Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 143
THE NATIONAL CHOLESTEROL EDUCATION PROGRAM
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
ax-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,
143
OCR for page 144
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
144
OCR for page 145
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 ~~~ ~~ - ~ - ~ ~ ~^^
and 160 ma/dl
160 mg/dl and above. The cutpoints of 130
_ 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.
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
This creates an enormous
145
OCR for page 146
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
146
OCR for page 147
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.
REFERENCE
The Expert Panel. 1988. Report of the National
Cholesterol Education Program Expert Panel on
Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Arch. Intern. Med. 148:36-69.
147
OCR for page 148
Representative terms from entire chapter:
coronary heart
