**EP55: Talking About Supplements**
**Dr. Warwick:** Welcome to Dr. Warwick's podcast channel. Warwick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warwick 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.
G'day, Warwick Bishop here, and I thought I'd take the opportunity to have a little bit of a chat about supplements. People are often asking about supplements; my patients are regularly asking, and in my Facebook group, there's been some questions specifically about bergamot and whether that can be used for lowering cholesterol. I thought I would take the opportunity to chat a little bit about supplements and cholesterol lowering, as I think it's a topic that people are often interested in.
So I'll start off with bergamot, because some people have asked about that within the group. Now, bergamot, as far as I understand, is a citrus-based plant. There is a belief that the flavonoids or components within that can be beneficial for lowering cholesterol. There has actually been at least one study done to show that that's the case, and that was done by a researcher called Peter Toth. I've actually seen Peter speak; he's one of the smartest guys you'll ever meet. There's no question that the research he would have done around that would have been robust and sound.
It looks, at least I had the chance to look up the paper, that the research was done with a specific proprietary brand of bergamot called BurgerVit. What I will say is that I'm not sure about the specifics of how that particular extract was obtained, but as far as I'm aware, I don't think that extract is available in Australia. Please correct me if I'm wrong.
The upshot of that study by Peter Toth was that bergamot, at the doses they used, did lower cholesterol levels and lowered them really quite well, between 0.5 and 1 millimole per litre, which is a really good outcome. Now, these were people who had LDL cholesterols that were moderately elevated already, but nonetheless, a really good result. The same study also looked at thickening within the carotid arteries. We call that carotid medial intimal thickness, and the study showed a suggestion that this got less on the therapy. So, again, a really good sign.
One of the questions that was asked in the Facebook group is whether Ross Walker, a cardiologist in Sydney who's got an interest in prevention and uses imaging—so he and I have a lot in common in that space—he recommends bergamot as well. Knowledge around the particular brand that he's recommending is limited, so I can't comment on whether it's Bergovit or not. I don't know about the active ingredients; he would give you more information on that.
As far as I understand, and I could be wrong, my understanding is that Dr. Walker also has an interest in the company that either produces, sells, or distributes that vitamin as well, so he would certainly know it very well. Having said all that, what I really do want to convey is that if bergamot does lower the LDL, then I think that is a good thing if it's indicated in you as an individual.
Now, that has two components to it. One is what is the reason you're taking a supplement or a medication to lower your LDL cholesterol? What's your risk? And therefore, what would the benefit be that that intervention would offer? So in regard to that, what I'd like to put to you is that if you do have a risk and you should be on a lipid-lowering agent, then a supplement like bergamot is certainly a reasonable thing to have in your therapeutic regime. No question.
A lot of what I've written about in terms of my book and a lot about what this page is centered on is trying to get the best understanding of the actual risk you may have from a cardiovascular perspective. So let me put that into some other context. Let's say you've actually had a heart attack. There's no question then your risk is very high, and your risk of another event is very high. That means that you need to be treated with a high intensity of therapy. Makes sense, yeah?
So bergamot on its own, with a one millimole LDL lipid lowering—and that's a good result—may not be enough for you. You may really need to be driving your LDL targets right down to the secondary prevention guideline targets or below that we currently have in Australia. So bergamot may provide some of what you need, but maybe not all. If your risk is actually fairly low, just say your cholesterol is up a little and you have nothing on your CT scan—say you've scanned your heart arteries or you've scanned your carotid arteries and there's no evidence of plaque anywhere—then it may be the case that you don't really need an aggressive lipid-lowering regime. In that situation, bergamot may be a good option and certainly one that would be reasonable to speak with your GP or, even preferentially, your preventative cardiologist about.
The role of bergamot in lowering LDL cholesterol, I believe, is going to be beneficial because I don't believe that the LDL lowering that we see as the beneficial outcome for high-risk patients is related to statin therapy alone. We talk about the LDL hypothesis; I think it's more complicated than a single mechanism giving rise to coronary artery disease, and I think most people would agree with that. There are concepts of inflammation, there are concepts of location within the arteries, but certainly, one of the components we deal with is cholesterol lowering.
Now, statins don't have a monopoly on that. I believe that if you can get your LDL cholesterol down by other ways, then that will be equally effective as the sort of statin lowering we see with statins. I don't believe there's any reason to believe otherwise.
So let's take the example that you really do need cholesterol lowering. Let's say that you've started on a cholesterol-lowering agent like a statin, which is appropriate. Let's say you can't take a particularly high dose. Let's say the target LDL you're trying to get to is 1.8 millimoles per litre or less. Let's say you've got to 2.2 millimoles per litre. In that situation, a conversation with your doctor about using bergamot may well be a sensible next step. I don't have an issue with that.
Having said that, what I do think is really important is to make sure you've got a formulation that actually works. So I've had patients try bergamot; they've tried it for several weeks or a couple of months, and we've retested their cholesterol levels only to find that they haven't moved at all. Well, that may well mean that we're not using a preparation which is effective. And I'll take you back to that original paper by Peter Toth, who used a proprietary acquired bergavit preparation in his trial.
So if you are going to use bergamot or any other supplement for that regard, if you are going to use bergamot, please do it in conjunction with your doctor, preferably your cardiologist, so that they know what targets you should be aiming for. Make sure it's working, make sure there aren't any side effects, and make sure that other organs like kidneys and liver are also not being impacted at all.
So I have supported my patients using bergamot in the past, and I've also supported some of my patients having a discussion about supplementation for lipid lowering. People want to do what they can if confronted with the situation.
So one of the other things I'll put to people is that they could use red yeast rice. Now, red yeast rice—which I get a bit dyslexic about and call it red rice yeast—either way, it's a fungus that grows on rice, and that fungus has in it the chemical that statins were originally derived from in lowish doses. But nonetheless, in a natural form, some patients feel comfortable using that. I'm pretty happy to support that. Again, what we're looking at from a clinical perspective from my side of the table is how big is the risk that this person has, and therefore what are we trying to achieve with their cholesterol levels? Are we really trying to drive those cholesterol levels down? If we are, on its own, red rice yeast may not be enough, but let's put it in the mix and let's follow it and monitor it closely.
One of the other things that has come to my attention and that patients ask me about is a supplement called berberine. Now, berberine appears to have a lipid-lowering effect as well, and berberine seems to replicate, to a small degree, some of the new injectable agents we have for lowering cholesterol that work through the PCSK9 system. So berberine may well have a role in lowering cholesterol as well.
What I would say is that when I engage a patient with a discussion around this—because bergamot, berberine, and red yeast rice are not what I routinely prescribe—what I will tend to do is ask those patients to go and see a naturopath or someone who's expert at using those preparations and ask the patient to work with that person who's got experience in that space together with me to get the best result for that individual. Because I'm not going to pretend that I'm across the different formulations, the different preparations, even the proprietary of some of those supplemented agents.
The other thing that I tend to give patients an introduction to is thinking about the use of nicotinic acid or niacin. This is a B-group vitamin and really has a role, I think, in just helping a little bit in trying to reduce LDL cholesterol. It can raise HDL cholesterol and it can lower triglycerides a little bit. Nicotinic acid was what we used to use before the statins came along, and it really fell out of favour as the statins and the ease of use for the statins became apparent.
Nicotinic acid or niacin tends to cause facial flushing and needs to be taken in a fairly large dose, so you get a lot of facial flushing. I tend to invite patients to try using niacin or nicotinic acid if they just need to get a little bit more LDL cholesterol lowering or if they have a low HDL cholesterol and no insignificant risk. I use that group of people with low HDL cholesterol and no insignificant risk because of the findings of a trial called the HATS trial, H-A-T-S. By all means, look that up. H-A-T-S, and if you write in there nicotinic acid as well, it will come up if you search it.
In that group of people, although subsequently there have been trials that have shown variability in terms of the efficacy of niacin, in the HATS trial, there was a clear indication that nicotinic acid plus statin really offered some benefit to those people on that combination who went into that study with low HDL cholesterol.
At the end of the day, what we're trying to do is find out what the patient's real risk or needs are in terms of treatment and balance that off around the medications or the manipulations we put in place, the treatments we put in place to try and achieve the goals required in that understanding of what that person needs.
So, at the end of the day, I like to see in high-risk patients that LDL cholesterol brought down as much as possible. If there's no risk, then that's a different conversation. But if there is risk there—and that's a little bit, well, actually, that's a lot about what my book is about and what the Know Your Real Risk of Heart Attack Facebook page is about—if you've got real risk there, then lowering that risk by lowering cholesterol is an appropriate thing to do. The statins are a great way to do it, and for the vast majority of people, they really work.
The addition of ezetimibe, which is also a proven agent together with statins—even if they're needed at a lower dose—really works also. But then if you want to supplement, fantastic! But do it in a structured, supervised, and monitored way. Do it with someone who knows those agents and knows how to use them, has experience with them, and do it also with your doctor at hand.
Well, I'm going to leave it there. I hope all that makes a little bit of sense. Thanks for joining me, and goodbye.
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