By Elizabeth Klodas, MD, FACC
The latest cholesterol guidelines, released in November 2013 by the American Heart Association and the American College of Cardiology, identify four specific groups of individuals who should be placed on statins: those with established cardiovascular disease (CVD), those with type 2 diabetes aged 40 to 75, those with a baseline LDL cholesterol level of 190 mg/dL or greater, and those between the ages of 40 and 75 with a calculated 10-year risk of cardiovascular events at or above 7.5%.
Although the guidelines attempt to be more holistic in their approach to addressing cholesterol levels, the guideline-advocated risk calculator is heavily weighted for age, essentially relegating every man to statin therapy by age 65 and every woman by age 70, even in the face of otherwise exemplary health. In short, the guidelines are advising universal statin use for a broad segment of the population, essentially based on age alone.
Although one could make the statistical argument for this approach, patients’ individual needs and circumstances appear to be summarily ignored, as are the potential negative consequences of the recommendation.
In addition, laboratory disturbances can be seen with statin use, including liver enzyme elevation, renal function deterioration, and worsening glucose homeostasis. Practically speaking, the laboratory disturbances tend to be mild, but in a more vulnerable, older population with multiple medical problems, even mild changes can be consequential.
A significant shortcoming in the new guidelines is their failure to consider how lifestyle and heredity affect patients’ cholesterol levels. Weight/BMI, physical activity, dietary composition, and family history are ignored in calculating risk. This makes a 54-year-old black man whose relatives routinely live into their 90s, who has a total cholesterol level of 190 md/dL, has an HDL cholesterol level of 50 mg/dL, is trim and fit, and has mild hypertension treated with low-dose lisinopril (Prinivil) to an average systolic reading of 118 mm Hg, a statin candidate with a risk calculator score of 8.9. Meanwhile, a 54-year-old obese, sedentary white man with the same cholesterol and blood pressure scenario, but a family history that includes two older brothers who have undergone bypass surgery and a father who died at age 55 from a massive myocardial infarction has a risk calculator score of 4.9 and goes home without a statin prescription.
Clearly, guidelines are just that, and every patient must be evaluated with respect to his or her specific situation. However, when it comes to the geriatric population, the tables have turned so that we physicians now need to stop finding reasons to put our patients on statins and instead focus on finding reasons to avoid doing so.
According to the American Heart Association, CVD affects 80 million Americans. This disease, like diabetes and obesity, is food related and largely preventable, yet nutrition rarely is used as a cornerstone of therapeutic intervention. Instead, most current disease management approaches, such as prescribing statins, paradoxically enable poor dietary patterns, perpetuating the underlying stimulus and creating a vicious cycle. This approach is like trying to put smokers on inhalers rather than trying to help them quit smoking.
This is fundamentally nonsensical and clearly unsustainable. However, it also points to a pathway that could reduce the number of primary prevention candidates and provide an option for statin-intolerant patients.
The problem is food. The answer is food. The treatment is food.
What About Food?
Providers often cite a lack of time as the main impediment to undertaking dietary surveys during patient exams, but it frequently can be accomplished during a one- to two-minute exchange. “So what’s a typical breakfast for you? Lunch? Dinner?” That information can be gleaned in fewer than 30 seconds, but you still have to dig a little further. It’s not enough to have your patient report eating cereal for breakfast; you need to find out which one and how much of it they eat. You also need to ask specifically about beverages, desserts, and snacks because patients don’t readily offer up that they eat a bag of cookies between meals.
You’ll be amazed at what you learn when you start doing this. You’ll encounter patients, as I have, who eat only Pop-Tarts for breakfast, rely on canned foods almost exclusively for lunch and dinner, or “love their soda.” You’ll quickly come to understand why these patients have hypertension, dyslipidemia, or a bulging waistline.
We assume that people with diabetes, obesity, and/or heart disease don’t have the best diets. But until you ask, you can’t possibly know the depths of your patients’ nutritional dysfunction.
One of the most prevalent patterns you’ll see emerge is that most people are lacking in the four essential building blocks of heart health: fiber, omega-3 fatty acids, phytosterols, and antioxidants—nutrients that have been extensively documented as possessing lipid-lowering properties as well as protecting against cardiovascular events. These nutrients come from whole foods, primarily plants.
Although it may be tempting to simply put people on supplements, this isn’t the answer. We know from multiple trials that most supplements are ineffective, if not counterproductive. This probably is related to the context in which they’re being delivered. Simply put, there’s something magical about a blueberry, for example. Taking the equivalent vitamin content of a bowl of blueberries, putting it in a pill form, and consuming it with a doughnut won’t have the same health effects as actually eating the fruit.
But handing out a rudimentary nutrition pamphlet—the default dietary counselor—also leaves patients wanting. These materials generally steer patients toward home cooking, even though Americans, and especially older Americans, are cooking less than they used to. According to a 2003 article in the Journal of Economic Perspectives, people have reduced their time in the kitchen by one-half in the last 20 years, relying instead on processed convenience foods and restaurants. So advice related to cooking at home largely is meaningless because it ignores life realities.
Prescription medications, on the other hand, are presented in a predosed format and come with precise instructions, ensuring ease of use and a minimal impact on daily routines. In other words, statins are easy, and food is difficult.
And what if you followed up on your dietary instructions like you do your medication instructions? After all, you’re altering the inputs, so it only makes sense to check the outputs. You’d never think of putting someone on an antihypertensive medication and not scheduling a follow-up visit to monitor his or her blood pressure. Shouldn’t you also see what your dietary intervention has accomplished?
You may be surprised at what you see. Patients who substitute even a couple of nutritional choices, such as flax, chia, walnuts, almonds, or oat bran, for nutritionally devoid choices can see lipid-lowering effects commensurate with those seen with low or even medium-dose statin therapy. That’s a game changer for a statin-intolerant individual.
Patients are hungry for this sort of approach. They’re looking for practical, sustainable solutions that they can implement for themselves by themselves. And if this can lead to reducing the doses of medications needed to achieve health goals, all the better.
So before we become a statin nation, let’s first try to become a food nation.
— Elizabeth Klodas, MD, FACC, is a Minneapolis-based cardiologist with Preventive Cardiology Consultants and the founder of Step One Foods.