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Monday, November 10, 2008

Reducing the risk from C-Reactive Protein

Today, statin drugs are in the news. The Jupiter study results, just published in the New England Journal of Medicine, says that patients with high C-reactive protein scores given Crestor "had a 45 percent reduction in serious heart problems and 20 percent reduction in death from all causes compared to those who received a placebo"[1]. The study participants were specially selected. They were all 50 or older, and chosen because they had high C-reactive protein scores, low to normal levels of LDL cholesterol, and did not have diabetes.[2] Many of them were overweight, had high LDL or triglycerides, or had metabolic syndrome.[3]

Crestor reduced the C-reactive protein of the Jupiter subjects by 37%, and their LDL by 50%. The earlier MERCURY trials of Crestor on high-risk patients with LDL cholesterol over 130 mg/dL, showed that Crestor could lower LDL cholesterol to below 70 in higher-risk patients,[4] but did not measure C-reactive protein.

So this study does not suggest that everyone can benefit from statins. It suggests that that the older, non-diabetic but perhaps pre-diabetic patients with high C-reactive protein levels may benefit from statins, whether or not they have high LDL cholesterol.

What is C-reactive protein?
C-reactive protein is related to inflammation in the body. It is very high following an injury (or surgery), and during a bacterial infection. C-reactive protein has been linked to heart disease, though it isn't clear just why. It doesn't seem to cause heart disease,[5] but it seems to be a good way to keep tabs on inflammation.

Inflammation, of course, is bad for the heart. Some foods cause inflammation. Body fat can cause inflammation. So anything that reduces inflammation seems like a good idea. Statin drugs appear to reduce inflammation while lowering LDL cholesterol. Of course, LDL cholesterol is not the best predictor of cardiovascular risk. The American College of Cardiology and the American Diabetic Association both recommend apoB and LDL particle concentration, or non-HDL cholesterol.[6]

C-reactive protein has also been associated with high triglycerides, coffee consumption, high blood pressure, insulin resistance, high protein diets, high fat diets[7], high glycemic index diets, inadequate sleep, too little exercise, depression, and age.

How to reduce C-reactive protein
Exercise, losing weight, reducing triglycerides, controlling blood pressure, getting enough sleep, eating a Mediterranean diet, eating antioxidant foods with meals, and cutting back on "bad" carbs like bread and pasta have all been recommended for reducing inflammation and C-reactive protein.

This is still a new area for medicine. If you get standard blood work done, you won't see C-reactive protin on the lab report. There seems to be evidence that reducing chronic inflammation through diet and exercise is a good idea. So where does that leave me? I'm going to rethink pancakes and muffins, change what I pack in our lunches, lean more towards bulgur and less toward rice, substitute sweet potatoes for potatoes whenever possible, suggest red wine instead of beer, and keep drinking unsweetened cocoa.

I've had a look at the South Beach diet and Neal Barnard's diet, and I'm wondering: what about Thanksgiving? And Christmas?

1. RPT-Crestor study seen changing preventive treatment. Bill Berkrot and Ransdell Pierson. Reuters
2. JUPITER - Crestor 20mg Versus Placebo in Prevention of Cardiovascular (CV) Events. Clinical Trial Registration.
3. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. Paul M Ridker, M.D. et al. WWW.NEJM.ORG. November 9, 2008 (10.1056/NEJMoa0807646)
4. Statin therapy alters the relationship between apolipoprotein B and low-density lipoprotein .... Ballantyne CM et al. J Am Coll Cardiol. 2008 Aug 19;52(8):626-32.
5. Genetically Elevated C-Reactive Protein and Ischemic Vascular Disease. Nordestgaard et al. New England Journal of Medicine. Volume 359:1897-1908 October 30, 2008.
6. CONSENSUS CONFERENCE REPORT: Lipoprotein Management in Patients With Cardiometabolic Risk. Witztum et al. Am Coll Cardiol, 2008; 51:1512-1524, doi:10.1016/j.jacc.2008.02.034 (Published online 27 March 2008).
7. Low Carbohydrate, High Fat Diet Increases C-Reactive Protein during Weight Loss. Turpyn et al. Journal of the American College of Nutrition, Vol. 26, No. 2, 163-169 (2007).

internal link repaired on 27 Feb 2009