Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr Warrick Bishop and I'd like to welcome you to my podcast and videocast station and of course to the Healthy Heart Network. Today I'm absolutely delighted to have the opportunity to speak with a colleague and close friend, Dr Karam Kostner. Welcome, Karam. Thank you, Warrick. Thank you for inviting me. Today, Karam and I have decided that we would like to share with you some thoughts about... the nutraceuticals that can be used to lower cholesterol. These are things that are not necessarily drugs, but that you might come across in your vitamin store or chemist. Is that how you describe a nutraceutical or the group of agents we're going to talk about today, Karim? Look, I perfectly agree. I think that's a good description. They're basically natural components of plants, sometimes animals, that have a beneficial effect on lipids or don't have a beneficial effect on lipids, as we will hear. very shortly so there's a bit of a list that i was going to work through and one um that's pretty well at the top of the list is one that comes up regularly on my facebook page with people advocating it as an alternative to statins because as you and i are both aware there's a lot of uh hype in social media about uh statins and potential side effects and tolerability and so a lot of people um in some of the social media that i'm involved with are advocating that we use this particular product called red yeast yeast rice as an alternate um maybe tell me a little bit more about it and the listeners i'm sure will find it interesting look that's i'm very happy to do that statins were originally developed from a fungus A very smart Japanese professor, Aikiro Endo, many, many years ago, and at the same time, scientists from a company called Merck Sharp and Dome, experimented with fungi, and mevalonin was one of the first ones. And that was the first version of a statin, basically. Now, chemically, this fungus looked very, very similar to lovastatin, which was one of the first statins approved in the United States and then worldwide. So all statins are virtually natural as well, if you want to call them that, even though they are produced by big pharmaceutical companies nowadays. And red yeast rice is very similar. It's basically a fungus derived from a rice, red rice, and lowers cholesterol in a very similar way to what statins do. So the active ingredient of red yeast rice is... Very similar to a statin or basically the same chemical formula as a statin. Is that what you're saying? That's correct. That's correct. So this is taking a statin just in another wrapper almost. That's exactly right. And there lies the problem because some of the companies that are producing red yeast rice are obviously not as well regulated as pharmaceutical companies and don't have to adhere to the same production standards. And potentially there are some impurities, but also potentially... They don't contain as much of the active ingredient as you would expect from a pharmaceutical. So things like quality and dosing could be quite unreliable. Correct. And, you know, the side effects can be the same as you see with statins and the interaction with certain drugs. You would see the same with red yeast fries. Presumably, though, a bit like me, you've had some patients who have used it and found it. complementary to their cholesterol-lowering regime, you wouldn't have an issue with people using it? I wouldn't have an issue if they really want to use it, especially overseas. It's very popular in the United States where some of these things are much less regulated than in Australia. But in my opinion, if you're willing to take... Red yeast rice, you could also take a statin, which is even better. And as I said, better controlled. But if people really choose a reputative brand and are happy with it, I don't have a big problem with it either. Okay. Well, look, one of the things that seems to swing in and out of favour, almost like a pendulum, is fish oil. Sometimes it's good for you. Sometimes we see it's not good for you. And I know myself, 15 to 20 odd years ago, I saw it on the horizon. and really embraced it. And I've been using it pretty well ever since, fairly broadly and for myself. And I've been following the literature and it's fascinating. Would you like to tell me where you see fish oil right at the moment? Yes. Thank you for bringing that up, Warrick. I think it's a very important one. And in fact, it's the most common nutraceutical that our patients take in Australia. And that's why it's important to talk about it. So my view on fish oil is the following, or omega-3 fatty acids, which is the active ingredients in fish oil. First of all, it has to be said that fish oil is good not only for cardiovascular disease and triglyceride lowering, but it is also important for brain development, which is why pregnant women take fish oil in many, many cases. It's good for membranes. It's an essential... fatty acid that our body needs and cannot produce itself for various biochemical processes, it is important. But we are today talking about cardiovascular disease and lipids and triglycerides. So there is no doubt that omega-3 fatty acids, which is the active ingredient in fish oil, mainly EPA, eicosapentaic acid, and DHA, doxosa hexaic acid, lower triglycerides. So that's why we use it in lipid clinics. So if you take two to four or even more grams of these omega-3 fatty acids, you get triglyceride reductions. And triglycerides are a fat like cholesterol that are more pronounced than if you take a statin, for example. So that's the first area where we use them, especially in people with very high triglycerides, in people who are prone to develop pancreatitis. Is that where you use them as well? Look, I tend to use them for people who are pre-diabetic. So I think they are good for insulin sensitizing. And I think that they're really valuable for general wellbeing, joints, inflammatory processes. And I've had a number of people over the years who've had, say, bowel issues, who've come back and said, believe it or not, doc, my bowels are more regular. my inflammatory bowel disease has settled down on these tablets. But generally, I think you need a reasonable dose. You were saying two to four grams. That's exactly what I say to my patients. Sometimes even ask them to start a little bit higher so they get a loading dose, if you like. And where it gets confusing, and you'll find the same with omega-3 fatty acids, is all the different preparations that are around. So I'd really like to remind our listeners that it's about the amount of EPA and DHA that's in the formulation. And if you use the cheap fish oil capsules, they contain approximately 300 milligrams of EPA and DHA per capsule. If you use the highest ranked omega-3 fatty acid capsules, they can contain up to one gram of EPA, DHA, or a combination of both. And if you use the liquid form of fish oil, such as Melrose or ethical nutrients, you will find approximately one gram per one milliliter of fish oil, and that's probably the cheapest way of getting it. But it does taste a bit fishy. So people who have problems with the palate of the liquid fish oil may find it difficult. So just for those who missed it, and I'm writing it down for my own supply, that was Melrose or Ethical Nutrients. That's correct, liquid fish oil. Yeah, because it is hard to get enough fish oil capsules in if they haven't got a high... Exactly. Exactly. But to answer the second part of your question, where it becomes a bit more confusing and controversial is when we talk about the benefits of omega-3 fatty acids in the sudden cardiac death, in heart failure, and in general cardiac conditions, because that's where the trials really are telling us different things in different trials. There were the initial trials in Italy that showed big benefit to prevent sudden cardiac death if you take fish oil after an MI. and in heart failure. And that has not been reproduced in other countries in some instances. And some of the meta-analyses have not found that. So that's a bit more confusing. But having said that, fish oil certainly doesn't have any side effects. And as we discussed initially, it's beneficial for a lot of different conditions. So it's certainly safe to take. Yeah. Okay. One of the things that comes up and seems to pop up in other foods is plant sterols. Sanitarium had released some Weet-Bix or a Weet-Bix preparation, a cereal, breakfast cereal with plant sterols in them. Can you explain what a plant sterol is and how it works and how it lowers cholesterol? Very happy to. So plant sterols are particles or molecules that look very similar to cholesterol. They're just slightly different from a biochemical point of view. And they occur naturally in legumes, vegetables and some fruits. but in very small concentrations. And that's why we need to take them either as a supplement, which is a capsule, or enriched foods such as margarines, certain cereals, yogurt, and milk products nowadays. So the way that they work is that the body thinks actually it is cholesterol and absorbs them instead of cholesterol. So it doesn't absorb as much cholesterol in our diet. But then it realizes that it can't use the plant sterols in a similar way to cholesterol and excretes them again into the bile. So it's basically a way of tricking the body into not absorbing as much cholesterol. And by doing that, you get LDL reductions of 10 to 15 percent by incorporating plant sterols or nutraceutical type formulations. Is this as a tablet that you can prescribe for someone or do you recommend patients? take it in these foods that have been enhanced with this product? No, it is available as a tablet or as a powder sometimes that you can mix with cereals, et cetera. And, you know, that's probably the best way of getting it. But a lot of supermarkets now have foods that are enriched with these plant sterols, and that's also a good way of getting it. Okay. One of the ones that pops up from time to time is a thing called polycosanol. Can you tell me what that is and where it comes from and how? someone might access it and use it. Polycosanol is another sort of nutraceutical that has shown to reduce cholesterol by a small amount and also triglycerides by a very small amount. It is derived usually from sugarcane. It's an alcohol type structure biochemically that, as I mentioned, does have an effect on lipids, but it can also have some significant side effects. You know, people can develop headaches on polycosanol. It does increase bleeding slightly, and so it's not something that we recommend regularly. So it's probably not as safe as plant sterols and some of the other things we're talking about today. Does it give an appreciable cholesterol lowering, Karim? About 8% to 12%, depending on which trial you look at. In some cases, a little bit more. Okay. That's not too bad if you're looking to get an incremental benefit for someone and take it in conjunction with other... medications or maneuvers. The one that pops up a fair bit and people talk about is Coenzyme Q10. Now, my understanding is that Coenzyme Q10 is not actually... It doesn't actually have a role to lower cholesterol, but it can be used to potentially offset some side effects from cholesterol statin therapy, cholesterol lowering therapy using statins. And so coenzyme Q10 seems to come up regularly in the conversation around cholesterol lowering. What's your take on coenzyme Q10? Where does it fit in? Look, I would agree with you. I don't use it at all as a lipid-lowering compound because it has virtually no effect on lipids in itself. We sometimes use it in patients who have significant muscle-related side effects, mainly to statins, but I always use magnesium first. So magnesium in orotate form or in another form is cheaper than coenzyme Q10 and almost has the same efficacy in clinical trials where this was looked at. There is no large no good evidence from large trials that either coenzyme Q10 or magnesium significantly reduces muscle side effects. But in the case of magnesium, it's something that our muscles need anyway, and that's good for the heart. So it's worth trying. And even if part of it is a placebo effect, some people do respond quite nicely to magnesium. And if they don't, it is worth trying coenzyme Q10. But I certainly don't think that everybody who is on a statin should have to be on coenzyme Q10. So something that could be optional, try it. If it isn't, that's okay. If it is, you can choose to go with it. That's right. That's right. Well, that brings me to pretty well the last sort of supplement that I was going to ask you about, and that's niacin. Personally, I've used niacin over the years in situations where patients have a low HDL or so-called good cholesterol. or they've got a raised lipoprotein little a, which is, I think we've spoken about that before, a more aggressive form of cholesterol. But I know before the statin era, we used to use niacin as a treatment for lowering cholesterol. So where does niacin fit for you, Karam? Look, I'm fascinated by niacin. Similar to you, I've used it in high concentrations for many years as a lipid-lowering compound. And as you mentioned, it really affects every lipid fraction. It increases HDL, it decreases triglycerides, it decreases LDL, and it lowers lipoprotein A. The problem with niacin is that you need fairly high concentration to get some of these lipid effects. And that's when it also causes flushing. So there's significant flushing side effects. with most niacin preparations and also gastrointestinal symptoms. So that's what has really limited it in clinical use. But the other thing is that unfortunately, big pharmaceutical companies who have tried niacin in big clinical trials haven't been able to show any sort of... big benefit from a mortality or morbidity reduction point of view. That may also have to do with the fact that some of these trials were probably not designed very well. And like you, I agree that niacin is still an option for people who are willing to take it, who can put up with the side effects. And it's a B vitamin, vitamin B6 in a fairly high concentration. So, you know, it's a natural sort of form of a lipid lowering compound. So in my own clinic, I access niacin in a 500 milligram slow release preparation because I know it's hard for my patients to find. And I simply sell it to them as I would to a friend because I don't have a license for selling vitamins. But I do make that available to my patients if they want to try and give it a try and if it adds to their therapeutic regime. I don't know, 500 milligrams, and I suggest one or two tablets a day, actually. Yeah, look, that's not unreasonable. I mean, the trial data is usually with slightly higher concentrations, but at one gram, as you say, you see already a lipid effect and the side effects can be reduced by giving the extended release or slow release form. So that's a good way of doing it. Good compound. So... So I was going to touch on food and exercise, but we've cracked 15 minutes and I think we'll have to do food and exercise on another talk. And so I'll wrap it up for now. I'm going to thank you very much for sharing with me today. I really, I know that I've always, that I always love stuff listening to you. And I know the people listening in will have also picked up some stuff as well. So thank you, Karim, for joining me today. Absolute pleasure. Thank you for inviting me. For those who are listening, thank you for your attention. I hope you've learned something. I'm sure you have. If you have any questions, please drop us a note. And if you've got any suggestions for future podcasts, also let us know. Use members at drarickbishop.online. Thank you so much again. Till next time, I wish you the very best. And please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. 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