Niacin and Cholesterol

”Is there any value to niacin for heart health?””If I’m taking niacin, should I keep taking it?”

Here are answers from the physicians and registered dietitians involved in heart-health education at the Pritikin Longevity Center.

“First and foremost, it is always essential to discuss your medications and any potential changes to them with your personal physician,” urges Tom Rifai, MD, member of the Pritikin Scientific Advisory Board and Medical Director of Metabolic Nutrition & Weight Management at St. Joseph Mercy Oakland Hospital in Michigan.

“For most patients, there is no robust evidence that niacin can substitute for statins, or that niacin added to statin therapy has value.

“I would also argue that there is no robust evidence that statins can be an alternative to a healthy, Pritikin lifestyle. But every patient is different. Every patient has his or her own physiological profile. That’s why it’s so important to talk to your personal physician.”

Niacin and cholesterol

In years past, doctors nationwide often prescribed niacin because of its documented ability to raise HDL cholesterol (the so-called “good” cholesterol) and modestly lower LDL (bad) cholesterol and triglycerides, all of which may reduce the risk of cardiovascular disease.

Of particular interest was niacin’s HDL-raising effect because very few other drugs were known to safely and successfully increase HDL.

But the two large recent studies on niacin and HDL found that niacin, though it improved HDL numbers, did not seem to improve outcomes. Taking niacin led to no reduction in cardiovascular-related events – no reductions in strokes and heart attacks.

In the AIM-HIGH trial¹, a study of 3,414 people funded by the National Institutes of Health, niacin was added to a statin in one group of heart disease patients in the hope of improving HDL and reducing cardiovascular-related events. A second group of heart patients took statins alone. The result? The statin-plus-niacin group achieved no better outcomes than the statin-only group. In fact, the statin/niacin takers actually suffered a slight increase in the likelihood of stroke.

The more recent HPS2-THRIVE trial² confirmed AIM-HIGH’s results. After nearly four years of follow-up involving 25,673 heart disease patients, adding niacin and an anti-flushing drug to statin therapy did not reduce the risk of coronary deaths, heart attacks, strokes, or procedures like bypasses and angioplasties.

HPS2-THRIVE also demonstrated that the possible side effects of niacin – flushing, aggravated gout or peptic ulcer, lowering of glucose tolerance, and increased likelihood of liver toxicity – reduced patient compliance with this therapy.

HDL cholesterol

But let’s step back a moment. We need to ask: Why are we focusing so much on HDL in the first place?

“We need to remember that good cardiovascular heart is not based solely on one factor, like HDL. Good cardiovascular health involves a multiplicity of factors,” points out cardiologist Ronald Scheib, MD, FACC, Medical Director at the Pritikin Longevity Center.

Among lifestyle-related factors, LDL cholesterol is likely most important, but also very critical is blood pressure, body weight, body fat, inflammatory factors, triglycerides, smoking, blood sugar, insulin levels, and now, research is finding, particles that flood the blood right after a fatty meal, called VLDL and chylomicrons, that promote the growth of cholesterol-filled plaques.

No pill – or combination of pills – is capable of keeping all these variables in good working order.

The far better approach, one that improves virtually all lifestyle-related risk factors for cardiovascular disease, is the more natural one – a very healthy lifestyle like the Pritikin Program.

When you exercise daily and eat well – an abundance of whole foods like fruits, vegetables, beans (legumes), and whole grains, all naturally low in salt, fat, sugar, and refined (“white”) carbohydrates – the following benefits happen, demonstrated in more than 100 peer-reviewed studies on the Pritikin Program:

• Decreased LDL levels
• Decreased blood pressure
• Decreased blood glucose (sugar) and insulin levels
• Loss of excess body fat
• Decreased levels of inflammatory factors
• Decreased fasting and postprandial (after meal) triglyceride levels, generally associated with decreased VLDL and chylomicrons

Moreover, it is a low-fat, fiber-rich, Pritikin-style eating plan plus daily exercise (not HDL-raising drugs) that has been scientifically documented to relieve angina, reverse atherosclerosis, and reduce cardiovascular events and total mortality. We do not have comparable data for any drug or drug combination, or for higher ‘good fat’ diets.

Reassessing HDL cholesterol

Growing research also suggests that increasing HDL, a goal of many doctors and patients nationwide, may not be so important after all.

The fact is, populations who enjoy the lowest incidences of heart disease in the world, such as the people of Okinawa and other rural regions of Japan, tend to have very low levels of HDL, often in the 20s and even lower.

Quality may trump quantity

Indeed, HDL levels tend to go down a little when people first start the Pritikin Program. But the functionality of HDL appears to improve significantly.

For heart health, in other words, what may be far more important than quantity of HDL is quality.

HDL, fats, and scavenger receptors

One of the main reasons HDL levels tend to drop on the Pritikin Eating Plan is because the diet is low in saturated and monounsaturated fats. These fats suppress the production of scavenger receptors called B1.

At first glance, squelching these scavengers seems like a good thing. That’s because they latch onto HDL particles in the blood, extract their cholesterol, then release the emptied HDL particles back into circulation, which tends to lower HDL cholesterol levels.

But this process also allows the HDL particles to return more quickly to the artery wall and pick up more LDL bad cholesterol, and, of course, that’s a very good thing.

Sponge squeezers

“Think of B1 scavenger receptors as sponge squeezers. They squeeze the HDL particle, which means the HDL is now able to soak up more LDL.”

Reverse cholesterol transport

A very low-fat, whole-foods diet like Pritikin, in effect, may be improving what scientists believe is one of HDL’s key roles in heart health – removing the garbage (LDL) from our arteries and transporting it to the “waste removal site” – our livers. This process is known as reverse cholesterol transport.

Two types of HDL

Scientists are also now learning that there are actually two different types of HDL. One is dysfunctional, or pro-inflammatory. This HDL hastens LDL build-up in the arteries.

The other type is anti-inflammatory in nature, which means it’s truly a good HDL. It decreases the amount of LDL that is embedding itself in the artery wall.

What’s really fascinating, research is finding, is that what we eat can impact, even change, the type of HDL we have. Science has found, for example, that a saturated-fat-rich diet can mess up the ability of HDL to protect against damage to arteries, and turn HDL from anti-inflammatory to pro-inflammatory.³

Studies following people who adopted the Pritikin Program found the reverse: pro-inflammatory HDL became anti-inflammatory despite the fact that total levels of HDL went down a little.⁴

Dysfunctional no more

The Pritikin Program, in short, “reverses the dysfunctional HDL,” sums up Dr. Danine Fruge, Medical Director at the Pritikin Center.

“It should also be noted that while HDL levels tend to drop, at least at first, for most people on the Pritikin Program, their HDLs don’t necessarily stay at these lower levels. If people stick to the program and continue to lose weight and exercise, odds are good their HDLs will increase, except now their HDLs will be more anti-inflammatory and more efficient at reverse cholesterol transport because of the increased scavenger receptor B1s.”

Niacin and cholesterol | Summing up

Always discuss your medications and any alterations with your personal physician. What’s right for the general public may not be right for you.

Regarding niacin, the research we have indicates that for most people, niacin does not appear to provide additional benefit when patients are well treated with statins.

The research we have also indicates that for overall good health, drugs, including statins, pale compared to the benefits of a healthy lifestyle like Pritikin. Sure, it’s easier to pop pills, but by embracing Pritikin living, you’re not only preventing cardiovascular-related events like a heart attack, you’re greatly lessening your risk of many other now-epidemic conditions in America, including diabetes, obesity, hypertension, cancer, gout, Alzheimer’s disease, and even impotence.

You’re also free of the side effects that almost always accompany drugs.

“To reduce the risk of cardiovascular disease, the general prescription is 1) improve your lifestyle and 2) take medications, if needed, in tandem with lifestyle changes,” sums up Dr. Scheib.

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• ¹ New England Journal of Medicine, 2011; 365; 2255.
• ² European Heart Journal, 2013; 34 (17): 1279.
• ³ Annual Review of Physiology, 2010; 72: 219.
• ⁴ Journal of Applied Physiology, 2006; 101: 1727.