E3.
`
`U?
`
`sie HmE’:~Em m E,e;:w2:m’
`
`E4%mfia.m-:~ ti3HEIi.l E4%E~_2E<
`
`3269
`
`with established CHD failed to demonstrate a protec-
`tive effect of vitamin E supplementation on subsequent
`cardiovascular
`
`Thus, in spite of the theoretical benefits of antioxidant
`vitamins for reducing risk for CHD, this potential has
`so far not been found in controlled clinical trials that
`have used a variety of antioxidant mixtures and doses.
`The failure to demonstrate benefit in controlled trials
`does not eliminate the possibility of benefit. It does,
`however, dilute confidence in benefit and stands in the
`way of a solid recommendation for high intakes of
`antioxidants for CHD prevention.
`
`The Institute of Medicine has recently released recom-
`mendations for Dietary Reference lntakes (DRls) for
`antioxidant vitamins. A specific recommendation was
`not made for beta-carotene because it has not been
`shown to be an essential nutrient nor have clinical
`trials demonstrated benefit for reduction in risk for
`either cardiovascular disease or cancer. The RDA for
`vitamin C was increased to 75 mg/day for women and
`90 mg/day for men. The RDA for Vitamin E was set at
`15 mg/day. Vitamin E supplementation was not recom-
`mended for prevention of chronic disease because of a
`lack of convincing evidence of benefit.
`
`E%.6’Em3%&’"%%2?%3%
`awirlzzimgs
`
`m be %rm3lxrz.><l its
`rlirsirinl i,:'"%;w_l.~:;~ m ~:l2m> lzmm
`<lz>sxm:sssi:'";1i,z> tlmi, Sm ::;.::lm.::>,smziims
`a,:;si%m.'i~:l2:;sis will
`Em"
`
`I
`
`m
`Ilsa? tlim wiils
`*5}.
`
`E4 Edmztv
`a,::si%m.'i~:l21;:iss
`
`,i’"w:lt.,.::?E,ia.m
`e.>:sm,,:j,.;ls m
`Em" a,1;si%m.'i~:l2mi
`its rlirsirial
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`g1
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`Eli
`
`m :'"e~<:la,::7:>
`<*m'":'"mE
`
`mg; azmil
`rlzw Em" w<.m::rss
`mg;
`marl zzmsa. W5;;1:v<*i,%w.>l2r. Em" xrimmirs
`amrl
`Em" xrimmirs ii.
`
`3) Moderate intakes of alcohol
`
`Observational studies consistently show a ]-shaped
`relation between alcohol consumption and total mor-
`tality. Moderate alcohol consumption is associated
`
`with lower mortality, and higher consumption with
`higher mortality. The lower mortality appears to be
`related to Cl-ID death, because CHD accounts for a
`significant proportion of total deaths. Case-control,
`cohort, and ecological studies indicate lower risk for
`CHD at low to moderate alcohol intake.755 A moderate
`amount of alcohol can be defined as no more than one
`drink per day for women and no more than two drinks
`per day for men.755757 This gender distinction takes
`into account differences in both weight and metabo-
`lism. Moreover, any cardiovascular benefit occurs not
`in the young age groups but in middle-aged adults,
`men 45 years of age or older and women 55 years of
`age or older.758 Mechanisms of putative risk reduction
`from moderate alcohol consumption are unknown;
`however, it could be due to an increase in I-IDL choles-
`terol and apo A-1 and modestly to an improvement in
`hemostatic factors.759 Prospective cohort studies
`suggest a similar relationship with CHD regardless of
`the type of alcoholic beverages consumed.750
`
`The dangers of overconsumption of alcohol are
`well known. At higher levels of intake, adverse effects
`include elevated blood pressure, arrhythmia, and
`Alcohol excess also pre-
`myocardial
`disposes to acute pancreatitis. Rarely it can precipitate
`pancreatitis by accentuating a pre-existing hypertriglyc-
`eridemia and chylomicronemia.751 A pooled analysis
`shows that alcohol intake increases the risk of breast
`cancer in women.752 Since up to 10 percent of U3.
`adults misuse alcohol, advice about alcohol intake
`should be given carefully with both advantages and
`negatives presented.753 For some persons, the negatives
`of alcohol consumption will outweigh any advantage.
`
`rs
`
`i$tmim*r"eesm.:
`mil
`<;;?Ht> (2.3
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`lzigli Ersiazlwsa;
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`Na} ( m m ? Llzms mm ~:l:'"%rsks,<
`ilzzm
`Em" mm; marl
`( m m ?
`Em" w:.m::rss 5:%lE&}{,,il{l be r:>_zs5mm.::,>~:l, 53.
`l:::>e.>;'".
`am 53% m,ass:7:>s,<
`e.mss:7:>5:<
`
`a..mss:7c>s:<
`(la; mu
`
`wlm
`ssl:m.sl::l mu liti’ :3;s:?m.mzg_;:>~:l m %rs%i%;m>
`
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`

`3270
`
`cm-ummn Duumbur 17/24, 2002
`
`4) Dietary sodium. potassium, and calcium
`
`5) Herbal or botanical dietary supplements
`
`Many individuals with hypercholesterolemia also have
`hypertension (see Section VlI.6). Evidence suggests
`that even those with normal blood pressure levels can
`reduce their chances of developing high blood pressure
`by consuming less
`Studi s in diverse pop-
`ulations have shown that a high sodium intake is asso-
`ciated with higher blood pressure.754 Also. a high salt
`intake increases the amount of calcium excreted in the
`urine, and has been independently associated with
`bone loss at the hip.754 The Dietary Approaches to
`Stop Hypertension (DASH) trial has provided evidence
`that a dietary pattern high in fruits, vegetables, low-fat
`dairy products. whole grains. poultry. fish. and nuts
`and low in fats, red meat. and sweets--foods that are
`good sources of potassium. calcium. and magnesium-
`favorably influences blood pressure even when sodium
`levels are held constant,755 but when these nutrients
`are consumed in combination with a low sodium
`intake, 2400 mg or l800 mg, blood pressure is
`lowered even more.755
`
`W
`
`(hm
`
`Evidence statement: _H\]('
`pi (with-s n
`v('vi('\x ( i t my (witlmx(
`((3 snppon (lw ( ( m ( cpl
`l()x\('r salt inlalw l(>\\(\l.s l)l(m(i
`Ui pr('v('ms
`llnilm sll(1\\s Illili
`iisrisv.
`iildl
`(7n('(lini(;1l
`(luv
`i:1ti(ii1s.x('g(~I:1
`l(>\\-t'zn (l21lI’y[)i’()(lU(,lS \ \ l m l ( - grains. p(>uluy.
`l7l(\s.
`Fish. and mus and km in tats.
`( m a t . and
`polassinrn.
`(n’(~ g(>o(l s ( m r (
`.s\\(:('1.s
`(\s
`hloml pv'(\s.snr('
`( a l ( i u m . and rnugiuz-si((ry1-~\(>
`(A2)
`(lim km in sail
`arc (*nlmn((*(l by 2!
`
`Recommendation: llw Dim and Health
`um] _]NC, \
`(4 sodium imukv nf<24UU
`rmmmm-n<i
`2.4g smlitnn or
`[00
`mg/(l
`(n()r('1ir2ni
`(islg .s()(linm (lrloritlttl. JNC Vi
`r<'((mmm1\(ls
`
`2nI(i(:i\(>(1gix
`(appmx'nnz1mly 90 mmol pm
`and magn(-sinnn for tg(-nvml ll(*&\lill.
`AH’
`tlwsv l('(UVl|ii|(tll(lEVll()lh (ox p(-i.s(ms
`ill
`(1n(i(\i’going (h(>l(\s((-,1’(:I
`in ( l i n i ( nl
`
`(\
`
`The 10 top-selling herbal or botanical dietary supple-
`ments are cranberry, echinacea, evening primrose.
`garlic, ginkgo. ginseng. goldenseal. grape seed extract,
`St. John's wor t, and saw palmetto.757 These botanical
`supplements are available in health food stores,
`pharmacies, and many supermarkets. Several of the
`compounds have been promoted as agents to reduce
`the risk of CHD. Data from controlled trials regarding
`in part because existing
`efficacy and safety are limited,
`food and drug laws do not require demonstration of
`safety and efficacy to support legal marketing of
`dietary supplements. Dietary supplements are regulated
`according to different standards than are drugs. In
`addition to concerns about efficacy and safety, there is
`a lack of standardization among brands of botanical
`supplements, As a result. the amount of bioactive
`constituent, by which the supplements are hypothesized
`to influence disease, can differ widely among brands.
`ln the case of garlic, a few randomized controlled
`studies are available, but the preponderance of avail-
`able evidence fails to establish that garlic reduces LDL
`cholesterol levels. Biological plausibility supports use of
`some supplements, but there are few controlled clinical
`trials to document benefit. Studies designed to evaluate
`efficacy for disease endpoints. long-tcrm safety. and
`drug interaction have not been reported.
`
`Evidence statement: D(~,.spi1(' x\i(l(\spx’(w\<l pi()m(>1i(m
`(iimznv s(1ppl(:(nmus
`lI(*ri>zIl or b()(2xni( al
`
`for
`pm<Iu((
`For ('ili
`Ii(m.s.
`
`[)()ll
`
`((>mmIl('(1 (lini(:al
`(rials
`my. and l(>u;;-1('rrn .sal’m_y and (hug inmmt
`Hievl(l2\l1i;H('il()i
`2i\’E)llEll)lU in sup
`lli(' uszv (>i'lx('(l>;\l and i>(:(;mi(z\l snpph-rn(-n1s in
`or m t z m n m u of hvzm
`
`Recommendation: All’
`in (l()(\s no:
`i n (>mnu:n<i
`lm|;mi(~2\l (limary sxipplmsmis H)
`[ i i
`( i t r v p((>i(>s
`r(\(l(1( 0 risk f(>1’CHL). Howt-\('1;
`ll(*2\l1l\
`si(m2xl.s six(>(1l(lq(1m’ypa(i('11is(()(~smi>lisi1xxlI(*(ivm’
`sH(l\ pimlmlsmt’lwlnggI1si'tll:0(;\\\s('
`(xlilw pmvn
`um rm (lrmr lHi(*|?H mm
`
`n s ( -
`
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`
`3271
`
`6) High protein, high total fat and saturated fat Weight
`loss regimens
`
`M the
`
`gem
`
`Periodically, weight-loss diets high in protein and fat
`and low in carbohydrate surge in popularity. Such diets
`will result in weight loss within a few weeks or months
`if calories are restricted. However, such diets have not
`been demonstrated to produce long-term weight loss in
`controlled trials. Although clinical trial data are lack-
`ing, several concerns have been expressed about the use
`of these diets in clinical weight reduction:
`
`Short-term, extreme diets rarely produce long-term
`weight reduction.
`High intakes of saturated fats can raise LDL
`cholesterol.
`Low intakes of fruits, vegetables, and grains can
`deprive persons of healthful nutrients and are not
`conducive to long-term health.
`
`Diets popularized as low-carbohydrate, high-fat,
`high-protein regimens for rapid weight loss should not
`be confused with ATP lll’s easing restriction of the
`percentage of dietary fat for persons with the metabolic
`syndrome. The latter allows dietary fat to rise to 35
`percent of total calories, provided it remains low in
`saturated fatty acids (<7 percent of total energy) and
`includes mostly unsaturated fats. This will reduce
`carbohydrate intake somewhat to prevent the actions
`of high-carbohydrate diets to raise triglycerides and
`reduce HDL cholesterol levels. The ATP lll recommen-
`dation allows for the dietary variety outlined in the
`Dietary Guidelines for Americans (2000).241
`
`M.&.%lTt:*:$E"%%?:%’?i.i
`azmil
`Em,
`l:::>e.>;s ~:lm.m:ssa<i:'";1i,z>
`
`;m>:sam. leiglz :<>:z:E fa:
`lE2WE.? mu
`HE ('i}.EEE,if"&}lli,’{l rlirsiml i,:'"%;w_l.~:;~ m
`in
`we~ig;lei re~<:l2.,,::?i,ims.
`i,l:vi:'" m_.:i:'"%msi rm::;::a>5a;iiims ~:l:w5a<
`a,2;::;.:::>a::" m be
`lsmlili,
`<*=.>:s<:l2.,,::7iw.> m
`
`Em,
`::::>;s<:l:>~:l Em"
`
`%:Ei5,.;h
`Eosssaa
`
`mini
`am~ mu
`its <*Eirs%<7al
`
`a. Weight control
`
`ATP H12 recommended increased emphasis on weight
`reduction as part of LDL-lowering therapy for over-
`weight/obese persons who enter clinical guidelines for
`cholesterol management. ATP lll confirms this recom-
`mendation. However, in ATP lll, emphasis on weight
`reduction is delayed until after other dietary measures
`are introduced for LDL lowering (reduced intakes of
`saturated fatty acids and cholesterol and possibly other
`options for LDL lowering [plant stanols/sterols and
`increased dietary fiber]) (see Figure V.2-l). The delay
`in emphasizing weight reduction is to avoid overload-
`ing new patients with a multitude of dietary messages
`and to concentrate first on LDL reduction. After an
`adequate trial of LDL-lowering measures, attention
`turns to other lipid risk factors and the metabolic
`syndrome (see Figure V.2-l). Weight reduction then
`becomes a major focus of TLC. In 1998, the NHLBI
`published Clinical Guidelines on the Identification,
`Evaluation, and Treatment of Overweight and Obesity
`in Adults from the Obesity Education lnitiative
`(OEI) .7879 This is an evidence-based report, and its
`recommendations for techniques of weight reduction
`are accepted by ATP III for persons undergoing man-
`agement for cholesterol disorders. The ATP lll report
`does not independently develop evidence statements
`beyond those in the OEI report. ATP lll endorses the
`importance of weight control described in the OEI
`report. lndeed, weight control alone, in addition to
`lowering LDL cholesterol, favorably influences all of
`the risk factors of the metabolic syndrome.
`
`b.
`
`Increased regular physical activity
`
`ATP II also recommended increased emphasis on
`regular physical activity. In ATP III, the emphasis is
`reinforced with particular attention to its benefits for
`management of the metabolic syndrome. The recom-
`mendation for increased physical activity is introduced
`when TLC is initiated and the recommendation is
`reinforced when emphasis shifts to management of the
`metabolic syndrome (see Figure V.2-l). Physical inac-
`tivity is a major risk factor for CHD.237238 It raises
`risk for CHD in several ways, notably by augmenting
`the lipid and nonlipid risk factors of the metabolic
`
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`

`3272
`
`{?;'r:'::.sM?ie:w:s
`
`5;i%e>e:es;wExe>t' ?I$’:’,;M,
`
`;.?&’3::3.3
`
`syndrome. It further enhances risk by impairing cardio-
`vascular fitness and coronary blood flow. Regular phys-
`ical activity can help reverse these adverse effects. It can
`have favorable effects on the metabolic syndrome and
`can reduce VLDL levels, raise HDL cholesterol and, in
`some persons, lower LDL levels. Regular physical activ-
`ity lowers blood pressure and reduces insulin resistance.
`It also has been reported to reduce risk for CHD inde-
`pendently of standard risk factors. The evidence base
`for the recommendation of increased physical activity as
`part of cholesterol management is presented in the U.S.
`Surgeon General’s Report on Physical Activity238 and
`will not be detailed in this report. The purposes of regu-
`lar exercise are to promote energy balance to maintain
`healthy body weight, to alleviate the metabolic syn-
`drome, and to independently reduce baseline risk for
`CHD. In certain circumstances, a physician has the
`option of referring a patient to an exercise specialist for
`prescription and guidance in exercise training. Exercise
`specialists can complement nutrition professionals in
`implementation of TLC by guiding individuals in a
`healthy exercise program.
`
`3%.
`
`El
`
`a. Role of the physician
`
`The physician is crucial to initiating and maintaining
`the patients dietary adherence. Physician knowledge,
`attitude, and motivational skills will strongly influence
`the success of dietary therapy. A positive attitude com-
`bined with effective dietary assessment,
`initiation of
`therapy, and followup are essential for initial and long-
`term adherence. The physician should try to determine
`the patients attitude towards acceptance of and com-
`mitment to TLC. The physician’s key responsibilities
`include: assessment of CHD risk, dietary assessment,
`explanation of the problem for the patient, decision
`about appropriate therapeutic plan, and description of
`the plan to the patient. The multiple benefits of lifestyle
`changes should be emphasized. The need for lifestyle
`change, even when drugs are prescribed, should be
`stressed. In this section, one model for the role of the
`physician in the institution and followup of dietary
`therapy will be described. This model can be modified
`according to the constraints of the practice setting. The
`key feature of this model is the introduction of dietary
`therapy in a stepwise manner, beginning with an
`emphasis on lowering LDL cholesterol and followed
`
`by a shift in emphasis to management of the metabolic
`syndrome, if the latter is present. The essential steps in
`this model are shown in Figure V.2-l.
`
`1) Visit 1 .' Risk assessment, diet assessment, and
`initiation of therapeutic lifestyle change
`
`Some persons do not qualify for immediate clinical
`management to lower LDL because their LDL level is
`not above the goal for their category of risk for CHD
`(see Section III). Nonetheless, the physican should
`appropriately control other risk factors, provide a
`public health message on overall risk reduction, and
`prescribe subsequent lipoprotein reevaluation as need-
`ed. Suggestions to assist the physician in conveying
`the public health message are outlined in Table V. 1-3.
`
`For persons who require dietary therapy, the first step
`is assessment of lifestyle habits. CAGE questions pro-
`vide the physician with a way to rapidly assess current
`intakes of LDL-raising nutrients (Table V.2-4). A more
`detailed tool for both assessment and as a guide to
`TLC is available in Table V.2-6. Therapeutic change
`in the first visit should begin with the TLC diet. If the
`patient demonstrates a lack of basic knowledge of
`the principles of the TLC diet, the physician should
`consider referral to a nutrition professional for medical
`nutrition therapy.
`
`2) Visit 2.’ lntensifying the TLC diet for LDL
`cholesterol lowering
`
`Approximately 6 weeks after starting the TLC diet,
`lipoprotein analysis is repeated and assessed. If the
`LDL cholesterol goal is achieved by 6 weeks, the
`patient should be commended for his/her adherence
`and encouraged to continue lifestyle changes
`(Figure V.2-l). If the LDL goal has not been achieved,
`the LDL-lowering TLC should be intensified.
`Depending upon the patient’s level of dietary adher-
`ence, various options exist. More vigorous reduction
`in saturated fats and cholesterol, adding plant stanols/-
`sterols (2 g/day), increasing viscous fiber (see Table
`V.2-5), and referral to a nutrition professional can
`all enhance LDL lowering.
`
`The physician should not ignore the power of TLC
`to reduce CHD risk. Despite the marked advances in
`drug therapy for elevated LDL cholesterol level,
`
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`
`REBEQ
`
`3273
`
`ATP lll places increased emphasis on nutrition and physi-
`cal activity for cholesterol management and overall
`risk reduction. The low prevalence of CHD in popula-
`tions that consume low intakes of saturated fats and
`cholesterol and high intakes of other healthful nutri-
`ents, and who maintain desirable body weight through
`balanced caloric intake and output, illustrate what can
`be achieved without drug therapy.532 Moreover, specifi-
`cally for LDL cholesterol reduction, the combination
`of several dietary modifications can produce a reduc-
`tion in LDL levels that rivals reductions produced by
`standard doses of statins. LDL cholesterol responses
`shown in Table V.5-2 represent conservative estimates
`based on the literature. Although cumulative responses
`have not been documented by clinical trial, a sizable
`summed response from the multiple components of
`TLC is likely.
`
`emit %?r.rrmaEi2iE;iisee: i..E.'L%i... Mir:iEeaE;i;:i"t:ii
`
`Dietary
`Change
`
`Approximate LDL
`Reduction
`
`8-1 0%
`3-5%
`5-8%
`
`3-5%
`6-1 5%
`
`20-30%
`
`Dietary
`Component
`
`Major
`Saturated fat
`Dietary cholesterol
`Weight reduction
`
`<7% of calories
`<200 mg/day
`Lose 10 lbs
`
`Other LDL-lowering options
`5-10 g/day
`Viscous fiber
`2g/day
`Plant stero|/
`stanol esters
`
`Cumulative estimate
`
`Adapted From Jenkins et al.768
`
`due to the log-dose characteristics of statin usage.
`Other studies revealed a much greater LDL reduction
`when dietary therapy plus plant stanols were combined
`with statin therapy.709770 These dietary options, if
`successfully implemented, are preferable to progressively
`increasing doses of LDL-lowering drugs.
`
`A second purpose of Visit 3 is to initiate lifestyle
`therapies for the metabolic syndrome, if it is present.
`Emphasis in TLC shifts to weight control and increased
`physical activity. The principles of weight control are
`described in the Obesity Education lnitiative
`
`Because of the complexities and frequent failures of
`long-term weight control in clinical practice, considera-
`tion should be given to referring overweight or obese
`individuals to a qualified nutrition professional for
`medical nutrition therapy.
`
`A second element of treatment of the metabolic syn-
`drome is to increase physical activity. The physician
`should provide specific recommendations for physical
`activity depending on the patients physical well-being
`and social circumstances. Consideration also can be
`given to referral to an exercise specialist for guidance
`if this resource is available. Moderate, sustained exer-
`cise can cause a significant reduction in baseline risk
`for CHD. Examples of moderate intensity exercise
`that may be useful to individuals are listed in Tables
`V.2-6 and V.5-3. Moderate intensity physical activity
`should be promoted for most people. Moderate
`amounts of vigorous activity also can be beneficial
`for some individuals, provided safety is ensured.
`Suggestions to incorporate more exercise into daily
`life are shown in Table V.5-4.
`
`3) Visit 3.’ Decision about drug therapy; initiating man-
`agement of the metabolic syndrome
`
`If the LDL cholesterol goal has not been achieved after
`3 months of TLC, a decision must be made whether to
`consider adding drug therapy. lf drugs are started, TLC
`should be continued indefinitely in parallel with drug
`treatment. Although the apparent ease of drug use is
`appealing, the additive effect of TLC to drug therapy
`in LDL cholesterol lowering is substantial and should
`not be overlooked. For example, Hunninghake et al.759
`reported an extra 5 percent lowering of LDL choles-
`terol when lovastatin therapy was combined with
`dietary therapy. This additional LDL cholesterol
`lowering equates to doubling the dose of the statin,
`
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`3risk walking (3-4 mph) for 30-40 minutes
`
`Swimming-laps for 20 minutes
`
`Bicycling for pleasure or transportation, 5 miles in 30 minutes
`Volleyball (noncompetitive) for 45 minutes
`
`Qaking leaves for 30 minutes
`
`oderate lawn mowing (push a powered mower) for 30 minutes
`
`care-heavy cleaning
`
`3asketball for 15-20 minutes
`
`_. Golf-pulling a cart or carrying clubs
`
`Social dancing for 30 minutes
`
`Moderate intensity defined as 4-7 kcal/minute or 3-6 METS. METS (work
`metabolic rate/resting metabolic rate) are multiples of the resting rates of oxygen
`consumption during physical activity. One MET represents the approximate rate
`of oxygen consumption of a seated adult at rest, or about 3.5 mL per min per kg.
`
`T This table was adapted from the recommendations of the Surgeon Generals
`Report on Physical Activity and Health238 and the Centers for Disease Control
`and Prevention and American College of Sports Medicine.77l
`
`hie
`
`to
`
`Walk more-look for opportunities!
`- Park farther away in parking lots near a mall so you have a
`longer walk
`- Walk or bike if your destination isjust a short distance away
`- Walk up or down 1-2 flights of stairs instead of always
`taking the elevator
`- Walk after work for 30 minutes before getting in the car and
`sitting in traffic
`- Walk home from the train or bus-take a longer route so it
`takes 20 minutes instead of 5-10 minutes
`- Walk with a colleague or friend at the start of your lunch
`hour for 20 minutes
`
`Do heavy house cleaning, push a stroller, or take walks with
`your children
`
`Exercise at home while watching television
`
`Go dancing orjoin an exercise program that meets several
`times per week
`
`If wheelchair bound, wheel yourself for part of every day in a
`wheelchair
`
`4) Visit N: Long-term follow-up and monitoring
`adherence to therapeutic lifestyle changes (TLC)
`
`The patient who has achieved the goal LDL cholesterol
`as a result of TLC must be monitored for the long term.
`TLC is maintained indefinitely and reinforced by the
`physician and, as appropriate, by a nutrition profession-
`al if medical nutrition therapy is necessary. The patient
`can be counseled quarterly for the first year of long-term
`monitoring and twice yearly thereafter.
`
`LDL cholesterol is measured prior to each visit, and the
`results are explained at the counseling session. When
`no lipoprotein abnormalities other than elevated LDL
`cholesterol are present, monitoring at 6-month inter-
`vals is appropriate. If elevated cholesterol level redevel-
`ops, the procedure outlined above for diet therapy of
`elevated LDL cholesterol should be reinstituted.
`
`Persons who fail to achieve their goal LDL cholesterol
`by dietary therapy can be classified as having an
`inadequate response to diet. Such responses fall into
`four categories:
`
`Poor adherence. Some persons adhere poorly to
`diet modification despite intensive and prolonged
`dietary counseling. They are not ready to change
`for various reasons. Physician endorsement of
`the importance of diet is essential for facilitating
`increased interest on the part of the patient.
`If the patient admits a lack of willingness to
`change diet or other life habits, drug therapy
`may be the only reasonable option to effectively
`lower LDL.
`Gradual change. Some individuals modify eating
`habits only gradually. They may adhere poorly to
`diet in the first few months but eventually will
`modify their eating habits to meet the goals of
`therapy. Up to a year of instruction and
`counseling may be required for these persons.
`This is especially true for persons who are
`following a weight reduction plan. Ongoing
`follow-up and reinforcement is crucial for
`developing long-term adherence. A continued
`effort to achieve adherence to life-habit changes
`should not be abandoned if drug therapy is started.
`Poor responders. A minority of persons are
`non-responders to dietary therapy and will have
`high LDL cholesterol levels that are inherently
`resistant to dietary modification despite good
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`adherence.772-774 The mechanisms for this
`resistance are not well understood. Recognition
`of such persons is important, and care must be
`taken not to accuse them of failing to adhere to
`diet when they are non-responders. Drug therapy
`may be the only effective means of treatment of
`high blood cholesterol in such persons, but
`continued adherence to TLC is helpful for
`maintaining an overall healthful dietary pattern.
`Inadequate responders. Persons with severe
`elevations of LDL cholesterol often do respond
`to dietary therapy, but the cholesterol lowering
`achieved is inadequate to reach the LDL
`cholesterol goal. For such persons, a 3-month
`period of intensive diet therapy before adding
`drugs is not necessary.
`
`b. Role of nurses, physician assistants, and pharmacists
`
`Other health professionals associated with the
`physician facilitate patient management. The role of
`nutrition professionals is addressed in more detail
`below. Other health professionals-nurses, physician
`assistants, nurse clinicians, pharmacists, and other
`professionals-can participate in patient education
`(e.g., explaining the rationale for dietary change, goal
`setting, selection of appropriate foods, diet adherence),
`promoting behavioral changes, and monitoring dietary
`changes. These health professionals should receive
`appropriate training in dietary assessment, dietary
`education, and counseling. Hospital nurses play a
`vital role in guiding patients during hospital admissions
`for acute coronary events. NCEP and AHA offer
`various educational materials to assist in training
`health professionals.
`
`American Dietetic Association. The American Dietetic
`Association (www.eatright.org; 216 W. Jackson Blvd.,
`Suite 800, Chicago, IL 60606-6995; 312-899-0040)
`maintains a roster of dietitians and responds to
`requests in writing or e-mail for assistance in locating
`a registered dietitian in a given area. Dietitians with
`particular expertise in cholesterol management are
`available in most large medical centers where they are
`often part of a multidisciplinary lipid clinic or cardiac
`rehabilitation team.
`
`Medical nutrition therapy provided by a registered die-
`titian is a service that involves a comprehensive assess-
`ment of a patient’s overall nutritional status, medical
`data, and diet history, followed by intervention to pre-
`scribe a personalized course of treatment.
`
`The following medical nutrition therapy CPT Codes
`can be found in the American Medical Association
`Current Procedural Terminology: CPT 20012775
`
`97802 Medical nutrition therapy; initial
`assessment and intervention, individual face-
`to-face with the patient, 15 minutes each.
`97803 Reassessment and intervention,
`individual face-to-face with the patient,
`15 minutes each.
`97804 Group (2 or more individual(s),
`30 minutes each.
`
`(For medical nutrition therapy assessment and/or inter-
`vention performed by a physician, see Evaluation and
`Management or Preventive Medicine service codes.)
`
`CPT codes currently cover consideration of MNT for
`management of diabetes mellitus and renal disease.
`
`c. Specific role of registered dietitians and other
`qualified nutrition professionals
`
`1) Role of the nutrition professional in LDL-1oWering
`therapy
`
`Registered and/or licensed dietitians are certified
`providers of medical nutrition therapy (MNT), and
`qualify for Medicare reimbursement. lndividual state
`licensure laws have established credentials for deter-
`mining qualifications for nutrition counselors.
`Dietitians with expertise and experience in dietary
`counseling for lipid lowering can be especially effective
`in facilitating adherence to TLC. Registered dietitians
`and other licensed nutritionists can be located through
`local hospitals and state and district affiliates of the
`
`When the physician chooses to consult a nutrition
`professional at Visits 1 or 2 for medical nutrition therapy,
`the goal is to enhance adherence to TLC. Medical nutri-
`tion therapy should start with dietary assessment, includ-
`ing the patients motivational level and willingness to
`change. A dietary assessment questionnaire, MEDFICTS,
`which was originally developed for and printed in ATP
`I112 is included in Diet Appendix A. Other cardiovascular
`dietary assessment tools are also available.775782 Proper
`assessment leads to a tailored dietary prescription. This
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`prescription then goes to the physician, who can encour-
`age adherence and monitor progress.
`
`a) First.’ dietary assessment
`A thorough and detailed assessment of the patients
`knowledge, attitudes, and behavior regarding diet is
`essential for effective nutrition counseling. Assessment
`requires attention to dietary history, cultural influences,
`and current eating habits. It also includes recording the
`patients weight and weight history, BMI, and waist
`circumference. The presence of abdominal obesity
`points to the metabolic syndrome. To assess current
`eating habits, the following information is needed:
`
`What times of the day does the patient usually eat?
`Are some meals routinely skipped?
`At what time does the patient eat his/her largest
`meal?
`Where are meals typically prepared and eaten
`(e.g., in a restaurant, work cafeteria, fast-food
`restaurant, deli, at home, or in the homes of others)?
`Are there occasions when stress increases food
`consumption?
`Are meals eaten at home purchased out and
`brought in, prepared from processed pre-pack-
`aged foods, or prepared fresh from the market?
`Which are favorite foods and what foods are
`disliked?
`Who is responsible for food shopping and
`preparation?
`What foods will be most difficult to increase or
`decrease?
`How well does the patient recognize serving sizes?
`
`The nutrition professional should assess the patients
`general knowledge of nutrition as it relates to elevated
`LDL cholesterol, the ability to read labels, educational
`level, motivation, attitudes toward diet, and the extent
`to which family members can facilitate dietary changes.
`
`b) Dietary guidance on adopting the TLC Diet
`To help patients adapt to the TLC Diet, the dietitian can:
`
`Focus on dietary patterns to facilitate LDL
`lowering. These patterns are consistent with the
`Dietary Guidelines for Americans (2000)241 to
`achieve overall health and to further reduce
`baseline risk for CHD. This eating pattern is
`recommended for the entire family.
`Seek mutual agreement on an overall plan for
`
`diet modification as well as specific foods and
`eating habits that need to be changed. Emphasis
`goes first to dietary habits that affect LDL
`cholesterol levels. Highest on the list are foods
`rich in saturated fatty acids and cholesterol.
`The dietitian can review options for choosing
`preferred foods that lower LDL levels. The need
`for self-monitoring is reinforced; and simple
`approaches to tracking saturated fat, fiber, fruit,
`and vegetable intake are provided. Weight
`reduction includes learning how to control
`portion sizes. Also, documenting preparation and
`the quantities of different foods helps in
`long-term a