What the Research Really Shows About Cholesterol-Lowering Drugs

Under recent controversial guidelines from the American Heart Association, nearly half of all American adults between the ages of 40 and 75 would be advised to take a cholesterol-lowering statin drug. This class of drugs includes simvastatin (Zocor), atorvastatin (Lipitor), rosuvastatin (Crestor) and others. About 25% of adults are taking a statin now.

Statins do an impressive job of lowering LDL “bad” cholesterol—by up to 50% in some cases. How well do they achieve the real goal of reducing the risk for heart attacks? That evidence isn’t impressive. And statins can have serious side effects.

Is LDL Really the Enemy?

For decades, the public-health message hasn’t changed. High cholesterol—particularly high levels of LDL ­cholesterol—leads to atherosclerosis, blood clots and heart attacks.

Yet many important studies, including the Framingham Heart Study, have shown that most patients who have had a heart attack have cholesterol levels that are nearly identical to those who haven’t. Further, many experts believe that HDL “good” cholesterol is a more important predictor of heart disease than LDL.

Statins can lower the risk for recurrent heart attack by a small amount in people who already have had one. But most studies of statins have not shown a reduction in mortality. And way too often, they’re used for primary prevention—to lower LDL in those who haven’t been diagnosed with heart disease.

In people who haven’t been diagnosed with cardiovascular disease, the use of statins reduced the risk for heart attacks and other cardiovascular events by a paltry 1% to 2%.

Serious Side Effects

Statins are not the benign drugs that they’re made out to be. About 20% to 25% of patients experience side effects, some of which are serious. For example, statins reduce blood levels of CoQ10, which is involved in energy production inside cells. Low CoQ10 has been linked to heart failure, hypertension, fatigue and “mental fog.”

The most common side effect of statin therapy is myalgia, or muscle pain. The pain usually is mild, but the risk—and severity—increases at higher doses. Rhabdomyolysis is a severe form of statin-related muscle damage that can lead to kidney failure, which can be fatal.

Side effects are an acceptable trade-off when drugs truly save lives. This isn’t the case for the vast majority of patients who take statins.

Two exceptions: If you have high LDL and have had a heart attack…or if you’ve been diagnosed with cardiovascular disease (or diabetes if you are a man), a statin can make sense. I also recommend statins to patients who have familial hypercholesterolemia, sky-high cholesterol caused by a genetic abnormality.

A Better Approach

I advise most patients to work on their diets before resorting to statins. Dietary changes can increase HDL and reduce triglycerides, which is more important than reducing LDL

Mediterranean diet. The Lyon Diet Heart Study showed conclusively that heart attack patients who followed a Mediterranean-type diet (more whole grains, vegetables, fruit and fish, and less beef, lamb and pork, among other factors) greatly improve their odds of never having another heart attack. Compared with those who followed a “prudent” Western diet, they were 56% less likely to die from any cause…65% less likely to suffer cardiac death…and 70% less likely to have a heart attack.

You might assume patients in the Mediterranean diet group had lower LDL. Not so. Their LDL was roughly the same as that of people in the control group—further proof that you don’t need to reduce LDL to improve cardiovascular risks. For more on the Mediterranean diet, read my book or the book Low-Fat Lies, High-Fat Frauds and the Healthiest Diet in the World by Kevin Vigilante, MD, MPH, and Mary Flynn, PhD.

Why was the Mediterranean diet so effective? Some credit goes to ­olive oil and fish (see below) and ­antioxidant-rich fruits and vegetables, which reduce ­inflammation and blood clots. The diet also is low in pro-inflammatory ­omega-6 fatty acids (from corn and other ­vegetable-based oils) and high in fiber.

More olive oil. Extra-virgin olive oil is rich in phytochemicals, many of which inhibit oxidation. Oxidized cholesterol increases atherosclerosis and the “stiffening” of arteries that leads to higher blood pressure. Olive oil also has been shown to increase HDL.

I advise patients with low HDL to have three to four tablespoons of ­olive oil daily in addition to the small amounts that are used in cooking. Use it in salad dressings, or drizzle it on fish or poultry.

Don’t worry about saturated fat. Patients with high cholesterol usually are advised to consume less saturated fat. It’s true that saturated fat raises LDL—but only the “fluffy” LDL particles that are largely benign. Saturated fat, such as dairy fat, is an effective way to increase HDL. There’s some evidence that the saturated fat found in milk and other dairy foods reduces diabetes risk.

Seafood a few times a week. In parts of the world where people eat a lot of fatty fish (such as salmon and tuna), the risk for cardiovascular disease tends to be lower. The omega-3 fatty acids in fish reduce triglycerides and inflammation.

Enjoy your wine. Moderate drinking (no more than two drinks a day for men and one for women) has been shown to reduce the risk for heart disease. Red wine may be particularly helpful because it is high in antioxidants.

Be wary of “white” foods—simple carbohydrates such as white bread, white rice, white pasta and some breakfast cereals. These are essentially sugar and cause a surge of insulin, which increases the risk for cardiovascular disease. Insulin also increases fat storage, particularly in the abdomen. Abdominal fat is a leading risk factor for heart disease.

Don’t forget to exercise. You already know the importance of regular exercise, but it is worth repeating. Everyone should get at least 150 minutes of moderate-intensity exercise a week with brisk walking, biking, swimming, etc. It is among the best ways to lower the risk for diabetes, hypertension and heart disease.