Major Recommendations in the 2004 Cholesterol Guidelines

Fish Oils

Seasons Affect Cholesterol

Citrus Peels May Help Lower Bad Cholesterol

Low-Fat May Not be Best for Heart

Major Recommendations in the Update on Cholesterol Guidelines:  More Intensive Treatment Options for High-Risk Patients

High and Very High Risk:  For high-risk patients, the overall goal remains an LDL level of less than 100 mg/dL.  But for people at very high risk, a group this is considered a "sub-set" of the high-risk category, the update offers a new therapeutic option of treating to under 70 mg/dL.  For very high-risk patients whose LDL levels are already below 100 mg/dL, there is also an option to use drug therapy to reach the less than 70 mg/dL goal.

For the overall category of high-risk patients, the update lowers the threshold for drug therapy to an LDL of 100 mg/dL or higher and recommends drug therapy for those hight-risk patients whose LDL is 100 ro 129 mg/dL.  In contrast, ATP III set the threshold for drug therapy for high-risk patients at an LDL of 130 mg/dL or higher, and made drug treatment optional for LDL 100 to 129 mg/dL.

The National Cholesterol Education Program defines high-risk patients as those who have coronary heart disease or disease of the blood vessels to the brain or extremities, or diabetes, or multiple (2 or more) risk factors (e.g., smoking, hypertension) that give them a greater than 20% chance of having a heart attack within 10 years.  Very high-risk patients are those who have cardiovascular disease together with either multiple risk factors (especially diabetes), or severe and poorly controlled risk factors (e.g., continued smoking), or metabolic syndrome (a constellation of risk factors associated with obesity including high triglycerides and low HDL).  Patients hospitalized for acute coronary syndromes such as heart attack are obviously also at very high risk.

Moderately High-Risk:  For moderately high-risk patients, the goal remains an LDL under 130 mg/dL, but the update provides a therapeutic option to set a lower LDL goal of under 100 mg/dL and to use drug therapy at LDL levels of 100-129 mg/dL to reach this lower goal.

For high-risk or moderately high-risk patients, the report advises that the intensity of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40% reduction in LDL levels.  This can be accomplished by taking statins or by combining lower doses of statins with other drugs (bile acid resins, nicotinic acid, or ezetimibe) or with food products containing plant stanol/sterols.

Lower/Moderate Risk:  The update did not revise recommendations for lower risk persons:  those with moderate risk (2 or more risk factors plus an under 10% risk of a heart attack in 10 years) or those with 0 to 1 risk factor.  According to the report, the absolute benefits for people at the lower levels of risk are less clear cut and the recent clinical trails do not suggest a modification of treatment goals and cut points.

The report emphasizes the importance of therapeutic lifestyle changes (TLC) -- intensive use of nutrition, physical activity, and weight control -- for cholesterol management.

Lifestyle changes continue to be an essential part of controlling cholesterol.  TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering.

Like ATP III, the update addresses and emphasizes cholesterol lowering in older persons (age 65 or above).  High-risk older persons with established cardiovascular disease are included in the recommendations for intensive LDL-lowering therapy.

Although the update suggests that physicians use their clinical judgment to determine whether intensive LDL-lowering therapy is warranted in older persons, these people should not be excluded from the benefits of LDL-lowering treatment just because of age, according to NCEP.

A comparison of the key modifications in the update with the ATP III recommendations follows:

However, the update to the ATP III guidelines is not the final word on LDL goals.  There are three ongoing trials in high-risk individuals, that when completed, may lead to a broader recommendation for reaching very low LDL goals in high-risk patients.

A copy of the update and information on the ATP III guidelines can be found online by clicking here.  

(7/04)

Fish Oils

Fish oil supplements seem to be fulfilling their therapeutic promise.  Fish oils are rich in polyunsaturated fats known as omega-3 fatty acids.  These fatty acids have anti-inflammatory and blood pressure-lowering actions.  They interfere with platelet aggregation and therefore have an important anticoagulant effect.

Clinical studies with fish oil supplements have shown important clinical benefits.  A study of men following myocardial infarction revealed a lower mortality in patients taking fish oil supplements.  Fish oils are the only supplements known to possess anti-arrhythmic actions and have been shown to prevent sudden death in coronary patients.

Omega-3 unsaturated fatty acids can be derived in abundance by consuming fatty fish such as tuna, salmon, mackerel, and herring.  However, because of concerns about mercury contamination, children and pregnant women should restrict their consumption to no more than one portion weekly.  Fish oil supplements are a practical alternative for individuals unable to consume fish in adequate amounts.  They typically contain 1 to 3 grams of fish oil and are not contaminated with mercury.  Plant sources of omega-3 fatty acids are also available.  These include flaxseed oil, soybean oil, and walnuts.  (Excerpted from the March/April 2004 issue of Heart & Health Reports, Volume 6/Number 2.)  (7/04)

Study Finds Seasons Affect Cholesterol

Cholesterol levels tend to rise in the winter and fall in the summer -- variations that in some cases could affect treatment decisions.

A study conducted by the University of Massachusetts found the biggest seasonal changes occurred in women and in people with already elevated cholesterol, whose levels fluctuated as much as 18 points.

The findings could be useful to patients who want to try lowering their cholesterol through lifestyle changes instead of drugs.  He said many patients could end up getting discouraged if they started diets in the summer and did not see much change or even an increase by wintertime.

The study did not examine whether seasonal changes in cholesterol affected participants' overall health.  Without that evidence, there is no way of knowing whether the fluctuations are medically important or just an isolated chemical observation.  However, it's a reminder that a single cholesterol reading at any point in time is only a snapshot and can vary next time.  

The study appears in the April 26th issue of Archives of Internal Medicine (Vol. 164/Number 8).  (7/04)

Citrus Peels May Help Lower Bad Cholesterol

A substance found in the peels of citrus fruits may lower bad cholesterol, according to the results of a new study.  The study, a joint project by the U.S. Department of Agriculture and KGK Synergize, a Canadian nutraceutical company, was published in the May issue of the Journal of Agricultural and Food Chemistry.  

Low-Fat May Not be Best for Heart

A relatively high amount of fat in the diet may be a boon to a healthy person's cholesterol levels, a small study suggests.  One the other hand, limiting fat intake too much could have the opposite effect.

Researchers at the State University of New York at Buffalo found that when 11 healthy but sedentary adults followed a very low-fat diet (19 percent of calories from fat) for three weeks, they saw a drop in their HDL cholesterol.  In contrast, three weeks on a diet that provided 50 percent of calories from fat boosted participants' HDL levels, according to findings published in the Journal of the American College of Nutrition (April 2004).

To circulate in the blood, cholesterol must be attached to a protein to form a lipoprotein.  HDL (high-density lipoprotein) molecules carry cholesterol away from the arteries and to the liver to be cleared from the body.  Experts believe that an HDL level of 60 or more helps lower the risk of heart disease, while a level lower than 40 raises the risk.

The new findings suggest that adequate fat intake can help ward off heart disease by raising HDL.  Researchers note that this doesn't mean they think everyone should be on a 50% fat diet.  However, it's still important to calorie balance which means eating only enough to meet the body's calorie expenditure.  The findings indicate that moderation, and not tight restriction, is the way to go.  (7/04)