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Old answer to new targets on cholesterol

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Americans may be in love with pharmaceuticals known as statins, but the recently revised national cholesterol guidelines still tout boring old diet and lifestyle changes as the first line of defense.

The eternal problem is that it's far easier to pop a pill than to exercise, stop smoking or cut back on saturated fat and deadly trans fats. The $15 billion-a-year statin industry, meanwhile, can be an effective part of a health plan for those at high risk for heart disease, including heart attack patients and diabetics.

Not only are statins one of the best-studied methods for preventing heart disease and lowering levels of low-density lipoproteins (LDL), the artery-clogging cholesterol, but they are relatively safe, have few aggravating side effects and also limit inflammation that leads to heart attack and stroke.

The revamped guidelines, released in July by the federal National Cholesterol Education Program, call for more stringent cholesterol cutoff points. Now, those with the highest risk of a heart attack should try to drop LDL below 70, a much lower target than the current recommendation of 100.

The good news for the pharmaceutical industry, which financially assisted several authors of the guidelines, is that the changes are expected to add 7 million people to the 36 million already encouraged to take cholesterol-lowering drugs.

But statins are no cure-all, and even in studies that trumpet blockbuster results, about two-thirds of heart disease events still occur in people on the medication, said Dr. Richard Karas, director of preventive cardiology at Tufts-New England Medical Center.

Moreover, for those who need only a small reduction in cholesterol, there is no reason to take a statin simply so you can eat a cheeseburger with a clear conscience.

"Statins are the foundation of heart disease prevention, but they can only do so much," Karas said. "People feel like they can take a statin and not worry about their weight, their HDLs (high density lipoprotein levels, or good cholesterol), about exercise or about smoking. That's not true. Statins help, but they're not the whole picture."

They are not even the second step, after dietary and lifestyle changes, though you'd never know it, given the barrage of drug advertising. If eating healthier and exercising don't do the trick (and you're not high risk), the guidelines recommend trying sterols and stanols, which are plant fats that contain a chemical structure similar to cholesterol. They can help slow cholesterol absorption in the intestines.

Soybeans and flaxseeds are rich sources, but sterols also can be found insome oils and orange juice. Margarine products with sterols, such as Benecol and Take Control, help lower blood cholesterol levels by as much as 10 percent, according to some studies.

Other good cholesterol-lowering dietary sources are viscous, or soluble, fiber found in products and foods such as Metamucil (psyllium), oats, prunes and barley, said Dr. Kevin Maki, chief science officer and director of nutrition and metabolism research with Radiant Research, a clinical research company in Chicago.

The most proven herbal supplement is red yeast rice extract, which naturally contains lovastatin, the compound found in a patented statin drug called Mevacor. The brand Cholestin once contained red yeast, but the FDA considered it an unapproved drug, and it has been removed from U.S. products.

Supplements, however, are largely unregulated by the FDA. Because they don't necessarily contain the advertised dose, Maki believes a statin would be safer.

"Many people can lower LDL by anywhere from 5 to 15 percent by using non-drug approaches," Maki said. "For millions of people, that's enough to get them to the goal. For people who it isn't, consider drug therapy."

Often overlooked is that starting doses of statins often give a whopping initial reduction, in the neighborhood of 30 percent, Maki said. "But doubling each dose thereafter only gives you an extra 6 percent," he said. In other words, if a statin isn't working, try introducing more sterols, stanols and fiber, before increasing the amount of medication.

It's also important to raise levels of HDL, the good cholesterol, while trying to lower the levels of the bad cholesterol. "They are independent predictors of heart disease," Karas said. "We're not doing well in terms of getting LDL down, but we're doing worse with helping people increase low levels of HDL. That will be the focus for the next 10 years of cholesterol treatment."

Fortunately, the message is the same. Whether you want to lower your LDL or raise your HDL, first try diet and exercise.


(Julie Deardorff writes for the Chicago Tribune. Write to her at: the Chicago Tribune, 435 N. Michigan Ave., Chicago, Ill. 60611.)


(c) 2004, Chicago Tribune. Distributed by Knight Ridder/Tribune News Service.


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