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The New York Times, November 10, 2008, by Pam Belluck — A large new study suggests that millions more people could benefit from taking the cholesterol-lowering drugs known as statins, even if they have low cholesterol, because the drugs can significantly lower their risk of heart attacks, strokes and death.

The study, involving nearly 18,000 people worldwide, tested statin treatment in men 50 and older and in women 60 and older who did not have high cholesterol or histories of heart disease. What they did have was high levels of a protein called high-sensitivity C-reactive protein, or CRP, which indicates inflammation in the body.

The study, presented Sunday at an American Heart Association convention in New Orleans and published online in The New England Journal of Medicine, found that the risk of heart attack was more than cut in half for people who took statins.

Those people were also almost 50 percent less likely to suffer a stroke or need angioplasty or bypass surgery, and they were 20 percent less likely to die during the study. The statin was considered so beneficial that an independent safety monitoring board stopped what was supposed to be a five-year trial last March after less than two years.

Scientists said the research could provide clues on how to address a long-confounding statistic: that half of heart attacks and strokes occur in people without high cholesterol.

“These are findings that are really going to impact the practice of cardiology in the country,” said Dr. Elizabeth G. Nabel, director of the National Heart, Lung and Blood Institute, which was not involved in the research. “It’s at a minimum an extremely important study and has the potential to be a landmark study.”

The study is stirring debate over who should take a blood test to check CRP and under what circumstances someone with high levels of the protein should be given a statin. Because heart disease is a complex illness affected by many risk factors — including smoking, hypertension and being overweight — most researchers said high CRP alone should not justify prescribing statins to people who have never had heart problems.

Some experts cautioned against testing people for the protein unless they had other risk factors, and they said more research was needed to pinpoint the patients for whom the benefit of statins outweighs the risks. On rare occasions, statins have been linked to muscle deterioration or kidney problems, and some patients reported fogginess of memory. Other researchers recommended testing for CRP more frequently and using statins more aggressively.

The study, called Jupiter, is also fueling a debate among scientists about the protein’s importance and inflammation’s role in heart disease.

Dr. Nabel said national panels were likely to revise their official guidelines for doctors to recommend CRP testing and statin therapy for some people not previously considered candidates.

Current practice, she said, is to treat people with high cholesterol with statins and to counsel people at low risk for heart disease about diet and exercise.

“What cardiologists have never known what to do about is the intermediate range” of patients, Dr. Nabel said, who may be overweight, smoke or have hypertension but do not have the most serious red flags of high cholesterol or diabetes. “I think CRP will emerge as a new risk factor added to traditional risk factors.”

The leader of the Jupiter study, Dr. Paul M. Ridker, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital in Boston, said expanding statin use could prevent about 250,000 heart attacks, strokes, vascular procedures or cardiac deaths over five years.

Some experts not involved in the study said several million more Americans should probably be taking statins. About 16 million to 20 million do now.

“The Jupiter trial very convincingly used CRP as a way to identify another group of high-risk individuals who would not otherwise have been treated and supports the concept that those people should be treated with a statin,” said Dr. Daniel J. Rader, a heart researcher at the University of Pennsylvania School of Medicine who was not connected to the study.

Some consumer advocates and doctors raised concerns about the expense of putting relatively healthy patients on statins, which would cost the health system billions of dollars. Name-brand statins can cost $3 a day, but generics are much cheaper. Dr. Ridker said he believed that the widening use of the drugs might prevent costs associated with heart attacks and surgery.

Several experts said that although the research was significant and would affect clinical practice, the study as published did not give enough detail about which patients should now be tested for CRP or given statins.

In an accompanying editorial, Dr. Mark A. Hlatky, a professor of health research at Stanford University, questioned the cost of expanding statin use. He also said that the study, which tested people with levels of the protein over two milligrams per liter, did not indicate whether that level or a higher CRP level should be the threshold for treatment.

Dr. Sidney Wolfe, director of the health research group for Public Citizen, a nonprofit consumer advocacy group, said the study did not give enough detail about the effect of statins on participants who had only high protein levels, compared with those who also smoked or had a condition called metabolic syndrome.

Some experts questioned whether stopping the trial early had limited the possibility of some more meaningful data. Dr. Ridker said it had not.

He said the published study, as well as unpublished data, indicated that all the statin-takers experienced the same benefit, including those considered “very low risk” because they had no risk factors other than high levels of the protein.

The trial was one of the few to test statins that included many women, Hispanics and blacks, groups that all showed similar benefit from statins.

Like many clinical trials, the Jupiter study was sponsored by a pharmaceutical company, in this case AstraZeneca. It makes the drug in the trial, rosuvastatin, which is sold as Crestor. The most potent statin on the market, Crestor has been criticized by consumer health advocates who say it is more likely to lead to muscle deterioration and kidney problems.

In 2005, the Food and Drug Administration rejected a petition by Public Citizen to ban Crestor, saying its risks were not substantially different from similar drugs.

In the Jupiter study, in which people got either rosuvastatin or a placebo, there was no increase in muscle or kidney problems for those taking the statin. There was a small increase in diabetes.

Dr. Timothy J. Gardner, president of the American Heart Association, said some recent statin trials “have been either negative or in some ways concerning in terms of complications.” But, he added, “this one is pretty clearly a winner for statin therapy.”

Dr. Ridker, a co-inventor of a CRP test, said he first sought federal financing for the study and was turned down. He and the other scientists interviewed for this article, except for Dr. Nabel, Dr. Gardner and Dr. Wolfe, have consulted for or received research money from stain makers.

Although Crestor, which has 9 percent of the American cholesterol-lowering market, was used in this study, several experts said it seemed likely that the effect would be the same for other statins in appropriate doses, including generics.

Lisa Nanfra, executive director of commercial operations for AstraZeneca, said the company believed that there was a “unique profile of Crestor” and that the drug was “the most effective statin at lowering” bad cholesterol. The company plans to use results from the Jupiter study to seek F.D.A. approval to widen its claim about Crestor’s effectiveness.

The role of the protein and inflammation in heart disease is hotly debated. Dr. Ridker believes inflammation plays an important role, probably by causing plaque in the arteries to rupture. “Screening for cholesterol alone is like having two passengers in a car but only one air bag,” he said. “If we’re not screening for CRP, we don’t have the opportunity to save that person’s life.”

Others say cholesterol is much more important. Dr. Scott Grundy, a heart expert at the University of Texas Southwestern Medical Center, pointed out that in the Jupiter study, the statin not only lowered the protein but also significantly cut already low cholesterol levels, raising questions about whether the benefit actually came from giving patients superlow cholesterol. And because CRP can rise with short-term infections unrelated to chronic inflammation, some experts said test results needed to be weighed against other aspects of the patient’s health.

“CRP is not a standard test that everyone should have,” Dr. Rader said. “It is an additional test that you should do if you’re on the fence.”

Dr. Andrew M. Tonkin, head of cardiovascular research at Monash University in Melbourne, Australia, said though the results for those who took the statin were “strikingly positive,” given that the people in the study were relatively healthy, there needed to be a cost-benefit analysis to decide: “Are there people in whom the potential gains, although significant, are not so great as to warrant taking statins?”

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Stuart Bradford

In Brief:

Cholesterol can rise suddenly for unknown reasons, as it did for one Times reporter.

Dozens of measures, individually or together, can help to lower cholesterol, including exercise, weight loss, yoga and diet.

Cutting LDL, so-called bad cholesterol, by 60 milligrams can reduce heart attacks and sudden death by 50 percent after only two years.

Drugs, such as statins, should be a last resort but can be very effective.

The New York Times, November 10, 2008, by Jane Brody — Last December, a routine nonfasting blood test revealed that my total cholesterol level, which had long wavered between 190 and 205 milligrams per deciliter of blood serum, was now 222 and flagged as “high” by the laboratory’s computer. A heart-healthy reading should be under 200.

The HDLs, the so-called good cholesterol that protects against heart disease, were also high at 69, so that was good. My triglycerides, at 95, were well within the normal range of zero to 149. The VLDLs, also a potentially harmful form, measured 19, again within the normal range of 5 to 49.

But the LDLs, the bad guys that deposit plaque on artery walls, were 134 — “high” since they should be under 100 if I want to maintain a healthy cardiovascular system.

My doctor wasn’t too concerned because my blood pressure is low, I eat a healthful diet and I exercise every day for 60 to 90 minutes and run up and down scores of steps. Still, I decided to cut out cheese, lose a few pounds and return in three months for another test, this time after an all-night fast.

So in early March, three pounds lighter and taking a daily supplement of plant stanols, which are supposed to lower cholesterol, I had a second test. But now my total cholesterol had risen to 236 and the LDLs were up to 159.

Still, my doctor was not as alarmed as I was. My father and his father and his father’s brother had heart attacks in their 50s, and my father and grandfather died of their second attacks at 71. I was 65. Were my days going to be numbered by a surprise coronary or stroke? Not if I could help it.

Now it was time to further limit red meat (though I never ate it often and always lean), stick to low-fat ice cream, eat even more fish, increase my fiber intake and add fish oils to my growing list of supplements. But the latest test, in early June, was even more of a shock: total cholesterol, 248, and LDLs, 171.

My doctor’s conclusion: “Your body is spewing out cholesterol and nothing you do to your diet is likely to stop it.” I was not inclined to become a total vegetarian to see if that would help. The time had come to try a statin, one of the miraculously effective cholesterol-lowering drugs.

By studying the effects of statins in thousands of people who already had heart disease or were likely to develop it, researchers finally proved that lowering total and LDL cholesterol in people at risk was both health-saving and life-saving. I’ll know by fall if the low-dose statin I now take nightly will do the trick, or if I’ll need a higher dose. [See Fall Update, below.]

Lifestyle Changes

Americans tend to turn far too quickly to drugs to solve their health problems. Drugs should be the last resort, if there are reasonable measures people can take first to control a problem. And there are dozens of such measures that, individually or together, can help to lower LDLs.

High LDL cholesterol is an independent risk factor for coronary heart disease, and lowering it by 60 milligrams can reduce coronary events like heart attacks, angina and sudden death by 50 percent after only two years, experts from Oregon Health and Sciences University wrote recently in The Journal of Family Practice.

The Oregon specialists, Dr. Elizabeth Powers, Dr. John Saultz and Andrew Hamilton, recommended that doctors start with lifestyle modifications when a patient has high LDLs. And Dr. Vincent Lo of French Camp, Calif., suggested that the patient’s culture, preferences and practical issues like cost and availability be considered. Not everyone can afford to join a gym, and a traveling salesman may have a hard time sticking to a low-fat, calorie-controlled diet.

These are the measures that have been found to work, based on randomized, controlled clinical trials, the gold standard of clinical research.

Alcohol. Consuming one or two drinks a day can lower LDLs by 4 to 10 milligrams. Red wine is considered most effective. For those who cannot drink alcohol, purple grape juice may be a reasonable, albeit less effective, substitute.

Exercise. Aerobic exercise, like brisk walking, jogging, cycling and lap swimming, can reduce LDLs by 3 to 16 milligrams and raise the good HDLs. Consistency is important. Aerobic activities should be performed at least five times a week for maximum benefit.

Weight loss. When achieved through diet and exercise, weight loss can reduce LDL levels by as much as 42 milligrams. When achieved through drug therapy, weight loss has been associated with an LDL drop of 10 to 31 milligrams.

Yoga and tai chi. These forms of exercise, which are accessible to just about everyone who can walk, even the elderly, have reduced LDLs by 20 to 26 milligrams when done for 12 to 14 weeks.

Smoking. An analysis of several studies found that LDL cholesterol was 1.7 percent higher in smokers, but two smoking cessation studies found little or no difference. In any case, smoking is a strong independent risk factor for heart disease and sudden coronary death, so it is best avoided.

Modifying Your Diet

About 85 percent of the cholesterol in your blood is made in your body. The remaining 15 percent comes from food. But by reducing dietary sources of saturated fats and cholesterol and increasing consumption of cholesterol-fighting foods and drink, you can usually lower the amount of harmful cholesterol in your blood. My college roommate, for example, recently adopted a mostly vegetarian-and-fish diet, minus cheese but with occasional meat and chicken, and lowered her total cholesterol from 240 to 160 milligrams.

There are exceptions, of course, and I happen to be one of them. Still, I intend to continue to follow a heart-healthy diet, because that will enhance the effectiveness of the medication I’m taking.

Start by switching to low-fat and nonfat dairy products, like skim milk and, if you can stand it, fat-free cheese. Substitute sorbet, sherbet or fruit ices for ice cream, or choose ice milk or ice cream with half the fat.

For protein, choose fish and shellfish, poultry without the skin and lean meats, all prepared with low-fat recipes. Eat more dried beans and peas (cooked, of course), soy products like tofu, and nuts like walnuts and almonds. Grains should be mostly or entirely whole — 100 percent whole wheat bread and cereals made from whole wheat or oats, brown rice, bulgur and the like. Oats and oatmeal are rich in soluble fiber, which lowers cholesterol.

Pile on the vegetables and fruits. Especially helpful are those high in fiber like Brussels sprouts, cabbage, spinach, carrots, blueberries, oranges and apples.

Cook with canola or olive oil, and use margarine made from plant stanols.

And enjoy a glass of wine with dinner.

Equally important are the foods to limit or avoid: organ meats like liver, egg yolks, most fried and fast foods, doughnuts and pastries, full-fat cheeses and ice cream, processed meats like salami, bacon and other fatty cuts of pork, and untrimmed red meats.

Fall Update

The low-dose statin I’d been taking did the trick. After four months of taking 10 mg a day of Lipitor, my total cholesterol went from 248 to 159. The bad cholesterol, or LDL, went from 171 to 84. My good cholesterol also went up slightly. My ratio of total cholesterol to good cholesterol has me living forever!

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Marilynn K. Yee/The New York Times
Dr. Antonio Gotto, the dean of Weill Cornell Medical College, has been a lipid researcher for more than 40 years.

The New York Times, November 10, 2008, by Laurie Tarkan

Q. If you had to rate the importance of reducing risk factors for heart disease, where does lowering so-called bad cholesterol, or LDL, fit in?

A. Lowering LDL is right up at the top of the list. The evidence of the benefits of LDL lowering is overwhelming. If you look at the demonstrated therapeutic benefits of the statins, whose primary effect is to lower LDL, they slow the progression of atherosclerosis, reduce major coronary events and reduce the need for surgical interventions like angioplasty. In secondary prevention [in those who already have coronary heart disease], they also reduce the risk of stroke, dying from heart disease and overall mortality.

Q. Even before statins, people were advised to lower their LDL. Have the clinical studies on statins given credence to this approach?

A. Yes, cardiologists were skeptical of the benefits of lowering cholesterol until the so-called 4S trial [Scandinavian Simvastatin Survival Study] came out in 1994, which showed statins could increase life span in people with coronary heart disease. That was a turning point. The fact of the matter is if we hadn’t had statins, we probably would never have been able to make such a convincing case and obtain such a consensus for the benefits for lowering LDL.

Q. How much can diet lower LDL?

A. Diet is very important. Usually most people can achieve a 5 to 10 percent decrease in LDL level with diet. If you can maintain the diet over a period of time, that’s very good. Also, if you’re taking statins and you’re not following a diet, you could partially undo the effects of statins. In Japan they’re able to get by with much lower doses of drugs largely because of their healthier diet.

Q. What is aggressive lipid lowering, and who requires it?

A. Aggressive lipid lowering is bringing the LDL very low. It’s for people who are at high risk, meaning they already have coronary disease, and for those who are at very high risk, meaning they’ve already had an event and still have risk factors like diabetes or uncontrolled hypertension. The recommendations state that for people at high risk, their LDL should be under 100 [milligrams per deciliter], and for those at very high risk, they have the optional target of getting LDL under 70.

Q. It that achievable?

A. It is achievable, but it’s not easy for many people. It depends on what your LDL is to begin with. It requires a combination of nonpharmacologic measures, such as diet or exercise, along with one or more medications to lower the LDL. If you don’t reach your target on statins and diet, there are other drugs you can use on top of that.

Q. Why is it important to get LDL so low?

A. There was a study called the Treating to New Targets, or T.N.T., trial, which showed that in people with coronary heart disease, lower is better. The study compared taking 80 millligrams of atorvastatin (Lipitor) versus 10 milligrams. The 10 milligram group achieved an average LDL of 101, whereas the 80 milligram group had an LDL of 77 and had a 22 percent greater reduction in cardiovascular events than the 10 milligram group. Patients down in the 70 range do better than those in the higher range.

Q. A recent study found that women are much less likely than men to drive their cholesterol down to the recommended levels. What explains this?

A. We haven’t been aggressive enough when treating women. We tend to think they’re not at risk of coronary disease. Another undertreated group is diabetics. They ought to start taking a statin at the same time as they’re given medications for diabetes. Cardiovascular disease is a major complication of diabetes.

Q. Are there a lot of people who have borderline risk factors that should be treated but aren’t?

A. Most people are asymptomatic. We could do a lot of good and prevent a lot of events if we started treatment early in life and treated borderline people, not just those with moderate to high risk. We could treat people with a 5 to 10 percent risk of having a heart attack in 10 years with diet and exercise primarily. In the 10 percent range, we’d treat with diet first, but if the response isn’t satisfactory, we add a statin.

Q. Do patients typically have to stay on statins the rest of their lives?

A. Yes, you have to take it for two to three years before you see a maximum benefit. Once started, you should stay on it for the rest of your life.

Q. But many people go off of statins?

A. Yes, for a number of reasons. There’s a misconception — some people think if you get your cholesterol down to normal, then you don’t have to take it anymore. That’s not true. Studies have shown that you’ll have the benefits for a period of time after stopping, but after a couple of years, you’ll lose them.

Q. Why does LDL go up for certain people, even if they’re following a very good diet?

A. It goes up with age, due to a decrease in the body’s ability to clear cholesterol out of the blood. But for some people, their bodies are cranked up to make LDL, or they can’t remove it as efficiently as others, so they need the help of the drugs. The reason statins are so helpful is that even those who are trying their best to reach their target and still can’t do it have something else to rely on.

Q. Let’s turn to HDL, the “good” cholesterol that helps clear “bad” cholesterol out of blood vessels. Cardiologists had high expectations for the experimental drug torcetrapib, which raises HDL, but the study surprisingly found that people on the drug had higher rates of coronary events.

A. We know that a low HDL is associated with an increase in risk. The question is, if you raise it, do you reduce the risk, and does it matter how you raise it? Obviously, it does. Raising it with torcetrapib, which increased HDL by 70 percent and also decreased LDL by 40 percent, caused an increase in deaths and more events. So we don’t know if the mechanism is flawed or if it was just that particular chemical entity, torcetrapib, that was flawed. There are other drugs in the class that are being tested, so the jury is out. The cardiology community is not nearly as enthusiastic now as it was before this trial came out.

Q. How are doctors treating low HDL now?

A. Patients who have low HDL still benefit from statins, which raise HDL between 5 and 15 percent. Not much, but they’re still helpful, plus they get the benefits of a lower LDL. Niacin is the most effective drug we currently have, raising it 20 to 25 percent. It causes flushing, which is why it’s not more widely used. You can take an extended-release formula or take an aspirin an hour before taking niacin to reduce flushing. When you get the LDL down to 50 or 60, you probably have as close to as much benefit you’ll get from lowering LDL. At that point, you have to look at other mechanisms, such as raising HDL or reducing triglycerides.

Q. Is there a special diet for raising HDL?

A. Well, we know a high-carbohydrate diet lowers HDL. Exercise is very important in raising HDL, in weight control and in lowering triglycerides. Exercise is more helpful in raising HDL than it is in lowering LDL.

Q. What should people know about their own cholesterol?

A. It’s important to know what your total cholesterol and LDL and HDL are, but also to know what your overall risk is, including your family history, smoking, blood pressure and diabetes, because your overall risk determines where your LDL should be and what treatment you might need.

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Function

Cholesterol helps the body produce hormones, bile acid, and vitamin D. Cholesterol moves through the bloodstream to be used by all parts of the body.

Food Sources

Cholesterol is found in eggs, dairy products, meat, and poultry. Egg yolks and organ meats (liver, kidney, sweetbread, and brain) are high in cholesterol. Fish generally contains less cholesterol than other meats, but some shellfish are high in cholesterol.

Foods of plant origin (vegetables, fruits, grains, cereals, nuts, and seeds) contain no cholesterol.

Fat content is not a good measure of cholesterol content. For example, liver and other organ meats are low in fat, but very high in cholesterol.

Side Effects

In general, your risk of developing heart disease or atherosclerosis goes up as your level of blood cholesterol increases.

Recommendations

More than half of the adult population has blood cholesterol levels higher than the desirable range. High cholesterol levels often begin in childhood. Some children may be at higher risk due to a family history of high cholesterol.

To lower high cholesterol levels:

* Limit total fat intake to 25 – 35% of total daily calories. Less than 7% of daily calories should be from saturated fat, no more than 10% should be from polyunsaturated fat, and no more than 20% from monounsaturated fat.
* Eat less than 200 mg of dietary cholesterol per day.
* Get more fiber in your diet.
* Lose weight.
* Increase physical activity.

The recommendations for children’s diets are similar to those of adults. It is very important that children get enough calories to support their growth and activity level, and that the child achieve and maintain a desirable body weight

The following two sample menus provide examples of an average American diet and a low-fat diet.

AVERAGE AMERICAN DIET

* Breakfast
o 1 egg scrambled in 1 teaspoon of butter
o 2 slices of white toast
o 1 teaspoon of butter
o 1/2 cup of apple juice
* Snack
o 1 cake donut
* Lunch
o 1 ham and cheese sandwich (2 ounces of meat, 1 ounce of cheese)
o White bread
o 1 teaspoon of mayonnaise
o 1-ounce bag potato chips
o 12-ounce soft drink
o 2 chocolate chip cookies
* Snack
o 8 wheat thins
* Dinner
o 3 ounces of broiled sirloin
o 1 medium baked potato
o 1 tablespoon of sour cream
o 1 teaspoon of butter
o 1/2 cup of peas, 1/2 teaspoon of butter

Totals: 2,000 calories, 84 grams fat, 34 grams saturated fat, 425 milligrams cholesterol. The diet is 38% total fat, 15% saturated fat.

LOW-FAT DIET

For the same number of calories, a low-fat diet provides 190 mg of cholesterol, compared to 510 mg of cholesterol for an average American diet. Because fat is high in calories, the low-fat diet actually has more food than the typical American diet. An example follows:

* Breakfast
o 1 cup of toasted oat ring cereal
o 1 cup of skim milk
o 1 slice of whole-wheat bread
o 1 banana
* Snack
o 1 cinnamon raisin bagel, 1/2 ounce light cream cheese
* Lunch
o Turkey sandwich (3 ounces of turkey) on rye bread with lettuce
o 1 orange
o 3 Fig Newton cookies
o 1 cup skim milk
* Snack
o Nonfat yogurt with fruit
* Dinner
o 3 ounces of broiled chicken breast
o 1 medium baked potato
o 1 tablespoon of nonfat yogurt
o 1/2 cup of broccoli
o 1 dinner roll
o 1 cup skim milk

Totals: 2,000 Ccalories, 38 grams fat, 9.5 grams saturated fat, 91 mg cholesterol. The diet is 17% fat, 4% saturated fat.

Note: The low-fat diet example is too low in fat for small children to promote good growth. In addition, it may be difficult for them to eat such a large volume of food. Children should have a diet that is closer to 30% of calories from fat. Lower-fat diets may be appropriate in some children. Ask your doctor what is best for your child.

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THE FACTS

The New York Times, November 10, 2008, by Anahad O’Connor — Soy foods have been credited with all sorts of health benefits, but perhaps none so appealing as this assertion.

The notion was cemented in 1999, when the Food and Drug Administration allowed companies to claim that 25 grams of soy protein a day, in a diet low in saturated fat and cholesterol, “may reduce the risk of heart disease.” The agency evaluated studies — including an industry-financed analysis published in The New England Journal of Medicine in 1995 — concluding that soy protein could cut cholesterol.

But studies since have raised doubts. In 2006, an American Heart Association advisory panel reviewed a decade of studies and determined that soy products had no significant effects on HDL (“good” cholesterol) or triglycerides, and little or no ability to lower “bad” cholesterol, or LDL. Another study, published in August in The American Journal of Clinical Nutrition, found that consuming 24 grams of soy protein daily had no “significant effect on plasma LDL” in people with mildly elevated cholesterol.

But the issue is far from clear-cut. Another line of research shows that soy seems to help when combined with foods low in fat and high in fiber and the compounds called plant sterols — in other words, an overall healthy diet.

THE BOTTOM LINE

There is evidence that soy can improve cholesterol, but the jury is still out.

PROGRAM DESCRIPTION

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Cholesterol
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Cholesterol Producers

The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) launched the National Cholesterol Education Program (NCEP) in November 1985. The goal of the NCEP is to contribute to reducing illness and death from coronary heart disease (CHD) in the United States by reducing the percentage of Americans with high blood cholesterol. Through educational efforts directed at health professionals and the public, the NCEP aims to raise awareness and understanding about high blood cholesterol as a risk factor for CHD and the benefits of lowering cholesterol levels as a means of preventing CHD.

Evidence of Progress

The NCEP has made significant strides toward its goal of reducing the prevalence of high blood cholesterol in the United States. Evidence of this progress is clearly visible in the results of national surveys. The latest Cholesterol Awareness Survey (CAS) of physicians and the public shows that from 1983 to 1995, the percentage of the public who had ever had their blood cholesterol checked rose from 35 to 75 percent. This means that some 70 to 80 million Americans who in 1983 were unaware of their blood cholesterol level have taken action to learn where they stand. In 1995, physicians reported initiating diet and drug treatment at much lower cholesterol levels than in 1983, levels close to NCEP recommendations. The CAS also shows that core elements of the NCEP guidelines for blood cholesterol detection and treatment have become established practice. The efforts of the NCEP and Coordinating Committee member organizations have led to significant improvements in professional and public attitudes, knowledge, and practices regarding high blood cholesterol and heart disease. The Third National Health and Nutrition Examination Survey (NHANES III) (1988-1994) demonstrates that the public’s intake of saturated fat and total fat has declined. NHANES III also shows that blood cholesterol levels have dropped. Since 1978, average total cholesterol levels among U.S. adults have fallen from 213 mg/dL to 203 mg/dL, and the prevalence of cholesterol of 240 mg/dL or higher has declined from 26 percent to 19 percent. Moreover, CHD mortality has continued to decline. Taken all together, the progress indicators demonstrate that cholesterol education has had a significant impact.

The NCEP Science Base

From its inception, the NCEP has based its recommendations and messages firmly on sound scientific evidence. In January 1984, the Lipid Research Clinics Coronary Primary Prevention Trial provided the long-sought, definitive evidence that lowering high blood cholesterol reduces the risk for CHD. These results and a large body of evidence from laboratory, epidemiologic, and clinical studies showed that not only are high blood cholesterol levels an important risk factor for CHD, but that these levels can be lowered safely by both diet and drugs.

A series of recent clinical trials that used cholesterol-lowering drugs called “statins” has provided conclusive evidence that lowering the level of low density lipoprotein (LDL) cholesterol, the “bad” cholesterol, dramatically reduces heart attacks and CHD deaths as well as overall death rates in patients with or without existing CHD.
The NCEP Program Areas

The scientific evidence supports a continuation of NCEP’s two-pronged strategy for reducing blood cholesterol levels:

* The high-risk or clinical approach, which promotes the detection and treatment of individuals whose elevated blood cholesterol places them at significantly increased risk for CHD;
* The population approach, which seeks to lower average levels of blood cholesterol by encouraging the gerneral public to adopt reduced intakes of saturated fat and cholesterol, increased physical activity, and weight control.

The NCEP Partnership

Since 1985, the NCEP has relied on partnerships to promote implementation of its strategies and guidelines. The NCEP Coordinating Committee, with its membership of more than 40 partner organizations, embodies this partnership principle. Through the Coordinating Committee, the NCEP brings cholesterol information to a wide audience. Consisting of representatives from major medical and health professional associations, voluntary health organizations, community programs, and governmental agencies, the Coordinating Committee is the NCEP’s policy-setting body and board of directors.

An important Coordinating Committee activity is sponsorship of expert panels to develop guidelines for health professionals. The NCEP distributes the panels’ guidelines and recommendations to physicians and other health care professionals and laboratories across the country. The reports of these panels serve as the platform for a wide variety of NCEP educational activities and materials. These panels include:

* Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel)—guidelines for detecting, evaluating, and treating high blood cholesterol in adults.
* Laboratory Standardization Panel— guidelines for standardizing laboratory measurements and reporting of blood cholesterol tests.
* Expert Panel on Population Strategies for Blood Cholesterol Reduction (Population Panel)— recommendations for reducing blood cholesterol levels through populationwide adoption of eating patterns low in saturated fat and cholesterol.
* Expert Panel on Blood Cholesterol Levels in Children and Adolescents—recommendations for heart-healthy eating patterns for children and adolescents, and for detecting and treating high blood cholesterol in children and adolescents from high-risk families.
* Working Group on Lipoprotein Measurement— recommendations to improve the measurement of LDL-cholesterol, HDL-cholesterol, and triglyerides.

Member Organizations of the NCEP Coordinating Committee

American Academy of Family Physicians
American Academy of Pediatrics
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Nutrition
American College of Obstetricians and Gynecologists
American College of Occupational Medicine
American College of Preventive Medicine
American Diabetes Association, Inc.
American Dietetic Association
American Heart Association
American Hospital Association
American Medical Association
American Nurses Association
American Osteopathic Association
American Pharmaceutical Association
American Public Health Association
American Red Cross
Association of Black Cardiologists
Association of Life Insurance Medical Directors of America
Association of State and Territorial Health Officials
Citizens for Public Action on Blood Pressure and Cholesterol, Inc.
National Black Nurses Association, Inc.
National Heart, Lung, and Blood Institute
National Medical Association
Society for Nutrition Education
Society for Public Health Education
Associate Member Organizations of the NCEP Coordinating Committee

American Association of Office Nurses
Federal Agencies

NHLBI Ad Hoc Committee on Minority Populations
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
Coordinating Committee for the Community Demonstration Studies
Department of Agriculture
Department of Defense
Food and Drug Administration
Health Resources and Services Administration
National Cancer Institute
National Center for Health Statistics
Office of Disease Prevention and Health Promotion
Department of Veterans Affairs
The NCEP Goal and Objectives

The goal of the NCEP is to reduce the prevalence of elevated blood cholesterol in the United States, and thereby contribute to reducing CHD morbidity and mortality. To attain this goal, the NCEP has established the following objectives for health professionals, patients and the public, and the community.
Objectives for Health Professionals

* To increase awareness among health professionals that elevated blood cholesterol is a cause of CHD, and that reducing elevated blood cholesterol levels will contribute to the reduction of CHD risk.
* To improve the knowledge, attitudes, and skills of health professionals to identify and intervene with patients who have elevated blood cholesterol, and to provide guidelines regarding methods and approaches to use in detection, treatment, and followup of patients.
* To encourage health professionals to consider an individual’s blood cholesterol level in relation to other CHD risk factors.
* To increase the awareness and understanding of health professionals regarding the major role that diet plays in reducing elevated blood cholesterol.
* To increase the awareness and understanding of health professionals regarding the role of weight control and physical activity in the management of high blood cholesterol.
* To increase the knowledge of health professionals about the appropriate use of cholesterol-lowering drugs.
* To increase the proportion of health professionals who diagnose and treat patients with high blood cholesterol in accordance with the best existing information (e.g., measuring blood cholesterol levels at appropriate intervals, initiating treatment at appropriate levels of blood cholesterol, and providing adequate counseling support to patients).
* To promote interdisciplinary collaborative efforts in the management of patients with elevated blood cholesterol. Proper management of this condition requires close cooperation among health professionals, including physicians, nurses, dietitians, and pharmacists.
* To improve the knowledge, attitudes, and skills of students in the health professions regarding high blood cholesterol and its management.
* To improve precision and accuracy in the measurement of blood cholesterol levels and to promote standardized reporting of laboratory results.

Objectives for Patients and the Public

* To increase awareness that elevated blood cholesterol is a cause of CHD, and that reducing elevated blood cholesterol levels will contribute to the reduction of CHD risk.
* To increase the proportion of Americans who have reduced their dietary intake of saturated fat and cholesterol as part of a nutritionally adequate diet.
* To increase the proportion of Americans who know their blood cholesterol levels.
* To encourage people identified as having high blood cholesterol to seek professional advice and followup.
* To increase awareness that diet plays a major role in lowering high blood cholesterol, and that weight control and physcial activity also play a role in the management of high blood cholesterol, and that, if necessary, drugs may be added to the regimen.
* To increase public knowledge about the dietary principles for reducing blood cholesterol levels.
* To increase the proportion of people with high blood cholesterol who adhere to their cholesterol-lowering regimen.

Objectives for the Community

* To increase activities for blood cholesterol control at the state and community level.
* To increase awareness and knowledge among students, especially those in primary and secondary schools, with respect to blood cholesterol and cardiovascular risk factors in general.
* To increase worksite activities to reduce elevated blood cholesterol levels.
* To develop program activities and products that are appropriate to the needs of minorities and other special populations and to actively involve health professionals and organizations that serve these populations.
* To promote increased dissemination of scientifically accurate cholesterol-related information by print and electronic media.

For more information on the NCEP, contact:

National Cholesterol Education Program
NHLBI Health Information Network
P.O. Box 30105
Bethesda, Maryland 20824-0105
(301) 592-8573 phone
(301) 592-8563 fax
http://www.nhlbi.nih.gov