetable oils, mainly corn oil, and sesame seeds [17]. Phytosterols isolated mainly from vegetable oils and their commercially produced esters can be ingredients of fortified foods and supplements as a non-pharmacological therapy of hypercholesterolemia. In European Union countries, products enriched in plant sterols are mainly milk and yogurt, margarine, and spreadable fats [18]. Plant sterol-enriched foods that provide 2 mg of phytosterols daily, combined with a healthy lifestyle, in patients with mild to moderate hypercholesterolemia have been found to reduce LDL-C levels by 10% [19,20]. However, the effect of long-term use of phytosterol-enriched foods on cardiovascular risk factors is unknown [21].

A few population-based studies, but not in the Polish population, have analyzed the effects of dietary phytosterol intake on CVD [10,11,14], but none included phytosterolenriched products. Therefore, the present study aimed to investigate whether there is an association between habitual intake of total phytosterols and individual phytosterols (β-sitosterol, campesterol, and stigmasterol), or a diet combined with phytosterol-enriched products, and CVD in a cross-section of Polish adults.

#### **2. Materials and Methods**
