Latest / Heart Health, Reimagined with Dr. Mona Shah, MD / Berberine, Bergamot, Red Yeast Rice, or Plant Sterols — What Actually Works?

Transcript

Berberine, Bergamot, Red Yeast Rice, or Plant Sterols — What Actually Works? · Heart Health, Reimagined with Dr. Mona Shah, MD

• 0:00
  SPEAKER_00: Because I practice holistic cardiology, I get asked this question all the time.
• 0:05
  SPEAKER_00: Do I really need medication?
• 0:07
  SPEAKER_00: Can I try supplements and lifestyle first?
• 0:10
  SPEAKER_00: Actually, I'm very open to that conversation.
• 0:13
  SPEAKER_00: There are natural supplements that really can lower LDL and sometimes APOB.
• 0:19
  SPEAKER_00: And registry rice, berberine, bergamot, and plant stols are the primary ones people ask me about.
• 0:26
  SPEAKER_00: The main options in the supplement world for this.
• 0:29
  SPEAKER_00: I also have a separate video on the five supplements I recommend to most patients more broadly.
• 0:36
  SPEAKER_00: This one here is specifically about cholesterol and APOB.
• 0:41
  SPEAKER_00: These four do not all work the same way.
• 0:44
  SPEAKER_00: They don't all lower cholesterol by the same amount.
• 0:47
  SPEAKER_00: Some have much better evidence than others, and some may have benefits beyond just lowering a cholesterol number.
• 0:54
  SPEAKER_00: So in this video, I'm going to show you what actually works, what the evidence really says, and most importantly, when a natural first approach might be completely reasonable, and when unfortunately, supplements just may not be strong enough.
• 1:11
  SPEAKER_00: But before any supplement, diet and lifestyle are always the foundation.
• 1:16
  SPEAKER_00: What you eat, how you exercise, your metabolic health, your sleep, your blood pressure, your weight, if that's an issue, those things come first.
• 1:27
  SPEAKER_00: Then we decide whether we need something more.
• 1:32
  SPEAKER_00: So before we go supplement by supplement, the bigger question is who might actually be a good candidate for a natural first approach?
• 1:40
  SPEAKER_00: Because this is where the whole picture matters.
• 1:43
  SPEAKER_00: This is a conversation I have with my patients all the time.
• 1:47
  SPEAKER_00: Imagine somebody has very minimal plaque.
• 1:50
  SPEAKER_00: Their APOB is a little higher than I would like.
• 1:53
  SPEAKER_00: Their overall risk is fairly low.
• 1:55
  SPEAKER_00: And maybe I just want to lower their LDL or APOB another 10 or 15% to keep them safe.
• 2:01
  SPEAKER_00: We optimize diet and lifestyle first.
• 2:04
  SPEAKER_00: Then, depending on that person, I may use one supplement or sometimes combine a few evidence-based options.
• 2:12
  SPEAKER_00: And then I repeat the labs a few months later.
• 2:14
  SPEAKER_00: And I look.
• 2:15
  SPEAKER_00: Did the LDL come down?
• 2:17
  SPEAKER_00: Did the Apo B come down?
• 2:19
  SPEAKER_00: Did the triglycerides improve?
• 2:21
  SPEAKER_00: We measure the response rather than guessing.
• 2:24
  SPEAKER_00: I think that can be a very reasonable approach in the right patient.
• 2:29
  SPEAKER_00: Now compare that with somebody who has already had a heart attack or somebody whose coronary imaging shows a significant amount of plaque, or someone with a very high APOB plus other major risk factors.
• 2:43
  SPEAKER_00: That is a completely different conversation.
• 2:46
  SPEAKER_00: If I need a 50 or 60% reduction, I'm not going to pretend supplements that lower LDL by 10 or 15% is going to do the same job.
• 2:57
  SPEAKER_00: Sometimes supplements are useful.
• 3:00
  SPEAKER_00: Sometimes I combine them with medication.
• 3:02
  SPEAKER_00: But sometimes, unfortunately, they simply are not a substitute for medication when medication is actually needed.
• 3:10
  SPEAKER_00: That is where shared decision making comes in and precision medicine.
• 3:15
  SPEAKER_00: I'm Dr.
• 3:15
  SPEAKER_00: Mona Shaw, a holistic cardiologist focused on prevention and looking at the whole picture.
• 3:20
  SPEAKER_00: And if you like these kinds of deeper dives, every week I put out videos on early detection and prevention of heart disease, advanced cardiovascular labs, coronary imaging, nutrition and lifestyle.
• 3:33
  SPEAKER_00: Subscribe if you want to keep learning how to understand your actual cardiovascular risk before you have a problem.
• 3:41
  SPEAKER_00: Today we are comparing four of the natural options I get asked about most: Reg yeast rice, berberine, bergamot, and plant sterols or stanels.
• 3:54
  SPEAKER_00: I also have another video coming out on natokinase, turmeric, garlic, and coQ10.
• 4:01
  SPEAKER_00: Those are slightly in a different conversation because we are not necessarily using all of them primarily to lower LDL or APOB.
• 4:09
  SPEAKER_00: So let's start with red yeast rice.
• 4:11
  SPEAKER_00: Red yeast rice is probably the one people most often think of as the natural statin.
• 4:16
  SPEAKER_00: And there's a reason for that.
• 4:18
  SPEAKER_00: Red yeast rice can contain monocline K, and monocalin K is chemically identical to Lovastatin.
• 4:26
  SPEAKER_00: So this is not just something that vaguely acts like a statin.
• 4:30
  SPEAKER_00: One of its active compounds is literally the same molecule.
• 4:34
  SPEAKER_00: And that is one reason it can lower cholesterol.
• 4:37
  SPEAKER_00: Depending on the preparation and dose, studies have shown LDL reductions roughly in the 15 to 25% range, and Apo B can come down as well.
• 4:47
  SPEAKER_00: Now clinically, I'll tell you that I often see people tolerate Reggie strice better than prescription statins.
• 4:54
  SPEAKER_00: And the research does suggest that significant muscle symptoms and serious adverse effects at the lower doses used in many studies are relatively uncommon.
• 5:05
  SPEAKER_00: But that does not mean side effects can't happen.
• 5:08
  SPEAKER_00: You can still get some muscle symptoms, it can affect your liver enzymes, and there can be drug interactions.
• 5:15
  SPEAKER_00: So if somebody tells me I don't want to take a statin, but I'm taking red yeast rice, I explain that you're not completely avoiding statin pharmacology.
• 5:24
  SPEAKER_00: You're getting a naturally produced statin compound.
• 5:28
  SPEAKER_00: The other major issue is quality control.
• 5:31
  SPEAKER_00: Different products can contain very different amounts of monoculin K, and some products have been contaminated with citronin, which can be toxics.
• 5:40
  SPEAKER_00: So the product you choose really matters.
• 5:44
  SPEAKER_00: But red yeast rice may also do more than LDL lowering.
• 5:48
  SPEAKER_00: Small human studies have shown reductions in inflammatory markers, improvements in how well the lining of the blood vessels function, improvements in arterial stiffness, and modest improvements in triglycerides.
• 6:03
  SPEAKER_00: There are also effects on enzymes involved in plaque inflammation and stability that are biologically interesting.
• 6:11
  SPEAKER_00: Now, that doesn't mean we have proven that an over-the-counter registrice supplement stabilizes coronary plaque.
• 6:18
  SPEAKER_00: These are encouraging signals.
• 6:20
  SPEAKER_00: They are not the same as proving fewer heart attacks.
• 6:24
  SPEAKER_00: Registrice is also unique among these four because there is some cardiovascular outcome data.
• 6:31
  SPEAKER_00: A standardized registrice extract was studied in almost 5,000 Chinese patients who had already had a heart attack.
• 6:38
  SPEAKER_00: Over the next several years, major coronary events dropped from about 10% in the placebo group to under 6% in the treatment group.
• 6:48
  SPEAKER_00: That's roughly a 45% relative reduction.
• 6:52
  SPEAKER_00: But let's be realistic about what that actually means.
• 6:55
  SPEAKER_00: In absolute terms, it's about a 4-5% point difference.
• 7:00
  SPEAKER_00: Of course, that's still meaningful, but it was one specific standardized preparation.
• 7:06
  SPEAKER_00: Doesn't mean every red yeast rice supplement you buy online or in a store has been proven to prevent heart attacks.
• 7:13
  SPEAKER_00: Next is berberine.
• 7:15
  SPEAKER_00: And this one's interesting because it seems to affect several metabolic pathways at once.
• 7:21
  SPEAKER_00: You have probably heard berberine called nature's metformin.
• 7:26
  SPEAKER_00: I don't really love that description because it makes it sound like the two are interchangeable.
• 7:31
  SPEAKER_00: They're not.
• 7:32
  SPEAKER_00: Berberine can modestly lower LDL.
• 7:35
  SPEAKER_00: Across studies, the average reduction is generally somewhere around 12 to 18 milligrams per deciliter.
• 7:42
  SPEAKER_00: And there are also limited data suggesting an APOB can come down.
• 7:47
  SPEAKER_00: One of the most interesting mechanisms involves the LDL receptor and PCSK9 pathway.
• 7:54
  SPEAKER_00: Your liver has LDL receptors that pull LDL particles out of your bloodstream.
• 7:59
  SPEAKER_00: PCSK9 contributes to the breakdown of those receptors.
• 8:04
  SPEAKER_00: When we preserve more LDL receptors, the liver can pull more LDL out of the blood.
• 8:10
  SPEAKER_00: That is the same general pathway we target very powerfully with drugs like Rappatha and newer PCS-K9 therapies.
• 8:20
  SPEAKER_00: Berberine appears to influence that pathway by increasing LDL receptor activity and reducing PCS-K9 expression.
• 8:29
  SPEAKER_00: But I want to be clear, berberine is not natural ripatha.
• 8:33
  SPEAKER_00: The LDL reduction is nowhere near as large.
• 8:35
  SPEAKER_00: It's just an interesting biological overlap.
• 8:39
  SPEAKER_00: One reason I find berberine particularly useful to think about is that its effects are not limited to cholesterol.
• 8:46
  SPEAKER_00: It can also improve triglycerides, glucose, insulin resistance, and sometimes hemoglobin A1C.
• 8:53
  SPEAKER_00: So if somebody has mildly elevated ApoB or LDL, but also has insulin resistance, higher triglycerides, or worsening glucose, that broader metabolic effect can make berbering an interesting option.
• 9:07
  SPEAKER_00: There are also anti-inflammatory and antioxidant effects being studied, as well as effects on how cholesterols handle inside cells involved in plaque formation.
• 9:19
  SPEAKER_00: A lot of the really exciting plaque biology, though, is still coming from animal and laboratory studies.
• 9:26
  SPEAKER_00: So again, biologically interesting, yes.
• 9:30
  SPEAKER_00: Proven to regress coronary plaque or prevent heart attacks in humans, not yet.
• 9:35
  SPEAKER_00: But berberine also has real drug interaction potential.
• 9:39
  SPEAKER_00: It can affect several pathways your body uses to metabolize medications.
• 9:44
  SPEAKER_00: So particularly if someone is taking several prescription medications, I want those interactions checked before adding it.
• 9:53
  SPEAKER_00: GI symptoms like constipation, diarrhea, or abdominal discomfort can happen as well.
• 10:00
  SPEAKER_00: Next is bergamot.
• 10:01
  SPEAKER_00: This one is getting a lot of attention.
• 10:03
  SPEAKER_00: You may already know bergamot as a citrus oil that flavors oral gray tea.
• 10:08
  SPEAKER_00: But the doses used in these supplements are far higher than what's in your teacup.
• 10:14
  SPEAKER_00: Bergamot contains polyphenols and flavonoids, and there are studies showing reductions in LDL and triglycerides.
• 10:22
  SPEAKER_00: Some individual studies have shown surprisingly large LDL reductions.
• 10:27
  SPEAKER_00: But this is where I think we have to be cautious.
• 10:30
  SPEAKER_00: These trials are generally small, and different studies use different preparations.
• 10:36
  SPEAKER_00: And the results are extremely valuable.
• 10:38
  SPEAKER_00: So I'm not comfortable telling somebody, take this much bergamot and your LDL will drop 25%.
• 10:45
  SPEAKER_00: We just don't have that predictability yet.
• 10:48
  SPEAKER_00: But bergamot also has potential effects beyond cholesterol.
• 10:53
  SPEAKER_00: Its polyphenols appear to have antioxidant and anti-inflammatory effects.
• 10:58
  SPEAKER_00: There's research looking at blood vessel function, nitric oxide, and LDL oxidation, and even some small human vascular studies.
• 11:08
  SPEAKER_00: So I don't dismiss it.
• 11:09
  SPEAKER_00: I would describe bergamot as promising and biologically interesting, but with the smaller and less standardized evidence based on some of the other options.
• 11:19
  SPEAKER_00: Depending on how the product is prepared, bergamot may contain compounds that interfere with medication metabolism in a way somewhat similar to grapefruit.
• 11:29
  SPEAKER_00: So again, product selection and medication review matters.
• 11:35
  SPEAKER_00: Finally, plant sterols and stannols.
• 11:38
  SPEAKER_00: These probably sound the least exciting, but they actually have some of the most consistent evidence.
• 11:44
  SPEAKER_00: Plant sterols look structurally similar to cholesterol.
• 11:47
  SPEAKER_00: Inside the intestine, they compete with cholesterol for absorption, so you absorb less cholesterol.
• 11:54
  SPEAKER_00: Your liver responds by increasing LDL receptors, and then more LDL particles get cleared from your blood.
• 12:03
  SPEAKER_00: At about two grams per day, taken consistently, LDL generally falls somewhere around 6 to 12%, and Apo B comes down as well.
• 12:13
  SPEAKER_00: The key word is consistently.
• 12:15
  SPEAKER_00: This is not something you take once or twice a week and expect the same result.
• 12:19
  SPEAKER_00: The studies generally use daily intake, usually with meals.
• 12:23
  SPEAKER_00: There are also newer data suggesting small improvements in inflammatory markers, blood pressure, and some measures of vascular function.
• 12:33
  SPEAKER_00: Again, those are encouraging findings.
• 12:35
  SPEAKER_00: But we don't have randomized cardiovascular outcome trials showing that adding plant sterols prevent heart attacks or strokes.
• 12:43
  SPEAKER_00: One important exception, if somebody has a rare genetic condition, cytosterolemia, plant sterols are something we actually don't want to give because those patients absorb excessive amounts of these sterols.
• 12:59
  SPEAKER_00: I also get asked about niacin a lot, usually for lipoprotein A.
• 13:04
  SPEAKER_00: Remember, lipoprotein A is that genetic sticky protein that can attach itself to cholesterol particles and make you more likely to have cardiovascular risk.
• 13:15
  SPEAKER_00: Niacin can lower lipoprotein A to some degree, and I actually used to reach for it more with my patients myself.
• 13:23
  SPEAKER_00: But the outcome studies with niacin were disappointing.
• 13:27
  SPEAKER_00: Adding it on top of other cholesterol lowering therapy did not reduce cardiovascular events, and in some trials it caused more harm.
• 13:36
  SPEAKER_00: In my personal experience, the doses I needed to use to move the lipoprotein A meaningfully also were so high that most people couldn't tolerate them.
• 13:45
  SPEAKER_00: They had flushing, itching, and potential liver issues became real problems.
• 13:50
  SPEAKER_00: So for most patients, niacin is not something I reach for anymore.
• 13:55
  SPEAKER_00: Do you have to pick just one of these supplements?
• 13:58
  SPEAKER_00: Not necessarily.
• 13:59
  SPEAKER_00: And this is actually something I sometimes do with my own patients when I think a natural first approach is appropriate.
• 14:06
  SPEAKER_00: I may actually combine two or three of these, sometimes even more than that.
• 14:11
  SPEAKER_00: There is some clinical trial evidence suggesting that combinations can lower LDL and APOB more than just using one ingredient alone.
• 14:21
  SPEAKER_00: And that makes sense because they're working through different pathways.
• 14:25
  SPEAKER_00: Plant sterols reduce cholesterol absorption, red yeast rice reduces cholesterol production, berberine affects LDL receptor activity and several metabolic pathways.
• 14:38
  SPEAKER_00: So potentially you can get an additive effect.
• 14:41
  SPEAKER_00: There are trials, for example, where red yeast rice combined with plant sterols or berberine produce a greater LDL lowering than one supplement alone.
• 14:51
  SPEAKER_00: But I don't want anyone watching this to go by four supplements and create their own cholesterol cocktail.
• 14:59
  SPEAKER_00: The more things we combine, the more important dosing, product quality, side effects, and medication interactions become.
• 15:08
  SPEAKER_00: What I may do in an appropriate patient is optimize diet and lifestyle first, choose a thoughtful combination, and then repeat the LDL and APOB in a few months.
• 15:19
  SPEAKER_00: If we achieved what we wanted, great.
• 15:21
  SPEAKER_00: If not, then we have objective evidence that we need to pivot and change plans.
• 15:27
  SPEAKER_00: So do these supplements do more than just lower cholesterol?
• 15:30
  SPEAKER_00: Yes, and I think that's important.
• 15:32
  SPEAKER_00: These supplements are not placebos.
• 15:35
  SPEAKER_00: Regis rice has human data involving inflammation and blood vessel function.
• 15:39
  SPEAKER_00: Berberine has effects on glucose metabolism, insulin resistance, triglycerides, inflammation, and oxidative stress.
• 15:48
  SPEAKER_00: And bergamot has interesting polyphenol and vascular effects.
• 15:52
  SPEAKER_00: Plant sterols appear to have small measurable effects on several cardiovascular biomarkers beyond LDL.
• 16:00
  SPEAKER_00: That really gives us options as a legitimate role to discuss for somebody who strongly prefers a natural first approach.
• 16:09
  SPEAKER_00: But again, we need to keep two different levels of evidence separate.
• 16:13
  SPEAKER_00: Improving a blood marker or endothelial function is encouraging.
• 16:17
  SPEAKER_00: Proving fewer heart attacks or strokes is a much higher bar, and we simply don't have that level of evidence for most of these supplements.
• 16:27
  SPEAKER_00: For me, diet and lifestyle always comes first.
• 16:31
  SPEAKER_00: Then I look at the whole person.
• 16:33
  SPEAKER_00: How high is the APOB?
• 16:34
  SPEAKER_00: How low do I need to get it?
• 16:36
  SPEAKER_00: What is the lipoprotein A?
• 16:38
  SPEAKER_00: What is family history?
• 16:39
  SPEAKER_00: What does the imaging show?
• 16:41
  SPEAKER_00: Is there a lot of soft plaque and vulnerable plaque?
• 16:45
  SPEAKER_00: How has this person already had a cardiovascular event?
• 16:49
  SPEAKER_00: If someone has almost no plaque, mildly elevated APOB, and otherwise relatively low risk, I'm very open to trying an evidence-based natural approach first and measuring what happens.
• 17:01
  SPEAKER_00: But if somebody has extensive coronary plaque, has already had a heart attack, has very high APOB, or carries another major risk factor like glypoprotein A, I may need a much larger reduction.
• 17:15
  SPEAKER_00: And I'm just not sure these supplements can get me to that target that I want for that patient.
• 17:23
  SPEAKER_00: And it also doesn't have to be natural versus prescription.
• 17:27
  SPEAKER_00: Sometimes I use lifestyle, nutrition, and supplements, sometimes medication, sometimes a combination of all of those.
• 17:35
  SPEAKER_00: The goal is to choose enough treatment for the actual level of risk.
• 17:40
  SPEAKER_00: That's precision medicine.
• 17:42
  SPEAKER_00: And that's combining East and West.
• 17:45
  SPEAKER_00: If you prefer a natural first approach, there are legitimate options.
• 17:49
  SPEAKER_00: Reggie's rice probably has the strongest LDL lowering potential of this group.
• 17:54
  SPEAKER_00: Plesterols give you a smaller but fairly predictable effect.
• 17:57
  SPEAKER_00: Berberine may be especially interesting when cholesterol issues travel with insulin resistance, higher glucose or triglycerides.
• 18:05
  SPEAKER_00: And bergamot is promising, although the evidence is still less standardized.
• 18:10
  SPEAKER_00: In the right patient, I may combine some of these and then repeat LDL and APOB a few months later to see if we've accomplished that.
• 18:27
  SPEAKER_00: If you're interested in why I don't think statins are always the answer, watch that video next.
• 18:34
  SPEAKER_00: It's on your screen now.