Yehuda Handelsman, MD: Let’s look at the approach for treating patients who have high cholesterol. We can’t talk enough about how the mainstay of therapy is lifestyle.

Christie Ballantyne, MD: Lifestyle is the mainstay of therapy, and we’ve talked about the entire patient, and the issue of both diet and exercise. I see the residents rotating through, and they typically will say, “I want you to walk,” which is great, in the DPP [Diabetes Prevention Program], it’s 30 minutes, 5 or 6 days a week. But they also will say, “I want you to get 10,000 steps.” There was a paper that just came out that said the optimal was at least 7000 steps for older people, and closer to 10,000 for younger people. The average number of steps if people walk an hour is 57 steps per minute, so times 60, that’s around 3500. It ends up that 30 minutes will not give you 10,000 steps. It takes a lot of walking and hours in a day to get that, and that can be broken up. We need to do this early in life. Unfortunately, for cholesterol, diet and lifestyle, unless you are going to make radical changes, it has very modest impact for most people. It’s important for diabetes prevention, because if you start a high intensity statin, there is a little increase in risk for diabetes. If you do the lifestyle, you can blunt all of that, and in fact turn it the other way. It is important, particularly if you are looking at total patient management—the blood pressure, glycemic control, obesity—lifestyle is critical. For cholesterol, it’s helpful, but you usually, with genetic disorders, will require pharmacotherapy.

Yehuda Handelsman, MD: Does anybody have something on lifestyle?

Erin D. Michos, MD, MHS: We’ve said in our guidelines, any bit is worth the effort. We have these goals that we want to strive for. But the evidence suggests that even for individuals who can’t meet the recommended amount of physical activity, if they are doing some physical activity more than sedentary, they have some benefit. It’s worth the time to counsel patients about diet and physical activity. And the number needed to counsel, to get somebody to increase their physical activity, is only 12. It is worth the time to carve out 5 minutes in the clinic to start the conversation. Then utilize the team-based approach with your extended health care team, dieticians, exercise physiologists, nurses, and our case managers, to get our patients to implement lifestyle better.

Yehuda Handelsman, MD: What you said is very important. There were some studies that with 7000 and even 5000 steps, 3 times a week, 20 minutes by itself, can reduce mortality in the older population. So if you do anything, you get some benefit out of it.

Transcript Edited for Clarity