New Cholesterol Guidelines

On May 15, 2001, the National Cholesterol Education Panel (NCEP) issued significant new clinical practice guidelines on the prevention and treatment of high cholesterol levels in adults. This is the first major update of the NCEP guidelines since 1993. An executive summary of the Third Report of the NCEP Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (a.k.a., Adult Treatment Panel III or ATP III) appeared in the May 16, 2001 issue of the Journal of the American Medical Association. The NCEP predicted that the new ATP III guidelines will increase the number of Americans requiring treatment for elevated cholesterol levels (from 52 million to 65 million) and nearly triple the number of Americans who will need to take cholesterol-lowering medications (from 13 million to 36 million Americans). This is in order to reach the more aggressive blood cholesterol-lowering treatment goals established by the ATP III.LDL Guidelines ChangeThe new ATP III guidelines do not change the goal level for total cholesterol. Rather, the new ATP III guidelines have established goals for LDL or “bad cholesterol” levels for the general public that are much more aggressive than earlier goals. These more aggressive LDL lowering goals, if achieved, will be much more likely to prevent or successfully treat atherosclerosis than previously defined goals. This means fewer heart attacks and strokes for patients who achieve them. The new LDL categories are shown in Table 1.Why are the goals more aggressive?In ATP II, an LDL level below 130 was categorized as “desirable” for prevention of heart disease. However, an LDL of 100-129 is often associated with progression of atherosclerotic lesions, particularly when several other coronary heart disease risk factors are present. While an LDL of <130 mg/dl was more “desirable” than even higher levels, it was certainly not “optimal” for either the prevention or treatment of atherosclerotic disease or clogged arteries. A meta-analysis of 14 cholesterol-lowering trials calculated that atherosclerotic plaque usually progresses when LDL rises above 100.1 No doubt it was this type of data that convinced ATP III scientists to lower their LDL targets for people at high risk of CHD.It should be noted that nearly 10% of CHD patients have LDL levels below 100, although most of these have several other coronary heart disease risk factors. Therefore, in patients deemed at very high risk for heart attacks due to advanced atherosclerosis, an LDL clinical target even lower than 100 may be warranted in some or most patients.2 Several studies are now being conducted to determine if there is a benefit to lowering LDL well below 100 in patients with atherosclerotic disease.These goals are healthy for allClearly the new focus on the measurement of LDL in all adults over age 20 years, along with lower targets for “safe” LDL levels for many patients, is warranted by the bulk of the scientific research. Whether even lower target levels for LDL are clinically warranted for some patients awaits results of ongoing clinical trials.The ATP III now states that an LDL of less than 100 mg/dl is “optimal” for people at high risk for coronary heart disease. It would be prudent, however, to advise all patients to shoot for this goal. After all, several hundred thousand Americans will have heart attacks and strokes each year even though they are not deemed to be in the high-risk category.What is the safest and most effective dietary approach to achieving this optimal LDL goal? The answer, while simple, may be difficult for most people accustomed to a typical Western diet. To achieve the “optimal” LDL level, one should follow a diet low in animal products and hydrogenated fat and high in minimally processed fruits, vegetables and whole grains. Following all 10 steps in the box below will help most Americans lower their LDL cholesterol level from 20 to 50% in 3-4 weeks. A handout is available online at www.foodandhealth.com/handout.shtml.Our next article will discuss other revisions to the NCEP guidelines including HDL and triglycerides. Health professionals may obtain the corresponding CPE course or full text article with references for a nominal fee by calling 800-462-2352. We will have a presentation kit for this topic out soon.By James J. Kenney, PhD, RD, FACN.References:1. Am J Cardiol 1995;76:86C-92C2. Clev Clin J Med 2000;67:489-96