Supporting the use of medication with nutrition: A focus on statins
Statins are the most commonly prescribed medications in the UK, with an estimated 7 million people currently being prescribed them. There are several types of statins available in the UK, including simvastatin, fluvastatin, pravastatin, rosuvastatin and atorvastatin, all of which are used for both cholesterol management and protection from cardiovascular disease.
Cholesterol is important for our health and is required for many purposes, including the production of hormones, as well as supporting the wall of all cells in the body. Whilst we can obtain cholesterol from the diet, namely from animal products, roughly 80% of the body’s cholesterol is made by the liver. There are several types of cholesterol ‘transporters’, including low-density lipoprotein (LDL) cholesterol – considered the ‘bad’ cholesterol – and high-density lipoprotein (HDL). LDL cholesterol is required to transport cholesterol from the liver to the body; however, it has a stickier consistency so when levels of LDL cholesterol increase, it can stick to the walls of blood vessels and possibly to a narrowing of the vessels, and thus an increase in blood pressure. When this happens, there is an increased risk of stroke and heart attack. High-density lipoproteins (HDL) on the other hand, are considered ‘good’ cholesterol as they help transport cholesterol back to the liver and help to clear out excess LDL from clogging arteries. High cholesterol levels can be genetic, although other contributing factors include obesity, diabetes, inactivity, smoking and having an unhealthy diet rich in trans fats (fried and processed foods).
Statins are prescribed to people with high cholesterol levels, as they reduce the amount of cholesterol produced in the liver, and are estimated to prevent the occurrence of a major vascular event (including heart attack, angina, cardiac arrest and stroke) by 5-10% for those taking them for at least 5 years (1). Whilst they can have a positive effect on health, they also carry their own side effects, with an estimated 0.5-1% of patients experiencing ‘statin intolerance’, with symptoms of muscle pain and weakness, otherwise known as myopathy. Memory loss is another side-effect of statin treatment. Furthermore, they deplete an important enzyme in the body that supports energy production, co-enzyme Q10 (CoQ10).
The role of CoQ10
CoQ10 is an enzyme produced in the body, well known for its role in energy production, as well being a powerful antioxidant; however, statins significantly reduce the number of transport carriers of CoQ10, leading to lower serum levels of the coenzyme, around 50% less after thirty days of statin treatment (2). As CoQ10 is required for energy production, this leads to a reduction of ATP, the body’s energy currency, with the reduction of CoQ10 being associated with myopathy, possibly as a side-effect of reduced antioxidant support from CoQ10 within the muscles. A simple way to overcome the reduction in CoQ10 is by use of a supplement, the benefits of which work threefold. Firstly, a supplement will provide an external source of CoQ10 to continue to support energy production. Secondly, it provides additional support for the heart which is under strain from high cholesterol levels, and requires a lot of energy to function. Finally, it provides antioxidant protection for the body from the free radical damage, with supplementation reducing the occurrence of statin-induced myopathy by 40% (3). CoQ10 supplements come in two forms, as ubiquinol or ubiquinone, with ubiquinol being the body-ready, active, antioxidant form. Using a delivery technology such as VESIsorb also increases the bioavailability of the large, fat-soluble molecule, to a ‘pre-digested’, water-soluble molecule allowing easier access into the bloodstream.
A further benefit of CoQ10 is its cholesterol-lowering effects, which is enhanced when taken alongside fish oil, with the long-chain omega-3 fatty acid EPA the most beneficial form of fish oil to take in cholesterol management (4, 5).
Reducing side-effects with nutrition
In the same way that CoQ10 provides antioxidant support against free radical damage within the muscles, supplementing with other antioxidants such as creatine or vitamin E may provide further antioxidant protection for statin use (6). It is also worth getting your vitamin D levels checked, as a deficiency status is associated with muscle pain and weakness and low vitamin D status may be a risk factor for statin-induced myopathy (7, 8). Again, a supplement is another easy way to overcome vitamin D deficiency, especially during the winter months, and if your skin is not being exposed to the sun for at least 15 minutes per day without sunscreen.
Nutrients that support the action of statins by reducing cholesterol levels
As discussed, the use of CoQ10 supplementation alongside fish oil enhances the cholesterol-lowering effects of statins. Similarly, soluble fibre supplementation is also recommended to help with the reduction of LDL cholesterol, as soluble fibres, such as psyllium husk, decrease the assimilation of cholesterol in the digestive tract, as well as increasing their rate of elimination. Studies show that the daily use of psyllium husk alongside a statin reduced LDL cholesterol more than taking a statin alone (9, 10). If you do decide to supplement with psyllium husk, ensure that you take it at least 2 hours away from food as it may reduce absorption of nutrients.
There is also lots of research on the benefits of probiotics in supporting the reduction of LDL cholesterol, with certain strains such as Lactobacillus plantarum CECT 7527, 7528 and 7529 showing particular efficacy (11, 12). Probiotics are microorganisms better known as ‘friendly bacteria’ that inhabit the digestive tract, offering lots of health benefits such as supporting digestion, energy production and immunity. These probiotic strains are believed to have several mechanisms of action in lowering cholesterol, including binding to cholesterol to stop it from being re-absorbed into the blood (12).
A few nutrients and foods to look out for
Whilst certain foods and supplements can have a complementary effect to statins, there are a couple of medications and supplements that you should be cautious of using alongside statins. It is advised, for example, to take antacids 2 hours apart from statins as they may block the absorption of the drug into the bloodstream and therefore reduce their effectiveness. Furthermore, St John’s Wort, a herbal medicine often used to support those with symptoms of depression, has been shown to increase levels of LDL cholesterol when taken alongside simvastatin or atorvastatin (13, 14, 15). This is because St John’s Wort increases the detoxification of these statins, thereby reducing the blood levels more quickly and reducing their action.
Both grapefruit and pomegranate have the opposite effect of St John’s Wort and inhibit the liver from detoxifying some types of statins (simvastatin, atorvastatin and rosuvastatin), meaning that blood levels of the drug remain high, which could lead to toxicity. It is recommended, therefore, to limit these foods, and on the odd occasion you do have them, eat them at the opposite point in the day to your statins, when your blood levels should have naturally dropped. (16, 17)
Studies have shown that use of red yeast rice, recommended in Traditional Chinese Medicine for high cholesterol levels, has shown promise in reducing levels, although it is not recommended to take red yeast rice alongside a statin, as the long-term safety of red yeast rice has yet to be established (18, 19).
Niacin, a form of vitamin B3, has also been used to lower cholesterol. This can be prescribed or taken as a supplement, but the prescription dosage of niacin is usually much higher than that found in a supplement. Cases of myopathy have been reported with simultaneous use of niacin and statins, so beware if you’re supplementing with this form of vitamin B3 and instead opt for vitamin B3 in nicotinamide form (20).
Whilst having high levels of LDL cholesterol is a risk factor for heart disease, oxidised LDL cholesterol is of more concern as when it collates and oxidises, similar to rust, it causes inflammation which is linked to most health conditions. Smoking, poor diet, obesity and diabetes all lead to oxidative stress in the body; reducing exposure to these sources of oxidative stress will therefore benefit those with high cholesterol. Furthermore, not only can antioxidant supplements such as CoQ10 and Vitamin E provide protection, but consuming an antioxidant-rich diet containing fresh and brightly coloured fruit, vegetables and herbs, as well as lentils, legumes and green tea, provides protection to LDL cholesterol from oxygen-related damage. Many of these foods are also rich in fibre which will support cholesterol clearance from the gut. Consuming oats, nuts and seeds will further increase your fibre intake.
There has been a lot of controversy over the consumption of eggs for those with high cholesterol as they are a source of dietary cholesterol; they are safe to eat for most as they are not rich in saturated fats. The exception to this rule is those with familial hypercholesterolemia who need to restrict their dietary intake of cholesterol to 300mg per day. Foods that contain cholesterol and saturated fat should be avoided as these increase the rate at which cholesterol is oxidised. Foods that fall into this category include processed meats (sausages, luncheon meats), full fat dairy products, fatty meats and animal fats such as butter and lard. Healthier swaps include lean meats such as chicken and turkey, and plant-based milk alternatives such as almond or oat milk.
- Collins R., Reith C., Emberson J., et al. (2016). ‘Interpretation of the evidence for the efficacy and safety of statin therapy’, Lancet, 388 pp. 2532-2561.
- Rundek T., Naini A., Sacco R., et al. (2004). ‘Atorvastatin decreases the coenzyme Q10 level in the blood of patients at risk for cardiovascular disease and stroke’, Archives of Neurology, 61 (6), pp.889-892.
- Caso G., Kelly P., McNurlan M.A., et al. (2007). ‘Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins’, The American Journal of Cardiology, 99 (10), pp. 1409-1412.
- Toth S., Sajty M., Pekarova T., et al. (2017). ‘Addition of omega-3 fatty acid and coenzyme Q10 to statin therapy in patients with combined dyslipidemia’, Journal of basic and clinical physiology and pharmacology, 28 (4), pp. 327-336.
- Nakamura N., Hamazaki T., Ohta M., et al. (1999). ‘Joint effects of HMG-CoA reductase inhibitors and eicosapentaenoic acids on serum lipid profile and plasma fatty acid concentrations in patients with hyperlipidemia’, International journal of clinical and laboratory research, 26 (1), pp. 22-25.
- Busanello E.N.B., Marques A.C., Lander N., et al. (2017). ‘Pravastatin chronic treatment sensitizes hypercholestolemic mice muscle to mitochondrial permeability transition: protection by creatine or coenzyme Q10’, Frontiers in pharmacology, 8 (185), pp. 1-11.
- Glueck C.J., Budhani S.B., Masineni S.S., et al. (2011). ‘Vitamin D deficiency, myositis-myalgia, and reversible statin intolerance’, Current medical research and opinion, 27 (9), pp. 1683-1690.
- Riche K.D., Arnall J., Rieser K., et al. (2016). ‘Impact of vitamin D status on statin-induced myopathy’, Journal of clinical and translational endocrinology, 6, pp. 56-59.
- Moreyra A.E., Wilson A.C., and Koraym A. (2005). ‘Effect of combining psyllium fiber with simvastatin in lowering cholesterol’, Archives of internal medicine, 165 (10), pp. 1161-1166.
- Agrawal A.R., Tandon M., and Sharma P.L. (2007). ‘Effect of combining viscous fibre with lovastatin on serum lipids in normal human subjects’, International journal of clinical practice, 61 (11), pp. 1812-1818.
- Fuentes, M.C., Lajo, T., Carrion J.M., et al. (2006). ‘Cholesterol lowering-efficacy of lactobacillus plantarum CECT 7527 7528 and 7529 in hypercholesterolaemic adults’, British journal of nutrition, 109 (10), pp. 1866-1872.
- Bosch, M., Fuentes, M.C., Audivert, S., et al. (2013). ‘Lactobacillus plantarum CECT 7527 7528 7529: probiotic candidates to reduce cholesterol levels’, Journal of the science of food and agriculture’, 94 (4), pp. 803-809.
- Eggertsen R., Andreasson A., and Andrén L. (2007). ‘Effects of treatment with a commercially available St John’s Wort product (Movina) on cholesterol levels in patients with hypercholesterolemia treated with simvastatin’, Scandinavian journal of primary health care, 25 (3), pp. 154-159.
- Andrén L., Andreasson A., and Eggertsen R. (2007). ‘Interaction between a commercially available St. John’s wort product (Movina) and atorvastatin in patients with hypercholesterolemia’, European journal of clinical pharmacology’, 63 (10), pp. 913-916.
- Sugimoto K., Ohmori M., and Tsuruoka S. (2001). ‘Different effects of St John’s wort on the pharmacokinetics of simvastatin and pravastatin’, Clinical pharmacology and therapeutics, 70 (6), pp. 518-524.
- Rouhi-Boroujeni H., Rouhi-Boroujeni H., Heidarian E., et al. (2015). ‘Herbs with anti-lipid effects and their interactions with statins as a chemical anti- hyperlipidemia group drugs: A systematic review’, ARYA atherosclerosis, 11 (4) pp. 244-251.
- Lee J.W., Morris J.K., and Wald N.J. (2016). ‘Grapefruit Juice and Statins’, The American journal of medicine’, 129 (1), pp. 26-29.
- Li Y., Jiang L., Jia Z., et al. (2014). ‘A meta-analysis of red yeast rice: an effective and relatively safe alternative approach for dyslipidemia’, PLoS One, 9 (6),
- Peng D., Fong A., and Pelt A.V. (2017). ‘Original Research: The Effects of Red Yeast Rice Supplementation on Cholesterol Levels in Adults’, American journal of nursing, 117 (8), pp. 46-54.
- Davignon J., Roederer G., Montigny M., et al. (1994). ‘Comparative efficacy and safety of pravastatin, Nicotinic acid and the two combined in patients with hypercholesterolemia’, American Journal of Cardiology, 73, pp. 339-345.
Whilst this article provides guidance for supporting the use of statins, personal differences do occur as everyone has an individual genetic make-up, lifestyle, diet and so on, which all affect health. If you require more support, feel free to contact our approachable team of nutrition professionals who will be more than happy to support you further or point you in the right direction.