How to Talk to Patients about the New Cholesterol Guidelines

By John Henry Dreyfuss, MDalert.com staff.

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  • The guidelines for LDL cholesterol have not changed. It remains the primary target of therapy.
  • Cholesterol blockers may be superior to statins for LDL control.
  • Advise patients to try eat a diet that contains more lean protein and vegetables and less carbohydrates and sugars.
  • The Mediterranean diet continues to be an attractive approach to maintaining heart health.

One thing that is sure to result from the new cholesterol guidelines proposed by the influential Dietary Guidelines Advisory Committee: Patients will be confused. You are going to get a lot of questions from curious and concerned patients. What is the best advice for them?


 
Jonathan Bradlow, MD

The More Things Change, the More They Stay the Same

“Many cardiologists have long believed that dietary cholesterol is not the culprit in heart disease,” said Jonathan Bradlow, MD, Assistant Professor at Albert Einstein College of Medicine, Attending Physician in at Montefiore Medical Center in Bronx, New York, and a member of the Advisory Board for MDAlert.com. The amount of dietary cholesterol consumed by the average American is dwarfed by the amount produced endogenously by a person’s liver in a ratio of about 80% to 20%.

 The recent change in guidelines support this long-held view among cardiologists. The bottom line is that dietary cholesterol is no longer a thing about which health-conscious Americans should worry. Those of us who are not health-conscious can continue to ignore dietary cholesterol and eat a few more eggs without worry.

High-density lipoprotein (HDL) is no longer considered a nutrient of concern. Low-density lipoprotein (LDL) and other non-HDL lipids, however, are still considered to be risk factors for heart disease. If you experiment with different values in this atherosclerotic cardiovascular disease (ASCVD) risk estimator you see that elevated LDL levels confer significantly increased risk of CVD disease and death.

“Really, people should eat a lot of vegetables and lean protein and very little else,” Dr. Bradlow explained. “By lean protein I mean low-fat dairy, fish, chicken, nuts and beans, pork, even beef and eggs in moderation.”

For example, an egg contains only 70 calories but contains 6 grams of protein. Peanuts and peanut butter contain about 25% protein. A serving of Greek yogurt can contain 15g to 20g of protein. Of course, fish, poultry, and other meats are concentrated protein sources. In the case of red meat, however, the protein can often be associated with saturated fats and LDL.

The Short Answer

So, after decades of being labeled a dangerous food ingredient that increases the risk of heart disease, dietary cholesterol is no longer considered to be a harmful nutrient (Figure).

Figure. A stick and ball model of the cholesterol molecule.

As with most of medicine, the devil is in the details, and this where you can really help your patients.

 

When a worried patient asks you, “What do I do about cholesterol?” You can advise him to continue to monitor his LDL. By age 65 or so, most of your patients may well need to take a statin or a cholesterol blocker, Dr. Bradlow noted. In fact, the new drug evolocumab, a non-statin, has shown significant promise in reducing the risk of CVD in patients with high pre-treatment LDL levels. Statins have a long track record of safety and efficacy.

Figure 1. A ball and stick model of an LDL cholesterol molecule.

This Is a Significant Change

While Dr. Bradlow may assert that savvy physicians were never genuinely concerned about dietary cholesterol, most health-conscious patients have long been drinking the Kool Aid. These patients will be challenged to integrate the information contained in the new guidelines. “This is pretty significant,” noted Dr. Bradlow.

Physicians are accustomed to guidelines changing as new studies are completed, evaluated, and integrated into best practices. Patients, however, rely on physicians to tell them what the new findings mean. Overall, the committee summarized its findings as described in Figure 2.

Figure 2: Nutrient intakes and nutrients of concern.*
Based on intake data, together with nutritional biomarker and health outcomes data, identified nutrients that may pose a public health concern:

  • Vitamin D, calcium, potassium, and fiber are under consumed across the entire US population.
  • Iron is under consumed for adolescent and premenopausal females.
  • Sodium is overconsumed across the entire US population.
  • Saturated fat is overconsumed and may pose the greatest risk to those >50 years old.
  • Cholesterol is not considered a nutrient of concern for overconsumption.

*Source: http://www.health.gov/dietaryguidelines/2015-BINDER/meeting7/docs/DGAC-Meeting-7-SC-1.pdf.

 

Based on a review of the current literature and an interview with Jonathan Bradlow, MD, a member of the MDAlert.com Editorial Advisory Board.


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