Statins, healthy diet and cholesterol. January 2014

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1 Position Statement Statins, healthy diet and cholesterol January 2014 Recent media coverage claiming that high cholesterol does not cause heart disease, and also questioning the benefits of using statins to treat heart disease, has caused much uncertainty about the use of statin medication and the importance of healthy eating. Australian Diabetes Council (ADC) recognises the importance that cholesterol levels play in the health of people with diabetes. ADC supports the use of statin therapy and/or the adoption of a healthy lifestyle, as prescribed by your health professional, in the effort to reduce diabetes complications, the risk of heart disease and heart attacks. Recommendations: Australian Diabetes Council urges people with diabetes not to stop cholesterol-lowering medication without first discussing it with your doctor Discuss the need for statin therapy with your doctor or cardiologist. It is important that your doctor explains the benefits and possible side effects of medication therapy to enable you to make a fully informed decision The use of statin medication does not substitute for a healthy lifestyle such as being active, eating healthily, not smoking and maintaining a healthy weight It is imperative for people living with or at risk of diabetes to reduce their intake of total fats, especially saturated fats. This can help improve diabetes management or even help prevent the disease in people who have not yet been diagnosed, as well as reduce the risk of cardiovascular disease All people living with or at risk of diabetes should: o o choose a daily diet based on fresh foods which are lower in fat, especially saturated fat, low in sodium (salt) and high in fibre see an Accredited Practising Dietitian (APD) at least once a year for individualised dietary advice

2 Diabetes, Statins and Cholesterol Statins work to reduce the production of cholesterol in the liver. This lowers the levels of Low-Density Lipoprotein (LDL, or bad ) cholesterol in the blood. LDL cholesterol is a primary cause of atherosclerosis (thickening of artery walls which obstructs blood flow), resulting from a build-up of material such as fats and cholesterol. LDL cholesterol is considered as important a risk factor as hypertension, diabetes, smoking, lack of physical activity and obesity for cardiovascular disease. Research shows that every 1mmol/L reduction in LDL cholesterol results in a 22% reduction in major cardiovascular events over a five-year period 1. Some statins are derived from fungi, while others are produced in the laboratory. There is no evidence to suggest one source is superior to the other 2. Common brand names of statins available in Australia 3 include Torvast, Lipitor Lescol, Lescol XL, Altocor, Mevacor Pitava, Livalo, Selektine, Pravachol, Crestor LIPEX and Zocor. Some people are not able to take statins due to the side effects these medications can cause, the most common being muscular inflammation and damage. This can lead to symptoms such as cramps, aches and pains, weakness, fatigue and stiffness. In most cases people can resume statin treatment after a brief drug holiday. It is important to discuss side effects with your doctor. Australian Diabetes Council urges people with diabetes NOT to stop cholesterollowering medication without first discussing it with their doctor. The vast majority of medical research over the last 20 years has shown that statins can reduce the risk of experiencing a heart attack, particularly for those people who have existing heart disease or those who are at high risk 4. Drug therapy is indicated for people who have more than a 15% chance of cardiovascular disease within the next five years 5. Risk is calculated by assessing the following factors: age, gender, blood pressure, the presence of diabetes, whether you smoke, and your blood cholesterol levels (including HDL cholesterol and total cholesterol). In Australia the absolute cardiovascular disease risk calculator is used to assess your risk (see for details). 1 Cholesterol treatment trialists collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. The Lancet, Volume 380, Issue 9841, Pages , 11 August National Prescribing Service A-Z guide on medication available at ibid Page 2 of 6

3 The Australian absolute cardiovascular disease risk calculator indicates diabetes and age equal to or over 60 years as an increased absolute risk of cardiovascular disease. In November 2013 new guidelines on managing blood cholesterol were released by the American College of Cardiology (ACC) and the American Heart Association (AHA), developed in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) 6. These guidelines moved away from hard treatment targets and instead focused on identifying the appropriate level of treatment for a particular patient, in order to reduce his or her risk. The guidelines identified a number of groups of people who should be treated with statins. (This was on the basis of randomised, controlled clinical trials showing that the benefit of treatment outweighed the risk of adverse events.) These guidelines said that for people with diabetes who are between 40 to 75 years of age, a moderate-intensity statin, (defined as a drug that lowers LDL cholesterol by 30% to 49%) should be used. The guidelines also said a high-intensity statin is a reasonable choice if the patient has a 10-year risk of atherosclerotic cardiovascular disease exceeding 7.5%. National guidelines emphasise that the use of statin medication does NOT substitute for a healthy lifestyle such as being active, eating healthily, not smoking and maintaining a healthy weight. In summary, both the Australian and American guidelines identify diabetes as a risk factor for cardiovascular disease. However other risk factors need to be considered in determining your absolute risk. It is therefore crucial to discuss your situation and the need for statin therapy with your doctor or cardiologist. Australian Diabetes Council recommends discussing the need for statin therapy with your doctor or cardiologist. It is important that your doctor explains the benefits and possible side effects of medication therapy, to enable you to make a fully informed decision. For further information Australian Doctor has produced a patient handout question and answer sheet. The patient facts sheets are available at: 6 Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. The Lancet, Volume 382, Issue 9907, Pages , 30 November 2013 Page 3 of 6

4 Diabetes, healthy eating and cholesterol There has been recent public debate about the role of saturated fats in Australian diets and whether they have a positive or negative impact on cardiovascular health. Cardiovascular disease (CVD) refers to conditions and diseases affecting the heart and blood vessels and is the leading cause of death in Australia 7. If you have diabetes, your risk of developing CVD is even greater 8 9. ADC provides general nutrition and dietary recommendations to promote the prevention and management of diabetes (including type 1, type 2 and gestational diabetes) and reduce the risk of diabetes complications such as CVD. All recommendations are based on reliable scientific evidence and are generalised for the wider population for people living with or at risk of diabetes. However, no standard meal plan works universally for all people with diabetes, therefore it is recommended that you seek individualised advice 10. Australian Diabetes Council recommends all people living with or at risk of diabetes to: choose a daily diet based on fresh foods that are low in fat, especially saturated fat, low in sodium (salt) and high in fibre see an Accredited Practising Dietitian (APD) at least once a year for individualised dietary advice. ADC recommends that you choose foods low in total fats, based on the fact that fat is an energy-dense nutrient containing double the energy content of either carbohydrate or protein. Your daily energy requirement is based on a number of factors including (but not limited to) height, body weight and physical activity level. A diet high in excess kilojoules increases your risk of weight gain, which can lead to you becoming overweight or obese. There is substantial evidence demonstrating an association between being overweight or obese with an increased risk of chronic disease, including CVD and type 2 diabetes 11. However, fat is an essential part of a healthy diet and should not be entirely cut out of your meal plan. It is important for you to not only consider the quantity but also the type of fat you consume. 7 Australian Institute of Health and Welfare (AIHW) (2012). Australia s Health American Heart Association (2012). Cardiovascular disease and diabetes. Diabetes_UCM_313865_Article.jsp# 9 Diabetes UK (2009). Cardiovascular disease and diabetes American Diabetes Association (2013). Position statement: Nutrition therapy recommendations for the management of adults with diabetes National Health and Medical Research Council (2013). Australian Dietary Guidelines. Page 4 of 6

5 ADC recommends that you limit your intake of saturated fats and replace them with unsaturated fats. Saturated fat is most commonly found in foods such as fatty meats, full-fat dairy products, butter, ghee, palm oil, coconut products and some fried takeaway foods. This position is supported by organisations such as the World Health Organisation 12, the American Diabetes Association 13, the National Heart Foundation of Australia 14 and the British Heart Foundation 15. The link between most saturated fats, increased blood cholesterol and CVD is well established 16. Diets high in saturated fats result in an increase in total blood cholesterol and LDL cholesterol 17, both increasing your risk of developing CVD 18. Importantly for people with diabetes, saturated fat also has a negative impact on insulin sensitivity. Studies have shown that saturated fat increases insulin resistance, making diabetes harder to manage 19. However unsaturated fats reduce insulin resistance through modifications to the composition of body cell membranes 20. It is imperative for people living with or at risk of diabetes to reduce their intake of total fats, especially saturated fats. This can help improve diabetes management or even help prevent the disease in people who have not yet been diagnosed, as well as reduce the risk of CVD. Other factors for consideration Other factors can also affect your blood cholesterol level. Physical activity is one thing which helps prevent and manage chronic disease. Being physically active has been proven to have a protective effect on the heart, with many cardiovascular benefits associated with exercise. For example, exercise helps to increase high-density lipoprotein (HDL) cholesterol and lower both LDL cholesterol and triglycerides. Higher levels of HDLs have a protective effect 12 World Health Organisation (2010). Fats and fatty acids in Human Nutrition 13 American Diabetes Association (2013). Position statement: Nutrition therapy recommendations for the management of adults with diabetes National Heart Foundation of Australia (2008). Position statement: Dietary fats and dietary sterols for cardiovascular health British Heart Foundation. Healthy eating National Health and Medical Research Council (2013). Australian Dietary Guidelines National Heart Foundation of Australia (2008). Position statement: Dietary fats and dietary sterols for cardiovascular health Australian Institute of Health and Welfare (AIHW) (2012). Australia s Health Riccardi G et al (2004). Clinical Nutr Aug; 23 (4): Dietary fat, insulin sensitivity and the metabolic syndrome 20 ibid Page 5 of 6

6 against heart disease by helping to reduce plaque, whereas LDL cholesterol contributes to atherosclerosis ADC physical activity guidelines recommend: at least 30 minutes of moderate intensity aerobic activity every day eg. swimming, walking, running, cycling resistance training (ie. moving your muscles against a load such as dumbbells, your own body weight or resistance bands) 2-3 days a week (on non-consecutive days) and balance exercises increase levels of incidental activity by thinking of exercise as an opportunity rather than an inconvenience, and move more every day Familial Hypercholesterolemia is a hereditary condition in which a person is genetically predisposed to have increased levels of LDL cholesterol 23. Dietary and lifestyle behaviours can help manage this condition, but in some cases medication may be required. People with this condition should seek medical guidance. ADC encourages those who are overweight, living with diabetes, or concerned about their diet and health to speak with their health care team members, such as an Accredited Practising Dietitian (APD) or General Practitioner (GP). For further information refer to our fact sheet Diabetes, Lipids and Heart Disease or call us on to speak with a health professional. 21 Australian Institute of Health and Welfare (2010). Australia Health Australia s health series no. 12. Cat. No. AUS 122. Canberra; AIHW 22 Australian Institute of Health and Welfare (AIHW)(2004). Heart, Stroke and Vascular Disease- Australian Facts, Cat. No. CVD 27. Canberra: AIHW and National Heart Foundation of Australia (Cardiovascular Disease Series no. 22) 23 A.D.A.M. Medical Encyclopedia (2012). Familial Hypercholesterolemia. Page 6 of 6

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