Disorders of Lipid Metabolism

DLM: Executive Summary of Recommendations (2011)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics Disorders of Lipid Metabolism (DLM) Update Evidence-Based Nutrition Practice Guideline. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers under Major Recommendations. 

To see a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.

The DLM Update Recommendations are listed below. [Note: If you mouse-over underlined acronyms and terms, a definition will pop up.]

  • Screening and Referral
    DLM: MNT and Referral to a Registered Dietitian
    Medical Nutrition Therapy (MNT) provided by a registered dietitian (RD) is recommended for patients with an abnormal lipid profile as defined by current National Heart, Lung and Blood Institute (NHLBI) Clinical Practice Guidelines and low-density lipoprotein cholesterol (LDL-C) goals. All patients who have existing coronary heart disease (CHD) should receive MNT provided by an RD. Patients who attend multiple RD visits for MNT lasting an average of 45 minutes (30-60 minutes per session) over six to twelve weeks can reduce daily dietary fat (5% to 8%), saturated fat (2% to 4%) and energy intake (232-710kcal per day). This can result in a reduction in serum total cholesterol (TC) (↓7% to 21%), LDL-C (↓7% to 22%) and triglycerides (↓11% to 31%). 
    Strong
    Imperative
    DLM: MNT Number and Duration of Visits
    Registered Dietitians (RD) should provide more than two visits for Medical Nutrition Therapy (MNT) (three to six visits) to further improve a patient's lipid profile. The magnitude of low-density lipoprotein cholesterol (LDL-C) reduction increases with additional visits or time spent with the RD. Studies report that further reduction in total cholesterol (TC) (↓19% with four RD visits vs. ↓12% with two RD visits) and LDL-C (↓21% with four RD visits/180 minutes vs. ↓12% with two RD visits/120 minutes) were observed. Further research is needed to define the optimal duration and frequency of follow-up visits with the RD.
    Fair
    Imperative
    DLM: Lipid-Lowering Medication Re-evaluation
    If a patient is on lipid-lowering medications, the Registered Dietitian (RD) should provide three or more visits for Medical Nutrition Therapy (MNT) averaging 45 minutes per session over a six to eight week period to improve the patient's lipid profile. Three studies have examined the reduction in the use of lipid lowering medications when MNT is provided by an RD. Two retrospective studies showed 50% of patients were obviated from lipid drug eligibility after three MNT visits with the RD. In a randomized controlled trial (RCT), at the end of 12 months, no subject in the MNT group needed lipid-lowering drugs, while six of 44 in the Usual Care group needed medication at an average cost of $446 (in 1995 dollars) for months seven to 12 of the trial.  
    Fair
    Conditional
  • Nutrition Assessment
    DLM: Assessment of Food and Nutrient Intake
    The registered dietitian (RD) should assess the food/nutrition intake and related history of adults with disorders of lipid metabolism (DLM) including, but not limited to the following:
    • Food, beverage and nutrient intake including:
      • Energy intake, serving sizes, meal-snack pattern, fat, types of fat and cholesterol, carbohydrate, fiber, micronutrient intake
      • Bioactive substances (alcohol intake, plant stanols and sterols, soy protein, psyllium, fish oil)
    • Food and nutrient administration (patient's experience with food)
      • Previous and current diet history, diet orders, exclusions and experience, cultural and religious preferences
      • Eating environment, eating out
    • Medication and herbal supplement use: Prescription and over-the-counter medications, herbal and complementary product use (coenzyme Q-10, red yeast rice)
    • Knowledge, beliefs or attitudes: Motivation, readiness to change, self-efficacy
    • Behavior: Diet adherence, disordered eating, meal timing and duration
    • Factors affecting access to food: Psychosocial/economic issues (e.g., social support) impacting nutrition therapy
    • Physical activity and function: Exercise patterns, functionality for activities of daily living, sleep patterns.
    Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes. Dietary intake can be assessed using a variety of approaches, including multiple 24-hour recalls or three non-consecutive days of food records (i.e., two weekdays and one weekend day). In addition, the more sophisticated multiple-pass technology may be used. Dietary results can be analyzed using nutrient analysis software programs that have complete nutrient data. Manufacturers' nutrition facts labels may also be included.
    Consensus
    Imperative
    DLM: Assessment of Anthropometric Data
    In addition to body mass index (BMI), the Registered Dietitian (RD) should use waist circumference (WC) or waist-to-hip ratio (WHR) to assess obesity and cardiovascular disease (CVD) risk. BMI alone is not a good predictor of CVD risk in persons over 65 years old. Increases in WC, WHR, and BMI are associated with coronary heart disease (CHD) events and CVD mortality.
    Strong
    Imperative
    DLM: Assessment of Biochemical Data
    The Registered Dietitian (RD) should assess the biochemical data, medical tests and procedures of adults with disorders of lipid metabolism (DLM) including, but not limited to lipid profile [total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, low-density lipoprotein cholesterol (LDL-C), triglycerides (TG)], blood pressure, and fasting glucose. Additional values such as Lp(a), hemoglobin A1c (HbA1c), 25-OH vitamin D, thyroid function tests and C-reactive protein (CRP) may also be assessed. Assessment of these factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    DLM: Assessment of Medical and Health History and Physical Findings
    The registered dietitian (RD) should assess the medical and health history of adults with disorders of lipid metabolism (DLM) for the presence of other disease states and conditions, such as endocrine/metabolism disorders, metabolic syndrome, HIV/AIDS, hypertension (HTN), obesity and food allergies and intolerances. Adults with DLM, have a higher prevalence of comorbidities, which are risk factors for the progression of cardiovascular disease (CVD). The RD should note observations of fat distribution (i.e., abdominal obesity or lipodystrophy) and fluid retention (i.e., edema or ascites), as well as any evidence of xanthomas, xanthelasma, corneal arcus, and palmar discolorations. Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    DLM: Determining Energy and Macronutrient Needs
    The registered dietitian (RD) should determine energy and macronutrient needs (e.g., quantity and quality of fat, carbohydrate and protein) of adults with disorders of lipid metabolism (DLM). Use of indirect calorimetry is preferred for measuring energy needs. When indirect calorimetry is not available, predictive equations can be used. After estimation of current energy needs, a recommended energy intake can be developed with consideration of whether the goal is weight maintenance or weight loss.   The recommended macronutrient intake is:
    • Total fat of 25-35% (achieving goals of saturated fat (SFA) and trans fat <7% of kcals and dietary cholesterol <200 mg per day is typically feasible only with total fat ≤30% kcals per day)
    • Total protein of 15-20% (encourage vegetable protein to help achieve SFA goals and cholesterol goals)
    • Total carbohydrates (CHO) of 45-60% of kcals (with emphasis on high fiber/complex CHO sources and avoidance of refined CHO foods).
    Comparison of the assessed food and nutrient intake with estimated needs will help the RD to develop strategies to meet the recommendations of the cardioprotective diet. Estimating current (or baseline) energy and macronutrient intake, is essential to establishing the relevant nutrition diagnoses and tailoring the appropriate medical nutrition therapy (MNT).
    Consensus
    Imperative
  • Nutrition Intervention
    DLM: Marine-Derived Food Sources of Omega-3 Fatty Acids and Risk for CVD Events
    If consistent with patient preference and not contraindicated by risks or harms, the Registered Dietitian (RD) should encourage food sources of marine-derived omega-3 fatty acids, preferably from fish to reduce risk of cardiovascular disease (CVD).
    • For patients without coronary heart disease (CHD): Recommend two fish servings per week (4oz servings each)
    • For patients with CHD: Recommend two or more fish servings per week (4oz servings each).
    Studies report, that in persons with CHD higher plasma levels of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are associated with a reduction in arrhythmias and fatal heart disease and reduced progression of coronary atherosclerosis. In persons without CHD, consumption of fish and marine-derived omega-3 fatty acids may or may not be associated with reduced incidence of arrhythmia, including atrial fibrillation.
    Fair
    Conditional
    DLM: Plant-derived Omega-3 Fatty Acids and Risk for CVD Events
    If consistent with patient preference and not contraindicated by risks or harms, the Registered Dietitian (RD) can recommend foods rich in plant-derived omega-3 fatty acids (ALA; alpha-linolenic acid) to reduce the risk of cardiovascular disease (CVD) or CVD events. In persons with coronary heart disease (CHD), higher intakes of plant-derived omega-3 fatty acids, are associated with a decreased rate of cardiac death and non-fatal myocardial infarction (MI) and may be protective against recurrence of MI. One study reported use of 4.8% of calories from ALA In persons without CHD, higher intakes of food sources of ALA are associated with a lower risk of fatal ischemic heart disease (IHD) and prolonged repolarization (mean intake 0.74g per day of ALA). In case-control studies, ALA lowered the risk of IHD in men and women (amount of ALA from mustard oil not specified) and sudden cardiac death in women (median intake 1.16g per day ALA). Alpha-linolenic acid, however, was not related to other non-sudden fatal CVD events or to non-fatal MI. These studies contrasted lower intake of approximately 0.6g per day with higher intakes of approximately 1.4g per day.  This recommendation can be followed within the context of diets that meet the Adequate Intake (AI) for ALA of 1.6g per day for men and 1.1g per day for women (within the Acceptable Macronutrient Distribution Range of 0.6% to 1.2% of energy) (DRI).
    Fair
    Conditional
    DLM: Omega-3 Supplements and Risk for CVD Events
    If persons choose to consume eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplements or EPA alone to reduce the risk of cardiovascular disease (CVD) mortality and events (sudden death and re-infarction), the Registered Dietitian (RD) should advise:
    • Patients without coronary heart disease (CHD): Intervention studies of omega-3 supplementation have not been done in patients without CHD
    • Patients with CHD, but no angina or implantable cardioverter defibrillators (ICD): Supplementation with 850mg per day EPA and/or DHA reduced sudden death by 45%
    • Patients with CHD with angina or ICDs: EPA and DHA supplements may be contraindicated.
    The US Food and Drug Administration advises that consumption of more than three grams of omega-3 fatty acids per day may cause gastrointestinal symptoms.
    Fair
    Conditional
    DLM: Antioxidants and the Cardioprotective Diet
    The Registered Dietitian (RD) should specifically plan antioxidant-rich foods such as fruits, vegetables, whole grains and nuts containing Vitamin E, vitamin C and ß-carotene (and other carotenoids), into a cardioprotective dietary pattern. These foods have been shown to be associated with reduced coronary heart disease (CHD) risk.  
    Consensus
    Imperative
    DLM: Antioxidant Supplements and Cardiovascular Disease
    The Registered Dietitian (RD) should not recommend taking supplemental vitamins E, C and/or ß-carotene for the prevention and treatment of cardiovascular disease (CVD). Research indicates high doses of these antioxidants [above the Recommended Dietary Allowance (RDA)] do not provide cardiovascular benefit and may cause harm and even shorten life span.  
    Strong
    Imperative
    DLM: Nuts and Coronary Heart Disease
    If consistent with patient preference and not contraindicated by risks or harms, the Registered Dietitian (RD) may isocalorically incorporate daily consumption of unsalted peanuts and lower saturated fat tree nuts, specifically walnuts, almonds, pecans, and pistachios into a cardioprotective dietary pattern. Consuming five ounces (average ~900kcals) of nuts per week is associated with a reduced risk of coronary heart disease (CHD). Because of their beneficial fatty acid profile, as well as other nutritional components, nuts may be isocalorically incorporated into a cardioprotective dietary pattern to achieve lipid lowering. Studies demonstrate that 1.75 to 4oz (½ to 1 cup or 315 to 720kcals) nuts per day lowers total cholesterol (TC) by 4% to 21% and low-density lipoprotein cholesterol (LDL-C) by 6% to 29%. The practicality of this recommendation is limited, because of the significant caloric contribution this amount of nuts provides.  
    Fair
    Conditional
    DLM: Fat Components of the Cardioprotective Diet
    The Registered Dietitian (RD) should tailor the cardioprotective dietary pattern to the individual's needs to provide a total fat intake of 25% to 35% of calories, (ATP III) with <7% of calories from saturated fat and trans-fatty acids (TFA). Because TFAs raise total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and may decrease high-density lipoprotein cholesterol (HDL-C), TFA consumption should be as low as possible. Cholesterol should be <200mg per day. The majority of total fat intake should be derived from unsaturated fat sources. For individuals at their appropriate body weight, without elevated LDL-C or triglyceride (TG) levels, and with normal HDL-C levels, saturated fat calories could be replaced by unsaturated fat and/or complex carbohydrate (CHO). This dietary pattern can lower LDL-C up to 16% and decrease risk of coronary heart disease (CHD) and CHD events. 
    Strong
    Imperative
    DLM: Replacing Saturated Fat in the Diet
    The Registered Dietitian (RD) should develop a nutrition prescription within a cardioprotective dietary pattern that replaces saturated fat calories with calories from either complex carbohydrate (CHO) principally contributed by fruits, vegetables and whole grains, protein and/or unsaturated fat. Robust evidence documents that saturated fat increases low-density lipoprotein cholesterol (LDL-C). Under isocaloric conditions, large scale, randomized controlled trials (RCTs) indicate that a cardioprotective diet reduced LDL-C by 9% to 16% in both normo- and hyperlipidemic individuals. Advantages for substituting complex CHO for saturated fat calories include the following:
    • It is difficult to achieve a saturated fat reduction of <10% of calories in diets that are 30% to 35% of total calories from fat
    • A diet high in complex CHO includes shortfall nutrients (e.g., dietary fiber, potassium and magnesium and other micronutrients)
    • A diet high in complex CHO is nutrient-dense and is less likely to contribute excess calories
    • In addition, a diet rich in omega-3 fatty acids and/or monounsaturated fat, and reduced in refined CHO may also be effective in reducing serum triglycerides (TG) without adverse impact on high-density lipoprotein cholesterol (HDL-C).
    In treating overweight or obese patients, where the goal is reduction of total energy, reduction rather than replacement of saturated fat calories may be warranted, depending on current intake of unsaturated fat.
    Strong
    Imperative
    DLM: Plant Stanols and Sterols
    If consistent with patient preference and not contraindicated by risks or harms, the Registered Dietitian (RD) should consider incorporating plant sterol and stanol ester-enriched foods into a cardioprotective diet, to be consumed two or three times per day, for a total consumption of two to three grams per day. These doses further lower total cholesterol (TC) by 4% to 11% and low-density lipoprotein cholesterol (LDL-C) by 7% to 15%. Doses beyond three grams do not provide additional benefit. To prevent weight gain, isocalorically substitute stanol- and sterol-enriched foods for other foods. Plant stanols and plant sterols are also effective in people taking statin drugs.  
    Strong
    Conditional
    DLM: Plant Stanols and Sterols and Adverse Effects
    The Registered Dietitian (RD) should be aware that research to date has not documented adverse effects, including reduced absorption of carotenoids, retinol and tocopherols. Plant stanols and sterols may be included in a patient's nutrition prescription (e.g., two or three grams per day) to lower cholesterol. Research from 17 randomized controlled trials (RCTs) indicates effective serum cholesterol-lowering benefits without any reported adverse effects, including no significant effect on plasma fat soluble vitamin status. Two observational studies reported an association between plasma levels and aortic tissue concentration of stanols and sterols in a small number of individuals who consumed foods supplemented with plant sterol and stanol esters. The clinical significance of the association has not been documented.  
    Fair
    Imperative
    DLM: Alcohol Intake
    If a patient currently drinks alcohol, and if not contraindicated by risks and harms, then the Registered Dietitian (RD) could incorporate a maximum of one drink per day for women and up to two drinks per day for men into a cardioprotective dietary pattern that meets the patient's caloric needs. This level of alcohol consumption has been associated with a reduced risk of cardiovascular disease (CVD). One type of alcohol does not appear to be better than another. Current evidence does not justify recommending that non-drinkers begin drinking alcohol.   
    Fair
    Conditional
    DLM: Physical Activity and Coronary Heart Disease
    If not contraindicated by risks and harms, the Registered Dietitian (RD) should recommend resistance exercise for a minimum of two days a week and moderate intensity physical activity for at least 30 minutes most, if not all, days of the week. Many individuals will have to start slowly and increase gradually to achieve goals. Moderately intense physical activity reduces the risk of cardiovascular disease (CVD) events, decreases low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG), and increases high-density lipoprotein cholesterol (HDL-C).
    Strong
    Conditional
    DLM: Coenzyme Q10 and Disorders of Lipid Metabolism
    If a patient is taking coenzyme Q10 supplements, then the Registered Dietitian (RD) may discuss the insufficient evidence for the association of CoQ10 and coronary heart disease (CHD) and allow the patient to make an individual decision based on his or her specific needs. The clinical significance of normalizing CoQ10 levels in patients treated with statin medications is inconclusive.
    Weak
    Conditional
    DLM: Metabolic Syndrome
    For individuals with metabolic syndrome, the Registered Dietitian (RD) should recommend a calorie-controlled cardioprotective dietary pattern that avoids extremes in carbohydrate and fat intake, limits added sugar and alcohol, and includes physical activity at a moderate intensity level for at least 30 minutes on most (preferably all) days of the week. Weight loss of 7% to 10% of body weight should be encouraged, if indicated. These lifestyle changes improve risk factors of metabolic syndrome.
    Fair
    Imperative
    DLM: Elevated Triglycerides and Macronutrients
    For individuals with elevated triglycerides (TG) (≥150mg per dL), the Registered Dietitian (RD) should recommend a calorie-controlled, cardioprotective dietary pattern that avoids extremes in carbohydrate and fat intake and includes physical activity. Non-nutrient dense calorie sources including alcohol and added sugar, should be limited as much as possible. Weight loss of 7% to 10% of body weight should be encouraged, if indicated. These lifestyle changes have been shown to lower TG levels.
      It is unclear what the ideal macronutrient composition (e.g., protein and unsaturated fat) should be for someone with borderline high TG. At this time it seems prudent to follow recommendations appropriate for people with the metabolic syndrome, as moderately elevated TG are a component of this disease.
    Fair
    Conditional
    DLM: Elevated Triglycerides and EPA/DHA Supplements
    In patients with elevated triglycerides (TG), in addition to lifestyle modification with a cardioprotective diet, the Registered Dietitian (RD) can advise that high-dose supplemental eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (two to four grams per day) may be utilized under medical supervision. High-doses of supplemental EPA and DHA have been shown to lower TG in patients with elevated TG (greater than 200mg per dL).        
    Strong
    Conditional
    DLM: Homocysteine, Folate, Vitamin B6, Vitamin B12 and CHD
    The Registered Dietitian (RD) should include food sources of folate, vitamin B6, and vitamin B12 in the cardioprotective dietary pattern to meet the Dietary Reference Intakes (DRI). Supplemental doses of these vitamins to lower cardiovascular disease (CVD) risk should not be recommended. Although supplemental B-vitamins (folic acid, vitamin B6, and vitamin B12) may lower homocysteine in people with high serum homocysteine levels (>13umol per L), this has not translated into reduced CVD events and in fact, may be harmful.   
    Strong
    Imperative
    DLM: Carbohydrates and Protein in the Cardioprotective Diet
    The Registered Dietitian (RD) should consider replacing saturated fat and trans-fatty acids with unsaturated fatty acids, complex carbohydrates and/or protein in the cardioprotective dietary pattern. Saturated and trans fatty acids should be as low as possible. Studies are needed to determine the ideal percentages of these macronutrients as replacements for saturated fat.    
    Strong
    Imperative
    DLM: Fiber in the Cardioprotective Diet
    The Registered Dietitian (RD) should incorporate fiber-rich foods that contribute at least 25g to 30g of fiber per day, with special emphasis on soluble fiber sources (7g to 13g) into the cardioprotective dietary pattern. These foods rich in soluble fiber include: fruits, vegetables and whole grains, especially high-fiber cereals, oatmeal, and legumes, especially beans. Risk factors associated with coronary heart disease (CHD) and cardiovascular disease (CVD) are decreased as dietary fiber intake increases. Diets high in total and soluble fiber, as part of a cardioprotective diet, can further reduce total cholesterol (TC) by 2% to 3% and low-density lipoprotein cholesterol (LDL-C) up to 7%.     
     
    Strong
    Imperative
    DLM: Hypertension
    For individuals who need to lower their blood pressure, the registered dietitian (RD) should recommend a cardioprotective dietary pattern, such as the DASH diet, to include nine to 12 servings of fruits and vegetables and two to three servings of low-fat dairy products. Sodium should be reduced to less than 2,300mg per day and gradually lowering to the Adequate Intake (AI) of 1,500mg per day (DRI). In addition to this dietary pattern, weight loss (if necessary), and increased moderate-intensity physical activity have been demonstrated to lower systolic blood pressure (SBP) by at least four to 12mmHg.
    Strong
    Conditional
  • Nutrition Monitoring and Evaluation
    DLM: Monitor and Evaluate Food and Nutrient Intake
    Following the nutrition intervention, to check progress, the registered dietitian (RD) should monitor and evaluate at each visit the food/nutrition intake of adults with disorders of lipid metabolism (DLM) and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. This may include, but is not limited to the following:
    • Food, beverage and nutrient intake:
      • Energy intake, serving sizes, meal/snack pattern, fat, types of fat, and cholesterol, carbohydrate, fiber, micronutrient intake
      • Bioactive substances (alcohol intake, plant stanols and sterols, soy protein, psyllium, fish oil)
    • Food and nutrient administration (patient's experience with food)
      • Current diet history, diet exclusions, cultural and religious preferences
      • Eating environment, eating out
    • Medication and herbal supplement use: Prescription and over-the-counter medications, herbal/complementary product use (coenzyme Q10, red yeast rice)
    • Knowledge, beliefs or attitudes: Motivation, readiness to change, self-efficacy
    • Behavior: Diet adherence, disordered eating, meal timing and duration
    • Factors affecting access to food: Psychosocial/economic issues (e.g., social support) impacting nutrition therapy
    • Physical activity and function: Exercise patterns, functionality for activities of daily living, sleep patterns.
    Dietary intake can be assessed using a variety of approaches, including multiple 24-hour recalls or three non-consecutive days of food records (i.e., two weekdays and one weekend day). In addition, the more sophisticated multiple pass technology may be used. Dietary results can be analyzed using nutrient analysis software programs that have complete nutrient data. Manufacturers' nutrition facts labels may also be included. Monitoring and evaluation of the above factors is needed to effectively determine nutrition diagnoses that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    DLM: Monitor and Evaluate Anthropometric Data
    Following the nutrition intervention, to check progress, the Registered Dietitian (RD) should monitor and evaluate at each visit, the anthropometric data of adults with disorders of lipid metabolism (DLM) including body mass index (BMI), waist circumference (WC), or waist-to-hip ratio (WHR) and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. BMI alone is not a good predictor of cardiovascular disease (CVD) risk in persons over 65 years old.
    Strong
    Imperative
    DLM: Monitor and Evaluate Biochemical Data
    Following the nutrition intervention, to check progress, the Registered Dietitian (RD) should monitor and evaluate after three months (according to ATP III), the biochemical data, medical tests and procedures of adults with disorders of lipid metabolism (DLM), including but not limited to lipid profile [total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, low-density lipoprotein (LDL-C), triglycerides (TG)], blood pressure and fasting glucose and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. Additional values such as hemoglobin A1c (HbA1c), 25-OH vitamin D, thyroid function tests and C-reactive protein (CRP) may also be monitored and evaluated. Monitoring and evaluation of the above factors is needed to effectively determine nutrition diagnoses that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    DLM: Monitor and Evaluate Energy and Macronutrient Needs
    Following the nutrition intervention, to check progress, the registered dietitian (RD) should monitor and evaluate the energy and macronutrient needs (e.g., quantity and quality of fat, carbohydrate and protein) of adults with disorders of lipid metabolism (DLM). If changes in weight or serum lipid parameters warrant an adjustment of initial energy and macronutrient needs, estimated energy needs can be revised based on indirect calorimetry, predictive equations or comparison of energy intake and weight changes. If indicated by changes in energy needs or serum lipids, recommended levels of macronutrients can be recalculated using the macronutrient standards:
    • Total fat of 25-35% (achieving goals of saturated fat (SFA) and trans fat <7% of kcals and dietary cholesterol <200 mg per day is typically feasible only with total fat ≤30% kcals per day)
    • Total protein of 15-20% (encourage vegetable protein to help achieve SFA goals and cholesterol goals)
    • Total carbohydrates (CHO) of 45-60% of kcals (with emphasis on high fiber/complex CHO sources and avoidance of refined CHO foods).
    Results of the evaluation of caloric and macronutrient needs and intake will help the RD to develop strategies to meet the recommendations of the cardioprotective diet. Monitoring and evaluation effectively tracks patient’s progress, or lack thereof, and determines whether or not nutrition care goals have been achieved, or further action is warranted.  
    Consensus
    Imperative