Digital Repository Doctoral Projects Fall 2022 Lifestyle Changes for Cholesterol Benefit Shauna Bennee Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Bennee, S. (2022) Lifestyle changes for cholesterol benefit. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 1 Lifestyle Changes for Cholesterol Benefit by Shauna Bennee DNP-FNP, RN A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 _______________________________ ______________________________ Shauna Bennee, RN Date December 16, 2022 _______________________________ _____________________________ DNP Project Faculty (Electronic Signature) Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Diane Leggett-Fife, Ph.D., RN December 16, 2022 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 2 Table of Contents Abstract ---------------------------------------------------------------------------------------------------------- 4 Lifestyle Changes for Cholesterol Benefits ---------------------------------------------------------------- 6 Search Methods ------------------------------------------------------------------------------------------ 6 Background and Problem Statement ------------------------------------------------------------------ 7 Diversity of Population and Project Distribution --------------------------------------------------- 7 Significance for Practice Reflective of Role-Specific Leadership -------------------------------- 8 Hypercholesterolemia Literature Review and Framework ---------------------------------------------- 8 Incidence -------------------------------------------------------------------------------------------------- 9 Risk Factors----------------------------------------------------------------------------------------------- 9 Solutions ------------------------------------------------------------------------------------------------- 10 Statin Drug Therapy-------------------------------------------------------------------------------10 Diet--------------------------------------------------------------------------------------------------12 Activity---------------------------------------------------------------------------------------------13 Stress Reduction-----------------------------------------------------------------------------------14 Framework ----------------------------------------------------------------------------------------------- 14 Discussion ----------------------------------------------------------------------------------------------- 15 Implications for Practice ------------------------------------------------------------------------------- 15 Project Design ------------------------------------------------------------------------------------------- 16 Needs Assessment of Population and Gap Analysis ----------------------------------------------- 16 Cost Analysis and Sustainability of Project --------------------------------------------------------- 17 Project Outcomes --------------------------------------------------------------------------------------- 17 Consent Procedures and Ethical Considerations --------------------------------------------------- 18 Instruments to Measure the Effectiveness of Intervention ---------------------------------------- 18 Project Implementation -------------------------------------------------------------------------------- 18 Project Intervention ------------------------------------------------------------------------------------- 19 Eat Well--------------------------------------------------------------------------------------------20 Exercise--------------------------------------------------------------------------------------------20 Reduce Stress--------------------------------------------------------------------------------------20 This Multifaceted Lifestyle Intervention Aligns with Goals ------------------------------------- 20 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 3 Project Timeline ---------------------------------------------------------------------------------------- 21 Project Evaluation -------------------------------------------------------------------------------------- 21 Data Maintenance/Security ---------------------------------------------------------------------------- 21 Data Collection and Analysis ------------------------------------------------------------------------- 22 Findings -------------------------------------------------------------------------------------------------- 22 Figure 1 --------------------------------------------------------------------------------------------------- 23 Figure 2 --------------------------------------------------------------------------------------------------- 23 Figure 3 --------------------------------------------------------------------------------------------------- 24 Table 1 ---------------------------------------------------------------------------------------------------- 24 Strengths-------------------------------------------------------------------------------------------25 Weaknesses----------------------------------------------------------------------------------------25 Discussion----------------------------------------------------------------------------------------------------- 26 Translation of Evidence into Practice ---------------------------------------------------------------- 26 Implications for Practice and Future Scholarship -------------------------------------------------- 27 Sustainability -------------------------------------------------------------------------------------------- 27 Dissemination ------------------------------------------------------------------------------------------- 28 Conclusion ----------------------------------------------------------------------------------------------- 28 References ---------------------------------------------------------------------------------------------------- 29 Appendix A: Trifold Flyer ---------------------------------------------------------------------------------- 37 Appendix B: Website Link --------------------------------------------------------------------------------- 38 Appendix C: Exit Survey for Practitioners --------------------------------------------------------------- 39 Appendix D: Survey for Website Users ------------------------------------------------------------------ 40 Appendix E: Project Timeline ----------------------------------------------------------------------------- 41 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 4 Abstract Healthy lifestyle changes can impact hypercholesterolemia. Despite the effectiveness of statin drugs in reducing cholesterol, many patients deny this treatment. In addition to medications, practitioners need a resource to help their patients navigate making healthy lifestyle changes. An evidence-based, well-developed lifestyle website can be a tool for practitioners to offer patients that will benefit cholesterol levels. Purpose: This DNP project aims to provide practitioners with a toolkit they can confidently prescribe to patients that can benefit from making healthy lifestyle changes. Methodology: Practitioners were provided a trifold flyer to give patients directing them to the website titled “What’s your One?”. The website is built around three areas of focus: eating well, exercise, and stress reduction. A Qualtrics survey on the website asked patients if their practitioner discussed lifestyle changes with them and what area they would focus on. Analytics embedded into the site quantify users and their browsing patterns. A follow-up survey of practitioners evaluated if they plan to continue using the website, why or why not. Results: Data analysis showed 0 to 42 users over four months. The website analytics showed that 74.3% of users engaged with the meditation section, 54.3% went to the diet section, and 48.6% of users utilized the exercise section. Ninety percent of users were prescribed the website by their practitioner; 88.5% of those prescribed received education about the benefits of making healthy lifestyle changes. Of the eight family practitioners that trialed the lifestyle website, 100% said that they thought the website was beneficial to their practice, and 100% made favorable comments about it. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 5 Implications for Practice: For cholesterol benefits, practitioners can prescribe a multifaceted lifestyle change website for patients who deny statins, want to decrease their statin medication, or are at risk of hypercholesterolemia. Keywords: lifestyle change; toolkit for lifestyle change, hypercholesterolemia, Mediterranean diet, meditation, breathing for stress reduction. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 6 Lifestyle Changes for Cholesterol Benefits One of the most pervasive diseases of the modern era is hypercholesterolemia. Today, 29 million people in the United States have hypercholesterolemia (Centers for Disease Control and Prevention [CDC], 2020). Hypercholesterolemia is defined as a serum cholesterol level with LDL-C values greater than 130 mg/dL. Cholesterol is essential to support life and bodily functions. It is a compound required to make cell membranes and hormones; however, too much cholesterol can be the most significant contributor to cardiovascular disease (CVD). In addition, atherosclerotic buildup on the vessel walls can harden and narrow arteries blocking blood flow and oxygen to the brain, heart, and other organs. The buildup also contributes to dangerous plaque that can break off and lodge elsewhere in the body; it is the most common cause of heart attacks and strokes (McCance et al., 2019). There are currently two medical recommendations for these 29 million people, statin medications and healthy lifestyle changes (Arnett et al., 2019). However, non-compliance has been a long-standing challenge; 45% of these people will stop taking statin medication within the first year due to negative symptoms (Guglielmi et al., 2017), leaving them vulnerable to CVD and possible death. Non-compliance to statins places greater importance on the role of lifestyle changes in decreasing cholesterol levels. The CDC estimates that approximately 25% of CVD deaths could be prevented with diet changes and increased exercise (CDC, 2020). This project utilizes the most current science-based evidence in developing a ready-to-go healthy lifestyle toolkit for healthcare providers to assist them in treating hypercholesterolemia patients. This resource will help curb the escalating problem of hypercholesterolemia and CVD. Search Methods LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 7 Search terms for this project include lifestyle change, hypercholesterolemia, a clinical guide for diet and exercise, statin drugs, adherence to statin drugs, Mediterranean diet, barriers to a healthy lifestyle, nursing change theories, risk factors of high cholesterol, American Heart Association, motivation for a lifestyle change. Databases used were Google Scholar, PubMed, EBSCO, CINAHL, and Science Direct. Background and Problem Statement CVD continues to climb in the U.S. About 17 million deaths were linked to CVD worldwide in 2016; the World Health Organization (WHO) (2017) estimates that this number will increase to more than 23 million by 2030 (as cited in Ayatollahi et al., 2019). In addition, the American Heart Association states that the financial burden in the United States is more than 200 billion dollars yearly in lost productivity, patient healthcare management, and medications (Arnett et al., 2019). Uncontrolled cholesterol can lead to heart disease, strokes, and death. The principal aim of this project is to offer a plan for lifestyle modification to healthcare providers to use as they guide patients in lowering cholesterol levels. Practitioners already have a challenge taking care of disease and its consequences; the added time and cost required to organize a multifaceted lifestyle program for each patient makes this goal unrealistic (Brandt et al., 2018; Sturgiss & Douglas, 2016). An evidence-based lifestyle toolkit is a valuable way to support practitioners in making their job more attainable. Diversity of Population and Project Distribution This project targets two populations; healthcare providers and the end-user, their patients. The toolkit is accessed through a website distributed to ten nurse practitioners in the greater Salt Lake area; these practitioners have family practice clinics that serve diverse ages, ethnicities, and LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 8 socioeconomic backgrounds. The practitioner could then prescribe and make this toolkit accessible to any patients at risk for or who currently have hypercholesterolemia, whether or not they are taking medications as part of their intervention. It is then the patient's resource to use alone or with a support team they may choose to create. This toolkit has applications for anyone at risk for CVD or as a primary prevention tool. The Mediterranean diet followed in this program; has evidence-based credentials and the flexibility to suit multicultural tastes and preferences and meet special diet needs for vegetarians, vegans, or gluten-free patients. The exercise and stress reduction sections will be sensitive to different ages and skill levels. This toolkit reaches a diversity of cultures, ages, skill levels, and preferences. Significance for Practice Reflective of Role-Specific Leadership Every culture in the U.S. needs to be concerned with the mortal realities of hypercholesterolemia. Nurse leaders have a responsibility to improve the health of communities through education and programs to reduce high cholesterol in all populations. The core of all health begins with personal choice and a healthy lifestyle. As nurse leaders, providing nutritional lifestyle programs to practitioners and patients fulfills their responsibilities as community leaders. In addition, practitioners can recommend this lifestyle program to patients with increased confidence because of the evidence-based literature the toolkit reflects. Hypercholesterolemia Literature Review and Framework This literature review explores the most relevant aspects of lifestyle changes for improved cholesterol levels. Themes of incidence, risk factors, and solutions in diet, exercise, and stress management have become essential layers to developing this healthy lifestyle toolkit. In addition, evidence-based guidelines are significant in assuring the safety and efficacy of this project. Karl Lewin's Change Theory is the framework used for this project. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 9 Incidence Statistics show that 100 million people in the U.S. have cholesterol levels that put them in an at-risk category (CDC, 2020; Karr, 2017). With hypercholesterolemia as the most significant risk factor in CVD and peripheral vascular disease (PVD), the incidence of these diseases becomes very relevant. Twenty-five percent of all deaths in the U.S. are related to CVD, which accounts for 655,000 deaths per year and 37% of all premature deaths (CDC, 2020; Ma, 2018; WHO, 2017). CVD includes, but is not limited to, heart attacks, strokes, brain injuries, embolism, and deep vein thrombosis. About 43 million Americans are affected by PVD (Gul & Janzer, 2020). Another consequence of CVD is the economic burden in the United States; the cost of heart disease in 2014 was $219 billion (Arnett et al., 2019; CDC, 2020). This figure represents prescriptions, medical care, lost work time, and productivity due to early, unnecessary death. Risk Factors According to the American Heart Association (AHA, 2021; Arnett et al., 2019), heredity, an unhealthy diet, lack of exercise, and stress are among the biggest reasons for high cholesterol in the United States. Not only will familial hypercholesterolemia increase the risk of CVD by six times, but the risk of CVD will also happen 10-20 years sooner for males and 20-30 years sooner for females (Virani, 2020). Lifestyle choices of diet and exercise become central in impacting cholesterol levels. Aiming for a heart-healthy diet cannot be underestimated, as evidence supports the conclusion that the most prominent cause of early death and disability in the U.S. is an unhealthy diet (Mather et al., 2015; Murray, 2013). Physical activity is another essential lifestyle component stressed by many national and international associations necessary to help minimize CVD risk (AHA, 2021; CDC, 2020; WHO, 2017). In a study done with over 24,000 participants, regular LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 10 aerobic exercise and resistance training improved HDL-C, a component that helps endothelial function and may help prevent CVD risk (Hsu et al., 2019). It is important to note that the WHO and others point to additional underlying causes and risk factors of CVD. These risk factors include poverty, heredity, population aging, stress, and economic, social, and cultural changes like globalization and urbanization (Arnett et al., 2019; WHO, 2017). These risk factors are substantiated in the U.S. as well; considering 1.3 million Americans in low-income brackets that turned 35 years old in 2015, 250,000 of them will likely experience CVD before they are 65 years old (Hamad et al., 2020). Thus, there is a great need for evidence-based interventions to provide solutions for hypercholesterolemia, with many Americans at risk. Solutions Current solutions to hypercholesterolemia focus on lifestyle changes, including diet, activity, medications, and stress reduction. Because of the chronic progressive nature of this disease, the value of lifestyle changes accrues with consistency over time (Hill, 2021; O'Malley et al., 2020; Pascoe et al., 2017). The CDC estimates that approximately 25% of CVD deaths could be prevented through lifestyle changes and managing risk factors (CDC, 2020). In addition, national clinical guidelines recognize statin medications as the pharmacological solution of choice (Grundy et al., 2018; Reiter-Brennan et al., 2020; Virani et al., a2020). Statin Drug Therapy Statins are the mainstay of pharmacotherapy; they are a class of drugs that lower lipids by blocking the enzyme in the final reduction phase of cholesterol synthesis. In addition, statins also prove helpful as they remove the cholesterol from plaque, making it more stable and less likely to break off and travel, which can cause a thrombosis elsewhere. Statins can reverse endothelial LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 11 dysfunction and reduce the tendency for blood to clot. However, once a person follows a statin drug protocol, it takes about six months to begin to see clinical benefits (Rosenson, 2021). Despite the benefits and efficacy, adherence is extremely low for this gold standard medication. The unwillingness to take statins begins before the first prescription is ever picked up; 57.2% of patients with new prescriptions for statin drugs never filled the prescription, and 42.8% who did fill their original prescription but never started taking the medication (Maningat et al., 2013; Tarn et al., 2021). These patients had unfavorable perceptions about statin drugs, leading to their decision to act contrary to their provider's advice. Not only is primary non-adherence a problem, but even patients that have experienced a cardiovascular event are non-adherent to their statin drug therapy (Guglielmi et al., 2017). This study shows that only 61% of patients were still taking their statin prescriptions three months after their CV event; this number continued to drop to 55% after six months. Non-adherence to statin therapy is complex, but two themes stand out; the perceptions of statin use and the adverse side effects experienced are the critical reasons for non-adherence (Guglielmi et al., 2017; Maningat et al., 2013; Vrablik et al., 2019). Some of the perceptions surrounding statins are revealed as Golder et al. (2020) analyzed tweets made on Twitter, a social media platform. This perspective of spontaneous comments is relevant and unique. The perceptions ranged from statins being lifesaving to statins killing people. Some of the perceived fears surrounding statins are supported by research. Myalgia, defined as muscle weakness, pain, soreness, and cramping, impacts 10-24% of statin users (Auer et al., 2016; Vrablik et al., 2019). The Vrablik et al. (2019) study concluded that statin users were ten times more likely to develop myalgia or myopathy within 12 weeks of starting a statin therapy than if not on a statin. Ailments of myalgia, mood disorders, memory, and cognition, as well as LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 12 gastrointestinal, renal, and hepatic issues, were frequent complaints in the study. Another retrospective cohort study of 13,698 patients (after propensity score matching; 5273 statin users and 5273 non-statin users were studied) with no history of CVD or diabetes were cohort participants. The cases were reviewed 7.1 years later and showed that long-term statin drug therapy significantly increased the chances of developing type II diabetes (Na et al., 2020). Whether or not someone chooses to do statin drug therapy, many other valuable strategies are available. Diet One of the best strategies for improving high cholesterol is the Mediterranean diet; one of its hallmarks is lowering LDLs or 'bad cholesterol' (Mertens et al., 2014; O'Malley et al., 2020; Romagnolo & Selmin, 2017; USDA, 2020). In the Veterans clinical guidelines, O'Malley et al. (2020) cited a study reporting a 30% decrease in cardiovascular events for those high-risk patients following the Mediterranean diet. The American Heart Association explains that a heart-healthy diet is low in saturated fats found in red meats, processed meats, and fried foods; it is also low in sugar and moderate in alcohol and dairy consumption. In addition, eating a variety of fruits, vegetables, fish, nuts, and whole grains is essential to a heart-healthy diet (AHA, 2020; Arnett et al., 2019). Healthy, fresh foods are ideal for everyone; however, not everyone can access these foods. About 23 million people in the U.S. live in a food desert (United States Department of Agriculture, 2009). Food desert (F.D.) is defined as low-income, rural neighborhoods more than 10 miles away from a supermarket. People living in an F.D. are often limited to a corner mart or fast food as their primary food source. We see this reality of life and death in Chicago, where diabetic patients living in an F.D. have a death rate twice that of people with diabetes with access LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 13 to supermarkets (Curry, 2009). Statistics from the World Health Organization (WHO) and Fryar et al. (2012) concur with Curry's findings that low income is a risk factor for CVD. In the U.S., people in a low-income group were 60% more likely to have at least one of the three CV risk factors; high blood pressure, high cholesterol, and smoking. This number compares to 47% for middle-income people and 38% for higher-income brackets (Fryar et al., 2012; WHO, 2017). Activity Exercise is a vital part of the solution to decrease cholesterol and reduce CV risk. Clinical guidelines recommend 40 minutes of aerobic activity 3-4 times per week that is moderate to robust in intensity (American Heart, 2020; CDC, 2020; Physical Activity Guidelines, 2018). This amount of exercise time each week can be intimidating, so when striving to adhere to an activity program, it is essential to note that even exercising less than recommended is significantly beneficial. In a systematic review and meta-analysis that was done by Hupin et al. (2015), of the 835 reports screened show that a low dose of robust physical activity resulted in a 22% reduction in mortality risk for adults older than 60 years old (RR=0.78 (95% CI 0.71 to 0.87) p<0.0001). Finding activities that fit the patients' abilities and preferences will have greater adherence. For example, Tai Chi is easier for some of the older population and is even more effective at reducing cholesterol (Chan et al., 2019). Other elements of motivation are worth exploring when making lifestyle changes. A multifactorial lifestyle change can bring specific health improvements, but the motivation for change is complex. Seifert et al. (2012) observed that the rewards of feeling better, looking better, living longer, and even being free of disease are all intangible rewards connected to the distant future. The pull of instant gratification is stronger than the slow yield of delayed gratification. Sevild et al. (2020) delineate the benchmarks for starting and maintaining LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 14 motivation in a lifestyle change program. Participants were interviewed about the motivation required to start and maintain a new lifestyle program. Three concepts emerged: 1. Supportive relationships and environment were significant. 2. Coping strategies were required as life's challenges presented themselves. 3. Intrinsic skills like prioritizing, self-monitoring, and balancing daily life proved to be more lasting and impactful than extrinsic motivations. Sevild determined that increasing intrinsic skills and life balance are valuable stress reduction tools that can significantly improve health. Stress Reduction Reducing stress has lasting effects on physiological markers. In a meta-analysis of randomized controlled trials, 42 studies concluded that yoga and mindfulness practices could reduce physical stress markers, including LDL cholesterol (Pascoe et al., 2017). Coping strategies are necessary to meet stressful challenges in life; learning yoga, tai chi, and meditation will provide significant new insights and techniques to deal with daily stressors and unforeseen difficulties. Therefore, becoming well-practiced in yoga, tai chi, and meditation is worthwhile to significantly improve physiological and psychosocial well-being (Chan, 2018; Sevild et al., 2012). Mindful meditation, yoga, and deep breathing techniques are all promising interventions for stress reduction. These practices are easily accessible online through many free apps (American Heart Association, 2017; Newman et al., 2021). Framework This quality improvement project will use Karl Lewin's Change Theory; the basic premise is to unfreeze, change, then refreeze. The strength of this theory is its focus on fears and LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 15 uncertainty that create the resistance people feel when faced with changing behavior. The first stage, unfreeze happens as the patient realizes a change needs to take place. This occurs through patient assessments and practitioner education about the dangers of hypercholesterolemia; this will help create the need for change. Next, the multifaceted lifestyle toolkit will be offered as momentum for the next phase, bringing attention to the website's user-friendly nature, the support available, and the benefits to be gained. Hopefully, this will quell the patient's dubiety and bring a high level of motivation as they lean into the second step, change. The change phase will begin as the patient engages with the website incorporating the Mediterranean diet, exercise, and mindful practices into their daily living. The third phase, refreeze, will occur months later as the patient finds self-satisfaction and the positive feedback necessary to maintain new lifestyle changes (Shirey, 2013). Discussion Evidence shows that a Mediterranean diet, exercise, and stress reduction practices can improve hypercholesterolemia, reducing CVD risk (Becker et al., 2013). By implementing a multifaceted lifestyle change program, patients will have all the elements they need in one place for a successful lifestyle change and improved health outcomes. Barriers include the lack of social support within this project; motivation is harder to maintain when making complex changes alone. Further research to identify methods of maintaining motivation for long-term behavior modification would benefit anyone engaging in a lifestyle change effort. Implications for Practice Creating a multifaceted lifestyle change program will decrease the burden on practitioners to guide patients through lifestyle changes. The program is duplicatable, free, and accessible via the internet to any patients needing this benefit; it is also relevant and applicable across all LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 16 cultures. The evidence-based foundation of this project ensures its safety and efficacy for all users. Project Plan This project provides a toolkit for healthcare providers to utilize as an intervention for patients with high cholesterol at risk for cardiovascular disease (CVD). Eight family practitioners from the greater Salt Lake area recommended the multifaceted lifestyle change program as part of their prescription to patients needing to make lifestyle changes. This program is a nutrition, fitness, and stress management resource. Project Design This quality improvement project is a website accessed through a QR code found on an informational tri-fold flyer given to the patient by their provider (See Appendix A) The website is a motivating, user-friendly resource for accessing recipes, fitness videos, meditations, and educational references (See Appendix B). In addition, the provider can customize the patient's experience by setting goals together and appropriate follow-ups to create accountability. Needs Assessment of Population and Gap Analysis This toolkit is for patients with high cholesterol and the practitioners that care for them. This project recognizes that the home environment is a socially determining factor with a broad reach. Studies have shown that adults will likely repeat the childhood lifestyle present in their homes (Fonseca et al., 2018). Therefore, it is a social determinant of health to be raised in a home environment that promotes wellness through healthy choices. For practitioners who care for patients at risk of CVD, this quality improvement project bridges the gap in their ability to influence lifestyle changes for their patients. Practitioners already have a challenge taking care of LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 17 disease and its consequences; the additional time and cost required to organize a multifaceted lifestyle program for each patient make this goal unrealistic (Brandt et al., 2018). Along with patients and providers who will benefit from this evidence-based resource, other stakeholders, including insurance companies and community services driven by lifestyle preferences like grocery stores, community centers, and green spaces, will feel a positive impact. Most significantly, families for generations to come will reflect healthier lifestyles. Cost Analysis and Sustainability of Project Friends and family have donated approximately 85 person-hours required for the initial design and construction of the deliverables, tri-fold flyer, and website. Each practitioner started with 20 trifold flyers; the cost of these flyers was $159.00 at Kinkos Copy Center. This project will evolve into a paid subscription website that practitioners will pay for yearly: • The one-year subscription price for a clinic is $600.00. • Each clinic will pay for the flyers used at their clinic. There is no limit to the number of patients that can access the website. • Number of subscriptions required to cover costs; 25-30. Paid positions include: • DNP-FNP $10,000 /year for reviewing and controlling the website's content. • Technical assistant manages a website for $2,000.00 yearly (50 hours @ $40.00 hourly). • Personal assistant to oversee logistics and flyers. $2,500.00 - $4,500.00 (25.00 hourly, hours increasing over time). Project Outcomes The project outcomes serve to evaluate the following goals: • 50% of practitioners take the time to explain the benefits of a healthy lifestyle. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 18 • 60% of patients visiting the website are willing to make some lifestyle changes. • 50% of practitioners enrolled in the project will recommend the website to a patient(s). • 50% of practitioners find the website helpful and want to continue. Consent Procedures and Ethical Considerations The Institutional Review Board (IRB) at Weber State University has approved this project, stating that it meets the requirements for quality improvement. Practitioners determined who was safe to participate in the lifestyle change program; no further IRB approval was necessary. Project survey results are all anonymous and aggregated for analysis. Instruments to Measure the Effectiveness of Intervention Evaluation will take place as follows: • The QR code used to access the website is also the means of evaluation. The QR code will track how many people go to the website. • Analytics are embedded into the site to evaluate how long people engage with the site and what pages and resource links are popular. • An anonymous Qualtrics survey featuring three simple questions is easily accessible on the website for participants. These questions determine how they got to the site and their willingness to make lifestyle changes (See Appendix D). • A two-question survey was emailed to participating practitioners to determine if they found the program beneficial, why, or why not (See Appendix C). Project Implementation Initially, the implementation plan was to introduce practitioners to this DNP project in a monthly Utah Health Practitioners (UHP) meeting. However, the project was introduced individually because of the pandemic and social health concerns. Some practitioners declined LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 19 participation, stating they did not think it was a match or already had clinic lifestyle protocols. The participants comprised nurse practitioners and one medical doctor working in clinics stretching from Davis County to Utah County. Some practitioners own their businesses; others work for an established group. Project implementation began as practitioners recommended the "What's Your One?" website to patients with high cholesterol or at risk for high cholesterol. This lifestyle toolkit is an excellent resource for patients needing to make lifestyle changes. After discussing the significance of high cholesterol and the benefits of healthy lifestyle choices, providers gave a tri-fold flyer to appropriate candidates at their appointment. This trifold flyer briefly explains the program, and a QR code directed patients to the lifestyle change website titled "What's Your One?". This title promotes the idea of starting small as a realistic way to begin a healthier lifestyle. Project Intervention Lifestyle is a choice. What's Your One? website is an intervention that empowers participants with the satisfaction of feeling better, looking better, and lowering cholesterol levels. This intervention aimed to offer a toolkit to practitioners that they, in turn, felt confident in recommending to their patients needing to reduce cholesterol levels. This resource makes lifestyle change approachable and removes obstacles that prevent many patients from improving their cardiovascular health while it supports practitioners' efforts to serve their patients effectively. This project is a multifaceted approach to making necessary lifestyle changes. The website is a springboard of ideas and resources to inspire and motivate patients to begin on the path to better health. The website is easy and intuitive to navigate and formats well to a smartphone if preferred. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 20 Once patients were linked to the website, they were presented with three categories to choose from; Eat Well, Exercise, and Reduce Stress. Eat Well This intervention centers around the evidence-based Mediterranean diet. The Mediterranean diet is a philosophy of eating high in plant-based foods, including daily amounts of fruits, vegetables, whole grains, and healthy fats. Fish, seafood, and omega-3 rich foods are eaten three times per week, while poultry, eggs, and dairy are consumed twice weekly. In addition, the diet recommends that red meats and sweets be enjoyed sparingly. The What's Your One? website provides guidelines from the American Heart Association, recipes, links to great Mediterranean websites, and even a question-and-answer video from a dietician about the Mediterranean diet. Exercise The exercise section is user-friendly and offers links to exercise videos that are free of charge and do not require any special equipment to participate. There are three levels of intensities to choose from, and the length of the videos ranges from eight to twenty minutes each. Conceptually, as patients participate and enjoy moving, they will transfer that enthusiasm to additional activities. Reduce Stress This part of the intervention offers meditation resources, links for sleeping applications, breathing techniques, and yoga practices. The stress reduction section also provides recommended reading and listening resources for increased motivation and education on stress reduction. This Multifaceted Lifestyle Intervention Aligns with Goals Inspiring a healthier approach to daily living is the means to the overarching goal of reducing cholesterol levels. This intervention is a starting point for participants; as they have LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 21 gained new levels of confidence and experience, hopefully, they will continue to embrace healthy living. Ideally, practitioners set measurable goals with patients and followed up at subsequent appointments to track compliance and measure cholesterol levels. Practitioners utilized the toolkit for three months; at which time they completed a brief exit survey (see Appendix C) as part of the evaluation. An additional evaluation tool came from a survey link found on the website for participants (see Appendix D). Embedded analytics served as another evaluation tool to examine the participants' usage patterns. Project Timeline The timeline began with the literature review, followed by the development of deliverables. Implementation was next after Weber State IRB approved the project. The implementation period continued for three months and concluded with a compilation of data and a final review before peers and faculty. The table in Appendix E was a tool used to stay on task during this process. Project Evaluation This DNP project is a resource for practitioners to improve their toolbox in helping patients reduce cholesterol. The patient is the end-user of the project and the best measure of the inherent value it provides. The project evaluation measures the practitioner and the patient using simple instruments to gauge compliance and interest. The evidence presented indicates that lifestyle changes can positively benefit participants' cholesterol levels. Therefore, this evaluation does not attempt to measure cholesterol changes but rather the usability and interest in a program that offers a multifaceted approach to making lifestyle changes. The project's goal is to assist the practitioner in having a lasting influence on a patient's lifestyle choices. Data Maintenance/Security LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 22 Following the practitioner's recommendation, patients accessed the website from their personal devices. The Qualtrics surveys found on the website were anonymous, and only the answers were accessible for analysis. Practitioners received a follow-up survey by email from a password-protected computer; after the answers were cataloged and evaluated, the names were electronically deleted. Data Collection and Analysis The quantitative data collected from the website was divided into three graphs. First, a line graph identified active users and their endurance with the website for the past four months. Pie charts and a bar graph were used to accentuate numerical proportions and frequencies for answers to the questions asked. Finally, the follow-up survey was quantitative (yes/no answer) and qualitative - an explanation of their yes or no answer. The qualitative data were classified as favorable or unfavorable and notated in Table 1. Findings The findings showed that 88.5% of practitioners educated their patients about the importance of making healthy lifestyle changes (See Figure 1). Stress reduction (meditation) was the most popular section initially, with 74.3% of patients selecting the meditation section as their first choice to focus on, followed by diet at 54.3%, and exercise showed 48.6% initial interest (See Figure 2). The active user's line graph shows a steep incline initially, with a taper down over the next two months (see Figure 3). This data suggests an initial interest in the website, but endurance with the website only lasted about two months. This information has two implications: one, those lifestyle changes are challenging to maintain; and two, there was not enough website content to hold users' interest beyond two months. The incline in June and July results from additional LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 23 practitioners engaging in the program. Eight practitioners engaged in this project: 100% answered "yes," they thought the website was beneficial to their practice, and 100% of the practitioners had favorable comments about why they thought the website was beneficial (See Table 1). Figure 1 Did the Practitioner Explain the Benefits of Lifestyle Changes? * * 35 responses Figure 2 User’s Preferred Area of Focus * * 35 responses LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 24 Figure 3 Active Website Users Jan.1, 2022- July 17, 2022 Table 1 Exit Survey Results Practitioner Was the website beneficial to your practice? Practitioners’ responses to the website Yes No Favorable Not Favorable 1 x x 2 x x 3 x x 4 x x 5 x x 6 x x 7 x x 8 x x LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 25 Strengths The first strength of this project is the quality of the website; it is user-friendly and offers excellent material and free resources. The content on the website is evidence-based and current with the culture and trends. Determining how many active users are accessing the website on any given day is the second strength of this project. Tracking highs, lows, and trends allow analyzers to extrapolate data conclusions. Seeing the drop-off of active users after two months of engaging with the website is excellent information; it suggests that follow-up from the practitioner, goal setting, and continual influx of new material may be helpful to achieve increased user longevity. Another notable strength of the project is the practitioner and patient education before engaging on the website. This education will improve patient motivation to make lifestyle changes. In addition, discovering through data that there is a significant interest in meditation is helpful; perhaps patients have the least experience with meditation and welcome guidance in that area. Another way to capitalize on this information is to change or add meditations weekly and offer different stress reduction modalities to keep the interest high. Weaknesses One of the project weaknesses is that there is no synchronized start time; practitioners prescribe the website to patients as they have appointments, making it harder to derive conclusions from the active user data. A second weakness is the lack of qualitative information from the end-users: What is working? What is not working? Why did they stay with the site, or why did they lose interest? A third weakness is the lack of accountability and follow-up built into this program. Through goal setting and scheduled follow-ups, people maintain momentum better to do hard things like making lifestyle changes. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 26 Discussion This project responds to the significant need to reduce hypercholesterolemia in this country. The CDC (2020) reports that 29 million people in the United States objectively fall into this classification. This project aims to offer providers a way to enhance their toolbox as they guide patients in lifestyle modifications. Eight practitioners had access to a multifactorial website to simplify and inspire patients as they made needed lifestyle changes. Translation of Evidence into Practice The CDC makes a convincing statement when they estimate that 25% of CV deaths could be eliminated by managing risk factors and making lifestyle changes (CDC, 2020). This project aimed to address CV risk factors through a lifestyle website called "What's Your One?"; this website is a collection of links and resources addressing areas of diet, activity, and stress reduction. The Mediterranean diet is the framework that inspires recipes found on the "What's Your One?" website. One study validating the value of this diet is discussed in the Veterans clinical guidelines, reporting a 30% decrease in cardiovascular events for high-risk patients following the Mediterranean diet (O'Malley et al., 2020). While the gold standard for exercise includes 40 minutes of robust aerobic activity 3-4 times per week (American Heart, 2020; CDC, 2020), this project also recognizes the work of Hupin et al. (2015), showing that even a low dose of robust physical activity resulted in a 22% reduction in mortality risk. Accordingly, the exercise element in this website has activity links and resources ranging from low effort to high effort, depending on the person's level of time, fitness, and motivation. Stress reduction is the final focus of great importance to this project because of its measurable impact on reducing cholesterol. A Pascoe et LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 27 al. (2017) meta-analysis showed that yoga and mindfulness could reduce LDL cholesterol. Breathing techniques, yoga, and mindfulness are all found on the “What's Your One?” website. The outcomes for this project were met convincingly, demonstrating that practitioners favor a ready-made lifestyle website they can confidently prescribe to patients with cardiovascular risk. In addition, the results show that such practitioner recommendations motivate patients to make lifestyle changes to varying degrees. This knowledge is valuable to any practitioner wanting to be more effective in helping patients reduce cholesterol or risk factors for CVD. Implications for Practice and Future Scholarship The implications of this knowledge connote that a lifestyle website is helpful when inspiring patients to make needed changes. Will the patients adhere to the practitioners' recommendations? Will the patients continue using the website? These are questions for further scholarship. Making lifestyle changes is challenging at best. The study of motivation and endurance generated in a clinical setting calls for better understanding in future studies. How significant are goal setting and accountability in creating motivation for change? Additionally, a scholarship project could test concepts brought to light through the work of Sevild et al. (2020). This study suggested the following elements are required to maintain proper motivation while making lifestyle changes: 1) Supportive relationships and environment, 2) Strategies for coping with life's challenges 3) Intrinsic skills like prioritizing, self-monitoring, and balancing daily life. Sustainability "What's Your One?" website is a working template for any practitioner to step in and use. It is made with WordPress software that can be easily customized to fit any practitioner's protocols, only requiring upkeep from the office staff to keep the website fresh and current. The blueprint for sustaining this project is a subscription-based revenue model that allows dynamic LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 28 customization for clinics and providers. This project provides a head start on either of these sustainable options. Dissemination This project will be disseminated using a video to include a complete tour through the website as the project concepts are discussed. A verbal and poster presentation were delivered to the Weber State nursing faculty and fellow DNP students. This project continues to be available online through the Weber State University Doctor of Nursing Practice Project repository (https://weber.edu/Nursing/GradProjects.html). In addition, the plan is to share this project with the Utah Health Practitioners group, a group of family nurse practitioners and medical doctors (MDs) that meet monthly to discuss and educate each other about relevant topics. Their practices range from Davis County to Utah County. Another option is to present this video as a vendor at a national conference signing practitioners up for an ongoing subscription to the website. Conclusion Uncontrolled cholesterol can lead to heart disease, strokes, and death. While practitioners acknowledge the value of lifestyle modifications for cholesterol benefits, creating a customized multifaceted lifestyle change program for each patient is not realistic in their already busy schedule. One hundred percent of the participating practitioners said they thought the project was helpful and would recommend it to future patients. The knowledge gained in this project demonstrates that family practitioners desire an evidence-based lifestyle website that invites and motivates their patients to make needed lifestyle changes. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 29 References American Heart Association (AHA). (2021). Causes of high cholesterol. www.heart.org. https://www.heart.org/en/health-topics/cholesterol/causes-of-high-cholesterol American Heart Association (AHA). (2017). Meditation to boost health and well-being. www.heart.org. https://www.heart.org/en/healthy-living/healthy-lifestyle/mental-health-and-wellbeing/meditation-to-boost-health-and-wellbeing. American Heart Association (AHA). (2020). What is the Mediterranean Diet? www.heart.org. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet. Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., Himmelfarb, C. D., Khera, A., Lloyd-Jones, D., McEvoy, J. W., Michos, E. D., Miedema, M. D., Muñoz, D., Smith, S. C., Virani, S. S., Williams, K. A., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: Executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation, 140(11). Article e596-e646. https://doi.org/10.1161/cir.0000000000000677 Auer, J., Sinzinger, H., Franklin, B., & Berent, R. (2016). Muscle-and skeletal-related side-effects of statins: Tip of the iceberg? European Journal of Preventive Cardiology, 23(1), 88–110. https://doi.org/10.1177/2047487314550804 Ayatollahi, H., Gholamhosseini, L., & Salehi, M. (2019). Predicting coronary artery disease: A comparison between two data mining algorithms. BMC Public Health, 19(1). Article 448. https://doi.org/10.1186/s12889-019-6721-5 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 30 Becker, D. J., French, B., Morris, P. B., Silvent, E., & Gordon, R. Y. (2013). Phytosterols, red yeast rice, and lifestyle changes instead of statins: A randomized, double-blinded, placebo-controlled trial. American Heart Journal, 166(1), 187–196. Article e2. https://doi.org/10.1016/j.ahj.2013.03.019 Brandt, C. J., Søgaard, G. I., Clemensen, J., Sndergaard, J., & Nielsen, J. B. (2018). General practitioners’ perspective on eHealth and lifestyle change: Qualitative interview study. JMIR MHealth and UHealth, 6(4). Article e88. https://doi.org/10.2196/mhealth.8988 Centers for Disease Control and Prevention [CDC]. (2020). High cholesterol facts. https://www.cdc.gov/cholesterol/facts.htm Chan, A. W. K., Chair, S.Y., lee, D.T.F., Leung, D.Y. P., Sit, J. W. H., Cheng, H.Y., & Taylor-Piliae, R.E. (2018). Tai Chi exercise more effective than brisk walking in reducing cardiovascular disease risk factors among adults with hypertension: A randomized controlled trial. International Journal of Nursing Studies, 88, 44-52. https://doi.org/10.1016/j.ijnurstu.2018.08.009 Underline removed and spelling corrected Curry, A. (2009). Bringing healthy fare to big-city. Diabetes Forecast. https://archives.diabetesforecast.org/2009/dec/bringing-healthy-fare-to-big-city-food-deserts.html Fonseca, A. L., Koyama, J., & Butler, E. A. (2018). The role of family of origin in current lifestyle choices: A qualitative secondary data analysis of interracial and same-race couples. Family & Community Health, 41(3), 146–158. https://doi.org/10.1097/FCH.0000000000000188 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 31 Fryar, C. D., Chen, T.-C., & Li, X. (2012, August). Prevalence of uncontrolled risk factors for cardiovascular disease: The United States, 1999–2010. https://www.cdc.gov/nchs/data/databriefs/db103.pdf Golder, S., O’Connor, K., Hennessy, S., Gross, R., & Gonzalez-Hernandez, G. (2020). Assessment of beliefs and attitudes about statins posted on Twitter. JAMA Network Open, 3(6). Article e208953. https://doi.org/10.1001/jamanetworkopen.2020.8953 Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., . . . Yeboah, J. (2018) AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Journal of the American College of Cardiology, 73(24), e285–e350. https://doi.org/10.1016/j.jacc.2018.11.003 Guglielmi, V., Bellia, A., Pecchioli, S., Della-Morte, D., Parretti, D., Cricelli, I., Medea, G., Sbraccia, P., Lauro, D., Cricelli, C., & Lapi, F. (2017). Effectiveness of adherence to lipid-lowering therapy on LDL-cholesterol in patients with very high cardiovascular risk: A real-world evidence study in primary care. Atherosclerosis, 263, 36–41. https://doi.org/10.1016/j.atherosclerosis.2017.05.018 Gul, F., Janzer S. F. (November 2020). Peripheral vascular disease. StatPearls. NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK557482/ Hamad, R., Penko, J., Kazi, D. S., Coxson, P., Guzman, D., Wei, P. C., Mason, A., Wang, E. A., Goldman, L., Fiscella, K., & Bibbins-Domingo, K. (2020). Association of low socioeconomic LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 32 status with premature coronary heart disease in US adults. JAMA Cardiology, 5(8), 899. https://doi.org/10.1001/jamacardio.2020.1458. Hill, M. F. (2021, February 7). Hyperlipidemia. StatPearls. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559182/ Hsu, C.-S., Chang, S.-T., Nfor, O. N., Lee, K.-J., Lee, S.-S., & Liaw, Y.-P. (2019). Effects of regular aerobic exercise and resistance training on high-density lipoprotein cholesterol levels in Taiwanese adults. International Journal of Environmental Research and Public Health, 16(11). Article 2003. https://doi.org/10.3390/ijerph16112003 Hupin, D., Roche, F., Gremeaux, V., Chatard, J. C., Oriol, M., Gaspoz, J. M., Barthélémy, J. C., & Edouard, P. (2015). Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: A systematic review and meta-analysis. British Journal of Sports Medicine, 49(19), 1262–1267. https://doi.org/10.1136/bjsports-2014-094306 Karr, S. P. (2017). Epidemiology and management of hyperlipidemia. AJMC. https://www.ajmc.com/view/epidemiology-and-management-of-hyperlipidemia-articl Ma, H. (2018) Cholesterol and human health. http://www.sciencepub.net/nature/0204-supplement/04-mahongbao.pdf Maningat, P., Gordon, B. R., & Breslow, J. L. (2013). How do we improve patient compliance and adherence to long-term statin therapy? Current Atherosclerosis Reports, 15(1). Article 291. https://doi.org/10.1007/s11883-012-0291-7 Mather, M., & Scommenga, P. (2015, September). Up to half of U.S. premature deaths are preventable; Behavioral factors Key. PRB. https://www.prb.org/resources/up-to-half-of-u-s-premature-deaths-are-preventable-behavioral-factors-key/. LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 33 McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby. Mertens, E., Mullie, P., Deforche, B., Lefevre, J., Charlier, R., Huybrechts, I., & Clarys, P. (2014). A cross-sectional study on the relationship between the Mediterranean diet score and blood lipids. Nutrition Journal, 13(1), 88. https://doi.org/10.1186/1475-2891-13-88 Murray, C. J. (2013). The State of US Health, 1990-2010. JAMA, 310(6), 591-608. https://doi.org/10.1001/jama.2013.13805 Na, E., Cho, S., Kim, D. J., Choi, J., & Han, E. (2020). Time-varying and dose-dependent effect of long-term statin use on the risk of type 2 diabetes: A retrospective cohort study. Cardiovascular Diabetology, 19(1). Article 67. https://doi.org/10.1186/s12933-020-01037-0 Newman J, K., Ho, J., Barron, K., Bahl-Milne, S., Whitney-Coulter, A., Naidoo, U., Smookler, E., Fisher, J., Angangco, T., & Wolkin, J. (2021, April 29). Five free mindfulness apps worthy of your attention. Mindful. https://www.mindful.org/free-mindfulness-apps-worthy-of-your-attention/. O’Malley, P.G., Arnold, M.J., Kelley, C., Spacek, L., Buelt, A., Natarajan, S., Donahue, M.P., Vagichev, E., Ballard-Hernandezk J., Logan, A., Thomas, L., Ritter, J., Neubauer, B.E., & Downs, J.R. (2020). Management of dyslipidemia for cardiovascular disease risk reduction: Synopsis of the 2020 updated U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Annals of Internal Medicine, 173(10), 822-829. https://doi.org/10.7326/m20-4648 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 34 Pascoe, M. C., Thompson, D. R., & Ski, C. F. (2017). Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta-analysis. Psychoneuroendocrinology, 86, 152–168. https://doi.org/10.1016/j.psyneuen.2017.08.008 Physical Activity Guidelines Advisory Committee, Buchner, D. M., Campbell, W., DiPietro, L., Erickson, K., Hillman, C., Jakicic, J. M., Janz, K. F., Katzmarzyk, P., King, A. C., Kraus, W. E., Macko, R. F., Marquez, D. X., McTiernan, A., Pate, R. R., Pescatello, L. S., Powell, K. E., & Whitt-Glover, M. (2018). Physical activity guidelines for Americans (2nd edition). https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf Reiter-Brennan, C., Osei, A. D., Iftekhar Uddin, S. M., Orimoloye, O. A., Obisesan, O. H., Mirbolouk, M., Blaha, M. J., & Dzaye, O. (2020). ACC/AHA lipid guidelines: Personalized care to prevent cardiovascular disease. Cleveland Clinic Journal of Medicine, 87(4), 231–239. https://doi.org/10.3949/ccjm.87a.19078 Romagnolo, D. F., & Selmin, O. I. (2017). Mediterranean diet and prevention of chronic diseases. Nutrition Today, 52(5), 208–222. https://doi.org/10.1097/nt.0000000000000228 Rosenson, R. S. (2021). Statins: Actions, side effects, and administration. https://www.uptodate.com/contents/statins-actions-side-effects-and-administration#references Seifert, C. M., Chapman, L. S., Hart, J. K., & Perez, P. (2012). Enhancing intrinsic motivation in health promotion and wellness. American Journal of Health Promotion, 26(3), 1–12. https://doi.org/10.4278/ajhp.26.3.tahp Sevild, C. H., Niemiec, C. P., Bru, L. E., Dyrstad, S. M., & Husebø, A. M. L. (2020). Initiation and maintenance of lifestyle changes among participants in a healthy life center: A LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 35 qualitative study. BMC Public Health, 20(1), 1006–1018. https://doi.org/10.1186/s12889-020-09111-8 Shirey M. R. (2013). Lewin's Theory of Planned Change as a strategic resource. The Journal of Nursing Administration, 43(2), 69–72. https://doi.org/10.1097/NNA.0b013e31827f20a9 Sturgiss, E. A., & Douglas, K. (2016). A collaborative process for developing a weight management toolkit for general practitioners in Australia—an intervention development study using the Knowledge to Action framework. Pilot and Feasibility Studies, 2(1). Article 20. https://doi.org/10.1186/s40814-016-0060-4 Tarn, D. M., Pletcher, M. J., Tosqui, R., Fernandez, A., Tseng, C. H., Moriconi, R., Bell, D. S., Barrientos, M., Turner, J. A., & Schwartz, J. B. (2021). Primary nonadherence to statin medications: Survey of patient perspectives. Preventive Medicine Reports, 22. Article 101357. https://doi.org/10.1016/j.pmedr.2021.101357 Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S., Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T., . . . Tsao, C. W. (2020). Heart disease and stroke statistics—2020 update: A report from the American Heart Association. Circulation, 141(9), 139–596. https://doi.org/10.1161/cir.0000000000000757 Vrablik, M., Catapano, A. L., Wiklund, O., Qian, Y., Rane, P., Grove, A., & Martin, M. L. (2019). Understanding the patient perception of statin experience: A qualitative study. Advances in Therapy, 36(10), 2723–2743. https://doi.org/10.1007/s12325-019-01073-7 LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 36 United States Department of Agriculture. (2009) 11 Facts about food deserts. DoSomething.org. (n.d.). https://www.dosomething.org/us/facts/11-facts-about-food-deserts. USDA. (2020). Dietary guidelines for Americans 2020-2025. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf World Health Organization. (2017). Cardiovascular diseases (CVDs) https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 37 Appendix A: Trifold Flyer LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 38 Appendix B: Website Link http://whatsyourone.net/ LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 39 Appendix C: Exit Survey for Practitioners 1. Did you find the website What’s Your One? (www.whatsyourone.net) beneficial in your practice? 2. Why or why not? LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 40 Appendix D: Survey for Website Users LIFESTYLE CHANGES FOR CHOLESTEROL BENEFIT 41 Appendix E: Project Timeline TASK START COMPLET E Planning Phase Literature Review 1/1/21 8/9/21 Developed Deliverables 7/31/21 5/13/22 Weber State IRB application 10/ 1/21 2/28/22 Planning and projecting dates for UHP with UHP president 2/17/22 6/15/22 Implementation Present Project to UHP Group 8/1/22 8/1/22 Deliver Trifolds with Instructions 5/30/22 8/15/22 Practitioners Begin Implementation 6/1/22 8/15/22 Practitioner Exit surveys 8/2/22 9/10/22 Evaluation Compile Qualtrics Survey, Website Analytics, Practitioner Survey 8/30/22 9/15/22 Follow-up meeting with Faculty Member to Discuss Results 9/15/22 9/15/22 Complete project evaluation and dissemination 9/30/22 11/15/22