Stop Counting Cholesterol? New Dietary Guidelines say so

At the end of 2014, The Dietary Guidelines for Americans Council issued its 2015 guidelines and analysis of what we should eat, what we do eat, and what the consequences of what we eat are.  Many of the recommendations and observations are what we expected – we eat too much sodium and sugar, not enough fruits, and are overweight.  What was surprising is that they do not recommend watching cholesterol intake any longer – saturated fat yes, but cholesterol, no.

What did the report say?

The main thrust of the report emphasizes a diet with lots of fruits and vegetables, whole grains, low in saturated fat.  Limiting processed meats, refined grains (white bread) and drinks with added sugar is also recommeded.  Good food such as seafoods, nuts and legumes, as well as low-fat dairy are emphasized.
Notably, the report for the first time removed the recommendation to limit cholesterol intake.  Prior recommendations were to limit cholesterol intake to under 300mg daily.  Instead, it is recommended to limit saturated fat and empty calories such as processed sugars.  It is these foods that are contributing to obesity and its consequences much more that dietary cholesterol.  Added sugars and saturated fat should be < 10% of total calories in a day.
Saturated fat has 9 calories per gram.  So in a 2000 calorie diet, saturated fat should be limitied to 22 grams daily.  Sugar has 4 calories per gram.  In the same diet, sugar should be limited to 50 grams daily.
For a real world example, a Snickers bar has 250 calories.  That is over 10% of a 2000 calories diet.  It has 4.5 grams of saturated fat, which is 20% of daily recommendation, and 27 grams of sugar, which is 54% of the daily recommendation!  By contrast, 2 scrambled eggs has about 200 calories and the same amount of saturated fat, but only 2.1 grams of sugar, or about 4% of the daily recommendation.

So what does this mean?

The report brings dietary guidelines more in line with current research.  We have seen several studies showing the benefits of a Mediterranean style diet – high in fish, nuts, vegetables and good fats such as olive oil.  The guidelines now support those findings.  It means a heart healthy diet can include some fats, and should limit the empty starches – those made with refined flour that add little nutrition but many calories.  It means that moderate intake of eggs and lean meats is healthier than meals based on breads, rice and pasta.
Perhaps the best news in the report (at least for me) is that up to 5 cups of coffee a day does not seem to be harmful!!!

The path to wellness begins with a proper diagnosis 

The “new” cholesterol guidelines – what’s really the issue?

For decades people and doctors have been obsessed with cholesterol levels.  Books have been written, diets promoted, medications prescribed – all with the purpose of getting your cholesterol to “goal”.  You get your labs done and your doctor tells you your cholesterol is high.  You are instructed to eat a low-fat diet, exercise more and possibly start a medication.  Often you are not sure which numbers are high, or what they mean.  But you know that high cholesterol is a bad thing, and so you try to follow the doctor’s advice and lower your cholesterol.  
11/12/13 was a unique date – not only the second to last sequential month/day/year in our lifetimes; it is also the day the American College of Cardiology (ACC) and American Heart Association (AHA) released new guidelines for cholesterol management that recommend treating high cholesterol but not to any specific number.
This represents a change in over a decade of “goal oriented” recommendations which specified a level of bad cholesterol (LDL) to aim for, using multiple medications if needed to get there.
New Guidelines for Cholesterol:
  • Aim for cholesterol to be reduced by half
  • Only use a statin medication
  • Not necessary to add other medications if you don’t get quite there
Why were these changes recommended?
The theory behind the changes is that the guideline committee felt there wasn’t strong enough evidence supporting a specific target.  For example, if a person’s LDL cholesterol is reduced from 195 to 95, is there any real additional benefit in getting to the previous high risk goal of 70? Or is 95 good enough?
So what are the recommendations?
People are broken down into 2 risk groups in terms of deciding if a statin should be used
  1. High Risk:  people with a prior heart attack, bypass surgery, a stent or diabetes should take statins.  Statins are also recommended for those with very high LDL cholesterol (>190)
  2. Future Risk:  those whose 10 year risk of a heart attack is 7.5% or greater.  This number is calculated with a risk calculator that uses cholesterol, weight, blood pressure, smoking and other factors to come up with your number.
The High Risk group is not a  major change in terms of starting treatment.  The change is not recommending a target value for the LDL cholesterol.
The Future Risk group is different – the previous recommendations used a higher 10 year risk 15-20% before starting a statin.
Besides statin therapy, lifestyle changes are a cornerstone of the new recommendations:
  • No smoking
  • A health body weight
  • Exercise
  • A diet with lots of vegetables, fruits and lean protein
Controversy
Not all doctors agree that the 10-year risk is the best guide for starting treatment – why not lifetime risk?  There also have been questions about the risk calculator itself – the formula used appears to overestimate risk – including more people needing treatment than may truly benefit.  In addition, several of the members of the guideline committee quit due to disagreement on the direction the committee was going with their recommendations.  The remaining committee members only considered evidence from very specific types of trials, ignoring other trials that made compelling arguments but did not meet their standard of evidence.  The committee also chose not to include other markers of cardiovascular disease such as LDL particle number, Apolipoprotein B, PLAC testing and LDL particle size.
So how will this affect MY practice?
I think the guidelines are an opportunity to talk to people about their real diagnosis – their risk of cardiovascular disease.  As I have told many patients – to a certain extent, I don’t care what your cholesterol is, I care about you having a heart attack or stroke.  Cholesterol is a marker of how much artery clogging gunk is in your system.  There are several studies that show that the standard cholesterol profile underestimates cardiac risk.  I think that using the LDL particle number (LDL-p) is a better marker for assessing that risk.  If we reduce your LDL-p, your risk for cardiovascular disease goes down.  Statins are a tool (a very powerful one) to reduce cardiovascular disease risk.
I’m also not a fan of 10 year risk as a cutoff for starting treatment – I prefer lifetime risk, as the process that blocks your arteries is ongoing.  If we know 20 years before you have a heart attack that the risk is there, why wait until a heart attack is only 10 years away to start reducing risk?
How do I assess risk?
Risk can be estimated with a good history, a physical and testing.
History:
  • Prior heart attack, stroke or known cardiovascular disease?
  • Family history of heart attack or stroke – a male relative under age 55 or a female under age 65
  • Diabetes
  • High Blood Pressure
  • Smoking
Physical:
  • weight
  • waist size – belly weight is riskier than just being overweight
  • blood pressure
  • leg swelling
Diagnostic Testing
  • Cholesterol Assessment
    • there are several tests for this besides the standard cholesterol (called LDL-c) test which I will be reviewing in a future article in detail.  There have been several studies that show that other tests like LDL particle number (LDL-p) are better predictors of risk.
    • LDL cholesterol particle number (NMR Lipoprofile)
    • Apolipoprotein B (ApoB)
    • LP(a)
    • PLAC testing
    • Cholesterol particle size
  • C-reactive protein
  • Glucose
Once we put together your history, physical and test results we can have a discussion not about your LDL number, but your real diagnosis – your risk of cardiovascular disease.  The goal of that discussion is to reduce your risk of having a heart attack or stroke.
How can we reduce risk?
  • Blood pressure control
  • No smoking
  • Maintain a healthy body weight
  • Control diabetes
  • Being physically active
  • Control cholesterol
So the benefit of the new guidelines is they can inspire a conversation that leads to a proper diagnosis – not treating a number, but treating cardiovascular risk.

The path to Wellness begins with a proper Diagnosis