Medical Nutrition Therapy for Disorders of Lipid MetabolismManual of Clinical Nutrition Management C- 41 Copyright © 20 13 Compass Group, Inc.
For patients hospitalized due to a cardiac event, LDL cholesterol levels begin to decline in the first few hours
after an event and are significantly decreased within the first 24 to 48 hours. These levels may remain low for
up to 3 months. Thus, the initial LDL cholesterol level obtained in the hospital may be substantially lower than
is usual for the patient (1). The NCEP ATP III emphasizes the need to begin drug therapy for high-risk patients
(Refer to Table C-8) in addition to the Therapeutic Lifestyle Changes Diet to reach the goal for LDL cholesterol.
When drugs are prescribed, the Therapeutic Lifestyle Changes Diet should always be maintained and reinforced
(1).
Clinical trials demonstrate that lowering LDL cholesterol reduces total mortality, coronary mortality, major
coronary events, coronary artery procedures, and strokes in persons with established CHD (1,4). The ATP III
specifies LDL cholesterol less than 100 mg/dL as the goal of therapy in secondary prevention. The ATP III
recognizes that the risk of CHD is influenced by other factors not included among the major, independent risk
factors listed previously. Life-habit risk factors include obesity, physical inactivity, and atherogenic diet (1).
Emerging risk factors, for which scientific evidence demonstrates varying degrees of contribution to CHD risk in
select persons, include lipoprotein, homocysteine, prothrombotic and proinflammatory factors, and impaired
fasting blood glucose levels (more than 110 mg/dL) (1). At this time, the evidence does not support specific
modifications to target LDL cholesterol based on these risks.
Metabolic Syndrome
Metabolic syndrome is a clustering of three or more risk factors that include abdominal obesity, atherogenic
dyslipidemia (elevated triglycerides level and low HDL cholesterol), hypertension, and insulin resistance (with
or without glucose intolerance) (1). The NCEP ATP III recognizes the need to address metabolic syndrome as a
secondary target of risk-reduction therapy, after the primary target of LDL cholesterol lowering (1).
Management of metabolic syndrome primarily focuses on reducing underlying causes (eg, obesity and physical
inactivity) and to treat associated nonlipid and lipid risk factors. Physical activity at any level (light, moderate,
or vigorous) as well as food patterns emphasizing a diet high in fruits, vegetables, and whole grains is
associated with reduced incidence of metabolic syndrome (Grade II)* (5). In the metabolic syndrome patient, a
cardioprotective dietary pattern (low in saturated fat, trans fat, and cholesterol; limited in simple sugar intake;
and increased in consumption of fruits, vegetables, and whole grains) provides the background for modifying
the energy balance to achieve weight loss (Grade IV) (5). Extremes in intakes of carbohydrates or fats should be
avoided (Grade IV) (5). Restricted energy intake combined with at least 30 minutes of physical activity on most days
of the week should be used recommended for individuals with metabolic syndrome (Grade II) (5). Weight loss of
7% to 10% of body weight should be encouraged if indicated (Grade II) (5).
Table C-9: Clinical Identification of the Metabolic Syndrome
Risk Factor Defining Level
Abdominal obesitya Waist circumference
Men >102 cm (>40 inches)b
Women >88 cm (>35 inches)
Triglycerides >150 mg/dL
HDL cholesterol
Men <40 mg/dL
Women <50 mg/dL
Blood pressure >130/>85 mm Hg
Fasting blood glucose >100 mg/dLc
a Overweight and obesity are associated with insulin resistance and the metabolic syndrome. However, abdominal obesity is more highly
correlated with the metabolic risk factors than is an elevated body mass index. Therefore, the simple measure of waist circumference is
recommended to identify the body weight component of the metabolic syndrome.^
b Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased, such as 94
to 102 cm (37 to 39 inches). These patients may have a strong genetic contribution to insulin resistance. They should benefit from
changes in life habits, similar to men with categorical increases in waist circumference.
c The ATP III criteria for the metabolic syndrome are now the same as the American Diabetes Association’s revised definition of impaired
fasting glucose. Thus, the threshold for elevated fasting glucose was reduced from 110 mg/dL to 100 mg/dL.