The Facts About Cholesterol
The National Cholesterol Education Program (NCEP) encourages
physicians to prescribe stringent dietary therapy of hyper
cholesterolemia for at least 6 months before initiating drug therapy.
Physicians should also be cautioned about premature use of
hypercholesterolemic medications: no known study has demonstrated decreased mortality in recipients of such medications.
Dietary therapy should strongly be encouraged, and physicians should
adopt mandatory referral to a registered dietitian or other qualified
nutrition professional before dietary therapy is declared a failure and
drug therapy is started.
Lowering cholesterol levels decreases the incidence of heart
disease. In fact, several studies have convincingly shown that adequate
hypercholesterolemic treatment can not only prevent CHD, but can also
reverse it. [Kuo, P.T., Hayase, K., Kostis, J.B., and Moreyra,
A.E.: Use of combined diet and colestipol in longterm treatment of
patients with type II hyperlipoproteinemia. Circ 59:199, 1979. ]
Recently these topics have been comprehensively reviewed. Dietary
therapy is the cornerstone of all hypercholesterolemic therapy, and it
has been estimated that 60 million adult Americans may be candidates
for dietary instruction.
Findings suggest that blood lipid cholesterol levels predict
subsequent mortality in men, especially those with preexisting
cardiovascular disease. Those with high blood cholesterol levels have a
risk of death from cardiovascular disease, including coronary heart
disease, that was 3? times higher than that for men with a "desirable"
blood cholesterol level.
Familial hypercholesterolemia carries a marked increase in the risk
of coronary heart disease (CHD), but there is considerable variation in
susceptibility to CHD between individuals. Results indicate that an
elevated level of lipoprotein is a strong risk factor for CHD in these
individuals; the risk is independent of age, sex, smoking status, and
serum levels of total cholesterol, triglyceride, or HDL-cholesterol.
The higher level of lipoprotein observed in patients with CHD is the
result of genetic influence. The New England Journal of Medicine: 322:1494, 1990.]
The efficacy of hypercholesterolemic diets lowering cholesterol and
in some cases, in preventing CHD, has been convincingly demonstrated.
Such efficacy does depend, however, on the vigour which the physician
and dietitian support dietary therapy. Many physicians have declared
dietary therapy a failure without providing their patients with real
dietary advice and support.
Two factors that probably contribute to physicians disinterest in
dietary therapy are extensive advertising of hypercholesterolemic drugs
compared with the little advertisingof dietary therapy and patient
reluctance to alter diet and life-style. Getting patients to alter
their life-style is often a challenging task. A recent survey [Schucker,
B., Bailey, K., Heimbach, J.T., Wittes, J.T., Cutler, J.A., Mackintosh,
D.R., Gordon, D.J., Haines. C.M., Mattson, S.E., Goor, R.S., and
Rifkind, B.M.: Change in public perspective on cholesterol & heart
disease.JAMA 258:3527,1987] suggests, however, that the public
is ready and able to embrace dietary therapy as the primary solution to
hypercholesterolemia.
To further facilitate dietary therapy, recent research suggests that
certain forms of fat (eg. fish and monounsaturated fatty acids) may be
hypocholesterolemic, especially if they replace saturated fatty acids
in the diet. Food technology is improving daily in palatably, removing
fat from items like cheese, chips, and crackers. Frozen yogurt has
become a popular replacement for ice cream. Fat substitutes, as they
become available, may also facilitate compliance with a low-fat diet.
Psyllium is an especially attractive hybrid intervention in that it
is well tolerated, lowers LDL-cholesterol by 10% to 20%, has no adverse
effects on triglycerides, high-density-lipoprotein (HDL) cholesterol,
or serum glucose, and is readily available and fairly inexpensive. It
has a long history of use without any evidence of long-term adverse
effects.
A recent article estimated that oat bran supplementation (90 gm per
day) was a much more cost-effective method of lowering serum
cholesterol than either cholestyramine or colestipol. [Kinosian,
B.P., and Eisenberg, J.M.: Cutting into cholesterol: Cost-effective
alternatives for treating hypercholesterolemia. JAMA 259:2249, 1988.]
In addition, high-fibre diets may decrease risk of colon cancer,
improve glucose tolerance, lower blood pressure, and assist in weight
loss.
Many physicians think that they or their staff can tell the patient
everything he or she needs to know about hypercholesterolemic diets by
issuing the usual, though imprecise, dietary admonitions (eg. avoid red
meat, whole fat dairy products, and egg yolks) and by photocopying a
few sample menus. Without explanation and reinforcement, the patient is
unlikely to achieve the dietary goals. Even if the patient does reduce
intake of fat and cholesterol from the obvious dietary sources, he or
she may continue to eat other notable, but perhaps somewhat hidden,
sources of saturated fat (eg. baked goods, tropical oils, organ meats).
An additional advantage of dietary over drug therapy is that diet
simultaneously ameliorates several cardiovascular risk factors
(hyperlipidemia, hypertension, obesity, and diabetes) whereas drug
therapy usually deals with only one. In fact, drug therapy for one risk
factor often exacerbates another (eg. beta blockersfor hypertension may
increase serum lipids, and niacin may accentuate glucose intolerance).
Dietitians are the best-qualified health professionals to help
patients lower their cholesterol levels. With the impetus of the NCEP
behind them, RDs should be aggressively promoting their services to
physicians and the public, devising methods to obtain reimbursement,
and making themselves visible as the best-qualified authorities on diet.
The public is increasingly interested in dietary control of
hypercholesterolemia, as evidenced by the widespread media attention
devoted to cholesterol. A major, but clearly surmountable, obstacle is
inadequate referral to dietitians by physicians in their communities,
about their knowledge, skills and availability to counsel clients on
the dietary treatment of hypercholesterolemia. Via these mechanisms,
dietitians will become increasingly recognized as the best sources of
nutrition information, with ultimate benefit to the public. [Zeev
Yetiv, MD, PhD. Jack, & Del Tredici, MS, RD. Ann M. Bringing the
cholesterol message to the public: Dietitians must be proactive in
nutrition counselling. JADA 90: 1383-1386]
The National Cholesterol Education Program (NCEP) encourages
physicians to prescribe stringent dietary therapy of hyper
cholesterolemia for at least 6 months before initiating drug therapy.
Physicians should also be cautioned about premature use of
hypercholesterolemic medications: no known study has demonstrated decreased mortality in recipients of such medications.
Dietary therapy should strongly be encouraged, and physicians should
adopt mandatory referral to a registered dietitian or other qualified
nutrition professional before dietary therapy is declared a failure and
drug therapy is started.
Lowering cholesterol levels decreases the incidence of heart
disease. In fact, several studies have convincingly shown that adequate
hypercholesterolemic treatment can not only prevent CHD, but can also
reverse it. [Kuo, P.T., Hayase, K., Kostis, J.B., and Moreyra,
A.E.: Use of combined diet and colestipol in longterm treatment of
patients with type II hyperlipoproteinemia. Circ 59:199, 1979. ]
Recently these topics have been comprehensively reviewed. Dietary
therapy is the cornerstone of all hypercholesterolemic therapy, and it
has been estimated that 60 million adult Americans may be candidates
for dietary instruction.
Findings suggest that blood lipid cholesterol levels predict
subsequent mortality in men, especially those with preexisting
cardiovascular disease. Those with high blood cholesterol levels have a
risk of death from cardiovascular disease, including coronary heart
disease, that was 3? times higher than that for men with a "desirable"
blood cholesterol level.
Familial hypercholesterolemia carries a marked increase in the risk
of coronary heart disease (CHD), but there is considerable variation in
susceptibility to CHD between individuals. Results indicate that an
elevated level of lipoprotein is a strong risk factor for CHD in these
individuals; the risk is independent of age, sex, smoking status, and
serum levels of total cholesterol, triglyceride, or HDL-cholesterol.
The higher level of lipoprotein observed in patients with CHD is the
result of genetic influence. The New England Journal of Medicine: 322:1494, 1990.]
The efficacy of hypercholesterolemic diets lowering cholesterol and
in some cases, in preventing CHD, has been convincingly demonstrated.
Such efficacy does depend, however, on the vigour which the physician
and dietitian support dietary therapy. Many physicians have declared
dietary therapy a failure without providing their patients with real
dietary advice and support.
Two factors that probably contribute to physicians disinterest in
dietary therapy are extensive advertising of hypercholesterolemic drugs
compared with the little advertisingof dietary therapy and patient
reluctance to alter diet and life-style. Getting patients to alter
their life-style is often a challenging task. A recent survey [Schucker,
B., Bailey, K., Heimbach, J.T., Wittes, J.T., Cutler, J.A., Mackintosh,
D.R., Gordon, D.J., Haines. C.M., Mattson, S.E., Goor, R.S., and
Rifkind, B.M.: Change in public perspective on cholesterol & heart
disease.JAMA 258:3527,1987] suggests, however, that the public
is ready and able to embrace dietary therapy as the primary solution to
hypercholesterolemia.
To further facilitate dietary therapy, recent research suggests that
certain forms of fat (eg. fish and monounsaturated fatty acids) may be
hypocholesterolemic, especially if they replace saturated fatty acids
in the diet. Food technology is improving daily in palatably, removing
fat from items like cheese, chips, and crackers. Frozen yogurt has
become a popular replacement for ice cream. Fat substitutes, as they
become available, may also facilitate compliance with a low-fat diet.
Psyllium is an especially attractive hybrid intervention in that it
is well tolerated, lowers LDL-cholesterol by 10% to 20%, has no adverse
effects on triglycerides, high-density-lipoprotein (HDL) cholesterol,
or serum glucose, and is readily available and fairly inexpensive. It
has a long history of use without any evidence of long-term adverse
effects.
A recent article estimated that oat bran supplementation (90 gm per
day) was a much more cost-effective method of lowering serum
cholesterol than either cholestyramine or colestipol. [Kinosian,
B.P., and Eisenberg, J.M.: Cutting into cholesterol: Cost-effective
alternatives for treating hypercholesterolemia. JAMA 259:2249, 1988.]
In addition, high-fibre diets may decrease risk of colon cancer,
improve glucose tolerance, lower blood pressure, and assist in weight
loss.
Many physicians think that they or their staff can tell the patient
everything he or she needs to know about hypercholesterolemic diets by
issuing the usual, though imprecise, dietary admonitions (eg. avoid red
meat, whole fat dairy products, and egg yolks) and by photocopying a
few sample menus. Without explanation and reinforcement, the patient is
unlikely to achieve the dietary goals. Even if the patient does reduce
intake of fat and cholesterol from the obvious dietary sources, he or
she may continue to eat other notable, but perhaps somewhat hidden,
sources of saturated fat (eg. baked goods, tropical oils, organ meats).
An additional advantage of dietary over drug therapy is that diet
simultaneously ameliorates several cardiovascular risk factors
(hyperlipidemia, hypertension, obesity, and diabetes) whereas drug
therapy usually deals with only one. In fact, drug therapy for one risk
factor often exacerbates another (eg. beta blockersfor hypertension may
increase serum lipids, and niacin may accentuate glucose intolerance).
Dietitians are the best-qualified health professionals to help
patients lower their cholesterol levels. With the impetus of the NCEP
behind them, RDs should be aggressively promoting their services to
physicians and the public, devising methods to obtain reimbursement,
and making themselves visible as the best-qualified authorities on diet.
The public is increasingly interested in dietary control of
hypercholesterolemia, as evidenced by the widespread media attention
devoted to cholesterol. A major, but clearly surmountable, obstacle is
inadequate referral to dietitians by physicians in their communities,
about their knowledge, skills and availability to counsel clients on
the dietary treatment of hypercholesterolemia. Via these mechanisms,
dietitians will become increasingly recognized as the best sources of
nutrition information, with ultimate benefit to the public. [Zeev
Yetiv, MD, PhD. Jack, & Del Tredici, MS, RD. Ann M. Bringing the
cholesterol message to the public: Dietitians must be proactive in
nutrition counselling. JADA 90: 1383-1386]
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