• Supplements are not a replacement for a healthy diet, statin medication, and physical activity. Speak with your doctor and/or registered dietitian/nutritionist about the quality, safety, and effectiveness of dietary supplements before making a purchase.
  • Supplements and nutraceuticals are not FDA-approved to reduce the risk of heart and vascular disease or stroke.

Blood cholesterol is a waxy, fat-like substance made by the liver. It is essential for good health because the body needs it to perform important jobs, such as making hormones, cells, vitamins, digesting fatty foods, as well as promote normal growth and development.

Cholesterol in your diet is found in animal foods, including meat, seafood, poultry, eggs, and dairy products. Diets that include less cholesterol can reduce the risk of heart attack, blocked arteries, and stroke.

Low-density lipoprotein (LDL) cholesterol is often called the “bad” cholesterol because it narrows and builds up in the arteries when the level in the blood is too high.

HDL cholesterol is the good cholesterol because a healthy level may protect against heart attack and stroke.  HDL carries LDL (bad) cholesterol away from the arteries and back to the liver, where the LDL is broken down and passed from the body.

The cornerstone of treatment to lower your LDL-cholesterol is a healthy diet and lifestyle.  Some dietary supplements may help to further reduce your LDL-cholesterol, even if you are already taking statin medication, but they are not intended to replace your medications.  They may work by:

  • Preventing absorption of cholesterol from the intestines
  • Preventing production of cholesterol in the liver
  • Helping with removal of LDL-cholesterol

* The above mechanisms may work in combination and there may be other mechanisms that are still unclear.

Dietary Supplements: Come in a non-food form (pill, capsule, or extract) from a food source.
Dietary supplements are:

  • Not intended to replace your prescribed medications.
  • Not FDA approved to prevent or treat a medical condition or disease.
  • Not regulated by the Food & Drug Administration (FDA).

It is important to learn about dietary supplements before deciding to take one. Have a conversation with your health care provider and your dietitian if you are considering or already taking a supplement.

Plant Sterols & Stanols1,2

  • What are they?
    • Plant sterols and stanols are extracted from vegetable oils, nuts, seeds and/or legumes. They may also be found in soft chews or fortified foods such as spreads, juices or bars.
    • They occur naturally in foods such as apricots, cantaloupe, carrots, kale spinach and sweet potatoes.
  • How do they work?
    • They reduce absorption of dietary cholesterol.
  • Are they effective?
    • Yes, they may cause an 8-12% decrease in LDL-cholesterol with 2-3 g/day (dose recommended by the National Lipid Association).
  • Are they safe?
    • Yes, but plant sterols & stanols should not be taken if you have a rare genetic disorder called sitosterolemia. Taking plant sterols & stanols supplements may keep some vitamins from being absorbed in your gut.  Eat at least 5 servings of fruits and vegetables each day. Try apricots, cantaloupe, carrots, kale, spinach, and sweet potatoes.
    • Although they have a favorable effect on blood cholesterol, their effects on reducing heart attack and stroke have not been determined.

Viscous Fiber1,2

  • What is it?
    • A dietary supplement derived from psyllium husk, pectin and guar gum.
    • Found in many foods such as oats, barley, legumes, fruits (e.g., apples, pears, citrus), vegetables (e.g., broccoli, eggplant, okra)
  • What does it do?
    • Helps to traps cholesterol in the intestines, reducing its absorption. It also helps to trap bile acids which forces the liver to use up cholesterol to make more.
  • Is it effective?
    • Yes, it may cause a 5-11 mg/dL decrease in LDL-cholesterol with 5-10 g/day (dose recommended by the National Lipid Association). However, the amount of cholesterol reduction depends on the type of fiber. Start with a small dose mixed with water. Slowly increase the dose and take as directed.
  • Is it safe?
    • Yes, viscous fiber is safe for adults and children, but you should not take more than 20 g/day, as it may cause occasional mild stomach upset.  Drinking more water when you increase your fiber intake may help to prevent bloating.

Red Yeast Rice2,3

  • What is it?
    • A dietary supplement extracted from the Xuezhikang plant.
  • What does it do?
    • Reduces production of LDL-cholesterol.
  • Is it effective?
    • Yes, may lead to a 15-25% decrease in LDL-cholesterol with doses varying from 1200 mg/day to 4800 mg/day containing from 4.8 mg to 24 mg of its active ingredient.
  • Is it safe?
    • Yes, Red Yeast Rice is usually well-tolerated, with a safety profile like low-dose statins. However, grapefruit juice or medications, such as verapamil, as well as HIV protease inhibitors may increase the risk of side effects.
    • Be careful when buying, as there is high variability between products as well as inconsistencies between label and actual contents. As a reminder, these supplements are NOT regulated by the FDA!

Berberine2,3

  • What is it?
    • A dietary supplement extracted from the Barberry shrub’s roots, rhizomes, and stem barks.
  • What does it do?
    • Berberine may reduce LDL-cholesterol through several mechanisms.
  • Is it effective?
    • Yes, it may lead to a 15-20% decrease in LDL-cholesterol with 500-1500 mg per day, and may also lower triglyceride levels. However, it has not been shown to reduce the risk of heart attack or stroke.
  • Is it safe?
    • Yes, berberine is usually well-tolerated, but it may cause occasional mild side effects including diarrhea, constipation, and abdominal bloating.  Although it may have a favorable effect on lipids, its effects on reducing heart attack and stroke have not been determined.

Bergamot2,3

  • What is it?
    • A dietary supplement extracted from the peel of a bitter citrus fruit (Citrus bergamia), rich in flavonoids.
  • What does it do?
    • Decreases production of LDL-cholesterol.
  • Is it effective?
    • Yes, it may lead to a 15-25% decrease in LDL-cholesterol with 500-1500 mg per day and triglycerides from 28-39%. Reductions obtained depend on the dose used.
  • Is it safe?
    • You should not take more than 1500 mg/day, and it may cause occasional mild heartburn.  Bergamot may cause your blood sugar to drop. If you have diabetes, your blood sugar might reach unsafe levels. It’s important to monitor those levels if you choose to use bergamot supplements. Bergamot should be stopped for at least two weeks prior to surgery. Although it may have a favorable effect on lipids, its effects on reducing heart attack and stroke have not been determined.

Artichoke Leaf Extract2

  • What is it?
    • A dietary supplement extracted from the leaves of the artichoke plant.
  • What does it do?
    • Decreases LDL-cholesterol, total cholesterol, and triglycerides.
  • Is it effective?
    • Yes, may lead to a decrease in total and LDL cholesterol and triglycerides with 1-3 g per day.
  • Is it safe?
    • Yes. Although it may have a favorable effect on lipids, its effects on reducing heart attack and stroke have not been determined.

Garlic2,3

  • What is it?
    • A dietary supplement extracted from garlic. Aged extract is more effective.
  • What does it do?
    • Prevents LDL-cholesterol oxidation, increases HDL-C, decreases total cholesterol and triglycerides.
  • Is it effective?
    • Yes, may lead to a decrease in LDL-cholesterol with 5-6 g per day of aged garlic extract.
  • Is it safe?
    • Yes, garlic is safe but note that you may experience a garlic aftertaste with a higher dose!  Very high doses may lower the blood pressure. Although it may have a favorable effect on lipids, its effects on reducing heart attack and stroke have not been determined.

Green Tea Extracts2,3

  • What is it?
    • A dietary supplement extracted from green tea leaves.
  • What does it do?
    • A compound found in green tea extract called Epigallocatechins-3-gallate (EGCG) reduces absorption   and production of LDL-cholesterol.
  • Is it effective?
    • Yes, may lead to a 5% decrease in LDL-cholesterol with 500 mg of EGCG twice daily. This equates to 60-100 ounces per day of brewed green tea.  Canned and bottled green teas are not as effective because the beneficial catechin flavonol breaks down during processing. Although it may have a favorable effect on lipids, its effects on reducing heart attack and stroke have not been determined.
  • Is it safe?
    • Yes, but high doses of green tea (as above) or its extract can cause iron and folate deficiency.  

Coenzyme Q 10 (CoQ 10)

  • What is it?
    • A naturally occurring substance produced in the body. It is also a dietary supplement.
  • What does it do?
    • It helps the body to perform many functions. In some patients who are taking statin medications, its deficiency may lead to muscle pain.  Supplementation with Coenzyme Q10 has not been shown to reduce muscles cramps due to statins.
  • Is it safe?
    • Yes. In rare cases it may cause stomach upset or headache.

Do vitamin and mineral supplements help prevent heart disease?4

  • Multivitamins, vitamin C, vitamin D, beta-carotene, calcium, and selenium have no effect on the prevention of heart disease.
  • Some antioxidant mixtures may lead to an increased risk of heart disease.
  • Although having favorable effects on lipids by reducing triglycerides, raising HDL cholesterol, and reducing LDL cholesterol, niacin has not been shown in recent clinical trials to reduce cardiovascular events, and may have unwanted side effects such as flushing, increased blood sugar, liver injury, and gout.
  • Some evidence suggests that folic acid may help prevent heart disease, although the data is controversial.
  • Some evidence suggests that folic acid with B-vitamins may help prevent stroke in patients with cardiovascular disease.4,5 
  • Folate is found mainly in fruits and vegetables. Spinach, asparagus, and brussels sprouts are all good sources, along with beans (such as chickpeas), citrus fruit, and whole grains.

Since conclusive evidence for the benefit of any supplement has not been demonstrated or FDA approved for reducing cardiovascular events, any benefits seen must be balanced against possible risks. Always check with your healthcare team first before taking a vitamin or mineral supplement!

Calcium Supplements6

  • Randomized controlled trials studying the effect of calcium/vitamin D supplements did not show that theyreduce the risk of heart disease. 
  • Calcium supplements are linked to an increased risk for kidney stones, constipation, and may cause calcium deposits to form in your arteries and heart valves. Constipation may lead to the formation of colon polyps.
  • Calcium from food sources (instead of supplements) is preferred. Good sources of calcium include daily products, kale, almonds, canned fish, greens and beans.

Let’s review some common claims about dietary supplements:

  1. Red yeast rice is a healthier alternative to statins for those who have never had a heart attack.

MYTH

Why? There is no research that red yeast rice prevents heart attack in patients who have never had a heart attack. One study in 5000 Chinese patients with a history of a previous heart attack who received Xuezhikang (XZK), an extract of RYR, 600 mg daily for 4.5 years vs. placebo, reported LDL-cholesterol decreased 17.6%; HDL-C increased 4.2% and death from heart attacks decreased 30%.  However, this data is not applicable to patients who have never had a heart attack.  

CoQ10 improves blood sugar regulation.

MYTH

Why? There is very little research suggesting that CoQ10 regulates blood sugar. Studies show that one in 10,000 people may get muscle pain from a statin.

Prescription fish oil is exchangeable with fish oil supplements found on the shelves in the marketplace.

MYTH

Why? Research supports omega-3 fish oils have been shown to reduce triglyceride levels. Prescription omega-3 fish oils, containing 100% EPA, have been shown to reduce the risk of heart attack and stroke, stabilize artery plaque, as well as reduce triglycerides.  Only prescription omega-3 fish oils are produced through an 8-step purification process that assures they are free of heavy metals, PCBs, and dioxin.

Those with artery calcifications should avoid calcium supplements.

MAYBE! Speak with your doctor before taking calcium supplements.

Why? Some research has reported an increased risk for heart disease with calcium supplementation.6 Your doctor will evaluate whether you will benefit from a calcium supplement based on whether you are at a greater risk for heart disease or for a bone fracture.

CONCLUSIONS

  • Most can be effective in lowering LDL-cholesterol when combined with a heart-healthy diet and prescribed medications (when needed, such as statins).2
  • With use of appropriate dietary supplements, there is potential for needing a lower dose of statin medication.
  • They can sometimes lead to other positive effects, including reduced artery stiffness, improved artery health & reduced inflammation.
  • Many supplements appear to be well-tolerated, safe, and effective for patients who cannot tolerate a statin.
  • No studies have shown reduction in heart disease from supplements with the possible exception of red yeast rice, which is, essentially, a low dose statin medication.
    • Remember that the FDA does not regulate dietary supplements. So, if you are taking red yeast rice the actual dose you are taking could change.  

This blog was inspired by a webinar titled, “Lipid Myth Busters: Dietary Supplements and Cardiovascular Risk” supported by Amgen, Esperion, and Novartis. Watch the webinar here.

References

  1. Jacobson, Terry A., et al. “National Lipid Association recommendations for patient-centered management of dyslipidemia: part 2.” Journal of clinical lipidology 9.6 (2015): S1-S122.
  2. Cicero AFG et al. Lipid-lowering nutraceuticals in clinical practice: position paper from an International Lipid Expert Panel. Nutr Rev. 2017;75(9):731-767.
  3. Banach M et al. The role of nutraceuticals in statin intolerant patients. J Am Coll Cardiol. 2018; 72:96-118.
  4. Jenkins DJ et al. Supplemental Vitamins and Minerals for CVD Prevention and Treatment. Journal of the American College of Cardiology. Volume 71, Issue 22, June 2018, Pages 2570-2584. https://doi.org/10.1016/j.jacc.2018.04.020
  5. Wang, Yuan MSa; Jin, Yang BSc; Wang, Yao BSb; Li, Li MSb; Liao, Yanhong BSb; Zhang, Yun MSb; Yu, Dan MDb,∗ The effect of folic acid in patients with cardiovascular disease, Medicine: September 2019 – Volume 98 – Issue 37 – p e17095 doi: 10.1097/MD.0000000000017095
  6. Michos E et al. Vitamin D, Calcium Supplements, and Implications for Cardiovascular Health. J Am Coll Cardiol 2021;77:437–49.
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