DLM: Scope of Guideline (2011)
Below, you will find a list of characteristics that describe the scope of this guideline.
Counseling, Management, Prevention, Treatment
Cardiology, Endocrinology, Family Practice, Geriatrics, Internal Medicine, Nutrition, Pharmacology, Physical Medicine and Rehabilitation, Preventive Medicine
To provide Medical Nutrition Therapy (MNT) guideline recommendations for Disorders of Lipid Metabolism (DLM) that support improvement in lipid levels and risk factor management of cardiovascular disease (CVD).
- To define evidence-based recommendations within the scope of practice for Registered Dietitians (RDs) that are carried out in collaboration with other healthcare providers
- To guide practice decisions that integrate medical, nutritional, and behavioral elements
- To reduce variations in practice among RDs
- To promote self-management strategies that empower the patient to take responsibility for day-to-day management and provide the RD with data to make recommendations to adjust MNT, or recommend other therapies to achieve clinical outcomes
- To enhance the quality of life for the patient, utilizing customized meal planning strategies based on the individual’s eating preferences, lifestyle, and goals to improve metabolic control
- To develop content for intervention that can be tested for impact on clinical outcomes
- To define highest quality of care within cost constraints of the current healthcare environment.
Adult (19 to 44 years), Middle Age (45 to 64 years), Aged (65 to 79 years), Male, Female
Target Population Description
Adults with risk factors for cardiovascular disease (CVD), including Disorders of Lipid Metabolism (DLM).
Considerations and Assumptions Based on the National Heart, Lung and Blood Institute Clinical Practice Guidelines for Those With High Blood Cholesterol
Diagnosis and treatment of DLM for prevention of heart disease has been rooted in clinical guidelines from the National Heart, Lung and Blood Institute (NHLBI). In 2011, as this guideline from the American Dietetic Association (ADA) was released, new clinical guidelines were anticipated from NHLBI. This set of guideline recommendations was framed within the context of the therapeutic lifestyle changes (TLC) National Cholesterol Education Program’s Adult Treatment Panel (ATP) III and it 2004 update. 1
Recommendations from the Recent Clinical Trials and NCEP ATP III report that form the basis for the MNT approach for treatment of lipid metabolism disorders are as follows:
Recommendations From the 2004 Update to ATP III1
- Therapeutic Lifestyle Changes (TLC) remain an essential modality in clinical management. TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL-lowering.
- In high-risk persons, the recommended low-density lipoprotein cholesterol (LDL-C) goal is <100mg per dL
- An LDL-C goal of <70mg per dL is a therapeutic option on the basis of available clinical trial evidence, especially for patients at very high risk
- If LDL-C is >100mg per dL, an LDL-lowering drug is indicated simultaneously with lifestyle changes. If baseline LDL-C is <100mg per dL, institution of an LDL-lowering drug to achieve an LDL-C level <70mg per dL is a therapeutic option on the basis of available clinical trial evidence.
- If a high-risk person has high triglycerides (TG) or low high-density lipoprotein cholesterol (HDL-C), consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When TGs are 200mg per dL, non-HDL-C is a secondary target of therapy, with a goal 30mg per dL higher than the identified LDL-C goal.
- For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is <130mg per dL; an LDL-C goal <100mg per dL is a therapeutic option on the basis of available clinical trial evidence. When LDL-C level is 100mg to 129mg per dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level <100mg per dL is a therapeutic option on the basis of available clinical trial evidence.
- Any person at high risk or moderately high risk, who has lifestyle-related risk factors (e.g., obesity, physical inactivity, elevated TG, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level
- When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels
- For people in lower risk categories, recent clinical trials do not modify the goals and cutpoints of therapy.
1Grundy 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.
Interventions and Practices Considered
The Disorders of Metabolism (DLM) guideline is based on ADA’s Nutrition Care Process and Model, which involves the following steps. Terms relevant to the treatment of DLM come from the International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process. Third Edition.
- Nutrition Assessment
- Nutrition Diagnosis
- Nutrition Intervention
- Nutrition Monitoring and Evaluation.
This guideline addresses topics that correspond to the following areas of the Nutrition Care Process. Please refer to the DLM algorithm in this guideline for a more detailed view of the recommendations and their application within the Nutrition Care Process.
I. Referral to a Registered Dietitian (RD)
II. Medical Nutrition Therapy (MNT)
A. Nutrition Assessment
Below you will find the nutrition assessment terms related to DLM care from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process. Third Edition.
- Food/nutrition history
- Anthropometric measurements
- Biochemical data, medical tests, and procedures
- Nutrition-focused physical findings
- Client history
B. Nutrition Diagnosis
Below you will find the more common nutrition diagnoses related to DLM care from International Dietetics & Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process. Third Edition.
- Excessive energy intake
- Excessive intake of saturated fat
- Inappropriate intake of refined carbohydrate (CHO)
- Excessive alcohol intake
- Inadequate fiber intake
- Physical inactivity.
C. Nutrition Intervention (Planning and Implementation)
Specific nutrition intervention terminology related to the DLM might include: Nutrition counseling and education which addresses the type and amount of food and nutrients such as major dietary fat components (saturated fat, trans-fat, unsaturated fat, omega-3 and omega-6 fatty acids), protein and CHO, addition or change in provision of bioactive substances (plant sterols and plant stanol esters, soy protein, psyllium), and adoption of healthful lifestyle habits such as limiting alcohol and increasing physical activity.
Individualized nutrition prescription based on current reference standards and dietary guidelines and the patient/client’s health condition and nutrition diagnosis:
- Major dietary fat components (includes CHO and protein consideration): Fat composition, trans-fatty acids, omega-3 fatty acids, and fiber
- Vitamin and mineral adequacy
- Food recommendations: Nuts, fish, soy products, plant stanol/sterol products
- Healthful habits limiting alcohol, increasing physical activity.
Below you will find the nutrition interventions related to DLM care from International Dietetics & Nutrition Terminology Reference Manual. Standardized Language for the Nutrition Care Process. Third Edition.
- Meals and snacks
- Enteral or Parenteral nutrition
- Medical Food Supplements
- Bioactive Substance Management
- Feeding Assistance
- Feeding Environment
- Nutrition-Related Medical Management
- Nutrition Education
- Nutrition Counseling
- Coordination of nutrition care
- Discharge planning and transfer of nutrition care to new setting or provider.
D. Monitoring and Evaluation
The monitoring or progress, measuring of outcomes, and evaluating of outcomes against criteria to determine changes in specific indicators of MNT outcomes.
Below you will find the nutrition monitoring and evaluation terms related to DLM care from International Dietetics & Nutrition Terminology Reference Manual. Standardized Language for the Nutrition Care Process. Third Edition.
- Food and nutrient intake
- Nutrition-related ADLs and IADLs
- Physical activity
- Nutrition-focused physical findings.