Manual of Clinical Nutrition Management C- 40 Copyright © 20 13 Compass Group, Inc.
MEDICAL NUTRITION THERAPY FOR DISORDERS OF LIPID METABOLISM
Description
The dietary approach for the treatment of disorders of lipid metabolism, which include both
hypercholesterolemia and hypertriglyceridemia, is a progressive reduction in total fat, saturated fat, trans fat,
and cholesterol, coordinated in a plan to obtain or maintain reasonable body weight. The diet follows the
recommendations of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III of
the National Institutes of Health and the American Heart Association (AHA) (1-4).
Indications
Medical nutrition therapy (MNT) is recommended as the primary treatment and management tool for disorders
of lipid metabolism. MNT is recommended before administration of cholesterol-lowering medication in lower
risk cases or in combination with drug therapy in higher risk cases. Recommended therapeutic lifestyle changes
and target goals for low-density lipoprotein (LDL) cholesterol levels are based on risk factor assessment. Major
independent risk factors (exclusive of LDL cholesterol) that predict the 10-year risk for coronary heart disease
(CHD) are based on Framingham risk evaluation scores (1). These risk factors include (1):
cigarette smoking
hypertension (blood pressure greater than 140/90 mm Hg and/or receiving antihypertensive medication)
low level of high-density lipoprotein (HDL) cholesterol (less than 40 mg/dL)
family history of premature CHD (CHD in male first-degree relative younger than 55 years; CHD in female
first-degree relative younger than 65 years)
age (men, 45 years or older; women, 55 years or older)
The high-risk category consists of persons who have existing CHD, persons who have CHD risk equivalents
that confer a 10-year risk of CHD greater than 20%, and persons with diabetes. The target LDL cholesterol level
for these individuals is less than 100 mg/dL. A subcategory of high risk, very high risk, contains persons with
existing cardiovascular disease and diabetes and persons with cardiovascular disease and severe or poorly
controlled multiple risk factors (4). The very high-risk category has a therapeutic option to target the LDL
cholesterol to less than 70 mg/dL (4). Persons with more than one risk factor and a 10-year risk of CHD of 20%
or less have an LDL cholesterol target goal of less than 130 mg/dL. Persons with one or no risk factors and a
10 - year risk of CHD less than 10% have an LDL target goal of less than 160 mg/dL. Primary intervention using
therapeutic lifestyle changes and drug therapy should begin after evaluation of the patient’s fasting lipid profile,
consisting of levels of LDL cholesterol, total cholesterol, HDL cholesterol, and triglycerides and consideration of
the risk factor assessment (1,4). LDL cholesterol is the primary target for risk reduction intervention (1,4).
Targeting lower LDL goals, in combination with initiating cholesterol-lowering drug therapy at lower
thresholds, is based on evidence from five randomized controlled trials demonstrating significant risk reduction
for cardiac events at the recommended lower thresholds (4). The NCEP recommends pharmacologic therapy
that is sufficient to achieve a 30% to 40% reduction in baseline LDL cholesterol levels in all high risk and
moderately high risk patients (4).
Table C-8: LDL Cholesterol Goals (4)
Risk Categorya LDL Cholesterol Goal (mg/dL)
LDL Cholesterol Level (mg/dL) to
Consider Drug Therapyb
High risk and very high risk:
CHD or CHD risk equivalent,
10 - year risk >20%
<100
<70 optional> 100
< 100 for very high riskModerately high risk:
Two or more risk factors,
10 - year risk 10%-20%
< 130 > 130
100 - 129 optionalcModerate risk:
Two or more risk factors,
10 - year risk <10%
<130 > 160
Lower risk:
Zero or one risk factor
<160 > 190
160 - 189 optional
aRisk factors that modify LDL goals are given in the bulleted list above, under Indications.
bIt is advised that intensity of drug therapy be sufficient to achieve a 30% to 40% reduction in LDL cholesterol levels (4).
c (^) For moderately high risk persons, when LDL cholesterol is 100-129 mg/dL at baseline or on lifestyle therapy, initiation of an LDL-
lowering drug to achieve an LDL cholesterol level <100 mg/dL is a therapeutic option (4).