It's peculiarly American to think that if a little of something is good, a lot is better. In the case of cholesterol levels, that translates to if low is good, then very low is even better. This thinking was driven home recently when news headlines talked about lowering the target total cholesterol level from less than 200 mg/dl to less than 180 mg/dl or so -- a boon for the statin manufacturers, no doubt. Some medical professionals are so enchanted with statins that they would like everyone over a certain age to take them routinely as a preventive measure.

But before you sign up for a lifetime supply of Lipitor, keep in mind that there are two whopping problems with this thinking -- cholesterol is essential for the body to function... and statins can have devastating side effects with little or no benefit for large groups of people.

Cholesterol is a type of fat (lipid) that forms the lining of all cell walls and provides a protective sheath around the peripheral nerves. The body also uses cholesterol as the basis for estrogen, testosterone and cortisone. Low-density lipids, or LDL (the type of cholesterol that can plug up the works), transports cholesterol from the liver to other parts of the body for use. High-density lipids (HDL) come along behind the LDL, so to speak, to remove it from the blood vessels and take it back to the liver. The liver then converts it to bile for use in digestion. The liver produces at least 75% of the body's cholesterol. The balance comes from dietary sources.

Nearly everyone knows about the problems caused by too much cholesterol -- of the LDL kind. But few people realize that not having enough cholesterol, a level generally considered to be less than 160 mg/dl, is associated with a variety of serious problems, as a substantial number of studies over the last 10 years have established. As far back as 1994, the American Heart Association reported that low cholesterol is associated with increased deaths from trauma, cancer, hemorrhagic stroke (bleeding into the brain) and respiratory and infectious diseases. More recently, a number of studies have linked low cholesterol levels to depression, anxiety, suicide and even violent behavior. Among the studies: A large French study reported that men with low cholesterol were three times more likely than other men to kill themselves. In Finland, a study of 29,000 men discovered that those with low cholesterol were at increased risk for being hospitalized with major depression.

Beatrice Golomb, MD, PhD, an epidemiologist at the University of California, San Diego, is closely involved in analyzing research on cholesterol and statin use. She reports that the reason low cholesterol is associated with depression and anxiety may be because it is linked with decreased levels of serotonin, the brain hormone that is responsible for a sense of well-being. When I discussed this issue with her, she expressed many other concerns about low cholesterol and the vast number of people taking statins.

Dr. Golomb's Views

One group of people absolutely benefits from very low cholesterol (even below 160): Middle-aged men who are at high risk for heart disease. Dr. Golomb says that unless you are part of this group -- and match all three of those descriptions -- there is no data that shows having low cholesterol and taking statins will benefit you. She explains that cardiologists are the ones driving the intense focus on statins, and obviously their interest is in the high-risk, middle-aged men group.

There are two other groups of people whom many doctors are urging to take statins as well -- women and people aged 70 and over. But guess what? The data shows that these people receive no benefit from having low cholesterol or using statins. In fact, statin use is increasing serious risks, especially for the older group, and creating quality-of- life issues.

Cholesterol and Aging

With age, the body begins to function somewhat differently. Ironically, because of these changes, having higher cholesterol (considered more than 200) seems to help the older body function better, says Dr. Golomb. She says that there are several likely reasons for this. Older people have more trouble absorbing nutrients, and cholesterol is an important factor in nutrient absorption. Cholesterol also seems to help enhance the body's immune system and antioxidant level. Taking statin drugs removes these benefits along with the cholesterol, thus making older people who use them more vulnerable to illness.

There are other, more alarming problems related to taking statins, especially for the over-70 group. Studies have shown a side effect of statins to be cognitive changes, and Dr. Golomb has anecdotal evidence. She says that she has seen a number of older people who were taking statins institutionalized for progressive dementia. When they went off the statins, they returned to their previous cognitive states. (However, she cautions that drug-related damage in older people isn't always reversible, even when a questionable medication is stopped.) Many doctors are reluctant to take people off statins, though, for fear that the patients will then die of a heart attack. Consequently, Dr. Golomb urges everyone -- doctors and patients -- to become informed and aware. If a patient develops a seemingly unrelated problem after starting statin therapy -- such as dementia -- consider the very real possibility that it may be a result of the drug and not an age-related development.

Anyone not in the high-risk group (middle-aged men at high risk for heart disease) that has been shown to benefit from statin therapy also should think carefully about possible side effects of statins. In addition to the ones listed above, these include fatigue, muscle weakness, personality changes and neuropathy (diseases of the nervous system) as well as, in rare cases, liver failure. Statins also have been found to suppress the body's production of coenzyme Q10 (coQ10), an enzyme that helps control inflammation. Individuals who take statins should talk to their doctor about supplementing with coQ10.

Given that the data shows no benefits of statin use outside of the high-risk group, patients should ask themselves if taking the drug is worth the risk of these possible side effects. And furthermore, they should consider whether they might actually need that cholesterol after all.

Sources...

Beatrice Golomb, MD, PhD, epidemiologist, University of California, San Diego.