Cholesterol - a problem solved?
HEART UK 31st Annual Medical and Scientific Conference, 5-7th July 2017 : University of Warwick
Jaqui Walker General Practice Nurse and Medical Writer
This year’s conference focused on cholesterol management in the future and reflected the current period of change in health care delivery and expectation.
Professor David Wald explored the benefits of child-parent screening for familial hypercholesterolaemia (FH)
Detection rates are highest if you screen for FH between 1-2 years of age. Screening is effective with (4 children and 4 parents identified for every 1000 children screened). The child benefits twice from having their own FH detected and from preventing the premature death of their parents. This population screening will help achieve the ultimate goal of identifying all or nearly all of those children with FH in the general population and is inexpensive when combined with routine immunisation.
The signs, symptoms and management of inborn errors of lipoprotein metabolism in children was explored by Dr Uma Ramaswami
She explained how some children present over and over again with symptoms before being diagnosed. A lipid profile for children that present with non-specific abdominal pain to paediatric clinics should be considered. Although, with the exception of heterozygous FH, these conditions are mostly rare they can cause significant morbidity and mortality. They require specialist input from paediatric dietitians and clinicians, there are several emerging therapies and early diagnosis is important.
Professor Steve Humphries explored Polygenic familial Hypercholesterolaemia and explained the LDL-SNP score
Overall in FH a monogenic molecular cause is found in only 35-47% of patients. Single nucleotide polymorphisms (SNP) scores, can be used to help stratify the remaining patients. A score using the top 6 SNPs appeared to work best. Once a mutation in LDLR/APOB/PCSK9 is ruled out, the most likely cause of the FH phenotype is a polygenic inheritance and this would be better called polygenic hypercholesteroleamia. Polygenic patients have been shown to have less severe disease and therefore could be more easily managed in general practice.
Practical advice on the use of Proprotein Convertase Subtilisin-kexin Type 9 (PCSK 9) inhibitors was shared by Professor Elizabeth Hughes
NICE have approved the use of these agents for high risk patients including those with familial hypercholesterolemia and with increasing numbers of people now using these drugs for life long therapy shared care pathways with primary care are important.
Dr Tim Chadborn explored the psychology behind decision making processes and explained how these can be used to plan lifestyle interventions
Dr Chadborn showed the audience some examples that had been successful e.g. social contracts signed and witnesses by someone else significantly increased the ability of an intervention group sticking to their planned behavioural goals. PFE are developing and evaluating some apps to help behaviour change and guidance is also available to help commissioners, clinicians and researchers use behavioural insights in the interventions they plan.
Dr Stephen Lawrence
Dr Lawrence discussed the current concerns surrounding type 2 diabetes with its high prevalence and 75% increased risk of dying from CVD Preventing diabetes occurring in the first place is vital and studies show simple life style changes can reduce the incidence of and complications from diabetes. Taking a multifactorial interventional approach to control BP, cholesterol, Hba1c and make lifestyle changes has been shown to translate into a 53% relative risk reduction in CVD and a 60% reduction in microvascular complications.
The Myant Lecture
Professor Tom Sanders gave an excellent historical overview of the research surrounding our understanding of the role diet plays in cholesterol management and emphasized the importance of decreasing the intake of trans and saturated fatty acids and maintaining a healthy weight. While death rates from cardiovascular disease had declined substantially, the prevalence of obesity was increasing and having adverse effects on lipid metabolism. Although, the effects of modification of dietary fat intake on blood cholesterol are modest, much greater effects are seen when the overall diet is changed particularly when a vegan diet is adopted. The Portfolio diet which is a largely vegetarian diet with added plant sterols, nuts, and soya and wholegrains brings about substantial reduction in LDL but for many people it is difficult to follow. Current UK dietary guidelines have been shown to lower LDL cholesterol by 10% and also decrease risk of cardiovascular disease by mechanism such as by lowering blood pressure.
Professor Jane Ogden
Professor Ogden led the audience through the evidence and reasons for food choice being largely a modifiable psychological factor rather than just a biological one. The schema in our heads (which develops from our childhood and culture) as well as environmental triggers act as the key drivers for weight gain and this differs from the current public perception of weight gain being something to do with biological factors such as genetics, metabolism or gut hormones. Current habits of grabbing and eating food on the go encourage a higher overall consumption.
Professor Gary Frost
Professor Frost described the “devastating change” in the UK and other countries with wealth on body weight and how this is a massive public health problem with no current solution. Three generations ago people living in the 1900s when malnutrition was rife benefited from the body’s adaptive mechanisms that today make it hard to lose weight. For example, the brain has an ability to override a sensation of satiety and enable a person to eat pudding after a big meal. In the past this ability to eat food to excess when it was available was important for survival.
Professor Frost’s group are working on developing a functional fibre which can manipulate anorectic peptides in the colon to reduce appetite thus helping people use their natural body systems to manage their appetite. It is hoped that this inulin-propionate ester can be added to food people normally use such as smoothies or bread.
Dr Hilary Jones confronts mixed messages in the media
Dr Hilary Jones explained that whilst the media can create confusion and distress with often conflicting sensational attention grabbing headlines they also present a useful opportunity for trusted clinicians to get involved and ensure balanced accurate messages are put across to large audiences in an authoritative way with confidence, consensus and perspective. Dr Jones recommends being proactive and using current technology to ensure you are up to date with current news stories and the balance of opinion. There are apps that can be used for this and the NHS Choices web site provides an unbiased, evidence-based analysis of news stories.