The Therapeutic Lifestyle Changes diet (TLC) is a cholesterol-lowering diet developed by the National Cholesterol Education Program (NCEP). The TLC diet is a set of dietary guidelines for medical professionals to prescribe when using medical nutrition therapy as the first treatment for patients who have heart disease or are at high risk for developing the disease due to their elevated levels of total cholesterol and low-density lipoprotein cholesterol (LDL), and possibly a low amount of high-density lipoprotein cholesterol (HDL). The diet emphasizes heart-healthy lifestyle choices that lower a person's total cholesterol and LDL levels while raising their HDL level. These changes reduce their risk of developing heart disease, future heart attacks, and other heart disease complications.
The TLC diet follows these dietary guidelines:
The NCEP classifies blood cholesterol levels as:
In November 1985, to standardize the medical approach to treating high blood cholesterol levels, the National Heart, Lung, and Blood Institute (NHLBI) launched the National Cholesterol Education Program (NCEP). The overall goal of the NCEP is to “reduce illness and death from coronary heart disease (CHD) in the United States by reducing the percent of Americans with high blood cholesterol.”
For the general population, the NCEP still recommends a diet following the Step 1 recommendations. In May of 2001, however, the NCEP issued the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (updated in 2004), which recommended the new TLC dietary therapy for subgroups of people with high LDL cholesterol or other lipid disorders, coronary heart disease or other cardiovascular disease, diabetes mellitus, and insulin resistance or metabolic syndrome. Soon after the report was issued, health organizations such as the American Heart Association (AHA) began to accept and endorse these recommendations. Now a majority of organizations have incorporated the TLC diet into materials on dietary and lifestyle change for people with high blood cholesterol.
Cholesterol is a waxy substance found only in foods of animal origin such as poultry, beef, fish, eggs, and dairy products. Cholesterol can be made from the liver, and thus is not needed in the diet for normal cellular processes. Cholesterol must be combined with fats and proteins to form lipoproteins before it can be transported through the body within the blood. The many different lipoproteins vary in size, function, and composition. One type is low-density lipoprotein (LDL). Commonly referred to as “bad” cholesterol, it comprises approximately two-thirds of the total circulating blood cholesterol. Because the LDL transports high levels of cholesterol through the bloodstream, it is associated with plaque deposits on the walls of the arteries, resulting in a higher risk for cardiovascular events. High-density lipoprotein (HDL) is referred to as the “good” cholesterol because it scavenges excess cholesterol from the blood and brings it back to the liver for excretion. Another class of lipoproteins, the very low-density-lipoproteins (VLDL), are responsible for carrying triglycerides through the bloodstream.
Evidence is clear that the major dietary contributors to elevated cholesterol are saturated fat, trans fat, dietary cholesterol, and an imbalance in caloric intake and energy expenditure resulting in weight gain. In some cases, elevated cholesterol may be due to an underlying medical condition or certain prescribed medications to treat those conditions, including:
Other factors known to influence a person's blood cholesterol level include:
The three cornerstones of the TLC lifestyle modification diet are:
The TLC Program is adjusted using a set of four categories that are based on a person's heart disease risk profile to decide on LDL goals and treatment steps. For a person who has heart disease or diabetes, they are considered a category 1, carrying the highest risk. For people free of those conditions, their needs are based upon their personal risk of having a heart attack in the next 10 years, based upon the Framingham Heart Study. The higher a person's risk category, the more important it is for them to lower their LDL and control any other heart disease risk factors (including smoking and high blood pressure).
The TLC diet is prescribed for people who need to reduce their risk of heart disease. The main goal in treating high cholesterol via the TLC program is to lower a person's LDL level without medications. Patients are usually given three months to make changes using the TLC diet and lifestyle changes to lower their total and LDL cholesterol. If their goals are not met, medication is usually introduced as a secondary treatment option, but if goals are met, the physician may choose not to utilize medication as a treatment. Research has proven that lowering LDL levels can prevent or decrease the risk of heart attacks and reduce deaths from heart disease in both men and women. The TLC program can decelerate, stop, or reverse the buildup of plaque. When followed, it can also lower the cholesterol content in unstable plaques, making them less likely to burst and cause a heart attack. For those who have already experienced a myocardial infarction, the diet can reduce the risk of another heart attack, possibly prolonging life.
By following the TLC approach, a person is following a healthful lifestyle that has a synergistic effect on other disease risks. They are also benefitting from the ability to treat a disease without the side effects of medications. The TLC program has been shown to help control other risk factors for heart disease such as high blood pressure, overweight/obesity, diabetes, and metabolic syndrome, as well as decreasing the likelihood of blood clots. Research has shown that for every 10 percentage points cholesterol is reduced, the risk of death from heart disease drops by 15%. For those who take cholesterol-lowering medications, following the TLC program can ensure that they take the lowest dose needed to achieve results.
Along with a qualified physician, other professionals who can assist with safe dietary and lifestyle changes include registered dietitians, nurses, psychologists, and exercise physiologists.
Positive risk factors for heart disease include:
Scores of research articles support a direct relationship between LDL cholesterol levels and the rate of coronary heart disease (CHD). Within-population studies, such as the Framingham and MRFIT studies, and between-population studies, most notably the Seven Countries study, support this research as well. Studies on people with familial hypercholesterolemia, a genetic disorder characterized by high levels of LDL cholesterol, indicate that these individuals have an exceedingly high rate of premature atherosclerosis. The majority of research from experimental animals, laboratory investigations, epidemiology, and genetic forms of hypercholesterolemia indicate that elevated low-density lipoprotein (LDL) cholesterol is a major cause of CHD. In addition, clinical trials demonstrate a reduction of coronary heart disease risk when low-density lipoprotein-lowering therapy is instituted. Research also shows that higher levels of HDL are related to lower levels of certain cardiovascular events. For these reasons, the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) continues to identify elevated low-density lipoprotein cholesterol as the primary target of cholesterol-lowering therapy.
See also Calories ; Coronary heart disease ; Diabetes mellitus ; Dietary cholesterol ; Dietary guidelines ; Fats ; Fiber ; Heart-healthy diets ; Insulin ; Ketogenic diets ; Metabolic syndrome ; Protein ; Sodium ; Triglycerides .
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Megan C. M. Porter, RD, LD, CDE
Revised by Anne P. Nugent, PhD