We have talked about the comorbidities of high visceral fat and insulin resistance; well, dyslipidemia is one of them. What you need to know about dyslipidemia is that it is a condition linked to abnormally high concentration of lipids in the blood. It is considered one of the main risk factors for the development of cardiovascular disease (CVD).
ACC/ AHA treatment guidelines
The diagnosis of dyslipidemia in adult patients comes after a complete assessment of the blood’s lipid concentration. It should be followed by an advanced anthropometric analysis, clinical medical history, and lifestyle habits. Consequently, the standard of care takes the following markers as part of the risk assessment procedure.
Diagnosis criteria of Dyslipidemia
|Total Cholesterol: <200mg/dL|
|Low-density lipoprotein (LDL): <100mg/dL|
|High-density lipoproteins (HDL): >40mg/DL|
In addition to these markers, this approach recommends taking a personalized point of view by measuring Lipoprotein (a) (<50mg/dL) and Apolipoprotein B (>120mg/dL). Also, taking into account the patient’s ethnicity, family history of premature ASCVD, antecedents of chronic inflammatory disorders, metabolic syndrome, chronic kidney disease, preeclampsia or premature menopause in women, and proinflammatory markers such as Hs- CRP <2.0mg/L. This criterion allows improved risk prevention and has a patient-focused approach.
Nowadays, clinical practice guidelines assure that the best way to treat this condition is by assessing the risk factor that might affect the patient. In fact, the guideline of the management of blood cholesterol of the American College of Cardiology and American Heart Association published in 2018 states the next:
“In all individuals, emphasize a heart-healthy lifestyle across the life course. A healthy lifestyle reduces atherosclerotic cardiovascular disease (ASCVD) risk at all ages. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.”
Therefore, this statement sends a direct message; prevention is the first and most important treatment you can provide to your patient. Indeed, this same statement is number one of the top 10 take-home messages to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Also, the standard of care and the clinical guidelines are considering a much broader angle to treat this condition.
The contributions of the standard of care are outstanding and should be followed. However, personalized treatment, assessment, and lifestyle modifications should always be considered in the clinical guidelines. In fact, ACC/AHA mentions lifestyle modification but does not state how to introduce those changes into the treatment. Instead, the information focuses on the pharmacological treatment with statins.
Treatment with statins represents a challenge since they come with secondary effects linked to lower quality of life (QOL).
Statin Side effects experienced by doctors
|Dr. A. 50 years old, Radiologist treated with Atorvastatin 80mg reported adverse effect of cognitive impairment, neuropathy and glucose intolerance. These effects ceased when the medication was discontinued.|
|Dr. B. In his 40s, Internist treated with Atorvastatin 10mg reported muscle weakness, fatigue, pain, shortness of breath, and myalgia. Muscle biopsy showed mitochondrial myopathy attributed to statin use.|
|Dr. C. Cardiac surgeon in his 40s, treated with Atorvastatin 40mg and Ezetimibe 40mg, reported symptoms of irritability (reported by coworkers), myalgia, and fatigue. Statin discontinuation resolved myalgia and fatigue (self-reported). Also, coworkers confirmed lower irritability issues.|
|Dr. E. Physical medicine and rehab, in his 50s treated with Simvastatin 20mg and Niacin 1500 UI reported muscle weakness, low libido, and exercise intolerance. His symptoms were confirmed with NCS/EMG that showed slowed nerve conduction and fasciculations. Low libido was associated with low testosterone levels. Although he discontinued statins, his symptoms have not resolved completely.|
What do we need to know about lifestyle changes to lower dyslipidemia? Diet pattern modification is an excellent example of how food is medicine. Functional Medicine’s personalized approach is evidence-based. Mediterranean diet interventions have positively impacted the lipid profile, protect against oxidative stress, inflammation, and platelet aggregation, and promote gut microbiota-mediated production of metabolites influencing metabolic health.
Mediterranean diet traditional characteristics
|1. A variety of minimally processed whole grains and legumes as the staple food|
|2. Plenty of a huge diversity of fresh vegetables consumed daily|
|3. Fresh fruits as the typical daily dessert; sweets based on nuts, olive oil, and honey consumed only during celebratory occasions|
|4. Cold-pressed extra-virgin olive oil, nuts, and seeds as the principal source of fat|
|5. Moderate consumption of fish|
|6. Dairy products (mainly local cheese and yogurt) consumed in low amounts; butter, cream, and milk never used, except for milk in coffee (caffé macchiato) or infants|
|7. Red and processed meat consumed in shallow frequency (only once every week or two) and amounts;|
|8. Wine consumed in low to moderate amounts only with meals|
The adherence to the Mediterranean diet (MD) is associated with protective effects against cardiovascular disease, stroke, obesity, diabetes, hypertension, several types of cancers, allergic diseases, and, most recently, Alzheimer’s and Parkinson’s disease.
- In an epidemiological study involving 22,304 men and women, MD showed a lower total cardiac mortality.
- In another study of 2,339 men and women aged 70- 90 y/o, adherence to MD was linked to a 23% or a lower rate of all-cause mortality.
- In the Lyon Diet Heart Study, involving 605 men and women who had suffered prior myocardial infraction were assigned into two groups, the American Heart Association step 1 diet or a diet resembling MD, supplemented with ALA margarine. After a 27-month intervention, the MD group showed a significant 70% reduction in all-cause mortality due to a 73% reduction in coronary heart disease mortality and major reductions in nonfatal complications.
- An “Indo-Mediterranean diet” study was conducted in 1000 Indian patients with high risk or existing coronary heart disease. The MD group was compared to a step 1 National Cholesterol Education program diet. Furthermore, the study resulted in an approximate 50% reduction in nonfatal myocardial infarction and an approximate 60% reduction in the rate of sudden cardiac death in the “Indo-Mediterranean diet” group.
- The PRIDIMED study supplemented the MD with approximately 1liter per week of extra-virgin olive oil or 30g of mixed nuts. This study was conducted on 7.447 men and women at high cardiometabolic risk. Furthermore, after a follow-up of 4.8 years, the absolute risk reduction was about three major cardiovascular events per 1,000 person-years, for a relative risk reduction of approximately 30%.
- Sub-studies from PRIDIMED authors resulted in reducing peripheral artery disease, atrial fibrillation, breast cancer, and type 2 diabetes.
Evidence-based medicine and clinical guidelines are blueprints to follow by clinicians when they are applying their critical thinking. However, the pharmacological approach needs extra help to acquire the patient’s needs. All of the time, care providers are looked upon like healers, and it’s our job to meet the requirements. By looking outside of the prescription pad, we can be able to visualize a personalized treatment.
I am the daughter of an Internist. I had the pleasure of working along with my dad as his nutritionist. I have seen many patients improve their lipid profile with statins, a personalized diet, and exercise inclusion (the hardest part of the treatment). However, they never come to me for the side effects since erectile dysfunction is a topic our patients prefer to talk about with my dad. Most of the time, my dad prescribes a statin for a three-month period. This allows the patient to deal daily with the lifestyle changes while providing the sense of security and health that comes with the lower lipid concentration in the lab work. Ultimately, the promise is that the patient would keep low lipid concentration without the pill if they can adhere to the dietary and exercise adjustments. My dad and I can say that an integrative care plan results in better outcomes. – Ana Paola Rodríguez Arciniega, MS
Kozlik, Hayley J., Athena Hathaway Meskimen, and Beatrice Alexandra Golomb. “Physicians’ experiences as patients with statin side effects: a case series.” Drug safety-case reports 4.1 (2017): 3.
Stein, Ricardo, Filipe Ferrari, and Fernando Scolari. “Genetics, dyslipidemia, and cardiovascular disease: new insights.” Current cardiology reports 21.8 (2019): 1-12.
Grundy, Scott M, et al. “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Journal of the American College of Cardiology vol. 73,24 (2019): 3168-3209. doi:10.1016/j.jacc.2018.11.002
Tosti, Valeria et al. “Health Benefits of the Mediterranean Diet: Metabolic and Molecular Mechanisms.” The journals of gerontology. Series A, Biological sciences and medical sciences vol. 73,3 (2018): 318-326. doi:10.1093/Gerona/glx227
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Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, CTG*
Licensed in Texas & New Mexico