Jane Brody, the New York Times’ Personal Health columnist, recently cited one of our Clinical Inquiries that has been published in The Journal of Family Practice. On August 21, her “Patient Education” column about lowering cholesterol critiques the tendency for Americans to turn first to pharmaceutical solutions to resolve health problems, and then follows up by referencing researched solutions published in JFP in June by FPIN contributors Drs. John Saultz and Elizabeth Powers and Andrew Hamilton, MLS (OHSU), with a Clinical Commentary provided by Dr. Vincent Lo (French Camp, CA) - (June 2007, Vol. 56, No. 6: 483-489). Congratulations!
Read the entire article NYT article here
Read the CI in its entirety below:
Which lifestyle interventions effectively lower LDL cholesterol?
Elizabeth Powers, MD; John Saultz, MD; Andrew Hamilton, MLS
Oregon Health and Sciences University, Portland
Evidence-based answer
Counseling, weight loss, exercise, and drinking alcohol all effectively lower low-density lipoprotein cholesterol (LDL-C). Specifically, one to 2 daily drinks of alcohol lowers LDL-C, if consumed regularly for more than 4 weeks (strength of recommendation [SOR]: A, based on consistent results of multiple randomized controlled trials [RCTs]).
Counseling by physicians, dieticians, or pharmacists is effective at increasing patient compliance with medications, thereby lowering LDL-C (SOR: C, good evidence that intervention lowers LDL-C, insufficient to prove that it reduces mortality/morbidity).
Weight loss has been associated with reductions in LDL-C. However, other factors—including degree of caloric restriction, drug intervention, and diet composition—may play a more significant role than weight loss alone (SOR: A, based on a meta-analysis and consistent results of RCTs).
Exercise significantly lowers LDL-C (SOR: A, based on meta-analyses and consistent results of RCTs). Smoking cessation may have a beneficial effect (SOR: B, based on inconsistent results from RCTs that it lowers LDL-C). Exercise-based alternative practices (yoga and tai chi) lower LDL, and meditation may have a beneficial effect (SOR: C, moderate evidence that intervention lowers LDL, insufficient evidence to prove that it reduces mortality/morbidity).
Clinical commentary
Consider patient preference when discussing lifestyle modification
Vincent Lo, MD
San Joaquin Family Medicine Residency, French Camp, Calif
Therapeutic lifestyle changes are the initial treatment of choice for reduction of cardiac risk factors, but both patients and physicians often see these modifications as confusing and difficult to achieve. A recent year-long study on different diets concluded that dietary adherence is more important than a specific type of diet for weight loss and reduction of cardiac risk factors.1 Another recent study reports no difference in weight loss among diets, based on different exercise duration and intensities over 1 year in a group of sedentary and overweight women.2 Therefore, family physicians should consider culture, patient preference, and practical issues such as cost and availability, when discussing therapeutic lifestyle modification with patients.
Evidence summary
FAST TRACK:
Weight loss lowers LDL-C, although some studies suggest it may be short-term |
Elevated LDL-C is an independent risk factor for coronary heart disease (CHD),3 the leading cause of death in the US.4 Lowering LDL-C by 60 mg/dL reduces CHD events by 50% after 2 years.5 Although medications successfully lower LDL-C and decrease CHD risk, therapeutic lifestyle changes remain the initial therapy for most adult patients.3,6
Our search located evidence about alcohol consumption, counseling, exercise, weight loss, alternative lifestyle measures, and smoking cessation. The TABLE summarizes the evidence for each.
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TABLE
A- and B-level
evidence points
to effectiveness of
lifestyle Interventions
LIFESTYLE
INTERVENTION
|
MAGNITUDE OF
EFFECT
ON LDL-C
|
% REDUCTION ON
DATA
LDL-C
|
DATA SOURCES
|
SOR
|
| Alcohol |
4-10 mg/dL
|
4%-8%
|
4 RCTs
|
A
|
| Counseling |
0-58 mg/dL
|
0%-33%
|
15 RCTs, 8 CTs
|
A
|
| Exercise |
3-16 mg/dL
|
2.5%-4%
|
5 meta-analyses
|
A
|
| Meditation |
0-28 mg/dL
|
0%-19%
|
3 RCTs
|
B
|
|
Smoking
|
0-5 mg/dL
|
0%-4%
|
2 RCTs
|
B
|
| Weight Loss: |
|
|
|
|
diet, exercise,
supplements |
0-42 mg/dL
|
0%-22%
|
28 RCTs, 14 CTs,
1 meta-analysis
|
A
|
| drug therapy |
10-31 mg/dL
|
11%-32%
|
4 RCTs, 2 CTs
|
|
| Yoga/tai chi |
20-26 mg/dL
|
15%-20%
|
2 RCTs, 1 CT
|
A
|
LDL-C, low-density lipoprotein
cholesterol; SOR, strength of
recommendation; RCT,
randomized controlled trial
CT, clinical trials |
|
|
|
|
SOR: A, good evidence that
intervention lowers LDL.
SOR: B, moderate evidence |
|
|
|
|
1 to 2 drinks daily reduced LDL-C
One 5-year-long cohort study (N=933) showed that alcohol was associated with LDL-C reduction in a dose-dependent manner.7 Two crossover trials (4–6 weeks in duration) conducted among heavy drinkers showed that LDL-C increased when alcohol intake decreased. Two randomized crossover trials (8–12 weeks in duration) found a statistically significant decrease in LDL-C with consumption of 1 to 2 drinks daily.
Counseling improves medication adherence
FAST TRACK
2 clinical trials found that LDL decreased significantly with 1 to 2 alcohol drinks per day |
An RCT (N=167) with 8 years of follow-up found that patient education and counseling effectively improved medication adherence.8 Another RCT (N=1162) lasting 1 year, however, found that nutrition counseling by primary care physicians resulted in no significant change in LDL-C compared with usual care.9 Studies focused on enhancing dietary compliance did not find consistent post-intervention improvement. Greater medication adherence or improved dietary compliance did result in consistent significant improvements in LDL-C.
Exercise lowers LDL; weight loss a factor
Aerobic exercise effectively lowers LDL-C. This reduction is enhanced by weight loss and diet and mitigated by weight gain.10 An analysis of 4 RCTs showed that LDL-C also decreased with resistance training.
A higher body-mass index is associated with higher LDL-C. However, the effect of weight loss perse on LDL-C remains unclear. Multiple short-term studies have found that a modest amount of weight loss (5%–10%) is associated with a significant reduction in LDL-C.11 A meta-analysis found a 0.8 mg/dL LDL-C decrease for every kg of weight lost. Long-term follow-up, however, showed that LDL-C returned to baseline even when weight loss was maintained. Eight clinical trials failed to demonstrate a reduction in LDL-C postintervention with up to 10 kg of weight loss. Studies using weight-loss drugs (Sibutramine, Orlistat) found more significant weight loss during treatment, along with greater decrease in LDL-C, when compared with studies using only lifestyle modifications.
Other measures have mixed results
High-quality RCTs (N=267) with yoga or tai chi as the exercise intervention showed a statistically significant decrease in LDL-C over 12 to 14 weeks.12 Two RCTs investigated the effect of meditation on LDL-C with mixed results. One (N=16) showed a significant decrease in LDL-C over 8 weeks, while a second (N=60) showed no difference in LDL-C. A high-quality RCT (N=91) with a combined intervention (counseling, exercise, and meditation over 1 year) showed a significant decrease in LDL-C.
In cross-sectional surveys, LDL-C does not appear to differ between smokers and nonsmokers. One meta-analysis found a dose-dependent relationship between smoking and LDL-C, with overall LDL-C 1.7% higher for smokers compared with nonsmokers.13 Two RCTs investigated the effect of smoking cessation on LDL-C with mixed results. One (N=935) showed a decrease in nonfasting LDL-C while a second (N=140) showed no difference in LDL-C.
Recommendations from others
According to ATP III guidelines,3 all adults with LDL-C above goal should be treated with therapeutic lifestyle changes for primary and secondary prevention of CHD. These include a diet intervention, increased physical activity, and weight loss. Physicians are encouraged to refer patients to a nutritionist. If LDL-C is not at goal after 6 weeks, changes are intensified; physicians should consider pharmacologic therapy if a patient is still unable to attain his or her goal. ACP III guidelines recommend an office visit every 4 to 6 months to monitor adherence.
American Heart Association guidelines recommend that physicians counsel smokers at every office visit to stop smoking. The American College of Cardiology recommends abstinence from alcohol for patients with suspected alcoholic cardiomyopathy. For patients with heart failure from any other cause, alcohol consumption is usually limited to 1 drink per day.
References
1. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for weight loss and heart disease risk reduction. JAMA 2005;293:43–53.
2. Jakicic JM, Marcus BH, Gallagher KL, Napolitano M, Lang W. Effect of exercise duration and intensity on weight loss in overweight sedentary women. JAMA 2003;290:1323–1330.
3. National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP III). Executive Summary. JAMA 2001;285:2486–2497.
4. Deaths: Final Data for 2003. National Vital Statistics Report 2003; 54(13). 120pp. (PHS) 2006–1120.
5. Law MR, Wald NJ, Rudnicka AR. Quantifying effects of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 2003;326:1423.
6. Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterole Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227–239.
7. Nakanishi N, Yoshida H, Nakamura K, Kawashimo H, Tatara K. Influence of alcohol intake on risk for increased low-density lipoprotein cholesterol in middle-aged Japanese men. Alcohol Clin Exp Res 2001;25:1046–1050.
8. Rachmani R, Slavacheski I, Berla M, Frommer-Shapira R, Ravid M. Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study. J Am Soc Nephrol 2005;16:S22–S26.
9. Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med 1999;159:725–731.
10. Kelley GA, Kelley KS, Tran ZV. Exercise, lipids, and lipoproteins in older adults: a meta-analysis. Prev Cardiol 2005;8:206–214
11. Poobalan A, Aucott L, Smith WC, etal. Effects of weight loss in overweight/obese individuals and long-term lipid outcomes: a systematic review. Obesity Rev 2004;5:43–50.
12. Tsai JC, Wang WH, Chan P, etal. The beneficial effects of Tai Chi Chuan on blood pressure and lipid profile and anxiety status in a randomized controlled trial. J Altern Complement Med 2003;9:747–754.
13. Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. Br Med J 1989;298:784–788.
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