Manual of Clinical Nutrition

Medical Nutrition Therapy for Disorders of Lipid Metabolism

Manual of Clinical Nutrition Management C- 50 Copyright © 2 013 Compass Group, Inc.

composition for lowering triglycerides in patients with hypertriglyceridemia > 150 mg/dL is unclear (Grade III) (5).
A calorie controlled, cardioprotective dietary pattern that avoids extremes in carbohydrate and fat intake, limits
alcohol, limits refined sugar while increasing complex carbohydrate food and includes physical activity is
suggested (Grade III) (5). Weight loss of 7 to 10% of body weight should be encouraged if indicated (5). These
lifestyle changes have been shown to lower triglyceride levels (Grade III) (5). If a patient is identified to have very
high triglycerides (> 500 mg/dL), the dietitian should refer to the ATP III guidelines described below and
recommend a very low-fat diet (< 15% of energy intake) (Grade II) (5). High doses of supplemental EPA/DHA have
been shown to lower triglycerides in patients with elevated triglycerides (Grade II) (5). If a patient has high
triglycerides (> 200 mg/dL) supplemental EPA/DHA capsules of 2 to 4 grams per day may be prescribed by the
physician or be considered a therapeutic intervention (Grade II) (5).

Table C-13: Recommended Approaches for Elevated Triglyceride Levels

Triglycerides (TG) Level ATP III Recommended Approaches (1)

Borderline high (150- 199

mg/dL)

 weight reduction

 increased physical activity

High (200-499 mg/dL) (^)  weight reduction
 increased physical activity
 drug therapy (LDL-lowering drugs and/or nicotinic acid or fibrate to lower
TG)
Very high (>500 mg/dL)  very-low-fat diet (<15% of energy intake) to prevent acute pancreatitis
 weight reduction
 increased physical activity
 drug therapy (LDL lowering-drugs and/or nicotinic acid or fibrate to lower
TG)
When low HDL cholesterol (less than 40 mg/dL) is associated with a high triglycerides level (200 to 499
mg/dL), the secondary priority is achieving the non-HDL cholesterol goal (as previously described). The HDL-
raising drugs, which include fibrates and nicotinic acid, can be considered in persons with CHD and CHD risk
equivalents. Fibrates and nicotinic acid can be used in combination with LDL-lowering drugs to achieve lipid
goals (1,4). Also see Section III: Hypertriglyceridemia.
Physical Activity and Weight Management
Excess body fat, or obesity, is a major risk factor for CHD and also contributes to the development of other risk
factors, such as diabetes and hypertension. Weight management plays a vital role in achieving and maintaining
good health while enhancing the quality of life. Proper nutrition and physical activity are key factors that
influence weight control. The National Heart, Lung, and Blood Institute has established clinical guidelines on
the identification, evaluation, and treatment of overweight and obesity in adults. These guidelines identify a
need for MNT weight management (61).
An important adjunct to long-term change in eating habits and lifestyle is an increase in physical activity. There is
evidence that regular exercise alone reduces CHD mortality by increasing HDL cholesterol levels and, in some
patients, lowering LDL cholesterol levels. The exercise should emphasize aerobic activity, such as brisk walking,
jogging, swimming, bicycling, and tennis. Improvements in cardiovascular fitness result from exercising at moderate
intensity for 30 to 45 minutes on most, if not all, days (Grade II) (1,5). Vigorous, high-intensity exercise must be
performed with caution in high-risk persons and only with the advice of a physician and under the supervision of
trained personnel (1).
Self-Management Training for the Patient with Disorder of Lipid Metabolism
Once the patient’s risk assessment, clinical status, motivation, comprehension, and environmental support are
assessed, the dietitian should set goals with the patient and/or caregiver and provide self-management training
to meet the patient’s individualized needs. Refer to the following evidence-based nutrition practice guidelines
(5, 62) or a combination of treatment guidelines as needed for treatment and frequency of MNT intervention:
 Morrison Nutrition Practice Guideline - Coronary Artery Bypass Graft (CABG) or Angioplasty (63)
 Disorders of Lipid Metabolism Evidence-Based Nutrition Practice Guideline from the Academy of
Nutrition and Dietetics (5)
*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide, page
III-1.