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Cholesterol & Statin Drugs

November 2004

By William Davis, MD, FACC

What the Doctor Does Not Tell You
Cholesterol is nothing more than one of many risk factors for coronary heart disease, and just one of the contributors to the silent growth of plaque. Lowering cholesterol is still a good idea, but should be viewed in the proper perspective. Cholesterol does not reliably identify all people with hidden heart disease, nor does lowering it cure you of heart disease.

Let’s dispel some popular statin and cholesterol myths:

“High cholesterol {and LDL} is the number-one cause of heart disease in this country.”
Dead wrong. High cholesterol is among the risk factors for heart disease, but is not the leading risk factor. The most prevalent risk factor is low HDL, along with small LDL particles, which commonly occur together. In fact, of every 100 people with coronary heart disease, 60-70 will have low HDL and small LDL particles, but fewer than 30 will have high LDL. If this is the case, why do we not hear more about low HDL and small LDL particles? The answer is simple: because treating these is not as profitable for drug companies. But just wait—when a profitable drug becomes available to treat this more prevalent risk factor for heart disease, we can expect to hear about an “epidemic” that will justify billions of dollars in new drug expenditures.46-49

What qualifies as low HDL? National guidelines say it is a level of less than 40 mg/dL for men and less than 45 mg/dL for women.50 In fact, a level of less than 60 mg/dL is probably very significant.51 HDL is already a standard measure in everyday cholesterol panels. Small LDL particles, on the other hand, need to be measured specifically. The medical world focuses on statin therapy for LDL, while the most prevalent risk factor for heart disease goes untreated in the great majority of cases.

“If I take a statin agent, I won’t have a heart attack.”
This is simply untrue. Lowering cholesterol (even to rock-bottom levels) reduces, but does not eliminate, the risk of heart attacks. Many heart attacks still occur in people with low cholesterol levels, whether or not they take cholesterol-lowering drugs.52 We must consider that there are other risk factors for heart disease besides cholesterol, such as small LDL particles, low HDL, lipoprotein(a), homocysteine, and high insulin levels. Results from the most recent National Health and Nutritional Survey show that 47 million US adults have metabolic syndrome (low HDL, high triglycerides, high blood pressure, excess abdominal fat), which substantially heightens the risk of heart disease even in the presence of low cholesterol levels.53

“I feel fine and my stress test was normal. My doctor says I don’t have heart disease.”
This is among the most widely propagated fallacies spread by many primary care physicians and even cardiologists. First, lack of symptoms should not be reassuring, as most heart disease is silent—without symptoms and undetectable by conventional means such as electrocardiograms and cholesterol testing. Second, stress testing is a miserable failure for screening asymptomatic people. Most future deaths and heart attacks, in fact, occur in people with normal stress tests (when symptoms are not present). This is why you will hear about your neighbor passing a stress test on Tuesday, only to drop dead from a heart attack on Thursday. The net result of this misperception is that most future heart-attack victims are walking around now, feeling fine and unaware of their risk.54 Cholesterol can be high, low, or in between, but all too frequently fails to shed light on this murky situation.

Giving the Paradigm Shift a Shove
Really lowering your risk for heart disease requires a dramatic shift in focus. Cholesterol is one way to reduce risk, but there are others as well.

Let us discuss the most prevalent risk factor for heart disease: low HDL and small LDL particles. Testing for HDL is included in any standard lipid (or cholesterol) panel, along with testing for LDL, total cholesterol, and triglycerides. Small LDL particles, on the other hand, need to be specifically measured.

Generally, the lower your HDL level is below 60 mg/dL, the more likely you are to also have small LDL particles, and the greater your risk for hidden coronary disease. Both abnormalities are also strongly associated with insulin resistance (i.e., an inability to respond to your own insulin) and risk for diabetes. Low HDL and small LDL particles respond to the same treatments and lifestyle changes, and the risks associated with each are hugely magnified by excess weight. With 47 million adults with metabolic syndrome in the US today, low HDL and small LDL are epidemic.

Weight loss (if you are overweight) is the most powerful and healthy way to correct the entire picture. Losing even the first 10 pounds of excess weight can raise HDL, suppress the small LDL pattern, and enhance insulin response. Some people will, however, require dramatic weight loss before full correction is seen, depending on genetic factors and their amount of excess weight. Carbohydrate restriction (eliminating or minimizing flour products such as pasta, bread, cookies, cakes, and other processed foods) is an effective way to lose some weight when you have these patterns.

Among supplements, white bean extract is a great way to accelerate weight loss if you have the low HDL and small LDL pattern. White bean extract blocks intestinal carbohydrate absorption by 66% with minimal side effects, unlike its prescription counterpart (which causes abundant gas).55,56 Taking 1000 mg twice a day with meals can lead to 3-7 pounds lost in the first month.

Calcium pyruvate (2500 mg twice a day) is another weight-loss accelerator that is safe and free of ephedra. Calcium pyruvate has a two-pronged benefit. First, it accelerates weight loss (by a poorly understood mechanism), usually resulting in a few extra pounds of weight loss over several weeks. Second, it also has the interesting property of enhancing exercise by making it easier and less taxing, thus enabling you to exercise longer and harder with easier recovery. Exercise “highs” are achieved more easily with calcium pyruvate supplementation.57

Supplementing with niacin (vitamin B3) is a direct, effective way to raise HDL and lower small LDL. Doses of up to 500 mg daily can be taken safely; higher doses of 1000 mg or more should be taken under medical supervision, as these occasionally result in liver dysfunction, elevation of blood sugar, stomach intolerance, and gout. Niacin typically causes a hot flush (usually of the chest, neck, and face) that is harmless though annoying. The flush usually can be inhibited by drinking plenty of water, taking niacin with solid food, and avoiding spices and alcohol when you take the tablet.58,59 Always take folic acid and vitamin B12 with niacin to protect against disruption of healthy methylation patterns. Folic acid and vitamin B12 also help to lower homocysteine, another important piece of the atherosclerosis puzzle.

Fish oil can also raise HDL and lower small LDL when taken in the form of a concentrated omega-3 preparation that provides at least 1400 mg of EPA and 900 mg of DHA per day. Fish oil has tremendous benefits beyond its lipid effects, including reduced mortality from heart attack, anti-inflammatory and mood-improving effects, and reduced cancer risk.60,61