This week, the Journal of the American College of Cardiology published its Guidelines on Lifestyle Management to Reduce Cardiovascular Risk. This report has set the stage for the implementation of a new paradigm that will guide physicians’ recommendations to reduce risk for cardiovascular disease.
The guidelines now direct physicians away from metrics such as total cholesterol and LDL, which have served to justify prescribing statin medications for so many years.
Now the door has been opened, widely, to a new set of rules that allows doctors to recommend these medications for a much larger population who now are considered “at risk” by virtue of a calculated risk for heart disease of 7.5% over the next 10 years. It's a huge change from the previous guidelines, which had recommended treatment when 10-year risk was estimated to be between 10 and 20%.
The new recommendations abandon the idea that statin medications should be implemented when LDL, so-called “bad cholesterol,” is above a specific value.
This guidance seems to fly in the face of conventional wisdom. After all, LDL has been absolutely vilified over the past 20 years as playing a pivotal role in heart disease. So surely lowering LDL would seem justified?
But in reality, the LDL story is intriguing because its relationship to cardiovascular risk is virtually nonexistent. Trials of medications specifically designed to just lower LDL have consistently revealed no benefit in terms of cardiovascular risk. And yet, for years LDL has been branded as “bad cholesterol” in a coup that paved the way for an explosive increase in medication utilization. (One could only wonder if Don Draper was smart enough to dream up this kind of marketing for the drug companies as LDL is not actually bad—it supplies vitally needed cholesterol to cells throughout the body, and it's not technically a kind of cholesterol. LDL is low-density lipoprotein, a protein.
It’s not a stretch to expect, based on the title of the document, Guidelines on Lifestyle Management to Reduce Cardiovascular Risk, that it would indeed provide commentary on the role of lifestyle as it relates to the goal of lowering cardiovascular risk. But therein lies another irony. The guidelines basically pave the way for expansion of the use of statin medications while basically ignoring the role of lifestyle changes.
In fact, while some dietary recommendations are made, they emphasize high carbohydrate foods like “whole grains” while advocating low-fat dairy products and warning against saturated fat consumption. These recommendations are baseless and may well increase the risk for type 2 diabetes, a powerful risk factor for the very disease for which the Guidelines was created.
Despite the strong media response to the publication of the Guidelines, there’s little doubt that it will soon become a template for the practice of medicine in America. After all, it's being enthusiastically promoted by the American Heart Association, an organization receiving major funding from the very pharmaceutical manufacturers who stand to benefit from these recommendations.
But you can act now to reduce your risk for coronary artery disease. Here’s how:
1. Know your numbers.
While lowering LDL is essentially meaningless in terms of coronary risk, the value of oxidized LDL seems to be far more important as a modifiable risk factor. Blood lipid panels include LDL but generally neglect reporting the level of oxidized LDL. But a good estimate of the degree of oxidation of LDL can be inferred by looking at a commonly used measure of average blood sugar, the A1c. Levels of A1c greater than 5.7% are associated with higher degrees of LDL oxidation. A1c directly reflects carbohydrate consumption.
2. Adopt a strict low-carbohydrate diet that limits total daily carbohydrate consumption to no more than 80 grams.
At the same time, increase daily fat consumption by adding in generous amounts of healthful fats like olive oil, wild fish, nuts, seeds avocado, coconut oil and if you choose to eat meat, select those that are grass-fed.
3. Exercise, aerobically, at least 20 minutes 6 days a week.
A target heart rate should be around 180 minus your age. But this will depend on your degree of physical conditioning.