Robert DuBroff and Michel de Lorgeril
July 2015
Abstract
The role of blood cholesterol levels in coronary heart disease (CHD) and the true effect of cholesterol-lowering statin drugs are debatable. In particular, whether statins actually decrease cardiac mortality and increase life expectancy is controversial. Concurrently, the Mediterranean diet model has been shown to prolong life and reduce the risk of diabetes, cancer, and CHD. We herein review current data related to both statins and the Mediterranean diet. We conclude that the expectation that CHD could be prevented or eliminated by simply reducing cholesterol appears unfounded. On the contrary, we should acknowledge the inconsistencies of the cholesterol theory and recognize the proven benefits of a healthy lifestyle incorporating a Mediterranean diet to prevent CHD.
STATIN DRUGS HAVE UNINTENDED CONSEQUENCES
If statins have failed to consistently reduce mortality one must ask if statins improve the quality of life. Serious or fatal statin adverse events are rare, but side effects are not. The incidence of muscular aches and weakness in statin trials is highly variable, and real world experiences may differ from clinical trial reports. Consider that the adherence rates for statins in the elderly are poor with nearly 75% of primary prevention patients stopping the drug within the first two years[35]. More recently a cohort study of statin users reported a 53% discontinuation rate although a very high percentage were able to continue statin therapy after being rechallenged[36]. In the largest statin survey ever conducted, the National Lipid Association observed that roughly 30% of statin patients reported experiencing muscle pain and weakness and 57% of surveyed patients reported stopping the drug due to side effects[37]. One may debate the relationship of statins to diabetes and dementia, but the fact remains that the FDA now requires disclosure of these warnings. Most distressing is the recent report of gluttonous behavior among statin users who mistakenly believe they are “protected” by taking statins and can eat whatever they want[38].
CONCLUSION
The debate over the cholesterol hypothesis and statins has raged for decades. Some may point to the recent decline in cardiovascular deaths in the United States as proof of statin effectiveness, but this view fails to incorporate the impact of smoking cessation, lifestyle changes, and dramatic improvements in heart attack survival rates due to timely reperfusion and the availability of external and implantable defibrillators. Others may argue that statins are started too late in life to be effective (the horse may already be out of the barn) and reference Mendelian randomization studies which show that rare individuals with genetically low cholesterol levels have a much lower incidence of CHD[39]. However, this concept should not be extrapolated to the 99.99% of us who lack these genes and also fails to explain how the Mediterranean diet reduces mortality within months of initiation[2-4]. In 1996 Nobel laureates Brown and Goldstein anticipated the eradication of coronary disease in their Science editorial, “Exploitation of recent breakthroughs - proof of the cholesterol hypothesis, discovery of effective drugs, and better definition of genetic susceptibility factors - may well end coronary disease as a major public health problem early in the next century”[40]. History has proven otherwise, and the global prevalence of CHD, despite worldwide statin usage and cholesterol lowering campaigns, has reached pandemic proportions. Coronary heart disease is an extremely complex malady and the expectation that it could be prevented or eliminated by simply reducing cholesterol appears unfounded. After twenty years we should concede the anomalies of the cholesterol hypothesis and refocus our efforts on the proven benefits of a healthy lifestyle incorporating a Mediterranean diet to prevent CHD[2-4,41,42].
