Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States and globally [1]. The annual estimated cost of CVD in the United States is over US $200 billion in health care services, medications, and lost productivity. Dyslipidemia has been established as a strong risk factor for CVD. It has been estimated that one in three adults in the United States has dyslipidemia [2]. Dyslipidemia refers to elevated total cholesterol, low-density lipoprotein cholesterol (LDL-C), or triglycerides, or low levels of high-density lipoprotein cholesterol (HDL-C) [3]. While this condition can be due to genetic factors, it is usually associated with unhealthy lifestyle behaviors such as poor diet and physical inactivity.

Atherogenic lipoproteins play an important role in the initiation and progression of atherosclerosis; therefore, maintaining optimal lipid levels is crucial for achieving ideal cardiovascular health [4]. LDL and other apolipoprotein B–containing lipoproteins slowly accumulate in the artery wall early in life, which eventually can result in large amounts of atherosclerotic plaque. This can lead to obstruction of blood flow, which could cause cardiovascular events such as acute coronary syndrome and myocardial infarction. Statins are the most commonly prescribed lipid-lowering drug in patients with dyslipidemia. Other LDL-lowering drugs include PCSK9 inhibitors, ezetimibe, and bile acid sequestrants [5]. Despite high awareness of abnormal lipid levels (>80%), statin use has been found to be low (37.6%) among adults with severe dyslipidemia [2]. Issues with nonadherence or unwillingness to take cholesterol-lowering medications pose obstacles to reducing CVD risk.

For years, guidelines have suggested dietary modification to be a crucial component in strategies to reduce CVD risk [5,6]. Diet has been shown to have a major impact on lipid levels and CVD [7,8]. Studies have suggested that nuts, plants, and fiber-rich foods may reduce LDL-C levels [3]. Additionally, a dietary pattern low in saturated fats, low in refined carbohydrates, and rich in unsaturated fatty acids and proteins has been shown to be successful in reducing plasma LDL-C levels [9,10]. Despite the strong associations between dietary changes and cholesterol levels, many patients fail to adopt a healthy dietary pattern or make lasting changes. Thus, adoption and sustainability of a healthy diet are critical issues.

Many barriers to adopting and sustaining a healthy dietary pattern exist, such as time, cost, accessibility, and knowledge. Foodsmart is a digital nutrition and meal planning platform that is designed to make healthier eating achievable and sustainable among the general population, and it addresses the most common barriers to eating well. Foodsmart uses a multipronged approach including educating individuals on how to eat healthy, leveraging the food frequency questionnaire, recommending personalized healthy recipes based on food preferences, and automating grocery list creation and online grocery purchasing, all while tracking the individual’s improvements in biometrics. The platform has been found to be associated with at least 5% weight loss and has been shown to sustain weight loss over 3 years [11,12]. Previous research has suggested that by simply cooking at home rather than ordering food or eating out, diet quality improves [13]. Therefore, this digital platform that uses precision nutrition to encourage healthier eating and sustained practices has broad potential to improve important health markers such as lipid levels.

While many digital applications seek to improve eating behaviors and health outcomes, few studies have evaluated their effectiveness for changing lipid levels among users with dyslipidemia. The aim of this study was to examine the characteristics of users with dyslipidemia and evaluate the changes in lipid markers over time.

In our study, of 653 users who reported at least two lipid markers, we found that 54.1% (353/653) of participants had dyslipidemia at baseline, and of those, 36.3% (128/353) showed improvements in their lipid levels to normal by the end of follow-up. Participants with dyslipidemia at baseline were more likely to be older, be male, and have a higher weight and BMI. Baseline obesity and Nutriscore were associated with a higher likelihood of achieving normal lipid levels. Between the start and end of using the Foodsmart platform, total cholesterol, cholesterol ratio, LDL-C, and triglycerides all significantly decreased and HDL-C significantly increased. These findings suggest that usage of the Foodsmart platform may be associated with improvements in lipid markers, most likely through improved diet quality.

The results of this study support the findings of previous studies that found beneficial effects of dietary interventions on lipid levels among people with dyslipidemia. A meta-analysis of over 200 studies that examined the impact of dietary interventions on cholesterol levels found that a reduction in saturated fats and an increase in polyunsaturated fats were primary factors in lowering total cholesterol levels [19]. Another meta-analysis of 60 trials found that replacing trans fats with polyunsaturated fats was successful in improving blood lipids [20]. Increasing dietary soluble fiber has also been shown to decrease total and LDL cholesterol levels, although the effect was modest (5 mg/dL) [21]. In the landmark PREDIMED randomized controlled trial that tested the effect of two Mediterranean-style dietary patterns against a low-fat dietary pattern among participants at high risk of CVD, investigators found that just after 3 months, the cholesterol ratio decreased by 0.38 and 0.26 for a Mediterranean-style diet supplemented with extra-virgin olive oil and nuts, respectively [22].

Though the association between diet and cholesterol is strong and has been established for decades, implementing and sustaining behavior change in real life, especially with diet, is complex and challenging. It has been noted that physicians face many challenges in encouraging behavior change to improve lipid profiles and other CVD risk factors in patients [23]. A review found that patients who received dietary advice reduced total cholesterol levels by 6.2 mg/dL and LDL-C by 7.0 mg/dL, although there were no significant changes in HDL-C [24]. Another review found that dietitian advice was more successful in reducing cholesterol levels compared to physician advice (−9.7 mg/dL difference for total cholesterol), although it was not better than self-help materials [25]. There is sparse evidence of a digital intervention improving cholesterol levels, especially among commercial nutrition applications.

The annual per person expenditure related to dyslipidemia among people without CVD has been estimated to be about US $856 [26]. Annual national expenditure has been estimated to be US $23.1 billion. The majority of expenditures (59%-90%) were attributable to prescription medications, namely statins. High-intensity statins, such as rosuvastatin and atorvastatin, can lower LDL-C by 50% or more, while moderate-intensity statins lower LDL-C by 30%-49% and low-intensity statins lower LDL-C by less than 30% [5]. While statins have generally been regarded as safe, there are some side effects, such as myalgia, which is observed in 5%-20% of patients, leading to nonadherence [5]. Additionally, patients who are initially adherent to statin therapy may not continue to have long-term adherence for other reasons [27,28]. While PCSK9 inhibitors can result in further reductions in LDL-C and reduce risks of cardiovascular events, cost-effectiveness models have suggested that their high costs do not outweigh the potential benefits yet [5,29]. Given the high pharmaceutical costs of treating dyslipidemia, with questionable adherence, prevention and treatment of high cholesterol through a healthy diet can be considered an attractive option. Unfortunately, we did not have information on whether participants were on statins or other cholesterol-lowering medications. Therefore, we do not know whether participants had started taking medications before enrolling in Foodsmart, and if so, for how long they had been taking medications. Despite this lack of data, we sought to make a ballpark comparison of price points in lowering lipid levels between Foodsmart and prescription medications. Digital platforms represent an affordable alternative, as the mean annual cost for the Foodsmart platform is US $12.30 per eligible member as of 2021. Based on our analysis, the cost per 1% reduction in LDL-C was US $0.95 using Foodsmart. In the case of statins, on the low end, it would cost US $12.89 per 1% reduction in LDL-C for lovastatin (20 mg), and on the high end, it would cost US $77.50 per 1% reduction in LDL-C for rosuvastatin (10 mg) [30,31]. From these calculations and assuming that participants in the analysis were not on cholesterol-lowering medications, we estimate that a digital platform like Foodsmart is 93% to 99% more affordable per 1% reduction in LDL-C compared with standard statin treatment.

The present study has several limitations worth addressing. The first is that all lipid measurements were self-reported and were not validated. However, in a validation study among about 40,000 female health professionals in the Women’s Health Study, investigators found that the Spearman correlation coefficients between self-reported and blood samples for triglycerides and HDL-C were 0.57 and 0.63, respectively [32]. This suggests there is moderate correlation between self-reported and blood measures. Since users were not obligated to enter their cholesterol levels, it is more likely that people who did report their lipid levels had accurate reports (no guessing) and entered them into the app for the purpose of tracking. This also means that our participant pool may be subject to selection bias, as participants who were more aware of their cholesterol levels, possibly due to having a health condition, were more likely to be in our sample. Another limitation is that we unfortunately did not have participants’ medical history or medication use. Participants may have been on cholesterol-lowering medications, which could have contributed to improvements in lipid levels. We also did not know whether participants had a genetic condition related to high cholesterol levels. However, genetics-related cholesterol conditions are usually marked by extremely high cholesterol levels (>300 mg/dL) or triglyceride levels (>500 mg/dL) and therefore would not have been included in the analysis [2]. Future studies would benefit from collecting medical history and medication use to better elucidate and better understand these associations. In our analysis, we did not account for the frequency of engagement with the platform, which could have an effect on the associations. We also did not account for socioeconomic factors, such as baseline education, that are potential confounders. For future studies, we plan on assessing and incorporating engagement activities and education levels.

There are also many strengths of this study. Very few studies have demonstrated the real-life application of a digital intervention that changes a user’s meal planning and food ordering behaviors, and its effect on cholesterol levels. By leveraging our large database of users of the Foodsmart platform, we could evaluate real-world data to draw patterns and associations that provide insights into the utility of commercial digital applications. Additionally, many participants were enrolled for at least a year, allowing us to examine changes in lipids over a long time span. Few studies, especially randomized clinical trials, on digital applications have follow-up data for lipids after more than 2 years.

In conclusion, this is one of the first studies of this scale and duration to examine changes in lipids among individuals with dyslipidemia who were users of a digital nutrition platform with personalized dietary recommendations, as well as online meal planning, food ordering, and grocery discounts and incentives. Future studies are warranted to examine specific food components that are associated with lowering cholesterol levels, perform cost comparisons between pharmaceutical and digital interventions, and identify causal associations by comparing interventions to a control.