Recommendation #7: Refine therapeutic target levels to the equivalent population percentile.
ATP III set non-HDL-C goals 30 mg/dL higher than LDL-C goals
• With this approach, non-HDL-C goals are higher than the equivalent population percentile for an equivalent LDL-C goal.
• Equivalent goals based on population percentiles are:
» LDL-C <70 mg/dL = non-HDL-C <90 mg/dL = apoB <60 mg/dL
» LDL-C <100 mg/dL = non-HDL-C <120 mg/dL = apoB <80 mg/dL
Recommendation #8: Remove misleading descriptors such as “borderline high.”
ATP III labels a LDL-C of 130 to 159 mg/dL as “borderline high”
• Consider: Average LDL-C levels range from 50 to 70 mg/dL in groups naturally free of atherosclerosis (these include native hunter-gatherers, healthy human neonates, free-living primates, and other wild mammals)
• The value range described as “borderline high” is 2 to 3 times higher than humans have evolved to have, is not evidence-based, and provides false reassurance to patients whose LDL-C is actually dangerously high; either the ranges or descriptors need reassessment
• We recommend removing the misleading descriptors or reframing lipid levels in the context of normal levels by evolutionary, rather than modern American, standards
Recommendation #9: Make lifestyle messages simpler, “user-friendly.”
Try telling a patient: “Up to 10% of your total calories should be from polyunsaturated fat, up to 20% from monounsaturated fat,” and so on. Not effective communication.
• Here are lifestyle messages that are evidence-based and that we find helpful in clinic:
• Rather than nutrient percentages, emphasize a dietary pattern
• Encourage patients to follow a DASH–like (Mediterranean-style) diet10
• Associated with reduced cardiovascular and all-cause mortality
• Easy to discuss with a patient: increase consumption of fresh fruits, vegetables, whole grains, low-fat dairy, oily fish, poultry over red meat; eat a modest amount of nuts and beans, herbs and spices in place of salt, and limit added fats (eg, olive oil in place of butter and margarine)
• Patients can use cookbooks following a DASH-like eating pattern
• Advise patients to wear a pedometer with a goal of 10,000 steps/day
• This intervention is linked with increased exercise and improved health
Recommendation #10: Adopt an ABCDE approach in clinic.
• Optimizing risk reduction in a busy primary care clinic is as easy as ABC, D, and E!
» A: Assessment of risk, Aspirin/antiplatelet therapy, Affordability, ACE-I/ARB, Apnea
» B: Blood pressure, Beta-blocker
» C: Cholesterol, Cigarette smoking
» D: Diet, Diabetes
» E: Exercise
• As a nod to this approach, here are our ATP IV recommendations, summarized in ABDCE format:
» A: Assessment of risk - use a more comprehensive, accurate approach
» A: Algorithm - directly link risk to therapy; relax/personalize follow-up testing
» B: Biology - consider particles vs. cholesterol, use evolutionarily normal lipid levels
» C: Cholesterol - deemphasize baseline cholesterol as a starting point in algorithms
» D: Drug classes - prioritize statins
» D: Descriptors - remove them; they are misleading
» D: Diet - convey a simpler message (eg, a DASH-like or Mediterranean diet)
» E: Exercise - convey a simpler message (eg, 10 000 steps/day)
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