phc

Personalized Dietary Guidelines for LDL-C Management

Patient: Yunjie Dai, 43-year-old male Date: 2025-10-10 Current Status:

LDL-C: 5.77 mmol/L (223 mg/dL) - Very High Risk
Coronary Disease: Left coronary artery calcification (established CAD)
Lp(a): 526 mg/L (52.6 mg/dL) - Elevated (genetic, non-modifiable)
Triglycerides: 1.92 mmol/L (170 mg/dL) - Borderline high
HbA1c: 5.50% - Excellent glucose control
BMI: 21.6 kg/m² - Optimal
Exercise: 200km/month running - Exceptional
Current Rx: Rosuvastatin 20mg QD (since 2025-08-20)

Treatment Goal: LDL-C <1.4 mmol/L (<55 mg/dL) AND ≥50% reduction from baseline (ESC/EAS 2019 very-high-risk criteria)

Core Principles

Your condition is classified as secondary prevention + very high risk:

Established coronary artery disease (left coronary artery calcification) → Requires most aggressive treatment
Extremely elevated Lp(a) (526 mg/L, normal <300) → Independent cardiovascular risk factor, cannot be modified by diet
Extremely elevated LDL-C (223 mg/dL) → Requires dual approach: medication + diet
Borderline high triglycerides (170 mg/dL, normal <150) → Requires dietary modification

Treatment Strategy:

Primary: Pharmacotherapy: Rosuvastatin 20mg can reduce LDL-C by approximately 50% (223 → ~112 mg/dL)
Adjunctive: Portfolio Diet: Additional 17-29% LDL-C reduction (potentially 19-38 mg/dL further decrease)
Combined Goal: Achieve LDL-C range of 65-93 mg/dL within 6 months
If target not met: Add ezetimibe or PCSK9 inhibitor

Critical Understanding: For your LDL-C baseline (223 mg/dL) and CAD history, diet alone cannot achieve target. Pharmacotherapy is mandatory.

PART 1: Required Daily Nutritional Intake

Priority Classification

⭐⭐⭐ Highest Priority: Saturated fat restriction (greatest impact)
⭐⭐ High Priority: Portfolio Diet four core components (plant sterols, soluble fiber, soy protein, nuts)
⭐ Moderate Priority: Omega-3, dietary cholesterol

1. ⭐⭐⭐ Saturated Fat - Most Important

Daily Target: <7% of total calories (approximately <15g, based on 2000 kcal/day)

Evidence:

AHA 2019: Replacing saturated fat with PUFA reduces CVD risk by 30% (similar to statin effect)
2020 Cochrane Review: Reducing saturated fat ≥2 years lowers LDL-C by 7.3 mg/dL and CVD events by 17%
Each 1% reduction in saturated fat calories lowers LDL-C by 2.1 mg/dL

Why Most Important:

Saturated fat directly raises LDL-C by reducing hepatic LDL receptor expression
Impact on LDL-C far exceeds that of dietary cholesterol

Practical Implementation:

2000 kcal/day × 7% ÷ 9 kcal/g = 15.6g saturated fat/day
Absolutely avoid high saturated fat foods (see PART 2)
Prioritize MUFA (olive oil, avocado) and PUFA (nuts, deep-sea fish)

2. ⭐⭐ Plant Sterols/Stanols

Daily Target: 2-3g

Evidence:

Meta-analysis of 124 RCTs: 2g/day reduces LDL-C by 8-10%, 3g/day reduces by ~12%
FDA and EFSA approved health claims
Effect for you: 18-27 mg/dL LDL-C reduction

Mechanism:

Competitively inhibits intestinal cholesterol absorption (reduces absorption by ~50%)
Complementary to statins (statins inhibit synthesis, plant sterols inhibit absorption)
Takes effect in 2-4 weeks, sustained efficacy

Sources:

Fortified foods (essential):
- Plant sterol-fortified soy/oat milk (approximately 0.5-1g per serving): need 2-4 servings/day
- Plant sterol-fortified yogurt (approximately 1-2g per serving): 1-2 servings/day
- Plant sterol-fortified spreads (20-25g = 2g sterols): approximately 1-1.5 tablespoon/day
Natural sources (supplementary):
- Nuts, whole grains, legumes (natural content 160-500 mg/day, far below therapeutic dose)

Current Status:

✓ You are currently taking Plant Sterols 2g/day supplement (since 2025-09-01)
✓ Continue this dose, can supplement further with fortified foods (total not exceeding 3g/day)

Safety:

EFSA upper limit: 3g/day (under medical supervision)
Rare adverse effects (e.g., sitosterolemia, extremely rare genetic condition)
Safe to combine with statins

3. ⭐⭐ Soluble Fiber

Daily Target: Total fiber 25-35g, of which soluble fiber 10-20g

a) Beta-Glucan from Oats/Barley

Daily Target: 3g beta-glucan

Evidence:

FDA and EFSA approved health claims
Each 1g soluble fiber reduces LDL-C by 1.7 mg/dL
Effect for you: 3g/day can reduce LDL-C by 11-22 mg/dL (5-10%)

Mechanism:

Increases intestinal viscosity, binds bile acids, increases fecal excretion
Upregulates hepatic LDL receptor expression

Sources: Achieving 3g beta-glucan

Oat Bran: 45g (contains ~6.9% beta-glucan)
Rolled Oats: 60g or ¾ cup dry oats (contains ~5% beta-glucan)
Barley: 40-60g (contains ~4.75% beta-glucan)

Practical Recommendation:

Breakfast: ¾ cup dry oats cooked as porridge (provides 3g beta-glucan)
Or: Oat bran + barley combination

b) Psyllium Husk

Daily Target: 7-10g (as supplement if unable to achieve oat intake)

Evidence:

Meta-analysis of 28 trials: 10.2g/day reduces LDL-C by 12.7 mg/dL (5-12%)
Moderate-to-high quality evidence (AJCN 2018)

Mechanism:

Similar to beta-glucan, but requires higher dose (7g vs 3g)

Sources:

Psyllium husk powder: 2-3 tablespoons/day (each tablespoon approximately 3.5g)
Mix into water, smoothies, yogurt

Important Notes:

Must consume with 8-10 oz water (prevent choking risk)
Separate from rosuvastatin by 2-4 hours (avoid affecting drug absorption)
Gradually increase dose (avoid bloating)

Your Choice:

Prioritize oats (food source easier to sustain)
Supplement with psyllium husk if daily oats not feasible

c) Other Soluble Fiber Sources

Legumes: 1 cup cooked (180g) beans (black beans, kidney beans, chickpeas, lentils) → 2-3g soluble fiber
Eggplant, okra, apples, citrus, berries: Daily diverse intake

Portfolio Diet Standard: 20g/day soluble fiber (from oats, barley, psyllium, eggplant, okra, berries, apples)

4. ⭐⭐ Nuts

Daily Target: 30-60g (approximately 1-2 oz)

Evidence:

Meta-analysis of 61 trials: 28.4g/day reduces LDL-C by 4.8 mg/dL
Dose-response: ≥60g/day shows stronger effect (3-7% LDL-C reduction)
2023 network meta-analysis: Pistachios most effective for cholesterol reduction, but all nuts are effective

Mechanism:

Replaces saturated fat
Provides PUFA (especially ALA from walnuts)
Contains plant sterols, fiber, plant protein

Recommended Types (priority order):

Walnuts: 6-7 walnut halves/day (~30g) → Highest Omega-3 (ALA)
Pistachios: 20-25 nuts/day (~30g) → Best cholesterol-lowering effect
Almonds: 12-15 nuts/day (~30g) → Lowers LDL-C + improves lipoprotein particles
Hazelnuts: 15-20 nuts/day (~30g)

Flaxseed and Chia Seeds:

Ground flaxseed: 1-2 tablespoons/day (provides ALA, Omega-3 precursor)
Chia seeds: 1 tablespoon/day (Omega-3 + fiber)

Practical Implementation:

Daily 60g nuts divided into 2-3 servings (breakfast oats with walnuts, afternoon snack pistachios, dinner salad with almonds)
Choose plain, unsalted, not fried
Calories: 60g ≈ 380 kcal → Completely manageable for your exercise volume (200km/month)

Portfolio Diet Standard: 45g/day nuts

5. ⭐⭐ Soy Protein

Daily Target: 25-30g soy protein

Evidence:

Meta-analysis of 46 FDA-reviewed trials: 25g/day for 6 weeks reduces LDL-C by 4.76 mg/dL (3-4%)
Higher dose (47g/day) shows 12.9% reduction (dose-response)

Mechanism:

Replaces animal protein (reduces saturated fat)
Soy isoflavones may enhance effect (but effective even without isoflavones)

Sources: Achieving 25g soy protein

Tofu: 300g (10 oz) → ~25g protein
Unsweetened soy milk: 3 cups (750 mL) → ~21-24g protein
Edamame: 1.5 cups cooked → ~25g protein
Tempeh: 150g → ~25g protein
Soy protein powder: 1 large scoop → ~20-25g protein

Practical Recommendation:

Breakfast: 2 cups unsweetened soy milk (~15g protein)
Lunch or dinner: 150-200g tofu (~15-20g protein)
Or: Edamame, tempeh alternatives

Portfolio Diet Standard: 50g/day plant protein (can come from soy or legumes)

6. ⭐⭐ Legumes/Beans

Daily Target: 1 serving (130-180g or ¾-1 cup cooked)

Evidence:

Meta-analysis of 26 RCTs: 130g/day reduces LDL-C by 0.17 mmol/L (~6.6 mg/dL, approximately 5%)
2019 Advances in Nutrition: 5% LDL-C reduction = 5-6% reduction in major vascular events

Mechanism:

Soluble fiber, plant protein, resistant starch, low GI

Recommended Types:

Lentils: Red lentils, green lentils, brown lentils
Chickpeas
Black beans, kidney beans, pinto beans
Mung beans

Practical Recommendation:

Daily 1 cup cooked legumes (add to soups, salads, stir-fries, wraps)
Canned beans (drained, rinsed) equally effective and convenient

Portfolio Diet Standard: 50g/day plant protein can come from legumes (complementary with soy)

7. ⭐⭐ Omega-3 Fatty Acids (EPA+DHA)

Daily Target: 1g EPA+DHA (or EPA alone)

Evidence:

ESC 2019: 1g/day n-3 PUFA for secondary prevention (Class IIa, Level B)
2022 Frontiers meta-analysis: 0.8-1.2 g/day is “optimal dose”, reduces MACE, CVD death, MI
2024 European Journal of Preventive Cardiology: 11% MI reduction, 10% revascularization reduction, 8% CVD death reduction
2021 eClinicalMedicine: EPA alone superior to EPA+DHA combination (28% MI reduction, 22% revascularization reduction)
REDUCE-IT trial: High-dose EPA (4g/day) reduces CVD events by 25%

Mechanism:

Minimal impact on LDL-C (not primary cholesterol-lowering pathway)
Primarily lowers triglycerides (15-30%)
Improves endothelial function, anti-inflammatory, anti-thrombotic, stabilizes plaques

Special Significance for You:

Your triglycerides 1.92 mmol/L (170 mg/dL) borderline high → Omega-3 can reduce 15-30%
Secondary prevention → Omega-3 provides additional cardiovascular protection through non-LDL-C pathways

Sources:

Food (preferred):

Deep-sea fish 2-3 times/week (120-150g per serving):
- Salmon: 100g = ~2.3g EPA+DHA → Best choice
- Sardines: 100g = ~1.5g EPA+DHA
- Mackerel: 100g = ~2.5g EPA+DHA
Cooking methods: Steam, bake, poach (avoid frying)

Supplements (if food intake insufficient):

Molecularly distilled fish oil: 1g EPA+DHA/day
Or EPA-only supplement: 1g EPA/day (better)
Algal oil: Vegetarian option

Safety:

≤1g/day: Minimal AF (atrial fibrillation) risk
2-4g/day: AF risk increased 51% → Avoid high doses
No drug interaction with rosuvastatin (2022 Korean study confirmed)
Low bleeding risk, but monitor if on anticoagulants

Practical Recommendation:

Salmon/sardines 2-3 times/week (120-150g each time)
+/- Supplement 1g EPA+DHA/day (if fish intake insufficient)

8. ⭐ Dietary Cholesterol

Daily Target: <200 mg/day (strict) or <300 mg/day (moderate)

Evolution of Evidence:

AHA 2019 & 2020-2025 US Dietary Guidelines: Removed 300mg/day upper limit
Current guidance: “Minimize dietary cholesterol, but not at expense of nutritional adequacy”
2019 AJCN meta-regression (55 RCTs): Each 100mg increase in dietary cholesterol raises LDL-C by 1.90-4.58 mg/dL
15-25% of population are “hyper-responders”, LDL-C extremely sensitive to dietary cholesterol

Special Considerations for You:

Your LDL-C baseline extremely high (223 mg/dL) + established CAD → Still recommend <200 mg/day
UK NICE recommends <200 mg/day for familial hypercholesterolemia patients (though you lack FH diagnosis, baseline similar)

Key Distinction: High cholesterol + low saturated fat foods vs High cholesterol + high saturated fat foods

Food	Cholesterol (mg)	Saturated Fat (g)	Status	Reason
Eggs	186mg/egg	1.6g/100g	⚡ Moderate	Low saturated fat, AHA 2019 considers moderate intake acceptable
Shrimp	152mg/100g	0.4g/100g	⚡ Moderate	Extremely low saturated fat, rich in Omega-3
Fish roe (e.g., mentaiko)	300-500mg/100g	1.5-2g/100g	⚪ Occasional	Low saturated fat, but extremely high cholesterol, small portions 1-2x/month
Red meat	70mg/100g	8-15g/100g	🚫 Forbidden	High saturated fat is main problem
Butter	215mg/100g	51g/100g	🚫 Forbidden	Extremely high saturated fat

Practical Implementation:

Eggs: 3-4 per week, maximum 1 per day (if no other high-cholesterol foods that day)
Shrimp: 1-2 times/week, 100-120g per serving (deheaded, shelled to reduce cholesterol)
Fish roe (mentaiko, salmon roe): 1-2 times/month, 15-30g per serving (small portions, as seasoning)
Avoid organ meats, animal brains, mayonnaise

Example Dietary Cholesterol <200mg/day:

Breakfast: 1 egg (186mg) + cholesterol-free foods → Near limit
Or: No-egg day, can add small amount shrimp (100g = 152mg)

9. ⭐ Trans Fat

Daily Target: 0% (absolutely forbidden)

Evidence:

ACC/AHA 2019, ESC 2019: Class III (contraindication), Level A
2024 JACC report: Trans fat increases CHD death 28%, CHD risk 21%, all-cause mortality 34%

Mechanism:

Dual harm: Raises LDL-C + lowers HDL-C
Affects apolipoprotein metabolism

Sources (to avoid):

Hydrogenated vegetable oils, margarine (partial), shortening
Processed baked goods: Cookies, cakes, pie crusts, frozen pizza
Fast food fried foods

Practical Implementation:

Read labels: Avoid “partially hydrogenated oil”
Choose natural butter alternatives (olive oil, avocado oil)

10. Whole Grains

Daily Target: 3+ servings (48-80g whole grains)

Evidence:

Meta-analysis of 25 RCTs: Whole grain oats significantly reduce TC (SMD −0.54) and LDL-C (SMD −0.57)
Improves HbA1c and CRP (inflammatory marker)

Recommended Types (prioritize beta-glucan content):

Oats → Optimal choice
Barley → High beta-glucan content
Brown Rice
Quinoa → Complete protein
Whole wheat bread/pasta → 100% whole wheat

Practical Recommendation:

Breakfast: Oat porridge (¾ cup dry oats)
Lunch/dinner: Brown rice, barley, quinoa instead of white rice
Snacks: Whole grain bread (1 slice)

11. Monounsaturated Fatty Acids (MUFA)

Daily Target: 45g/day (Portfolio Diet standard, from plant sources)

Sources:

Extra virgin olive oil: 2-3 tablespoons/day
- Cold salads, low-temperature cooking
Avocado oil: High-temperature cooking (smoke point 270°C)
Avocado: ½-1 per day
Camellia oil: Chinese-style cooking

Practical Implementation:

Daily 2-3 tablespoons olive oil (salads, vegetables, cooking)
Replace all animal fats and tropical oils

12. Vegetables and Fruits

Daily Target:

Vegetables: ≥5 servings (especially leafy greens, cruciferous)
Fruits: 2-3 servings (prioritize low-medium GI)

Glycemic Control Optimization (maintain your HbA1c 5.5%):

Bitter Melon: Contains charantin, lowers blood sugar
Winter Melon: Traditional blood sugar control
Eggplant: High soluble fiber + cholesterol-lowering

Fruit Selection (low GI priority):

Berries (GI <40): Blueberries, strawberries, blackberries, raspberries, cherries
Citrus (GI <50): Grapefruit, oranges, lemons
Avoid fruit juice (even fresh-squeezed) → GI spikes

PART 2: Foods to Avoid

🚫 Absolutely Forbidden (Any Amount Harmful)

1. High Saturated Fat Meats and Animal Fats

Why: Saturated fat directly raises LDL-C, impact far exceeds cholesterol

Forbidden List:

Fatty portions of red meat: Pork belly, ribs, beef brisket, steak fat, lamb (most cuts)
Processed meats (Group 1 carcinogen): Bacon, sausage, hot dogs, lunch meat, ham
Animal fats: Lard, tallow, poultry skin, animal fat renderings

Exception (occasional, 1-2 times/month):

Extra lean pork tenderloin: 40-60g, all visible fat removed, special social occasions only

2. High Saturated Fat Dairy Products

Forbidden:

Whole milk, cream, butter, ghee
Full-fat cheese, ice cream

Allowed (low-fat/non-fat):

Skim milk, low-fat yogurt (unsweetened) → Moderate amounts

3. Tropical Oils (High Saturated Fat)

Forbidden:

Coconut oil: 90% saturated fat
Palm oil: 50% saturated fat

Alternatives: Olive oil, avocado oil, canola oil

4. Trans Fat

Forbidden:

Partially hydrogenated vegetable oils, margarine (containing trans fat), shortening
Commercial baked goods: Cookies, cakes, pies, frozen pizza
Fast food fried items

Check labels: Avoid “partially hydrogenated”

5. Fried Foods

Why: Adds large amounts of saturated and trans fats

Forbidden:

All fried foods: Fried chicken, fried fish, fried shrimp, tempura, fried dough sticks, fried spring rolls, French fries

Alternative cooking methods: Steam, bake, poach, light stir-fry

6. High Sugar Foods and Beverages

Why: Raises triglycerides, increases CVD risk

Forbidden:

Sugary beverages: Soda, juice (including fresh-squeezed), sports drinks, milk tea, bottled tea drinks
Desserts: Cakes, pastries, mooncakes, candy, chocolate (high sugar + high fat)
High sugar condiments: Ketchup, BBQ sauce, teriyaki sauce, seafood sauce

7. High Sodium Condiments and Processed Foods

Why: Though not directly affecting LDL-C, increases CVD risk and blood pressure

Forbidden/Strictly Limit:

High sodium condiments: Regular soy sauce, dark soy sauce, oyster sauce, fish sauce, chicken bouillon/MSG, fermented tofu
Pickled foods: Salted fish, cured meats, pickled vegetables
Processed foods: Instant noodles, frozen dumplings (high sodium + high fat), canned soups

Alternatives:

Low-sodium soy sauce (<50% sodium)
Spices: Garlic, ginger, scallions, cilantro, basil, cumin, black pepper, vinegar

Daily sodium limit: <2300 mg/day (ideal <1500 mg)

8. Alcohol

Why: Raises triglycerides, increases CVD risk

Forbidden:

All alcoholic beverages: Spirits, beer, wine, cocktails

Exception:

Cooking wine (Shaoxing wine): Small amounts (1-2 tablespoons/dish) acceptable (alcohol evaporates)

⚪ Severely Restricted

1. High Cholesterol Organ Meats

Restriction Reason: Extremely high cholesterol (though saturated fat not highest)

Strictly Limit:

Animal organs: Liver, kidneys, brains, heart
Fish roe/caviar: Only 1-2 times/month, 15-30g per serving

2. Squid/Cuttlefish

Limit: 1-2 times/month, 80-100g per serving

Reason: Cholesterol 233mg/100g (high), though saturated fat extremely low (0.4g/100g)

3. Whole Eggs

Limit: 3-4 per week, maximum 1 per day (if other diet strict)

Reason: Cholesterol 186mg/egg, but low saturated fat (1.6g/100g)

4. Refined Grains

Restriction Reason: High GI, lacks fiber, raises triglycerides

Strictly Limit:

White rice: Small portions (½ cup/meal), prioritize brown rice alternative
White bread, white steamed buns, white noodles: Occasional, prioritize whole wheat
Glutinous rice products (GI 87-98): Rice dumplings, rice cakes, sweet rice balls → Avoid

5. High-Fat Plant Foods (Though Healthy Fats, Need Portion Control)

Moderate Intake:

Avocado: ½-1 per day (high calorie, but healthy MUFA)
Nuts: 60g/day upper limit (high calorie)
Coconut milk: Occasional small amounts (high saturated fat)

PART 3: Supplement Recommendations

Currently Taking (Continue)

✓ Rosuvastatin 20mg QD → Continue, recheck lipids after 6 weeks
✓ Plant Sterols 2g QD → Continue, can supplement further with food (total not exceeding 3g)
✓ NAD+ 1000mg QD → Continue (cellular health/anti-aging)
✓ Finasteride + Minoxidil → Continue (hair loss treatment, unrelated to lipids)

Consider Adding

1. Omega-3 EPA+DHA or EPA Alone

Dose: 1g/day

Reasons:

Your triglycerides 170 mg/dL (borderline high) → Omega-3 can reduce 15-30%
Secondary prevention (established CAD) → Reduces MI, revascularization, CVD death risk

Choices:

EPA alone (e.g., Vascepa/Icosapent Ethyl): Better (2021 meta-analysis shows superior to EPA+DHA)
Or EPA+DHA molecularly distilled fish oil: 1g/day

Timing: If food source fish intake insufficient (<2-3 times/week)

2. Psyllium Husk

Dose: 7-10g/day (2-3 tablespoons)

Reason: If unable to achieve daily oats, supplement soluble fiber

Administration:

Mix into water, smoothies, yogurt
Separate from rosuvastatin by 2-4 hours

3. Vitamin D (If Deficient)

Recommend Testing: 25(OH)D level

Dose: 1000-2000 IU/day (if deficient)

Reason: Related to CVD risk, but decide after testing

Not Recommended

1. Coenzyme Q10 (CoQ10)

Reason:

Often promoted as “statin companion”
Insufficient evidence: Multiple RCTs show no benefit for muscle symptoms
If you have no muscle pain, no supplementation needed

2. Red Yeast Rice

Reason:

Contains natural statin (monacolin K = lovastatin)
You are already on prescription statin, no need to duplicate
FDA warning: Unstable quality, may contain citrinin (nephrotoxic)

3. Garlic Supplements

Reason:

Weak cholesterol-lowering effect (~5%)
You already have potent statin, garlic adds minimal benefit

PART 4: Portfolio Diet Daily Checklist

Macronutrient Basics

Saturated fat <15g/day (<7% total calories) → Highest priority
Trans fat 0g → Absolutely forbidden
Dietary cholesterol <200mg/day → Strict (<300mg moderate)
MUFA (olive oil etc.): 45g/day (2-3 tablespoons)

Portfolio Diet Four Core Elements

Other Key Nutrients

Omega-3: 1g EPA+DHA/day
- Deep-sea fish 2-3 times/week (salmon 120-150g per serving)
- +/- Supplement 1g/day
Whole grains: 3+ servings
- Oats, brown rice, barley, quinoa, whole wheat bread
Vegetables: ≥5 servings
- Priority: Bitter melon, winter melon, eggplant, leafy greens, cruciferous
Fruits: 2-3 servings (low-medium GI)
- Berries, citrus

Absolutely Avoid

No red meat fat, animal fats, processed meats
No full-fat dairy, butter, cream
No coconut oil, palm oil
No trans fat (hydrogenated oils)
No fried foods
No sugary beverages, juices
Sodium <2300mg/day

PART 5: Expected Outcomes & Monitoring

Treatment Goal Timeline

Timepoint	Expected LDL-C Range	Action
Baseline	5.77 mmol/L (223 mg/dL)	Start Rosuvastatin 20mg + Portfolio Diet
6-8 weeks	2.3-3.0 mmol/L (89-116 mg/dL)	First lipid recheck (DUE 2025-10-15)
3 months	2.0-2.6 mmol/L (77-100 mg/dL)	Confirm sustained efficacy
6 months	Target: <1.4 mmol/L (<55 mg/dL)	If LDL-C ≥1.8, add ezetimibe 10mg
12 months	Maintain <1.4 mmol/L	Long-term maintenance, annual recheck

Expected Effect Breakdown

Rosuvastatin 20mg:

Expected 50% LDL-C reduction (high-intensity statin standard)
223 → ~112 mg/dL (5.77 → ~2.9 mmol/L)

Portfolio Diet (perfect adherence):

Additional 17-29% LDL-C reduction (meta-analysis range)
From 112 mg/dL further reduce 19-32 mg/dL → 80-93 mg/dL (2.1-2.4 mmol/L)

Combined Expected (6 months):

Best case: 65-80 mg/dL (1.7-2.1 mmol/L) → Near target
Realistic case: 80-100 mg/dL (2.1-2.6 mmol/L) → Still needs ezetimibe addition

Escalation Plan If Target Not Met

If LDL-C ≥1.8 mmol/L (≥70 mg/dL) after 6 months:

Verify medication adherence (pill count, pharmacy refill records)
Assess dietary adherence (food diary)
Add Ezetimibe 10mg QD (additional 15-20% LDL-C reduction)
- Expected: 2.0 → 1.6 mmol/L (77 → 62 mg/dL)

If dual therapy still ≥1.8 mmol/L:

Consider PCSK9 inhibitor (alirocumab or evolocumab)
Additional 50-60% LDL-C reduction

Other Monitoring Parameters

Parameter	Current Value	Target	Monitoring Frequency
Non-HDL-C	5.88 mmol/L (227 mg/dL)	<2.2 mmol/L (<85 mg/dL)	Each lipid check
Triglycerides	1.92 mmol/L (170 mg/dL)	<1.7 mmol/L (<150 mg/dL)	Each lipid check
HDL-C	1.45 mmol/L (56 mg/dL)	≥1.0 mmol/L (≥40 mg/dL)	Each lipid check
Apolipoprotein B	0.94 g/L (2020)	<0.80 g/L	Annually
Lp(a)	526 mg/L (52.6 mg/dL)	Cannot change (genetic)	No repeat testing needed
hsCRP	[To be tested]	<2 mg/L	Annually (inflammatory marker)
HbA1c	5.50%	Maintain <5.7%	Annually (statins may raise)
Liver function (ALT/AST)	[To be tested]	Normal range	Baseline + annually
Creatine kinase (CK)	[To be tested]	Normal range	If muscle symptoms

PART 6: Practical Implementation

Daily Meal Framework

Breakfast:

¾ cup dry oats cooked as porridge (provides 3g beta-glucan)
+ 1-2 tablespoons ground flaxseed (Omega-3 ALA)
+ 1 tablespoon chopped walnuts or almonds (nuts)
+ 1 cup blueberries or strawberries (low GI fruit + antioxidants)
+ 2 cups unsweetened soy milk (soy protein ~15g)

Lunch:

Large vegetable salad (leafy greens, tomatoes, cucumbers, eggplant)
+ 200g grilled salmon or tofu (Omega-3 or soy protein)
+ 1 cup cooked chickpeas or lentils (legumes + soluble fiber)
+ 2 tablespoons extra virgin olive oil + vinegar dressing (MUFA)
+ 1 small handful nuts (pistachios or almonds)

Afternoon Snack:

1 apple or orange (low GI fruit + soluble fiber)
+ 1 small handful nuts (walnuts or hazelnuts)

Dinner:

1 cup cooked brown rice or quinoa (whole grains)
+ Large portion stir-fried vegetables (bitter melon, broccoli, mushrooms, using olive or avocado oil)
+ 150g steamed tofu or small portion white fish (plant protein or low-fat animal protein)
+ 1 cup bean soup (miso soup with tofu, or lentil soup)

Before Bed (Optional):

1 tablespoon psyllium husk + 8 oz water (if daytime soluble fiber target not met)

Shopping List (Weekly)

Staples:

Rolled oats 2-3 bags
Brown rice, quinoa, barley
Whole wheat bread (100% whole wheat)

Protein:

Tofu 3-4 blocks
Unsweetened soy milk 6-8 cartons (or make homemade)
Edamame 2 bags
Salmon or canned sardines 2-3 cans
Eggs 6-8 (if consuming)

Legumes:

Lentils, chickpeas, black beans, kidney beans (dried or canned)

Vegetables:

Leafy greens 3-4 types (spinach, kale, lettuce)
Cruciferous (broccoli, cauliflower, cabbage)
Bitter melon, winter melon, eggplant
Tomatoes, cucumbers, carrots

Fruits:

Blueberries, strawberries (fresh or frozen)
Oranges, grapefruit, lemons
Apples 2-3

Nuts and Seeds:

Walnuts 1 bag (plain, unsalted)
Almonds or pistachios 1 bag
Ground flaxseed (or whole, grind yourself)
Chia seeds

Oils:

Extra virgin olive oil
Avocado oil (high-temperature cooking)
Avocados 2-3

Condiments:

Low-sodium soy sauce
Vinegar (rice vinegar, aged vinegar)
Garlic, ginger, scallions, cilantro
Spices (cumin, black pepper, cinnamon)

Functional Foods:

Plant sterol-fortified soy milk/yogurt (if supplement insufficient)
Psyllium husk powder (if need to supplement soluble fiber)

Cooking Methods

Prioritize:

Steam: Fish, tofu, vegetables
Bake: Salmon, chicken breast (skinless)
Poach: Legumes, whole grains, vegetables
Light stir-fry: Vegetables (using olive or avocado oil, small amount)

Avoid:

Deep frying, pan frying, high-oil stir-frying

Dining Out Strategies

Restaurant Selection:

Mediterranean restaurants: Priority choice (grilled fish, salads, hummus, olive oil)
Japanese restaurants: Sashimi, miso soup, tofu, edamame, small amount sushi (brown rice)
Chinese restaurants: Steamed fish, tofu vegetables, bean soups (request less oil, less salt)

Ordering Tips:

Request: “Less oil, less salt, steamed/baked/poached”
Avoid: Braised, oil-braised, high-heat stir-fried, deep-fried dishes
Add: Extra vegetables, tofu

PART 7: FAQ

Q1: Can diet replace statin medication?

A: No. For your LDL-C baseline (223 mg/dL) and established CAD, diet alone cannot achieve target <55 mg/dL.

Diet maximum reduction: 17-29% (38-65 mg/dL) → Reduces to 158-185 mg/dL (still far above target)
Statin + diet: Synergistic effect, may achieve 65-100 mg/dL
To reach target <55 mg/dL: Usually requires adding ezetimibe or PCSK9 inhibitor

Conclusion: Pharmacotherapy primary, diet necessary adjunct.

Q2: Can I be completely plant-based (vegan)?

A: Yes, but need to ensure nutritional adequacy.

Vegan Portfolio Diet:

✓ All plant proteins (soy, legumes)
✓ Omega-3 from algal oil supplement (1g EPA+DHA)
✓ Important to supplement vitamin B12 (mandatory!), iron, zinc, vitamin D

Your Situation:

You already consume substantial plant protein, can easily transition to vegan
Recommendation: Salmon 2-3 times/week provides Omega-3 (if going vegan, replace with algal oil)

Q3: My Lp(a) is 526 mg/L, very high. Can diet lower it?

A: No. Lp(a) is genetic, cannot be changed by diet or lifestyle.

Management Strategy:

More aggressive LDL-C control: Target <1.4 mmol/L (even lower)
Consider aspirin: Primary prevention (discuss with physician)
Emphasize all other modifiable CV risk factors: LDL-C, blood pressure, glucose, exercise, diet
No need to retest Lp(a): Stable throughout life

Q4: I run 200km/month, can I eat more fat?

A: Yes, more total calories, but fat type still needs control.

Your Exercise Expenditure:

200km/month ≈ 50km/week ≈ Approximately 3500-4000 kcal additional weekly expenditure
Your BMI 21.6 indicates good caloric balance

Strategy:

✓ Increase healthy fats: Nuts, olive oil, avocado, fish → Can freely increase
✓ Increase carbohydrates: Whole grains, fruits, legumes → Replenish glycogen
✗ Do not increase saturated fat: Even with high exercise volume, saturated fat still needs <7%

Your Advantage:

2022 Mayo Clinic case report: High-intensity exerciser + Portfolio Diet, LDL-C reduced 43% (similar to your situation)
Exercise amplifies dietary effects → You may achieve upper limit of Portfolio Diet effect (29%)

Q5: Do I need to take supplements?

A: Continue current ones, consider adding Omega-3.

Current:

✓ Rosuvastatin 20mg → Must continue
✓ Plant Sterols 2g → Must continue
✓ NAD+ 1000mg → Continue (anti-aging)

Consider Adding:

Omega-3 EPA+DHA 1g/day (if fish intake insufficient)
Vitamin D (if testing shows deficiency)

Not Needed:

CoQ10 (insufficient evidence)
Red yeast rice (you already have prescription statin)
Garlic supplements (weak effect)

Q6: How long until I see lipid improvement?

A: 6-12 weeks to see maximum effect.

Timeline:

Statin: Takes effect in 2 weeks, maximum effect 4-6 weeks (50% LDL-C reduction)
Plant sterols: Takes effect in 2-4 weeks
Soluble fiber: Takes effect in 3-4 weeks
Complete Portfolio Diet: Maximum effect 6-12 weeks (17-29% additional reduction)

First recheck: 6-8 weeks later (2025-10-15 due)

Q7: What if statin side effects (muscle pain) occur?

A: Contact physician immediately, do not stop medication on your own.

Management Options:

Rule out other causes: Overexercise, muscle strain
Test creatine kinase (CK): If normal, usually can continue
If confirmed statin-related myalgia:
- Try lowering dose (20mg → 10mg)
- Switch to different statin (e.g., atorvastatin)
- Alternate day dosing
- Add CoQ10 (though evidence insufficient, can try)
If statin intolerant:
- Ezetimibe 10mg monotherapy (reduces 15-20% LDL-C)
- Bempedoic acid (new non-statin lipid-lowering drug)
- PCSK9 inhibitor (injection, 50-60% LDL-C reduction)

Your Situation:

Currently no muscle symptoms
200km/month running well-tolerated → Likely good statin tolerance

PART 8: Summary & Action Plan

Key Takeaways

Your risk is extremely high: LDL-C 223 mg/dL + established CAD + Lp(a) 526 mg/L → Requires most aggressive treatment
Treatment goal: LDL-C <1.4 mmol/L (<55 mg/dL) AND ≥50% reduction
Treatment strategy: Medication (rosuvastatin 20mg) + diet (Portfolio Diet) + exercise (already excellent)
Dietary core:
- ⭐⭐⭐ Highest priority: Saturated fat <7%
- ⭐⭐ Portfolio Diet four elements: Plant sterols 2g, soluble fiber 10-20g, nuts 45g, plant protein 50g
- ⭐ Omega-3: 1g/day (lowers triglycerides + secondary prevention)
Expected effect: Within 6 months LDL-C may reduce to 65-100 mg/dL, if target not met add ezetimibe

Immediate Action Items

This Week:

Recheck lipids, liver function, kidney function (2025-10-15 due)
Purchase Portfolio Diet ingredients (refer to PART 6 shopping list)
Begin daily checklist (PART 4)
Consider adding Omega-3 supplement (1g EPA+DHA/day)

First Month:

Establish dietary habits (breakfast oats, lunch salad, dinner tofu)
Keep food diary (first 2 weeks, understand adherence)
Continue rosuvastatin 20mg QD (ensure daily intake)

Months 2-3:

Assess lipid improvement (6-8 week recheck)
Optimize dietary adherence (if LDL-C reduction suboptimal)
Monitor statin side effects (muscle pain, liver function abnormalities)

Month 6:

Recheck lipids again
If LDL-C ≥1.8 mmol/L: Discuss adding ezetimibe 10mg with physician
Long-term maintenance (lifelong dietary pattern)

Long-Term Maintenance

This is not a short-term diet, but a lifelong lifestyle.

Key:

Consistency > Perfection: 80% adherence sustained long-term superior to 100% adherence for 2 months then abandonment
Flexibility: Occasional social occasions can moderately relax (1-2 times/month), but maintain overall principles
Regular monitoring: Annual lipid checks, ensure LDL-C continuously <1.4 mmol/L

Your Advantages:

✓ Excellent exercise habits (200km/month)
✓ Excellent glucose control (HbA1c 5.5%)
✓ Excellent blood pressure (106/64)
✓ Excellent BMI (21.6)
✓ High adherence (already started Portfolio Diet)

Conclusion: You possess all conditions for success, sustained execution will achieve goals.

Appendix: Key References

AHA 2019 Scientific Advisory: Dietary cholesterol and cardiovascular risk
ESC/EAS 2019 Guidelines: LDL-C goals for dyslipidemia management (<1.4 mmol/L for very high risk)
Chiavaroli et al. 2018 (Portfolio Diet Meta-analysis): 17% LDL-C reduction, high-certainty GRADE evidence
2020 Cochrane Review: Saturated fat reduction for cardiovascular disease
2022 Frontiers Meta-analysis: Omega-3 optimal dose 0.8-1.2 g/day for CHD patients
2023 Circulation (Glenn et al.): Long-term Portfolio Diet and CVD outcomes
REDUCE-IT Trial: High-dose EPA reduces CVD events 25%

Document Version: 1.0 Last Updated: 2025-10-10 Next Review: 2025-10-15 (after lipid recheck)

Disclaimer: This document is for reference only and does not constitute medical advice. All treatment decisions should be discussed with your physician (Dr. Ying Chen / Dr. Wu Jia Yu Celine, Shanghai United Family Hospital).