Management of Hypercholesterolemia

The American public currently consumes about 40% of total calories as fat. The goal of the Step I and Step II NCEP diet is to reduce total fat consumption to less than 30% of the total calories consumed. The goal of the Step I diet is to reduce total cholesterol to less than 300 mg/day, but in the Step II diet to less than 200 mg/day.

Weight loss, exercise and smoking cessation are critical elements as well. Overall reduction in fat intake will facilitate weight loss since fat is calorically dense (over twice as many calories per gram as protein or carbohydrates). Exercise, besides promoting weight loss, has been shown to independently increase longevity. Smoking has been shown to lower HDL levels and to raise homocysteine levels.

	In patients without two or more risk factors drug therapy should be considered if the LDL remains above 190 mg/dl and dietary therapy for at least six months duration has failed.
	In patients without evidence of atherosclerotic disease and with two or more risk factors drug therapy should be considered if the LDL cholesterol remains greater than 160 mg/dl .
	Patients with atherosclerotic disease should be considered candidates for drug therapy if LDL is greater than 100 mg/dl.

HMG CoA Reductase inhibitors and bile acid sequestrants are good combination therapy in patients with resistant hypercholesterolemia. By having different mechanisms of action these compounds work synergistically and are the preferred agents for combination therapy. Alternatively, niacin alone or in combination with a bile acid sequestrant or HMG CoA Reductase inhibitor can be used. It remains controversial whether slow release niacin is more hepatotoxic than regular crystalline niacin. Remember, when using either reductase inhibitors or niacin, liver function tests must be checked initially for the first several months and then again with any increase in dose.

More recently, attention on more natural methods of cholesterol lowering are coming into vogue. Dietary soluble fiber enhancement, with commercial dietary supplementation is proving to be a very effective all natural approach to cholesterol lowering. In a recent trial examining the effects of dietary soluble fiber supplementation, total serum cholesterol and LDL cholesterol fell on average by (-14.9%) and (-17.9%) respectively, while HDL cholesterol increased (+30.1%). Serum triglycerides decreased (-30.7%) and the cardiovascular risk ratio (LDL/HDL) fell by (-36%). Total cholesterol reduction was seen as low as (-45%) with LDL decreasing as low as (-59%) and HDL increasing as high as (+48%). Soluble fiber supplementation is a safe, effective, all natural approach to cholesterol lowering and can be used as first line therapy or in conjunction with Reductase inhibitors replacing the bile acid sequestrants.