March newsletter – cholesterol and statins.
Welcome to my March newsletter
This entire newsletter is dedicated to cholesterol and statins, a subject that has turned out to be one of the most controversial health topics in the last ten years. As there are two entirely different schools of thoughts on the subject I‘m here to tell you what they are and to let you make up your own mind.
There are over seven million people in England taking statins and this number is expected to rise steeply. As an advocate of freedom of choice in all things, I would get yourself as armed as you can with as much information as you can and then make informed decisions that are right for you.
Some jaw dropping statistics
There is widespread concern about the over prescription of certain drugs. We have seen this particularly with antibiotics in the last 30 years and now the numbers on statins are set to increase even further as the Government’s new health checks for the over-40s take effect. Analysis by the NHS Information Centre, which collects data on all drugs dispensed in England, reveals there were 48.5m prescriptions dispensed for statins in 2008, up from just 7m a decade ago. The cost to the NHS was £238m in 1999 and increased steadily to a peak of £738m in 2004 before dropping again as many big-name brands came off patent. In 2008 the NHS spent £450.5m on statins. Officials at the Department of Health said statins save around 10,000 lives a year. Statins, which can cost as little as 85p for a month’s supply, are prescribed to people who have had a heart attack, in order to reduce the risk of suffering a second, and to those who are calculated to be at more than a one in five risk of suffering their first heart attack in the next 10 years. The majority of patients taking statins are aged over 45 and are prescribed their drugs every two months by their GP.
What is cholesterol?
Cholesterol is an essential part of every cell structure and is needed for proper brain and nerve function. It is also the basis for the manufacture of sex hormones. Cholesterol is manufactured in the liver and transported through the blood stream to the sites where it is needed. It is a fatty substance and because blood is mainly water it has to latch on to molecules called lipoproteins to travel around successfully. LDL’s are the major transporters of cholesterol in the bloodstream and because LDL’s seem to encourage the deposit of cholesterol in the arteries it is known as bad cholesterol. High density lipoproteins (HDL’s) on the other hand are considered to be good cholesterol because they carry the unneeded cholesterol away from the cells and back to the liver where it is broken down for removal from the body. If everything is functioning as it should this system remains in balance. However if there is too much cholesterol for the HDLs to pick promptly or if there are not enough hdls to do the job, cholesterol can form plaque that sticks to artery walls and may eventually cause heart disease.
What is the difference between serum and dietary cholesterol?
It is important to distinguish between serum cholesterol and dietary cholesterol. Serum is the cholesterol in the bloodstream, whilst dietary cholesterol is in food. While eating foods high in dietary cholesterol can raise serum cholesterol it is not the only source of serum cholesterol. Indeed you would have some amount of serum cholesterol even if you never ate any food containing dietary cholesterol because the body produces its own cholesterol. Cholesterol levels are greatly influenced by diet but they are also affected by your genetic make up. The consumption of foods high in cholesterol and or saturated fat increases cholesterol levels while a vegetarian diet regular exercise and the nutrients niacin and vitamin c may lower cholesterol.
What about the ratio between HDL and LDL?
So now we know about good and bad cholesterol – there is an extra point to note – the ratio between good and bad is a crucial part of the cholesterol picture. The desirable LDL level is considered to be less than 2.6 mmol/L, although a newer upper limit of 1.8 mmol/L can be considered in higher risk individual. A ratio of total cholesterol to HDL, less than 5:1 is thought to be healthier. Total cholesterol is defined as the sum of HDL, LDL, and VLDL. Usually, only the total, HDL, and triglycerides are measured. For cost reasons, the VLDL is usually estimated as one-fifth of the triglycerides. Don’t worry if you are confused – it is confusing. Essentially you are looking at least at a 2:1, or 3:1 ratio of good to bad cholesterol. The government have set new standards for the overall cholesterol which should be 5.0 mmol/L (4.0 if you have CHD). However unless you have high risk factors I think taking statins at this level is unnecessary, if the HDL is high. It may be of interest that in London the average cholesterol is 5.8 and in Southern Japan its 3.8 – that is diet related so do not listen to anyone who tells you diet cannot help cholesterol levels. A GP recently told me diet alone could only reduce cholesterol by 0.5 mmol. When I sent a patient back to her with a reduced cholesterol from 12 to 5 with the help of diet and supplements, she said it was a fluke, so I sent her another, and another!
What are Statins?
Statins or HMG-CoA reductase inhibitors are a class of drug used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase, which plays a central role in the production of cholesterol in the liver. Increased cholesterol levels have been associated with cardiovascular diseases and statins are therefore used in the prevention of these diseases. The best-selling of the statins is atorvastatin, marketed as Lipitor and manufactured by Pfizer. By 2003 it had become the best-selling pharmaceutical in history, with Pfizer reporting sales of $12.4 billion in 2008.
Are their any naturally occurring statins?
Yes! Some types of statins are naturally occurring, and can be found in such foods as oyster mushrooms and red yeast rice. Randomized controlled trials found them to be effective but I am not advocating you go and eat a load of oyster mushrooms!
How effective are statins?
Statins differ in their ability to reduce cholesterol levels. Mostly in my experience they do work however doses should be individualized according to patient characteristics. The most common adverse side effects are raised liver enzymes and muscle problems. In randomized clinical trials, reported adverse effects are low; but they are “higher in studies of real world use”, and more varied. In randomized trials statins increased the risk of an adverse effect by 39% compared to placebo; two thirds of these were myalgia or raised liver enzymes. Some patients on statin therapy report myalgias, muscle cramps, or, less frequently, gastrointestinal or other symptoms. Certainly many patients I see have complained of muscle pains sometimes so bad they have had to change brands or come of them altogether. However it is not always the case, and often people can tolerate statins with no problems whatsoever
Why do I need to take CoEnzyme Q10?
Co Q10 is a vitamin like substance present in all cells. The heart, liver and kidneys have the highest CoQ10 content. Coenzyme Q10 (ubiquinone) levels are decreased in statin use; Some statins can reduce your CoQ10 levels by a staggering 40%. CoQ10 supplements are sometimes used to treat statin-associated myopathy, though evidence of their effectiveness is currently lacking. It is certainly a good idea to take between 30mg and 90mg of CoQ10 if you are on a statin. Ironically circulating CoQ10 in LDL prevents oxidation which in turn helps prevents heart disease!
So what’s the other side of the story?
Over the past couple of decades there has been a growing concern about fats and cholesterol. Governments have introduced national policies based around the reduction of fat. Eat less cholesterol, saturated fat and salt, eat more fibre-rich foods we are all told. The evidence is incontrovertible that if we do not, we are doomed to heart disease. Despite the certainty implied by the propaganda, the debate continues in the medical journals, behind the scenes. Apart from those with a very rare disease, has cholesterol got anything to do with heart disease — or any other disease? And even if it has, will a change of diet be beneficial?
Like all debates, this one about cholesterol has two sides. You may want to read The Great Cholesterol Con by Dr Malcolm Kendrick although there are many other books about the “cholesterol myth”. These books look at the evidence on which present healthy eating’ dietary recommendations are based.
he Great Chole
The advice given to the British people in 1938 was higher fat levels. The Government introduced free school milk — full cream, and later we ‘went to work on an egg’. As a consequence, child deaths from diphtheria, measles, scarlet fever and whooping cough fell dramatically — well before the introduction of antibiotics and widespread immunisation. The recommendations above shaped our diet for nearly fifty years and helped to give us a mean life expectancy that is now among the highest in the world. Sixty years in 1930, our mean life expectancy had climbed to seventy years by 1960 and to seventy-five years by 1990. Now we are told they are shortening our lives — killing us with coronary heart disease. Why the sudden change?
There are many diseases that affect the heart but the one that the ‘healthy eating’ strategies seek to prevent is Coronary Heart Disease a condition where the coronary arteries that supply blood to nourish the heart muscle are narrowed by a build-up of material on their walls (an atheroma) to such an extent that they become blocked. This cuts off the blood supply to part of the heart muscle, and we have a heart attack. The narrowing also encourages the clotting of blood and, in consequence, it is possible for a clot to cause a heart attack long before the atheroma is large enough to do so. The material generally blamed for the build-up is cholesterol and the ‘healthy eating’ advice given to the public to reduce the incidence of CHD is aimed simply at reducing the levels of cholesterol in the blood. Because of the propaganda, you can be forgiven for thinking that cholesterol is a harmful alien substance that should be avoided at all costs. In fact, nothing could be further from the truth. Cholesterol is an essential component in the body. It is found in all the cells of the body, particularly in the brain and nerve cells. Body cells are continually dying and new ones being made. Cholesterol is a major building block from which cell walls are made. Cholesterol is also used to make a number of other important substances: hormones (including the sex hormones), bile acids and, in conjunction with sunlight on the skin, vitamin D 3 . The body uses large quantities of cholesterol every day and the substance is so important that, with the exception of brain cells, every body cell has the ability to make it.
Cholesterol may be ingested in animal products, but less than twenty percent of your body’s cholesterol needs will be supplied in this way. Your body then makes up the difference. If you eat less cholesterol, your body merely compensates by making more. Although the media and food companies still warn against cholesterol in diet, it has been repeatedly demonstrated that the level of cholesterol in your blood is affected very little by the amount of cholesterol you eat.
In 1950 a US doctor, John Gofman, hypothesised that blood cholesterol was to blame. This was supported in 1951 when pathologists were sent to Korea to learn about war wounds by dissecting the bodies of dead soldiers. They discovered unexpected evidence of CHD: unexpected because these men averaged 22yrs old. So the pathologists performed detailed dissections on the hearts of the next 300 corpses. In thirty-five percent they found deposits of fibrous, fatty material sticking to the artery walls. A further forty-one percent had fully formed lesions, and in three percent of the soldiers these lesions were sufficiently large that they blocked at least one coronary artery. So, over 70% of the men examined showed evidence of serious coronary heart disease — and they were barely out of their teens. Doesn’t that sound slightly odd?
As there are no symptoms with the partial blockage of the coronary arteries, how could they tell, without resorting to surgery, who was in danger? They had to find what was different in those with the disease and those free of it. They found cholesterol in the material that builds up on artery walls and causes them to become blocked; people who died of heart disease often had high levels of cholesterol in their blood; and those who suffered the rare hereditary disease, familial hypercholesterolaemia (hereditary high blood cholesterol), also suffered a higher incidence of CHD. And so, not unnaturally perhaps, cholesterol and heart disease became linked.
There are a number of points that the cholesterol theory overlooks. Firstly there is a marked difference between the build-up found in those with familial hypercholesterolaemia and those with coronary heart disease: hypercholesterolaemia causes large deposits at the mouths of the coronary arteries, often leaving the arteries themselves unblocked, and so does not reproduce the type of obstruction found in coronary heart disease. Secondly raised blood cholesterol is not a good predictor of CHD in people over sixty. Lastly, cholesterol is only one of the constituents of an atheroma and, if you think about it, cholesterol is so necessary and so widespread in the body, it would have been surprising if it had not been found. Nevertheless the lowering of blood cholesterol became the sole objective in the fight against CHD; and the two principal methods used to achieve this are with diet and drugs.
When was the last time you ate an egg without feeling guilty? Since the 1960’s when doctors first hypothesized that lowering blood cholesterol levels would prevent heart attacks and strokes, everyone in the Western world has become obsessed with their cholesterol. Even McDonald’s has recently got in on the act, boasting the low fat content of their hamburgers. The recent evidence now shows that the neither cholesterol lowering drugs nor the recommended diet does anything to prevent heart disease and may even do harm. Since WWII, CHD has become a more important part of the lives of both doctors and lay people. Epidemiologists (the study of patterns in health and illness) have expressed their interest by examining factors associated with an increased probability of developing CHD, so called risk factors. At the moment some three hundred risk factors for CHD have been described and the list continues to grow. At the moment it includes: cigarette smoking, high cholesterol, high blood pressure, obesity, diabetes, low levels of high density lipoproteins, selenium, not drinking, not exercising, not having siestas, not eating fish (especially mackerel), living in Scotland, speaking English as a mother tongue, having a high level of phobic anxiety, not taking cod liver oil, and even snoring. However the important risk factors are being male and living in the western world – can you believe that!
So where does this leave me?
Well it probably leaves you confused. But there is no need to be. If you have raised cholesterol do go and see your GP. Depending on the figure and the levels of good and bad cholesterol you may not be put on a statin anyway as GP’s tend to vary on their opinions on this. If you don’t want to go on a statin and are being pressured, ask your GP to give you a couple of months and see if you can bring it down through diet, but you will need expert help with this as it is not about cutting out fat. That could possibly be the problem with GP’s thinking diet does not work because it’s left to the patient to dig around and do it themselves with the knowledge they have and often it doesn’t work simply because they don’t have the right information. It is not uncommon for me to see cholesterol levels drop from 12 to 5 mmol over a few months but you do need to know what you are doing. Diet can change the HDL/LDL ratio as well but again its more complicated than drinking cholesterol lowering drinks.
If you would like to learn how to reduce your cholesterol safely then get in contact on 01323 737814