When you hear the word ‘cholesterol,’ you might imagine pictures of grotesquely clogged arteries, greasy bags of food, and scary-sounding diseases. Vivid scenes of heart attacks and towering slabs of heart-stopping meat is enough to scare anyone!
Cholesterol, though, doesn’t have to be intimidating. Not all cholesterol is bad, but it can become a problem. When cholesterol does become an issue, the treatment is always simple and cookie-cutter: You go to the doctor, get the same old blood tests, get the same old pills, and sweep the issue under the rug.
Recently, however, the National Lipid Association has introduced new recommendations to help you manage your cholesterol more efficiently. First, new cholesterol measurements can give you a more complete look at your cholesterol status. Second, the NLA discourages the use of quick-fixes in favor of personalized patient care.
Few understand the new recommendations better than Dr. James Underberg and Dr. Terry Jacobson. Their combined expertise in cardiovascular disease and cholesterol provides an unflinching look at the new recommendations. With unmatched expertise and unyielding passion, they took the time to discuss NLA’s new recommendations and what that means for you.
1. What does the National Lipid Association (NLA) do?
A multidisciplinary specialty society, the NLA focuses on prevention of cardiovascular disease and other lipid-related disorders. It is the mission of the NLA to enhance the practice of lipid management in clinical medicine.
2. In what ways is HDL “good”? In what ways is LDL “bad”?
HDL cholesterol (HDL-C) is the measure of the cholesterol carried in particles called high density lipoproteins (HDL). HDL is known as the “good” cholesterol because the high density lipoproteins usually carry harmful cholesterol molecules away from the vessel walls and return them to the liver where they are metabolized. This healthy process is called “reverse cholesterol transport.” Optimal HDL levels should be greater than 40 for males and greater than 50 for females.
On the other hand, LDL cholesterol floats in the blood stream and transports cholesterol from one cell in your body to another. Too much LDL cholesterol in your blood stream can lead to excess cholesterol being deposited in the walls of blood vessels making them narrower and causing the onset of heart disease. High levels of LDL cholesterol can put patients at risk for cardiovascular disease.
Of note, however: Having normal or elevated levels of HDL cholesterol does not necessarily protect one from the impact of elevated LDL cholesterol levels.
3. What is non-HDL cholesterol (non-HDL-C)? Why should physicians include it along with traditional cholesterol measurements?
Non-HDL cholesterol is simply the difference between the total cholesterol concentration and the HDL, or “good cholesterol.” Non-HDL-C is a more comprehensive measure of cholesterol-related risk, and it is a better primary target for treatment than the traditionally reported LDL cholesterol.
4. What does non-HDL-C reveal about a patient compared to that of HDL and LDL?
There’s more to bad cholesterol than just the LDL cholesterol—there are also triglycerides, which are bad. This is a very important measure of cholesterol-related risk that providers need to know about, and it’s set 30 points higher than your LDL goal, so if, for example, a patient’s LDL goal is 100, the non-HDL-C goal is 130. It’s very simple, and once providers start to learn this language in addition to what they’ve learned with LDL, they’ll communicate more effectively with patients about changing it.
5. Does the current U.S. healthcare system present challenges with regards to the new collaborative approach to cholesterol management? If so, how can patients and healthcare workers overcome these difficulties?
To draw on a classic phrase, effective healthcare takes a village. The provider needs to work with the patient, a family, a dietician, athletic trainers, coaches if they have access to one, pharmacists, people who are credible sources of information, the Internet, etc.
But having said that, it isn’t just the current healthcare system that presents challenges in regard to a collaborative approach to improving the health of the nation—we are all time-crunched, and we feel that everywhere from the grocery store to the workplace to the doctor’s office. This issue needs to be solved in mutual partnership with many groups; the more groups involved in helping patients—or consumers—the better. We all are starved for credible health information that we can act on. But information alone is not enough. We need the tools to implement those behaviors.
6. How will providers use these new cholesterol treatment recommendations?
The 2013 American Heart Association (AHA) and the American College of Cardiology (ACC) guidelines adhered to evidence from randomized clinical trials; as a result, the AHA-ACC guidelines did not include some patient populations seen in practice. The guidelines also moved away from the use of goals for low-density lipoprotein (LDL) cholesterol based on what was identified as a lack of evidence of clinical benefit.
In contrast, the new NLA guidelines inform healthcare providers with practical, evidence-based approaches to provide high-quality preventive care for their patients and to help guide physicians through managing patients at risk with high cholesterol by utilizing a more patient-centered, individualized approach. With that focus, the NLA reiterated the benefit of setting cholesterol goals, which advocates argue motivate patients and allow physicians to monitor adherence. It means a greater emphasis on the provider-patient relationship.
7. What else do patients need to know about controlling their cholesterol levels?
Medication and lifestyle interventions, either separately or in conjunction, can be used to lower cholesterol. The NLA’s recommendations allow practitioners and patients to have an interaction and choose the best treatment, tailored to the patient rather than a population.
8. What are the NLA’s recommendations around drug therapy to manage cholesterol levels?
Drug therapy should be started with a statin, with the exception of patients who are intolerant, and treatment should be determined on a case-by-case basis. Our message is that after statins, it is OK to use nonstatins for the appropriate reasons. And we list those very clearly: in high-risk patients and in patients with inherited cholesterol disorders.
9. There can be confusion out there about cholesterol levels. How do the NLA recommendations differ to what many patients and doctors have been saying?
Diet and lifestyle therapies should be tried first in patients at low and moderate risk, while drug therapies can be started concurrently in those at very high risk and in some at high risk. The NLA perspective is that lifestyle intervention plus evidence-based statin therapy is the first choice in preventive drug therapy, but non-statin options play an important additional role when lipid goals are not achieved or when patients are statin intolerant.
The use of lipid goals is one method of enhancing provider-patient partnership to achieve long-term adherence to preventive recommendations. Emphasis on reduction of blood lipids and achievement of lipid-related goals, rather than on specific doses of drug therapy, helps to emphasize for patients the basic cause of cardiovascular disease and helps them to focus on improving their cholesterol numbers through lifestyle and drug therapy.
Ultimately, cholesterol is an essential element of patient care. It is often a battle fraught with difficulty. Fortunately, you have formidable allies. Dr. Underberg, Dr. Jacobson, and the National Lipid Association will continue to fight for your health. Beginning now, your weapons are more powerful than ever. Armed with new treatment options and newfound knowledge, your health is now a straight shot.
Dr. Terry A. Jacobson, MD, FACP, FNLA is President of the National Lipid Association, Director, Office of Health Promotion and Disease Prevention, Professor of Medicine at Emory University, and Director of Penn’s Lipid Evaluation and CHD Risk Assessment Center.
Dr. James Underberg, MD is a Clinical Assistant Professor of Medicine at NYU School of Medicine as well as the NYU Center for Prevention of Cardiovascular Disease. He is also the Director of the Bellevue Hospital Lipid Clinic.