Dyslipidemia Podcast

A Natural Winner: Plant-Based Diets and Statins vs Dyslipidemia Risk

Laurence Sperling, MD; Kim A. Williams, MD

Disclosures

January 13, 2022

This transcript has been edited for clarity.

Laurence Sperling, MD: Welcome to Medscape's InDiscussion series on dyslipidemia. This is episode 5. We'll be discussing nonpharmacologic approaches to cholesterol management. This is a critically important topic. The foundation of cardiovascular disease prevention is a lifestyle and behavioral approach. And we have truly a national and world's expert here today to have this discussion.

First, we'll start off with a case. This is a case of a recently hospitalized patient, Mr. D, who is 58 years old. He's returning to clinic for a follow-up after a stent was placed in the mid-right coronary artery in the setting of unstable angina. He remains on dual antiplatelet therapy, but he has self-discontinued the high-intensity statin he was prescribed because he read about dietary approaches and supplements to address his cholesterol and cardiovascular risk.

He asks for your guidance about the optimal diet or dietary approach for his heart. His preference is to treat his cholesterol naturally. He has several questions. His baseline HDL cholesterol level is 35 mg/dL, triglyceride level is 176 mg/dL, and LDL cholesterol level is 132 mg/dL. I want to ask our listeners, how would you handle this case? And we'll certainly come back to it during our discussion today.

We are honored and really fortunate to have Dr Kim Williams with us today. Dr Williams, thank you so much for joining. I'll tell you a little bit about Dr Williams. He is the James B. Herrick Professor and Chief of the Division of Cardiology at Rush University Medical Center. He's a specialist in preventive cardiology/cardiac imaging. He also serves as the Associate Dean for Faculty Diversity, Equity, and Inclusion at Rush University where he focuses on recruitment and retention of underrepresented minorities and women.

Dr Williams has served in many national leadership positions. He's the past president of the American College of Cardiology, past president of the American Society of Nuclear Cardiology, chairman of the Board of Directors of the Association of Black Cardiologists, and he's the founder of the Urban Cardiology Initiative in Detroit, Michigan, to reduce ethnic disparities in cardiovascular care. Thank you for joining us today, Dr Williams.

I'd like to start out, for our listeners, tell us a fun fact about you — something that many don't know about Dr Kim Williams.

Kim A. Williams, MD: First of all, thank you very much for having me. I was warned that you were going to ask me that question, and I couldn't think of anything fun. Probably the most fun I have is actually playing tennis. I still play with members of The University of Chicago varsity tennis team, even though I played about 50 years ago with them. I would probably attribute this more to my diet than anything else — that I can still be competitive. The fun fact would be that, for all of my promoting plant-based nutrition for longevity based on several studies, the studies on tennis and racquet sports in general, but tennis specifically, are actually way better in terms of mortality reduction. So as you put the two of them together, you can make sure that your risk factors are under control. Play tennis and eat a plant-based diet, and you're going to suffer through a few more decades.

Sperling: Certainly, tennis would be a nonpharmacologic approach to cardiovascular disease prevention. And maybe we'll plan a future podcast specifically focused on the data related to tennis and longevity. So Dr Williams, we're going to come back to that case because we definitely want to get your opinion about it.

But first of all, what are your thoughts as an expert about the optimal dietary approaches for cardiovascular disease prevention? And then, what's the difference between a diet and a dietary pattern? I think that's important for our listeners to hear.

Williams: In the medical literature, we have a fair amount of literature describing dietary patterns where you go into a population and you categorize them. In the REGARDS trial from The University of Alabama at Birmingham, they talk about the plant-based vs the alcohol-based, vs believe it or not, the Southern diet. The Southern diet, everyone's familiar with. It's what we had on the south side of Chicago when I was growing up, and it's different brands of fried chicken, a lot of fried foods, a lot of animal protein that means cholesterol, saturated fat, and sugar-sweetened beverages. And not just greens, but putting ham hocks in the greens, and processed meat. When you put all that together, it dramatically increases heart disease, kidney disease, and stroke. That's the one pattern we really are concerned about.

When you say diet, it usually means that someone is trying to reach a goal. And a lot of times, it's weight because we have this preponderance of obesity in this country. There are a lot of successful diets for losing weight, but not all of them are healthy — anyone who's about to take on a so-called diet and change their dietary pattern, I'd encourage them to just do an internet search and put in those words. And they'll find out that the keto diet, for example, if you do it with animal fats as opposed to plant fats, is associated with a high mortality, particularly if you've had a heart attack in the past. I think if we get the information out that way, people will make the distinction between dietary pattern and diet and make more healthy choices.

Sperling: Well, thank you. I'd like to ask you a couple of questions I think our listeners are trying to understand themselves. But also, how can they counsel their patients in the clinic or somebody who has had a cardiovascular event like in our case scenario here? Is there a difference between a low-cholesterol dietary approach and a cholesterol-lowering dietary approach? And as an aside, I know there's still some questions, or maybe controversy, about saturated fat and dietary cholesterol. Are those cardiovascular risk factors?

Williams: Let's start with the saturated fat issue. We have a wonderful summary of this from 2017 by the American Heart Association putting out the president's advisory just because so many people were saying saturated fat is good for you. Well, the only time it's good for you is if you're comparing it with something that's worse, such as refined grains. In the PURE trial, even they said that polyunsaturated and monounsaturated fats are better than saturated fat, which is better than trans fats, but that refined grains are even worse.

That said, saturated fat can actually come in a couple of varieties. One is animals and another is plants. If you have a plant-based saturated fat, sure, the caloric exchange is a bit better than animal fat. It is slightly less dyslipidemic, but it is still dyslipidemic. So, if you're eating saturated fat, your low-density lipoprotein (LDL) cholesterol level is likely to go up. Your triglyceride level as well.

And so we ought to do whatever we can. I know there's a lot of people who believe in coconut oil, and some of them are really good friends of mine. But I encourage them to show in data that either you improve outcomes or somehow it's going to make things better. Right now, the data and preponderance of the evidence show it's something we probably should avoid.

Sperling: Wonderful. Thanks. And then just coming back to that cholesterol-lowering dietary approach, are there things we can help our patients do that remain within the context of a heart-healthy dietary pattern that will help lower their cholesterol without medications?

Williams: Yes, but I have to give you sort of a little bit of background. This is a constant struggle in my preventive cardio-nutrition clinic where I have clinicians telling patients, even now after their stents, that it's all genetic. And that their diet didn't do it. It's not their fault.

Then I have patients like the one you describe, who look me or other vegan cardiology-minded people up on the internet and decide they want to come off their statins. I would just love to get the two of them in the room and let them know that when I have a patient who's had an event and has a revascularization, or is about to have one, and they've done both the high-dose statin and the plant-based diet, and they're doing an exercise program, the outcomes are amazing.

All we need is what our latest European Society of Cardiology guidelines say. Get the LDL level to less than 55 mg/dL. Those two things together — diet and a statin — are the best tools I've ever seen for getting the LDL down. When that happens, people — I'm not saying they're immortal — but they don't tend to have a lot of events. I haven't seen one yet. All the events are in the people who are eating plant-based without a statin, or taking a statin without eating a plant-based diet.

Sperling: I know you talked about tennis. I'm going to hit you a lob right now as you're rushing the net because I know you are so passionate about plant-based, whole food approaches to overall health promotion and disease prevention. Everybody can't go from the Southern diet, for instance, to plant-based whole food — but tell our listeners, what are the data about plant-based, whole food approaches and how we should think about them as heart-healthy dietary patterns?

Williams: Our biggest issue with this is the lack of huge, randomized trials. We have some. Dean Ornish put studies out back in the late '90s that showed plaque stabilization and regression, and that's really great. But the Institute of Medicine — when we write guidelines — wants a big, prospective, randomized trial that's long term, has events, and has at least 50 people in each group. We just don't have that for a whole food, plant-based diet. But what we have, some would argue, is even better, which are large-scale, long-term observational trial such as Adventist Health Studies, Nurses' Health Studies, and the Health Professional Follow-Up Study done at Harvard.

We have other datasets, as well. All of them point to more plants and less animal protein. That lowers your cholesterol level. That lowers the amount of saturated fat that you're eating. It usually lowers the sodium you eat, and increases your potassium.

Your trends — if anyone has not seen trimethylamine-N-oxide (TMAO) data, please — the moment you're done here, look up that four-letter word and you'll probably be vegan by the time you finish reading The New England Journal of Medicine articles on it because TMAO is associated with heart failure, death, overall mortality, heart attack, and stroke. And if that wasn't enough, the recent connection to chronic kidney disease makes it really compelling to try to decrease or eliminate animal protein so you don't have this change in your microbiome that then results in all of the complications I just mentioned in addition to bad COVID outcomes. So, this is really the time to make these adjustments to your diet. It's really important.

Sperling: Thanks. You brought up the COVID-related outcomes. These are challenging times. We are certainly adapting and hopefully developing resilience. How should we think about this when we counsel our patients on diet, lifestyle, and behavioral approaches to cardiovascular disease prevention in the context of COVID?

Williams: It's a really great question. It started off within a month of the COVID pandemic. By April, we had a plant-based organization saying that this is all about hypertension, diabetes, hyperlipidemia, and obesity. All you have to do is change your diet and you're going to be fine. That has had some consequences.

One is, it is true. I have a lot of vegan friends. Vegan people tend not to get really sick with COVID. And the wraparound or boomerang effect is that you can actually get sick, not know it, and spread it. So, please do the social distancing and the masking particularly if you're vegan because you're not likely to get sick.

Number two is, after a long time — that is, after about a year — we have had enough outcome studies to say two things. One thing is all of the stuff about Black and brown people having more mortality — it actually isn't exactly true. It's numerically true. But if you adjust for the risk factors of obesity, socioeconomic conditions, and the incidence of diabetes, being Black actually had a tiny protective effect. It was just that we have so many risk factors, and that's why we're dying so much.

The second major issue is the data on the microbiome. They are stunning data. They are perfectly consistent with what Cleveland Clinic has been publishing about TMAO. However, it turns out that your inflammatory response, the cytokine storm, is all about the bacteria in your gastrointestinal tract for any illness, particularly COVID. And it takes about 4-14 days to change your microbiome from the dysmetabolic ones to the good ones if you do a plant-based diet. So, everybody could just come off of here today, change your diet, and you'll be safer than you would be before.

Sperling: We often say that you are what you eat. But you are what your bacteria eat as well. So, thanks for bringing that forth. I'm going to take a little bit of a rapid-fire Q&A for you here because I do want to come back to the case. First of all, there's a lot of interest in time-restricted eating or intermittent fasting right now. Is that a heart-healthy dietary approach?

Williams: I think it really is. If you look only at weight and not at cardiovascular outcomes, any type of eating that does a caloric restriction will actually work for losing weight. And there's data from a few years ago, from Brie Turner-McGrievy at University of South Carolina, saying that, meh, that's true that this will improve you, but a vegetarian and vegan diet is more sustainable.

A lot of that has to do with the fact that people who go vegetarian or vegan often have some social, ethical, global warming, animal rights kind of twist to it that makes them sustain it and makes them want to continue to do it. And I think that gives the vegan diet a sort of an unfair advantage over the other ones. But the fact of the matter is that anything that lowers your caloric intake will improve things, and that includes time-restricted feeding.

Sperling: I'm sure you get this question a lot in your cardio-nutrition clinic. What's your thought about red yeast rice and coenzyme Q10 (CoQ10)?

Williams: CoQ10 actually has good data for statin myopathy or statin-associated muscle symptoms. A fraction of our patients will actually be relieved of these symptoms. Now, you could argue, is it really the placebo effect or the nocebo effect published in the SAMSON trial in The New England Journal of Medicine last November — that a lot of what we're seeing actually isn't real? It's more fear of the statins or it's sort of a mental condition.

Many of those people in the SAMSON trial, when they found out their placebo pill caused them the same symptoms, were able to take the statin without a problem. So, we have to leave some room for variation there, but there seems to be good data that CoQ10 works for [managing statin-induced myopathy]. I don't see much use for it otherwise.

Red yeast rice, I'm always concerned about. Yes, it is a naturally-occurring lovastatin. And for those of you who doubt it, you could check the record books of the lawsuit when the company making lovastatin thought they had a patent on it and that the stuff couldn't be sold because it was identical. Well, it turns out that it's a nutritional supplement. The courts decided that it'd be fine. The problem isn't that it is not a statin. It's just that because it is a statin, you might get the same degree of statin-associated muscle symptoms. Sometimes you will not because it tends to be weaker.

The real issue for me is that you don't have the seal of the US Food and Drug Administration and the GMP, or Good Manufacturing Practice, which means that you don't know whether you're getting 3 mg or 30 mg per pill. And so I tend not to use it. If someone is taking it and they have a lot of success, then I do accept it as statin therapy. But I've got to have that LDL level less than 55 mg/dL.

Sperling: So, let's come back to the case we started with here. Any words of advice for the clinicians and those listening in about how to approach a patient like this? Start the conversation. Maybe you want to just take a brief time to give some guidance here.

Williams: Oh, so this would be great. I'd be all over this case. One of the things that's nice about using electronic health records is that you're sitting in front of a computer. I turn it sideways and let the patient see it. The first thing I would do here is show the data. If you just put in those two words — and I encourage all of the listening audience to do this with their statin-resistant patients who don't want to take it. Put two words into a search engine: "statin mortality." And then hit "Images." You're going to see a whole bunch of Kaplan-Meier curves that look terrible. And you tell the patient to choose which curve they want.

In fact, one of the curves that comes up is statin stoppers. This patient was a statin stopper, and it's a huge mortality difference they're putting themselves up for. Obviously none of those studies, or very few of those studies, or very few of the patients in those studies were going to try plant-based eating to get their LDL level down.

That's what I would hold out to them. That is, you've got an LDL cholesterol of 132 mg/dL. We need to make it 55 mg/dL. And if you can come along with me — I don't know about red yeast rice, necessarily, for the reasons I stated — there's a whole lot of plant-based stuff. It's berberine and Brazil nuts and bergamot, and my favorite is goji berries just because they taste so good.

In order to get on my little list, which is about 12 different things — in order to get on that list — there has to be a published, peer-reviewed, randomized trial vs placebo saying that there's LDL lowering. The problem is that I don't know anything about combinations, and I don't know anything about outcomes. Whereas with statins, I have both of those. Why would we put a patient in a category of risk to avoid the one drug that I tell everybody is breaking Medicare?

Sperling: Well, this patient listened to your advice. He started taking the statin. He enrolled in cardiac rehab. As part of cardiac rehab, he met with a registered dietitian, embracing the advice of his clinical team. Dr Williams, thank you for joining us today and providing a lot of important information about what is at the core and the heart of cardiovascular disease prevention, lifestyle, and behavioral approaches. Certainly, for all of our patients, we need to be providing advice like you've given us here today.

We thank you for joining us today on Medscape's InDiscussion. We look forward to our next episode. Our next episode will be "Frontiers of Lipid Management" with Dr Peter Toth, the current president of the American Society for Preventive Cardiology, and Dr Erin Michos, who is at Johns Hopkins. She's the co-editor of the American Journal of Preventive Cardiology. This is Dr Laurence Sperling for Medscape's InDiscussion.

Resources

Exercise and CVD Mortality

Associations of specific types of sports and exercise with all-cause and cardiovascular-disease mortality: a cohort study of 80,306 British adults

Diet and Dietary Patterns

The reasons for geographic and racial differences in stroke study: objectives and design

Heart disease and stroke

Effects of ketogenic diets on cardiovascular risk factors: evidence from animal and human studies

Dietary fats and cardiovascular disease: a presidential advisory from the American Heart Association

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study

Intensive lifestyle changes for reversal of coronary heart disease

Dietary adherence and acceptability of five different diets, including vegan and vegetarian diets, for weight loss: the New DIETs study

Guidelines and Population Studies

2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk

TMAO

Trimethylamine-N-oxide (TMAO) predicts cardiovascular mortality in peripheral artery disease

Gut microbes impact stroke severity via the trimethylamine N-oxide pathway

Statin Adverse Effects

Effects of coenzyme Q10 on statin‐induced myopathy: an updated meta‐analysis of randomized controlled trials

N-of-1 trial of a statin, placebo, or no treatment to assess side effects

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