The National Lipid Association (NLA) has released recommendations that specifically address the importance of managing blood cholesterol levels in special patient populations. “Over the years, we’ve learned that taking a ‘one size fits all’ approach to managing cholesterol is ineffective,” says Terry A. Jacobson, MD, who was part of the NLA group that developed the recommendations. “Our goal was to highlight groups of patients who are at high risk for cholesterol problems and to develop recommendations for each of these groups based on their unique characteristics.”

The NLA recommendations—published in the Journal of Clinical Lipidology and available for free at—offer guidance on managing cholesterol among diverse ethnic and racial groups. They also provide recommendations for conditions that cover the lifespan. Chronic conditions not previously identified as being high-risk for heart disease are also covered in the recommendations (Table).

Lifestyle is the Cornerstone

According to Dr. Jacobson, the NLA recommendations reinforce the importance of lifestyle changes as the cornerstone of therapy. “Lifestyle therapies like nutrition, physical activity, and exercise often get short-changed during patient care,” he says. “Clinicians need to refocus the bullseye on lifestyle modifications and become more comfortable offering practical strategies to assist their patients.”

The recommendations provide new detailed advice for specific changes in diet, dietary patterns, and the amount of physical activity and exercise required for cardiovascular health. “For example, patients should understand that there are many types of cardioprotective diets available to them that may help manage cholesterol, but the key is to change their patterns of eating and incorporate a greater variety of plant foods and leaner sources of protein,” explains Dr. Jacobson.

Clinicians should strongly consider involving registered dietitians before placing patients on lifetime drug therapies, according to Dr. Jacobson. Any diet that is implemented should be individualized based on each patient’s type of lipid disorder. Also, patient cultural and food preferences are important to help guide decisions about dietary patterns so that adherence to these diets can be optimized.

Ethnic Groups & High-Risk Conditions

The NLA recommendations provide guidance on caring for patients at risk based on ethnicity or race, including African Americans, Hispanics, and South Asians. “These groups have increasing rates of obesity, metabolic syndrome, and diabetes, which is of great concern,” Dr. Jacobson says. “Aggressive efforts in lifestyle control are needed, and the recommendations discuss why these groups are at higher risk for cholesterol and heart disease problems. The key is to offer individualized care approaches, understand genetic predispositions, and factor in cultural patterns that may increase risks for cardiovascular disease (CVD) when caring for these people.”

After lifestyle therapy, cholesterol-lowering medications remain the treatment of choice for people with high-risk chronic conditions like HIV and rheumatoid arthritis. “Many healthcare providers do not realize that patients with HIV and rheumatoid arthritis are at high risk for CVD,” says Dr. Jacobson. “These patients are now living longer than before as treatments for these chronic diseases have become more effective.” The NLA recommendations offer guidance on factors to consider when using medications for cholesterol treatment in patients with HIV and rheumatoid arthritis.

Treatment Over the Lifespan

According to Dr. Jacobson, atherosclerosis often begins early in life and progresses for decades. “Recognizing and reducing atherogenic cholesterol in children and adolescents is important for long-term cardiovascular health,” he says. The NLA recommends universal lipid screening of all children—regardless of general health or the presence or absence of atherosclerotic CVD risk factors—between the ages of 9 and 11, with repeat lipid screening at age 20 or earlier if dyslipidemia is present.

Cascade screening, which takes into account family history of premature heart disease and elevated levels of cholesterol in other family members, is recommended to enhance the detection of children and adolescents at risk for familial hypercholesterolemia. If lipid-altering pharmacotherapy is provided, potential side effects should be monitored in pediatric patients.

Recommendations are also available to help implement primary prevention strategies for managing lipids in patients aged 65 to 79. Patients in this age range who have atherosclerotic CVD or diabetes should be considered for moderate or high-intensity statin cholesterol-lowering therapy after carefully weighing the risks and benefits. If statin intolerance is an issue, consideration should be given to the use of alternate cholesterol-lowering treatment regimens.

“The current data on patients aged 80 and older is lacking with regard to optimizing the management of lipids,” explains Dr. Jacobson. “A key research initiative for the future is determining which patients older than 80 will benefit from statin therapy.” For secondary prevention in patients in this age range, the NLA recommends that moderate intensity cholesterol-lowering therapy be considered based on clinician and patient discussions about the risks and benefits of such therapy. Important considerations include drug-drug interactions, polypharmacy, cost considerations, patient preference, and concomitant medical conditions, including frailty.

Addressing Adherence

Dr. Jacobson says adherence to both lifestyle therapies and lipid-lowering drugs is paramount to reducing CVD risk. The NLA recommends discussing adherence at each patient visit to identify problems, barriers, or side effects of therapy. An interdisciplinary team of healthcare providers—including nurses, nurse practitioners, clinical pharmacists, physician assistants, and registered dietitian nutritionists—should also be utilized to assist patients with adherence issues.

“The NLA recommendations are intended to provide additional expert guidance to currently available guidelines for treating cholesterol,” says Dr. Jacobson. “The recommendations will be a living document in that updates will be incorporated as new data emerge. Our mission is to help clinicians make a difference at the front lines and provide practical tools to help implement the recommendations into daily practice.”