If you have high cholesterol and your doctor is concerned you may be at risk of cardiovascular disease (CVD), you may have been prescribed a statin – a class of drugs that help lower cholesterol levels, specifically the unhealthy low-density lipoprotein (LDL) cholesterol. Statins have been in the news for all the wrong reasons, in Australia and overseas, with high-profile media stories questioning their effectiveness, especially for people with low to moderate risk of heart disease, and casting doubt on their safety. As a result, people have stopped taking statins, often without consulting their doctor.
While it's true there are side effects associated with statins, especially muscle weakness or pain, most people don't experience these problems. For people who've suffered side effects or who prefer, for various reasons, not to take statins, a quick search on the internet or a chat with a pharmacist, personal trainer or naturopath will turn up a multitude of more 'natural' alternatives.
But are these alternatives any good?
CHOICE sought the advice of people working in the health industry to see what they suggested for lowering a moderately raised total cholesterol level, and then evaluated the evidence behind their recommendations. Sources included pharmacists, naturopaths and other complementary and alternative medicine practitioners, dietitians, and people working in health food/supplement stores.
Here's what they recommended.
Supplements and other products
The soluble fibre found in psyllium husk can help reduce LDL cholesterol levels by 5–10%. Soluble fibre is thought to work by binding to bile acids in the gut, which is then excreted rather than being absorbed back into the bloodstream. The liver then uses LDL cholesterol from the blood to make more bile to replace it. Soluble fibre is found in many plant foods, such as oats (see below) and other grains, nuts, legumes and some fruits and vegetables, but is particularly prevalent in psyllium husk.
To be effective, it needs to be taken with food and plenty of water, and you need about 10–12g per day, which is about 1.5 to 2 tablespoons. It can cause gastrointestinal effects such as gas and stomach pain, and also has a laxative effect – it's what Metamucil is made from – so introduce it gradually to your diet. It can interfere with the action of some common medications, so talk to your doctor before using it.
Beta-glucan / oats
Beta-glucan is a type of soluble fibre found in oats, with amounts of 3g or more per day found to lower total and LDL cholesterol by around five percent. A pharmacy assistant recommended a product called Betaglucare, which are sachets of cereal rich in beta-glucan – each sachet contains the 3g of beta-glucan studies have found to be effective.
You can also find beta-glucan in porridge oats. According to the packet, one serve of Uncle Toby's oats, or 40g (half a cup), supplies 1.8g of beta-glucan – if you want the recommended 3g, you need to eat 66g of oats (about three-quarters of a cup), which isn't made clear on the package. If you don't like porridge, the Betaglucare is a good compromise – you can mix it with your favourite cereal.
Plant (phyto) sterols and stanols
Phytosterols and stanols are cholesterol-like molecules produced by plants, and their similarity to cholesterol means they interfere with cholesterol absorption from food you eat. On their own, they can reduce LDL cholesterol by around 10% and when taken with statins, add to the effect of statins.
To be effective, phytosterols have to be taken with food. They're available in some processed foods, such as margarine or milk. Read the labels to determine how much you need to eat to get the effect. Consuming more than the recommended amount won't increase the effect, and consuming less will mean they have little or no effect.
If you don't normally eat the kinds of foods that contain added sterols, you could take tablets. For example, you'd need to eat about 1–1.5 tablespoons of margarine to get the recommended 2–3g of phytosterols per day. That's a lot of margarine and if it's more than you'd normally eat, you may gain weight – which itself impacts on CVD risk.
Red rice yeast
Red rice yeast is a rice product used in Asian cooking (for example in Peking duck and pickled tofu), made by fermenting rice using red yeast fungus. It contains a naturally-occurring substance called a monacolin K, which has the same structure as the statin called lovastatin, and you'll often find it recommended on the internet for treating high cholesterol.
In certain formulations, red rice yeast has been shown to work in clinical trials. However, the TGA doesn't permit the ingredient in over-the-counter medicines in Australia, and it's available by prescription only. This is due to concerns about consumers taking it without the oversight of a doctor or medical professional.
We were able to buy some from a health supplement shop, where it was (legally) sold in powder form for use in cooking. The shop assistant asked our shopper if it was for reducing cholesterol, and the shopper said yes – no further advice or caution was offered.
Artichoke leaf extract (ALE)
Used in traditional medicine for treatment of liver failure and jaundice, globe artichoke leaf is available in capsule form for treatment of high cholesterol. There've been some trials to test the effect of ALE on people with high cholesterol, though unfortunately most studies are too small or of too poor quality to be considered reliable. One fairly reliable six-week study found that 1800mg of ALE per day had a modest effect in reducing total and LDL cholesterol, with only minor side effects reported. However, longer studies are needed.
Lowering cholesterol is one of the many reputed benefits of garlic, and numerous trials have been conducted to test its effectiveness. Unfortunately, the better quality studies have failed to find any meaningful impact of garlic supplements on cholesterol levels.
Fish oil tablets
Fish oil is often recommended for reducing cholesterol, although the evidence suggests it's better for reducing triglycerides.
Blood cholesterol levels can be reduced through diet. To lower LDL cholesterol, the Dietitians Association of Australia recommends reducing saturated fat and choosing low-fat dairy products; eating healthy fats found in nuts, seeds, avocado, oily fish and olive oil; eating a diet rich in fibre; including plant sterols; and, if you're overweight, losing weight. Physical activity of 30–60 minutes per day is also recommended.
The so-called Portfolio diet, developed by Canadian researchers, introduces four different cholesterol-lowering food types to a healthy diet low in saturated fat and salt, high in fibre and rich in fruit and vegetables. Each of the four foods has some cholesterol-lowering effect on its own, and the effects are cumulative.
The four key foods are:
- 2g plant sterols/stanols (which reduce cholesterol by 7–10%)
- 30g almonds or other tree nuts (3% reduction)
- 20g of soluble fibre (5–10% reduction)
- 50g of soy protein (3–10% reduction)
Research has found that when these key foods are eaten in those amounts daily, cholesterol is lowered by 5–24% (average 13%), with people who stick more closely to the diet achieving the greatest reduction.
One naturopath we visited recommended drastically reducing or, preferably, eliminating gluten, grain foods, dairy products and legumes from the diet, which is broadly in keeping with a Paleolithic-type diet.
There's some evidence a "Paleo diet" will help reduce LDL cholesterol in the short-term. However, other eating patterns that emphasise wholefoods rather than highly processed and junk foods, such as a Mediterranean diet and Australian Guide to Healthy Eating, which are low in saturated fat, also reduce LDL cholesterol, without the risks of nutritional deficiencies from eliminating entire food groups.
The Royal Australian College of General Practitioners has information on the Mediterranean diet for reducing cardiovascular risk in its Handbook of Non-Drug Interventions, HANDI.
Regular exercise can help improve blood lipid levels, and can provide other cardiovascular benefits such as reduced blood pressure and weight loss.
Different types of exercise have different effects on cholesterol. Moderate aerobic exercise, such as walking, helps increase HDL cholesterol, while vigorous aerobic exercise also reduces LDL cholesterol and triglycerides. Resistance training reduces LDL cholesterol and triglycerides, and may be a more accessible form of exercise for people unable to do vigorous aerobic exercise.
Worried about statins?
High cholesterol on its own isn't usually enough to warrant medical intervention – it's your overall cardiovascular disease risk factor that's important, and that takes into account other risk factors such as high blood pressure, diabetes, Aboriginal or Torres Strait Islander descent, or a family history of CVD.
Try diet and lifestyle changes first. Doctors can only prescribe statins if diet and lifestyle changes have been attempted and haven't reduced cholesterol. Diet and lifestyle changes may have effects on CVD risks other than high cholesterol – for example, weight loss, lower blood pressure or better blood sugar control. Remember, it's total CVD risk, not just cholesterol levels, that matters.
None of the alternative products we looked at were able to reduce cholesterol in a clinically meaningful way on their own. Some can be used in conjunction with others, or with statins, to produce a greater overall effect. Talk to your doctor about which ones are worth trying.
If you've suffered side effects from one kind of statin, your doctor could prescribe another one, as they're all slightly different. Diet and lifestyle changes may mean you can take a lower dose of statin, and therefore reduce side effects.
Finally, if you've been prescribed statins and you're not happy with them, talk to your doctor – don't just stop taking them.