**4. Discussion**

The prevalence of CVD and its risk factors among Poles is high [32]. CVD in this present population-based cross-sectional study was found in one fifth of the participants, which is concordant with the literature. This population requires interventions to reduce the incidence of CVD. One of the non-pharmacological treatment measures is a dietary modification to improve the quality of nutrition. Phytosterols, present in food and phytosterol-enriched food products, depending on the dose, can be effective in reducing LDL cholesterol, which is one of the risk factors for CVD [9].

Scientific evidence based on supplementation studies shows that the intake of 2 g of phytosterols is effective in lowering LDL cholesterol [20]. The relationship between dietary phytosterols and CVD is, however, controversial, as foods provide phytosterols in lower doses than dietary supplements do. The usual intake of phytosterols is generally less than 400 mg/day [10–15], and higher levels have been found only in vegans [33]. In this study, intakes higher than 400 mg/day were observed only in the highest tercile of phytosterol consumption, both in men and women. Previous evidence indicates, however, that phytosterols from natural foods may have an LDL cholesterol lowering effect [9]. In this study, both men and women with CVD were found to have lower intakes of total and individual plant sterols from diet and from diet and phytosterol-enriched margarine, than their healthy counterparts.

Diabetes predisposes one to CVD and people identified with diabetes are at a greater risk of developing cardiovascular diseases [5]. Scientific evidence shows that plant sterols can have beneficial effects on diabetes by reducing insulin resistance [34]. In this study, men with diabetes had significantly lower intakes of total and individual plant sterols, but no significant difference was observed in women.

Recent studies conducted in Poland support the belief that it is men who require special preventive measures to reduce cardiovascular risk factors, especially hypertension, dyslipidemia, diabetes, excessive body weight, and smoking [32,35]. Our cross-sectional study suggests that it is men who may benefit from habitual plant sterol intake. This is particularly evident after adjusting plant sterol intake for confounding variables, which were age, lipid-lowering medication, HDI, BMI, and alcohol. Among women, the findings are ambiguous because, after adjusting for confounders, most of the previously significant differences were not further observed for the second tercile of total and individual plant sterol intake. This might be due to the generally lower intake of plant sterols among women relative to that observed among men, and in the second quartile, it is low enough to observe beneficial effects. It is only in the third tercile of total and individual plant sterol intake that a lower incidence of CVD is observed among women.

The results of our study are in line with those of a Swedish study, which found that consumption of naturally occurring plant sterols was associated with a lower risk of a first heart attack in men, but not among women [10]. It is possible that women may benefit not from a single dietary component, but from a combination of foods and nutrients, which, for example, can be found in the Mediterranean diet or Dietary Portfolio [36]. Dietary recommendations to date regarding the consumption of a varied diet, and particularly emphasizing the consumption of plant-derived products, are reasonable in terms of providing various compounds of importance in the prevention of noncommunicable diseases. The contribution of phytosterols to the diet is highlighted by the Dietary Portfolio, which

uses a combination of established nutritional approaches to lowering cholesterol, such as consumption of plant protein, nuts, soluble fiber, and monounsaturated fats and phytosterols [37,38]. It has been shown to improve LDL cholesterol fraction and other CVD risk factors [37–39]. In several other studies, lower levels of total cholesterol and LDL cholesterol were observed in relation to dietary phytosterols [40–42]. A recent study found that closer adherence to a plant-based diet was significantly associated with a lower risk of total CVD, coronary heart disease, and heart failure in postmenopausal women [36]. In contradiction to the Swedish study is the Danish study, which found no reduced CVD risk despite lower LDL-C concentrations in men [14]. However, the authors concluded that the study population had a narrow range of phytosterol intake.

Our study suggests that, in terms of intake of substances with beneficial effects on CVD, such as polyphenols, antioxidants, and dietary fiber, individuals with low and high intakes of plant sterols do not differ. However, they do differ in their intake of foods considered pro- and anti-atherogenic. It was found that study participants who had higher plant sterol intakes consumed more anti-atherogenic foods and fewer animal fats.

Phytosterol-enriched foods are recommended for people with hypercholesterolemia for the prevention of CVD [19]. However, in the WOBASZ II study, consumption of phytosterol-enriched foods was observed in a small proportion of the study group (less than 2% of participants). This translated into similar intakes of plant sterols and plant sterols along with phytosterols from fortified products.
