Clarity on Cholesterol Management and Why We Need It

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By Jennifer Robinson, MD, MPH

In the winter of 2013, the American College of Cardiology and the American Heart Association released new guidelines for treating blood cholesterol. These new guidelines, which I helped draft, moved away from focusing on a patient’s blood cholesterol level and, instead, put a focus on a patient’s risk for atherosclerotic cardiovascular disease (ASCVD) to decide who would benefit from drug treatment.

Heart attacks and strokes are common outcomes of ASCVD caused by cholesterol build-up in the arteries.  Its risk factors include a person’s age, sex, race, smoking and diabetes status, blood pressure, and blood cholesterol levels. We felt this focus on atherosclerotic risk was the best way to determine who would benefit from cholesterol lowering therapy, be it lifestyle changes and/or statin use, because it focused on the whole person – as opposed to one piece of the puzzle. In other words, whether your cholesterol is too high for you depends on your other risk factors. This 360o view is intended to help people prepare for a heart healthy life, which includes controlling blood cholesterol (a quick look at Life’s Simple Seven provides the other six guidelines that aid a healthy and happy heart).

Recently, dietary guidelines moved away from limiting cholesterol intake in the diet, and this has resulted in confusion. The Dietary Guidelines Advisory Committee recommended removing dietary cholesterol as a “nutrient of concern” because, it turns out saturated fat, rather than dietary cholesterol, is the main contributor to blood cholesterol levels. It is extremely clear that low lipid density protein, or “bad,” cholesterol (LDL-C), in the blood is a significant risk factor for heart disease and stroke, the leading causes of death among Americans. This message was lost in the dietary cholesterol discussion as seen by news headlines and fellow clinicians’ anecdotes.

I am working with the National Forum for Heart Disease and Stroke Prevention to raise awareness about cholesterol and its effect on ASCVD risk. With the help of an expert panel and funding from Sanofi US and Regeneron Pharmaceuticals, Inc., we are creating an initiative aimed at preventing cardiovascular events, such as heart attacks and stroke episodes, through increased awareness about cholesterol management. While this multi-sector initiative is in its early stages (we had our first meeting in March!), it is well-timed. Most adults in the US can benefit from lifestyle or drug therapy to lower their cholesterol level to reduce their risk of heart attack and stroke.  Among people with genetically high cholesterol, who have very high LDL-cholesterol levels of 190 mg/dl or higher, more than 80% are underdiagnosed and, therefore, untreated. And, sadly, these numbers are estimated to be growing.

As a public health MD focused on cardiovascular prevention, I want people to be armed with the information needed to live a long healthy life. I also want people to live a good and happy life. The best way to do that is to start taking care of oneself now. Keeping yourself healthy is the best way to prepare for long, happy, healthy life. I urge people to learn more about how cholesterol affects the heart and to talk to their doctors to find out how they can manage their ASCVD risk.

2014 robinson_jennifer
Jennifer Robinson, MD, MPH

Jennifer G. Robinson, MD, MPH is a Professor in the Departments of Epidemiology and Medicine (Division of Cardiology), and Director of the Prevention Intervention Center at the University of Iowa, Iowa City, Iowa. She was Vice-Chair for the 2013 American Heart Association/American College of Cardiology Cholesterol Guidelines (formerly known as the National Cholesterol Education Program Adult Treatment Panel IV) and a member of the 2013 American Heart Association/American College of Cardiology Risk Reduction Guidelines (formerly known as the National Heart, Lung, and Blood Institute Risk Reduction Working Group). She is currently the Chair for the National Forum Cholesterol Initiative. She is also a diplomate of the American Boards of Internal Medicine and Clinical Lipidology, and a Fellow of the American Heart Association.

Dr. Robinson is an active researcher, performing numerous clinical trials sponsored by the National Institutes of Health and the pharmaceutical industry. She has published over 150 peer-reviewed articles in the area of lipids-modifying drugs, cardiovascular risk stratification, and cardiovascular prevention and has lectured widely on preventive cardiology and the diagnosis and treatment of disorders of lipid metabolism.  While at the University of Minnesota in Minneapolis, Dr. Robinson received her medical degree and completed an Internal Medicine residency with the College of Medicine, and received a Master’s of Public Health from the College of Public Health. 


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21 comments on “Clarity on Cholesterol Management and Why We Need It”

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    You all need to get out of the dark ages and teach the whole story about cholesterol and stop just wanting to prescribe statins. Drugs that have more side effects than good!!!
    Cholesterol is only one factor in determining heart health.
    1. Quit relying on the total cholesterol numbers.
    2. Aim for cholesterol balance – idea ratio of LDL to HDL – 3:1.
    3. Raise the good cholesterol – HDL.
    4. Triglycerides are more important to watch.
    5. Decrease blood sugar.
    6. Decrease body inflammation.
    7. Know the triglyceride/HDL ratio and keep it under 3.

    Thank you so much Jennifer for the the article. It’s educative to me.
    On a sad note, this kind of information is missing in my country. The only intervention is on treating those who present with the heart and stroke conditions as opposed to public health education for prevention. The organization I work with focuses on prevention of non communicable diseases as one of the priority program areas. I m going to use this information to reach out to the public. It’s simple messages that I strongly believe will save our communities if disseminated consistently. Please keep me updated on what you do through the National Forum for Heart and Stroke disease prevention. At one point I would like to team up with you through partnership between our organizations to save lives.
    Thank you.

    Rev. Evatt M. Mugarura MPH, BHA (Hons), ADHSM, DPPM
    Executive Director/ Public Health Advisor /Consultant
    Africa Youth Leadership Development and Health Initiative (AYLDH)
    Willis Road, Namirembe (Church Commissioners’ House),
    P.O. Box 27597, Kampala, Uganda
    Tel. +256 772 322103 / +256 702 881105

    As a health professional involved with seniors, I’m tasked to bring this information to my peers in the groups to which I belong. But as a former high school biology teacher, I ask, “What is the CDC, public health across the country, etc. doing to bring cholesterol education to those who will be the spouses, parents, parental caregivers, or policy makers of the future? I was not a health professional when I taught high school. There was no curriculum content that had me educate a single student about how to be healthy, how to speak to an MD, how to decipher food or medicine labels, etc.
    In today’s world of ed cutbacks, there are no school nurses, and the curriculum for nutrition/ diet instructors doesn’t speak to the medical aspects in grades K-12. The average teacher for these grades is not routinely “inside the loop” on this kind of data, and consequently, Americans continue to be the most naive recipients of health care. Just one additional way to fragment health proficiency. The best, most informed instructors are not teaching the general public from the beginning.
    And what ar3e you going to do about it?

    I found it interesting that the dietary guide lines have changed about the cholesterol intake to prevent heart disease or stroke. This relates to my life because i have elevated cholesterol but have not been placed on any types of medications to help reduce my levels. They are still low enough to change with diet and exercise. After reading this blog, I now know that I don’t have to watch specifically my cholesterol intake but the different categories of fats I should limit in my diet to help my levels go down.

    Hello Jennifer,
    Thank you for your post. I found it interesting that there is now a move for a new guidelines in treating high cholesterol. The use of screening for risk factors for ASCVD in order to determine treatment modalities for high cholesterol certainly can provide more benefits in the future. I, personally, have family members who have diabetes and cardiovascular diseases that are all related to high cholesterol. Hopefully, this new guideline would initiate more preventative measures and treatment for high cholesterol and its related diseases. I also found it interesting that cholesterol is no longer a “nutrient of concern”. This would help me become more aware of the food I eat and closely look at the labels for the presence of “bad cholesterol”
    or saturated fats.

    An interesting concept discussed in this blog were risk factors for high cholesterol, I had no idea that the individual’s race, sex, and age were significant enough to be used as a risk factor for this illness. I can relate this to my own life due to the fact that a high cholesterol level is an issue in my family, I believe it is the way we traditionally cook our food. An adjustment that I will be able to make with this knowledge will be dietary changes for myself, my family, and I will be able to identify a higher amount of patients that are at higher risk for this condition.

    Knowing how to manage your cholesterol levels are very important now a days because in recently the health of our population has declined, and more people are developing heart diseases. According to the blog, people who have high cholesterol are prone to have heart attacks and strokes because cholesterol can build up and block the arteries.
    This relates to something in my life because both my parents are pre-hypertension and they always tell me to watch my weight and the foods that I ate because I might become hypertensive.
    The adjustments that I can make towards my health after reading this blog is to monitor my cholesterol levels, watch what I eat and exercise to reduce the cholesterol in my body.

    What was interesting about this blog was the fact that it explained to the reader a different way to look at how cholesterol levels are continually increasing. It also explained to us how high cholesterol levels can lead to atherosclerosis. While reading this article i learned that saturated fat was a main contributing to blood cholesterol levels which i was not aware of.

    This relates to something in my life because i was often checking cholesterol levels on the labels and not really the saturated fat content. Now that i am more aware i will look at both contents before making a purchase.

    The changes that i can make after reading this blog is as stated above i will check the saturated fat content along with the cholesterol content before making a purchase.

    This blog is very interesting because it educates the reader on how to monitor cholesterol intake. Nutrition fact labels lack a section for cholesterol levels but this articles tells the reader to look at saturated fat levels because it contributes greatly to blood cholesterol.
    This article relates to me because I have a long list of high cholesterol levels in my family. My dad is one of those affected by it so I enjoyed learning from this article.
    From my new found knowledge I plan to closely monitor my cholesterol levels by reading food labels properly.

    The interesting thing about this blog is that it raises awareness about how important cholesterol management is to someone’s cardiovascular health. It is important for one to know this so that he or she can make changes to their lifestyle and also take medicine to lower cholesterol if need be. This relates to my life because my father has high cholesterol. Because of this, I am at risk for developing high cholesterol as well. As of now, I do not have high cholesterol, but now that I am aware, I can make the necessary adjustments and changes to my diet as well as incorporating regular exercise into my life. Also, I do eat fast food often so one thing I will have to eliminate is the amount of times I eat out as well as cutting down ice cream because of its high saturated fat content.

    1. What is interesting about this blog?
    This blog post is intriguing because of the large portion of population that is affected by issues with cholesterol. The alteration in prevention, diagnostic, and treatment approaches of persons at risk for ASCVD makes sense.

    2. How does this relate to something in your life?
    As a healthcare provider in America, where high cholesterol runs rampant among it’s citizens, encounters with persons who have issues with cholesterol management is unavoidable. As such knowledge of the issue and current research is essential for proper patient education and care.

    3. What changes or adjustments can you make from the knowledge gained in this blog
    Based on the approach discussed it is fair to say that instead of the prior common low fat diet or other fat associated management of high cholesterol people should take a well rounded approach to their healthcare. Increasing levels of good cholesterol , exercising, lowering blood sugar, lowering stress and other general practices should be implemented to improve quality of life and decrease probability of ASCVD.

    This blog is interesting because it mentions how the importance of a patient’s cholesterol management has gradually been overshadowed by their risk of atherosclerotic cardiovascular disease. The post is relatable to my life because high cholesterol is not an unfamiliar concept in my family due to our poor moderation of cholesterol in our diets. With the knowledge gained in this blog, I should definitely remind my loved ones about the dangers of high cholesterol and emphasize the importance of its management. As a nursing student, I feel like this information will be extremely critical when dealing with patients who have high cholesterol.

    Whats interesting about this blog was how it made me think more as a clinician of how I can educate my patients on what exactly hyperlipidemia (High cholesterol) really means. This is knowledge that i will be able to use on a daily basis when it comes to patient education. Often people thing of cholesterol as a negative thing, but there are the good kinds and the bad like what is stated in this blog. The good kind (High density Lipoprotein HDL) is needed for normal cell function and LDL is (low density lipoprotein) is the cholesterol that builds up and clogs your blood vessels which could lead to heart disease and conditions like ASCVD. The fact that guidelines have changed just shows that the we should be focusing more the risk factors of conditions like ASCVD including people who are genetically more at risk of developing some type of secondary heart disease. By reading this blog it has made me thing more about prevention and how we people who are already effected by high cholesterol should be educated on how they have choices and they can explore their options instead of medicating and using harmful drugs if they are not going to benefit from them due to their specific risk factors. If the drugs used are going to do more harm then good, maybe trying the therapeutic route first would be a valuable decision.

    It is interesting to learn how public health is focusing on patients’ risk for atherosclerotic cardiovascular disease (ASCVD) rather than their blood cholesterol level. Instead of just focusing on blood cholesterol level, which was seen as just a piece of the puzzle, the focus should be moved to analyzing the whole person. Risk factors such as age, sex, race, smoking, and diabetes status should also be looked at in order to prevent heart attacks and strokes from ASCVD. Today, risks and issues of cholesterol affect a large part of society. Even my family has a history of high cholesterol level, which makes me weary of my lifestyle and diet. In the article, it states that those with genetically high cholesterol are often under diagnosed and untreated. It saddens me that this is probably the issue with my family since my dad’s side live in Vietnam, a third world country, and probably does not even bother to seek care because they can not afford to.

    It is amazing to know that there is a team that aims at preventing cardiovascular events, such as heart attacks and stroke episodes, while also increasing awareness about cholesterol management. In my opinion, it is important to take preventive measures now rather than having to fix it later. With the growing numbers of under diagnosed and untreated patients, it is vital that we are educated on cardiovascular prevention.

    Wow, I am surprised that the guidelines for treating blood cholesterol has been changed. I would have never thought that focusing on the risk of atherosclerotic cardiovascular disease (ASCVD) would be more beneficial in treating than just focusing on a patient’s blood cholesterol. I really do believe that preventing diseases help in the long run than spending time finding the cure. It would save a lot more patients and time/costs as well. I think this new guideline will help lower blood cholesterol in the future. It makes me happy that there are changes made in order to get information out to patients so that they can live a healthier life.

    I found this article very informative, straight forward, and clear! It was a great read and my interest and knowledge on atherosclerotic cardiovascular disease (ASCVD) has grown. I agree that focusing on the whole effect rather than one aspect of ASCVD is much more effective than just dealing with cholesterol levels itself because it allows room for improvement in all aspects of life. As quoted from this article, “…risk factors include a person’s age, sex, race, smoking and diabetes status, blood pressure, and blood cholesterol levels,” so changes in even certain parts of one’s lifestyle can greatly reduce their risk. In support of raising awareness about cholesterol management the 80% who are at risk genetically and formerly was not diagnosed will finally be conscious of their health status. This is an important movement and will definitely allow people to live a long happy, healthy life.

    This blog is interesting because it talks about new guidelines for treating blood cholesterol and that the new focus is on people at risk for atherosclerotic cardiovascular disease. This relates to my life because I plan on being a nurse and I must keep up on current research and guidelines. However, I also come from a family with a history of cardiovascular disease and this information can help me avoid any issues. I can changes my diet focusing on health foods and eliminate saturated fats to help avoid developing atherosclerotic cardiovascular disease. I can use this blog in the future to help people at high risk for atherosclerotic cardiovascular diseases manage their cholesterol and saturated fat intake. This is very important since WebMD states that” Cardiovascular disease is the No. 1 killer in America, with more than 800,000 deaths in 2005”.

    This is a great article bringing awareness to why we should be concerned about cholesterol in our lives. I have a family history of cardiovascular disease and family members that are currently battling to lower their cholesterol levels so that they prevent the disease or lessen their problems. I think it’s great that they mentioned that the new dietary guidelines focus less on dietary cholesterol reduction and more on saturated fat intake reduction because of new research showing saturated fat intake to correlate with cholesterol levels. This new correlation might give insight into why a vegetarian diet to be beneficial in reducing cholesterol levels 13% to 14% according to a study done at the University of Toronto and those who are vegetarian have on average a lower, healthier cholesterol levels as compared to omnivores in as shown in a study done in 2007. More information like this getting out to the public might help us to have a healthier USA.

    This article is very confusing. Saturated fat will increase the dietary cholesterol. If you eat more fatty food, your LDL (Low-density protein) goes up and you will have atherosclerosis and blood vessels will get blocked. As a result, we will have heart attacks and strokes. Increased dietary cholesterol will increase the blood pressure. We should watch our carbohydrate and cholesterol intake to prevent early diabetes and atherosclerosis. We can never completely remove all the elements that lead to heart attack and stroke. Our blood vessels loose their elasticity and our cholesterol will go up anyway. However,eating healthy should always be a concern. We can slow down the process of getting old but eating healthier food. Genetic is also play a role in how our body metabolize carbohydrates and cholesterol. For example, high cholesterol is a major issue in my family who are Persian and my husband’s family who are American. My American family members live longer than my Persian family members. My both parents died before the age 60. I am 37 years old and trying to eat healthy and keep my weight within normal range. I know that I inherit those bad genes from my parent. I cannot prevent things from happening but I maybe able to slowdown the process.

    This article interests me because my mother’s side of the family has a history of heart disease and heart attacks. This relates to me, I think, because, since it runs in my family, I am more at risk than others of suffering from heart problems due to high cholesterol. Some changes I could make to prevent high cholesterol in myself is being aware of how my saturated fat I am consuming daily and make the effort to consume healthy foods that will benefit me in the long run rather than giving me temporary satisfaction. Blogs like this are very valuable because they spread awareness of the consequences of eating unhealthily and increasing the risk of suffering from heart related diseases/complications. The information presented in this blog and others similar to this can help make sure people are aware of the risks and help them take precautionary measures. According to the American Heart Association, foods high in saturated fats are fatty beef, lamb, pork, poultry with skin, beef fat, lard and cream, butter, cheese, and other dairy products made from whole or reduced fat milk(Unknown, 2015). Avoiding or reducing the consumption of these foods will help reduce high cholesterol.

    A proper diet plan with routinely workout can be very effective in lowering cholesterol. Avoiding food high in saturated fats and saturated sugar and including soluble fibers in diet is very important for flushing out bad cholesterol. But, sometimes it becomes difficult to keep a track of the diet consumed throughout the day. So, in that case one can use health related apps such as Cholesterol Down app with is designed with a daily diet tracker and allows you to maintain your diet record.

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