Today, we continue our series on the critically important topic of how to lower LDL cholesterol, the primary driver of our primary killer. And, we start with a story about a dietary supplement that might lead you astray.
According to cholesterol-lowering guidelines, dietary modifications are the cornerstone for starting to control the circulating concentrations of LDL cholesterol. But what about dietary supplements, so-called nutraceuticals you can buy online or over the counter? For many of them, the evidence is very limited, and, therefore, often debatable. A perfect example is policosanol, a waxy extract from sugarcane that showed an impressive 24% reduction in LDL cholesterol over placebo––more than twice as effective as phytosterols. Policosanol even rivaled or beat out a statin drug for lowering cholesterol.
So, if I recommend people consider taking phytosterol supplements, why don’t I recommend policosanol, since it works more than twice as well at a tiny fraction of the dose, and is cheaper too? More than 50 studies have reported substantial reductions in cholesterol with as little as 2 mg of policosanol. In contrast, it takes a thousand times that dose—2 grams of phytosterols—to have less than half the effect. Almost all these studies, though, were sponsored by the commercial enterprise in Cuba that markets policosanol.
Independent researchers failed to replicate the positive outcomes, though they didn’t use the exact same formulation. So, the Cuban researchers continued to claim that the efficacy is attributed to the unique purity and composition of their preparation. Okay, so this study independently tested the authentic Cuban policosanol preparation, and it totally flopped. It didn’t work. They used 10 mg, which is a typical dose. This independent study used up to eight times that dose, and saw a drop in LDL between 2% and 8%. The problem is that the placebo also led to an 8% drop. So, none of the doses worked, compared to a sugar pill.
The bottom line is policosanols lost their luster as cholesterol-lowering agents, but if you didn’t know any better and just checked the latest meta-analysis and saw the significant drop in LDL cholesterol on par with statin drugs, you might run out and buy some. You’d have to know to look at the subgroup analysis, and that remarkable 55-point drop in LDL cholesterol turns into a big fat zero when performed by researchers who hadn’t been paid to promote it.
When it comes to nutritional supplements and blood cholesterol, does anything work? Yes, red yeast rice and phytosterols work. Next, I’ll explain why red yeast rice is a terrible idea.
Among cholesterol-lowering dietary supplements, red yeast rice extract, produced by a purplish-red mold, is one of the only things that have been shown to actually reduce the risk of cardiovascular events. Based on studies including more than 10,000 patients, red yeast rice extract cut the risk of a subsequent heart attack in half and significantly decreased not just sudden death but premature death in general. No wonder, since it can decrease LDL cholesterol by an average of 36 points––comparable to what’s seen with low doses of cholesterol-lowering statin drugs. That’s because it is a statin drug. The mold produces lovastatin, the identical compound in the pill sold as Mevacor. In fact, that’s how the drug was first produced—by having that exact mold make it. No wonder it’s lowering cholesterol and saving lives.
So, are red yeast rice supplements suitable substitutions for statins? Unfortunately, no, since there’s such a large variability in statin content. So, predicting or understanding dose-related efficacy and safety is practically impossible. For example, this study on the variability in strength of red yeast rice supplements purchased from the mainstream retailers GNC, Walgreens, Walmart, and Whole Foods: researchers analyzed 28 brands of red yeast rice supplements, and the active ingredient, lovastatin, also known as monacolin K, was not detected at all in two brands, and in the other 26 brands, the quantity ranged more than 60-fold. Following the manufacturers’ recommendations for daily servings, the quantity consumed per day would range more than a hundred-fold. In the United States, manufacturers don’t list the amount, but in Europe, where they do, not a single supplement matched what it said on the label. Nine were lower, 24 were higher, and three basically had nothing. So, in other words, Buyer Beware!
An independent U.S. laboratory recently analyzed ten popular red yeast rice products, and most didn’t contain any, and those results were even worse than previous years. But wait, what’s this about 30% being contaminated with a kidney toxin called citrinin, exceeding the allowable safety limit by 65-fold?
The U.S. Food and Drug Administration has been warning consumers for years to avoid red yeast rice products because they contain kidney toxins, including citrinin, a type of mold toxin, which is considered toxic to the kidneys, liver, and fetus, found at high levels contaminating up to 80% of red yeast rice products. Given that it’s also classified as a DNA-damaging compound, Europe dropped the maximum amount permitted in food supplements down to 100 μg/kg. Thirty-seven red yeast rice supplements were screened. Guess how many exceeded the safety limit: 97%! 36 out of 37. Only a single product was compliant. And all of them contained the toxin, even though four of the products swore they were “citrinin free.” Liars. The bottom line is this toxin is almost always present and above safety limits.
In Japan, there was an outbreak of serious kidney problems linked to red yeast rice supplements causing hundreds of hospitalizations and five deaths, which is particularly alarming because the supplement company had evidently addressed the known citrinin concern by using a mold strain reportedly incapable of producing citrinin. It turns out the batch was contaminated by another type of mold that made a different kind of kidney toxin. So, as far as I’m concerned, if you want to take a statin drug, just take a statin drug; so, by law you know exactly how much you’re getting, and you don’t have to worry about mold toxin contamination issues. Modern medicine contains lots of examples of natural substances whose active ingredients were identified, isolated, studied, standardized, and regulated to create a product whose net benefits outweigh the harms. Without these steps, we are left relying on anecdotes, hearsay, and blind faith that a substance will have its desired effect.
Finally today, the whole-food equivalents of some of the most powerful cholesterol-lowering supplements.
Of all the cholesterol-lowering supplements, the best available evidence is for phytosterols, which I suggested trying and red yeast rice, which I strongly suggested avoiding. Also considered an A level of evidence is viscous soluble fiber, the sticky fiber that’s part of the Portfolio Diet, which recommends 20 grams a day from foods like oats, barley, eggplant, okra, apples, oranges, or berries. Each serving of these foods only has a few grams; so, getting 20 on a daily basis might be a challenge. That’s where psyllium can come in. Powdered psyllium seed husk has more than two grams of viscous fiber per teaspoon.
Based on dozens of randomized controlled trials, psyllium, also known as Plantago, can reduce LDL cholesterol by 13 or 14 points. The psyllium husk works best, reducing LDL by more like 16 or 17 points. Dose-wise, a tablespoon a day should get you about a 10% drop in LDL. Just make sure you follow the instructions and take it with lots of water.
Though even a three- or four-point drop in LDL could be considered clinically important, here’s all the dietary supplements found to lower LDL cholesterol by at least 10 points. Bergamot appears to lead the pack. There’ve only been a half dozen studies with a few hundred people, but bergamot resulted in a remarkable 55-point drop in LDL, thought to be because it seems to act like a PCSK9 inhibitor.
Any safety issues with bergamot? Well, bergamot contains bergamottin, which is one of the constituents of grapefruit that suppresses the detox enzymes in our liver and intestines, potentially increasing levels of certain drugs we may be taking. So, if you’re on any medications, make sure to talk to your doctor first.
There is a report of a case of Earl Grey tea intoxication. Earl Grey is just black tea flavored with bergamot. A man was drinking a gallon a day (3,785 ml), and ended up with muscle cramps and twitches thought to be due to a compound called bergapten; so, don’t drink a gallon of Earl Grey tea a day. Higher doses of bergamot extract supplements don’t necessarily have a greater effect; so, if you do want to try it, I would recommend the lowest effective dose of 500 mg a day. The latest study got away with only 375 mg a day, but only got half the effect.
Artichoke extracts are next on the list. Thirteen studies gave people 50 to 2700 mg of artichoke extracts for a few months, and saw drops in LDL of 17 or 18 points. Again, more is not necessarily better, with doses under 500 mg perhaps working better than higher doses. Of course, this is assuming there’s actually artichoke in your artichoke supplement. One study found that only three out of seven dietary artichoke supplements contained as much of one of the purported active ingredients you’d expect. Another study found all sorts of issues, not only lower concentrations than expected, but nondisclosed fillers and other plants entirely. That’s the problem with dietary supplements. They are so poorly regulated that’s it’s hard to know what’s actually in them. In the very least, you should test your cholesterol before and after starting a purported cholesterol-lowering supplement to make sure you’re at least getting some benefit. Ideally though, we’d use the whole food. In the case of artichokes, that may be a hundred grams of artichoke hearts a day, which is about half a cup. I think they’re delicious—I could totally do that, but I haven’t been able to find any canned or jarred artichoke hearts without added salt. The solution? Frozen! Look for no-salt-added artichoke hearts in the frozen vegetables section in your local grocery store.
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