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NAD 560
HYPERLIPIDEMIA
DR. NALEENA DEVI MUNIANDY
Senior Lecturer,
Department of Nutrition and Dietetics,
Faculty of Health Sciences,
UiTM Puncak Alam Campus, Selangor
HYPERLIPIDEMIA

Medical
Nutrition Therapy 1
Lipoproteins

 LDL-C
 HDL-C
 Triglycerides
Lipoprotein Metabolism

 Further reading
ATP 111 GUDELINES

 Adult Treatment Panel”

 Developed by the NCEP (National
Cholesterol Education Program), a
project of the NHLBI
 Nine-step algorithm for the treatment
of hyperlipidemia
 Revised in 2004 to include findings from
five recent clinical trials
Hyperlipidemia

 Leading risk factor for Coronary Heart

Disease and Stroke
 May be primary or secondary
 Generally symptomless (unless severe)
 NHLBI: Desirable lipid levels: LDL <100,
Total Cholesterol < 200
 Step 1:
Obtain lipoprotein levels (9-12 hr fast)
• LDL is the primary therapy target
• LDL < 100 is optimal*
• Total Cholesterol <200
• HDL Cholesterol > 40*
 Step 2:
Determine CHD Risk Equivalents

• Clinical CHD
• Symptomatic carotid artery disease
• Peripheral artery disease
• Abdominal aortic aneurysm
• Diabetes*
• Multiple risk factors and 10-year risk >
20%*
 Step 3:
Determine CHD risk factors
• Cigarette Smoking
• Hypertension ((BP >140/90 mmHg or on
antihypertensive medication)
• Family history of premature CHD (CHD in
male first degree relative
• Age: men > 45; women > 55)
• * HDL > 60 removes one risk factor
 Determination of Risk
 ATP Guidelines match the goal levels
to absolute risk
 Reduction of ‘composite risk’: long-
term plus short-term
 Three identified risk categories:
CHD/CHD risk equivalent, Multiple
(>2) risk factors, 0-1 risk factor
 Step 4
10-year risk assessment (for >2 risk
factors)
1) >20% (CHD risk equivalent
2) 10-20%
3) <10%
 Step 5: Determine Risk Category

 Establish LDL goal of therapy

 ■ Determine need for therapeutic lifestyle
changes (TLC)
 ■ Determine level for drug consideration
 LDL level to LDL level to
Risk Category LDL Goal
initiate TLC consider drug tx

> 130 mg/dL

CHD or CHD (100-130: drug
< 100 mg/dL > 100 mg/dL
risk equiv optional)

10-yr risk
10-20%: > 130
> 2 risk factors < 130 mg/dL > 130 mg/dL
<10%: > 160

> 190 mg/dL

0 -1 risk factor < 160 mg/dL > 160 mg/dL 160-189: drug
optional
 Step 6
Initiate Therapeutic Lifestyle Changes

Your role as a dietician/ nutrition

 TLC Diet: Saturated fat <7% calories,
cholesterol < 200 mg/day; consider plant
sterols and soluble fiber
 Weight management
 Increased physical activity
 Step 7: Initiate drug therapy

 For CHD or CHD risk equivalent,

consider drug and TLC
simultaneously
 For other risk categories, consider
adding drug to TLC after 3 months
 Handout: ‘Drug Therapy in
Hyperlipidemia’
Drug Treatment

HMG-CoA Reductase Inhibitors,

“Statins”
 LDL: 18-55%, HDL 5-15%, TG 7-
30%
 ADRs: Myopathy, LFTs
 Contraindications: Liver disease
 Drug Interactions: cyclosporine,
macrolides, antifungals, CYP450
inhibitors
HMG-CoA Reductase Inhibitors,
“Statins”
 Good clinical evidence for use through
clinical trials
 Reduce major coronary events, CHD
deaths, need for coronary procedures ,
stroke, and total mortality
 Bile Acid Sequestrates

 LDL 15-30%, HDL 3- 5%, TG: No

effect
 Side effects: GI upset, constipation
 Drug interactions: can decrease
absorption of multiple other drugs:
warfarin, digoxin, fluvastatin, ezetimibe
 Bile Acid Sequestrates

 CIs: TGs >400 (possibly >200),

dysbeta-lipoproteinemia
 Shown to reduce major coronary
events and CHD deaths
 Nicotinic Acid (Niacin)
 LDL 5-25%, HDL 15-35%, TG 20-50%
 Difficult to tolerate side effects:
flushing, GI upset, increase in uric acid,
hyper-glycemia, hepatotoxicity
 Contraindications: Gout, Chronic liver
disease, diabetes, PUD
 Reduces major coronary events/total
mortality(?)
 Fibric Acids (Fibrates)
 LDL 5-20%*, HDL 10-20%, TG 20-50%
 S/Es: GI upset, Gallstones, Myopathy
 C/Is: Severe renal or hepatic disease
 Reduced major coronary events
 Unexplained deaths in WHO study
 *LDL may actually increase if a patient has
high TGs
 Step 8:
Identify and treat metabolic Sx

 Initiate after 3 months of TLC

 Treat underlying causes
 Weight management
 Increase physical activity
 Treat lipid and non-lipid risk factors
 Hypertension
 Aspirin, if indicated
 Treat elevated TGs and/or low HDL
 Any 3 or more of the following:

Risk Factor Defining Level

Abdominal obesity: Waist circumference
Men > 40 in
Women > 35 in
Triglycerides > 150 mg/dL
HDL cholesterol
Men < 40 mg/dL
Women < 50 mg/dL
Blood Pressure >130/> 85
Fasting glucose > 110 mg/dL
Step 9: Treat elevated triglycerides

Classification (ATP III)

< 150 mg/dL Normal
159-199 Borderline High
200-499 High
> 500 Very High
 Consider adding medication therapy when:

 Triglycerides
remain 200-499
when LDL goal is reached
 Triglycerides are > 500 mg/dL
 Fibrate or nicotinic acid
ATP III vs. ATP II

 Adds Diabetes as a risk equivalent

 Uses 10-year absolute risk assessments
(Framingham tables)
 Identifies patients with metabolic
syndrome as candidates for more
aggressive TLCs
 Recommends total lipoprotein analysis
ATP III vs. ATP II
 Plant sterols and soluble fiber as
dietary recommendation
 Presents more comprehensive explan-
ations of how to achieve TLCs
 LDL < 100 mg/dL is optimal
 Low HDL is now defined as < 40 mg/dL
 Recommends drug therapy for TGs >
200
Objective of Diet
Management
Component Recommendation
LDL raising nutrients
Total fat 25 % - 30 %
Saturated fat < 7% of total calories
Dietary cholesterol Less than 200mg/day
PUFA Up to 10%
CHO 50%-60% of calories
Protein Approximately 15%
MUFA Up to 20%
Therapeutic action
Plant stanols/sterols 2 g /day
Increased viscous (soluble) fiber 10–25 grams per day
Total calories (energy Adjust total caloric intake to
maintain desirable body
weight/prevent weight
gain/achieve weight loss if obese

ATP 111 guidelines

Diet Recommendation
 The 25–35% fat recommendation allows for increased
intake of unsaturated fat in place of carbohydrates in
people with the metabolic syndrome or diabetes.
 Carbohydrate should come mainly from foods rich in
complex carbohydrates. These include grains
(especially whole grains), fruits and vegetables.
 Daily energy expenditure should include at least
moderate physical activity (contributing about 200
Kcal a day).
 Options include adding 10–25 grams of viscous
(soluble) fiber; 2 g/day of plant-derived sterols or
stanols. Soy protein may be used as a replacement for
some animal products.
 Limit salt to ,2400mg /day
Physical Activity
Recommendations
Recommendation of exercise for CVD prevention in
healthy adultsregardless of age is:
 at least 150 minutes a week of moderate intensity
or
 75 minutes a week of vigorous intensity PA or an
equivalent combination
For weight loss:
increased physical activity to 250 to 450 minutes of
moderate-intensity physical activity per week
strength training 2 to 3 times per week is required.
 accompanied with a calorie restricted diet.
Thank you