Serum cholesterol and LDL-C are causally related to the development and progression of coronary heart disease (CHD), and alteration of lipoprotein levels can modify the clinical course of CHD. The evidence comes from epidemiologic investigations; (3-6) animal studies; (3, 7-9) studies of pts post-coronary artery bypass surgery; (10) and from a series of intervention studies in pts who are either at increased risk for or have had a coronary event, showing a diminution in myocardial infarction, CHD death, repeat hospitalization, and need for bypass surgery or coronary angioplasty with cholesterol reduction. (11-13) Studies have shown both slowing of progression and actual regression of CHD with both drug and diet therapy.(14-19) A recent review by Gaziano and colleagues of the benefits and risks of cholesterol lowering concluded that “nonpharmacologic interventions for about 30% of U.S. adults . . . seem both justified and warranted.” 20).

Based on the accumulated evidence, the National Cholesterol Education Program (NCEP) promulgated guidelines for lipid screening and treatment. (21) Initial lipid classification should be by total blood cholesterol and high-density cholesterol (HDL-C) measurement in all adults over 20 years of age. Levels of total cholesterol >240 mg/dl and above are classified as “high blood cholesterol”. The level of 240 mg/dl is approximately the 75th percentile value for the total adult U.S. population. A low level of HDL-C is recognized as an important risk factor. Further classification is based on lipoprotein analysis, with further therapy then based on LDL-cholesterol levels. Dietary therapy is the cornerstone of intervention. A series of guidelines guide the clinician to further dietary intervention, retesting, and pharmacologic therapy if needed (appendix E).

The Healthy People 2000 guidelines discuss the relationship between nutrition and disease, and list “marked improvement in accessibility of nutrition information and education for the general public” as one of the “cornerstones” needed for the achievement of the year 2000 objectives. (22) They also note that “To increase the likelihood of behavior change, nutritional education programs should incorporate the principles and techniques of behavior modification”.

Helping individuals to lower dietary fat intake is one of the greatest challenges facing medical and public healthcare providers today. This, coupled with the fact that 80% of all adults in the United States have at least one contact per year with a physician, (23) leads us to conclude that the physician and the medical system have great potential importance in education and counseling for elevated lipids. Four basic attributes of primary care: 1) first contact and easy access; 2) continuity; 3) comprehensiveness; and 4) integration and coordination; make the primary care setting the ideal location for screening and brief intervention. (24, 25)

Since the initiation of the NCEP in 1986 there has been a progressive increase both in physician interest in the therapy of hyperlipidemia and in adherence to the NCEP practice guidelines. Thus the physician-described median ranges of serum cholesterol for initiating dietary treatment fell from 240 to 259 mg/dl in 1986 to 200 to 219 mg/dl in 1990. (26, 27) In both years, however, only half of the physicians described themselves as “prepared” to provide diet counseling, and only 15% in both years thought of themselves as “successful” in helping pts achieve such dietary changes. In the 1986 survey, three-fourths of physicians noted the time required for counseling and two-thirds noted lack of staff with nutrition training as impediments to successful diet therapy in their practices. (26) By 1990 over 90% of physicians reported awareness and use of the NCEP guidelines. (27) Despite this, studies in which the primary intervention was the provision of information, even when accompanied by a program of physician reminders and prompts, have not demonstrated efficacy. (28, 29)