I WAS READING A SCIENTIFIC PAPER in the Journal of the American Medical Association a number of years ago by Dr. David Jenkins from the University of Toronto. He showed that using a combination of soy, fiber, almonds, and plant sterols (cholesterol-lowering fats) could lower cholesterol levels as much as statin medications.(i) Diet can lower cholesterol as much as statins — a surprise to many but common in my practice. Using a comprehensive approach of diet and lifestyle change, I routinely see effects that are more powerful than any medication. That was not why the article struck me. It was a finding buried in the text of the paper.
What I found fascinating was that the patients who lowered their cholesterol with statins had higher levels of insulin, while those who lowered their cholesterol through diet had lower insulin levels. Why is that important? Because elevated insulin levels are the first step on the road to diabetes — they make you gain weight around the middle, cause high blood pressure, increase inflammation, and promote stickiness of the blood. Each of these conditions, in turn, contributes to heart attacks and heart disease.
On reading this, the question that lingered in my mind was: Did statins contribute to the development of pre-diabetes and diabetes which are among the most significant risk factors for heart disease? In other words, did lowering cholesterol with statins — a treatment purported to reduce the risk of heart disease — actually increase the risk of heart disease by some other mechanism?
In treating thousands of patients with pre-diabetes, diabetes, high cholesterol, and heart disease, I have noticed one thing: Lowering insulin through diet and lifestyle corrects almost all of the risk factors for heart disease. It lowers blood pressure, increases good cholesterol (HDL), lowers triglycerides and bad cholesterol (LDL), leads to weight loss, lower levels of inflammation (C-reactive protein), and thins the blood. Lowering insulin even increases the light fluffy harmless cholesterol and lowers the level of small dense harmful cholesterol particles.
Lowering insulin is a good thing. However, statins — the best selling class of drugs on the market — appear not to do this. Do they actually increase the risk for diabetes and thus heart disease by increasing insulin levels?
The Truth about Statins and Insulin
The answer, according to a recent study in the Lancet, is yes statins do increase the risk of diabetes.(ii) The authors completed a meta-analysis of both published and unpublished randomized controlled trials from 1994 to 2009 for a total patient group of 91,140 who were treated with statins or a placebo. In the patients treated with statins there was a 9 percent increase in the risk of diabetes. The authors suggest this is a minimal risk and that current guidelines for cholesterol treatment should not change. I would suggest we think a little more deeply.
Nutrition, exercise, and stress management can no longer be considered alternative medicine. They are essential medicine.
The study did not analyze any data for pre-diabetes, which dramatically increases the risk of heart disease well before a formal diagnosis of diabetes can be made. It could be that by taking these medications many people developed pre-diabetes or their pre-diabetic condition worsened. If this is true, the full risk of statins was not appreciated. The researchers also failed to consider a simple question: Why should we use a medication with significant potential risks when other treatments have proven MORE effective for reducing the risk of heart disease?
The treatment I’m talking about is dietary and lifestyle change-popularly referred to as lifestyle medicine. The recent “EPIC” study published in the Archives of Internal Medicine studied 23,000 people’s adherence to 4 simple behaviors-not smoking, exercising 3.5 hours a week, eating a healthy diet (fruits, vegetables, beans, whole grains, nuts, seeds, and low meat consumption), and keeping a healthy weight (BMI less than 30). In those that adhered, 93 percent of diabetes, 81 percent of heart attacks, 50 percent of strokes, and 36 percent of all cancers were prevented. (iii)
The fundamental focus of lifestyle or functional approaches (which includes nutrition, exercise, and stress management) is the restoration of normal function and balance in each individual. When you do this, risk factors and symptoms go away automatically. Conventional interventions, on the other hand, are primarily focus on blocking, interfering with, or excising a biochemical or physical manifestation of disease. This is the reason biology shifts towards normal when using lifestyle medicine, instead of medication, and the only side effects are good ones: weight loss, more energy, better sleep, increased well being, a reduction of most disease, and increased longevity.
While it is still a matter of public debate, there is ample evidence that lifestyle therapies equal or exceed the benefits of conventional therapies such as medication and surgery. Nutrition, exercise, and stress management can no longer be considered alternative medicine. They are essential medicine, and often the most effective and cost-effective therapies to deal with the chronic disease epidemic that afflicts millions of Americans and is now the primary cause of death worldwide.
Addressing the Global Burden of Chronic Disease
Chronic disease has replaced infectious and acute illnesses as the leading cause of death in the world, both in developed and developing countries.(iv) In 2002, the leading chronic diseases, including heart disease (17 million), cancer (7 million), chronic lung diseases (4 million), and diabetes (1 million), caused 29 million deaths worldwide. These ailments are almost entirely attributable to lifestyle risk factors including poor diet, sedentary lifestyle, and tobacco and alcohol use. The misperception that these diseases affect primarily developed and affluent societies has led to a misappropriation of resources, which fails to deal with the exponential growth of chronic lifestyle- and diet-related disease.
By 2030, 50 million will die from preventable chronic diseases compared to less than 20 million from infectious diseases. We need to include chronic disease in our global efforts to improve health. In Haiti, the poorest nation in the Western hemisphere, the major admitting diagnoses to the largest and main public health hospital where I worked after the earthquake in January 2010 was not tuberculosis or AIDS, but heart disease, diabetes, and hypertension related heart failure.
The major global health policy makers and agencies do not allocate appropriate resources to the prevention of chronic lifestyle diseases either because they have yet to recognize the problem or the economic and social benefits of focusing on chronic disease are underestimated. Heads of state, health ministries, the World Health Organization, academic and research institutions, non-governmental organizations, private donors, the World Bank, and the United Nations allocate only a fraction of their resources to chronic disease prevention despite a rich evidence base for the role of lifestyle and diet in the prevention of the major chronic diseases.
When compared to doing nothing, the argument can be made for high cost, technological interventions. When compared to changing our medical care system from one focused on treating end-stage disease, to one whose goal is to prevent disease and promote optimal health through nutrition, lifestyle, stress management, and adjunctive complementary therapies, the conversation shifts dramatically.
Diet, Lifestyle, and Chronic Disease: A Model for Increased Quality of Care and Lower Costs
Let’s briefly look at the science of nutrition and compare it to efforts for preventing or treating chronic disease with medication. This will highlight the powerful, cost-effective, and critical role nutrition plays in the cause, prevention, and treatment of chronic illness.
Science provides a firm foundation for moving nutritional and lifestyle interventions to the center of medical practice and public policy.(v) A single nutrient, food, or lifestyle habit when studied as an isolated intervention, while helpful, may not show significant effect, but when assessed collectively, the power of lifestyle over pharmacological approaches to prevent and treat chronic disease is overwhelming. That is why we have to stop looking at single nutrients or interventions and look at the whole picture. In his recent article in the Journal of the American Medical Association, Dr. David Ludwig of Harvard calls for a shift from a nutrient-based to a whole foods-based approach to our dietary guidelines.(vi) He indicts our current dietary guidelines showing how these recommendations have led to our chronic disease epidemic. Let us eat food, he says — real, whole, fresh, complex, interesting food. It’s the whole picture, not just fats or carbs or this or that nutrient that makes a difference.
For example, healthful lifestyle practices in an elderly population that included eating a whole foods Mediterranean-style diet, exercising moderately, not smoking, and moderate alcohol consumption were associated with nearly a 70 percent reduction in death from all causes.(vii) What’s remarkable is that these people didn’t start this healthy lifestyle until they were 70 years old, yet they still reduced their risk of death by 70 percent compared to a similar group of elderly who didn’t follow a healthy lifestyle.
Other studies(viii), (ix), (x) showed similar results including an 83 percent reduction in heart disease,(xi) 91 percent reduction in diabetes in women,(xii) and a 71 percent reduction in colon cancer in men.(xiii)
The Lyon Diet Heart Study,(xiv) showed a 79 percent reduction in heart disease in patients with established heart disease after a few years of following a Mediterranean diet. In another study of patients with existing heart disease, an integrated lifestyle approach of a plant-based diet, exercise, smoking cessation, and stress reduction found a 50 percent reduction in heart attacks and heart disease related deaths.(xv)
The evidence is simply overwhelming that healthful dietary patterns which include whole grains, legumes, nuts, vegetables, fruits, olive oil, fish, and, perhaps, moderate alcohol intake are associated with a decrease in chronic disease and death from all causes. The harmful effects of trans and certain saturated fats, refined carbohydrates, and other food additives or toxins are well known in the medical literature.
It is time to start putting into practice what we know, and stop the domination of our medical practice by the pharmaceutical industry. The Lancet paper on how statins increase the risk of diabetes should be front-page news. Medications such as statins that cost more, are less effective, and lead to serious side effects including diabetes should not be our first line of treatment for preventing or treating heart disease. The recent proposal that statins be handed out with cheeseburgers and fries at fast food restaurants is dangerous and misses the point.
You can’t eat a horrible diet, avoid exercise and expect to be healthy. A whole foods, plant-based diet, moderate physical activity, not smoking, and creating a supportive social network of friends and family is the best medicine. It works in ways we don’t yet understand and don’t need to-just eat real food, enjoy, and don’t worry. Your body knows what to do from there.
To your good health,
Mark Hyman, MD
(i) Jenkins D.J., Kendall, C.W., Marchie, A., et. al. 2003. Effects of a dietary portfolio of cholesterol-lowering foods vs Lovastatin on serum lipids and C-reactive protein. JAMA. 290(4): 502-10
(ii) Sattar, N., Preiss, D., Murray, H., et. al. 2010. Statins and risk of incident diabetes: A collaborative meta-analysis of randomised statin trials. Lancet. 375(9716): 735-42.
(iii) Ford E.S., Bergmann M.M., Kroger J., et. al. 2009. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 169(15): 1355-62.
(iv) Yach D., Hawkes C., Gould C.L., et. al. 2004. Global burden of chronic diseases: Overcoming impediments to prevention and control. JAMA. 291(21): 26
(v) Rimm E.B., and M.J. Stampfer. 2004. Diet, lifestyle, and longevity-the next steps? JAMA. 292(12): 1490-2. No abstract available.
(vi) Mozaffarian, D. and D.S. Ludwig. 2010. Dietary guidelines in the 21st century-a time for food. JAMA. 304(6): 681-682.
(vii) Knoops K.T., de Groot L.C., Kromhout D., et. al. 2004. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: The HALE project. JAMA. 292(12): 1433-9.
(viii) Trichopoulou A., Costacou T., Bamia C., et. al. 2003. Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med. 348(26): 2599-608.
(ix) Salmeron J., Manson J.E., Stampfer M.J., et. al. 1997. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA. 277(6): 472-477.
(x) Liu S., Willett W.C. 2002. Dietary glycemic load and atherothrombotic risk. Curr Atheroscler Rep. 4(6): 454-461.
(xi) Stampfer M.J., Hu F.B., Manson J.E., et. al. 2000. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 343: 16-22.
(xii) Hu F.B., Manson J.E., Stampfer M.J., et al. 2001. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 345: 790-797.
(xiii) Platz E.A., Willett W.C., Colditz G.A., et. al. 2000. Proportion of colon cancer risk that might be preventable in a cohort of middle-aged US men. Cancer Causes Control. 11(7): 579-588.
(xiv) de Lorgeril M., Renaud S., Mamelle N., et. al. 1994. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet. 343: 1454-1459. [published correction appears in: Lancet. 1995; 345(8951): 738]
(xv) Ornish D., Scherwitz L.W., Billings J.H., et. al. 1998. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 280: 2001-2007.