Lifestyle Changes and Lipids
Abstract & Commentary
By Michael H. Crawford, MD
Source: Becker DJ, et al. Simvastatin vs therapeutic lifestyle changes and supplements: randomized primary prevention trial. Mayo Clin Proc. 2008;83:758-764.
Despite considerable evidence that statins in appropriate patients reduce coronary heart disease events, many patients prefer to try lifestyle changes rather than take drugs. Thus, Becker et al from the University of Pennsylvania randomized 74 patients with dyslipidemia who met ATP III criteria for drug treatment, to simvastatin 40 mg/day or lifestyle changes that included red yeast rice and fish oil. The primary endpoint was LDL cholesterol. Patients were excluded who had known coronary heart disease or had contraindications to statins or exercise. The lifestyle intervention also included a 3.5 hour/week meeting with members of the health care team. The statin group got traditional counseling once, including preprinted material. The only significant difference in the baseline characteristics of the two groups was that the lifestyle group was heavier on average (88 vs 81 kg).
Results: Weight decreased more in the lifestyle group (4.7 vs 0.3 kg, p < .001). Blood pressure decreased in both groups equally. LDL cholesterol decreased in both groups (-67 vs -64 mg/dL) but was not different between groups. Triglycerides decreased more in the lifestyle group (-51 vs -14 mg/dL, p = .003). HDL cholesterol and glucose were not affected by either therapy. In the statin group, three patients experienced musculoskeletal symptoms and one had elevated transaminase levels. In the lifestyle group, two patients experienced heartburn and one developed high blood CK levels. Becker et al concluded that lifestyle changes plus ingestion of red rice yeast and fish oil resulted in similar beneficial effects on LDL cholesterol as moderate dose statin therapy in patients meeting current guidelines for drug therapy for high LDL cholesterol.
Commentary
When confronting patients with newly diagnosed hyperlipidemia who meet criteria for drug therapy, I am often met with resistance to taking statins. Many patients have bad eating habits, are overweight, and are sedentary. They know this, and promise to clean up their act. It has been estimated that about 20% of American adults take numerous natural products of unproven efficacy without their physician's knowledge or consent. I have often wondered how effective this lifestyle and over-the-counter products approach is.
In this study, lifestyle changes and natural products looked pretty good. Statins and lifestyle both decreased LDL cholesterol by about 40%, but the lifestyle approach also reduced weight and triglyceride levels. HDL was unchanged in both groups, and both approaches lowered blood pressure for inexplicable reasons. Both groups got the standard advice about diet and exercise, but the statin group got it once with written material provided and the lifestyle group got it every week for 3.5 hours. This seems a bit like joining a "bad lifestyle anonymous" group therapy organization. Also, red yeast rice is known to contain the natural equivalent of lovastatin, but at a dose about half the usual therapeutic dose. Finally, fish oils are known to reduce triglycerides. So, the lifestyle group got an intensive intervention that included natural products of known efficacy.
There are several limitations to this study. It was a small study of short duration and was not blinded. In such a study, the relative contribution of each part of the lifestyle intervention could not be determined. The intense counseling sessions every week may not be feasible for all patients, nor sustainable long term. Also, there were adverse events in both groups, so the long-term tolerance of the lifestyle changes and natural products is unknown. In addition, red yeast rice is not approved by the FDA, but is readily available. However, the exact composition and consistency of this product is unknown. Besides lovastatin, even low doses of red yeast rice can produce adverse effects. Finally, if there are pleiotropic effects of statins beyond their ability to lower LDL cholesterol, those not on them are missing these potential benefits.
At this time for my patients who do not want to take statins, but meet guideline criteria for them, I recommend the Mediterranean diet, exercise, weight loss if necessary and fish consumption or oil, especially if their triglycerides are elevated. If they want to try red yeast rice, I advise them to take a small dose of lovastatin instead to ensure quality and consistency of the active ingredient in red yeast rice.
Despite considerable evidence that statins in appropriate patients reduce coronary heart disease events, many patients prefer to try lifestyle changes rather than take drugs.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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