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National Cholesterol Education Program
Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction

I. Overview and Summary

Coronary heart disease (CHD) is a major public health problem in the United States. Despite substantial success in reducing premature deaths from CHD in the past two decades, this disease continues to kill more than 500,000 Americans annually. About 1,250,000 Americans suffer myocardial infarctions each year, and millions more have angina pectoris. In addition, significant degrees of asymptomatic CHD are very common in our population. In addition to its impact on the Nation's health, CHD costs the U.S. economy over $50 billion annually.

Coronary heart disease is the result of atherosclerosis, in which deposits of cholesterol and other lipids, along with cellular reactions, thicken artery walls. This process gradually reduces the caliber of the artery and restricts blood flow. Inadequate blood flow may cause injury to or death of tissue beyond the site of reduced flow; in the coronary arteries, this leads to myocardial infarction or sudden death,

Many factors influence not only whether a person will develop CHD but also how rapidly atherosclerosis progresses. Genetic predisposition, gender, and advancing age are recognized factors over which we have little control. High blood cholesterol, cigarette smoking, high blood pressure, excessive body weight, and long-term physical inactivity are also key risk factors over which we have considerable control. Control of each of these factors is important in the prevention of CHD. People with diabetes may also be able to avoid or delay vascular disease by controlling the other risk factors.

High blood cholesterol levels clearly play a causal role in CHD. This conclusion is based on experimental laboratory work, extensive clinical and pathological research, and numerous epidemiologic studies over the past several decades. The magnitude of the problem posed by elevated blood cholesterol levels is very clear. High CHD rates occur among people with high blood cholesterol levels of 240 mg/dL (6.21 mmol/L) or above. However, an even larger number of cases occurs in Americans with blood cholesterol levels below 240 mg/dL. It is important to note that the average cholesterol level for the adult U.S. population is about 210 mg/dL. Furthermore, approximately 55 percent of adult Americans have cholesterol levels at or above 200 mg/dL.

For these reasons, two kinds of strategies are needed: patient-based strategies, which seek to help those with the highest blood cholesterol levels, and population-based strategies, which seek to reach all Americans. The population approach aims both to lower the blood cholesterol level of individuals and to reduce the average cholesterol level throughout the population. When both approaches are used, the effects are synergistic.

Two important types of research provide ground for optimism that CHD morbidity can be reduced, and that the trend of reduced CHD death rates will continue or accelerate. First, studies consistently indicate that reducing blood cholesterol can reduce the likelihood of developing or dying from CHD. Dietary factors in individuals and in entire populations have important effects on blood cholesterol levels (although genetic makeup, expressed, in part, as a low level of HDL cholesterol or as a high level of LDL-cholesterol, also plays a major role). Second, this report clearly indicates that many effective strategies exist for helping Americans develop more healthful eating patterns and lifestyles.

The Population Panel of the National Cholesterol Education Program offers a set of recommendations designed to help healthy Americans lower their blood cholesterol levels through changes in eating patterns and thus reduce their likelihood of developing CHD. Recognizing that Americans' food consumption is influenced by many factors, the panel directs its recommendations to individuals, to special population groups, to health professionals, to the many components of the food industry, to relevant government agencies, and to public and private education systems. In addition, the panel's recommendations address cholesterol screening, and the need for continued research and evaluation as eating patterns change, blood cholesterol levels decrease, and CHD continues to decline.

The panel recommends the following nutrient intakes for healthy Americans:

  • Less than 10 percent of total calories from saturated fatty acids.
  • An average of 30 percent of total calories or less from all fat.
  • Dietary energy levels needed to reach or maintain a desirable body weight.
  • Less than 300 mg of cholesterol per day.

    Each is intended to be achieved by an individual as an average of nutrient intake over several days.

    These recommendations concerning nutrient intakes are appropriate for the general population, including healthy women and individuals 65 years of age and older.

    As healthy children join in the eating patterns of others in the family, usually at about 2 years of age or older, they should follow the recommended nutrient intake and eating patterns.

    To achieve more healthful eating patterns, the panel recommends that healthy Americans select, prepare, and consume foods that contain lower amounts of saturated fatty acids, total fat, and cholesterol; choose a variety of foods to ensure recommended intakes of carbohydrates, protein, and other nutrients; and consume only enough calories to maintain desirable weight.

    The panel also makes recommendations for other groups:

    Health professionals should both practice and advocate the recommended eating patterns; ensure that education of future health professionals includes appropriate nutrition education; and work with industry, government, voluntary groups, and health care agencies to facilitate adoption of the recommended eating patterns.

    The food industry, food and animal scientists, and food technologists should increase efforts to design, modify, prepare, promote, label, and distribute good-tasting, safe foods that are lower in saturated fatty acids, total fat, and cholesterol.

    Government agencies should provide consistent, coordinated nutrition statements and policies emphasizing low saturated fatty acid, low-fat, and low-cholesterol eating patterns; should expand and standardize food labeling requirements to identify clearly the content of saturated fatty acids, total fat, cholesterol, and total calories; and should take other steps to improve the consumer comprehension necessary to achieve the recommended eating patterns.

    Educational programs at all levels should incorporate curricula that emphasize the background, benefits, and methods of achieving eating patterns that are lower in saturated fatty acids, total fat, and cholesterol. This recommendation includes elementary through high schools, vocational programs (especially in culinary arts), colleges, universities, and health professional schools.

    Measurement of blood cholesterol, followed by appropriate education and counseling, is best initiated in the health care setting; but in specific circumstances and especially for selected segments of hard-to-reach population groups, public screening for blood cholesterol, when carried out with high quality standards, is appropriate.

    Research and surveillance must be ongoing to develop new information concerning diet, blood lipids, and CHD; the development of better data bases concerning food composition, food consumption patterns, illness rates, food product development, and nutrition education and communication is critical.

    Implementation of these recommendations will promote adoption of eating patterns that will help most Americans lower their levels of blood cholesterol. The result, an approximate reduction of 10 percent or more in the average blood cholesterol level of the U.S. population, will lead to an approximate reduction of 20 percent or more in coronary heart disease and, in consequence, to significant improvement in the health and quality of life of Americans.

    SOURCE: Public Health Service - National Institutes of Health - National Heart, Lung, and Blood Institute National Cholesterol Education Program NIH Publication No. 93-3047 Reprinted March, 1993

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