New Cholesterol Guidelines Expected To Lead To A Tripling Of Americans Taking Cholesterol-Lowering Drugs

Dr. Scott Grundy, director of the Center for Human Nutrition at UT Southwestern Medical Center at Dallas, chaired the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), the executive summary of which is published in today’s Journal of the American Medical Association. Grundy also chaired the NCEP Adult Treatment Panel II, which issued the last cholesterol guidelines in 1993.

"The new guidelines are expected to substantially increase the number of Americans being treated for high cholesterol," said Dr. Claude Lenfant, director of the NHLBI. "If these guidelines are followed, about 65 million adults will be on dietary treatment and about 36 million will be prescribed a cholesterol-lowering drug."

The report includes several important new features:

* A major focus on identifying people who have multiple risk factors for coronary heart disease.

* More aggressive cholesterol-lowering treatment for people at high risk.

* Modifications of low HDL (high-density lipoprotein) and triglyceride classification to better identify people at risk for heart disease.

* New dietary and lifestyle recommendations to enhance both LDL lowering and other risk factors.

* Identification of the metabolic syndrome as an enhancer of risk beyond elevated LDL cholesterol.

The report reaffirms that elevated LDL is a major cause of coronary heart disease and LDL-lowering therapy significantly reduces that risk.

Coronary heart disease (CHD) is the No. 1 killer of Americans, claiming about 500,000 lives yearly. Studies have consistently shown that by lowering LDL levels, risk for coronary heart disease is reduced by as much as 40 percent. Those at highest risk for heart attack include those with heart disease; however, other conditions confer as high a risk for heart attack as having heart disease itself. These conditions include the presence of atherosclerosis in other arteries, diabetes and multiple risk factors. These risk factors include cigarette smoking, hypertension, low HDL, family history, or age (men over 45 or women over 55).

For this reason, the panel recommends that adults 20 and over have their total cholesterol, LDL, HDL and triglyceride levels evaluated once every five years.

Low HDL is now defined as less than 40 milligrams per deciliter; the 1993 report defined low HDL as less than 35 mg/dL. Studies have shown a significant link between low HDL levels and an increased risk of heart disease. A higher HDL level, above 60 mg/dL, is considered a "negative" risk factor and is protective against heart disease.

"The aggressive management and treatment of high blood cholesterol leads to significant improvement," said Grundy.

"ATP III maintains attention on intensive treatment of patients with CHD. But it also adds a new feature. The new focus is on prevention of coronary heart disease in persons with multiple risk factors. Many of these persons are at high risk and deserve more intensive intervention than recommended in ATP II," Grundy said.

In some individuals a change in lifestyle and eating patterns can have a powerful effect on lowering LDL, Grundy said. Today’s report recommends "therapeutic lifestyle changes" (TLC), which have four components: * The TLC diet, which replaces the Step I and Step II diets, reduces intake of saturated fats to less than 7 percent of total calories and dietary cholesterol intake to less than 200 mg per day. * Reducing saturated fats and cholesterol will lower LDL. LDL lowering can be enhanced by consuming 2 grams of either plant stanols or sterols, which are found in certain margarines and salad dressings, and/or 10 to 25 grams of soluble fiber each day. Fruits, oats, barley and legumes contain high concentrations of soluble fiber. "It is possible to double LDL lowering by these latter recommendations." Grundy said. "These new approaches to dietary treatment of LDL represent a major new feature of ATP III."

* Weight reduction. The report defines abdominal obesity as a waist circumference of more than 40 inches in men and more than 35 inches in women. "Overweight and obesity are recognized as major, underlying risk factors for coronary heart disease…weight reduction will enhance LDL lowering and will reduce other risk factors as well," the panel said.

* Increased physical activity, which improves HDL.

A new area of emphasis for the ATP III is the metabolic syndrome, which occurs in one-fourth of Americans. It consists of a constellation of risk factors that include overweight and obesity, high triglycerides (200 mg/dL or greater), low HDL, high blood pressure, high blood glucose and a tendency to form blood clots. The panel identifies these people as candidates for intensified therapeutic lifestyle changes.

"The metabolic syndrome has emerged as being as strong a contributor to early heart disease as cigarette smoking," Grundy said. "In addition, the insulin resistance that goes along with the syndrome is one of the underlying causes of Type II diabetes (non-insulin dependent diabetes mellitus). It’s thus very important to recognize the syndrome and treat it with lifestyle changes."

The ATP III also advises against use of hormone-replacement therapy as an alternative to cholesterol-lowering drugs. Clinical trials have failed to show that the use of estrogen reduces a woman’s risk for heart disease, Grundy said.

The first Adult Treatment Panel report, published in 1988, focused on the prevention of CHD, before any signs of clinical disease. The report identified LDL cholesterol as the primary target of therapy and emphasized clinical management of patients with higher levels of LDL. In the second report, published in 1993, the panel reaffirmed the importance of treating high LDL cholesterol to prevent the development of CHD. It also outlined an intensive plan to manage LDL cholesterol in people who already have heart disease.

"In a perfect world, everyone would have low cholesterol," said panel member Dr. Margo Denke, associate professor of internal medicine at UT Southwestern, an investigator in the Center for Human Nutrition.

"In this third panel, we tried to more carefully define who is most at risk of coronary heart disease," Denke said.

Twenty-seven experts in the fields of heart disease, lipid measurement and management, primary-care medicine, nutrition, epidemiology, health economics and other areas developed the guidelines over 20 months. The National Heart, Lung and Blood Institute, part of the National Institutes of Health, established the National Cholesterol Education Program in 1985.