Advancing Skills in the Delivery of Personalized, Proactive, Patient-Driven Care Lipids Summary Clinical Tool This document has been written for clinicians. The content was developed by the Integrative Medicine Program, Department of Family Medicine, University of Wisconsin-Madison School of Medicine and Public Health in cooperation with Pacific Institute for Research and Evaluation, under contract to the Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration. Information is organized according to the diagram above, the Components of Proactive Health and Well-Being. While conventional treatments may be covered to some degree, the focus is on other areas of Whole Health that are less likely to be covered elsewhere and may be less familiar to most readers. There is no intention to dismiss what conventional care has to offer. Rather, you are encouraged to learn more about other approaches and how they may be used to complement conventional care. The ultimate decision to use a given approach should be based on many factors, including patient preferences, clinician comfort level, efficacy data, safety, and accessibility. No one approach is right for everyone; personalizing care is of fundamental importance.
Lipids Summary Clinical Tool This clinical tool is a brief summary of the Lipids clinical tool, also available in this module. See the larger document for additional details, including all references. New Prevention Guidelines The American Heart Association and American College of Cardiology jointly released four new cardiovascular prevention guidelines in 2013, including updated cholesterol management guidelines. The recommendations were not intended as new thresholds for automatic and mandatory statin therapy, but as a starting point for discussion with patients. Key takeaway points include the following: Little to no evidence supports use of specific LDL-C and non-hdl-c levels as treatment goals. Lipids should still be considered along with other risk factors. Diet and lifestyle modifications should be emphasized. Moderate- or high-intensity prescription statin therapy is recommended in at least the following patient populations: o Known cardiovascular disease (CVD) o Very high LDL-C ( 190 mg/dl) in adults o 40-75 years of age with diabetes o 40-75 years of age with estimated risk of cardiovascular disease of 7.5% or greater without known cardiovascular disease. Prescription statin therapy may also be considered for those with the following: o Significant family history of premature cardiovascular disease o High lifetime risk of atherosclerotic cardiovascular disease o LDL-C of 160 mg/dl or greater o Hs-CRP 2 o Concerning results from coronary artery calcium scoring or ankle-brachial index measurements. Many of the benefits ascribed to statins may be attained through comprehensive diet and lifestyle changes. Statin therapy may be most effective for reducing secondary CV risk. Non-statin therapy may be considered for patients with statin intolerance, or who are taking medications that may interact with statins. o Evidence for non-statin drugs (fibrates, niacin, bile acid sequestrants or ezetimibe) reducing risk of heart attack or stroke is considered weak. Healthy nutrition, regular exercise, and weight management are the most important influences on lowering cholesterol and preventing heart disease. Page 1 of 5
Food and Drink WHOLE HEALTH: CHANGE THE CONVERSATION Lyon Diet Heart Study Following Mediterranean diet compared to low-fat diet resulted in a 70% (12% vs. 4%) reduction in heart events in those with preexisting CVD. Mediterranean diet was three times more effective than statin therapy for secondary prevention. PREDIMED Study Over 7,000 Spanish subjects (ages 55-80) at high risk but without active CVD, randomized to one of three diets: 1) Mediterranean diet rich in nuts 2) Mediterranean diet rich in extra-virgin olive oil 3) Active control group with prudent reduction in dietary fat. Primary endpoint = combination of stroke, heart attack and cardiovascular deaths. Trial stopped early; compared with controls, endpoint reduced by 30% in Mediterranean diet plus extra virgin olive oil group; by 28% Mediterranean diet with nuts group. Also reduced incidence of stroke in intervention groups. Components of the Mediterranean diet Olive and canola oils Whole grains Vegetables Nuts and seeds Fruits Fresh fish and seafood Legumes Eggs Moderate amounts of dairy (primarily yogurt and cheese) Moderate amounts of red wine with meals Minimal amounts of red and processed meat, refined flours Key dietary factors for lowering cholesterol Water soluble or viscous fiber (pectin, oat bran, ground flaxseed, barley; fiber supplements may be considered). o Caution: Fiber may inhibit absorption of pharmaceuticals, vitamins, and minerals. Soy protein (20-50 grams daily; not all studies suggest benefit). Plant stanols and sterols (inhibit gut cholesterol absorption by approximately 50%). Nuts (excellent source of omega-3 polyunsaturated fat), fiber, plant sterols, and flavonoids. Daily dose is about one small handful per day. Legumes (peas, beans, lentils, soy, and peanuts). Page 2 of 5
The portfolio diet Mediterranean-style eating plan found to reduce LDL cholesterol by ~ 30% (similar to 20 mg of the statin lovastatin). Daily amounts for a 2000 calorie per day diet include the following: o 30 grams of almonds (walnuts, cashews, Brazil nuts, and macadamia nuts also considered beneficial). o 20 grams of viscous fiber (oats, barley, psyllium). o 50 grams of soy protein (tofu, soy milk). o 2 grams of plant sterols (specially formulated spreads, avocado, soybeans, olive oil, and green leafy vegetables). o Increased legume consumption (peas, beans, lentils, and peanuts). Essential fatty acids Reductions in cholesterol, triglycerides, and inflammation occur when saturated fats were replaced with monounsaturated (MUFA) and polyunsaturated fatty acids (PUFA). o Experts question the influence of dietary fats on CVD risk. The more likely culprits are highly processed, manufactured foods including processed meats. MUFAs (olive and canola oils, avocados and nuts). o Lower LDL, may even raise HDL. PUFAs o GISSI study (> 11,000 men with CVD). o 850 mg of omega-3 fatty acids reduced risk of sudden cardiac death by 45%. o Important to consume more omega-3 fatty acids and fewer omega-6 fatty acids (both are necessary for optimal health). Omega-3 fatty acids: cold water fish, nuts, vegetables, flax seed, soy, hemp. Most efficient source: cold water fish, which provides Eicosapentaenoic Acid (EPA) and docosahexaenoic acid (DHA). Omega-6 fatty acids include partially hydrogenated vegetable oils. o Fish oil supplementation To lower triglycerides: 3-4 grams of EPA + DHA daily. Dose for health promotion/disease prevention = 1 gram daily. Other food groups Garlic o Significantly reduces total cholesterol and triglyceride levels, but does not affect HDL and LDL. Artichoke o Constituents block HMG-CoA reductase like statins. Food better than extract (600 mg three times daily or 900 mg twice daily). Grapes o Constituent phenolic compounds may not lower cholesterol levels, but appear to be cardioprotective. Page 3 of 5
o Other polyphenol-rich foods include olive oil, wine, blueberries, cranberries, bilberries, black currant, peanuts, onions, green and black tea, legumes, and parsley. o Resveratrol little impact on longevity, risk of CVD, or cancer. Ethanol o Moderate versus occasional alcohol consumption leads to small but significant CVD risk reduction. o Moderately increases HDL (12%). o Some protection against ischemic stroke, but increased risk of hemorrhagic stroke. Other supplements Note: Please see the module on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual. Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind. Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer. This applies to the supplements mentioned above, as well. Red yeast rice (RYR) o Ferment white rice with the yeast, Monascus purpureus. o Produces mevinic acids, one of which (monacolin K, also known as mevinolin) is also found in lovastatin. Inhibits HMG-CoA reductase, reduces cholesterol. o Also contains sterols, isoflavones, and monounsaturated fatty acids. o Less myopathy than with prescription statins, but is still possible, as is hepatotoxicity, so monitor liver function. o Dose: 600 to 1200 mg twice daily. 3.6 grams RYR = 6 mg of lovastatin. Inappropriate fermentation can produce the chemical citrinin (nephrotoxic). Choose products wisely (www.consumerlab.com). Niacin o Little role in management of dyslipidemia based on results of AIM-HIGH and HPS2-THRIVE. Page 4 of 5
Whole Health: Change the Conversation Website Interested in learning more about Whole Health? Browse our website for information on personal and professional care. http://projects.hsl.wisc.edu/service/index.php This clinical tool was created by Russell H. Greenfield, MD, Director of Greenfield Integrative Healthcare, PLLC, and President of Greenfield Consulting, LLC. Sections of this clinical tool were adapted from the University of Wisconsin Integrative Medicine Pearls for Clinicians document on Non-Pharmaceutical Therapy for Lowering Cholesterol written by David Rakel MD, Assoc. Prof. and Director of the Integrative Medicine Program, Dept. of Family Medicine, University of Wisconsin-Madison, Steve Humpal MS4, Pacific Northwest University College of Osteopathic Medicine, and Charlene Luchterhand, MSSW, Education/Research Coordinator, University of Wisconsin-Madison Integrative Medicine Program. Page 5 of 5