Should we put statins in the water?

Recently, I ran into my friend from medical school who is a prominent doctor. He said he believes statins should be prescribed en masse, for every American adult. Basically, “put it in the water” he said. My friend looked at me and said, do you agree?

I am asked this question by patients all the time. Some of those patients I would consider to be extremely healthy. 

Here’s what I’m advising them – and why. I’ve also asked myself this question, so skip to the bottom for an insight into whether I’d personally take statins.

The research says: 

Over 86 million American adults have sub-optimal cholesterol, with 10% having high cholesterol as defined as 240 mg/dL per the CDC, and heart disease is the number one killer in America, with nearly 700,000 people dying each year – or 1 in 5 deaths – and over 800,000 people each year have had a heart attack. The optimal cholesterol for a non-diabetic is less than 200 mg/dl total cholesterol, with the optimal for the most important measure of cholesterol for heart disease risk, ApoB, being 80 mg/dl or less. 

I will use ApoB throughout this post, so don’t forget that it refers to the most important measure of cholesterol for heart disease risk. 

Blood sugar is also a primary driver of cardiovascular risk. More than 98 million Americans have prediabetes, and 80% of them don’t know it.  Almost 12% of Americans – about 35M people – have progressed to diabetes. 

Hot tip: Test fasting glucose, fasting insulin, and HgBA1C to assess blood sugar, not HgBA1C alone.

So what are statins?

Statins are cholesterol-lowering medications that have been around since 1987. Their primary mechanism of action is as an HMG-CoA reductase inhibitor – they block the enzyme that makes cholesterol in the liver. They do not stop or lower absorption of cholesterol from the GI tract however – drugs called fibrates, supplements like plant sterols or fiber supplements, and improving your diet with lots of leafy greens and fibrous vegetables, can do that. 

Side effects of a statin can be muscle pain and for a small percentage of people, worse insulin resistance. 

How does cholesterol play a role?

Firstly, cholesterol isn’t “bad.” The body makes cholesterol for several reasons – it is essential to the structure of every single one of our cells, and it’s the core building block for our steroid hormones (cortisol, estrogen, testosterone, and progesterone to name some examples) and it’s in and of itself an antioxidant – it helps soak up inflammation. 

TLDR: you need cholesterol to exist and function as a human. That is why the medical community has made total cholesterol our primary culprit. This is not correct. Here’s why. We need cholesterol With a nuance – it’s less about the volume of total cholesterol that matters and more the size and shape, plus the environment in which it’s working. Heart disease forms when lots of small, BB-like particles of LDL (which stands for low-density lipoprotein) bounce off the artery walls creating cracks in the plaster that the immune system shows up to repair and patch. If this happens over and over again, the build-up of immune cells under the arterial lining forms hardened plaques that push inward over time, squeezing off the arteries in the heart and neck, leading to reduced blood flow and eventually heart attacks and strokes, when blood flow is completely occluded, and the downstream muscle or brain dies. 

But imagine if you have big fluffy beach ball-like LDLs, bouncing off the artery walls and not doing damage. Well, you probably won’t develop heart disease. 

By the way, if you do develop these plaques, they can also go away. Research shows, this is what’s best for your heart health:

  • A majority plant-based diet
  • Exercise
  • Stress reduction
  • Avoiding tobacco 

Sorry, carnivores!

The root cause of why those LDLs are high matters. Is it coming from your diet? Or are you producing too much cholesterol in the liver as a response to inflammation? Is it genetic? And is your body responsive to an intervention other than a statin, or not? And will your overall health and well-being be better if you reduce cholesterol through diet and exercise vs taking a drug? Does one drug just lead to another?

These are all questions I ask my patients.

What I recommend doing about cholesterol and when I recommend a statin. 

My approach with my patients at Parsley can be summarized in 5 simple steps – it’s only in the last step that I’d prescribe a statin: 

  1. Test robustly: 
    • Run an NMR lipid profile with sub-particle fractionation including but not limited to Total Cholesterol, LDL-P, HDL-P, ApoB, Lpa, Triglycerides, measures of inflammation including hscrp, homocysteine, and blood sugar markers HgBA1C, fasting glucose, and fasting insulin. Also measure biometrics including blood pressure, weight, BMI, and waist-to-hip ratio. 
  2. Assess the impact of blood sugar, diet, exercise, inflammation, hormones, and genetics on current cholesterol status. 
  3. Assess if there is current heart disease or if we are preventing future heart disease. Blood markers can give an indication, but a calcium score (a CT scan of the heart that looks for present heart disease) is the best measure. 
  4. Implement a plan to get cholesterol to optimal ranges with diet and exercise if possible, and if that’s not moving the needle, add proven supplements. 
  5. If that doesn’t work, flip to a statin. 

When I prescribe this plan to my patients, I know that one of three things is likely going to happen. 

  1. The patient tries but can’t implement these diet and lifestyle changes either because they don’t want to, or it’s just too hard in a modern lifestyle with restaurants, travel, and work to eat and exercise in the way that will have an impact. In that case, I’d start a statin. 
  2. They implement the changes fully and they move the needle but not all the way to their goal. We start a statin in patients with evidence of heart disease on calcium score, or who are over 40 years old and want to prevent heart disease. In that case, I’d start a statin
  3. They implement them and they work beautifully, and they feel so good with greater energy and mood, better digestion and skin, that they are set. In that case, we do not start a statin, but we monitor a full cardiometabolic health panel every year. 

Of course, I want my patients to succeed without medication. And that is always what we will try to do first. But as doctors, we also have to recognize that sometimes we do need to rely on the medication option as a supplement to other lifestyle changes that can be introduced at the same time.

What would I do for myself: 

I’m prescribing statins more than ever and I’m open to taking one myself. That said, I plan to never need it because of my lifestyle. It’s not easy between three kids and a full-time job. But I do know that exercise and a healthy diet can do more than a statin can ever do. That gives me energy, clarity, and vibrance while slowing the aging process. I’ll take that over a pill, any day. 

Take care of yourself,

Robin Berzin MD

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