Last week we discussed cholesterol and the debate about when and what type of treatment is necessary. Now what do you do when it is clear that high cholesterol is a health concern? One thing you can do is put your numbers in this calculator and see what the standard medical community thinks: are you at risk?
Remember, if your risk of heart disease or stroke over the next 10 years is over 5 to 7.5%, a medication in the class of "statin" will be recommended. Check your numbers yourself with your last cholesterol reading and a recent blood pressure.
Play with this this calculator, look at how high your risk is now, then age yourself 5-10 years on the calculator. This tells you that even with numbers that are low risk now, age itself is a powerful risk factor for heart disease and in ten years you may be talking statin medications with your doctor if you don't get a hold of the factors that influence your health now.
This week we will start our supplement spotlights. When people go to the health food store to look for alternative options to standard prescription on cholesterol they will encounter a selection. How do you know what to choose? I will give you a review of a few of my favorites over the next few weeks.
Please remember these statements are not supported by the FDA and supplements are unregulated. Do not purchase supplements for cardiovascular disease without consulting your physician (or come see me, Dr Brie!) to see what is right for you. Supplement quality varies greatly, buying pharmaceutical grade supplements that are third party tested and verified are best. I have options for these quality therapeutic brands, and pass along the whole sale costs I receive to current members. It is always best to check with your doctor before purchasing something at a grocery store or GNC.
Red Yeast Rice
Red yeast rice is a supplement made from fermented rice. It creates a mold that grows a compound very similar in structure to statin medications. In fact, it is considered a naturally occurring statin compound. Statins and Red Yeast Rice, act on the liver to help decrease cholesterol production.
What is good about RYR?
Red yeast rice is good because it does act as a "weak statin". It will help decrease cholesterol production in the liver. It may have the other benefits that the statin class of medications has as well such as lowering inflammation and stabilizing plaques although further research is warranted. If your doctor says that you really "should" be taking a statin but you choose not to, this is good option. This treatment option primarily targets lowering your LDL or dangerous cholesterol. Some studies have shown that people who are statin-intolerant have been able to take RYR without untoward side effects, making it an important alternative option.
What is bad about RYR?
RYR quality varies a lot. There a an excellent consumer lab that reviews and verifies that supplement ingredients compared to labeling and detects for contamination. This review of RYR shows significant variation in quality referencing standard available store brands.
The consumer lab review shows a Whole Foods brand that is contaminated with citrinin, a potential toxin, and other brands that have unusually low amounts of the effective component, the monacolins. Some would argue that if you are going to take a statin, you might as well take one that is regulated, tested, and formulated to be exactly what it should be, not something in disguise. The other problem is that this medication has one strength, and at that dose it might not be enough to make the clinical impact you want to see.
As with all statin medications, RYR can deplete your body of the anti-oxidant coenzyme Q10. If you are taking RYR or a stain, it is best to take it wth CoQ10 because it can lower your risk of side effects such as muscle soreness that can come along with the medication effect.
The Bottom Line:
Red yeast rice might be good if you feel very strongly that you want a natural supplement and not a pharmaceutical. However, the quality of the RYR over the counter counter is variable so do your research or ask me where you can purchase wisely. If your cardiovascular disease risk is high, it may be safer and more cost effective to consider a traditional statin medication along with CoQ 10.
Information in this article references the following studies:
It started with eggs. Egg whites became the rage. "Heart Healthy" appeared on packages. Lowering your cholesterol seemed directly linked to saturated fat. It was the 1990s. Actively involved in the integrative medicine community in the Bay Area at the time, I listened to several talks by Dean Ornish M.D., who was reversing heart disease with a plant based diet.
Fast forward. It is 2017. Paleo and primal eating are the rage. Fat is back in, in large amounts. People have steered toward a protein rich low carb diet, and guess what? Some people lower their cholesterol that way.
It turns out that the story between your cholesterol, particularly the LDL cholesterol and your diet (including fats and carbs) is a much more complicated story than we thought 20 years ago.
When I was in my training we were taught to monitor cholesterol and get people to their "goal" LDL (the "dangerous cholesterol"). If you had had a stroke, a previous heart attack or diabetes your goal was under 70. For most people optimal was 100-130. If you had risk factors: family history of a male with a heart attack below 45 or a female with heart attack below 55 we wanted you lower than 130. If you were a smoker or had high blood pressure we wanted you below 130. If you had a good level of good cholesterol, we subtracted a point on your scale of risk factors. If you were older than 45 as a male or 55 as a female you were losing your protective traits of youth and your risk went up. It was a simple, mathematical calculation of goals. If there were no risk factors your LDL could be as high as 160 to 190 before physicians were talking medication management.
A few years ago there was a major over haul of this approach. The cardiovascular specialists were trying to make sense of people that had "good" cholesterol numbers, but still died of heart attacks. Or the ones with "bad" LDL numbers and lived many years, sometimes unmedicated.
To address this Doctors developed an algorithm and put out a calculator called the ASCVD risk estimator, taking into effect the big risk factors we know effect heart disease: age, high blood pressure, smoking and diabetes. They worked to move physicians away from a number-driven approach for LDL goals and instead wanted us to focus on the estimated percentage risk for heart disease over a ten year period. They determined that on the ASCVD risk calculator, anyone with greater than a 5% risk of having a heart attack in the next 10 years should be on a statin medication.
That is when the controversy came. Since the ASCVD risk calculator came out, I have determined the risk percentage with every cholesterol reading I've taken. One day I realized that it was over 5% in Caucasian males over 55 so often that, according to the guidelines, I should be recommending statins regularly.
So I decided to play with the values. I attempted to make the perfect 55 year old Caucasian male. One that was 55, with HDL (good) cholesterol as high as the calculator would let me guesstimate, total cholesterol 150 (very low), and of course a non smoker, non diabetic, and non hypertensive. That imaginary person didn't get the recommendation for a statin. Practically everyone else did.
I was not the only practitioner that held this grievance with the risk based approach. It seems, with 5% as the threshold, the risk for heart disease for any man over 55 or woman over 65 is so high that we might as well put statin medications in the water.
Luckily, the cardiologists have moved the mark and now 7.5% is an acceptable risk before medication is deemed necessary. Good thing, because I have been letting healthy five percenters off the hook for years.
The truth is, science continues to understand more and more about the complexity of cholesterol and heart disease. We now know there are dangerous forms of your LDL and less dangerous forms. There are attributes we can measure on your HDL to see if it is capable of doing its job to sweep up the cholesterol out of the plaques in your arteries (that is what makes it good). There is a role of inflammation, and we have markers in blood work we can follow to see if you are at risk for heart disease based on inflammation or inherited types of dangerous LDL known as Lp(a). For years I have referred to this testing as "fancy cholesterol" tests. Indeed, they cost more money but the value of further dissecting your risk is worth it in my mind.
Not everyone needs a fancy cholesterol test. However, if your cholesterol is high or you have the major risk factors (family history of early heart attack, smoking, diabetes, high blood pressure) you should talk with me about getting the in depth test at least once. We can even find out if you are someone who is more likely to respond to diet changes or if you are more genetically susceptible to getting a side effect front the statin medications.
Many people come to me because I try to manage cholesterol holistically as often as possible, and I do not force statin medications on patients that do not want to take them. I do see a role for these medications. They stabilize plaques, reduce cholesterol numbers effectively, and decrease inflammation in your arteries. I also recognize that medications have risks, and statins (Lipitor, etc) are no exception. There is a time and place for everything and sometimes we need this tool.
However, if you want to manage your cholesterol on your own, without a statin, I can help! I have been studying effective alternatives for years and actively use a variety of supplements and lifestyle changes to modify cardiovascular risk. We can do a Calcium Score, which is a coronary (heart) artery cat scan that helps us know if you have evidence of current heart disease. With this test, we can decide together if your risk of heart disease is high enough that you need the traditional medications, or if we have room to try some of the alternative options.
Stay tuned over the next several weeks for highlights from some of my favorite options for an alternative management of cholesterol. But please, don't stop any medications without consulting your doctor. If you aren't seeing me now, think about joining the practice or coming for a consultation on this issue so we can decide together the best approach for you. At the end of the day, personalized medicine is best, and I want to make sure we get this right.