Disorders of Lipid Metabolism

DLM: Introduction (2011)

Guideline Title

Disorders of Lipid Metabolism (2011) Evidence-Based Nutrition Practice Guideline

Guideline Narrative Overview

This guideline updates the 2005 ADA Disorders of Lipid Metabolism Evidence-based Nutrition Practice Guideline.

The objective of the Disorders of Lipid Metabolism (DLM) guidelines is to provide Medical Nutrition Therapy (MNT) guideline recommendations that support improvement in lipid levels and risk factor management of cardiovascular disease (CVD). The focus of this guideline is on the treatment of lipid metabolism disorders - that is, patients with elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC),  or triglyceride (TG) levels, and low high-density lipoprotein cholesterol (HDL-C) levels, as well as coronary health issues such as metabolic syndrome and hypertension (HTN).

Disorders of Lipid Metabolism are recognized risk factors for atherosclerotic diseases, including coronary heart disease (CHD). The relationship of TC and LDL-C subsequent to CHD events has been well documented in several major observational and clinical studies.1 An increasing body of evidence links dyslipidemias to the occurrence of stroke.2 Clinical trials have found that lowering LDL-C lowers coronary events. Evidence is also accumulating that risk for CHD can be reduced beyond LDL-lowering therapy by modification of other risk factors. One potential secondary target of therapy is the metabolic syndrome, which represents a constellation of lipid and non-lipid risk factors of metabolic origin. National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III recognizes the metabolic syndrome as a secondary target of risk reduction therapy.3 This guideline includes metabolic syndrome management as a consideration. Although the terms CVD and CHD are sometimes used interchangeably, this guideline intentionally differentiates relationships within the overall category of CVD. According to the American Heart Association,  CHD is a disease of the heart caused by atherosclerotic narrowing of the coronary arteries likely to produce angina pectoris or heart attack. Cardiovascular disease can include HTN, atherosclerotic disease, heart failure and less common disorders, such as congenital heart defects. Disorders of Lipid Metabolism can contribute to atherosclerotic disease that may manifest in CHD, stroke, abdominal aortic aneurysm and peripheral vascular disease. Hypertension can also contribute to atherosclerotic disease. Topics included in this guideline are:

  • DLM: Referral to a Registered Dietitian for Medical Nutrition Therapy
  • DLM: Nutrition Assessment 
  • DLM: Determining Energy and Macronutrient Needs
  • DLM: Major Fat Components*
  • DLM: Carbohydrate, Protein and Fiber
  • DLM: Omega-3 Fatty Acids *
  • DLM: Plant Stanols And Sterols*
  • DLM: Nuts*
  • DLM: Alcohol*
  • DLM: Antioxidant Supplements (Vitamin E, Vitamin C, and Beta-Carotene)
  • DLM: Homocysteine, Folate, Vitamin B6 or B12*
  • DLM: Coenzyme Q10
  • DLM: Physical Activity
  • DLM: Hypertension
  • DLM: Metabolic Syndrome
  • DLM: Triglycerides and Macronutrients
  • DLM: Triglycerides and Omega-3 Fatty Acid Supplements
  • DLM: Nutrition Monitoring and Evaluation
     

*In addition to an update of the evidence analysis related to the DLM topics above, results of this review were supplemented by a later evidence review of the literature conducted by the United States Department of Agriculture (USDA) and the 2010 Dietary Guidelines Advisory Committee (DGAC). Therefore, there may be some overlap of the studies included in the evidence analysis. 

Guideline Development 

This guideline is intended for use by Registered Dietitians (RDs) involved in providing MNT to individuals with DLM. The application of the guideline must be individualized to assist the RD to successfully integrate MNT into the overall medical management of individuals with DLM. The recommendations in the guideline were based on a systematic review of the literature.

The recommendations are based on the work performed by the American Dietetic Association (ADA) DLM expert working group. The number of supporting documents for these topics is below:

  • Recommendations: Eighteen (18)
  • Conclusion Statements: One hundred and seventeen (117) 
  • Evidence Summaries: Eighty-nine (89)
  • Article Worksheets: Four hundred and thirty-four (434).
     

At the time of this publication, the majority of research has been completed in the adult population; therefore, clinical judgment is crucial in the application of these guidelines for individuals in other age groups and settings.

Application of the Guideline

This guideline will be accompanied by a set of companion documents to assist the practitioner in applying the guideline. A toolkit will contain materials such as the MNT protocol, documentation forms, outcomes management tools, client education resources and case studies. The toolkit is currently under development and will undergo pilot-testing through the ADA's Dietetic Practice-Based Research Network prior to publication.

Revision

The literature search will be repeated for each guideline topic on an annual basis to identify new research that has been published since the previous search was completed. Based on the quantity and quality of new research, a determination will be made about whether the new information could change the published recommendation or rating.

If a revision is unwarranted, then the search is recorded, dated and saved until the next review and no further action is taken. If the determination is that there could be a change in the recommendation or rating, then the supporting evidence analysis question(s) will be re-analyzed following the standard ADA Evidence Analysis Process (see Methodology tab).

When the analysis is completed, the expert workgroup will approve and re-grade the conclusion statements and recommendations. The guideline will undergo a complete revision every three to five years.

Medical Nutrition Therapy and Dyslipidemia

Scientific evidence strongly supports the effectiveness of MNT as a means to manage dyslipidemia and reduce risk factors associated with CVD. In addition to the well documented role of saturated fat and trans fat on LDL-C and CHD, the nutrition prescription incorporates the use of foods containing specific key nutrients with proven benefits for achieving optimal lipid management and CVD outcomes.The RD plays an essential role on the interdisciplinary healthcare team by designing the optimal nutrition prescription tailored to the individual's needs and synergistic with pharmacotherapy when necessary. As part of the nutrition care process, the RD applies her/his knowledge, skills and training to first conduct a comprehensive nutrition assessment in order to determine an accurate nutrition diagnosis(es) for the patient/client. Following collection of the assessment data, the RD then considers other existing comorbidities and medical diagnoses to develop the nutrition prescription, according to the relevant, evidence-based nutrition practice guidelines. These may include weight management, HTN, and type 2 diabetes or other guidelines that will further influence the optimal treatment. The RD skillfully blends the macronutrient and micronutrient mix to achieve the appropriate diet prescription without compromising individual health needs and therapeutic goals. During MNT intervention, the RD plans the course of action and educates or counsels the patient/client on the appropriate diet, behavior and lifestyle changes in a manner and sequence that best meet the patient/client's needs. Use of motivational interviewing or other proven strategies can further enhance adherence. Following the initial intervention, the RD monitors and evaluates progress over subsequent visits to determine whether the goals are being met and provides ongoing support and adjusts the nutrition prescription, as needed.

Populations to Whom This Guideline May Apply 

Population groups, medical conditions, or coexisting diagnoses where the DLM recommendations may be indicated include:

  • CHD
  • Cerebral vascular disease
  • Familial or combined hyperlipidemia, hypertriglyceridemia, hypercholesterolemia
  • Metabolic syndrome
  • Diabetes mellitus
  • History of CVD and dyslipidemia in first degree relatives
  • Peripheral vascular disease
  • Abdominal aortic aneurysm
  • HTN
  • Obesity
  • Cigarette smoking
  • History of myocardial infarction (MI).

Other Guideline Overview Material

For more details on the Guideline components, use the links on the left to access:

Scope of Guideline

Statement of Intent

Guideline Methods

Implementation of the Guideline

Benefits and Harms of Implementing the Recommendations

Other factors to consider when exploring nutrition therapy options include the presence of secondary causes and conditions associated with hyperlipidemia. Total cholesterol, TG, and HDL-C levels may be affected by an individual’s medical history, including use of prescription and over-the-counter drugs, metabolic or endocrine conditions such as diabetes, hypothyroidism or obesity, kidney disease and liver disease. In addition, certain lifestyle and dietary practices such as current cigarette smoking habit and alcohol abuse, a high- or low-fat diet, high cholesterol intake, a low-fiber diet, weight gain and physical inactivity can affect lipid profiles as well.

1WRITING GROUP MEMBERS, Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Roger VL, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23; 121(7): e46-e215. Epub 2009 Dec 17. No abstract available. Erratum in: Circulation. 2010 Mar 30; 121 (12): e260. Stafford, Randall [corrected to Roger, VĂ©ronique L]. PMID: 20019324. Accessed online: http://circ.ahajournals.org/cgi/content/full/121/7/e46
 

2 Institute of Medicine, Committee on Nutrition Services for Medicare Beneficiaries. The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: National Academy Press, 2000.

3 Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ; Coordinating Committee of the National Cholesterol Education Program. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004 Aug 4; 44 (3): 720-732. Review. PMID: 15358046.