Manual of Clinical Nutrition

Medical Nutrition Therapy for Disorders of Lipid Metabolism

Manual of Clinical Nutrition Management C- 48 Copyright © 2 013 Compass Group, Inc.

Racial and ethnic populations: African Americans have the highest overall CHD mortality rate and the highest
out-of-hospital coronary death rates of any ethnic group in the Unites States, particularly at younger ages (1).
The increased incidence is partly attributed to increased prevalence of coronary risk factors, including
hypertension, ventricular hypertrophy, diabetes mellitus, cigarette smoking, obesity, and physical inactivity.
Other high-risk ethnic groups and minority populations in the United States include Hispanics, Native
Americans, Asian and Pacific Islanders, and South Asians. The NCEP ATP III recommends intervention for
cholesterol management consistent with recommendations outlined for all other populations (1).

ATP III Guidelines
Criteria that define candidates for MNT intervention and the Therapeutic Lifestyle Changes Diet and lifestyle
modifications have been established by the NCEP ATP III, which builds on the previous recommendations of
ATP II and ATP I (1). These guidelines emphasize the importance of MNT provided by a registered dietitian in
facilitating the behavior changes needed to follow the recommended diet and lifestyle changes before initiating
therapy with cholesterol-lowering medications or in adjunct with this therapy. The guidelines are expected to
substantially increase the number of Americans being treated for high cholesterol. The number of people
receiving dietary treatment is expected to increase from 52 million to 65 million, and the number of people
receiving prescribed cholesterol-lowering drugs is expected to increase from 13 million to 36 million (1).
Table C-11: Features of ATP III Guidelines
Focus on Multiple Risk Factors
 Identifies persons with diabetes but without CHD, most of whom have multiple risk factors, as CHD risk
equivalent
 Uses Framingham projections of 10-year absolute CHD risk (i.e., the percent probability of having a
CHD event in 10 years) to identify certain patients with two or more risk factors for more intensive
treatment
 Identifies persons with multiple metabolic risk factors (metabolic syndrome) as candidates for
intensified therapeutic lifestyle changes
Lipid and Lipoprotein Classification
 Identifies LDL cholesterol levels <100 mg/dL as optimal
 Categorizes low HDL cholesterol levels as <40 mg/dL
 Specifies lower cutoff levels for triglycerides to increase the attention given to moderate elevations
Support for Implementation
 Recommends a complete lipoprotein profile (total cholesterol, LDL cholesterol, HDL cholesterol, and
triglycerides) as the preferred initial test, rather than screening for only total cholesterol and HDL
 Encourages use of plant stanols and sterols and viscous (soluble) fiber as therapeutic dietary options to
enhance lowering of LDL cholesterol
 Presents strategies for promoting adherence to therapeutic lifestyle changes and drug therapies
 Recommends treatment beyond LDL lowering for persons with triglycerides levels >200 mg/dL

Table C-12: LDL Cholesterol (LDL-C) Goals and Recommendations for Therapeutic Lifestyle Changes

and Drug Therapy in Different Risk Categories (4)

Risk Category LDL-C Goal^

(mg/dL)

LDL-C Level (mg/dL) to

Initiate Therapeutic

Lifestyle Changes

LDL-C Level (mg/dL)

to Consider Drug

Therapya

CHD or CHD risk equivalent,

10 - year risk >20%

<100

<70 optional

> 100

> 100

< 100 optional

Two or more risk factors,

10 - year risk 10% to 20%

< 130 > 130

> 130

100 - 129 optional

Two or more risk factors,

10 - year risk <10%

<130 > 130 > 160

Zero or one risk factorb <160 > 160

> 190

160 - 189 optional

aIt is advised that the intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. If a person has high

triglycerides levels and low HDL levels, consider combining nicotinic acid or fibrate with the LDL-lowering drug.

bAlmost all people with 0 or 1 risk factor have a 10-year risk <10%; thus, 10 - year risk assessment in these individuals is unnecessary.

The degree of reduction of LDL cholesterol levels achieved by MNT depends on dietary habits before starting
therapy, degree of compliance, and inherent biological responsiveness. In general, patients with high
cholesterol levels experience greater absolute reductions in LDL cholesterol levels than do those with low