NLA Recommendations & Statements

The following is a National Lipid Association (NLA) Expert Clinical Consensus on the role of apolipoprotein (apo)B in adult patient care. This document is meant to clarify the role of apoB testing for clinicians who manage cardiovascular risk and lipid disorders, as well as health systems, payers, and medical associations. The 2021 NLA Scientific Statement, Lipid Measurements in the Management of section.

The lipoprotein(a) [Lp(a)] field is rapidly evolving on many fronts, including understanding of the association between Lp(a) levels and cardiovascular disease (CVD) risk in different contexts, and how best to manage other CVD risk factors in patients with elevated Lp(a). Considering new insights into the clinical management of these patients, and in the absence of FDA-approved therapies to specifically lower Lp(a) levels, the question of in whom Lp(a) should be measured has become an increasingly important issue in clinical practice.

Lifestyle habits can have a profound impact on atherosclerotic cardiovascular disease (ASCVD) risk. The National Lipid Association previously published recommendations for lifestyle therapies to manage dyslipidemia. This Clinical Perspective provides an update with a focus on nutrition interventions for the three most common dyslipidemias in adults: 1) low-density lipoprotein cholesterol (LDL-C) elevation; 2) triglyceride (TG) elevation, including severe hypertriglyceridemia with chylomicronemia; and 3) combined dyslipidemia, with elevations in both LDL-C and TG levels. Lowering LDL-C and non-high-density lipoprotein cholesterol are the primary objectives for reducing ASCVD risk. With severe TG elevation (≥500 mg/dL), the primary objective is to prevent pancreatitis and ASCVD risk reduction is secondary. Nutrition interventions that lower LDL-C levels include reducing cholesterol-raising fatty acids and dietary cholesterol, as well as increasing intakes of unsaturated fatty acids, plant proteins, viscous fibers, and reducing adiposity for patients with overweight or obesity. Selected dietary supplements may be employed as dietary adjuncts. Nutrition interventions for all patients with elevated TG levels include restricting intakes of alcohol, added sugars, and refined starches. Additional lifestyle factors that reduce TG levels are participating in daily physical activity and reducing adiposity in patients with overweight or obesity. For patients with severe hypertriglyceridemia, an individualized approach is essential. Nutrition interventions for addressing concurrent elevations in LDL-C and TG include a combination of the strategies described for lowering LDL-C and TG. A multidisciplinary approach is recommended to facilitate success in making and sustaining dietary changes and the assistance of a registered dietitian nutritionist is highly recommended.

Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.

Statin-associated muscle symptoms (SAMS) are the most common form of statin intolerance and are associated with increased risk of cardiovascular events that manifest from statin underutilization and discontinuation. 

Dyslipidemia, or high cholesterol, means you have too many lipids (fat) in your blood. Nutrition interventions in youth with dyslipidemia provide short- and long-term benefits without adverse effects on growth or maturation. Counseling by a registered dietitian nutritionist (RDN) is strongly recommended to help youth and their families successfully alter dietary intake to meet nutritional needs, provide ongoing support, and encourage long-term adherence to healthy nutrition and exercise patterns.

The statement provides updates on the evidence-based facts about statins and statin intolerance and makes practical recommendations to aid clinicians in determining a therapeutic objective in contemporary clinical practice. Statin intolerance is defined as one or more adverse effects associated with statin therapy which resolve or improve with dose reduction or discontinuation and can be classified as a complete inability to tolerate any dose of a statin, or partial intolerance with inability to tolerate the dose necessary to achieve the patient-specific therapeutic objective.

The NLA has released an official scientific statement on the use of genetic testing in the diagnosis and management of patients with dyslipidemia. The statement provides insights and guidance for health care providers seeking to further their understanding of the benefits, risks and patient preferences of genetic testing. 

The NLA has released a Clinical Perspective to provide strategies for early screening and education of the community and their healthcare providers, and offer practical prevention strategies and culturally-tailored dietary advice to lower the rates of ASCVD in this cohort.