Garlic & Red Yeast Rice: Manage Your Blood Lipids W/Out Statins - 12+1 Natural Alternatives Reviewed (Part I)

Red yeast rice is the "+1" in this SuppVersity Mini-Series because it is actually a "statin". Similar effects, similar side effects and all that (probably) because of the similar structure of its lipid lowering active ingredient(s).

"Twelve + 1"? I know that sounds odd, but I have my reason to single one of the natural alternatives, two scientists from the Chulalongkorn University in Thailand list in their 2016 review "A Review of the Efficacy, Safety, and Clinical Implications of Naturally Derived Dietary Supplements for Dyslipidemia", right from the start: red yeast rice (RYR).

While garlic, which will also be discussed in today's first installment of what is going to become a mini-series, also has the ability to decrease your HMG-CoA reductase activity, only RYR does that at a similar potency as statins do; which is why its use entails the risk of similar side effects as they have been reported for regular statin drugs Whether RYR is thus your best "natural alternative" is highly questionable.
On the other hand, the fact that the monacolins, the main bioactive compounds in RYR, is not debatable. Only recently, a meta-analysis by Li et al. (2014) reported no serious side effects and concluded based on 13 RCTs that "red yeast rice is an effective and relatively safe approach for dyslipidemia" (Li. 2014). Li et al. do yet also know that "further long-term, rigorously designed randomized controlled trials are still warranted before red yeast rice could be recommended to patients with dyslipidemia, especially as an alternative to statins" (Li. 2014).

Figure 1: Effects of 1,200mg/d red yeast rice (RYR) on blood lipids in statin-intolerant subjects (left | Venro. 2010) and subject-dependent reductions in LDL in the latest meta-analysis of the effects of RYR (right | Li. 2014).

If you are statin intolerant, however, Venro et al's study in 25 statin-intolerant subjects who received 1,200 mg RYR at bedtime, however, would suggest that you in particular could benefit from RYR as it appears to have a rather good tolerability in those subjects who cannot take regular statins.
Further evidence that, as so often, individuality is key comes from the differential effects in European, Asian and US subjects (see Figure 1 showing data from Li. 2014). The latter, however, may be explained by both, the genetic configuration of the subjects, and the high ingredient variability of commercially available RYR preparations of which a comparative analysis of 10 commercial red yeast rice products reports a >30-fold range in total monacolin content. The authors of said study also highlight:

"Furthermore, compared with the full spectrum of monacolins expected in a red yeast rice dietary supplement, with monacolin K representing 55% to 60%, 4 of the 10 products were >90% monacolin K, suggesting that they were actually food-grade red yeast rice “spiked” with lovastatin, the prescription statin that is chemically identical to monacolin K" (Mark. 2010).

And Mark et al. are not the only ones reporting an intolerable degree of cutting in the snake oil industry. Similar results have been presented by Gordon et al. who tested 12 products that are regularly sold and consumed in the US and found total monacolin contents ranging from 0.31 to 11.15 mg/capsule. Just like Mark et al. Gordon et al. also found monacolin K (lovastatin | 0.10-10.09 mg/capsule), which could occur naturally, albeit not at very high doses, in many and the kidney-damaging citrinin in four of the twelve tested products (33%).

Garlic is a HMG-CoA inhibitor that doesn't have the problems of statins & RYR ...

...or, we simply don't know about them yet, because the currently available garlic supplements all suffer from the pathetic bioavailability of allicin (which is broken down enzymatically before it reaches your bloodstream | Lawson. 2001), which could - in very high doses that have not been tested in studies yet - possibly have similar negative side effects as the monocalins in RYR.

More recently, however, studies have suggested that allicin may not even be necessary for some of the beneficial effects of garlic. In particular, its general anti-oxidant and anti-inflammatory effects appear to be mediated mainly by S-allyl cysteine. Furthermore, "various chemical constituents in garlic products, including nonsulfur compounds such as saponins, may contribute to the essential biological activities of garlic" (Amagase. 2006) - including their anti-lipidemic effect.
In contrast to their active ingredient, however, the efficacy of garlic and garlic supplements as anti-hyperlipidemic drugs is well-established. One of the most cited meta-analyses (39 RCTs with 2298 participants | Ried. 2013) found that, overall, garlic consumption caused significant changes in serum levels of total cholesterol (–15.25 mg/dl; p < 0.0001), LDL-C (–6.41 mg/dl; p = 0.02), and HDL-C (1.49 mg/dl; p = 0.02), whereas the triglyceride levels appeared to be unaffected (I will address this in a follow-up, but if you eat your garlic with fatty fish, this should address the triglyceride issue). In addition, a more recent meta-analysis revealed that it will also reduce the level of lipoprotein (a) in the blood of hyperlipidemic subjects (Sahebkar. 2016).

Figure 2: Effects of garlic supplements on LDL (left, red) and HDL (right, green) according to a 2013 meta-analysis of  39 RCTs with 2298 participants (Ried. 2013) - the results have generally been confirmed more recently (Ried. 2016).

Needless to say that, for garlic, just like RYR and any other drug or supplement, conflicting evidence exists. Early studies, for example, didn't report consistent effects on LDL and HDL. Whether that's due to different types (raw, powder, oil, and aged extract), processing and doses of garlic products used, or the subjects' baseline lipid levels and the study duration is something neither Thaipitakwong & Aramwit (2016), in their review, nor I can tell you due to the lack of studies that directly investigate the individual effects of these parameters. studies. The latter is also true for the bioavailability of raw garlic vs. supplements and the various types of 'garlic products' on the market. As the previously cited study from Thailand rightly concludes: the individual bioavailability simply has not been studied, yet (Thaipitakwong & Aramwit. 2016).
References:

• Amagase, Harunobu. "Clarifying the real bioactive constituents of garlic." The Journal of nutrition 136.3 (2006): 716S-725S.
• Gordon, et al. "Marked variability of monacolin levels in commercial red yeast rice products." Arch Intern Med 170.19 (2010): 1722-1727.
• Lawson, Larry D., and Z. Jonathan Wang. "Low allicin release from garlic supplements: a major problem due to the sensitivities of alliinase activity." Journal of agricultural and food chemistry 49.5 (2001): 2592-2599.
• Li, Yinhua, et al. "A meta-analysis of red yeast rice: an effective and relatively safe alternative approach for dyslipidemia." PloS one 9.6 (2014): e98611.
• Liu, Jianping, et al. "Chinese red yeast rice (Monascus purpureus) for primary hyperlipidemia: a meta-analysis of randomized controlled trials." Chinese medicine 1.1 (2006): 1.
• Mark, David A. "All red yeast rice products are not created equal—or legal." The American journal of cardiology 106.3 (2010): 448.
• Venero, Carmelo V., et al. "Lipid-lowering efficacy of red yeast rice in a population intolerant to statins." The American journal of cardiology 105.5 (2010): 664-666.
• Sahebkar, Amirhossein, et al. "Effect of garlic on plasma lipoprotein (a) concentrations: A systematic review and meta-analysis of randomized controlled clinical trials." Nutrition 32.1 (2016): 33-40.
• Ried, Karin, Catherine Toben, and Peter Fakler. "Effect of garlic on serum lipids: an updated meta-analysis." Nutrition reviews 71.5 (2013): 282-299.
• Ried, Karin. "Garlic lowers blood pressure in hypertensive individuals, regulates serum cholesterol, and stimulates immunity: an updated meta-analysis and review." The Journal of nutrition 146.2 (2016): 389S-396S.