Can you find a more polarizing topic than statins? One article says they are miracle drugs that should be given to everyone. Then you turn the page, and you read how they are poison and you should stay away from them no matter what.  How can one drug cause such differing views? And which should you believe?

The statin debate has intensified ever since the 2013 ACC/AHA cholesterol treatment guidelines increased the number of people without heart disease who “should” take a statin to 43 million Americans. That is for primary prevention, meaning the individual has never had a diagnosis of cardiovascular disease, never had a heart attack, and never had any type of a heart problem.

As you can imagine, this has been a windfall for the drug companies. But are we healthier and better off as a result? That is unknown.

The problem is understanding the bias of whoever is writing the story.

Subtleties of Science

But wait, you say. Won’t the science tell us if statins are good or not? Isn’t it an objective fact if they are good for us?

Not so fast. Beauty is in the eye of the beholder, and so is the application of science.

Are you getting advice from someone who believes prescribing more medicine is better? Or someone who believes a more natural lifestyle is better? 

Are you reading a report sponsored by the pharmaceutical company that paid for the research?

Or are you getting advice from a scientist who is more focused on statistical benefits, or someone who is more concerned with the potential benefit for the one individual they are taking care of at the moment?

It is a confusing sea of conflicting information, and you have to find which approach resonates more with your beliefs and your life.

The Three Keys

Regardless of who you are and your beliefs, I promised you the three most important things you need to know about statins. Here they are:

1. All statin studies are worthless! That’s right. All statin studies that have been done to date are worthless and don’t apply to anyone who follows healthy lifestyle principles.
2. Statins will not prolong your life. Not at all. Not for a single day.
3. Statins DO reduce your heart attack risk, by about 0.7% over 5 years.

All of a sudden, statins don’t seem so powerful, do they? Let’s go deeper into these points to learn why.

1-All Statin Trials Are Worthless

When designing a trial, you have to decide what your control group is going to be. You have to show that the drug is better than something. The key is defining what that something is.

Therein lies the problem. In order to show beneficial effects, primary prevention statin trials need thousands of subjects, studied over years. That is very expensive to do. The vast majority of trials, therefore, rely on drug company funding.

Do you think they are going to fund a trial that makes it easier or harder to show a benefit? Of course, that was a rhetorical question.

Pharma companies don’t have an interest in your health and wellbeing. Their priority is to their stock holders and their bottom line. They are going to sponsor trials that are most likely going to benefit them.

How does this make the trials worthless? They compare statins to “usual care.” That means a brief, and ineffective attempt to educate people about healthy nutrition and physical activity.

In addition, the specific nutritional guidance that was used has always been a low-fat diet. As we now know, what does a low-fat diet usually include? Lots of sugars and simple carbohydrates. What does that diet do? Increase your risk of obesity, diabetes, inflammation, and eventually heart disease.

That’s setting the bar pretty low to show a benefit from statins. And that is exactly what the drug companies want.

What we need is a control group that is involved in a comprehensive lifestyle intervention program. A program that helps participants get regular physical activity. Helps them eat vegetable based, real food, low in added sugars and simple carbs, and high in natural healthy fats.

Since that is the way we should all be living, THAT is what the control group should be. I guarantee you, the results would be far different compared to the standard control groups used to date.

That is the trial the drug companies never want to see and will never fund. And that is why all statin trials to date are worthless.

If you can focus on proper lifestyle interventions, using healthy foods, physical activity and stress management as medicine, then we have no idea what effect, if any, statins would have. But I assure you it will be minimal if any benefit.

2-Statins Will Not Prolong Your life

You read that right. For people who have never had heart disease before, the multi-billion dollar drug won’t help you live longer. The overwhelming majority of primary prevention trials involving statins show no difference in overall mortality between those who took the drug and those who did not.

That surprises a lot of people. Statins are promoted as if they are wonder drugs that save lives left and right. That’s good marketing and good PR. Reality is far different.

If they don’t help you live longer, they must increase the quality of your life, right? Nope. In fact, 30-40% of people on statins will experience muscle aches and weakness causing them to exercise less and decreasing the overall quality of their lives.

So, if they don’t help us live longer, and they don’t increase the quality of our lives, why do we take them????

3-Statins DO Reduce Your Heart Attack Risk

If the news was all bad there wouldn’t be any debate about their use. But the truth is that statins do reduce the risk of heart attacks, and that is why in some cases it may be beneficial for you to take one.

But the big question is: How much do statins reduce your heart attack risk? The answer is not as much as you would think. Considering the recommendations keep getting more and more aggressive for statin therapy, you would think statins would be immensely powerful at reducing heart disease risk.

In reality, they reduce the risk of a heart attack by 0.7-1.5% over 5 years. That means you need to treat 66-140 people for 5 years to prevent one heart attack.  (as an aside, for people with pre-existing heart disease, so called secondary prevention, you need to treat approximately 40 people for 5 years to prevent 1 heart attack and 85 people to prevent 1 death)

When presented like that, it should certainly temper the enthusiasm for statin therapy. Again, it may still be the right choice for some people, but given the potential risks and side effects, I would hope for a much greater benefit.

Better Than Statins

A common response is that statins are “the best we have to offer” to reduce one’s risk of cardiovascular disease.  If you are talking about a drug manufactured in a laboratory, then that would be correct. But what else are options?

It turns out following a Mediterranean eating pattern with vegetables, fruit, fish, legumes, and lots of nuts, olive oil and avocados reduces the risk of cardiovascular events as well. For something as simple as nutritional choices the benefit must be much less than a statin, right?

That is what the drug companies would want you to believe. In reality, you need to “treat” 61 people with the Mediterranean diet for 5 years to reduce 1 cardiovascular event (a “combined endpoint” of stroke, heart attack or death).

To be fair, you cannot compare one trial to another as they have very different populations studied, and the outcome measures are different. So, it is not scientifically fair to say, “The Mediterranean diet has been proven to be more beneficial that statins.”  That would require a head-to-head trial. Unfortunately, that trial is unlikely to ever happen.

But it makes for an obvious answer when asked “If statins aren’t all that helpful, what else can I do to reduce my risk of cardiovascular disease?

• Follow a real food, vegetable-based, Mediterranean style diet, low in sugar and high in healthy fats.
• Maintain a physically active lifestyle.
• Exercise with some form of moderate cardio exercise, resistance training and higher intensity interval exercises.
• Practice stress reduction techniques.
• Don’t smoke.
• Manage your other risk factors such as diabetes and high blood pressure.

If you can follow these healthy lifestyle principles, you will be doing far more for your health than any pill you could take. And the best part? The only side effects are having more energy, feeling more empowered, and reducing your risk for chronic diseases.  Sounds like a good trade off to me!

Thanks for reading.

Bret Scher, MD FACC

Cardiologist, author, founder of Boundless Health

www.DrBretScher.com

Did you know changing the way you eat may be able to normalize your blood pressure completely? For many people it’s true. But what’s surprising is that it isn’t changing to the diet that most doctors and dieticians recommend.

The DASH diet, Dietary Approach to Stop Hypertension, has long been the “go-to” diet for reducing blood pressure. The DASH diet is a high carbohydrate, low fat diet that recommendseating plenty of fruits, veggies, whole grains, and limiting salt and saturated fat. And while that works for some people, many others can normalize their blood pressure with a nearly opposite approach.

A 2023 study published in The Annals of Family Medicine, demonstrated that a very low carbohydrate diet with no limitations on the amount of salt or the amount or type of fat eaten was better at lowering blood pressure compared to the DASH diet.

Many wonder how this could be, but the answer is pretty straightforward.

Poor metabolic health, from insulin resistance to type 2 diabetes, is a leading cause of high blood pressure. And low carb diets are one of the best lifestyle approaches for improving or even normalizing metabolic health. Therefore, it makes complete sense that a low carb diet would be highly effective at normalizing blood pressure.

Of course there are many other ways to improve blood pressure, such as quitting drugs, tobacco and alcohol, getting regular exercise, managing stress, etc. And these are very important. But since everyone has to eat, it is powerful to eat in a way that can normalize blood pressure.

Let’s explore four ways how low carb diets can help blood pressure.

1- Weight loss
Having overweight or obesity is a strong contributing factor to high blood pressure. And while low-carb eating isn’t the only way to lose weight, it tends to be as good as or even better than low fat eating for weight loss. Some publications even demonstrate weight loss on par with highly effective GLP1 weight loss drugs like Ozemipic and Wegovy.

2- improved metabolic health
As mentioned, metabolic dysfunction is a clear trigger for elevated blood pressure. And while low carb eating isn’t the only way to improve metabolic health, it is likely the most effective dietary pattern for improving metabolic health, and can even do so with or without weight loss.

3- Ketosis
If someone lowers their carbohydrate intake enough, they can enter a state of ketosis, a normal physiologic state where we burn primarily fat for energy instead of carbohydrates. When this occurs, our insulin levels drop to a normal level and we have a natural diuresis, meaning we eliminate sodium and water more than usual. This can help lower blood pressure above and beyond weight loss.

4- Avoiding processed foods
Most well formulated low carb diets avoid highly processed junk foods like potato chips, candy, doughnuts, etc. that can lead to high blood pressure. So, simply eliminating these foods can also contribute to lower blood pressure.

What about salt?

One of the big misconceptions about blood pressure is that we all need to lower our salt intake for better blood pressure. However, this appears to be a gross over-generalization. There’s a growing understanding that a minority of individuals have “salt sensitive” hypertension. This means that the majority are unlikely to affect their blood pressure by altering their salt intake.

Furthermore, where we get our salt likely makes a difference. For insurance, if someone is getting their salt from highly processed foods like chips, pretzels, etc, they are hit with an ultra-processed combination of salt, calories, carbs, and sugars that is bound to raise blood pressure.

But what if someone is eating whole foods like broccoli, cauliflower, steak, and avocado, and they add salt to that meal? Clinical experience suggests our bodies react much differently to this type of salt exposure, and people can dramatically lower their blood pressure despite adding salt to their diet.

Low Carb Eating Works

So while it may not be the right approach for everyone, it is increasingly clear that eating a well-formulated low carb diet is a safe and effective way to lower blood pressure. It’s time to include low carb diets as a first line treatment option for normalizing blood pressure.

Thanks for reading!

Bret Scher MD FACC

We had an incredible turnout for our Webinar, aimed to help you transform your health in 2019. As a result, we decided to create a blog post that includes the full webinar recording, as well as an overview of the learnings for those that were unable to attend.

Webinar Recording

https://www.youtube.com/watch?v=pIyi11wMq5U&ab_channel=LowCarbCardiologist

Webinar Overview

Cardiovascular Disease Is the #1 Killer for Men and Women

• 1/3 of all Americans die from Cardiovascular disease
• Around 92 million Americans are living with CVD
• Every 34 seconds someone suffers a heart attack
• Annual health expenditure and lost productivity from CVD ~$330 billion

It’s been estimated that 50-80% of these are preventable! Unfortunately, our healthcare system and associated lifestyle guidelines have failed to prevent disease. We could say at best they have failed to prevent heart disease, obesity and diabetes. At worst they have been implicit in its prevalence. While this graph doesn’t show causation, it certainly shows the association of instituting national nutritional guidelines and the rise in diabetes.

Drugs Don’t Fix the Problem

• 60% of Americans take at least 1 prescription drug
• 15% take more than 5 drugs
• Despite this, our overall health and life expectancy continue to decline

HEALTH IS NOT THE ABSENCE OF DISEASE!

In this webinar, we will discuss how to be your own best advocate, why low carb, high fat nutrition should be an option for everyone, and how lifestyle really is the best medicine.

3 Interventions to Improve your Healthcare Experience and Be Your Best Advocate

1. Make sure your doc is working with accurate information! Lipids and blood pressure are two prime examples of when doctors make decisions based on limited and faulty information.
2. Get your questions answered by writing them down ahead of time so you don’t forget anything and tell your doctor at the beginning of the appointment that you have some questions you’d like to ask at the end.
3. Make sure you understand the purpose and benefit of each and every medication. Not some vague answer like “It will improve your cholesterol,” or “It will lower your blood pressure.” Rather, “what impact will it have on my longevity and quality of life?” Will I live longer? Will I feel better? What are the chances the drug will actually benefit me? These are the questions we need answered.

Why Low Carb, High Fat Nutrition Should be an Option for Everyone!

LCHF vs Low Fat Diets

LCHF Benefits

• Decreased hunger, increased energy, mental clarity
• Treats metabolic syndrome/insulin resistance
• Better weight loss
• Improves overall cardiovascular risk for most people

LCHF may not be the best for everyone, but it certainly should be an option for everyone. If you want tips that do work for everyone, follow these bonus tips for weight loss and overall health!

• Don’t drink your calories – even “natural” drinks are full of unnecessary calories. Think about it this way, you would drink a glass of orange juice, but would you really sit down eat the 5 or so oranges it takes to make it? If not, why drink that same amount?
• Get rid of “Food Delivery Systems” – Think about the big sandwiches or burritos we see everywhere in our culture. What is the food? The stuff in the middle! The meat, the cheese, the veggies. What is the unnecessary food delivery system? The bread, the tortilla, the outer layer that has a fraction of the nutrients and a multitude of the carbs!

Lifestyle Really is the Best Medicine!

Science says lifestyle, not drugs, reverse disease:

• NEJM study reported findings on patients at highest genetic risk for heart attack, over 90% more likely to suffer heart attack. Those with healthy lifestyles had a 50% reduced risk with no drugs and no surgeries!
• JACC study found 85% of all heart attacks could be prevented with greater attention to lifestyle.
• A 2018 British Journal of Sports Medicine study found that increasing walking pace to “brisk” for those over 50 reduced all-cause mortality and cardiovascular mortality by 20-24%.

Why is it so hard?

We have all been told that in order to be healthy, we need to eat less, move more, and reduce fat in our diets. But if that is the case, why is it that only 12% of Americans are metabolically healthy, and only 3% of Americans follow a healthy lifestyle?

Because the simple Eat Less, Move More, Reduce Fat approach DOESN’T WORK!!!

I want to assure you that it’s not your fault, you’ve been given the wrong information.

“I was always told I simply didn’t have enough willpower to stick to a diet. I couldn’t understand why I was always hungry and craving foods. I figured it was all genetics. But working with Dr. Scher showed me there is a better lifestyle that I can stick with and still feel great and enjoy my life! Thanks Dr. Scher!”

• E

Keys to Making Lifestyle Change Stick

• Beware of one-size-fits-all nutrition and lifestyle claims
• Individually tailored and flexible nutrition is the key.
• When you eat is just as important as what you eat
• Move your body more
• Get Serious about your sleep
• Don’t be afraid to test and adjust

A Word of Caution

Don’t try to Change Everything at one time.

Choose YOUR most important first step (nutrition, stress, fitness, etc.) and work on that until a new habit is created!

And remember, you don’t have to do it alone! Working with an expert who can help you on your health journey will increase your likelihood for long term success.

As you can see, this was a quick tour to highlight the main points in the webinar. To get the full benefit, I recommend watching the full recording to get all of the context and be able to see the Q&A session at the end.

If you want to get the full experience, here is that recording again:

https://www.youtube.com/watch?v=pIyi11wMq5U&ab_channel=LowCarbCardiologist

If you’d like to see the date and content of our next webinar, or be notified when our next webinar will be, please visit our Webinar Page.

I hope you enjoyed this recording, and that we will see you at the next live webinar!

Thanks for reading,

Bret Scher MD FACC

I live in McAllen, Texas, where it’s difficult to find a doctor who’s knowledgeable on the benefits of a low-carb lifestyle. Because I battle a high A1C AND high cholesterol, I reached out to Dr. Scher for a consultation to monitor my blood work and develop a plan that will keep my heart healthy and my A1C in check. Before our video-consultation, he responded personally to every question I had via email. When I first reached out, I figured it would take at least a month or more to schedule our consultation, but to my surprise, it was planned just over a week from my initial email!

I like Dr. Scher’s commonsense approach to a healthy lifestyle. He came up with a very-easy-to-follow plan and agreed to review my bloodwork every 6-8 weeks to make sure I’m on the right track. Because of my family’s history, it’s comforting to know I have a cardiologist monitoring my health so that I can prevent a significant problem down the road.

Nicole Southwell

Can we be certain that elevated LDL (Low-density lipoprotein) particles have no meaning and can be completely ignored?

Certainly not.

Can we be certain that all LDL particles are deadly and need to be treated to microscopically low levels?

Certainly not.

So, what do we do?

I have seen countless second opinion consults and enrolled numerous clients in my Boundless Health Program who have this exact question.  What’s the deal with LDL? Do we worry or don’t we?

Life is much easier when it is black and white, good and bad. I, however, believe in looking for the nuance and trying to understand things a little deeper.

But first, let’s back up a little.

What is LDL and LDL-P?

Cholesterol can be a complex topic that we frequently oversimplify, which I am about to do. In brief, LDL is known as the “bad” cholesterol, the cholesterol that is found in plaque buildup in our hearts. But the truth is that LDL is not inherently bad. In fact, LDL has a purpose in our bodies as part of our immune response and as a fuel and vitamin delivery mechanism to name a few.  If vascular injury and inflammation are present, then modified LDL may invade vessel walls and participate in a cascade of events leading to plaque buildup and an eventual heart attack.

LDL-C is a measure of the total amount of cholesterol in our LDL lipoproteins. LDL-P is the total number of the LDL lipoproteins. Studies show that LDL-P is a much better marker for CVD risk than LDL-C. As an analogy, the number of cars on the road matter more than the number of people in the cars.

What are the risks of LDL-P?

On the one hand, trials in the general population show that elevated LDL-P is a risk factor for cardiovascular disease (CVD).  This includes a combination of observational trials, genetic mutation trials (mendelian randomization), and drug treatment trials.

All things being equal, based on these trials alone, we should want our LDL-P to be low.

But does LDL alone cause heart attacks and death? Or are there other factors involved?

Of course there are other factors involved in CVD. Vascular injury and inflammation being the two most prominent factors.

Can lowering our LDL-P have risks greater than the potential benefits for certain populations?

Absolutely.  Since primary prevention statin trials show we have to treat over 200 people for five years to prevent one heart attack with no difference in mortality, it seems reasonable that certain populations will experience more potential risk than reward.

The Low Carb High Fat Reality

How many LDL or statin trials have specifically looked at individuals on a healthy, real foods, LCHF diet?

None. Not a single one.

How many LDL or statin studies have looked specifically at red headed, left handed boys born the second week of March? 

None, at least to the best of my knowledge.

This seems glib but bear with me.

Is there any reason to think a red headed, left handed boy born the second week of March would behave any differently than everyone else in these LDL studies? Not really. Especially if they are eating a standard American diet or a low -fat diet as was almost exclusively studied in every cholesterol or statin trial.

Here’s the more important question. Is there reason to believe individuals on a healthy, real foods, LCHF diet would behave any differently than everyone else in the decades of lipid and statin studies?

There absolutely is reason to believe they may behave differently. There is not clear proof, but there is plenty of reason to suspect it.

Think about the benefits of a LCHF lifestyle.

• Lowers inflammation
• Reverses insulin resistance
• Naturally raises HDL and lowers TG
• Converts majority of LDL particles to larger, more buoyant particles
• Lowers blood pressure
• Reduces visceral adiposity

Could these create an environment where an elevated LDL is less of a concern?

It sure could.

To be clear, I openly acknowledge that we do not have definitive proof that we should have no concern with LDL in this situation. In my opinion, this is a specific scenario that the existing trials simply do not address one way or the other.

So, it seems we have two choices.

1. Since we don’t have any proof we can ignore LDL in this setting, we plug the numbers into the 10-year ASCVD calculator and start a statin if the risk is above 7.5%, or we ask the individual to change their lifestyle in hopes the LDL will come down.
2. If the individual is enjoying multiple health benefits from their lifestyle, and they are rightly concerned about the potential risks of statin therapy, then we can follow them for any sign of vascular injury or plaque formation, or any worsening of their inflammatory markers or insulin sensitivity. In the absence of any potentially deleterious changes, we can reason that the risk is low, and the benefits of living the healthy lifestyle may outweigh the risks.

The “problem” is that the second option requires a detailed discussion of the risks and benefits. It requires close monitoring and follow up. It requires us to think outside general guidelines and consider everyone as an individual with their own unique circumstance. These are qualities that our current healthcare system sorely lacks.  Yet that is the exact care that each individual deserves.

What do we do in the meantime?

I hope someday soon we will have definitive long-term evidence that a high number of large buoyant LDL particles along with elevated HDL, low TG and low inflammatory markers is perfectly safe.

Until that day, we will have to continue to talk to our patients. To see them as individuals. To weigh the lifestyle benefits with the possible risks. That includes seeing the risks in real numbers- not quoting a 30% benefit with statin therapy. Instead, having a real discussion that statins may reduce your risk a heart attack by 0.6% with an increased risk of muscle aches, an increased risk of diabetes, and a potential increased risk for cognitive and neurological dysfunction.

And we will have to understand that the answer won’t be the same for each person. And we can be OK with that.

So, do you have to worry about your LDL? I don’t know. But I welcome the opportunity to explore the question and reach the best answer for you.

Do you have questions about what your lipids may mean for you? What they mean when taken in the context of your lifestyle and overall health picture? If so, you may want to learn more about my Health Coaching Consult.

Thanks for reading,

Bret Scher, MD FACC