Doctor’s Tip: How to treat high cholesterol if lifestyle change isn’t enough

The most effective way to lower cholesterol is with regular exercise and a total plant-based, unprocessed food, moderately low fat diet. This has been shown to be at least 90 percent — and most studies show 98 percent — effective in preventing heart attacks and strokes. People who have been on this diet all their lives don’t develop atherosclerosis and therefore don’t have heart attacks or strokes. In people who already have heart disease, Nathan Pritikin, Dean Ornish, M.D., and Caldwell Esselstyn, M.D., proved that this diet reverses the disease, starting in a matter of days.

Of course, not everyone is willing to make significant lifestyle changes, and people with severe cholesterol and/or plaque problems need to be on both lifestyle modification and medication.

Although some cholesterol comes from what we eat, our liver makes most of the cholesterol in our body. Statin drugs decrease the amount of cholesterol made in the liver. The first statin, lovastatin (Mevacor), was approved by the FDA in 1987, and was a “natural” product made from certain molds. Red rice yeast, a supplement that lowers cholesterol, works because it contains natural lovastatin. Several additional statins have been developed since then, and are made in the lab, but most of them are more effective than lovastatin. Statins are also anti-inflammatory, which is another mechanism by which they prevent heart attacks.

Before treating someone with high cholesterol it is often useful to confirm whether or not they have atherosclerosis, through a carotid IMT or a coronary calcium score. Because half of heart attacks occur in people with normal lipid panels (total cholesterol, LDL, HDL or “good” cholesterol, triglycerides), an advanced test is useful, and I use the Cleveland Heart Lab for this.

Statins are around 30 percent effective in lowering risk for heart attacks and strokes, i.e. just one-third as effective as lifestyle modification. Although many are generic, the ones that aren’t are expensive. Millions of lives have been saved or extended with statin drugs, but they can have side effects:

• Muscle aching and/or weakness is the most common one, and is usually not serious but is annoying. If you’re on a statin and have severe muscle symptoms, contact your physician so the rare, serious problem of muscle breakdown (rhabdomyolysis) can be ruled out. Often switching to a different statin and taking it with 1,000-2,000 units of vitamin D and 150-200 mg of CoQ10 is successful in preventing muscle symptoms.

• Statins, particularly atorvastatin and simvastatin, can increase the risk of diabetes, but studies show that the benefits still outweigh the risks.

• There have been rare reports of mental confusion with statins, although statins tend to decrease the risk of Alzheimer’s (risk factors for Alzheimer’s and multiple small stroke dementia are the same as for cardiovascular disease).

Niacin (nicotinic acid which is vitamin B3) has been used for decades to treat lipid abnormalities. It lowers total cholesterol, LDL and triglycerides and raises HDL. It tends to make people flush (red, hot, itchy skin) but this side effect can usually be prevented by taking the niacin after the evening meal with 81 mg of uncoated aspirin (e.g. chewable baby aspirin). Do not buy niacin across the counter because all OTC niacin products are supplements, and there is no FDA or other control. Generic extended-release niacin requires a prescription but is inexpensive. Endur-acin is made in Oregon, is inexpensive and can be purchased without a prescription (http://www.endur.com). Anyone taking niacin should do so under the guidance of a provider who is experienced in using it.

Zetia (ezetimibe) is not a statin. It lowers cholesterol by preventing its absorption from the gut. It is not yet generic, is expensive and needs more proof that it actually prevents heart attacks and strokes.

There is a new class of drugs called PCSK9 inhibitors (Repatha), which are much more effective when added to statins in lowering cholesterol than statins alone. Repatha has few side effects, none major. It is given by injection every two to four weeks, is very pricey and has not yet been proven to prevent heart attacks and strokes, although presumably it does. It likely will be shown to be a lifesaver for people with extremely high cholesterol levels and for people who don’t tolerate statins.

Bottom line: High cholesterol contributes to heart attacks and strokes. The most effective, safest and cheapest way to lower cholesterol and prevent and even reverse heart disease is plant-based nutrition and exercise. For people in whom that isn’t enough and for people who won’t change their lifestyle, medications are available.

For more information, read “Beat the Heart Attack Gene” by Bale and Doneen.

Dr. Feinsinger, who retired from Glenwood Medical Associates after 42 years as a family physician, now has a nonprofit Center For Prevention and Treatment of Disease Through Nutrition. He is available for free consultations about heart attack prevention and any other medical concerns. Call 970-379-5718 for an appointment. For questions about his columns, email him at gfeinsinger@comcast.net.