Does Red Yeast Rice Really Lower Cholesterol?
Answered by: Robert Newman, L.Ac.
Question from: Marge
Posted on: May 19, 2004

I would like to know if there is any truth to the fact that taking this supplement helps lower cholesterol? The old, "I have a neighbor" thing, says she takes it and her cholesterol stays down considerably. My doctor is not too keen or up on supplements as such.

The name of Red Yeast Rice in Chinese is "Hong Qu" ("hohng chew") or "Hong Qu Mi" ("hohng chew mee"). "Hong" means "red," "qu" means "fermented," and "mi" means "rice." The latin name of the yeast that is used to ferment the rice is Monascus purpureus. And in fact, there is indeed truth to the idea that Red Yeast Rice has the potential to lower cholesterol levels. As you will read below, from a western research standpoint, it is partly because it has a naturally-occurring compound in it which is the same as a well-known western medicine used for treatment of high cholesterol. And although it has yet to be demonstrated according to western research, it may even have some other compounds that are useful for lowering cholesterol levels.

From a traditional Chinese medicine (TCM) point of view, there are also reasons to believe that Red Yeast Rice could be useful in having a positive effect on imbalances linked to high cholesterol. This herb is said to have the properties of being sweet, acrid and warming and it affects the "Spleen," Liver and Large Intestine. It could be thought of as helping to keep the arteries clear through two functions. One primary function is similar to the TCM function of Hawthorn Berry (Crataegus pinnatifida, Shan Zha, "shawn jaw"), which interestingly, has also been found to reduce cholesterol, from a western physiological standpoint. The TCM function which both of these 2 herbs have in common is to treat what is known as food stagnation. This can be caused from someone eating too much food at a sitting, eating too much food which is too rich and heavy, eating too much cold food (cold food will slow down the activity of the digestive function and slow down the movement of material through the G.I. tract), eating too late at night (the reason this is felt to create problems is that the "Qi" or activity of the digestive function and the body, in general, is believed to slow down as it gets later in the evening -- this is when activity should be becoming less and one should be asleep or preparing to sleep rather than eating), or any combination of these imbalancing dietary behaviors. All of these factors are much more significant in impairing one’s health if they are done more rather than less often. Some emotional factors may also be involved in causing the stagnation or accumulation of undigested food in the G.I. tract -- especially if one is eating when one is emotionally upset or under stress and in a hurry. The emotional disturbance is said to knot up or bind up the "Qi" or activity of the digestive system (as well as in other areas of the body). The person with food stasis may have symptoms of severe bad breath, a distended or full feeling in the abdomen, pain, diarrhea or soft and difficult stools, constipation or incomplete stools, gas, belching, nausea, coughing up of clear sputum, a congested feeling of fluids in the throat, a thick and greasy coating on the tongue. This stagnation and accumulation is a sign that the food and fluids one is taking in are not digesting properly or completely. This can easily lead to the development of phlegm, according to TCM. And one form of phlegm is what we think of as fat in the tissues and plaque in the blood vessels. From a western viewpoint, poor digestion of fatty foods can contribute to the excessive absorption of fats into the bloodstream. Also, from a western viewpoint, this category of herbs may carry with them enzymatic activity and they may improve peristalsis and increase gastrointestinal secretions. As part of this function of helping the digestive process and therefore, helping the digestion of fats, Hong Qu is also said to strengthen the function of the "Spleen" and Stomach in Chinese medicine, to generally help with the body’s function of digestion and assimilation of food and fluids, to commonly help especially when there is undigested food in the stools (in Chinese medicine, the "Spleen" and Stomach are primarily involved with the functions of digesting and assimilating food and fluids; for more explanation about the idea of the function of the "Spleen" in TCM and a list of some of the symptoms that can be associated with its deficiency, see my answer to the question on Korean Ginseng and weight loss also on Richters Q & A page).

The other TCM function of Hong Qu that can help keep the arteries clearer is that it "invigorates blood circulation and eliminates blood stasis," meaning that it can improve the circulation of the blood in the vessels and possibly also thin the blood, reducing any present blockage and reducing the likelihood of the circulation becoming blocked in some part of the body. Part of the reason Hong Qu can act on the blood circulation, according to TCM theory, is because it has an effect on the Liver, which is an organ believed in TCM to be very important in making sure that the blood flows smoothly throughout the body. Assuming the Chinese are right about this herb influencing the Liver, this Liver impact is also possibly relevant for issues involving cholesterol since the Liver is involved in the production of cholesterol in the body, according to an understanding of western physiology.

The website, pdrhealth.com, has a good description of some background on the western research information on Hong Qu, Red Yeast Rice: "In addition to natural pigments such as monascorubin and monascin (azaphilone derivatives), Red Yeast Rice contains starch, fatty acids (oleic, linoleic, linolenic, palmitic, stearic), phytosterols (beta-sitosterol, stigmasterol), isoflavones and monacolins. Monacolins possess hydroxymethyglutaryl coenzyme A (HMG-CoA) reductase-inhibitory activity [this means monacolins inhibit the activity of the enzyme, HMG-CoA reductase, in the Liver: this enzyme is needed to produce cholesterol]. HMG-CoA reductase inhibitors are commonly known as statins. The first statin introduced in the U.S., for use as a cholesterol lowering agent, was Lovastatin. Lovastatin was originally derived from Monascus ruber [this is also a yeast and it is a relative of Hong Qu, Monascus purpureus], and was first called monacolin K. Monacolin K is a lactone which is converted in the body to the active form of the statin, the corresponding beta-hydroxy acid of monacolin K (Lovastatin, Mevinolin). The proprietary Red Yeast Rice product that was first introduced in the U.S. was processed to yield 0.4% HMG-CoA reductase inhibitors in the final product. In addition to monacolin K or Lovastatin, which comprises 0.2% of this product, it contains the corresponding beta-hydroxy acid of monacolin K at a concentration of 0.1%, and much smaller amounts of dihydromonacolin, monacolin I, monacolin II (hydroxy acid form), monacolin III, monacolin IV, monacolin V and monacolin VI, to give a total of 9 HMG-CoA reductase inhibitors. Traditional Red Yeast Rice [in comparison with the special proprietary form] does not contain as high an amount of these substances. The yeast in Red Yeast Rice is inactive. [Some of the other compounds found in Red Yeast Rice -- the mix of sterols (sitosterol, campesterol, and stigmasterol), isoflavones and unsaturated fatty acids -- are also thought to contribute to the cholesterol and lipid-lowering effects of the monacolins.]"

Furthermore, from wholehealthmd.com (see the link below): "A rigorous trial from the UCLA School of Medicine, published in the American Journal of Clinical Nutrition in 1999, confirmed that a supplement known as red yeast extract reduces cholesterol levels by an average of 40 points in 12 weeks when combined with a low-fat diet. That’s about the same result you’d expect from a low dose of the popular cholesterol drug, Mevacor [Lovastatin, or monacolin K]. Long-term studies are lacking. Several trials in China have shown that red yeast products have no toxic effects, and in the UCLA study, the liver tests of people taking the supplement remained normal. A five-year study of the safety of red yeast extract is underway."

The dosage cooked in a decoction as a tea is 6-12 grams. For capsules, the dosage would naturally vary depending on the amount present in the capsules. But a general protocol is to take approximately 2 capsules one hour after breakfast and 4 more capsules before bedtime. It’s also been recommended to take with Hong Qu a small dose (approximately 30-60 mg.) of Coenzyme Q10 two times a day: one important reason for doing this is that there may be some inhibition of HMG-CoA with Hong Qu, thus possibly depleting Coenzyme Q10. One should be careful not to use too high a dose of the Hong Qu if one’s digestive system is very weak (or else make sure to combine it with the taking of some additional herbs that will strengthen the "Spleen" -- i.e., the digestive system’s function). Also, if one doesn’t have signs of food stagnation or blood stagnation, as understood in TCM, one should be cautious not to use it in too high of a dose. It is more strongly contraindicated in individuals with active liver disease or serious kidney disease, in someone with elevated liver enzymes, and in pregnancy or by nursing mothers. One form of Red Yeast Rice known as Cholestin has been known to produce fairly good results and have minimal side-effects. Some mild heartburn, gas, bloating or dizziness has been known to occur temporarily in a few people that used Red Yeast Rice. In connection with this issue with effective results and side-effects, there was an abstract of a study I found on Medline (see the link below) which described some research done on different Red Yeast Rice products -- apparently they are not all equal in their properties: "RESULTS: Total monacolin content varied from 0% to 0.58% w/w and only 1 of 9 preparations had the full complement of 10 monacolin compounds. Citrinin was found at measurable concentrations in 7 of the 9 preparations. CONCLUSIONS: The findings from clinical trials demonstrating significant and clinically relevant cholesterol reduction using a defined Chinese Red Yeast Rice preparation containing 10 different monacolins cannot be generalized to preparations that do not contain the same levels and profile of monacolins. Standardized manufacturing practices should be established for Chinese red yeast rice sold as a dietary supplement in order ensure equivalence of content of active ingredients in preparations being sold to the public and to limit the production of unwanted by-products of fermentation such as citrinin." So different brands may have varying levels of therapeutic benefit on cholesterol levels.

John K. Chen wrote an article for the TCM newspaper, Acupuncture Today (see the link below), "Red Yeast Rice: Rediscovery of an Ancient Herb," which was taken from his and Tina Chen’s recent book, "Chinese Medical Herbology and Pharmacology." I have excerpted down below some information from the article, and I have added some of my own comments or other relevant information that I discovered.

Background

Hong Qu (Monascus), also known as Red Yeast Rice, is rice that has been fermented with the yeast Monascus purpureus. The fermentation process changes the color of the rice from white to red, thereby giving it the name "Red Yeast Rice." For centuries, Hong Qu has been used in China as both food and herbal medicine. It has also been used as a coloring agent to prepare fish, fish sauce, fish paste, rice wine, and red soybean curd. In the late 1970s, Professor Endo, from Japan, discovered monacolin-k from Red Yeast Rice, and found it could reduce the blood cholesterol of the human body. His great discovery provided scientific support for the effectiveness of the traditional Red Yeast Rice. In the late 1990s, it was introduced and used in the U.S. as a dietary supplement to promote healthy cholesterol levels.

Chemical Composition

Hong Qu is composed of onascidin, monacolin I (Lovastatin, Mevinolin), monacolin II (beta-hydroxy acid), monascin, starch, fatty acids, phytosterols, isoflavones.

Hong Qu has been shown to have antihyperlipidemic effects. Following ingestion, monacolin I (Lovastatin) is converted in the body to beta-hydroxy acid, which is known to inhibit cholesterol biosynthesis, leading to reduced levels of plasma total cholesterol, low-density lipoprotein cholesterol (LDL-C), very-low-density lipoprotein cholesterol (VLDL-C), and triglycerides. In addition, it may produce a slight increase in high-density lipoprotein (HDL-C). In one multi-center, randomized, single-blind trial, 502 patients with hyperlipidemia were treated with 600 mg of Hong Qu twice daily (1,200 mg total per day). After four weeks of treatment, the study reported a 17% reduction in total cholesterol levels, a 24.6% reduction in LDL-cholesterol, a 19.8% decrease in triglycerides, and a 12.8% increase in HDL-cholesterol. After eight weeks of treatment, the study reported a 22.7% reduction in total cholesterol levels, a 0.9% reduction in LDL-cholesterol, a 34.1% decrease in triglycerides, and a 19.9% increase in HDL-cholesterol. MedicineNet.com (see the link below) gives a good basic description about the importance of these 3 factors: "LDL-cholesterol is called "bad" cholesterol, because elevated LDL-cholesterol is associated with an increased risk of coronary heart disease. The LDL lipoprotein deposits cholesterol on the artery walls, causing the formation of a hard, thick substance called cholesterol plaque. HDL is called the "good cholesterol" because HDL-cholesterol particles prevent atherosclerosis by extracting LDL-cholesterol from the artery walls and disposing of them through the liver. Thus, high levels of LDL-cholesterol and low levels of HDL-cholesterol (high LDL/HDL ratios) are risk factors for atherosclerosis, while low levels of LDL-cholesterol and high level of HDL-cholesterol (low LDL/HDL ratios) are desirable. Also, it is becoming more recognized that elevated triglyceride is often associated with other conditions that increase the risk of atherosclerosis including obesity, low levels of HDL-cholesterol, insulin resistance and poorly controlled diabetes mellitus, and small, dense LDL-cholesterol particles."

Since Red Yeast Rice contains some amount of naturally-occurring Lovastatin (monacolin I), some of the same drug interaction issues and contraindications may apply to Red Yeast Rice as to Lovastatin. There is a Liver metabolism factor as a possible issue: Lovastatin is metabolized primarily by CYP3A4, and may interact with CYP3A4 inhibitors (CYP3A4, a type of enzyme very prevalent in the human liver and gastrointestinal tract, is involved in the metabolism and processing of many clinically used drugs and other chemicals. Because several drugs and also dietary factors can inhibit the functional activity of this CYP3A4 enzyme, inhibitors of CYP3A4 can increase the exposure to and the effect of drugs metabolised mainly via this enzyme pathway). So drug-drug interactions have the potential to significantly enhance the therapeutic effects of certain drugs (such as Lovastatin) AND also increase the risk of their adverse effects. Potent inhibitors of the CYP3A4 enzyme include: cyclosporine, itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, and large quantities of grapefruit juice. These have the potential to cause myopathy (muscle damage/disease) when used with Lovastatin -- particularly when using higher doses of Lovastatin. For example, research showed that azole antifungals such as itraconazole and ketoconazole increased Lovastatin levels twenty-fold in health volunteers, and increased the risk of myopathy. Bile acid sequestrants such as Questran (cholestyramine) and Colestid are used to bind bile acids and reduce cholesterol levels: co-administration of cholestyramine decreases the bioavailability of Lovastatin and therefore reduces its effect. To avoid this interaction, Lovastatin should be taken one hour before or four hours after bile acid sequestrants. Fibric acid derivatives are used to reduce high triglyceride levels and indirectly used sometimes to reduce cholesterol levels: avoid concurrent use of such drugs as gemfibrozil (Lopid), clofibrate (Atromid-S) or fenofibrate (Tricor) with Lovastatin, as severe myopathy and rhabdomyolysis (this means damage and destruction to muscles and tendons) have been reported. Isradipine: Isradipine is a high blood pressure drug to relax the blood vessels: it increases hepatic blood flow, and may increase the clearance (increase the speed of removal) of Lovastatin and its metabolites from the Liver, thus reducing the time period that Lovastatin can exert its effect. Warfarin is a drug used to prevent blood clots by stopping the formation of substances in the blood which cause clotting: bleeding and increased prothrombin time (a longer time needed for the blood to clot, as when one is injured) have been reported with concomitant use of Lovastatin and Warfarin. Also Lovastatin should not be used with high doses of Niacin (vitamin B-4).

Most medical journals attribute the hypolipidemic effect of hong qu to one single component, Lovastatin. This explanation, however, is neither sufficient nor entirely accurate. The therapeutic dose of hong qu delivers approximately 7.2 mg of Lovastatin, while the synthetic drug Lovastatin (Mevacor) contains from 10 mg to 40 mg of Lovastatin. Yet, despite the lower dose of the supposed active component, the hypolipidemic effects of hong qu are much greater than the synthetic drug Lovastatin. Thus, it is clear that Lovastatin is not the only active component, and more research needs to be done on hong qu as an herbal medicine, not just on Lovastatin as a single compound.

An interesting study was done in Taiwan which demonstrated not only a direct effect of Red Yeast Rice on the cholesterol levels of a subject -- in this case, chickens -- but also an indirect effect by impacting the cholesterol levels in the chickens’ eggs. From the Science News website (see the link below): "In an upcoming issue of the Journal of Agricultural and Food Chemistry, Pan and Jyh-Jye Wang of the Tajen Institute of Technology in Pingdon confirm that hens receiving the red food additive [Red Yeast Rice] indeed produce eggs with significantly less cholesterol than normal."

Lastly, for cholesterol issues, you might also want to look into Hawthorn Berries (Crataegus, Shan Zha, which I mentioned about in the first part of this message) and Guggul (this is an herb derived from the Mukul Myrrh Tree). If you are interested in the Hawthorn Berries, Richters sells seeds of Crataegus as well as the dried fruits and a fluid extract--see the website or their catalogue.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui

http://www.acupuncturetoday.com/archives2004/mar/03chen.html

http://www.sciencenews.org/articles/20030712/food.asp

http://www.medicinenet.com/cholesterol/article.htm

http://www.pdrhealth.com/drug_info/nmdrugprofiles/nutsupdrugs/red_0329.shtml

http://www.wholehealthmd.com/news/viewarticle/1,1513,29,00.html

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