Does He Get It Right for Both Sexes?
You’ve heard it before, “Men Are from Mars, Women Are from Venus.” True in many ways, but does this cliché apply to heart disease prevention and the role cholesterol plays in its development? If it does, then what is the best way for a woman to prevent heart disease?
On his show today, Dr. Oz interviews two experts from what I like to call the “anti-anti-cholesterol camp.” In their new book, The Great Cholesterol Myth, integrative cardiologist, Dr. Stephen Sinatra and nutritionist, Dr. Jonny Bowden argue that for the vast majority of people their cholesterol level has nothing to do with heart disease and lowering it with statins is a terrible idea foisted on doctors and patients by drug companies interested in profits and ignorant of the true cause of cardiovascular disease. If you didn’t see the show and you or your spouse is on a statin such as Lipitor or Crestor, you are probably getting a little nervous. If you did see the show, you may be ready to throw out your statin, but you are also likely still to be in the dark about what is the best way to prevent heart disease, particularly if you are a woman. I’m going to turn on the lights—you may be surprised by what you see.
Now I have to admit that I rarely watch Dr. Oz live (my patients wouldn’t appreciate my multitasking), though I field questions from patients about topics he covers—often quite well—every week. It happens that today I am flying to a medical conference covering heart disease/aging and there he is on the little screen right in front of me about to take on a major controversy. The electronics ban is still on. So I watch.
Dr. Sinatra explains that cholesterol is a vital substance, necessary for the proper functioning of our bodies. To name just a few: it keeps our cells flexible, is essential for hormone production, and is turned into vitamin D in the skin. He believes it has been vilified as the cause of heart disease because of a longstanding misinterpretation of the studies often cited to support its role. He rightly states that about half the people who have high cholesterol never get a heart attack and half who do have a heart attack have normal cholesterol. The message is clear: total cholesterol, the number we’ve all been obsessing about for the past few decades, is meaningless. It’s not the cause of heart disease.
I already knew that, you may be thinking, but what about LDL, the “bad” cholesterol, or HDL, the “good” cholesterol? If you know the breakdown, doesn’t that help you know if your cholesterol needs to be treated? You’re getting warmer. As Dr. Oz explains, LDL cholesterol is carried around in the blood on a protein (called ‘ApoB’ for you techies) that doesn’t shield the cholesterol from the artery wall. LDL can get into the arterial wall and cause what amounts to a foreign body response by your immune system. White blood cells and other molecules that cause inflammation come to “take out” the invader which over time can build up into a mass of pus and cholesterol goop called a plaque. If the plaque ruptures, an acute heart attack or stroke can occur. So the real culprit is inflammation. If the cholesterol doesn’t get into the wall, it can’t cause a problem because inflammation isn’t triggered. True to its nickname, HDL cholesterol is carried by a different protein (ApoA1) which keeps its cholesterol out of the artery and also helps to pick up extra LDL cholesterol to keep it out of the artery too.
Dr. Oz illustrates this with a 6-foot model of an opened artery and balloons filled with yellow goopy cholesterol that he gamely smashes into the model wall. If the balloon breaks, the cholesterol gets in. He goes on to explain that there’s even more to the story than knowing your LDL and HDL breakdown. Once again, size matters. The astute viewer notices that the balloons Dr. Oz is smashing into the artery wall are of varying sizes. The smaller LDL balloons get into the artery more easily and are thus more likely to cause inflammation. So the big message from the show is, ask your doctor to measure your LDL size. If it’s small and dense, then you may be at increased risk for cardiovascular disease.
So far so good. I’ll be agreeing with everything Dr. Oz has said to this point when one of my patients asks if I saw the show. I routinely measure LDL particle size in my practice and agree that the evidence points to its being a much better predictor of heart disease than total or LDL cholesterol alone. I also measure the size of the HDL particles because the larger ones are more protective than the smaller ones. To address the inflammation component, I measure high sensitivity C-reactive protein (hsCRP) because it has been shown to correlate with an increased risk of heart disease when elevated, even in people who have normal cholesterol and no other cardiac risk factors.
Inflammation, as Drs. Sinatra and Bowden point out, is caused by many things. One is obesity and insulin resistance that it causes and fuels in a vicious cycle, so keeping trim is important. Eating lots of colorful fruits and vegetables helps to reduce inflammation because of all the flavonoids they contain. These are the molecules whose structure enables them to reduce the corrosion of cholesterol molecules and reduce inflammation. They also point out that sugar is one of the biggest fanners of the fire of inflammation. Avoiding processed carbohydrates is important because they can cause the same insulin response and inflammation as pure sugar. Don’t even let me get started on high fructose corn syrup! Food is like medicine, it can be the right or the wrong kind when it comes to fighting inflammation.
Is there any role for statins? Dr. Sinatra rightly admits that statins do actually work well in one group of people: middle-aged men with multiple cardiac risk factors or who have already had a heart attack, particularly if they have a low HDL. But the reason, he explains, is not because of its cholesterol lowering effect. Statins are potent anti-inflammatory drugs which happen to lower cholesterol. Men like these have been well-studied and statins can save their lives because they reduce the inflammation that causes plaques to rupture. The cholesterol lowering effect of statins probably contributes more to the adverse effects (muscle aching, brain fog, liver toxicity) than to the beneficial effect on the cardiovascular system. Encourage your husband to eat better, but don’t throw out his statin if he is tolerating it well, and particularly if he is like the men above.
What about those Venusian women (from Venus—yes, it’s a word, I looked it up)? This is where I believe Dr. Sinatra goes astray and makes an astonishing omission. He states there is little evidence that women taking a statin have a reduction in heart disease. Because of this “fact” he has less than 1% of his women patients on statins. In essence he is saying, why risk all the side effects if you’re not going to get benefit? But the truth is that in the JUPITER trial, women with a normal LDL, no history of coronary artery disease, stroke, or diabetes, but who had a mildly elevated hsCRP (inflammation) had over a 40 percent reduction in heart disease if they took a statin. And a number of other primary prevention trials (with people who have not had a heart attack) have demonstrated reduced heart attacks in women on statins. The benefits were less, only about a 20% reduction in cardiovascular events and a 10% reduction in mortality. So statins can work in certain women. But, again, side effects were common.
Is the anti-inflammatory diet the only way for a woman to reduce her chances of having a heart attack or stroke while avoiding the nasty side effects of statins? Let me answer this by posing a question I often ask menopausal women in my practice. What if I told you there is natural therapy that reduces your risk of having a cardiovascular event by 41% and your chance of dying of any cause by 27%, while also being free of any of the side effects commonly seen with statins? Would you take it? In addition to heart disease prevention, this therapy’s common “side effects” include a reduction in hot flashes, vaginal dryness, depression, brain fog, insomnia, and vaginal dryness. Serious “side effects” include a 23% reduction in breast cancer (yes, reduction) and improved bone density. If you are a menopausal woman between 50 and 60 years old, you can expect all these benefits from estrogen replacement.
These are hard facts that come from the largest randomized trial of menopausal, middle-aged women, the Women’s Health Initiative. If you are premenopausal, you already have about four times the amount of estrogen as men cruising around in your blood helping to keep your LDL out of your artery walls and increasing HDL. This one of the major reasons premenopausal women have so much lower heart disease than men the same age, and probably why statins don’t help that them as much. But after menopause, women have less than a third of the estrogen of similarly aged men and rapidly catch up to them in heart disease.
Dr. Oz does a great job in explaining the more complex understanding of cholesterol particles and the role they play in inflammation and heart disease. Yet it astonishes me that he and his guests omit estrogen replacement when talking about alternatives to statins for heart disease prevention in menopausal women. Before worrying about your cholesterol or even your LDL size, ask your doctor about starting estrogen replacement therapy. If she balks at the suggestion, refer her to my previous posts on the widespread misunderstanding of the evidence supporting estrogen’s important role in preventing heart disease in women.