Tag Archive for: cholesterol

The Bottom Line on Red Yeast Rice

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If you remember the last Memo, I said that the active ingredient in red yeast rice (RYR) was monacolin K, which is chemically identical to a current statin medication: lovastatin. The problem with RYR in supplements is that the amounts of monacolin K varied depending on the exact type of Monascus mold used—it could be high enough to mimic the actual medication, or it could have none. You wouldn’t know because it wasn’t standardized.

As a result, the FDA declared that RYR could not be sold in the U.S. because of the lack of information on the amount of monacolin K in the supplements and because lovastatin had already been approved as a drug. Mostly the latter.

The next logical step would be to see if the FDA set a limit on the amount of monacolin K allowable in RYR products in the U.S. They have not; they consider it a drug that shouldn’t be sold in the U.S. at all. You can still find RYR as a dietary supplement, but it should not contain enough monacolin K to really do anything to lower cholesterol. On the other hand, the European equivalent of the FDA has set a limit of no more than 3 mg of monacolin K in a daily serving. You can buy it from a European company, but technically, it’s illegal in the U.S.

In this case, it makes no sense to obtain a product in the U.S. that may or may not have monacolin K in it and which could actually contain lovastatin in it as product analytics have shown. By the way, the side effects from both forms, monacolin K and lovastatin, are identical with muscle pain and the like. Doesn’t happen to most people, but it can happen. Obviously, if you’re taking a statin, don’t add RYR without your doctor’s approval.

The Bottom Line

That’s the deal with RYR in 2025. If you don’t want to take a medication, change your lifestyle to naturally lower your cholesterol. Check with your doctor to find out the limitations that he’s putting on you as it relates to exercise intensity and then get after it. Not to lose a whole bunch of weight. Not to win the next 5K. Not every day.  But to make your heart stronger and fitter. You want natural? That’s the most natural solution to high cholesterol for most people.

What are you prepared to do today?

        Dr. Chet

References:
1. Methodist Debakey Cardiovasc J. 2019 Jul-Sep;15(3):192-199.
2. NIH NCCIH 2024. Red Yeast Rice.

It’s Back: Red Yeast Rice

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I still get questions about using red yeast rice (RYR) instead of a statin to lower cholesterol. About 15 years ago, I looked up the data, wrote about it, and tucked it away. The answer was yes—but. What does that mean? Time to review it again in case you’ve been thinking about it.

Red yeast rice is actually not a yeast, it’s a mold that is produced by the fermentation of a fungus in the Monascus family that grows on, as you may have guessed, red rice. The genera Monascus purpureus is technically a mold—a fungus that produces filaments that include many cells rather than a yeast, a single-celled fungus. From a marketing perspective, you can understand why supplement manufacturers wanted to use red yeast rice rather than red mold rice.

Did RYR as a supplement work to lower cholesterol? Yes, based on several studies done in the late 1990s. There was only one problem. The RYR contained monacolin K, a by-product of fermenting the mold on the red rice. Why is that a problem? Because monacolin K is chemically identical to lovastatin, a pharmaceutical that lowers cholesterol. While no one wants to take medications any more than they have to, the RYR was a “natural” alternative. Is it still available and moreover, is it the same RYR? I’ll let you know on Saturday.

What are you prepared to do today?

        Dr. Chet

References:
1. Methodist Debakey Cardiovasc J. 2019 Jul-Sep;15(3):192-199.
2. NIH NCCIH 2024. Red Yeast Rice.

Food or Supplements? Yes!

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The results of the polyphenol study examining the impact on cardiovascular (CVD) risk factors were mixed. Here’s what the researchers found:

  • Neither the polyphenol-rich foods (berries, spices, herbs, teas, nuts, seeds, etc.) nor extracts had a significant effect on LDL- or HDL-cholesterol, fasting blood glucose, IL-6, and C-reactive protein.
  • When looking at the studies using polyphenol-rich food, there was a significant decrease in systolic and diastolic BP.
  • The polyphenol extracts had a significant effect on total cholesterol and triglycerides and had a greater reduction of waist circumference.
  • However, when both whole-food polyphenols and polyphenol extracts were used together, there was a significant reduction in systolic BP, diastolic BP, endothelial function, triglycerides, and total cholesterol.

The Upside

Polyphenols in foods and supplements were effective in reducing risk factors for CVD, both independently and when combined. This wasn’t a seminal paper that changes approaches to nutrition forever, but there were benefits. I think that’s something that was needed. It supports what my approach has always been: eat as healthy a diet as you can, and fill in the nutritional gaps with supplements.

The Problems

There were several issues. The studies included in the meta-analysis had little cohesiveness as to subjects used, sources of the foods, or the type of supplements; some used capsules while others used juices or drinks.

The issue with foods, among many, is the digestion and absorption of the active polyphenols. There’s competition with other nutrients and then the issue of the microbiome—is it functioning properly in every subject?

The issue with supplements, besides the delivery system, is whether the dose is appropriate or therapeutic. Would the amount of quercetin found in apples be the correct dose, or would you need to eat 10 apples? Would it respond the same way in the body isolated from the other polyphenols, or would another factor come into play?

The Bottom Line

In spite of its flaws, I think this study was fantastic. It demonstrated that nutrients extracted from foods can be effective in reducing CVD risk. It demonstrated that foods alone aren’t the answer and neither are supplements; it’s their use in a complementary fashion where the benefits may be found. The researchers set the stage for putting more effort into nutrition research, because there’s so much we don’t know. Yet. Until then, your best bet to support your health is to eat your vegetables and fruit, add herbs and spices, munch on seeds and nuts—and then supplement your diet with quality supplements.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.sciencedirect.com/science/article/pii/S2161831323000029

It’s Still All About the Calories

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The keto vs. Mediterranean diet study was interesting for a variety of reasons. The researchers deserve a lot of credit for even attempting to try a study of this magnitude; 40 subjects may not seem like a lot, but to provide food via delivery together with instructions on preparation is very expensive and labor intensive. It should be noted that a portion of the study took place during the lockdown phase of COVID-19; that delayed some testing, but to their credit, the subjects affected continued the particular diet they were on for the two weeks until testing could be scheduled. Here are my thoughts on the results.

Blood Lipids

  • Subjects on the keto diet showed a greater decrease in triglycerides (TG) than those on the Mediterranean diet.
  • On the other hand, those on the Mediterranean showed a greater decrease in LDL-cholesterol than did the keto diet subjects.

While the researchers discussed it at length, I don’t think it was relevant. All subjects began with average fasting TG in the normal range. While both diets decreased TG, that the keto diet reduced it slightly more isn’t earth shattering when you start at a normal reading.

The same holds true for the LDL-cholesterol. Yes, the Mediterranean diet reduced it while the keto diet increased it, but the net was 6 mg/dl over the initial readings. What could have been concluded was that neither diet reduced LDL-cholesterol by an amount that was clinically meaningful.

The Microbiome

There were no tests of the changes in the microbiome under each diet reported—at least not yet. Subjects had a definite decline in fiber intake, especially when they provided their own food in the keto diet. The Mediterranean diet saw an increase in fiber intake when subjects provided their own food.

Why mention this at all? The microbiome controls the initial processing of nutrients. In addition, the immune function begins in the gut. While the keto diet may have provided some benefit related to HbA1c, at what cost? We simply don’t know. What we do know based on other research is that the lack of fiber changes the probiotic content of the microbiome.

The Bottom Line

The data showed that the subjects averaged 200 to 300 fewer calories per day regardless of diet and maintained the reduction over both diets. They ate better, they ate less, and they lost weight.

I think this study was important because it leaves us with better questions to ask in the future, such as: how would health measures be affected if subjects reduced calories another way? It also proves what I’ve been saying for years. The average weight loss after the study was 13 to 17 pounds, and that was maintained during the follow-up period. This was not a weight loss study, yet regardless of the initial diet, the subjects lost weight. I’ve said it before and I’ll say it again: regardless of the type of diet, it’s still all about the calories.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

Causes and Risk Factors

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Rather than making this a statistics Memo, I’m going to use a couple of examples that illustrate the problems with establishing what prevents or causes disease.

Back in the late 1940s to early 1950s, there was a significant increase in cardiovascular disease. Trying to establish a single cause was complicated because there were so many variables to consider.

The Low-Fat Diet and CVD

If you read any background on the ketogenic diet, you’ll read about two factions: one that claimed a high-fat diet was the problem, while the other claimed carbohydrates from grains were the culprit. The high-fat diet faction won. While many suggest that era was the point when obesity and heart disease increased because of the explosion of carbohydrates, that was never true. They point to the Dietary Recommendations by the U.S. Senate Subcommittee on Nutrition, which focused on vegetables, fruits, and grains as the best sources of those carbohydrates. But without a decent Public Health Education Program, the recommendations were doomed to fail. The food industry flooded the market with simple carbohydrates and sugar; after all, they were carbohydrates.

Numerous randomized studies were conducted, and the largest ones failed because people didn’t follow a low-fat diet. The goal for one study was to reduce fat intake from an average of 38% to only 20%. It dropped to 24% after a year, but by six years fat had climbed back to 28%. Yet even last year, a ketogenic diet advocate was still claiming the low-fat diet failed and the study lied about the results; what the study really proved was that both reducing fat intake to 20% and increasing fruits, vegetables, and whole grains were difficult.

Cholesterol and CVD

The second story is about the relationship between levels of blood fats and CVD. It began with total cholesterol; that was the big deal for years. Then triglycerides became important based on large epidemiological studies. After that, it was LDL-cholesterol that really mattered. Then it was the ratio of total cholesterol to HDL cholesterol. The latest big thing is the size of the LDL cholesterol: fat, fluffy LDL doesn’t seem to be harmful, but small, dense LDL cholesterol does. I’d wager that tomorrow, there will be something else that will be The Big Thing.

The Bottom Line

The first story is about nutrition, and the second is about testing cholesterol. Can we predict with certainty whether you will get CVD if you follow the low-fat or high-fat dietary recommendations? No. Can a cholesterol test diagnose it? No. As the carbohydrate intake goes up, so will the risk of CVD; as blood cholesterol goes up or down, the rate of disease follows the same pattern. There’s no cause and effect. They seem to be related in some way, but they’re not predictive; they’re risk factors.

If you think back to Tuesday’s Memo when I gave the trillions of potential components that led to all the potential combinations, you can see why methods of prevention or causes of many diseases may never be known for sure. But it doesn’t change the approach to trying to find a solution: we can only know what we know today. With a methodical and rigorous approach to the scientific method, we’ll know more tomorrow.

Even if science veers in a new direction next week or next year, the only responsible course of action is for each of us to use the best knowledge we have today. And then be prepared to pivot if necessary. That’s how science works.

So what can the average person do with the flood of sometimes conflicting health information? One possibility is to let someone who understands science help you understand what’s significant and what’s not—which studies really mean something, and which are hopelessly flawed. That’s my job and my commitment to you: to sort through it all and keep you up to date on the best ways to improve your health.

What are you prepared to do today?

        Dr. Chet

Want Fewer Medications? Change Your Lifestyle

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The study that we examined on Tuesday showed that a regular exercise program can help reduce the number of medications related to cardiovascular disease and type 2 diabetes. We’re not talking about youngsters; 51 subjects completed the study with an initial mean age of 54. There were some outcomes that were likely unexpected; for example, waist circumference did not change between the experimental group and control group over the five years. There was a significant decrease in body fat in the exercise group that explained the difference in body weight. Still, the control group lost about two pounds in five years while the exercise group lost about six pounds. That actually turns out to be a good thing, as I’ll explain a little later.

The Exercise Program

The high-intensity interval training was just as advertised: intense. It included a 10-minute warm up, followed by four 4-minute intervals at 90% of maximum heart rate (HRMax) interspersed with 3 minutes of active recovery. They finished with a 5-minute cooldown. They used percentage of HRMax as assessed in the exercise test, because that’s an intense level. The focus is on the 4 minutes but those 4 are brutal. You do get to rest, but then you have to do it over again, and that’s a significant challenge to the cardiovascular system. As people got fitter, the intensity would be changed to sustain the 90% level.

What surprised me was that there was no organized exercise activity in the other eight months of the year; they just kept track of activity levels using the activity monitors. There were no differences between the control group and the exercise group in the eight months with no organized activity. That’s interesting.

Most Variables Didn’t Change

This probably surprised the researchers, but it was a desirable outcome. There were no significant differences in body fat, waist circumference, BMI, or overall percentage of body fat. While the subjects probably would have liked to have lost more weight, the fact that they didn’t shows that the changes that occurred in the risk factors for cardiovascular disease, such as high blood pressure and low HDL cholesterol as well as a lower insulin levels, showed that the difference was the actual exercise program itself. The differences in distribution of nutrients in the diet and in the total caloric intake were insignificant. As I mentioned earlier, the number of steps per day and other activities were still even. That means, again, the changes could be attributed to the exercise program alone.

The Bottom Line

What is abundantly clear is that if you really want to reduce medications, you have to pay the price by changing your lifestyle. In this study they focused on one variable: exercise. If you add a change in dietary intake, and or a change in the distribution nutrients, you may get even more benefits. But for me, it answers the question that I started with. You want to reduce medications? Change your lifestyle.

Is it worth it? That’s your call. But that’s what Aging with a Vengeance is all about.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

Can You Reduce Your Medications?

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One of the questions that I get asked frequently goes something like this: “Dr. Chet, how can I reduce the medications I’m taking?” Along with that question is, “I don’t want to have to take medications for blood pressure or cholesterol or diabetes. What can I do?” As we proceed with a focus on Aging with a Vengeance, a recently published study illustrated at least a partial answer to these questions.

Researchers in Spain recruited 64 subjects for an exercise program. The exercise program was a high-intensity interval training (HIIT) program, three days a week, that ran for four months under staff supervision. The rest of the year these subjects were given activity monitors that automatically uploaded data on activity, sleep, etc. The researchers also took a variety of blood samples for testing metabolic variables, tested the subjects’ fitness levels, assessed anthropomorphic measures such as body weight and waist circumference, and recorded medications related to blood pressure, cholesterol, triglycerides, and blood sugars. The subjects were retested after two years and again after five years.

Over the period of five years, an amazing 51 subjects completed the exercise sessions and all the testing required. That, in and of itself, is remarkable—I’ve done this type of study, and holding on to the subjects is one of the main challenges.

The primary question was answered: those who exercised as the study required took fewer medications for blood pressure, cholesterol, and blood sugar control. As you might expect, that isn’t the entire story, so we’ll wrap this up on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

Prescription Fish Oil Update

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“This Fish-Oil Heart Drug Could Be Big, Could Be Huge.” That was the headline in a well-known financial report after a Food and Drug Administration panel unanimously voted in favor of an expanded use for the prescription fish-oil drug. I mentioned this was a possibility when I first talked about Vascepa in October. The FDA is expected to make a final decision by the end of the year.

What is the expanded use? The medication could be prescribed to those who have established heart disease or type 2 diabetes with another CVD risk factor and are already taking statin medications to lower cholesterol. The advisory panel approved the use because research showed that when combined with statins, it could reduce CVD endpoints such as death, heart attacks, and strokes by an additional 4.8% when compared to a placebo over a 4.9 year follow-up period, 17.2% versus 22%.

One more thing. The medication could be prescribed to those with triglycerides as low as 150 mg/dl. That would include millions more potential users in the U.S. and Canada alone. You can see why the headline was in the financial news; the potential profit for investors could be huge. A lot is riding on what the FDA decides. I’ll explain that on Thursday.

What are you prepared to do today?

        Dr. Chet

Reference: Bloomberg Online. Max Nisen. Posted 11-15-2019.

Should You Try Prescription Fish Oil?

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The final marketing point that the prescription fish oil supplement makes is that the DHA omega-3 fatty acid found in many heart healthy fish oil blends may raise LDL-cholesterol. That’s the cholesterol, known as the lousy cholesterol, associated with an increased risk of cardiovascular disease.

Based on the studies I read, there may be a small increase in LDL-cholesterol in some studies. What they fail to mention is that there’s more than one type of LDL-cholesterol. The small, dense LDL cholesterol has been shown to be associated in CVD even when LDL-cholesterol is in the normal range; the large and fluffy LDL-cholesterol seems to have no relationship with CVD. The supplement fish oils that contain DHA seem to raise only the large LDL-cholesterol. That has led other researchers to call the effect of fish oil on LDL to be cardioprotective at best and benign at worst.

The Issues with the Marketing of Rx Fish Oil

Every company wants to put their best foot forward and prescription fish oil is no different. In reviewing the marketing materials as well as the research, here are my concerns:

  • The results of the studies they cite show a decrease in triglycerides of 33%. The mean level of triglycerides in one of the studies was about 660 mg/dl. That means it dropped the mean level to 440 mg/dl. While statistically significant, there’s no way to know whether that’s clinically significant in reducing the overall risk of CVD because the studies were so short.
  • The company clearly states that this medication is clinically relevant only to people with triglycerides greater 500 mg/dl; that’s a very small percentage of patients who may have familial high cholesterol. For the typical person with high triglycerides, this medication is not appropriate. That doesn’t mean it’s illegal to prescribe it for people with triglycerides between 250 and 500, but there’s also no evidence that it’s better than a change in diet or exercise. Will it be prescribed only for people with high triglycerides? We’ll see.
  • The company did not run comparative studies against fish oil supplements or with diet and exercise alone. Seems like that would be obvious.
  • Finally, while there are programs to get this medication for lower prices, I checked with my prescription plan and the cost would be $375 per month. For that kind of money, you can have someone prepare healthy meals specifically designed to reduce your triglycerides or take a class to learn to prepare them yourself; you could definitely join and inexpensive gym and buy more fresh fruits and vegetables.

The Bottom Line

Similar to statin medications when they were introduced decades ago, prescription fish oil should be limited to a very specific part of the population with familial high triglycerides. That’s all—no one else.

As for fish oil supplements, the issues they point out in their marketing material are not significant. You never use dietary supplements to treat any disease, but that doesn’t mean they can’t help you compensate for nutritional deficiencies. There will be a difference in the quality of any supplement so make sure you choose a quality manufacturer.

For the bulk of the population to reduce their triglycerides, reducing refined carbohydrates, saturated fats, and alcohol, increasing vegetable and fruit intake, and getting some exercise will help most. Like I always say: Eat better. Eat less. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. http://dx.doi.org/10.1016/j.atherosclerosis.2016.08.005.
2. J Clin Endocrinol Metab. 2018 Aug 1;103(8):2909-2917.
3. Am J Clin Nutr. 2004 Apr;79(4):558-63.

Review: That Sugar Film

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Summer gives us a chance catch to up on reading or binge watch a television series, so I thought I’d watch some of the nutrition documentaries that I’ve been asked about. I’ve done some in the past such as Forks Over Knives. It gives me a chance to check the facts on what’s said and how true or relevant it is. That’s the case with the film titled That Sugar Film. It was written, directed, and starred in by an Australian filmmaker Damon Gambeau. Hugh Jackson even performed the opening scene.

The premise of the movie is that all sugar is bad. There was at least one anti-sugar and ketogenic diet proponent in Gary Taubes author of Good Calories, Bad Calories. The filmmaker also assembled a team of experts who were going to provide information and medical supervision during an experiment he wanted to conduct on himself. The experiment was to see how a high-sugar diet, one typical of the average Australian, would impact him. Based on what he claimed to eat, he was somewhere between the paleo diet and the ketogenic diet before that.

There was the requisite discussion of the cholesterol hypothesis and how fat was chosen as the demon to avoid instead of sugar as they relate to heart disease. The sugar industry conspiracy was also talked about in the same vein as the tobacco industry. But it’s what he did to himself that was by far the most interesting: switching to a diet that contained 40 teaspoons of sugar a day for 60 days. What happened to him? That’s coming on Thursday.

What are you prepared to do today?

        Dr. Chet