Treating Cholesterol

Let us address approaches towards lowering an elevated cholesterol.  Of course, pretty much everybody knows about statins, such as atorvastatin (Lipitor) - and they do work.  Whereas many of my more traditional colleagues have many patients on statins without complaint, people that come to see me in my practice tend either to be the ones who have had undesirable side effects, or who for various reasons, simply do not want to be on pharmaceuticals, particularly that class of medications.  I have prescribed statins myself, but I generally do not begin there, unless there are pressing medical reasons to do so (history of heart attack or stroke, exceedingly high cholesterol levels, evidence of elevated vascular inflammation or calcification markers, associated risk factors such as diabetes and hypertension).  However, one of the problems I have with statins in general is how they are presented using statistical tomfoolery.  They can legitimately claim a 50% reduction in heart attack risk.  This is based on data that roughly show that if 2/100 people will get a heart attack within a period of time, and they are all given statins, and then just 1 person has a heart attack, that is in fact a 50% risk reduction - which is called "relative risk".  On the other hand, that also means that for 99% of the people, there will be no benefit, and what you will experience is really just a 1% reduction in what we call "absolute risk".  The misleading issue is that the benefits are listed in terms of relative risk, but the side effects, which in my experience tend to be frequent (profound muscle weakness of pain, memory loss, liver inflammation, to name a few), are listed in terms of absolute risk; and this means that most people will tend to think the drug is way more useful, with way fewer side effects, than it really is.  Additionally, in terms of muscular side effects, they break these down into something like 13 separate categories, so they can claim that there is no more than a 1% risk in a single category, when, in fact, the incidence is much much higher in practice.  One would think that if the drugs were really that great, they would use the same sort of statistical analysis, in other words, for benefit and risk, but they clearly do not do so.


I will just briefly mention a new class of anticholesterol medications called the PCSK9 inhibitors, such as Repatha.  These are injectable, very costly and reserved for individuals with severe genetically induced hyperlipidemias (i.e., high cholesterol and/or triglycerides), which can induce heart attacks even in very young people.  They can be, literally, lifesaving in these individuals, but these are uncommon situations.


But I suspect that people reading this are especially interested in supplements for cholesterol lowering.  My experience has been that what can work for one individual, will not work for another, so often these approaches need to be individualized.  Many people are familiar with red yeast rice, which has been used in China for centuries,  and is the natural product from which statins were originally derived.  They typical dosage would be up to 2400 mg daily, depending on the product used, and while most people will remain symptom free using red yeast rice, some people will unfortunately experience the same adverse effects that they might from a statin.  A European study showed benefit from drinking Earl Gray Tea, which is flavored with the herb bergamot, as well as the herb used by itself; and I use a bergamot product derived from the exact source of herbs used in that study.  I personally have benefited from using a supplement called pantethine, which also is liver protective.  There are varied products using a combination of ingredients including plant sterols, with this latter product working especially for those whose cholesterol levels respond strong to their diet, which is my experience is actually a minority of individuals, as most cholesterol is made in one's liver in response to various internal cues.  Cholesterol levels can go up with acute or chronic stress or hormone imbalance, for example, as cholesterol is essential not only for the construction of cell walls, but also of all sex hormones (estrogen, testosterone, and progesterone); and, especially, cholesterol is the building block for the stress hormone cortisol, which is essential for life.


Over the years, I have found stringent dietary restrictions often ineffective and miserable to maintain.  While I was taught that it was saturated fat, as in marbled beef, that was the culprit in elevated cholesterol, it would appear that excess refined and simple carbohydrates is more of a problem.  Similarly, dairy products, particularly homogenized milk, seems to be an issue, even more than eggs, which in many cases seems to have been unnecessarily victimized in terms of a cholesterol culprit.  Realize that people do respond differently to different foods, so trial and retesting with dietary changes are potentially a useful approach.  You can't go wrong by adding in fiber and fresh vegetables.  Healthy fats, such as olive oil and avocado and fish, are protective, whereas refined vegetable oils - corn, peanut, safflower, etc. - are inflammatory producing.  One can follow an inflammatory marker called a high - sensitivity C-reactive protein (CRP) to determine overall body inflammation, as this strongly seems to correlate with heart and vascular disease risk, especially in men.  In fact, some believe that statins work not so much by reducing cholesterol, but by their activity in decreasing elevated cardiac CRP levels.  Your genetics are obviously an important factor to consider, too.


I could go on and on, as the whole issue about cholesterol and cholesterol lowering is more complicated than most people realize.  The trick, again, is to individualize recommendations and treatment based on more factors than simply an elevated cholesterol level, even though that often drives routine statin prescribing in traditional practice.  One size does not fit all, in other words, so it is important to keep informed, and maintain a good relationship with your healthcare provider so you can work together to address issues such as these.


Robert W. Bruley, MD


Tuesday: 10:00 - 5:00
Wednesday: 9:00 - 5:00
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(lunch break: 12:00 - 2:30)
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