Cholesterol and Vascular Disease Part 5: Non-Statin Cholesterol Medications

Last week, in part 4 of this blog series we spoke about the statins. This week we will look at other cholesterol medications. Another very effective method for decreasing LDL is by combining a statin with other drugs.


  • One of the most effective add-on medications is Ezetimibe. This medicine works by blocking cholesterol absorption in our small intestine. It’s not just the cholesterol we eat that is blocked; more importantly it’s the enormous amount of cholesterol that is recycled daily between our liver and intestine. At this point, clinical trials have failed to demonstrate a reduction in heart attack and stroke by using Ezetimibe. Still, many lipid specialists (me included) believe that future trials will demonstrate its importance in particular patient populations.
  • Another important class of cholesterol-lowering drug is called the bile acid sequestrants. Welchol is the most commonly utilized of these medications. By blocking the reabsorption of bile acids in our intestine our liver is forced to produce more bile acids from their precursor, cholesterol. Interestingly, WelChol also has the added benefit of lowering blood sugar and increasing HDL. Patients with very high triglycerides should be careful of this medication because it can increase triglycerides further. Like Ezetimibe, WelChol is best used in combination with a statin.
  • Niacin, vitamin B3, is also often used in cholesterol management. It’s best known for its impact on raising HDL and lowering triglycerides. Niacin also has an effect on LDL however. It increases LDL particle size, and by so doing, can actually decrease LDL particle number. Niaspan is the pharmaceutical version of niacin that is most commonly utilized by the physicians. It’s method of action is poorly understood and quite complex. Like WelChol and Ezetimibe, niacin is also best used in conjunction with a statin.
  • Fenofibrates represent yet another class of medications that is used for cholesterol management. Their dominant effect is to lower triglycerides and raising HDL. At this point clinical trials have not found them to be effective in decreasing cardiovascular events, but they are improving lipids and lipoproteins.
  • The active ingredients in fish oil, DHA and EPA, can also have an effect on lipids and lipoproteins. They can lower triglycerides, increase HDL, and sometimes increase particle size and by so doing decrease particle number. In patients with very high triglycerides, fish oils can at times increase LDL cholesterol. Their method of action is also quite complex and beyond the scope of this blog.

Diet and Exercise

In managing cholesterol abnormalities we should never neglect the value of diet and exercise.  A healthful diet will unquestionably improve your lipid and lipoprotein profile. Even when taking a statin, a healthful diet must be maintained.  In fact, there is a specific dietary program called the Portfolio Diet that is geared specifically to lower cholesterol. Exercise can also benefit your lipid and lipoprotein profile. Daily exercise for 30-60 min. can significantly decrease your LDL particle number, increase your HDL, and lower your triglycerides. The bottom line, if you’re physically capable, exercise every day.

A few other cholesterol management strategies are either in the pipeline, or utilized only in very high risk patients. They will be the subject of next week’s blog, part 6 in this series, Cholesterol and Vascular Disease.

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9 Out of 10 Americans Eat Too Much Salt – Know the Foods to Avoid

Americans are eating too much salt. A recent study published by the Center for Disease Control found that the many Americans consume way too much salt. The study, based on surveys of more than 7,200 people in 2007 and 2008 (including nearly 3,000 children), found that approximately nine out of 10 persons in the United States ingest more sodium than recommended. Daily dietary sodium intake, excluding sodium added at the dinner table, averages 3,266 mg/day. The Dietary Guidelines for Americans recommends a daily sodium intake 2,300 mg overall and 1,500 mg for specific at-risk populations comprising about half of the population. Those numbers indicate that many Americans may be consuming up to twice their daily-recommended intake of sodium per day.

Health problems related to high sodium consumption include high blood pressure, or hypertension, which in 2008 was reported as a primary or contributing factor in approximately 348,000 deaths in the U.S. Hypertension is widespread, with thirty-one percent of adults in the United States being afflicted and fewer than half of those having their blood pressure under control. A mere 33% reduction in the average American’s daily sodium intake would potentially avert up to 81,000 deaths, and save an estimated $20 billion health-care dollars annually.

Sources of Dietary Sodium
Contrary to popular opinion, the problem with salt over-consumption lies not in the use of a salt shaker, but in eating the wrong foods. Americans get approximately two-thirds of their dietary sodium from processed foods and drinks purchased at their local supermarket or convenience store, and about one fourth from restaurant food — a source that has the highest per-calorie dietary sodium level.

Results of the CDC’s study indicate that a whopping 44% of sodium intake comes from 10 common foods (highest to lowest):

  • Bread and rolls
  • Cold cuts/cured meats
  • Pizza
  • Poultry
  • Soups
  • Sandwiches such as cheeseburgers
  • Cheese
  • Pasta mixed dishes
  • Meat mixed dishes
  • Savory snacks like chips and pretzels

What Can Be Done?
People must be more careful about their food choices. And food manufacturers need to make reducing the sodium content in their food products a top priority. Consumers need to become more proactive – demand that manufacturers and restaurants strive to reduce excess sodium added to foods. States and localities can implement policies to reduce sodium in foods served in institutional settings like schools, child-care centers, and government cafeterias.

Six simple tips:

  • NEVER use a salt shaker (it goes without saying, but I had to say it anyway).
  • Cooking fresh food at home is the best way to reduce sodium intake. It is also the best way to stay lean.
  • Do the math — monitor your daily sodium intake and try to keep that number under 2,300 mg.
  • Avoid high salt content processed foods and those on the list above — a typical frozen 5 oz. turkey dinner can contain over 700 mg of salt!
  • Read those supermarket food labels — choose low sodium alternatives. Watch out for misleading food labels that claim “low sodium’ but really mean slightly “less” sodium.
  • Avoid salty items at restaurants. For instance, Red Lobster’s Admirals’ Feast packs a staggering 7,106 mg of sodium and a McDonald’s Chicken Club Sandwich contains roughly 1,690 mg of sodium. Ouch!

Learn more about preventive cardiology at

Additional information is available at

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