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I’m in America right now, visiting my family for the first time in over a year. I’ve been having a wonderful time with them – right up until my older brother casually told me how, a year ago, his cholesterol was checked for the first time and “something was high, like I think my triglycerides were over 800, and my good cholesterol was low, and my total was over 300. Something like that…”

Well, that certainly perked up my ears. My oldest brother had cholesterol problems at such dangerously high levels (normal TG is under 150) that he was a “walking heart attack risk” before the age of 50. Needless to say, I picked up my jaw off the floor and had a long brother/doctor heart-to-heart discussion with him about how serious this was. I even showed him his cardiovascular risk score (from myhealthcheckup.com) and showed him how he has a 12% risk of having a heart attack or a stroke in the next 10 years (normal risk is ~5%; mine is 1.5%; anything over 10% worries us docs). I’m not exactly sure how that doctor last year let him get out of his office without medicines or strong warnings, but it doesn’t really matter now; I have no intention of letting my only older brother depart from this world prematurely.

One important point for my readers is that for many of you, as well as for my brother, lifestyle changes only take you so far. Honestly, even if my brother spent 3-6 months losing 10 kilograms and having a hardcore low-fat diet, his levels still would be higher than normal, certainly still high enough to be laying down that artery-clogging cholesterol plaque in his heart and brain. Many people cling to this noble idea that lifestyle changes will help a lot, and they absolutely do and should be a part of anyone’s treatment, including when on prescription meds. But for a great many of us, medicines are inevitable. That’s not a bad thing at all! It’s just the hard draw of our genetic makeup. This idea is called epigenetics, a very trendy and exciting research term: our genetic makeup determines a lot about which diseases we get, but our environment can dramatically effect how severe, or how quickly, we develop those pre-programmed diseases. In my brother’s case, he likely has a genetic weakness for cholesterol, especially triglycerides, but his decades of a typical American diet clearly makes his condition worse than it could be.

That’s why cholesterol-lowering medicines for many of us are not only inevitable but essential. The prescription statins such as Lipitor have been remarkably effective for tens of millions of people, and they literally can cut your risk of heart attacks and strokes more than 50%. But another take-home message is that a few natural medicines can also really help many of us. The best evidence is for omega-3 fatty acids as well as niacin, but fiber and other natural products also help a bit.

I’ve written a lot about omega-3, a natural fatty acid which is found in all the fatty fish, especially salmon, mackerel and sardines. The healthiest way to get this is to eat those fish as often as possible, at least twice a week. If that’s not too practical, all pharmacies carry fish oil supplements.
If you do decide to take it, and if you can tolerate the fishy aftertaste, there are some key facts:

• LOOK CLOSELY AT THE FINE PRINT. Sure, it may say “1000mg fish oil”, but we’re not interested in that. We want to know the TOTAL AMOUNT OF OMEGA 3 (DHA and EPA) – which is usually only a third of the total oil amount! So the key is to look at the nutrition label to see how much TOTAL omega 3 it has — again a combination of DHA and EPA. Usually, your 1,000mg of fish oil only has about 360mg of omega-3. That means, if you need to take 1 gram a day of omega 3, you need to take 3 capsules. (Shoppers tip: in the US, the megastores Costco and Sam’s Club have big bottles of higher-strength, and enteric-coated, softgel capsules. I always stock up at Costco when I go home).
• For general low cholesterol issues, people should usually take 1 gram a day of the omega 3.
• For more severe cholesterol problems (such as my brother), usually 2-3 grams a day of omega 3 is recommended. That means some of you may need to take ~8 pills a day, if you can tolerate them.
• Don’t forget that omega-3 is mostly beneficial for triglycerides; it can lower TGs by 23-45%. It is NOT very effective for lowering total cholesterol, and it actually raises LDL a bit, which may surprise many of you. But it also raises HDL, the “good cholesterol”, by a similar amount – thus canceling out the bad effect on LDL (we think). To be most effective in my brother’s case, he would need to take a lot, at least 2 grams – but 4 grams is even better, if he can tolerate it.

Another natural treatment for cholesterol, niacin, is actually a simple over-the-counter mineral which is quite cheap. Niacin is quite effective for some types of high cholesterol but isn’t commonly used – mostly due to the side effects and liver problems. Here are some important points:

• Niacin is great for lowering triglycerides, at high doses >1,500mg daily. It lowers triglycerides by 20% to 50%.
• Niacin decreases LDL-C by about 5% to 25%.
• It’s excellent for increasing HDL-C. It increases HDL-C by up to 35%.

But side effects of niacin are very common, and many people cannot tolerate this for too long. The most common problem is headaches and a flushing reaction people get after taking their medicines, almost like a hot flash. This can range from barely noticeable to intolerable. Some tricks to avoid the side effects are to take a baby aspirin 1/2 hour before your niacin, and also to buy the extended-release and not the immediate-release niacin. The most concerning — but rarer — side effect is liver toxicity; you should not start niacin by yourself without first getting your liver function tested by your doctor. And your doctor can help you choose which niacin is best. The extended-release pills have less flushing and headache effects but they also increase the risk of liver toxicity.
Niacin can also increase glucose levels, so diabetic or pre-diabetic persons should discuss this issue with their doctor before starting niacin.
One great thing about niacin is price – the OTC versions can be as cheap at $10 a month. But then you also cannot guarantee that the doses are totally accurate; in some cases, it’s still better to get the prescription versions. If you have insurance, it’s probably best to get it from your doctor, or at least get their recommendation as to which, if any niacin, you should take.

As for prescription medicine, my brother’s triglycerides are best treated with prescription fenofibrate, usually called Tricor in most countries. This medicine has a long track record and is, by far, the top choice that doctors would use in this case – much more than niacin, for example. Fenofibrate lowers TGs over 50%, and it also lowers LDL and raises HDL. Thus, it’s a potent triple-benefit for people with seriously high triglycerides. But since he’s currently waiting for his health insurance to kick in (welcome to America!), there’s nothing at all wrong with now starting omega-3 supplements right now, and perhaps niacin if he gets his liver tests first. There’s also a bunch of fiber supplements and others that work a bit: here’s a nice graph from the Natural Medicines Database article on natural ways to lower cholesterol:

natural medicines to lower cholesterol

So I’m now heading back to China, at least feeling a bit better that I could help my brother out. The hardest part – lifestyle changes and weight loss – will be up to him.