An Update on Statin Alternatives and Adjuncts

Matthew J Sorrentino


Clin Lipidology. 2012;7(6):721-730. 

In This Article

Soluble Fiber

Dietary fiber has been shown to decrease serum total cholesterol and LDL-C levels. Dietary fiber may also help improve glycemic control and reduce the risk of developing Type II diabetes. Dietary fiber can be classified into two groups depending on its solubility in water. Soluble fiber includes oats, flaxseed, barley, psyllium and pectin. Insoluble fibers include cellulose, lignins and wheat bran. Soluble fibers bind bile acids in the intestine causing increased elimination of the bile salts. This leads to upregulation of bile acid synthesis in the liver. Since cholesterol is an integral component of bile acid synthesis, there is an upregulation of hepatic LDL receptors and increased LDL-C clearance from the circulation. Insoluble fiber does not have the same effect on reducing LDL-C unless it replaces saturated fat in the diet. A meta-analysis of 67 trials showed that ingestion of 2–10 g/day of soluble fiber in the diet can reduce LDL-C by approximately 7%.[26] Adding soluble fiber to statin therapy can achieve a similar LDL-C-lowering effect as in doubling the statin dose. One study showed that adding psyllium fiber to 10 mg simvastatin/day achieved a similar LDL-C reduction to that achieved with 20 mg simvastatin/day.[27] This strategy may help individuals who can only tolerate a low dose statin achieve their LDL goal.

Epidemiologic studies have suggested that a diet high in dietary fiber is associated with a lower incidence of coronary heart disease events. The National Health and Examination Survey showed an inverse relationship between legume and soluble fiber intake, and the risk of coronary heart disease.[28,29] Legumes are high in bean protein and soluble fiber. A 12% lower risk of coronary heart disease was noted for individuals with a mean intake of approximately 22 g/day of soluble fiber. A meta-analysis of ten prospective cohort studies was performed to evaluate the association between dietary fiber and coronary heart diseases.[30] The consumption of dietary fiber from cereals and fruits was inversely associated with the risk of coronary heart disease, with a 10–30% lower risk for each 10 g/day increment of fiber.