Diabetologist Dr V Mohan says that the findings aren’t surprising, considering statins can be more effective than exercise and lifestyle changes when it comes to lowering LDL levels.

Why are statins the mainstay of treatments for cholesterol control?

When we talk about lipids, there are different categories like cholesterol and triglycerides. Within cholesterol, there are LDL or bad cholesterol and HDL or good cholesterol. Now, several studies, including our own, have shown that LDL is more important than triglycerides when it comes to managing heart diseases – triglycerides are important for pancreatitis but that too when the levels are very high.

Having said that, there are some Scandinavian studies that show that even triglycerides are an important factor for heart health. Also, when the triglycerides go very high, the LDL nature changes – it becomes small and dense that is more atherogenic (prone to getting deposited in the arteries). That is when the secondary role of triglycerides becomes important.

But if you pit them against one another – lowering LDL levels is much more important. Now, there are separate drugs for triglycerides – statins do not do much for them. Plus, triglycerides come down when you cut down sugar and carbohydrate intake but LDL won’t come down so easily.

It is now well established that statins reduce heart attacks, decrease all-cause mortality, cardiac mortality and bring all levels down. There are still some who point to the side-effects of statins but the benefits far outweigh the risks. I personally take statins and I prescribe them to my patients as well. It is only after controlling the LDL levels that you should think about triglycerides.

Who should be put on statins?

Statins aren’t for everyone. It has to be prescribed only in people with high LDL levels. Those with LDL levels of 130 and diabetes must take it. Non-diabetics must take it when their figures are above 160. Even without diabetes, those with a family history of heart disease, who have had a heart attack or have undergone stenting, should be on a course of statins. High dose statins – say, 80 mg instead of 10 or 20 mg — are used by cardiologists after heart attacks because they are supposed to reduce coronary plaques and help in stabilising them (plaques are lipid deposits in the arteries that can eventually cut blood flow and result in heart attack).

In fact, heart disease and diabetes are prevalent in a much younger population in India compared to the West. So, unless contraindicated, statins should be used in those that need it.

Why are statins more important than lifestyle changes when it comes to LDL?

Lifestyle modifications are also important. They can result in weight reduction, which in turn can result in various lipids, including triglycerides, coming down. Cutting down on saturated fats such as red meat also helps. But all of that – diet and exercise – has a milder impact on LDL than statins.

This is because LDL cholesterol is produced inside the liver. So, diet plays a small role. If your LDL level is 140, it will say come down to 125 with lifestyle changes, whereas, if you give statins, it switches off the production of LDL, and bang, it will come down to 80.

Increase in LDL levels can be genetic too– there are families where the people get heart attacks very early. I knew a family where they would get heart attacks at the age of 26 or 30. For a long time, many family members did not cross 35 years of age. After use of high dose statins, they are living longer.

Why is it that there are still people who hesitate to take statins?

These are harmless drugs. In fact, most people I see in my clinics do not refuse it, except those who have read too much on WhatsApp university.

There are some people – very few, probably one in 5,000 – who have statin intolerance. They develop severe muscle pains and cannot even walk. So, other than such contraindications, people can be safely prescribed.

Once you are put on statins, it is usually for lifelong. The moment you stop, there could be a rebound, it can go higher than what it was. But these are harmless drugs, hardly any side effects, inexpensive, and one tablet at night.

Do supplements like fish oil do anything for the heart?

Fish oil or Omega-3 fatty acids have always been there but they don’t reduce LDL but work on triglycerides. There is no harm in taking it, but those who have fish will get it anyway. And vegetarians anyway don’t like to take it because it comes from fish oil.

Omega-3 also slightly increases the risk of bleeding just like aspirin. So, it cannot be given to everybody. Statins can be used much more widely.

Why Dr V Mohan? Dr Mohan is a renowned diabetologist and the chairman of Dr Mohan’s Diabetes Specialities Centre. He is also the president of the Madras Diabetes Research Foundation, which is an ICMR-advanced centre for studying the genomics of Type-2 diabetes. He has over 1,500 publications. He has also received the highest honour for doctors in India Dr BC Roy Award and the fourth-highest civilian award Padma Shri.