Kathleen’s parents and grandfathers all died because of heart disease. Now 65, she assumed her risk was probably high due to family history, her 20-year history of hypertension, and her current overweight condition. She’d made some healthful lifestyle changes over the years but wondered whether there was more she could do to prevent heart attack or stroke. But with all the conflicting information in the news regarding cholesterol, diet, and lifestyle, she wasn’t sure where to begin. Should she get her cholesterol level checked, choose butter over margarine … was it OK to eat eggs? Should she follow a low-carb diet and not worry about fat?
Many of us remember the days of health fairs that included total cholesterol screenings accompanied by quick and basic diet advice, which usually included “eat a low-fat diet.” Today, CVD prevention and treatment have evolved dramatically to include in-depth risk assessment and personalized treatment goals.
Guidelines to Assess Risk Factors for ASCVD
The current standard of care for CVD prevention and treatment is the Guideline on the Management of Blood Cholesterol, released by the American Heart Association and American College of Cardiology in 2013 and updated in 2018. It defines atherosclerotic CVD (ASCVD) as acute coronary syndrome, history of myocardial infarction, stable or unstable angina or coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease, including aortic aneurysm.1 The guideline encourages physicians to conduct a lifetime ASCVD risk assessment. One tool that can be used to accomplish this task is the ASCVD Risk Calculator from the American College of Cardiology.
Personalized risk assessment should include an individual’s smoking habits, LDL cholesterol (LDL-C), and presence of hypertension or diabetes. “Risk-enhancing” factors such as family history of CVD events, ethnicity, medical conditions (including metabolic syndrome, chronic kidney disease, and chronic inflammatory conditions), HDL cholesterol, non-HDL cholesterol, total cholesterol, apolipoproteins, and triglycerides also should be considered. Emphasis is placed on LDL-C rather than total cholesterol or other biomarkers because people with LDL-C levels of ≤100 mg/dL tend to have lower rates of heart disease and stroke. These days, an optimal total cholesterol is no longer the 200 mg/dL that we used to suggest but around 150 mg/dL, which corresponds to a LDL-C of around 100 mg/dL.2
Prevention and Treatment of ASCVD
That once-favored low-fat diet has gone by the wayside as a broader understanding of the relationship between nutrition and heart disease has emerged over time. The 2018 guideline reinforces the importance of a healthful diet, physical activity, and weight management as the best first steps to reduce LDL-C levels. A diet high in vegetables, fruits, lean proteins, and whole grains that includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts and limits intake of sweets, sugar-sweetened beverages, and red meats is suggested.1,3 Of course, these broad recommendations should be personalized based on an individual’s calorie needs, lifestyle, food preferences, and ability to make changes.
Statin therapy (mild, moderate, or intense, depending on goals of treatment) to reduce LDL-C is another cornerstone of ASCVD prevention and treatment. There’s no evidence to support “treatment targets” for LDL, but “lower is considered better.”2 An LDL-C threshold of ≥70 mg/dL generally is recommended as a guide for initiating statins, depending on other risk factors and/or cardiovascular events.1 The 2018 guideline provides recommended doses of statins at each level of treatment (mild, moderate, or intense) as well as the patient’s expected reduction in LDL-C levels. Nonstatin medications (eg, ezetimibe, bile acid sequestrants, and PCSK9 inhibitors) may be initiated if statin therapy doesn’t reduce LDL-C levels.
CVD in Adults Aged ≥75
As with younger adults, treatment decisions for older adults should be personalized and based on a comprehensive risk assessment and an individual’s goals. The dietary pattern and physical activity recommendations outlined by the guideline are appropriate for healthy older adults if they’re willing and able to adopt them. If the risks of the eating pattern (for example, potential poor intake, loss of weight or muscle mass, or limiting favorite foods that could contribute to a poor quality of life) outweigh the benefits, the diet should be individualized as necessary.4
The guideline states that adults aged 75 or older with an LDL-C level of 70 to 189 mg/dL may benefit from moderate-intensity statin therapy.2 On the other hand, it also outlines conditions that may make it reasonable to stop (or not start) statin therapy, such as when the potential benefits could be limited by physical or cognitive functional decline, multimorbidity, frailty, or reduced life expectancy.1 Statins generally are considered safe, but the risk of drug interactions or polypharmacy may also factor into treatment decisions for frail older adults.
Counseling Clients and Patients
Given what we know now, we can’t view heart disease as simplistically as we did a few decades ago. Before we can counsel Kathleen or adults at any age, comprehensive and personalized risk assessment is essential for CVD prevention. Kathleen’s risk assessment indicated an LDL-C of 140, so we’d want to counsel her based on the details below. Advise adults who would benefit from LDL-C lowering to do the following:
1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes). Clients and patients can follow plans such as the DASH dietary pattern, the USDA food patterns, or the American Heart Association diet.
2. Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat.
3. Reduce percentage of calories from saturated and trans fats.
The 2018 Guideline on the Management of Blood Cholesterol can be accessed at www.ahajournals.org/doi/10.1161/CIR.0000000000000625. Becky Dorner & Associates’ Diet and Nutrition Care Manual: Comprehensive Nutrition Care Guide provides in-depth information on healthful eating patterns that can be used to prevent and/or treat CVD.
— Becky Dorner, RDN, LD, FAND, is widely known as one of the nation’s leading experts on nutrition and long term health care. Her company, Becky Dorner & Associates, Inc, is a trusted source of valuable continuing education, nutrition resources, and creative solutions. Visit www.beckydorner.com to sign up for free news and information.
1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol [published online November 10, 2018]. Circulation. doi: 10.1161/CIR.0000000000000625.
2. Highlights of the 2018 Guideline on the Management of Blood Cholesterol. American Heart Association website. https://healthmetrics.heart.org/highlights-of-the-2018-guideline-on-the-management-of-blood-cholesterol/. Published November 10, 2018. Accessed December 6, 2018.
3. Eckel RH, Jakicic JM, Ard JD, et al. 2013 ADA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-S99.
4. Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. J Acad Nutr Diet. 2018;118(4):724-735.