EP55: Talking About Supplements

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Welcome to Doctor Warrick's Podcast Channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick 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. Warrick 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 have been some questions specifically about bergamot and whether that can be used for lowering cholesterol. So, 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 and 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. And 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 - it looks like the research was done with a specific proprietary brand of bergamot called bergavit. And what I will say is that I'm not sure about the specifics of how that particular extract was obtained, that 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 1mmols 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 media intimal thickness. And this 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. Now my knowledge around the particular brand that he's recommending is limited. So I can't comment on whether it's bergavit 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 or 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 for, 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 centred 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, so that means that you need to be treated with a high intensity of therapy. Makes sense. So, bergamot, of its own with a 1mmol 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 might 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 C.T. scan, so 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. And in that situation, bergamot might be a good option, and certainly one that would be reasonable to speak with your GP, or even preferentially your preventative cardiologist with.

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. So we talk about the LDL hypothesis. I think it's more complicated than the 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 1.8mmols per litre or less. Let's say you've got to 2.2mmols 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, and 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 a 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. 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 because I do understand that people want to do what they can if confronted with a situation. So, one of the other things I'll put to people is that they could use read 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 the 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 red yeast rice. 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, of 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 asked 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 PCS-K9 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 the Bergamot, Berberine, 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 is 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 into 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 with the statins became apparent. Nicotic 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 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 that HATS Trial. By all means, look that up.

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's been trials that have shown variability in terms the efficacy of Niacin, but 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've put in place. The treatments we put in place to try and achieve the goals required in understanding 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 is 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's 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, really work.

The addition of ezetimibe, which is also a proven agent, together with statins, even if they needed 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 the 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. You've been listening to another podcast from Dr. Warrick. Visit his website at DrWarrickBishop com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.

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