February 08, 2010
 
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Lowering Your Cholesterol: Diet or Drugs?
Ernst John Schaefer, M.D., and< Robert M. Russell, M.D.
 
Ernst John Schaefer is professor of medicine at Tufts University School of Medicine, Director of the Heart Disease Prevention Program at New England Medical Center, and senior scientist and Chief, Lipid Metabolism Laboratory of the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University. He graduated from Harvard College, Dartmouth Medical School and Mt. Sinai School of Medicine, trained in internal medicine at Mt. Sinai and in endocrinology and lipoprotein research at the National Institutes of Health. Dr. Schaefer served on the first and second Adult Treatment Panels of the National Cholesterol Education Program which generated U.S. guidelines for cholesterol management. He is the U.S. editor of the journal Atherosclerosis. His research focuses on the nutritional and genetic regulation of plasma lipoproteins.


RMR
What's the right treatment for a person who has too much of the bad kind of cholesterol — LDL (low density lipoprotein)? Should he or she diet first or is it better to begin using drugs right away, even before diet is tried?

EJS
Elevated LDL cholesterol, levels over 160 mg/dl, have clearly been shown to be a significant risk factor for coronary heart disease (CHD). Lowering LDL cholesterol has been associated with significant reduction in risk (see Table 1 below).(1)(2)

Table 1.
Treatment Guidelines for Patients with Elevated LDL Cholesterol
  Initiate Diet Therapy After Diet Therapy, Initiate Drug Therapy Goal of Therapy
< 2 CHD risk factors 160 mg/dl (4.1 mmol/L) 190 mg/dl (4.9 mmol/L) < 160 mg/dl (4.1 mmol/L)
2 or more CHD risk factors 130 mg/dl (3.4 mmol/L) 160 mg/dl (4.1 mmol/L) < 130 mg/dl (3.4 mmol/L)
CHD 100 mg/dl (2.6 mmol/L) 130 mg/dl (3.4 mmol/L) < 100 mg/dl (2.6 mmol/L)
LDL = low density lipoprotein
CHD = coronary heart disease

You have less than two heart disease risk factors (see Table 2 below), diet is initiated if the LDL cholesterol is greater than 160 mg/dl. For those with LDL cholesterol higher than 190 mg/dl, the doctor will also add drug therapy. The goal of therapy in this higher group is to bring the LDL level below 160 mg/dl as soon as possible

Table 2.
NCEP CHD Risk Factors*
Positive Negative
  • Male > 45 years
  • Female > 55 years
  • Family History of Premature CHD
  • HDL C < 35 mg/dl
  • Smoking
  • Diabetes
  • HDL C > 60 mg/dl
*Subtract a risk factor if the HDL C 60 mg/dl, family history of premature CHD has been defined as the presence of CHD in a male first-degree relative prior to age 55 and prior to age 65 in a female first-degree relative


In people with two or more heart disease risk factors, for example if you smoke and have a family history of heart disease, diet and drug therapies are initiated at a 30 mg/dl lower level. Here, the goal is to lower LDL cholesterol values below 130 mg/dl. In patients with established heart disease, we are even more aggressive — we initiate diet if the LDL cholesterol is more than 100 mg/dl; we initiate drug therapy after diet if the LDL cholesterol is more than 130 mg/dl. The goal of therapy is to get the LDL cholesterol to less than 100 mg/dl.

Before placing someone on diet therapy, it is important to make sure they don't have other secondary causes of hypercholesterolemia, as follows:
  • Hypothyroidism
  • Obstructive Liver Disease
  • Nephrotic Syndrome
  • Diabetes Mellitus
  • Progestins
  • Anabolic Steroids

The ideal approach is to refer the person to a dietitian who can work with the patient and his/her spouse, either individually or in a group setting. There are some people whom we place on drug therapy immediately, especially those with established heart disease who are unlikely to achieve goal with diet alone. However, all such patients are also referred for diet counseling.

With regard to the diets that are recommended, they are shown in Table 3 below. Since the Step I diet is recommended for the entire U.S. population, we tend to go to the Step 2 diet when we refer the patient to the dietitian. The Step II diet, which is recommended for patients who have high blood levels of cholesterol, is generally more difficult to follow and requires the input of a registered dietitian or nutrition counselor who can spend substantial amounts of time with the patient to achieve these goals.

Table 3.
National Cholesterol Education Program Guidelines on Dietary Therapy*
Nutrient Average U.S. Diet** Step 1 Diet Step 2 Diet
Total Fat 34% < 30% < 30%
Saturated Fat 1 2% < 10% < 7%
Monounsaturated Fat 13% < 15% < 15%
Polyunsaturated Fat 7% < 10% < 10%
Total Energy Calories — To achieve and maintain desirable body weight
*Percent of total energy calories.
**Total population data from National Health and Nutrition Examination Survey (NHANES) III, excluding children under 2 years of age.

Obviously, it is also important to recommend daily exercise, 30 minutes per day. For elderly patients, especially those with established heart disease, often walking is the only thing they can achieve.

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