Q I am 71 years old, and have been fit and healthy all my life. Two years ago, however, I suddenly developed severe pain in my feet, which has meant I have now had to give up recreational walking. My doctor can't explain it, but he's checked my blood cholesterol level and found it is high - 9.1. He's put me on simvastatin, telling me I risk a stroke without it. I don't like the idea of taking drugs, but what's the alternative? - A.J. Burnett, Bexleyheath, Kent
A Simvastatin is one of a clutch of cholesterol-lowering drugs called statins that came on the market about 20 years ago. These have now become among the most profitable drugs in history, and many drug companies have at least one statin in their armoury.
The reason statins are a drug salesman's dream is that they are not prescribed for a defined illness, but for a condition which may or may not give rise to an illness. This means that it can be prescribed for virtually the whole lifetime of the putative 'patient'.
The claim is that statins lower cholesterol levels in the blood, so reducing the risk of atherosclerosis (furred arteries) and, thus, preventing strokes and heart attacks.
Although studies have shown statins to be of value, for some people, the benefits have come at a high price. When the drugs were first marketed, their side-effects were claimed to be minimal, but experience over the years has shown them to be potentially very hazardous.
Simvastatin is one of the worst offenders in its drug class. A recent review found that it was the statin that caused the most rhabdomyolysis - severe muscle weakness that can release toxic muscle cell components into the circulation and so cause life-threatening conditions such as kidney failure (Ann Pharmacother, 2002; 36: 288-95).
Other serious problems now known to be caused by simvastatin include pneumonia, liver toxicity, pancreatitis, polyneuropathy (nerve damage) and fatal ulcerative colitis.
The manufacturer (Merck) says simvastatin's main action is on the liver, where it reduces natural cholesterol output. However, independent researchers have found that the drug also crosses the blood-brain barrier, permitting it to have a direct action on the perfectly healthy (and necessary) cholesterol content of brain cells. This may explain the drug's mental side-effects, such as depression, sleep problems and memory loss.
In the US, the authorities are so concerned about simvastatin that an independent task force has been set up by the National Institutes of Health to 'scrutinise' the drug and decide whether the risks of treatment may, in fact, outweigh the potential benefits.
The scientist in charge of the investigation, Dr Beatrice Golomb, has some interesting views on the current vogue for cholesterol-lowering drugs, which you may find relevant to your case. She is especially hostile to the idea of prescribing statins to older people because of the possibly fatal side-effects. 'For the older elderly, possible reductions in muscle function or thinking ability must be viewed as not only important to quality of life, but to survival,' she says.
Moreover, Dr Golomb questions the whole assumption that cholesterol is necessarily a bad thing. 'There are factors that might lead higher cholesterol to be of benefit selectively in the elderly,' she goes on to say. 'Among older elderly persons, for instance, those over age 75 or 80, higher cholesterol is actually associated with living longer, rather than with dying earlier.'
This astonishing finding was made by Dutch scientists, who checked the medical records of over 700 old people with moderate cholesterol levels and found that those with the highest cholesterol counts lived longer - mainly by avoiding cancer and infectious diseases (Lancet, 1997; 350: 1119-23).
So, it may well be that, at your age of 71, a high cholesterol level may not be such a bad thing after all.
Another issue concerning your high cholesterol count is the amount of HDLs (the 'good' cholesterol that helps the body mop up the 'bad' LDLs) included in your 9.1 total. Your doctor should have been given your HDL percentage, as this is now known to be a crucial piece of information. A recent study has showed that, even if total cholesterol is high, as long as the blood contains enough HDLs, there is no increased risk of vascular problems (N Engl J Med, 1999; 341: 410-8).
The figures are: more than 30 per cent HDLs means you're highly unlikely to have cardiovascular problems; even with 20-30 per cent HDLs, you're still in pretty good shape; anything below 20 per cent is a risk factor; and less than 10 per cent means a stroke or heart attack is probably inevitable.
So, if your HDLs are below 20 per cent, how can you increase them without resorting to drugs?
A few simple changes to your diet may help, in particular, eating wholegrain cereals (high fibre and high vitamin). Epidemiological studies have shown a 30 per cent reduced risk of cardiovascular disease with moderate intakes of wholegrain foods. Just three 'servings' a day will reduce LDLs - and raise HDLs at the same time (Proc Nutr Soc, 2003; 62: 135-42).
Replacing saturated or trans fats with vegetable fats also decreases the amount of LDLs (Am J Med, 2002; 113 [Suppl 9B]: 13S-24S). Keeping up your intake of vitamin C appears to be important too.
In the 1990s, Dr Mathias Rath at the Linus Pauling Institute came up with the radical new theory that the cause of atherosclerosis is a lack of vitamin C. He claimed that the body uses vitamin C to maintain arterial wall strength and that, in the absence of vitamin C, it will use cholesterol instead as an artery-builder - an idea subsequently confirmed by animal experiments at the LPI (Proc Natl Acad Sci USA, 1990; 87: 6204-7). Since then, a Finnish study of more than 2400 men has shown that vitamin C can help prevent strokes - one of the major results of high cholesterol (Stroke, 2002; 33: 1568-73).
Vitamin E has also proved useful in reducing LDL and preventing cardiovascular disease, mainly by lowering the risk of blood clots. It only works, however, at the fairly high dosages of 100-400 IU per day (Clin Excell Nurse Pract, 1998; 2: 10-22). The major constituent of vitamin E is alpha-tocopherol, but a recent study has shown that it's mixed tocopherols that are primarily responsible for the blood-thinning effect (Am J Clin Nutr, 2003; 77: 700-6).
Another alternative to statins is herbal medicine. Gugulipid, extracted from the guggul tree, is an Ayurvedic remedy shown to be a potent LDL cholesterol-buster (Science, 2002; 296: 1703-6).
In Western herbalism, the traditional blood-thinner is garlic (Allium sativum). It can lower total cholesterol, particularly LDL. In one study, 20 men and women were given garlic powder tablets (900 mg/day). After 12 weeks, the garlic takers had an 11 per cent decrease in the LDL compared with 3 per cent in those taking a placebo (Am J Med, 1994; 94: 632-5).