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So your doctor told you that you have high cholesterol. Now what? If you’re really not into statins and are looking for a more natural way to lower your LDL levels, red yeast rice supplements have been touted for their cholesterol-busting abilities. But do they really work—and are they safe?
What is red yeast rice?
Red yeast rice is a metabolite—a substance the body uses to break down chemicals—produced from yeast that grows on rice. It’s used in traditional Chinese herbal medicine and recipes like Pekin duck. “It’s made in large fermentation vats. It looks a lot like dirt,” says Stanley Hazen, section head of preventive cardiology at Cleveland Clinic.
Some strains of yeast used to ferment red yeast rice contain trace amounts of the compound monacolin K, according to the National Institutes of Health. It’s chemically identical to lovastatin, which was discovered by a Japanese scientist working with yeast extracts and was the first statin drug approved by the FDA to lower cholesterol in 1987, says Daniel Soffer, an internist and clinical lipidologist in preventative cardiology at Penn Medicine.
In 2009, red yeast rice sales in the US were $20 million per year, according to the NIH. And sales may be growing. A Nutrition Business Journal study cited in Consumer Reports found that Americans spent $49 million on red yeast rice supplements in 2015.
What is red yeast rice used for?
Cholesterol comes from two places: what your body makes, and what you absorb from food. The monacolin K in some red yeast rice products is considered a “natural statin” that, like lovastatin, reduces production of cholesterol by the liver, Hazen says. "There’s a big international movement toward wanting to use non-pharmacological treatments that have health benefits," Soffer says, so this fits into the niche of people taking medicine that’s not ‘medicine.'"
High cholesterol, in turn, can narrow your arteries, leading to heart attacks, strokes, and death. “About 15 years ago, cardiovascular disease passed infectious disease as the number one killer in the world,” says Stephen Kopecky, a cardiologist at the Mayo Clinic. The amount you lower your cholesterol is proportional to your reduction in cardiovascular disease, Soffer adds.
Some research has found that people who can’t tolerate statins because of side effects can tolerate red yeast rice, possibly because of lower levels of monacolin K, according to the NIH. But that doesn’t mean the drug is without potentially big side effects.
Does red yeast rice really lower cholesterol?
Experts say red yeast rice indeed can lower your “bad” LDL cholesterol levels—it’s just not all that effective.
Most studies on red yeast rice have been short-term and in modest-size populations, Soffer says. As a more robust example, Hazen points to a 2008 Chinese study of almost 5,000 people with coronary artery disease taking at least 600 mg of red yeast rice extract for five years. It found their risk of death from coronary artery disease—or any other cause—as well as their need for heart surgery like angioplasty dropped by about a third. Another 2014 meta-analysis found that taking red yeast rice supplements daily for at least a month lowered LDL cholesterol more than a placebo.
Problem is, the amount of monacolin K in red yeast rice is “quite low and can be variable from source to source,” Hazen says. In fact, the FDA has banned red yeast rice with more than “trace amounts” of monacolin K due to unscrupulous practices within the supplement industry. “About ten years ago, people were finding marked reductions in their cholesterol because some manufacturers were literally spiking their plant products with the synthetic compound lovastatin to ensure it would lower cholesterol,” Hazen says.
Today, there’s no way to know how much monacolin K there is in the supplement you’re buying, although the typical red yeast rice pill has about 4 to 6 mg, versus 10 to 40 mg in generic lovastatin, Kopecky says. And lovastatin is one of the least potent statins—which means you can see more cholesterol-lowering benefits from lower doses of more powerful options. “I haven’t started anyone on lovastatin in 20 years, because it requires a high milligram dosage to achieve the same cholesterol lowering,” Soffer says.
Just how much monacolin K you’ll need to lower your cholesterol is genetically determined, Kopecky explains: While some people can lower their cholesterol on red yeast rice, for others their cholesterol actually goes up a bit. That’s why experts stress it’s important to work with your doctor to figure out if the treatment you’re on is actually working.
What are the side effects and downsides to red yeast rice?
Because red yeast rice extract contains the same active ingredient as prescription statins, it can cause side effects similar to statins, including muscle pain and weakness, experts say. Approximately 3 to 5 percent of all people on statins experience muscle aches or stiffness, Hazen says, with side effects increasing with the dose of the drug you’re taking. Kopecky, however, says the often-cited figures about side effects are underestimated, since the initial studies in 1987 excluded patients who couldn’t tolerate the drug—so more like 15 to 20 percent of people are likely to experience side effects on statins.
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Drug interactions on both statins and red yeast rice is another biggie. Taking red yeast rice with some OTC supplements like niacin can cause more muscle aches, Kopecky says. And taking other drugs processed in your liver, like antibiotics, or drinking a lot (a quart or more) of grapefruit juice daily can increase the levels of monacolin K in your blood stream because your liver has trouble processing it all. This can lead a condition known as rhabdomyolysis—the breakdown of muscle tissue that can cause kidney damage. “Rhabdomyolysis is genetically-based, not based on how much you take, so a tiny dose could cause problems,” Kopecky says.
Red yeast rice is also more expensive these days than generic statin drugs like lovastatin. “In some pharmacies they almost give away statins to get people in the door,” Kopecky says.
Is red yeast rice safe?
Consumer Reports puts red yeast rice on its list of 15 supplement ingredients to never take, and the NIH warns that since the FDA doesn’t investigate OTC supplements, there’s no way of knowing whether the red yeast rice you’re taking is safe or effective. “I’m not saying manufacturers don’t have quality control," Hazen says. "But no one is minding the store like the FDA would."
The NIH also warns that red yeast rice products may contain the potentially dangerous contaminant citrinin, which can cause kidney failure, due to a lack of sufficient controls during processing. A 2001 study found citrinin at measurable concentrations in seven of nine red yeast rice products studied, with quality and contents varying between each product. Kopecky says that although citrinin hasn’t been a problem in recent years, there’s still no way of knowing if your red yeast rice supplement is contaminated with other substances. “People think that because a drug is over the counter it’s safe, and that’s not the case,” he says.
“The supplement world in general is widely recognized as the wild west. The quality in supplements is often not at all there,” Hazens agrees. He often finds high white blood cell level counts in patients having allergic reactions to the OTC supplements they’re taking, including red yeast rice, and says it’s impossible to tell if the reaction is to what’s on the label or another contaminant. Bottom line, experts say, is there’s no way to ensure the quality, composition, or concentration of red yeast rice.
Is red yeast rice a good “natural” alternative to statins?
While some people take red yeast rice hoping it can lower cholesterol minus the muscle aches or stiffness, that’s not necessarily how it goes down. “Because it’s a natural statin, you can see exact same issues with it that you see with people on statins,” Hazen says. “I have patients who are not having problems on red yeast rice and then they get a new bottle and have muscle aches and stiffness” due to varying levels of monacolin K in each batch, he adds. Those varying concentrations can also mean that one bottle you buy could help lower your cholesterol, while the next could have no effect at all.
“Clinically, I’d only go that route if a patient doesn’t want to take a prescription drug for philosophical reasons and wants to have a natural approach to lowering their cholesterol,” Hazen says. “It is an option then, but you have to realize it’s a very weak option that doesn’t lower your cholesterol very much.”
“I’m sympathetic to patients averse to pharmacological therapy and their big pharma fears," Soffer says, "but there is a strong database supporting statin drugs."
Are there any other natural alternatives to statins?
Kopecky never recommends red yeast rice to his patients, instead suggesting other natural options that may work with fewer side effects. Both he and Hazen recommend plant stanols and sterols, which—when you take them before or during a meal—block the cholesterol in your bile from being reabsorbed into your lower intestine and can be even more effective at lowering cholesterol than red yeast rice. By taking two grams with meals every day, you can get up to 5 percent cholesterol reduction with each dose, which can lower your LDL cholesterol 10 to 15 percent on average if taken two to three times a day, Hazens says.
Similar to red yeast rice, the soluble plant fiber psyllium, found in oat bran, oatmeal, and supplements to keep you regular (like Metamucil), stops your body from manufacturing cholesterol when you take it with meals, although it’s slightly less effective. Together, however, plant stanols or sterols and psyllium can lower your cholesterol by up to 20 to 30 percent in some people, Kopecky says.
What else can I do to lower my cholesterol?
If you haven’t already been diagnosed with heart disease, Kopecky usually recommends lifestyle and diet changes first. “Lifestyle is so important. People think they can take a pill so they can eat whatever they want, but it doesn’t work that way,” he says.
That means cutting down on animal products and eating more plant foods—veggies, fruits, nuts, seeds—which have fiber that binds to cholesterol in your gut so your body is less likely to reabsorb it into your bloodstream. Hazen recommends the Mediterranean diet and points to a major 2017 study that found an approximately 30 percent reduction in heart attack, stroke, and death versus a low-fat or low-cholesterol diet. Regular cardiovascular activity—ideally 30 to 45 minutes straight—most days of the week can also raise levels of “good” HDL cholesterol and lower triglycerides, another type of fat in your blood.
If after 12 months of lifestyle changes your cholesterol hasn’t budged, Kopecky usually recommends a statin if you’re considered high-risk for heart disease. “Statins are incredibly safe drugs that are responsible for saving more lives than any other drug on the market outside of antibiotics, and they’re very prescribed and well-tolerated,” Hazen says. A traditional statin plus lifestyle changes can lower your risk of heart attack and stroke by 30 to 50 percent, he adds.
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