Statin Substitutes

Can you ditch your prescription statins and lower your cholesterol with dietary supplements? Maybe.

David Becker, MD, FACC, a cardiologist at the University of Pennsylvania Heath System, noticed something interesting: Some of his patients weren’t taking prescription statins to lower their cholesterol levels, but their levels were plummeting.

“They had tried red yeast rice [a dietary supplement used in China for centuries] without my knowing and came back to me with great results,” Becker says. He launched a study, and the results confirmed his patients’ experience: A regimen of red yeast rice, along with dietary changes, exercise, and fish oil, lowered LDL (“bad”) cholesterol as effectively as did a standard dose of the statin Zocor (simvastatin).

“People who choose supplements such as red yeast rice usually fall into two groups,” says Becker, whose study was published in Mayo Clinic Proceedings. “The first comprises those who want a more natural alternative. The second group includes those who have experienced side effects from a statin, such as liver or muscle damage or memory loss.”

Do They Work?

Supplements are, in many ways, preferable to statins, according to Judith Stanton, MD, an internal medicine physician who integrates nutrition and complementary therapies in her Berkeley, California, practice. “Statins do not lower triglycerides, but certain supplements, such as niacin, do,” Stanton says. “Also, niacin can lower lipoprotein(a), a risk factor for heart disease and stroke, but statins do not and, in fact, can increase it. Statins will not increase HDL [“good” cholesterol], but some supplements can. Supplements are generally safer than statins, and since most are synergistic, they can be taken together [for added benefit]. So I do recommend certain supplements to my patients, but this is not in lieu of diet modification and exercise, which is the best method for improving cholesterol levels with no side effects.”

Are supplements a good option for you? Before running off to the health food store, talk to your healthcare provider, who will consider factors such as your medical history and that of your family, how high your cholesterol levels are, and your motivation to commit to necessary lifestyle changes. “I work with athletes, who might be concerned with muscular weakness, a potential side effect of statins. So a supplement might be an option for them. But certainly, this should be a decision made in partnership with your primary healthcare provider, based on your risk of heart disease,” says Roberta Anding, RD/LD, CSSD, CDE, director of sports nutrition at Texas Children’s Hospital and a spokesperson for the American Dietetic Association.

Dietary supplements usually don’t offer the dramatic cholesterol-lowering benefits that statins provide. And supplements aren’t regulated by the FDA, so their purity, ingredients, and dosage may vary. A lot of supplements at health food stores claim to lower cholesterol, but many haven’t been sufficiently researched or have limited or no benefits, so it’s easy to get confused over what works and what doesn’t. But decades of research and use have proven that three supplements—phytosterols, niacin, and red yeast rice—do effectively lower cholesterol.

Phytosterols

Plant stanols and sterols, collectively known as phytosterols, are natural compounds found in plant-based foods such as nuts, seeds, legumes, fruits, and vegetables. They prevent cholesterol from being absorbed from the intestine into the blood and can reduce LDL cholesterol levels by about 10% to 15%. “In essence, phytosterols block the body’s cholesterol receptors, so the cholesterol is lost in the stool,” Anding says.

Studies dating from the 1950s have proven phytosterols’ effectiveness with no side effects, so they are often a first step for people with elevated cholesterol. People who take statins can also take phytosterols for an extra cholesterol-lowering boost.

The typical dose for phytosterols is 2 to 3 grams per day. “For maximum benefit, take 10 to 15 minutes before meals,” Anding says.

The easiest (and tastiest) way to get your daily dose is with phytosterol-enriched foods, such as spreads (Benecol, Smart Balance, or Promise Activ) or orange juice (Minute Maid Heartwise). But pay attention to the extra calories you may be consuming. If you can’t get the recommended dose in fortified foods, consider supplementing with phytosterol capsules after consulting with your healthcare provider.

Niacin

Your body uses niacin (better known as vitamin B3) to convert carbs to energy. While niacin is naturally present in many foods and found in multivitamins, when taken in much higher doses, it can raise HDL cholesterol levels by 15% to 35% and lower LDL cholesterol levels by as much as 25%. “Niacin is also one of the only agents that can reduce triglycerides and [lipoprotein(a)],” Stanton says.

In the megadoses required to control cholesterol, niacin is potent medicine. “There have been cases of liver damage resulting from doses greater than 1,500 milligrams of sustained-release or slow-release niacin, which keeps the high dose in your bloodstream longer,” Stanton says. “But multiple studies have shown no hepatotoxic effects in people using immediate-release niacin in daily doses of less than 3,000 milligrams or extended-release formulations up to 2,000 milligrams daily. If you don’t exceed these doses, niacin is extremely safe.”

Still, if you take niacin, it’s wise to have your liver function checked every few months via blood tests, especially if you have a history of liver disease or take statins or other medications that could affect the liver.

Start with no more than 500 milligrams daily of niacin. “You can slowly increase the amount by 500 milligrams per week, up to 1,000 milligrams twice daily,” Stanton says.

Flushing is a common yet harmless side effect of taking niacin. “Prevent this by taking aspirin 30 minutes before taking the niacin,” Stanton says. Extended-release tablets are also less likely to cause flushing.

Red Yeast Rice

Used medicinally and as a food staple in China for centuries, red yeast rice is derived when a strain of yeast is grown with rice. During fermentation, a compound called monacolin results. Chemically similar to the statin lovastatin (Mevacor), monacolin inhibits a cholesterol-producing enzyme in the body, thus significantly reducing total and LDL cholesterol levels.

“Red yeast rice lowers LDL cholesterol in the liver, most likely by the same mechanism as a statin,” Becker says. “But the actual amount of statinlike material seems to be much lower than a pharmaceutical statin, so it is usually well tolerated.”

The downside, Becker says, is that “the quality of the products and amount of the active ingredient, monacolin, varies widely, which makes it difficult to recommend a particular brand.”

A typical dose of red yeast rice is two 600-milligram capsules twice daily.

Consult with your doctor before taking red yeast rice. “Since monacolin is similar to a statin, the same side effects are possible,” Becker says. “I also recommend occasional blood tests for the small chance of liver problems.”

If you take a prescription statin, you should not take red yeast rice. Since red yeast rice contains a statinlike compound, you’d essentially be taking a double dose, thus increasing the risk of side effects.

— Maryann Hammers