Assessment of cardiovascular risk in primary careBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3022 (Published 13 June 2016) Cite this as: BMJ 2016;353:i3022
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Excellent use of a relevant case study incorporating use of decision aids in the context of cardiovascular risk assessment and management. I initially opted to read this article based on an interest in the dietary lifestyle advice in cardiovascular risk management. On the basis of what I read here, and the cited articles on the subject, I’m very interested in following how decision aids continue to be refined and how they ultimately directly or indirectly affect patient outcomes.
Regarding the specific dietary recommendations in this article, although almost all appropriate, it should be noted that the NICE Clinical Guideline CG181 are potentially due for an update with respect to the specifics of restricting dietary cholesterol intake and to placing an upper limit on total fat consumption.
According to the Scientific Report of the 2015 Dietary Guidelines Advisory Committee, “available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol “ and concluded that “cholesterol is not a nutrient of concern for overconsumption”. Additional investigation into dietary cholesterol factors in recent years indicate this is a misconception that’s been perpetuated for almost 40 years.
As the authors already noted, avoiding saturated fat is critical. Evidence indicates it is considerably more important in preventing cardiovascular disease than any limitation on total fat consumption. The unfortunate result of limiting total fat tends to lead to replacement with refined carbohydrates, which are in turn associated with dyslipidemia, one of the very conditions the dietary changes are intended to avoid or to address.
Regardless, educating patients on how to make the necessary healthy dietary choices is going to be far more challenging for clinicians than the therapeutic interventions being put into understandable terms in decision aids. Patients are unlikely to successfully comply with the simple directive to reduce sugar intake if they aren’t aware that food labeling uses more than fifty different names for sugar and they learn to recognize them. Half of all American adults have one or more preventable chronic diseases related to poor dietary quality patterns (and physical activity), including hypertension, diabetes and cancers as well as cardiovascular disease; the UK has similar challenges in the population. We have our work cut out for us.
Competing interests: No competing interests