At BOJANA MD, we continually strive to enhance patient care by closely observing our patients’ health outcomes in response to our modalities of care. Among other areas of internal and integrative medicine care, we provide medical care and health coaching to individuals with high cholesterol, high levels of inflammation in the body, elevated blood glucose levels, prediabetes or diabetes, and/or elevated body mass index. We do this with the goal of increasing our patients’ healthspan, their physical and mental functioning, and reducing chronic disease. Our team uses data-driven approaches from internal medicine, integrative and functional medicine, and advanced diagnostics. We personalize treatment plans to each person we are working with. We partner with each patient to help them achieve their health goals and optimal health.
We conducted an internal data review with the goal of answering the question: how effective is our approach at improving markers of metabolic dysfunction and inflammation in the body? These markers are related to chronic disease, morbidity and mortality, so improving them would lead to improved outcomes in these areas.
In plain terms, how does our work translate to improved health, reduced risk factors of cardiovascular disease, dementia and cancer?
Objective of the study
The aim of our data review was to quantify changes in key health indicators— LDL cholesterol (LDL-C), C-reactive protein (CRP), and Body Mass Index (BMI) during the internal review period, in our patient population whose markers met the criteria for this review and who had at least two sets of markers available for review. All of the patients are adults. This article highlights our findings and implications for patient health.
Our study focused on four critical metrics:
LDL Cholesterol: measures the amount of cholesterol associated with LDL particles; the smaller and more dense ones are associated with metabolic syndrome and are more atherogenic (more likely to lead to plaque formation in arteries). An LDL-C level of 130 mg/dL or higher indicates elevated cholesterol levels (although < 100 mg/dL is considered optimal, and stricter ranges < 70 mg/dL or lower apply to specific populations).
C-Reactive Protein: this is an inflammatory marker and cardiovascular risk marker. It is increased in the presence of inflammation (e.g., autoimmune condition), infection, metabolic syndrome and intestinal hyperpermeability, dental issues such as periodontal disease or dental infection. A CRP level of 3.0 mg/L or higher signifies increased inflammation in the body and an increased risk of cardiovascular disease.
Body Mass Index (BMI): A body mass index is calculated by taking a person’s weight in kilograms and dividing it by their height squared (in meters squared). It is a marker of underweight, healthy weight, overweight or obesity. A BMI of 25-29 indicates overweight, while a BMI >=30, obesity.
By assessing these metrics at baseline relative to initial lab work (after 1/1/2021) and follow-up (the last follow-up lab work until 10/31/2024), we aimed to evaluate the effectiveness of our interventions and compare them to standard of care.
Patient Population
Ninety-six adult patients who have received care or are receiving care in our medical practice are included in this review. They are individuals who had one or more markers that met the criteria for this review and who had at least two sets of markers available for review.
Key Findings
1. LDL Cholesterol (LDL-C)
Of the patients with initial LDL-C levels of 130 mg/dL or higher:
- 85% achieved lower LDL-C values.
- Average change was 33 mg/dL reduction from baseline LDL-C
Of those who achieved LDL-reduction:
- The average LDL-C reduction was 24% (40 mg/dL) from baseline
For those on pharmacological intervention (most often statin therapy):
- The average LDL-C reduction was 41% (69 mg/dL) from baseline
Non-pharmacological Interventions:
- The average LDL-C reduction was 21% (36 mg/dL) from initial
This finding demonstrates meaningful changes by using cholesterol-lowering strategies, which may include dietary changes, physical activity, nutraceuticals and pharmacotherapy.
2. C-Reactive Protein (CRP) – marker of inflammation
Among the patients with an initial CRP of 3.0 mg/L or higher:
- 76% experienced a reduction in CRP levels.
- Average reduction in CRP was 2 mg/L.
Subgroup analysis of those who achieved improved outcomes:
- Average reduction in CRP was 57% from initial
The improvement in CRP indicates a reduction in systemic inflammation and a potential decrease in cardiovascular risk, underscoring the importance of comprehensive management in our patient population.
3. Body Mass Index (BMI)
Among the patients meeting the criteria for overweight or obesity (BMI >= 25):
- 84% saw a reduction in their BMI.
- The average reduction in BMI was 1.6 kg/m2.
Subgroup analysis of patients who achieved reduced BMI outcomes:
- The average BMI reduction was 8% from initial
GLP-1 Agonist Assisted Therapy
- The average BMI reduction was 11% from initial
Without GLP-1 Agonist Therapy (Diet, Lifestyle and Supplemental support)
- The average BMI reduction was 6% from initial
This improvement highlights our practice’s commitment to weight management and the efficacy of our interventions, which include nutritional and exercise counseling and implementation, health coaching and lifestyle optimization, supplemental support, root-cause assessment and care, and medication if indicated.
Discussion
Our internal data review reveals that in our patient population with metabolic dysfunction, our outcomes in markers of cardiometabolic health exceed those of standard of care.
LDL-C
It has been shown that every LDL-C reduction of 39 mg/dL with statins leads to an average of 21% relative risk reduction of major vascular events 1,5, 6, 22, although in meta-analyses we reviewed, the risk reduction has been reported to vary between 16-38% in subsets of different risk groups and gender. 3 18 We therefore set to evaluate our results in lowering LDL-C.
In our practice, 85% of patients achieved reduction in LDL-C.
Of patients in our practice who only used lifestyle and dietary and/or supplemental interventions, the reduction in LDL-C was 21% (36 mg/dL) from baseline values of 131-200 mg/dl, (average baseline LDL-C was 163 mg/dl). The range of LDL-C reduction was 2 to 77 mg/dl in individuals using lifestyle and nutrition modalities. Clinical studies show lifestyle strategies such as diet result in an average LDL-C reduction of 5-10% (5.6-8.9 mg/dL) from baseline (130 mg/dl or greater) after one year.10 In the Women’s Health Initiative randomized controlled trial, a small average LDL-C reduction of 3.55 mg/dL was achieved with dietary modification. Their baseline mean LDL-C was 133.3 mg/dL (lower than our population) and most of the participants in the dietary intervention group were in the primary prevention group rather than secondary prevention (only 4.1% had a history of cardiovascular disease). 19
The magnitude of LDL-C reduction can vary depending on the type of dietary change as well as the addition of other lifestyle interventions such as physical activity and weight loss, and addition of supplemental support.
Our patients treated with non-pharmacological modalities achieved greater reductions in LDL-C in comparison to what has been reported in the literature.
Of those patients who were on cholesterol lowering therapy (in most cases, statin-based therapy), the relative LDL-C reduction was 40.8% (69.4 mg/dl) on average from 130-215 mg/dl at baseline (average for baseline LDL-C was 170 mg/dl). The range of LDL-C reduction was 28 to 95 mg/dl in individuals on cholesterol-lowering therapy.
According to the literature, 37-60% of at-risk individuals achieve their target LDL-C goals (100 mg/dl or less) with standard therapies.7, 8, 9. Studies show that average reduction in LDL-cholesterol ranges from 30-50% with moderate and high intensity statin therapy, respectively. 2, 3 21
When interpreting data in the context of existing literature, it is important to recognize differences in populations treated, differences in their inherent risk and distinction in LDL-C goals (e.g., in secondary vs primary prevention or in high-risk vs lower risk individuals). For instance, in the Voyager study, 51% of study participants had atherosclerotic cardiovascular disease (ASCVD) and 29% had diabetes, hence target LDL-C goals were stricter. 4 Secondary prevention (prevention of another cardiovascular event in individuals who have already had a cardiovascular event) warrants stricter LDL-C goals and more aggressive pharmaceutical management, which translates to a need for a greater magnitude of the LDL-C reduction. In our cohort, all patients were in the primary prevention category, and many of them were low risk. Therefore, their LDL-C goals were less strict, and many did not warrant cholesterol lowering therapy, unless they had evidence of atherosclerosis on imaging. 20
Given their ASCVD (atherosclerotic cardiovascular disease) risk profile, most of our patients did not require such stringent reduction goals, per current guidelines. It is important to note however, that both of our patient groups – treated with and without pharmacotherapy, had a clinically meaningful reduction in LDL-C, conferring a cardiovascular risk reduction.
CRP
There are a wide variety of reasons why CRP may be elevated. Some are transient (e.g., acute infection) and others chronic (e.g., autoimmune condition or inflammation in relation to metabolic dysfunction, diet, poor dental health and/or intestinal hyperpermeability). Chronically elevated (CRP >= 3 mg/L) is associated with a higher cardiovascular risk and cancer risk.27
After implementing our practice’s protocols, 76% of our patients with elevated CRP reduced their CRP. Further subgroup analysis revealed that, on average, CRP levels were reduced by 57%. This demonstrates our effective approach in lowering systemic inflammation and thereby reducing cardiovascular and cancer risk factors.
There are several treatment modalities that can lower chronically elevated CRP – from nutrition to supplements and pharmacotherapy. In the JUPITER study, treatment with rosuvastatin 20 mg daily resulted in 40% CRP reduction after 1 year in individuals with a CRP >=2..11,23 Anti-inflammatory diet has been correlated with a higher likelihood of lower CRP (< 3 mg/L).24 Healthy plant-based diet is also associated with lower inflammation, and in individuals with low to moderate degrees of inflammation, a healthy plant-based diet was associated with lower mortality, especially among those with obesity. 25 Other dietary interventions have also been assessed in CRP lowering. Interestingly, whey protein, administered at >=20g/day, resulted in a small CRP reduction of 0.67mg/L when baseline CRP was >= 3. 26
Body Mass Index
In our practice, 84% of our patients with overweight or obesity achieved a reduction in BMI. It has been reported that the probability for individuals with overweight to achieve normal weight is 1 in 19 annually, and 1 in 1667 in those with BMI > 45.14 In comparison, in our patient cohort, 1 in 5 patients with overweight achieved normal BMI, and 4 in 10 achieved normal weight in GLP-1 assisted subgroup. Standard interventions demonstrated modest BMI reductions, with averages ranging from 0.5-2%. 15 16 17 Our subgroup analysis revealed an 11% average reduction in BMI among patients using GLP-1 agonist-assisted therapy (semaglutide or tirzepatide), compared to a 6% average reduction in BMI achieved through diet and lifestyle modifications alone relative to baseline values. Our outcomes demonstrate superior improvements in BMI compared to standard treatments. Note that given the short duration of some of the patients’ follow up, the full potential of GLP-1 agonist treatment and other modalities is not yet reflected in the data. Our expectation is that with longer follow up, we will see greater weight reduction towards optimal range.
Limitations of the review
The limitations of this review include a small sample size, given the boutique nature of our practice and given that patients that we see have a variety of conditions that we manage. Additionally, there is variation in the duration of patient engagement, as some individuals had only been with the practice for as little as six weeks before their initial and follow up data were analyzed, compared to others who were followed for up to 3 years and 8 months (data points were assessed 1/2021-10/2024). The duration of treatment can influence the observed outcomes. Similarly, our personalized, integrative treatment, while incorporating standard of care guidelines, does not follow a “one size fits all” approach. This can pose limitations when assessing treatment effectiveness in a population, given the personalization of approaches (e.g., dietary, lifestyle, supplemental, and medications). Similarly, it is important to further analyze data from individuals who did not have the desired magnitude of responses and assess possible reasons for this. It will be useful to examine to what degree various factors (e.g., adherence to treatment plan, genetic variation related to response to/side effects of medication or other treatment), influenced outcomes. Other factors related to patient education and care approaches, health coaching, nutrition support and other provider services should also be examined. For future analyses, it would also be important to include additional medical care and other support: e.g., patients who work with a specialist, a personal trainer, a therapist etc, and how these factors impact their results. Furthermore, given the relatively short follow-up time in a population that is being managed for primary prevention of cardiovascular events, we do not have outcome data on adverse vascular events, and hence rely on our markers and the literature to extrapolate outcome benefits of our interventions.
Conclusions
Our internal data review reveals superior outcomes in multiple cardiometabolic health markers among our patients compared to the standard of care. The percentage of individuals who achieved lower values in LDL-C, CRP, and BMI highlights the effectiveness of our comprehensive, patient-centered, data-driven approach.
We combine a team-based approach with personalized, bespoke treatment plans tailored to each patient’s unique needs and lifestyle. Through collaborative care, we offer accountability and consistency with regular physician and Integrative Health Advisor visits, empowering patients to take an active role in their health. By blending expertise from multiple disciplines, including internal medicine, integrative and functional medicine, nutrition, mind-body medicine and health coaching, we deliver a seamless and comprehensive care experience designed to achieve improved healthspan, optimal physical and mental function, and reduction in chronic conditions. Our team is committed to preventing chronic disease and fostering long-term health for each one of our patients.
Moving forward, our aim is to collect data to further evaluate care delivery, treatment and patient specific factors, to gain greater insights into optimizing our patients’ outcomes and experience. This commitment to data-driven evaluation will enable us to enhance patient care and tailor our interventions for better health outcomes. We will continue to monitor these metrics and refine our strategies to ensure optimal patient outcomes.
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These statistics are based upon our practice’s internal quality improvement review from 1/2021-10/2024. Past success rates are not determinative of an individual’s success. Specific patient results may vary.