Statins lowers cholesterol by interfering with the cholesterol biosynthetic pathway, On the other hand, fibrates decrease fatty acid and triglyceride levels by stimulating the peroxisomal β-oxidation pathway, Apart from these drugs, ezetimibe, which selectively inhibits intestinal cholesterol absorption, cholestyramine, colestipol, and colesevelam, which sequester bile acids, torcetrapib, which inhibits cholesterol ester transfer protein, avasimibe, which inhibits acyl-CoA: cholesterol acyltransferase, implitapide, which inhibits microsomal triglyceride transfer protein [9], and niacin, which modifies lipoproteins, are providing clinicians with several therapeutic options for lipid lowering.

Dietary factors that influence lipid levels include modification of nutritional components, consumption of specific foods, use of food additives and supplements, and major dietary approaches. The most beneficial changes result from reducing intake of saturated and transfats; increasing intake of polyunsaturated and monounsaturated fats; fortifying foods with plant stanols or sterols; isocalorically adding tree nuts to the diet; consuming one or two alcoholic drinks per day; and adopting a Portfolio, Mediterranean, low-carbohydrate, or low-fat diet. Smaller but still beneficial effects result from reducing intake of dietary cholesterol, increasing intake of soluble fiber and soy protein, and eating fatty marine fish or taking marine-derived omega-3 fatty acid supplements. Red yeast rice supplements have effects similar to those of statin medications and are better tolerated in some patients. Regular aerobic exercise has beneficial effects on lipid levels, particularly if performed for at least 120 minutes per week. Brief physician counseling will have relatively small effects on unselected patients, so efforts should be concentrated on patients who are motivated and ready to make lifestyle changes.

SIMVASTATIN-40MG

Statins are definitely better , because they lower LDL cholesterol and reduce inflammation & stabilize the fatty plaques in the arteries of the heart & brain & reduce life threatening cardiac events . The major risk of high cholesterol is coronary & cerebrovascular disease , which is the leading cause of mortality in the elderly & should not be denied statins . The high cholesterol in the blood is not only due to dietary factors , but also due to genetic factors .

What about a combination of the two, according to patient's features (i.e., genetic background and lifestyle, either dietary and physical activity habits)?

Hi Ali,

It highly depends on which type of patient you are referring to. Generally speaking, when you are dealing with a patient with elevated triglycerides, your intervention focus must be on diet, since its concentration is primarily determined by dietary intake. However, when dealing with elevated cholesterol the story difers given that blockage of one pathway of cholesterol intake/biosynthesis usually increases the other and, as you mention, the greatest contribution to cholesterol levels comes from body biosynthesis. Therefore, the recommendations must be tailored for each individual patient.

If you are dealing with a young patient with elevated LDL levels but

Statin as almost all drugs exert adverse reactions in human body . I believe that if diet with low fat succeeded in lowering Cholesterol and LDL level, it will better . Statins will be the choice when diet failed to solve the problem .

As there are many types of dislipemia, the answer might be too wide and inconcrete. Could the question be more precise?

Depends on the type of hyperlipidemia and also on the fasting lipid profile. Treatment would be based on the severity (the levels) and relevant family history and other risk factors. Dietary control has to be there with follow up of levels.. Among the statins, considering the side effect profile, atorvastatin is avoided; Rosuvastatin is preferred with or without fibrates depending on lipid profile. Also, considering the risk of cardiovascular adverse events, recent guidelines are in favour of prescribing statins.

Dear Dr. Al-Snafi,

Certainly, lifestyle modifications (including a healthy diet and physical activity) should to be always considered the first-line therapy for hypercholesterolemia. If this type of approach was not sufficient for the patient to reach the recommended LDL-cholesterol target, nutraceuticals might be considered a valid option for selected cases (i.e. healthy subjects at low cardiovascular risk). A large body of research has individuated a number of food and plant bioactives which are potentially affective in preventing and reducing LDL-cholesterol levels, also exerting a positive effect on the endothelium. Promising data does not concern only red yeast rice (which has a mechanism of action similar to the one of the HMG-CoA reductase inhibitors), but also berberine (which reversibly suppresses the PCSK9 expression) and phytosterols (which have been safely tested also in children), for example. On this topic, I urge you to read one of the latest articles of Professor Arrigo Cicero and Professor Maciej Banach, which is very relevant in the field:

Cicero AFG, Colletti A, Bajraktari G, Descamps O, Djuric DM, Ezhov M, Fras Z, Katsiki N, Langlois M, Latkovskis G, Panagiotakos DB, Paragh G, Mikhailidis DP, Mitchenko O, Paulweber B, Pella D, Pitsavos C, Reiner Ž, Ray KK, Rizzo M, Sahebkar A, Serban MC, Sperling LS, Toth PP, Vinereanu D, Vrablík M, Wong ND, Banach M. Lipid-lowering nutraceuticals in clinical practice: position paper from an International Lipid Expert Panel. Nutr Rev. 2017 Sep 1;75(9):731-767. doi:10.1093/nutrit/nux047.

With regard to drug therapy (i.e. statins, ezetimibe, ion-exchange resins, etc.), it is undoubtedly effective and safe and has to be certainly preferred in the treatment of patients at moderate to high cardiovascular risk or when natural compounds are not sufficient to reach the LDL-cholesterol goal. In this regards, the ESC/EAS and AHA guidelines should be for you:

Ray KK, Kastelein JJ, Boekholdt SM, Nicholls SJ, Khaw KT, Ballantyne CM, Catapano AL, Reiner Ž, Lüscher TF. The ACC/AHA 2013 guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: the good the bad and the uncertain: a comparison with ESC/EAS guidelines for the management of dyslipidaemias 2011. Eur Heart J. 2014 Apr;35(15):960-8. doi: 10.1093/eurheartj/ehu107.

Best regards,

Federica

Dearly respected colleagues

Dietary fat restrictions and some guidelines have been shown to be not in line with the current evidence. Restriction of animal fat and the high intake of monounsaturated and even polyunsaturated fatty acids is not supported by randomized controlled trials. The use of cut-off levels is no longer favored, rather the risk stratification is more advised as the benefit of statins persists at levels as low as 20 mg/dl for LDL. The small risk of precipitating diabetes in those with prediabetes is over-weighed by the great benefit of lowering the macrovascular complications, also pitavastatin and pravastatin are not precipitating diabetes in those at risk.

In mild hyperlypemia is enough a strategy with fat restriction measures. In cases moderate or high levels are necessary both measures

I mean, if the carbohydrates and proteins can converted to lipids in our bodies, so what is the benefit of decreasing lipids intake

Dear Dr. Ali Esmail

I do agree with your comment, furthermore, the lipids are mainly endogenous rather than coming from the meals.

Both things are very important to combine in the long-term treatment of this problem

If I understand correctly your question, you touched specifically about de novo lipogenesis, what is fairly inefficient mechanism of transformation of energy into the adipose tissue. (see e.g. http://ajcn.nutrition.org/content/74/6/707.full). Let's assume you have a patient with isoenergic or euenergic diet (input and output equals) so the patient is not fattening anymore. If such a patient will not eat any fat apart of essentials fats 12g, which are necessary to survive, he will loose weight, because of inefficiency of de novo lipogenesis.

To answer the second part of your question — current recommendation is NOT to use statins in primary care as they DO NOT decrease all-cause mortality and have many side effects leading to various secondary problems. The science of decreasing saturated fats bellow 6% of energy income is well established, the science of decreasing of dietary cholesterol intake is well established — BOTH lead to decrease of LDL serum levels. What is not sufficiently established is the fact, that by unknown mechanism body tries to keep certain level of LDL and TC and it takes about 3 years on extremely low fat diet to decrease TC and LDL. One of the reasons points to a study showing that each kilogram of adipose tissue ignites certain increase in LDL production by body itself.

I have in my possession the database from TexCAPS/AFCAPS. If the patients reached the combined lipid and blood pressure goal with lifestyle changes alone, they dropped their rate of atherothrombotic disease (ATD) events by 23%. If however they reached the goal with lifestyle changes plus lovastatin, they dropped their ATD event rates by 47%. I choose the statin option for my patients.

The combined regimen of association of a diet low in fat content plus the statins are the best combination approach of this problem

A recent Cochrane review, that including almost 60,000 people who have been in studies assessing effects of reducing saturated fat for at least two years each. Together the studies provide moderate-quality evidence that reducing saturated fat and replacing it with polyunsaturated fats reduces our risk of cardiovascular disease. (Ref: Hooper, Lee, et al. "Reduction in saturated fat intake for cardiovascular disease." Cochrane database of systematic reviews 6 (2015).

Providing statin may be applicable at advance stage of lipid level.

I don't know of a single trial in which diet alone gives better results than statin therapy.

Depending of the case. Is better to start on a lipid low content diet and if its fail start on statins

Dear Sir

Atherosclerotic cardiovascular risk assessment is important, accordingly you guide the therapy: Either high, moderate statins therapy, or lifestyles modifications including a healthier diet. In the case of a high triglycerides (>500 mg), fat restriction together with the appropriate therapy is mandatory to avoid acute pancreatitis.