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New Nutritional Approaches for the Treatment of Hyperlipidemia

New Nutritional Approaches for the Treatment of Hyperlipidemia. Laura S. Kinzel, M.S., R.D. October 3, 2001. Intervention. Most successful when tailored to specific stages of change, goals, and challenges

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New Nutritional Approaches for the Treatment of Hyperlipidemia

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  1. New Nutritional Approaches for the Treatment of Hyperlipidemia Laura S. Kinzel, M.S., R.D. October 3, 2001

  2. Intervention • Most successful when tailored to specific stages of change, goals, and challenges • Effort is worthwhile: changes can be made and are an important adjunct to other therapies for CVD • Incorporates lifestyle changes (+ drug therapy)

  3. Team approach: time spent w/RD + correlated with degree of cholesterol lowering 3 visits: 88% post-MI at Step II diet at 90 days after admission type II DM: any contact w/RD produced better medical outcomes Cognitive-behavioral approach: stages of change goal setting contracting self-monitoring stimulus control reinforcement feedback individualization Optimizing Change

  4. What Motivates Change?Ernst, D; Berg-Smith S; Brenneman, D; Johnson M. WHI Intensive Intervention Protocol, August 1999 • If you are told what to do, there is a good chance that you will do the opposite • People want to feel in control • Values and beliefs • Link behavior change to core values • Beliefs more influenced by what you hear yourself say than by what is said to you • One’s own reasons are most persuasive

  5. What Motivates Change, cont. • Ambivalence is normal • Stage of change: Contemplation • Weighing pros/cons of choice can help • Decisional balance • Knowledge/perceived harm or benefit • Provide personal feedback, advice and/or education • Need to believe it can be done • Voice confidence in patient’s ability to change • Interaction between provider and client powerfully influences resistance, compliance and change • Never underestimate the power of relationship

  6. % of the Treatment-Eligible Population Receiving Treatment(Hoerger et al.Amer J Cardiol 1998;82:61-5

  7. New Features of ATP III • Modifications of Lipid and Lipoprotein Classification • Identifies LDL cholesterol <100 mg/dL as optimal • Raises categorical low HDL cholesterol from <35 mg/dL to <40 mg/dL • Lowers the triglyceride classification cutpoints to give more attention to moderate elevations (normal: <150 mg/dL)

  8. ATP III: More Therapeutic Options • Plant stanols/sterols (2g/day) • Increased viscous (soluble) fiber (10-25 g/day) • Weight reduction • Increased physical activity Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001.

  9. Maximizing LDL ReductionPlatt R; Prev Cardiol. 2000;3:83-87

  10. Nutrient Composition of Therapeutic Lifestyle Changes Diet (ATP III, May 2001)

  11. “First Line” Approach • Starting point for those with hyperlipidemias who are overweight: • Lower total fat to approximately 25% to promote weight loss • Emphasize low saturated fat intake • Carbohydrate: Promote complex sources and high soluble fiber • Tailor to individual medical/lifestyle needs

  12. Carbohydrate Controversy: High-CHO, Low-Fat Eating Patterns • Hypertriglyceridmeia associated with  risk ASHD Austin MA et al. Am J Cardiol 1998;81:7B-12B Gotto AM Am J Cardiol 1998;82:22Q-25Q Miller M Eur Heart J 1998;19(suppl):H18-22 • High CHO, low fat eating patterns linked to hypertriglyceridemia, as well as to low HDL • Added CHO (not removal of fat): hypertriglyceridemia • More CHO, less fat = greater  in TG when isoenergetic, remaining elevated for at least several months • Weight loss, fiber,physical activity modify TG response Parks, EJ and Hellerstein MK Am J Clin Nutr 2000;71:412-33

  13. Metabolic Syndrome: > 3 Risk Factors enhance risk for CHD at any given LDL cholesterol level (ATP III, May 2001)

  14. Metabolic Syndrome • Control LDL cholesterol (lifestyle + drugs) •  weight and  physical activity : • lower LDL, raise HDL • improves insulin resistance, cardiac fitness • Consider modifying eating pattern further: • Moderate CHO, high fiber, low sugar • ~30% fat (low sat. fat, high MUFAs) which may promote LDL and HDL Nydahl MC et al. Am J Clin Nutr1994;59:115-22 Lichtenstein AH et al. Arterioscler Thromb. 1993;13:1533-42 Reaven P et al. Am J Clin Nutr 1991;54:701-06

  15. High-CHO, Low-Fat Diets… Do incremental increases in carbohydrate and gradual decreases in fat attenuate the rise in triglycerides?

  16. High-CHO, Low-Fat Diet: Lower Plasma Lipids and Lipoproteins w/o Producing HyperTG? Ullmann D et al. Arterioscler Thromb 1991;11:1059-67

  17. High-CHO, Low-Fat Diet: Lower Plasma Lipids and Lipoproteins w/o Producing HyperTG? Ullmann D et al. Arterioscler Thromb 1991;11:1059-67

  18. High-CHO, Low-Fat Diet: Lower Plasma Lipids and Lipoproteins w/o Producing HyperTG? Ullmann D et al. Arterioscler Thromb 1991;11:1059-67

  19. High-CHO, Low-Fat Diet: Lower Plasma Lipids and Lipoproteins w/o Producing HyperTG? Ullmann D et al. Arterioscler Thromb 1991;11:1059-67 • Investigators’ conclusion: • Although sudden increases in dietary carbohydrate often lead to increases in triglyceride levels, a high-CHO, low-fat eating pattern fed gradually may achieve significant reductions in total- and LDL-cholesterol without carbohydrate-induced hypertriglyceridemia

  20. A very low-fat diet is not associated with improved lipoprotein profiles in men with a predominance of large, low-density lipoproteins Dreon DM et al. Am J Clin Nutr 1999;69:411-18 • Previous work: (FASEB J 1994;8:121-6) • phenotype A men (larger LDL) on 40% fat diet show less benefit with 22% fat than men with phenotype B (small, dense LDL) • 1/3 phenotype A on high fat converted to phenotype B when switched to low fat eating pattern • 38 men with phenotype A, after being on both 40% and 22% fat diets for 4-6 wk, on 10% fat diet x 10 days • Replaced fat with carbohydrate • No change in cholesterol content or ratio poly:sat fat • 12 converted to phenotype B (change group) • LDL did not differ from 22% fat diet in either group • Higher TG, apoB, more small LDL, less HDL and apoA-I • In this subset, changes are suggestive of  coronary risk

  21. Summary Notes: High-CHO, Low-Fat Patterns • Lower fat eating patterns optimize weight loss and LDL reduction • Weight reduction, fiber and physical activity attenuate rise in triglycerides • Rise in triglycerides may be transient • Certain individuals may have improved response to moderate CHO intake, combined with careful use of mono- and polyunsaturates • Incremental increases in CHO may help blunt potential rise in triglycerides

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