Dietetic Input in Primary Care can Decrease Risk of CVD
Hypercholesterolemia Patient Audit 2024
Joe Alvarez
First Contact Dietitian, Shoreditch Park and City PCN (London)
Background
There are around 7.6 million people living with heart and circulatory diseases in the UK. The British Heart Foundation (BHF) forecasts that there could be 1 million more people living with heart and circulatory diseases in the UK by 2030, and 2 million more than today by 2040. They expect the numbers to increase, largely due to an ageing population and improving survival rates (British Heart Foundation, 2024).
Those with CVD are also more likely to develop dementia/Alzheimer’s disease (Santiago & Potashkin, 2021) which is the leading cause of death in the UK (with CHD and stroke taking second and third place respectively), (Office for National Statistics, 2023).
High cholesterol is a significant risk factor for developing heart and circulatory diseases. With high LDL cholesterol being associated with 1 out of 5 heart and circulatory disease deaths in the UK, in addition to obesity and poor diet (British Heart Foundation, 2024).
As a first contact dietitian, I see a variety of patients with an array of health conditions. And many of those who come to my clinic will have raised cholesterol levels. As audit is an important part of our practice to improve the quality of patient care and clinical outcomes, I decided to carry out an audit comparing patients with high cholesterol before and after their appointment with me.
Methodology
An audit was carried out across 3 GP surgeries. EMIS searches were run (by the Digital Lead at the PCN) of all patients who had seen the first contact dietitian (FCD) from April 2023-April 2024, who had a total serum cholesterol level of above 5.0mmol/L prior to their appointment (considered as raised).
A desktop review of the individual patient notes was performed by the FCD. This involved recording when they saw the FCD, when they had their blood tests, and the reason for referral. The blood test results of those who had repeat tests after they had seen the dietitian, were recorded. It was noted if the patient was prescribed a statin at the time and/or prior to the repeat blood test.
Results
In total 122 patients who had a total cholesterol of 5mmol/L or above were seen by the FCD in the year April 2023 – April 2024. The majority (n=75, 62%) had not been referred for high cholesterol management but for another reason such as weight management, prediabetes or gastroenterological conditions. In total, 74 patients had a repeat blood test following the appointment, and 48 had not had a repeat blood test at the time of the audit.
Out of the 74 patients who had repeat bloods, 40 (54%) had an improvement in their total cholesterol levels after seeing a dietitian (defined as a reduction of >0.2mmol/L). Of those who had an improvement, a total of 57.5% were not taking statins, with an average reduction of -1.0mmol/L in total cholesterol. And 42.5% of people had an improvement but were taking statins, with an average reduction of -1.46mmol/L. In total, regardless of whether patients were prescribed statins or not, there was an average reduction of -1.23mmol/mol in total cholesterol levels after their appointment with the dietitian.
There were 13 patients who had no change in cholesterol levels (defined as ≤0.1mmol/L) with an average change of -0.03mmol/L. In addition, 21 (28%) patients had no improvement in TC (defined as an increase of more than 0.2mmol/L) with an average increase of +0.46mmol/L. Only 3 patients (7.5%) went on to take statins after seeing the dietitian.
Table 1. Combined results across PCN of Patients who had reduced cholesterol levels after seeing the dietitian
|
Out Those Who had an Improvement (40) |
No. Patients |
% of Total |
Initial Total Cholesterol (mmol/L) |
Repeat Total Cholesterol (mmol/L) |
Average Change (mmol/L) |
|
Prescribed Statins Before Repeat Bloods |
17 |
42.5% |
5.76 |
4.3 |
-1.46 |
|
Not Prescribed Statin Before Repeat Bloods |
23 |
57.5% |
6.3 |
5.3 |
-1.0 |
|
Total No. Patients |
40 |
100% |
6.03 |
4.8 |
-1.23 |
Conclusion
Total cholesterol levels are an indicator for long term heart health. Diet and lifestyle can have a significant impact on this, although this is not the only factor. Being one of the leading causes of death, there is an urgent need to improve the population’s metabolic health and prevent and delay the development of CVD.
This audit demonstrated that more than 54% of patients had a significant improvement in their total cholesterol after seeing a first contact dietitian in primary care and 18% stabilised their total cholesterol levels. This occurred, even when not necessarily having been referred for cholesterol lowering advice. It was also noted that even patients who were already prescribed statins had an marked improvement in their cholesterol levels, suggesting that the dietetic input may have improved adherance to medications in addition to encouraging dietary and lifestyle changes.
This demonstrates that there could be a significant improvement in patient’s overall health outcomes when seeing a dietitian in primary care, regardless of the reason for referral. This is likely to have a significant impact in the longer term, as this could mean a reduction in the need for statins earlier on in life, a decrease in development of CVD and reducing burden on the NHS.
References
Office for National Statistics (ONS), released 11 April 2023, ONS website, article, Death registration summary statistics: England and Wales: 2022
Furbatto, M., Lelli, D., Antonelli Incalzi, R., & Pedone, C. (2024). Mediterranean Diet in Older Adults: Cardiovascular Outcomes and Mortality from Observational and Interventional Studies-A Systematic Review and Meta-Analysis. Nutrients, 16(22), 3947. https://doi.org/10.3390/nu16223947
Santiago, J. A., & Potashkin, J. A. (2021). The Impact of Disease Comorbidities in Alzheimer's Disease. Frontiers in aging neuroscience, 13, 631770. https://doi.org/10.3389/fnagi.2021.631770