Welcome, my name's Dr. Auric Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand. blood pressure, weight, cholesterol, for better health. If you enjoy this podcast, I would be honored for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, Warwick Bishop here, and welcome to my podcast and videocast station. As always, I really do appreciate you taking a moment to tune in, and I really hope that what I share is interesting, informative, and encourage you to come back and listen to another podcast in the future, or even go back and listen to some of my early ones if this is one of the first you have listened to. Well, today I'd like to talk about some of the skepticism around cholesterol and statins, and in particular, I'd like to address some of the common beliefs that are held around cholesterol and statin. that could be said to be the non-believer cholesterol and statin beliefs. So, let's kick it off. I think this is super interesting, super important. Let's start with this. Firstly, cholesterol is not harmful. Well, of course cholesterol is not harmful. We're born with cholesterol. We need cholesterol in our... It's an essential part of functions within the body from help in transporting fat-soluble vitamins to making bile acids to generating vitamin D. And, of course, it's part of every cell membrane. However, cholesterol does end up in the arteries and can cause problems as part of atherosclerosis. It's not necessarily harmful, but it can end up in the wrong place. Heart disease is not caused by high cholesterol. Well, this is a pretty reasonable thing to say, as we do see people with raised cholesterol, and they can have clear arteries, but we also see people with low cholesterol, and they can have build-up of cholesterol in their arteries. Truth be told, cholesterol levels generally of their own don't directly correlate with what's going on in their arteries, but in general terms, higher cholesterols tend to be associated with greater risk of plaque in the arteries. And what we do know, that when we go from trying to predict who has plaque in their arteries based on their cholesterol levels, to knowing who's at high risk of having problems with their arteries because they've had an event, secondary prevention, then there is no question that high cholesterol is problematic. And when we lower cholesterol for people who've had a previous event, there is indisputable data that supports this is beneficial. Cholesterol levels are irrelevant. This is not true. I've just alluded to when we try to predict who's got cholesterol in their arteries, that people with high cholesterol And low cholesterol can have bad arteries. So in that setting for predicting, cholesterol levels may not be helpful. But once we've identified someone who's high risk, then lowering their cholesterol becomes absolutely central in terms of the mechanisms we can put in place to reduce future risk. Saturated fats are not harmful. Well, this is a bit of a conundrum at the moment. There are certain... schools of thought that think saturated fats are what we should be dominating our diets with well we don't really have the the answer to that dietary question at the moment what we do know is saturated fats tend to increase LDL cholesterol levels so if you are increasing LDL cholesterol levels you certainly can run into problems If you are trying to reduce cholesterol levels in someone who's got identified plaque in their arteries, we are waiting on studies that will inform what the outcome is of ketogenic diets. The feeling being that if we run keto, we reduce inflammation, supposedly, we reduce weight, reduce blood pressure, supposedly, or hopefully, that this is offset by the saturated fat. Unresolved at this stage. Probably needs a bit more attention. Best we can suggest at the moment is if you've got significant build-up of plaque in your arteries, then lowering your cholesterol makes lots of sense. And probably be very cautious with saturated fats. The cholesterol hypothesis is incorrect. Well, this is probably not true. And to suggest that... cholesterol and atherosclerosis are not linked is really just misleading and to be honest mischievous there is no question as i've already alluded to that we see high cholesterol and low cholesterol in the blood leading to plaque or not even presence of plaque in the arteries in a way that's unpredictable when we try to figure who may or may not be affected. But what is absolutely clear is when we take those high risk individuals, those who have demonstrable plaque in your arteries, and we lower their cholesterol levels, we lower their risk. So that component of the hypothesis, lowering cholesterol for high risk individuals, that's been borne out over and over and over with so many studies that we've alluded to. in the past that it's established science. But cholesterol is necessary for hormone production. And indeed it is. But we've also got to remember that when we think about cholesterol necessary for hormone production, probably our most synthetic and active stage in our entire life. is when we're newborn babies. And at that stage, our cholesterol levels are extremely low in the blood. And not only are they extremely low in the blood, but the cells that make the hormones will also make 80% of the cholesterol they use. So cholesterol from the diet is a smaller component of what the body actually has and the bulk of what the body has. is what it's produced de novo or itself so yes cholesterol is necessary for hormone production but you can have very low levels and still produce enough hormones in fact enough hormones for a brand new born child cholesterol doesn't even enter the artery via the endothelium therefore everything we know is rubbish well This is a really interesting concept, and we know that when we think about cholesterol, we often think about it coming out of the bloodstream and into the arterial wall. Well, a professor of pathology called Vladimir Subotin, S-U-B-B-O-T-I-N, Russian pathologist, has offered a theory that instead of the cholesterol going from the Inside out into the arterial wall, it is carried by the very, very small, fine network of blood vessels that supply the walls of these larger arteries. These fine network of blood vessels that actually provide blood to the blood vessels are called the vasophysorum, or the blood vessels. Well, this is certainly possible, and there's no reason why whether the cholesterol gets into the artery from the inside out or from the outside in has any bearing on what we observe when we find high-risk plaque and we lower cholesterol for those individuals. I think it's really very possible that the cholesterol could reach its destination within the artery from the outside in. It makes perfect sense. It may equally do it from the inside out. But either way, that distinction doesn't necessarily detract from what we've seen in our data when it comes to lowering cholesterol in high-risk individuals. So I'm certainly open to Professor Subotan's thoughts and theories. either way at this stage, but I think it certainly warrants merit and consideration. LDL particle size is the main driver of atherosclerosis. Well, I get this regularly from people who come in to my clinic because they've done a bit of research on Google and they know lots about cholesterol and they've seen a heap of YouTube clips and, well... I feel very privileged to be educated by these people who have such a depth of knowledge from their experience in the space. Sarcasm aside, honestly, I wish it were as simple as just size of the particle being central to the process. It is indeed far more complicated than that. Indeed, talking about Vladimir Subotin is a... clear indicator that it is more complicated than just particle size because if it were just particle size and it was from inside out then it dumbs it down really to how big is the hole and when you look at the size of the hole in the endothelium that could accept cholesterol particles from the lumen of the blood vessel the inside of the artery to move into the structure of the artery, that hole, that finaster it's called, that paw, is if we consider it in relative terms about the size of a basketball ring. If we then consider the size of the particles, a large particle the size of a basketball, a small particle the size of a volleyball, both will pass through that finaster. it seems that that particle size is more likely a contributor or an indicator of other metabolic processes that are going on that are detrimental to the health of that individual, such as insulin resistance and possibly inflammatory processes. Inflammation, not cholesterol, is the basis of atherosclerosis. Well, I have to actually agree to some degree that this is probably true. And we know inflammatory processes. And to my mind, something as simple as the wear and tear through the viscosity of blood down the artery is probably the initial inflammatory insult to an artery. But this is then followed by a healing process where cholesterol moves into that space to then try and restore the integrity of where that inflammation is occurring. So yes, inflammation is certainly important in atherosclerosis. And yes, we've got trials that show us if we lower inflammatory markers through different therapies, we reduce risk of event. But it is not. And in isolation, total solution to the complexity of the process. Going on about continuing with some of the beliefs held by the cholesterol and statin non-believers. Let's do a few more. Statins cause more harm than good. Well, this is a line that really in isolation is mischievous again. Like any medication, we always have to look at the pros and cons of providing an intervention. Will it offer an upside or will the side effects be greater than that upside and therefore it not be indicated? Well... We know that people with significant plaque, people who've had events, whether heart attack or stroke, there's no question that lowering cholesterol for these people is incredibly important and well documented in the literature, without question. In these people, then that risk-benefit equation really falls with taking statins. It is important to recognize though in people who have not had an event where we have no idea of what their risk of plaque is we wouldn't necessarily put them on cholesterol lowering therapy for no good reason because to take cholesterol lowering therapy for no good reason means that you carry the risk of the downside without the benefit of the upside and of course in that situation harm can be greater than good. But the way to evaluate that is not necessarily from cholesterol levels alone. As I've alluded to many times previously, it's about getting a feel for what plaque is present in that individual. So this is a question about what is it that we are treating in an individual's arteries, not a question about is that statin therapy good or bad. statin benefits are exaggerated. Well, they're exaggerated if you take them and you don't need them because they won't offer much benefit. But let me share with you, if you've got significant coronary artery disease, then there is no question that for every millimole reduction of cholesterol, you will see a 20% relative risk reduction. in likelihood of recurrent event. This is no exaggeration and this is the sort of thing that someone who's had an event who doesn't want to die from coronary disease would cling on to and quite rightly so. And their doctor should be supporting them to get that best care. Statin side effects are underreported. Well indeed, this is probably not true. We do in fact find that statin side effects are probably overreported. And we've got some fantastic literature which points towards that. When we think about statin side effects, probably 5-10% of individuals will report something in association with statin therapy. And I think it's really important to recognise and respect that everyone's an individual and we don't have any medications that are without a side effect. However... When we drill down scientifically and look at really how many of those 5-10% are truly suffering statin-specific side effects and not confusing those side effects with something else, it turns out about 75% of individuals who will initially put their hand up and say they're having troubles with the medication subsequently are able to take those medications. particularly when they're put in a double-blind trial situation and don't know what they're taking. There is a significant impost of the no-sebo effect in this space. I'm not saying that people can't have side effects from stans. Of course they can. But they are probably over-reported rather than under-reported. Cholesterol-lowering drugs are a scam. Well, that's just conspiracy theory. They're not a scam. They've been around for years, for several decades, and the data behind them is robust. There are many people walking the streets who take these medications on a regular basis and continue to live a healthy life because of these medications. Statins deplete vital nutrients. Well, this is a really important, I guess, concern to flag, if you are a statin and cholesterol non-believer, the particular nutrient that's at concern is coenzyme Q10 or ubiquinone. Coenzyme Q10 is used in the electron transfer chain of the mitochondria, which is the energy cell of every cell within the body. And yes, there is clear evidence based on the um metabolic pathways that statins can deplete coenzyme q10 it turns out though when we look at this in trials we're unable to demonstrate either clear-cut lowering of coenzyme q10 in people's blood nor benefit for people by adding coenzyme q10 nonetheless my personal opinion is if an individual is commencing statin therapy i'm certainly open to them supplementing with coq 10. No issue whatsoever. Statins impair cognitive function. Well, this is an interesting concern and of course one that we would have to take very seriously. There is a little bit of data that has looked at this. We've looked at a trial called the Jupiter trial where there was a small question about possible mental fogging with resuvastatin. Beyond that, there's been a number of randomized controlled trials looking at statins in particular and mental function and even progression to dementia. The good thing about those studies is they do not conclusively show in a randomized controlled way that the statins do cause mental fogging. What would I say about that? Well, it could be a side effect that an individual reports or suffers specific for that individual. It doesn't mean you can't change the cholesterol-lowering agent, maybe to one that has a different chemical signature or... different chemical characteristics, and it doesn't mean that every person is going to suffer a problem. In fact, it's incredibly rare in my experience to see people with any sort of mental fog or change in mental perception related to statin therapy. Too low cholesterol is bad for the brain. Well, again, we know that a... newborn baby has extremely low cholesterol levels in the blood and that newborn baby is producing and growing the most brain tissue of its entire extra utero life. So I think to suggest that low cholesterol levels are bad for the brain misses that clear and obvious situation where newborn babies have extremely low cholesterol levels but interestingly though we have found through research families that have extremely low cholesterol levels because of their genetic makeup and that's transmitted through the family. These people with extremely low cholesterol levels interestingly show no marker or problem whatsoever in relation to that low cholesterol level. What they do show is a long life free of cardiovascular disease. So no suggestions from these sort of common sense observations that low cholesterol is bad for the brain. We've also done studies where we've lowered cholesterol and tracked brain function and not seen a signal that there's a problem. Statins increased risk of diabetes. Well, there is some truth in that. And we do know that statins can in individuals who are at risk of progressing to diabetes speed that up the research around that tells us that these people probably would have developed diabetes anyway and the research also tells us that the cholesterol lowering in these individuals if they are high cardiovascular risk is offering them a greater protection in terms of lifetime outcome than the development of mild diabetes. So an important concern, but one that we are aware of and on balance is not prohibitive to using those drugs. Still going with some of these concerns from the cholesterol and statin non-believers. Pharmaceutical companies have a conflict of interest. Well, of course, they don't have a conflict of interest. What they're trying to do is produce a product which they can sell so that their company is able to make money for their shareholders. I don't think anyone actually ever doubts that. There is not a conflict of interest there, but there is no question that there is an unfortunate disconnect that our science is now driven by companies, not by... and our governments gave that away. I'm not sure I'm 100% comfortable with that, but with our governments that are democratic governments giving those responsibilities away to private organisations, this is the world we live in. Importantly, though, there are structures in place to try and mitigate what could be seen as inappropriate conduct. Individuals who are involved in the trials are people of ethical standards which are generally beyond reproach. These are leaders in the field who can't afford to fabricate or mislead the medical community. So in the vast number of situations, we're really dealing with the people who are at the cutting edge of the science and looking to maintain their own reputation and buy that. the reputation of the medications that they may well be researching or advancing historical data is misleading and when people say this that they're really talking about some of the early trials looking at cholesterol and heart disease being flawed well of course there are now many double-blind randomized control trials looking at cholesterol and reduction of coronary artery disease. So take your pick. You can sift through that research yourself, but there are places where you can find all those bits of research together and you can satisfy yourself. But honestly, the historical data, even if you wanted to accept it was misleading, doesn't negate our last couple of decades, which have clearly indicated that cholesterol lowering in those high-risk individuals is life-saving. medical guidelines are flawed. Well, if you're going to be saying medical guidelines are flawed, then you have to be saying that the science is flawed. And if you're saying the science is flawed, you have to say that the institutions and the labs and the individuals running all the tests are all flawed as well. Well, where does it end? And conspiracy is really running rife here once you start suggesting that. The guidelines... are a meticulous set of documents that look at the research that's available at the time the guideline is written and try to interpret that research in the best possible way to help inform other doctors, guide them, if you will, to make the best decisions for their patients based on the science that we have available. Some of the other statements are... cholesterol and statins non-believers will say is but diet is more important than medication and i think it probably is but it's not the only thing i often say to people when you think of diet and lifestyle and with coronary disease and we think about cholesterol-lowering therapies and aspirin or whatever it might be the medications that the lifestyle issues are a little bit like being a sensible driver in your car and adhering to the road rules and driving sensibly to the conditions and the medications the statins or the blood pressure therapy or the aspirin these are like the mechanics running of the car what the mechanic does for the car you need both and in fact diet lifestyle and good medical therapy all combined to give you the safest journey for your health as sensible driving, driving to the conditions and good maintenance of the vehicle with the right additives ensures a safe journey for you and your car. Oh, alternative therapies are better. Well, unfortunately, we have no data that supports that. We do know there's some supplements and bits and pieces that can be utilized, but we have nothing that tells us that alternative therapies are better. Red yeast rice is a safe alternate. Well, it's actually a naturally occurring statin. So if you do want to use red yeast rice, you are actually taking a statin, but one that was a very weak statin. And if you're taking it through any supplier, it will not be pharmaceutical grade and you can't rely on the dose. Exercise and lifestyle changes are adequate to reverse coronary artery disease. This is a really important point. And in fact, study which was called the Intensive Lifestyle Changes Study run by a cardiologist called Dean Ornish was published in 1998. He took only a small number of patients I think it was 30 or 40 maybe 50 and many dropped out but what he did was really implement significant lifestyle change. compared to a control group. He did demonstrate that by implementing a low-fat diet, regular exercise and stress management, he was able to get down significantly total cholesterol levels, LDL cholesterol levels and ApoB levels. But really noticeable in the raw data of that particular study was that he had significant weight reduction in the intervention group. For that intervention, he moved the intervention cohort from a 30% fat diet to a 6% fat diet. He had those individuals move from two and a half hours a week routinely to five hours a week routinely. And this is the kicker, which makes it probably close to impractical for the average individual to pursue, he was able to implement a stress management regime by getting the group who were receiving the intervention to meditate for on average 87 hours per day. No, 87 minutes per day. What am I talking about? So the intervention group or the experiment group were meditating for nearly an hour and a half daily. So major changes, but he did show significant improvement. So there is thin threads that show us you certainly can make major differences with exercise and lifestyle changes. So possible. but very hard to achieve for the average human being. Well, I'd like to finish that up there. It's such a complicated space. There are real and valued concerns that the cholesterol and statin non-believers raise, but they often are targeting just a small part of the story, and it's so important to put it in totality of the entire picture. Imagine if you looked through a keyhole at a party and just because you look through that keyhole you only see one table in the corner and on that table there's a couple of empty drinks. You could come to the conclusion that the drinks had run out at that party. until you open the door and see the entire room where people are standing with full drinks in their hand, waiters are moving around with drink trays, and the story is completely different when you get the whole picture. I hope that all makes sense to you, and I hope you've got a much fuller picture of... the cholesterol and statin non-believers concerns which are so important to raise but i think we can deconstruct many of them for now i'm going to wish you the very best i hope you live as well as possible for as long as possible i'd be super excited if you share and subscribe for now i'm going to wish you the very best take care and bye for now Join the Healthy Heart Network and become part of our growing community. If you're interested in your heart health and risk of heart attack, then join the Healthy Heart Network for only $5 as a lifetime member. This represents $55 worth of value. 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