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Q: My doctor recently recommended that I take a statin to lower my cholesterol, but I’d rather not start the drug unless I absolutely have to. A friend said he takes an over-the-counter supplement for his cholesterol — does that really work?
Statins are one of the most widely prescribed medications, taken by roughly one in four adults ages 40 and older in the United States. The drugs are used to lower cholesterol and reduce the risk of cardiovascular disease. Cardiologists are overwhelmingly in favor of statins, which are backed by four decades of research and are considered safe and effective.
Yet some patients are reluctant to take them, citing concerns about potential side effects like muscle pain or an increased risk of developing diabetes, or saying they would prefer to lower their cholesterol without taking a prescription drug. As a result, many people have turned to over-the-counter supplements, such as plant stanols and sterols (also called phytosterols), red yeast rice, niacin, fiber and fish oils containing omega-3 fatty acids.
Studies have found that while these supplements may slightly reduce cholesterol, they are not as powerful as statins. There is also little evidence that these supplements reduce people’s risk of heart attack or stroke — the ultimate goal when treating high cholesterol.
“They don’t achieve the percent lowering that you can get with taking statins and other drugs,” said Dr. Joseph Yeboah, an associate professor of cardiology at Wake Forest University School of Medicine.
In a study published in January in The Journal of the American College of Cardiology, for instance, researchers randomly assigned nearly 200 adults who had an increased risk of cardiovascular disease to one of eight treatment groups: one that took a low-dose statin, another that took a placebo and six other groups that took fish oil, cinnamon, turmeric, garlic, phytosterols or red yeast rice supplements, all of which claimed to lower cholesterol or otherwise improve heart health.
After four weeks, the people who took the statins reduced their LDL (or “bad”) cholesterol levels by 38 percent on average. Among the supplement groups, red yeast rice showed the greatest benefit, lowering LDL levels by about 7 percent, followed by phytosterols, which improved LDL cholesterol by about 4 percent. For comparison, those who took a placebo reduced their cholesterol levels by an average of 3 percent.
Dr. Steven Nissen, the chair of cardiovascular medicine at the Cleveland Clinic and a lead author of the study, said that while some of the supplements resulted in measurable changes to cholesterol, they were not enough to have a meaningful effect on cardiovascular health. “Those differences are trivial in comparison to what people need,” he said.
How do statins work, and when are they recommended?
Most of a person’s cholesterol comes from the liver, and statins work by reducing the amount of cholesterol produced there. The goal of taking statins is to lower blood cholesterol levels by 30 to 50 percent.
When too much cholesterol is present in the bloodstream, it can start to accumulate as plaque in the arteries and obstruct blood flow. Over time, this increases the risk of stroke, heart attack and other forms of cardiovascular disease.
LDL cholesterol levels over 190 are considered dangerously high and almost always warrant a statin prescription, Dr. Nissen said. But many people with lower cholesterol levels are also prescribed statins. Doctors recommend the medications based on a person’s overall risk for heart disease, which incorporates age, cholesterol levels and blood pressure, and whether the person smokes or has diabetes. The U.S. Preventive Services Task Force recommends statins when a person’s risk of developing cardiovascular disease within the next decade is 10 percent or greater.
“We’ve spent decades developing guidelines to make sure that the right people get cholesterol-lowering medications,” Dr. Nissen said.
What nonprescription alternatives are available for lowering cholesterol?
If someone has a moderate risk for cardiovascular disease but doesn’t yet qualify for statins, experts often recommend switching to a Mediterranean diet, which prioritizes fruits, vegetables, legumes, whole grains, nuts, seeds, lean proteins and healthy fats.
“If you are worried about your heart health, a much better approach rather than taking supplements will be to work on your diet and start physical activity,” said Dr. Salim Virani, the vice provost for research at the Aga Khan University in Pakistan and a cardiologist at The Texas Heart Institute in Houston. “If you’re on a very strict diet, you can get somewhere between 10 to 20 percent LDL cholesterol reduction.”
While cardiologists largely do not recommend taking supplements for cholesterol, many people are still interested in trying them. Here’s what the research says about some of the most popular ones.
Red yeast rice has been shown to lower LDL levels by as much as 15 to 25 percent (although Dr. Nissen’s study showed a much smaller benefit). It targets the same pathway in the liver that statins do, but not to the same extent. As a result, experts recommend taking a statin instead, particularly because the Food and Drug Administration does not evaluate supplements for safety or consistency.
Fiber supplements aim to replicate the cardiovascular benefits of diets high in soluble fiber, which is found in oats, barley, legumes and fruit. But research suggests that soluble fiber — either from diet or supplements — can lower LDL cholesterol levels by only 5 to 10 percent.
Phytosterols are plant-based compounds found naturally in vegetable oils, nuts and seeds, legumes, fruits and vegetables. Studies have found that phytosterols — again, either from diet or supplements — can lower LDL cholesterol by 6 to 12 percent.
Omega-3 fatty acids can lower levels of triglycerides (another type of fat that circulates in the bloodstream), but they are less beneficial for cholesterol. More important, several meta-analyses found no evidence that omega-3 fatty acids reduced the risk of cardiovascular disease.
Niacin (vitamin B3) has also been shown to improve triglyceride and HDL (or “good”) cholesterol levels by 15 to 30 percent, but the benefits to LDL levels are more modest — less than 10 percent. Two large studies found that when taken alongside statins, niacin did not further reduce people’s risk of cardiovascular disease.
The bottom line, Dr. Virani said, is that some supplements “do lower LDL cholesterol, but it’s not enough for me to actually recommend them as primary LDL cholesterol-lowering therapies when we have a drug like statin that has been studied for so long, and we know that it’s efficacious and it’s generally safe.” All of the experts we spoke with agreed.
“You should go where the evidence is,” Dr. Virani added, “and the evidence is with statin therapy, there’s no question about it.”
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