DeWitt S. Goodman

The National Cholesterol Education Program is providing new impetus for a change in nutrition education for medical students and for physicians. This program, launched approximately 2 years ago by the National Heart, Lung, and Blood Institute, involves collaboration among more than two dozen private and public organizations that have grouped together to develop a coordinated attack on many fronts related to high blood cholesterol levels and high rates of coronary heart disease in this country.

The work of the National Cholesterol Education Program is being done by four panels, two of which have been working for some time. One of them--the Expert Panel on Detection, Education, and Treatment of High Blood Cholesterol in Adults--prepared a report that was officially endorsed and made public on October 5, 1987 (The Expert Panel, 1988). Since its release, this report has received a very large amount of publicity and has led to the launching of programs by a number of organizations. The authoring panel (also called the Adult Treatment Panel) consisted of 22 members and 7 ex-officio members with a wide range of expertise and experience and produced its report after almost 2 years of hard work.

This report will have an impact on nutrition education in medical schools and among physicians. It deals with the high risk or patient-based approach--not with the public health strategy, which is being dealt with by a different panel. This panel's charge was to identify individuals at high risk who will benefit from intensive medical intervention. The goals of the report are to establish criteria for identifying candidates for medical intervention, to recommend ways to detect these people, to establish goals for treatment, and to monitor the subjects.

The report deals with two basic questions: Who should be treated in a medical setting to lower cholesterol and how should they be treated? Therefore, the report first consists of sections on the classification of patients according to total cholesterol levels and then according to low density lipoprotein, or LDL, cholesterol levels. Following are sections on dietary treatment, which is described in considerable detail, and on drug treatment.

This report was developed with certain principles in mind. One was to develop a set of guidelines that were as simple as possible and consistent with current knowledge. Another was to provide enough specific detail to guide a physician in dealing with an individual patient, that is, to provide a detailed primer for physician practice in this area.

The report classifies people according to total cholesterol level: 200 mg/dl or less is called desirable blood cholesterol, 200 to 239 mg/dl is designated as borderline high-blood cholesterol, and 240 mg/dl and above is classified as high blood cholesterol. These 200-and 240-mg/dl levels were based somewhat arbitrarily on a very large body of quantitative epidemiologic data (e.g., the Multiple Risk Factor Intervention Trial, or MRFIT study), which provide an enormous data base showing that the increasing cholesterol levels throughout the U.S. population lead to increases in the risk of coronary hear disease. The cholesterol cutpoint that defines high blood cholesterol--240 mg/dl- -is believed to be a level at which the risk among people with different backgrounds is sufficiently high to warrant medical care.

The follow-up recommended for people with total cholesterol levels below 200 mg/dl is that they should be given information about coronary heart disease and reexamined within 5 years. Most people with borderline high levels--200 to 239 mg/dl--and, specifically, those who do not have definite coronary heart disease or other major coronary heart disease risk factors, should be given dietary and other risk factor information and reevaluated annually. People with high levels, and those with borderline high levels who do have definite coronary heart disease or two other major risk factors, should have lipoprotein analyses; further action should be based on LDL cholesterol levels.

The classification by total cholesterol levels thus identifies those patients who should undergo lipoprotein analysis. The focus of attention should then turn to LDL cholesterol levels, which serve as the key index for clinical decision making about whether or not someone needs treatment. LDL cholesterol is really the more primary etiologic risk factor associated with coronary disease, and programs to lower cholesterol are really aimed at lowering LDL cholesterol levels, which are classified as follows: desirable, if below 130 mg/dl; borderline-high-risk between 130 and 159 mg/dl; and high-risk at 160 mg/dl and above. The cutpoints of 130 and 160 mg/dl were chosen because they correspond roughly to the total cholesterol cutpoints of 200 and 240 mg/dl.

The report contains very specific algorithms and charts that a physician can follow in first encounters with a patient and then use in deciding what to do and how to proceed in the evaluation, and ultimately in treatment. For example, the recommendations for people with desirable LDL levels are the same as those for people with desirable total cholesterol, namely, that a cholesterol test should be repeated within 5 years. Those with high-risk LDL cholesterol levels and those with borderline-high-risk levels and other risk factors for coronary heart disease should have a full clinical evaluation and then should be brought into cholesterol-lowering therapy.

The report and its recommendations very strongly emphasize dietary therapy--the primary modality and the cornerstone of treatment for people with high blood cholesterol. This is not a trivial statement, because if these recommendations are followed, at least one-quarter of the adult U.S. population, which is at least 40 million people, will be brought into medical treatment to lower their cholesterol levels. This creates an enormous market of patients who need to have dietary treatment, and most physicians providing primary care do not know how to prescribe this. Therefore, this report was written to provide a great deal of information for physicians about dietary counseling. This is done first with regard to nutrients, then to foods, and then to food patterns; the information given should enable physicians to take the first step toward delivering dietary information and treatment to patients. There is an emphasis on the importance of interaction with registered dietitians and others who have more professional expertise. The report states that treatment should be aimed minimally at lowering cholesterol levels below those levels that brought a patient into therapy, and it contains detailed descriptions of diets. There is a Step-One Diet and a Step-Two Diet designed to progressively reduce intakes of saturated fatty acids and cholesterol and to keep total calories at a desirable level. These kinds of recommendations conform to those of the American Heart Association and other major organizations that have dealt with this topic before.

The report recommends that once patients are brought into dietary therapy, they should be followed carefully and their cholesterol remeasured at 4 to 6 weeks and at 3 months. Monitoring can initially be limited to total cholesterol, which is much simpler to measure. If the goal is achieved, then there should be confirmation that the LDL goal is achieved and the patient brought into long-term monitoring. If the goal is not achieved, then a registered dietitian should be consulted for more intensive dietary treatment of the patient, and the patient may be then counseled about the Step-Two Diet or alternatively be given a more intensive trial on the Step-One Diet. Ultimately and hopefully the patient will thus achieve the cholesterol goal. If the goal is not achieved, drug treatment should be considered.

In the final chapter of this report, drug treatment is discussed in considerable detail, again to provide a detailed educational primer to physicians. Cutpoints are provided for drug treatment, and there are goals for creating what is called a protective barrier against the inappropriate overuse of cholesterol-lowering drugs. There are extensive exhortations in this report about the use of drugs only in the most severely and substantially elevated cases that persevere despite dietary therapy, which is again emphasized. The various drugs available are discussed.

Since the report's formal endorsement in October 1987, substantial programs have been launched by the American Heart Association, the American College of Cardiology, nurses organizations, dietitians, and family practitioners. The American Medical Association has also endorsed the report and is beginning an educational program. We are very gratified that this tremendous momentum for change in medical practice has followed in the wake of this report. Once this degree of acceptance has taken hold, we will find that doctors will feel obliged to try to implement, to try to put into practice, these guidelines because it will be considered proper medical care. We hope that there will follow appropriate reimbursement and other incentives that would encourage this kind of practice. This should have an impact on the need for nutrition education of physicians.