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When 2 + 2 is more than 4



ingredients for a healthy meal, including vegetables, fish, and whole grains

I am invited fairly frequently to speak to medical schools and allied health programs about Culinary Medicine and the evidence-based curriculum I have developed to integrate nutrition education into the training of medical students. As you can probably guess if you're a long-time Dr. Gourmet reader, the curriculum is based on the Mediterranean Diet, which among other effects has been shown to help improve cholesterol scores.

In medical school I had a teacher who liked to say that instead of giving up his thick, juicy steaks, he would just continue to take his statins. What he obviously didn't know at the time (although I'm not sure any of us did), is that you don't have to choose one or the other: with a Mediterranean Diet, not only can you have both, but you might actually see better results from a statin combined with a Mediterranean-style diet than you would with a statin alone.

Statins are a class of medications designed to lower cholesterol levels. Commonly-prescribed statins include simvastatin (common brand name: Zocor) and atorvastatin (common brand name: Lipitor). While these medications are often quite effective in improving cholesterol scores, they do have side effects that can include headaches, joint or muscle aches, and nausea.

If you've heard me speak about the Mediterranean Diet, you've likely heard me say that a Mediterranean Diet plus cholesterol medications are synergistic: rather than the effects of a statin being added to the effects of a Mediterranean-style diet simply being additive, like 2+2=4, the effects of a Mediterranean-style diet with statins are more like 2+2=4.6: the effects of both treatments together are greater than the sum of their parts. Today's research further bears this out.

Utilizing data from a long-term cohort study known as the Moli-sani Study (Int J Card 2019;276:248-254), researchers in Italy identified 1,320 persons who reported a previous diagnosis of cardiovascular disease (CVD) from an initial group of over 24,000. All participants responded to a detailed dietary and medical questionnaire at the start of the study, and the authors further excluded from their analysis those with unreliable or unbelievable dietary or medical histories. This left the authors with 1,180 men and women at least 35 years old who had been diagnosed with CVD and had submitted complete dietary and medical questionnaires.

The dietary histories allowed the researchers to assign the participants a Mediterranean Diet score ranging from 0 to 9, much like the one I describe on this site. Participants who had been prescribed statins were identified not only through the participants' self-report but also through linking to the Italian National drug index.

The authors broke the participants out into 4 groups for analysis:

1. Low Mediterranean Diet score (4 or less out of 9) + no statin use;
2. Low Mediterranean Diet score + statin use;
3. Average-high Mediterranean Diet score (5 or more out of 9) + no statin use;
4. Average-high Mediterranean Diet score + statin use

The authors kept track of the participants over the course of an average of almost 8 years, and at the endpoint of their study compared the Mediterranean Diet score and statin use of those who died with those who did not. When looking at the Mediterranean Diet score alone, the authors note that a 2-point increase in the score reduced the risk of death from any cause by 16%, reduced the risk of death from cardiovascular disease by 23%, and the risk of death from cerebrovascular mortality by 30%. Compared to a lower Mediterranean Diet score and no statins, however, combining a higher Mediterranean Diet score with statin use cut the risk of all-cause mortality by 48%, cardiovascular mortality by 50%, ad cerebrovascular mortality by 62%.

By comparison, those taking statins but with a lower Mediterranean Diet score cut their risk of all-cause mortality by only 10%, while their risks of cardiovascular and cerebrovascular mortality were actually higher than if they were not taking statins: 29% and 81% greater, respectively.

What this means for you

I've said elsewhere that medicine is not like math: if A = B and B = C, that does not necessarily mean that A = C. Here we've learned that 2 + 2, when it comes to Mediterranean Diet and statins, doesn't make 4: it seems to make 4.5 or more. If you have a cholesterol problem and your physician suggests that you take a statin, that doesn't mean that you shouldn't also improve your diet. Doing both together seems to be more than the sum of its parts.

First posted: February 13, 2018