Evidence of lifestyle modification in the management of hypercholesterolemia

Abstract

Background: Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. The growth of ageing populations in developing countries with progressively urbanized lifestyles are major contributors. The key risk factors for CHD such as hypercholesterolemia, diabetes mellitus, and obesity are likely to increase in the future. These risk factors are modifiable through lifestyle.

Objectives: To review current literature on the potential benefit of cholesterol lowering in CHD risk reduction with a particular focus on the evidence of non-pharmacological/lifestyle management of hypercholesterolemia.

Methods: Medline/PubMed systematic search was conducted using a two-tier approach limited to all recent English language papers. Primary search was conducted using key words and phrases and all abstracts were subsequently screened and relevant papers were selected. The next tier of searching was conducted by (1) reviewing the citation lists of the selected papers and (2) by using PubMed weblink for related papers. Over 3600 reports were reviewed.

Results: Target cholesterol levels set out in various guidelines could be achieved by lifestyle changes, including diet, weight reduction, and increased physical activity with the goal of reducing total cholesterol to <200 mg/dL and LDL-C<100 mg/dL. Various dietary constituents such as green tea, plant sterols, soy protein have important influences on total cholesterol. Medical intervention should be reserved for those patients who have not reached this goal after 3 months of non-pharmacological approach.

Conclusion: CHD remains as a leading cause of death worldwide and hypercholesterolemia is an important cause of CHD. Non-pharmacological methods provide initial as well as long-term measures to address this issue.

Fig. (1)

Illustrating the relationship of risk assessment at 10 years against clinical need for intervention at respective LDL-C levels. The figure demonstrates the relation of lifestyle changes to overall management of cardiovascular risk and drug therapy. Risk assessment at 10 years can be calculated using Framingham risk tables or via the risk assessment tool on the ATP III home website. The ATP II guidelines describe how the approach to hypercholesterolemia should be based upon the LDL-cholesterol (LDL-C) fraction in addition to CHD risk factors. CHD equivalents are medical factors which confer the same level of risk as a past medical history of CHD. The presence of CHD, any of the shown CHD equivalents, of multiple risk factors from the second column equating to a 10yr risk of CHD ≥ 20% (as calculated via Framingham risk tables or online ATP III calculation) require early lifestyle changes once LDL-C is ≥ 2.58 mmol/L. In the absence of CHD or CHD equivalents then a higher threshold of LDL-C ≥ 3.36 mmol/L for lifestyle measures can be employed. The final column describes the thresholds at which drug therapy is required in addition to lifestyle factors. All LDL levels are in mmol/L. LDL, Low-density Lipoprotein, CHD, Coronary Heart Disease; LDL-C, LDL-cholesterol fraction. Modified from the ATP III guidelines [28]

Fig. (2)

Illustrating the adult lipid profile classification. This diagram allows a clinician to rapidly assess the status of a patient's lipid profile in accordance with the ATP III guidelines. HDL, High-density lipoprotein; LDL, Low-density lipoprotein; TC, Total Cholesterol. Modified from the ATP III guidelines [28]