Lowering High Cholesterol

What you need to know about cholesterol, what is normal, and how to lower it – and the downsides and alternatives to statins.

Promise of longer life a myth

A study in the Lancet found that in these cases, even though the drugs prevented a few heart attacks, none of the patients lived any longer as a result. That’s bad enough – if you are told this pill will cut your risk of a heart attack, you assume that it will also make you live longer. But it gets worse. Men over 69 didn’t benefit from taking statins at all, they didn’t live longer and didn’t have fewer heart attacks, and women of any age didn’t benefit either. That’s right, not at all.

According to the study’s author, Harvard professor John Abramson, you do benefit a bit if you have a high risk (eg high cholesterol or are overweight) and you’re aged between 30–69 years. But the amount is hardly impressive. Fifty of you have to be treated for five years to prevent just one event involving the heart. To put that another way – out of 100 people who have been told by their doctors that they have a high risk of getting heart disease, 98 of them won’t get any benefit from a statin prescription at all.1

Suppose you were a woman with a very high risk of heart disease – how much benefit could you expect from taking statins? To answer this question for the GP magazine Pulse, Dr Malcolm Kendrick (author of The Great Cholesterol Con) analysed a major statin trial called HPS – which is frequently quoted as showing statins benefit women – and concluded that if you took statins for 30 years, you would gain, on average, just one extra month of life.

The downside of statins

All this might not matter too much if there was no downside to being prescribed statins for years. But since they can cause a variety of side effects, you might actually be at more risk from them than from a possible heart attack. Your doctor will very likely tell you about the risks of muscle pain and weakness (myopathy) and a harmful change in liver function, although he/she will say they are very rare. But again that may not be the whole story. One study in the British Medical Journal found that when 22 professional athletes with very high cholesterol levels were put on statins, 16 of them stopped the treatment because of the side-effects. Competitive athletes are known to be more sensitive to muscle pain than normal people.2

One of the reasons the studies for side effects, which doctors rely on, report low levels is because people who have any illness or who don’t respond well are excluded from the trials. The same British Medical Journal article found that in one recent big trial – used to show how safe statins are – almost half of the 18,000 people recruited to begin with weren’t included. But there is another reason why official adverse drug reaction (ADR) figures for statins are very low: when patients say the drugs are having a bad effect, doctors don’t believe them. While 98% of 650 patients surveyed reported a foggy mental state, only 2% of their doctors accepted it could be linked with taking statins. The figures for nerve pains in hands and feet (96% vs 4% believed) and muscle pain (86% vs 14%) were equally bad.3 Even more worrying is the question mark hanging over a possible link between statins and cancer.4 They certainly give cancer to laboratory animals and one of the big trials called Prosper, which involved elderly patients, found taking statins raised your risk. This was dismissed at the time because no other trials had found it. But because cancer is much more likely to occur in older patients and because Prosper is the only trial done on older patients, it’s quite possible that fewer patients had heart attacks but developed cancer instead.5

Why cholesterol is a good thing

Despite the poor odds in the statin lottery and the side-effects that have been downplayed, there is another reason for thinking seriously about a non-drug approach. All the talk of aggressively lowering cholesterol tends to ignore just how vital it is to the smooth running of our bodies. For example, it helps repair damaged arteries, is the raw material for making sex hormones, is vital for laying down memories in the brain and for the proper working of neurotransmitters.6 So it’s hardly surprising that blocking the production of cholesterol in the liver, which is what statins do, causes problems. Perhaps the most serious one involves a vital substance called co-enzyme Q10 (CoQ10), which is also made by the liver and is also blocked by statins.

CoQ10 reduces side effects

If you have decided to take statins because you have already had a heart attack or because you are at high risk and feel it is worth it anyway, you really ought to take a supplement of CoQ10. Among other things, this nutrient is vital for energy production in the muscles, which could explain why muscle pains are a major side-effect of taking CoQ10-blocking statins. Research in America has shown that a high-dose CoQ10 supplement can reverse muscle pains. Fifty patients who had been on statins for two years were taken off the drug because they were complaining of muscle pains and other side-effects. Giving them CoQ10 dramatically improved their symptoms.7 Like others, the scientist in this trial commented that statin-related side-effects were much more common than the big studies show. He also found that taking the patients off statins didn’t make their blocked up arteries any worse. This may be because there are many studies showing that CoQ10 has a positive effect on heart and artery health.8 Controlled trials have shown that it has a remarkable ability to improve heart function and it is now the treatment of choice in Japan for congestive heart failure, angina and high blood pressure, especially among older people. CoQ10, at a daily dose of 90mg, has also been shown to reduce oxidation damage in the arteries, thereby protecting fats in the blood such as LDL cholesterol from becoming damaged and contributing to arterial blockages.9 Action: Take 30 to 60mg of CoQ10 a day for prevention, and 90 to 120mg a day if you have cardiovascular disease or are on statins.

Lifestyle changes bring benefits

Reducing your risk of heart disease with dietary and lifestyle changes needs more care and dedication than taking a pill – but the benefits are much more widespread and long lasting. Some of the advice is conventional and almost certainly familiar. So, take exercise regularly and if you rate as obese – a BMI of over 30 – it would be worth trying to lose some weight. Being too heavy is linked with having more inflammation which, in turn, is not good for the heart. Also avoid refined carbohydrates (more on that later) and stay away from drinks sweetened with sugar, glucose or fructose, which are known to stimulate clumping of the blood platelets.

Fat offers protection

For decades now, doctors and nutrition experts have been advising us to eat a low-fat/high-carb diet – both to lose weight and to protect our hearts. However, this advice looks increasingly as if it may be contributing to making the problem worse. In fact we are now eating less fat than ever before; meanwhile levels of obesity are soaring. It’s perfectly clear that the amount of fat you eat has very little to do with putting on weight. As for heart disease, higher levels of the right sort of fat – natural and largely unprocessed – protect your heart. While we don’t advise you eat lots of saturated fat – and especially not hydrogenated fats found in some margarines and commercially baked goods – we do recommend you have more Omega 3 fat, the type you get from oily fish. Many studies show Omega 3 reduces cholesterol, decreases levels of harmful fats in the blood, and reduces the inflammation that’s linked with heart disease. The UK’s National Institute of Clinical Excellence recommends all doctors prescribe 1 gram of fish oil a day to patients who have had a heart attack for six months (after this time, the budget runs out!). Action: Take two Omega 3 fish oil supplements each day, providing 1000mg of the active compond EPA. Also, eat oily fish (eg anchovies, sardines, salmon, herring) three times a week.

Reduce your glycemic load

Official diet advice is that we should eat lots of starchy carbohydrates such as bread, rice and potatoes. But that takes little notice of the fact that, like fats, not all carbohydrates are good for you. The harmful ones such as sugary foods or those made with refined (ie white) flour are known as ‘high glycemic’ carbohydrates. This is because they are digested quickly and release their glucose (from which we make energy) into the blood very quickly, giving you high blood sugar levels. When your blood sugar becomes high, you produce more of a hormone called insulin – this causes some of the sugar in your blood to be converted into fat. So a frequent intake of high glycemic carbohydrates will cause you to pile on the pounds, which raises your risk of obesity-linked heart disease. As well as heart disease, high blood sugar also increases your risk of diabetes and certain types of cancer.

The link between high glycemic foods and dangerous fat levels showed up clearly in a recent study published in the journal Obesity. Mice fed a high-glycemic diet of starchy carbohydrates developed a potentially deadly condition known as ‘fatty liver’. They also had twice the amount of fat in their bodies as those on a low-glycemic diet, even though they weighed the same.10 Much more effective for maintaining a healthy heart is the Mediterranean diet. It’s based on foods which have had little processing such as fruits, vegetables, pulses and wholegrains. These foods release their ‘glucose’ (ie energy) much more slowly into your blood steam and are therefore classified as ‘low glycemic’. The Mediterranean diet also contains quite a lot of beneficial fats, especially olive oil and omega 3. This type of diet can reduce your cholesterol levels and is also an effective way of losing weight. Meanwhile, the healthy fats help to protect your heart. A recent meta-analysis of weight loss studies concluded that: “Overweight or obese people lost more weight on a low glycemic diet and had more improvement in lipid [ie fat] profiles than those receiving conventional diets.”11 Other benefits were greater loss in body fat, a reduction in bad ‘LDL’ and increase in good ‘HDL’ cholesterol. Action: Eat a low glycemic diet. My book the Holford Low GL Diet or Holford Low GL Diet Made Easy explains how to do this.

Raising HDL with niacin

Despite the relentless medical focus on reducing levels of LDL cholesterol as a cause of heart disease, 40% of all cardiovascular problems happen in people who have low levels of HDL cholesterol. But as yet, there is no safe drug developed that can raise HDL. However, like all the other risk factors for heart disease, there are non-drug ways of improving HDL levels. Many of them will be familiar – taking exercise, losing weight, stopping smoking, cutting back on alcohol, having some omega 3 fatty acids. A high glycemic diet brings levels down, a low glycemic one raises them. But according to a major review of what works in the New England Journal of Medicine, “the most effective way” is with the B vitamin niacin (also called B3).12 A number of studies show that it is effective not only in raising HDL by as much as 35%, but also in reducing LDL by up to 25%. By way of comparison, statins only raise HDL by between 2% and 15%. Niacin also reduces levels of two other markers for heart disease – lipoprotein A and fibrinogen. The most obvious side-effect of taking fairly high doses is a blushing effect which is diminished by taking with food, but non-blush or extended-release niacin is now easily available. Other reported side-effects include dyspepsia (indigestion), raised plasma glucose and uric acid levels. Action: Take 500mg of niacin twice a day to both lower LDL and raise HDL.

Check your ‘H’ score

One of the most exciting discoveries in the prevention of heart disease and strokes over the last decade has been that high levels of an amino acid called homocysteine in the blood increase your risk of these and other diseases. High levels are a risk factor for heart disease quite independent of cholesterol. In fact, studies have found that homocysteine is a better predictor of cardiovascular problems than either blood pressure or smoking. The obvious implication is that lowering these high levels – which you can do with B vitamins – will lower your risk. With over 10,000 studies now published on homocysteine, there’s a lot of circumstantial evidence that this is a sensible strategy. However, if you suggest this to your doctor, he/she may reply that several big trials have found that lowering homocysteine doesn’t reduce your risk of heart attacks or a stroke. It’s true that giving homocysteine-lowering B vitamins to people who have heart disease has been disappointing. However, it looks like giving these B vitamins to those without heart disease does reduce risk. Fortification of flour with folic acid (an important homocysteine-lowering B vitamin) in Canada and the US has coincided with a considerable drop in heart attack and stroke rates of between 10% and 15%. Translated into UK terms, that means that increasing folic acid intake could actually save more than 5000 lives a year. As far as strokes are concerned, lowering homocysteine by taking folic acid makes a big difference. If taken for three years, it can lower stroke risk by 31%, according to a recent analysis of all trials published in the Lancet.13

As well as folic acid, other B vitamins – B2, B6 and B12 – also help to lower homocysteine, along with zinc and a nutrient called TMG (trimethylglycine) which helps with chemical reactions in the body. These nutrients are found in greens, beans, lentils, nuts, seeds and root vegetables. Also, cut back on alcohol and coffee, reduce stress and stop smoking – all of which raise homocysteine. Action: Test your homocysteine level. If your doctor won’t do it, order a home test kit from Health Products for Life. If your level is high, supplement the appropriate amount of homocysteine-lowering nutrients daily. This is likely to be in the order of 25mg of B6, 500mcg of B12, 1000mcg of folic acid, 10mg of zinc and 1 gram of TMG.

Learn how to handle stress

A major factor usually overlooked in conventional approaches to heart problems is stress – both physical and psychological. Of course, stress in the form of exercise or a challenging job can be very good for you, but chronic stress from poor working conditions, a bullying boss or too many deadlines can damage your health and your heart. For instance, you respond to stress by producing adrenaline which in turn pushes up blood sugar levels, raises blood pressure, and increases both blood clotting agents and LDL cholesterol. Meanwhile, extra amounts of the stress hormone cortisol encourage the storage of dangerous ‘visceral’ fat in the abdomen. And visceral fat is strongly connected to a condition known as the metabolic syndrome, or syndrome X, which is a big risk factor for diabetes and heart disease.

So a vital part of any healthy heart regime involves turning off a damaging stress response and there are plenty of ways to do it such as exercise, watching your football team winning, passing an exam or organising an enjoyable social evening. You might also try learning to meditate – studies show it can drop heart disease deaths by 30%. Shift your outlook from pessimistic to optimistic with cognitive behavioural therapy (CBT) and learn to handle stress – in five year trials, this produces 50% fewer heart attacks. The exercise system Psychocalisthenics®, which includes the breathing exercise Dia-Kath Breathingsm, is also an excellent way of reducing stress. Action: Address the causes of stress in your life. Take up meditation, yoga, T’ai Chi or Psychocalisthenics®, all of which help reduce stress levels.

The magic of magnesium

Increasing your intake of magnesium may also help you relax because magnesium ensures that the muscle cells both in the arteries and heart don’t get too tense, improving heart muscle function and blood pressure. In fact, it has been shown to lower blood pressure by about 10%,14 as well as reduce cholesterol and triglycerides,15 thus substantially lowering the risk of death from cardiovascular disease. Unfortunately, a lot of us are deficient in magnesium: the average intake in the UK is 272mg, while an ideal amount is probably 500mg, especially if you have high blood pressure. The richest source of this mineral is dark green vegetables, nuts and seeds, especially pumpkin seeds. Action: Supplement 300mg of magnesium a day; a good multivitamin can provide 150mg. Also eat more greens and pumpkin seeds.

Beneficial plant foods

You would be wise to increase your intake of plant sterols which are found in seeds, nuts, and beans, especially soya, as well as soluble fibre found in oats, barley and aubergines. Plant sterol and soluble fibre both have a cholesterol-lowering effect. Eating more fruit and veg, high in antioxidants, may also help too. Vitamin-E-rich foods, such as fish and seeds, help protect cholesterol from oxidation. Vitamin-C-rich foods, such as broccoli, peppers and berries, also help. So do red grapes, high in an antioxidant called resveratrol – that’s the reason for red wine’s beneficial effect. Also try curcumin, found in the spice turmeric. Curcumin has been found to reduce the stickiness of platelets in the blood and relax arteries. Several trials are testing its effectiveness at the moment. As well as eating these foods, supplement an all-round antioxidant containing resveratrol. Patrick Holford (with Jerome Burne)

Supplements and Tests

To find out more about the supplements, tests and health products I really recommend, visiting www.totallynourish.com or calling 020 8874 8038.


1. J Abramson & J Wright, Are lipid-lowering guidelines evidence-based?, The Lancet (2007), vol 369, pp 168-169.

2. U Ravnskov et al, Analysis and comment controversy: should we lower cholesterol as much as possible?, British Medical Journal (2006), vol 332, pp 1330-1332.

3. B Golomb et al, Physician response to patient reports of adverse drug effects – implications for patient-targeted adverse effect surveillance, Drug Safety (2007); vol 30 (8), pp 669-675.

4. AA Alsheikh-Ali et al, Effect of the magnitude of lipid lowering on risk of elevated liver enzymes, rhabdomyolysis, and cancer: insights from large randomized statin trials, Journal of the American College of Cardiology (2007), vol 50, pp 409-418.

5. D Mangin et al, Preventive health care in elderly people needs rethinking, British Medical Journal (2007), vol 335, pp 285-287.

6. For a detailed discussion of the complex role of cholesterol in the body and a critical analysis of the big trials usually used to support statin use, see a long and authoritative article by biochemists and nutrition authors Sally Fallon and Mary Enig at: westonaprice.org/moderndiseases/statin.html

7. P H Langsjoen et al, ‘Treatment of statin adverse effects with supplemental Coenzyme Q10 and statin drug discontinuation’, Biofactors (2005), vol 25 (1-4), pp 147-52.

8. K Jones et al, ‘Coenzyme Q-10 and cardiovascular health’, Alternative Therapies in Health & Medicine (2004), vol 10 (1), pp 22-30; also M Dhanasekaran & J Ren, ‘The emerging role of coenzyme Q-10 in aging, neurodegeneration, cardiovascular disease, cancer and diabetes mellitus’, Current Neurovascular Research (2005), vol 2 (5), pp 447-59.

9. P Langsjoen & A Langsjoen, ‘Overview of the use of CoQ10 in cardiovascular disease,’ Biofactors (1999), vol 9 issue 21-4, pp273 –84.

10. K B Scribner et al, ‘Hepatic steatosis and increased adiposity in mice consuming rapidly vs. slowly absorbed carbohydrate’, Obesity (Silver Spring) 2007, vol 15, issue 9, pp 2190-2199.

11. D Thomas et al, The Cochrane Library (2007), issue 3.

12. M D Ashen et al, ‘Low HDL cholesterol levels’, New England Journal of Medicine (2005), vol 353.

13. X Wang et al, The Lancet (2007), vol 369, pp 1876-1881.

14. W J Mroczek et al, ‘Effect of magnesium sulfate on cardiovascular hemodynamics’, Angiology (1977), vol 28, pp 720-724.

15. B T Altura & B M Altura, ‘Magnesium in cardiovascular biology’, Scientific American (1995), May/June, pp 28-36.