London - Eating an apple a day could help cut your risk of heart disease as effectively as taking a statin.
Indeed, if everyone in the UK over 50 who is not taking statins followed Grandma’s advice, it could prevent 8,500 deaths a year, suggests a report published in the British Medical Journal.
Around five million Britons take statins - cholesterol-lowering drugs. Most people take them to prevent heart disease (known as primary prevention). The rest take them to avoid another heart attack having already had one (secondary prevention).
There’s little doubt statins do make a difference when used to prevent a second heart attack. But there is strong disagreement over just how much they benefit people without heart disease.
Could simple lifestyle changes - such as eating an apple a day - be an effective alternative? We ask the experts...
How can an apple be as good as a statin?
The finding about apples came from scientists at Oxford University. They did a mathematical analysis of studies that showed how much fruit and vegetables in general helped cut heart disease.
They worked out that the benefits to everyone over 50 taking statins were about the same as if these people ate a portion of fruit or veg every day (it doesn’t have to be apples). There would be 8,500 fewer heart disease deaths with eating apples, and 9,400 fewer deaths if everyone took statins.
The researchers concluded it was an impressive demonstration of how effective a simple change in diet could be. But they also said it showed a massive increase in statin use could be worthwhile.
Should I only ever eat apples, then?
Everyone agrees that eating more fruit and vegetables is beneficial but experts strongly disagree about to whom it is worth giving statins. When it came to making their calculations about the benefits of statins, the Oxford researchers used a study published last year.
This found that even patients at low risk of heart disease benefited from statins, and the known side-effects, such as serious muscle problems and diabetes, happened to fewer than one in 1,000.
But many other researchers are not convinced this is realistic. And if it is over-optimistic, that would mean the difference between the number of lives saved by statins compared with those saved by fruit and veg could be even smaller than the Oxford researchers found.
An article in the BMJ recently strongly criticised the study favourable to statins (known as the Cholesterol Treatment Trialist, or CTT, collaboration).
‘This analysis was based on results from trials run by the drug companies, which are likely to be excessively favourable,’ wrote Dr John Abramson, of the department of healthcare policy at Harvard Medical School.
Independent studies suggest that you have to treat as many as 5,000 low-risk patients over 60 years of age to prevent just one death from heart disease.
‘If you massively expand statin use among people at low risk, all you are going to do is to drive a huge increase in the number of people suffering side-effects,’ Dr Abramson told Good Health.
His paper estimated the risk of type 2 diabetes from statins to be five times higher than that claimed in the CTT study.
I have high cholesterol, so do I need a statin?
Statins are certainly effective at lowering cholesterol, but questions are being asked about whether that actually affects heart disease risk.
Studies show that 75 percent of people admitted to hospital with their first heart attack have normal levels of cholesterol. Drugs that only lower cholesterol, unlike statins which have other effects such as reducing inflammation, have never been shown to cut heart disease.
This approach is reflected in the latest guidelines from two of the big American cardiovascular societies. Their advice, which surprised many, was that driving your LDL (bad) cholesterol down as low as possible with statins was no longer thought to be a good idea.
Statins should be used to treat people at real risk, said the US. bodies. They now recommend paying special attention to diabetics (who are at higher risk of heart disease); they also lower the level of risk at which others should be treated.
Under UK guidelines, you are meant to be treated with statins if your risk of heart disease over ten years is above 20 percent; the U.S. organisations reduce that to 7 percent or more over ten years.
‘Many experts now think cholesterol is a sign that there is a problem but is not the cause of it,’ says Aseem Malhotra, a cardiology registrar at Croydon University Hospital. ‘Statins can help after a heart attack but probably because of their anti-inflammatory effect.’
Why not just switch to a healthy low-fat diet?
Following a low-fat diet and especially keeping saturated fats to a minimum has been a cornerstone of heart disease prevention for decades. But it, too, is being increasingly challenged.
‘This advice has, paradoxically, increased our cardiovascular risk,’ Dr Malhotra wrote recently in the BMJ. ‘In fact, saturated fat has been found to be protective. Vitamins A, D, E and K all need fat to carry them and to be effectively absorbed.’
Although he prescribes statins because the evidence shows they benefit heart attack patients, he also recommends a Mediterranean diet - rich in olive oil, nuts, oily fish, fruit and vegetables and a moderate intake of red wine.
Recently, a major clinical trial involving more than 7,000 people and lasting five years compared it to a low-fat diet and found it can prevent about 30 percent of heart attacks, strokes and deaths from heart disease, reported the researchers in the New England Journal of Medicine.
Other research has shown every additional portion of fruit and veg you have a day lowers your risk of heart disease by 4 percent, says Aidan Goggins, a pharmacologist specialising in nutritional medicine at the University of Surrey.
Why does my GP go on about my triglycerides?
These are another type of fat found in the blood, and having raised levels is certainly a sign you are at risk of heart disease.
But statins can’t lower them effectively so patient awareness isn’t like that for cholesterol. There are two older compounds that bring down triglycerides effectively - the B vitamin niacin, and a drug known as fibrates.
Drug firms have tried to improve statins’ effectiveness by combining them with niacin or fibrates, but studies found this doesn’t reduce the risk of death from heart disease. According to the American Heart Association, triglycerides don’t cause blocked arteries - they are just a ‘marker’ that something is wrong.
As well as eating apples, what else should I do?
It’s all very controversial, but if cholesterol and triglycerides are not causing the problem, yet are signs that there is a problem, what should our focus be on instead?
It is known that high blood pressure raises the risk of heart disease. So, too, does damage to the delicate lining of arteries (endothelium), irregular heartbeat and the body becoming more resistant to the effects of insulin (the hormone that mops up sugar from the blood).
Omega 3 fish oil could be the answer, as it helps with many of these active risk factors - which is why drug companies are looking at the oils with interest, and a new statin-plus-fish-oil combination is undergoing US. trials.
As well as fruit and veg, plenty of other foods come with calculated heart benefits. Every additional 10g of dietary fibre you have a day reduces the risk of cardiovascular problems by 17 percent. And each serving of nuts (up to four a week) reduces it by 8 percent. Two servings of wholegrains a day reduces the risk by a whopping 26 percent.
And then there’s exercise. There’s a mountain of evidence to show its very effective, yet 80 percent of the UK population don’t even hit the modest official target of 12 bouts of moderate exercise within four weeks.
So will statins actually help me?
Dr Abramson argues doctors should be giving a ‘much more honest picture’ of the amount of benefit you can expect from statins, and the risk of harm.
‘They should also tell patients that 80 percent of the risk of heart disease comes from lifestyle factors such as smoking, lack of exercise and an unhealthy diet,’ he says.
But blocking the way, according to Fiona Godlee, editor of the BMJ, is the financial muscle of the drug companies.
She recently wrote: ‘The benefits of lifestyle change are something the dominance of industry-sponsored clinical trials too often obscures.’ - Daily Mail