Medical Nutrition Therapy for Disorders of Lipid MetabolismManual of Clinical Nutrition Management C- 47 Copyright © 20 13 Compass Group, Inc.
omega-3 fatty acid), increases in specific fatty acid consumption (eg, oleic acid or linolenic acid), or increased
antioxidant consumption (eg, vitamins C and E) that cause the cholesterol-lowering effect (54).
Cardiovascular risk (1,3,4): Increased blood cholesterol levels or, more specifically, increased levels of LDL
cholesterol are related to increased risk of CHD. Coronary risk rises progressively with an increase in cholesterol
levels, particularly when cholesterol levels are greater than 200 mg/dL. Patients with established CHD are at high
risk of subsequent myocardial infarction or CHD death, a risk five to seven times higher than without established
CHD.
Substantial evidence indicates that lowering total cholesterol and LDL cholesterol levels (often combined with
drug interventions) will decrease the incidence of CHD in both primary and secondary prevention settings (eg,
patients with and without evidence of CHD, respectively) (3,4).
Short-term clinical trials support the projection that for individuals with serum cholesterol levels initially in the
250 to 300 mg/dL range, each 1% reduction in serum cholesterol level yields approximately a 2% reduction in
CHD rates. Epidemiologic studies suggest that the reduction in CHD rates achievable by a long-term cholesterol-
lowering regimen amounts to as much as 3% for each 1% reduction in serum cholesterol level. Thus, it is
reasonable to estimate that the 10% to 15% reduction in serum cholesterol level resulting from MNT should
reduce CHD risk by 20% to 30%.
Patient-Centered vs Population Approaches (1,3)
The patient-centered and population approaches are complimentary and together represent a coordinated
strategy aimed at reducing cholesterol levels and coronary risk.
Patient-centered approach: A clinical or patient-based approach seeks to identify individuals at high risk who
will benefit from intensive intervention efforts. Criteria define the candidates for medical intervention.
Guidelines describe how to detect hypercholesterolemia, how to set goals for patients, and how to treat and
monitor these patients.
Population approach: The population or public health approach attempts to lower blood cholesterol levels in the
whole population by promoting healthful changes in dietary habits and physical activity levels. The AHA and the
NCEP III take the position that a generalized reduction in cholesterol levels in Americans should decrease the
prevalence of CHD. It is widely assumed that the eating habits of Americans are primarily responsible for high
cholesterol levels. For this reason, the AHA and the NCEP III recommend that the population at large adopt an
eating pattern designed to maintain plasma cholesterol levels near the desirable range.
Special Groups
Older adults: According to the AHA, advanced age does not preclude the need to follow the Therapeutic
Lifestyle Changes Diet or heart-healthy guidelines (3,4). Postmenopausal women and older men with elevated
LDL cholesterol are at increased risk of developing cardiovascular disease and therefore should be managed
based on risk assessment (1,3,4). When older individuals follow a reduced saturated fat and cholesterol diet, LDL
cholesterol levels decrease (1,3,55). In addition, drug therapy (eg, statins) can be a beneficial adjunct in high-risk
patients and is the preferred therapy in place of hormone-replacement therapy in postmenopausal women (1,4).
Because older adults have decreasing total energy needs, they have the added challenge of requiring education
on the need for nutrient-dense foods within various food groups to meet nutritional needs (56).
Pregnant women with preexisting lipid disorders: Elevations in blood cholesterol and triglycerides levels may
occur during pregnancy, with maximal levels in the third trimester and a return to normal levels after delivery.
Generally, the MNT previously prescribed for the preexisting lipid disorder should be continued during pregnancy.
If MNT is very restrictive, careful consideration should be given to ensure adequate nutrient intake. Drug therapy
should be discontinued during pregnancy, since the effect of lipid-lowering drugs on the fetus has not been
carefully studied (1,3).
Children and adolescents: The AHA Guidelines 2000 are indicated for all healthy individuals older than 2
years (3). However, according to the AHA, it should not be assumed that a diet for adults is also appropriate for
children. Individual growth and nutritional requirements need to be considered at each stage of development.
Studies have demonstrated that diets low in saturated fat can support adequate growth and development in
children and adolescents (57,58). The prevalence of obesity and type 2 diabetes mellitus is increasing in the
pediatric population (3). Nutrition strategies for this population should focus on appropriate nutritional intake,
balancing energy intake, and increasing physical activity (3).^