NLA: Use shared decision-making to navigate dietary patterns for elevated lipids
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Key takeaways:
- A healthy dietary pattern improves dyslipidemia and atherosclerotic CVD risk factors.
- Combination nutrition interventions may have additive effects for lowering LDL.
Targeted nutrition interventions can mitigate atherosclerotic CVD risk for people with the three most common dyslipidemias, and adherence can be encouraged via shared decision-making, according to a speaker.
“The nutrition interventions ... are meant to be implemented with the foundation of a multi-dietary pattern,” Carol Kirkpatrick, PhD, MPH, RDN, CLS, FNLA, clinical scientist at Midwest Biomedical Research and adjunct faculty in the Kasiska Division of Health Sciences at Idaho State University, said during a presentation at the National Lipid Association (NLA) Scientific Sessions. “Luckily, there are many commonalities and similarities among the dietary patterns, which include the Mediterranean diet, [Dietary Approaches to Stop Hypertension], the healthy vegetarian or vegan or the healthy U.S.-style diet. All of these diets emphasize plant-based foods, fruits, vegetables, whole grains, healthy proteins and then nontropical, plant-based oils and reducing intake of highly processed foods.”
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An updated NLA clinical perspective, published in the Journal of Clinical Lipidology, provides a supplement to previously published recommendations for lifestyle therapies to manage dyslipidemia, with a focus on nutrition interventions for the three most common dyslipidemias in adults: LDL elevation; triglyceride elevation, including severe hypertriglyceridemia with chylomicronemia; and combined dyslipidemia.
LDL lowering
Nutrition interventions that lower LDL levels include reducing cholesterol-raising fatty acids and dietary cholesterol; increasing intakes of unsaturated fatty acids, plant proteins and viscous fibers; and reducing adiposity for patients with overweight or obesity. Selected dietary supplements may be employed as dietary adjuncts.
“I would like to emphasize a combination approach — working with your patients and, hopefully, with a team that includes [a registered dietitian] who can help your patients navigate through their lifestyle and what they are struggling with the most, identify the strategies they want to implement first, knowing it will have an additive effect and lead to a greater reduction in their LDL cholesterol.”
The dietary portfolio approach, a combined effect of plant sterols, soy proteins and viscous fibers, may be as effective as the starting dose of older first-line drugs in managing hypercholesterolemia, Kirkpatrick said.
“An additive approach to LDL lowering with these different dietary strategies can be very effective,” Kirkpatrick said.
Interventions for isolated elevated triglycerides
For adults with a hypertriglyceridemia, defined as a fasting triglyceride level of 150 mg/dL or greater or a nonfasting triglyceride level of 175 mg/dL or greater, Kirkpatrick said health care providers should emphasize a healthy dietary pattern and increased physical activity with tailored specific nutrition interventions based on the level of triglyceride elevation. Providers should also assess non-lifestyle secondary causes and lifestyle factors and practices, such as the types and quantities of dietary carbohydrates, fats and proteins a person consumes, and address those as needed.
“For people with a triglyceride level of less than 500 mg/dL, it is pretty clear-cut,” Kirkpatrick said. “Reduce added sugars, have a moderate fat intake, restrict alcohol and increase physical activity to reduce adiposity. For the next two categories, it is really important to identify what will work best for that patient. Some patients in that 500 mg/dL to 749 mg/dL [group] are also dealing with insulin resistance and hyperglycemia, factors that are contributing to their elevated triglyceride levels. Those above 749 mg/dL may also have lipoprotein lipase activity that needs to be considered and addressed.”
For those with severely elevated triglyceride levels, individualization and trial and error are required, Kirkpatrick said. The first goal should be to resolve chylomicronemia, which is typically present in these patients, with a very low-fat diet, ideally hypocaloric, for 1 to 4 weeks. Then, consider genetic testing for familial chylomicronemia syndrome. Those who test positive will likely need to follow a lower-fat diet for life; however, the optimal long-term diet will vary. More detailed guidance on dietary patterns for these patients is available in the NLA’s clinical perspective.
“For severely elevated triglycerides, emphasize an individualized approach, tailoring the intervention that will be the best fit for your patient not only to achieve triglyceride lowering, but also [a plan] they can adhere to,” Kirkpatrick said. “We all know that a person who cannot adhere to a lifestyle change will not be successful.”
Interventions for combined dyslipidemia
There are now several strategies available for patients with elevated LDL and triglycerides, Kirkpatrick said, noting a shared decision-making conversation will help identify which strategy to employ.
Dietary factors that lower atherogenic particles include unsaturated fatty acids, proteins (especially plant proteins), viscous dietary fibers and plant sterols/stanols.
Any recommended dietary pattern should also be employed within the context of an overall healthy lifestyle that includes adequate physical activity, avoidance of tobacco products, adequate sleep quantity and quality and psychosocial stress management, Kirkpatrick said.
Regardless of the pattern chosen, a multidisciplinary approach is recommended to facilitate patient success in making and sustaining any dietary changes, Kirkpatrick said. If feasible, the assistance of a registered dietitian is highly recommended, she said.
Reference:
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Kirkpatrick CF, et al. Late Breakers. Presented at: National Lipid Association Scientific Sessions; June 1-4, 2023; Atlanta (hybrid meeting).
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