Today, we're picking up from the last video where we cover the first section of the new 2026 guidelines focusing on screening and diagnosis. In this video, we're moving to treatment. Now, when people talk about the new guidelines, a lot of people want to jump straight into the lipid-lowering therapies, right? Statins, zetamine, injectables, all those fun things. And look, I get it, right? We all know the brutal constraints of clinical practice. It's incredibly tempting to write the prescription, gloss over the rest, and move on to the next room. But I'm here to tell you that lifestyle interventions are not just a preamble to a statin. In and of themselves, they are a drug level intervention. There's data showing that with aggressive lifestyle intervention, specifically talking about the AHA's Essential 8, people who are at high risk can potentially decrease their relative risk of a cardiovascular event by about 50%. And so, just so we're all on the same page here, the Essential Eight is the American Heart Association's master checklist for overall cardiovascular health. It tracks four daily behaviors, your diet. Physical activity, sleep quality, and nicotine exposure, along with four clinical numbers: your weight, cholesterol, blood sugar, and blood pressure. It sounds basic, but optimizing these targets is the absolute foundation for any. ASCBD risk reduction. It should always accompany medical therapy to obtain the best outcomes, right? So, this is kind of the baseline. I say this all the time when I'm talking to patients that for treatment, to think of a big pyramid, right? What's the base of that pyramid? That is lifestyle, always lifestyle. Then we move up to the next section. What we need to do, and then above that, you know, the more aggressive we go, the smaller it gets on the pyramid. But the base of that pyramid should always, always be lifestyle. And the guidelines have an entire section detailed all about that. And it goes far beyond the vague, just eat better and move, right? Which is not helpful. So, let's go through this section on lifestyle interventions and how we go from here. So first, for a quick review, our strategy must shift towards primordial prevention, preventing the onset of risk factors rather than just managing them once they appear. And this is reflected with the new recommendations of screening 9 to 11 year olds, right? So the 2026 guidelines emphasize that the damage from cholesterol is a lifelong damage, right? It's cumulative. It isn't just about today's LDL level, it's about the area under the curve over a lifetime. And as I mentioned previously, we actually have autopsy data of young trauma victims showing that coronary atherosclerosis can start in childhood. And so we want to get on top of this early. And on top of that, we know lifelong exposure leads to much higher risk, right? So, why does this matter? Well, because we kind of have some discordance here. In like three to five-year randomized controlled trials, we see a certain amount of risk reduction based on LDL, right? So, we see a certain amount and say, okay, that's great. But in genetic studies where people have lifelong, low cholesterol levels, the risk reduction is significantly greater than what we'd expect from the short trials, right? So we're saying lifelong exposure starting in childhood. Has a profoundly greater impact on lifetime risk than just trying to play catch up when someone turns 50 years old. So, this is exactly why the guidelines gave a class one recommendation to that screening at 9/11. And we are understanding now that the earlier we can identify risk factors, the better we'll have in terms of long-term outcomes. And moving on to our next section here, let's talk about diet. The 2026 guidelines signal a definitive shift in dietary strategy. We're moving away from cholesterol restriction and cholesterol bad towards, well, saturated fat should probably be replaced. That's kind of the gold standard. And I'll be honest with you, when a patient asks me what diet is the best diet, I just die a little bit inside. Diets tend to be almost tribal or religious in nature on the internet. And there's so much emotion going on there. And yeah, there's a lot going on. So I'm just going to point towards what they say and the outcome they talk about the data. And not get too far in it. So, overall, the recommendation is a nutrient-dense plant-based pattern, meaning fruits, vegetables, nuts, and fiber, while systematically replacing saturated fat and trans fats with monounsaturated or polyunsaturated fats. So, two specific diets they mentioned quite a bit are the meta-training diet and the DASH diet. And they also did mention another diet called the portfolio diet, which also adds additional things like soy protein, fiber, and plant sterilize. But if we look at the actual numbers, the effects of diet alone on lowering LDL are kind of modest. So, the best diet that they mentioned was this portfolio diet. Decreased LDL by an average of 26 milligrams per deciliter. A vegan diet decreased it by around 14. And in one study they referenced, a Mediterranean diet didn't actually reduce it at all. And so this is kind of Surprising to a lot of people. They say, oh my goodness, what's the guess? Well, everyone's going to be different, right? So there's lots of variables when it comes to a diet. But this is a framework I like giving people who are minimalists versus optimizers. So for the minimalists, If we focus entirely on replacing things, that's solid. The data shows that simply replacing saturated fat with unsaturated fat will help lower LDL more effectively than adapting a massive complex dietary dentin, right? Changing everything that may be helpful, but for someone who doesn't want to do that, replacing it should be fine. But if you are an optimizer, there are things you can do. You can Implement one of these specific diets they talk about, whether it's portfolio, Mediterranean, or fiber-heavy plant-based diet, that will get you the most amounts of point drops, is what we're looking for. And you might scoff at a 14 to 26 point drop. You say, that's nothing. But remember, if you make small, high yield changes in multiple different areas, so not just diet, that's when you really start to see the massive compounding effects. And so, diet, yes. A common theme here through all this is that there's not enormous changes with lifestyle for one specific thing, but adding them together is really going to be the benefit. Next, the guidelines discuss how to manage elevated triglyceride. Unlike LDL, which is sensitive to saturated fat, triglyceride levels are highly sensitive to processed carbohydrates, added sugars, and alcohol. And the intensity of your intervention depends entirely on the severity. So, here is a table directly from the guidelines, and it shows how we titrate sugar, total fat, and alcohol based on the numbers. And so, let's be clear here: they say, hey, The level of being unhealthy is greater than 150. So, 150 is where we start. So, this first section, triglycerides between 150 and 499. The goal is long-term cardiovascular risk reduction. So, sugar should be less than 6% of total calories. Total fat 30 to 35 percent and avoiding alcohol, ideally. Then we start getting up to trichlysterides between 500 and 999. Now we're moving from this long-term cardiovascular risk reduction to trying to prevent pancreatitis because nobody wants to have that. Sugar will drop to less than 5%, total fat between 20 and 25%, and completely abstaining from alcohol. And then, if treadless rads are over 1,000, it's all hands on deck, right? Eliminate added sugar completely, aggressively drop total fat to 10 to 15%, and absolutely zero alcohol. That's their general recommendations. And one thing I did find that was incredibly helpful is the guidelines note that if fasting triglycerides are above 150, that is a concerning feature for CKM syndrome, which remember is cardiovascular kidney metabolic syndrome. What they're saying is that elevated triglycerides aren't just an isolated number. They're actually a glaring signal potential instant resistance. So, you know, if you see 150 and above, don't brush it off. That could be a marker of something more going on. Let's move on to weight loss. The guidelines coin a term here called adiposopathy, which is a hard thing to say, but it means sick fat. So I don't see it catching on because that's tough to say, but sick fat. And they're making the point that not all adipose tissue is created equal. Accumulating excess dysfunctional adipose tissue drives a pro-inflammatory state, leading to the characteristic lipid profile we've already talked about: high triglycerides, low HGL, and the abundance of small, dense LDL particles. And weight loss is a massive lever we can pull. For every single kilogram a patient loses, we expect triglycerides to decrease by about four points. Unfortunately, we don't see the same drop with LDL, but We'll see anywhere from 0. 3 to 1. 7 points per kilogram lost. So, if you have a patient who loses 20 kilograms, that's a potential 25-point reduction in their LDL and an 80-point drop in their triglycerides. And on top of that, we can't talk about weight loss without talking about GLP-1 medications, right? These medications seem to lower triglycerides and LDL levels more than previous pharmacotherapy when it came to weight loss meds. And the jury is still out exactly as to why this happens, but the lipid lowering seems to generally be proportional to the weight that is lost. So it's not necessarily magic, you know, independent from the weight loss, but the outcomes are what matters, and the outcomes are really good right now. Next up, physical activity. The guidelines literally state that physical activity should be assessed as a fifth vital sign. That's how important it is. Its effect on LDL might be modest, but its impact on HGL and triglycerides is incredibly consistent. But, like most things in medicine, it's not very helpful just to tell a patient, move more, right? You have to prescribe a specific dose. You literally need to say to them, I want you to go on a brisk walk for 10 minutes. Three times per week. Then, at a follow-up, you celebrate that win and bump it up to 20 minutes, or slowly working them up to you know, four days a week, five days a week, until you get to that 150 minutes of moderate activity plus two days of muscle strength and exercise. That's very important. And even if the lipid lowering from exercise is modest, say lowering LDL by seven and triglycerides by eight, it's still the best medicine we could ever prescribe. We get improvements in blood pressure, insulin sensitivity, weight maintenance, and mood. We have to be doing it more. I say this time and time again. If we could put. Exercise into a pill, it would be the most prescribed medication ever because it has so many profound effects everywhere throughout the body. Moving on, the guidelines take a hard look at dietary supplements as well. So, this is super common. Patients constantly come into clinic looking for natural alternatives to traditional medications, right? So, one analysis they looked at found that 73% of participants with cardiovascular disease were taking at least one supplement. And when a patient brings this up, I always start by validating them, right? They're just trying to take ownership of their health. And that is a great thing. But my job is to be a guide and protect them from a bad internet device. The guidelines here take a very strong stance, maybe stronger than I would, but they are giving dietary supplements a class three grading, meaning there is no proven benefit. They explicitly do not recommend taking anything for lowering LDL or triglycerides. Their main reasons they referenced the sport trial, which compared to a low-dose statin, they gave five milligrams of resuvastatin. They compared it to six common supplements, including garlic, cinnamon, turmeric fish oil, red yeast, rice, and plant sterols. And overall, the statin unsurprisingly lowered LDL by thirty eight percent. But the dietary supplements, they didn't demonstrate a significant decrease in LDL compared to the placebo. And remember, the FDA does not approve supplements for efficacy before hitting the market. So that's a thing in America where you can just put a supplement out there and you don't have to test it for necessary safety or efficacy. And there's a lot of data out there saying that the stuff that's on the shelves Isn't what's on the label. So, they've done a ton of studies looking at supplements, and what they list on the label is very different from the actual components that are in the supplement. Something we have to consider. But if your patients are going to continue to take supplements, regardless of what you say, and many will, and that's okay, the best thing you can do though is to make sure they're well-informed. So don't fight them, but strongly recommend them they use products that are verified by a third-party testing company. That's really, really important. Because as I mentioned, studies routinely show that many supplements don't even contain what is printed on the label. We don't know anything in terms of the concentration, the strength, the dose. Are there any imperfections? Are there any contaminants? Who knows? But hey, if we're going to do this, third-party testing should hopefully catch some of that. Finally, the guidelines discuss when to refer to a registered dietitian. Medical nutrition therapy is a highly specialized intervention. The guidelines give a Class I recommendation to refer patients to an RD if their triglycerides are over 1,000 to prevent pancreatitis. They also give a class to a recommendation to refer patients with triglycerides over 150 who also show signs of metabolic syndrome. So, obviously, in clinic, we don't necessarily have 40 minutes in the exam room to do a deep dive on nutrition. So, use your team. Studies have shown that Registered dietitian intervention can drop cholesterol by 20 points and triglycerides by over 32 points. And so, what's the ultimate takeaway? Well, lifestyle is a treatment. It should be the cornerstone of every single lipid-lowering and cardiovascular disease prevention program out there. Let's take a look at the whole picture for a second if you do the math. So, let's say we have a patient who goes all-in, right? They're an optimizer, they adopt an intense new diet and they lose 20 kilograms and consistently hit their exercise goal. What would that actually look like? Well, you could see a 26-point drop in LDL from the diet. A 25-point drop from the weight loss, another seven points from exercise. That means an aggressive, comprehensive lifestyle intervention could realistically lower LDL by almost 60 milligrams per deciliter and totally plummet their triglycerides over 100 points. That is literally the equivalent of putting someone on a moderate intensity statin. Results will absolutely vary from person to person, but this is why we do not gloss over the section and it builds a foundation for lifelong health. My goal is that hopefully you can do all these things and never have to get to pharmacotherapy, which we'll cover in the next section. But A lot of people gloss this over, and I just want to say it's very important. And as we're winding down here, I do have to mention that this wasn't exhaustive in terms of they didn't cover every single lifetime intervention. There's so many out there. The Essential 8 has a lot of them as well. They talk about sleep and nicotine exposure as well. They didn't go into those sections, but we know that managing all those things will help us as well. That number that I gave you might actually be artificially low. There's a real chance that we could do even more with lifestyle than what was mentioned here. And so I just need to mention that But this does include the section of the lifestyle recommendations. If you found this helpful, it means the world to me. If you share this with a colleague or friend, but that's going to be it for today. Now, get off your phone and get outside. Have a great rest of your day. We'll see you next time.
