**3. Lifestyle modification**

All patients with an elevated LDL should be advised to attempt and undergo for therapeutic lifestyle changes. Therapeutic lifestyle changes involve weight loss (even in those who are only slightly overweight), exercise, and improvement in diet. Numerous studies have investigated and demonstrated the benefits of lifestyle modification. In the United Kingdom Lipid Clinics Program study, 2508 subjects who underwent diet modification experienced a 5–7% reduction in serum total and LDL cholesterol [128]. In the Lifestyle Heart Trial, 53 patients were randomized to either control diet (National Cholesterol Education Program-NCEP step 2 diet) or vegetarian therapy with exercise and relaxation therapy (intervention group). After 5 years of follow-up, the intervention group demonstrated a decrease in CV events (0.89 vs 2.25 events per patient) [129]. In the Lyon Diet Heart Study, 605 patients were randomized after a first myocardial infarction to either a Mediterranean diet or a control diet. After 4 years of followup, the Mediterranean diet group demonstrated lower rates of death and myocardial infarction [130].
