Download The National Cholesterol Education Program

Journal of Insurance Medicine
Volume 20, No. 3
I £88
Advanced Highlights For ALIMDA: "
"The National Cholesterol Education Program"
At a recent meeting of the HIAA/ACLI ADVISORY COM-.
MITTEE on Education For Health the following recommendations were accepted:
3. Drug Treatment
KEY CONCEPTS:
1. That the HIAA and ACLI Boards endorse the recommendations of the National Cholesterol Education
Program;
Classification and Patient Evaluation
(Initial Classification Based On Total Cholesterol)
2. That the Medical Directors of Member Companies
be informed of the program to elicit their support;
* Total blood cholesterol levels are the basis for initial
patient classification..
3. That companies be encouraged to circulate guidelines
and dietary information among their policyholders
and employees.
If you haven’t heard about the National Cholesterol
Education Program already, you certainly will hear about
it in the future. The advance information suggests that this
program will be as widely publicized as the National Blood
Pressure initiatives of the last decade.
The goal of the program is:
To reduce the prevalence of elevated blood cholesterol
in the United States and thereby contribute to reducing
coronary heart disease, morbidity, and mortality.
We medical directors have two important roles to fulfill in
helping the program to succeed.
1. We must become knowledgeable about the program
and about the recommended guidelines for
cholesterol treatment.
2. We must be prepared to encourage promulgation of
the guidelines and dietary information among our
employees and our policyholders.
The acceptable cholesterol "Normal Limits" have changed
remarkably in the last several years. Witness the normal
limits described on the lab slips of the 1970’s and the values
noted today. Even many of the "Lab Normals" of today are
out of date. We have entered an era in which normal is
derived from physiologic standards rather than population
standards. "Normal" today is what the cholesterol should
be, not what the value is for the mean (plus or minus two
standard deviations). Total cholesterol values are considered
desirable if they are less than 200mg/dl, borderline if the
value is between 200-239mg/dl, and high if the value is
greater than 240mg/dl.
Highlights from the 1987 National Cholesterol Education
Program Adult Treatment Panel’s Report offer practical
detection, evaluation, and treatment recommendations for
physicians. The report deals with three primary topics:
1. Classification and Patient Evaluation
2. Dietary Treatment
* All patients with a level of 240 mg/dl or above, should
receive a lipoprotein analysis. Patients with borderlinehigh blood cholesterol levels (200-239 mg/dl), who in addition have either definite CHD or at least two other CHD
risk factors, should also have a lipoprotein analysis
performed.
* All blood cholesterol levels above 200 mg/dl should be
confirmed by repeat measurements, with the average used
to guide clinical decisions.
* Other CHD risk factors should be taken into account in
selecting appropriate follow-up measures for patients with
borderline-high levels.
* CHD risk factors as defined in the report include:
--Male sex
--Family history of premature CHD: (definite myocardial infarction or sudden death before age 55 in a parent
or sibling)
--Cigarette smoking: (currently smokes more than 10
cigarettes per day)
--Hypertension
--Low HDL-cholesterol concentration (below 35 mg/dl
confirmed by repeat measurement)
--Diabetes mellitus
--History of definite cerebrovascular or occlusive
peripheral vascular disease
--Severe obesity (30 percent overweight)
* In public screening programs, all patients with a level
above 200 mg/dl should be referred to their physicians
for evaluation and remeasurement.
Classification and Patient Evaluation
(Initial Classification Based On LDL-Cholesterol)
* The LDL-cholesterol level is the basis for decisions about
initiating diet or drug therapy.
* Patients with LDL-cholesterol levels of 160 mg/dl or
greater are considered at high risk for CHD. These patients should be given cholesterol-lowering treatment.
* Patients with borderline-high-risk LDL-cholesterol levels
(130-159 mg/dl) should also be treated to lower their
cholesterol if they have definite CHD or two other CHD
risk factors.
Volume 20, No. 3
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* The therapeutic goals recommended in the panel report,
like the cholesterol levels for initiating therapy, are
influenced by the presence of other CHD risk factors.
Patients without definite CHD or two additional risk
factors should reduce LDL-cholesterol to below 160
mg/dl. Patients with definite CHD or two CHD risk factors should have a goal of reducing LDL-cholesterol to
below 130 mg/dl.
* The recommended goals are minimal goals. If lower levels
can be achieved, risk may be further reduced.
Dietary Treatment
* Dietary treatment is the cornerstone of therapy to reduce
blood cholesterol levels. The view that diet modification
is impractical or doomed to failure is not justified. Many
people have successfully modified their diets and reduced
blood cholesterol substantially.
* A cholesterol-lowering diet can be tasty, satisfying, and
consistent with good nutrition. Many patients will not
need to alter their eating habits radically.
" Step I of dietary treatment calls for an intake of saturated
fat of less than 10 percent of calories, total fat of less than
30 percent of calories, and dietary cholesterol of less than
300 mg/dl.
" Step 2 calls for further reduction in saturated fat intake
to less than 7 percent of calories and in cholesterol intake to less than 200 mg/day.
" Referral to a registered dietitian can facilitate dietary instruction and monitoring. With proper training, physician staff, may perform these functions.
* For most patients, dietary therapy should be continued
at least 6 months before deciding whether to add drug
treatment. It is important that dietary therapy not be
regarded as a failure prematurely.
* Although the goal of dietary therapy is to lower LDLcholesterol concentration, total cholesterol can be used
to monitor response to diet for convenience.
Drug Treatment
* Maximal effort at dietary therapy should be made before
initiating drug therapy and should be continued even if
drug therapy is needed.
Advanced Highlights for ALIMDA
* The panel set the initiation levels for drug treatment .in
such a way as to create a protective barrier to the inappropriate overuse of cholesterol-lowering drugs.
* Patients with LDL-cholesterol levels of 190 mg/dl or
greater, and those with LDL-cholesterol 160-189 mg/dl
who also have definite CHD or two other risk factors,
should be considered for drug therapy.
* Drugs available for consideration include: bile acid sequestrants (cholestyramine and colestipol), nicotinic acid,
HMG CoA reductase inhibitors (lovastatin), gemfibrozil,
probucol, and clofibrate.
* The bile acid sequestrants and nicotinic acid are considered the drugs of first choice. Both cholestyramine and
nicotinic acid have been shown to lower CHD risk in
clinical trials, and their long-term safety has been
e~tablished. These drugs require considerable patient
education to achieve adherence.
* Lovastatin is the first of a new class of drugs (the HMG
CoA reductase inhibitors). These drugs are very effective
in lowering LDL-cholesterol, but their effect on CHD incidence ond their long-term safety have not yet been
established.
* The other available drugs are not as effective in lowering LDL-cholesterol as are the drugs of first choice or
lovastatin. Gemfibrozil and clofibrate are primarily effective for lowering elevated triglyceride but are not FDA
approved for routine use in lowering cholesterol.
* Drug therapy is likely to continue for a lifetime. Thus,
when dealing with the selection of bile acid sequestrants
versus newer drugs that may be easier to take, safety must
be emphasized.
* Cholesterol is an active, changing field. Ongoing and
future investigations can be expected to expand, and refine
drug treatment options.
As physicians we recognize the real step in the direction of
disease prevention represented by this report and this national cholesterol initiative. As medical directors we appreciate the enlightened self interest our companies have in
its success.
Watch for further information on:
THE NATIONAL CHOLESTEROL
EDUCATION PROGRAM
A. Robert Davies, M.D.
m 7O