Final Exam
• Tuesday, 6/5, 2 PM
• Closed book
–
Essay and MC/TF
• Determining Energy Needs
p234-246
Indirect calorimetry
Be able to do the calculations given RQ table,
VO2, VCO2
– Principles of indirect calorimetry
– Don’t memorize H-B or WHO equations
–
–
–
Final Exam
• Protein status
–
–
AMA (will give you equations, 233-234)
Biochemical assessments (321-327)
• Iron status (327-332)
–
Know markers (and their rationale) of iron status
Be able to interpret lab values
–
principle & interpretation
–
Assessment only, not treatment
CHD risk assessment using ATP III
Know cut points
–
• Glucose (fasting & GTT) (303-307)
• Lipoproteins & CHD (262-272)
–
–
Update: Detection, Evaluation,
and Treatment of High Blood
Cholesterol in Adults
(ATP III)
David L. Gee, PhD
Professor of Food Science and Nutrition
Central Washington University
National Cholesterol Education Program
(NCEP)
History
• Adult Treatment Panel I (ATP I)
1988
– strategy for primary prevention of CHD
– established cutoff values for TC, HDL-C,
LDL-C and CHD risk factors
–
National Cholesterol Education
Program (NCEP)
• Children’s Treatment Panel
–
1991
• ATP II
1993
– reaffirmed ATP I
– secondary prevention of CHD
–
National Cholesterol Education
Program (NCEP)
• ATP III
May 2001
– reaffirms ATP I, II
–
• New features
primary prevention in persons with
multiple risk factors
– modifies lipid classifications
– modifies implementation of prevention
measures
–
Initial CHD Risk Assessment
• Fasting lipoprotein profile
– adults > 20 yrs old
– every 5 years
– TC, LDL-C, HDL-C,
• Non-fasted blood sample
–
–
only TC and HDL-C usable
LDL-C = TC - HDL-C - (TG/5)
TG
ATP III Classification of LDLCholesterol (mg/dl)
• LDL Cholesterol
–
–
–
–
–
< 100
100-129
130-159
160-189
>190
optimal
near/above optimal
borderline high
high
very high
ATP III Classification of
Total and HDL Cholesterol (mg/dl)
• Total Cholesterol
<200
– 200-239
– >240
–
desirable
borderline high
high
• HDL Cholesterol
<40
– >60
–
low (bad)
high(good)
LDL Cholesterol Goals and Cutpoints for
Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
Risk Category
CHD or CHD
Risk Equivalents
(10-year risk
>20%)
2+ Risk Factors
(10-year risk
20%)
0–1 Risk Factor
LDL Goal
(mg/dL)
<100
<130
<160
LDL Level at Which
to Initiate
Therapeutic Lifestyle
Changes (TLC)
(mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
10-year risk
10–20%: 130
130
10-year risk
<10%: 160
160
190
(160–189: LDLlowering drug
optional)
CHD Risk Equivalents
• Have risk of major coronary event
equal to that of established CHD
• Other forms of atherosclerotic disease
–
–
–
peripheral arterial disease
abdominal aortic aneurysm
symptomatic carotid artery disease
• Diabetes
• Multiple risk factors that confer a 10year risk for CHD > 20%
LDL Cholesterol Goals and Cutpoints for
Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
Risk Category
CHD or CHD
Risk Equivalents
(10-year risk
>20%)
2+ Risk Factors
(10-year risk
20%)
0–1 Risk Factor
LDL Goal
(mg/dL)
<100
<130
<160
LDL Level at Which
to Initiate
Therapeutic Lifestyle
Changes (TLC)
(mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
10-year risk
10–20%: 130
130
10-year risk
<10%: 160
160
190
(160–189: LDLlowering drug
optional)
Major Risk Factors that Modify
LDL-Goals
• Cigarette smoking
• hypertension (BP>140/90 or on anti-hypertensive
medication)
• low HDL-C (<40mg/dl)
–
high HDL-C (>60mg/dl) “negative risk factor”
• family history of premature CHD
–
–
1o male relative < 55yrs
1o female relative <65yrs
• age
–
–
men > 45 yrs
women > 55 yrs
Estimating 10-Year CHD Risk
Framingham Risk Score
• Short Term Risk (10-yr) for
myocardial infarction
–
Based on:
•
•
•
•
•
Age
Total Cholesterol
Smoking status
HDL
Systolic BP
Spreadsheet for determining
Framingham 10-yr risk.
• Downloadable at:
–
http://hin.nhlbi.nih.gov/atpiii/riskcalc.htm
• Palm III Operating System download
at:
http://hin.nhlbi.nih.gov/atpiii/atp3palm.htm
– includes other information from ATP III
–
Categories of Risk and
LDL-C Goals
Risk Category
LDL goal (mg/dl)
CHD and CHD risk
equivalents
Multiple (2+) risk
factors
0-1 risk factors
<100
<130
<160
LDL Cholesterol Goals and Cutpoints for
Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
Risk Category
CHD or CHD
Risk Equivalents
(10-year risk
>20%)
2+ Risk Factors
(10-year risk
20%)
0–1 Risk Factor
LDL Goal
(mg/dL)
<100
<130
<160
LDL Level at Which
to Initiate
Therapeutic Lifestyle
Changes (TLC)
(mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
10-year risk
10–20%: 130
130
10-year risk
<10%: 160
160
190
(160–189: LDLlowering drug
optional)
Therapeutic Lifestyle Changes in
LDL-lowering Therapy
• TLC Diet
• Therapeutic options to lower LDL-C
plant stanols/sterols (2g/d)
– viscous soluble fiber (10-25 g/d)
–
• Weight reduction
• Increase physical activity
TLC diet
•
•
•
•
•
•
•
SFA: < 7% of Calories
PUFA: up to 10% of Calories
MUFA: up to 20% of Calories
Total Fat: 25-35% of Calories
CHO: 50-60% of Calories
fiber: 20-30g/d
Cholesterol: < 200mg/d
A Model of Steps in
Therapeutic Lifestyle Changes (TLC)
Visit 2
Visit I
Evaluate LDL
6 wks response
Begin Lifestyle
Therapies
• Emphasize
reduction in
saturated fat &
cholesterol
• Encourage
moderate physical
activity
If LDL goal not
achieved, intensify
LDL-Lowering Tx
Visit 3
Evaluate LDL
Visit N
6 wks response
Q 4-6 mo
Monitor
If LDL goal not
Adherence
achieved, consider
to TLC
adding drug Tx
• Reinforce reduction
in saturated fat and
cholesterol
• Consider adding
plant stanols/sterols
• Increase fiber intake
• Consider referral to
• Consider referral to
a dietitian
a dietitian
• Initiate Tx for
Metabolic
Syndrome
• Intensify weight
management &
physical activity
• Consider referral
to a dietitian
Beyond LDL Lowering:
Metabolic Syndrome as a Secondary
Target of Therapy
• Cluster of risk factors
• Associated with insulin resistance
• Enhance risk of CHD at any LDL-C
level
Diagnosis of Metabolic
Syndrome
• Three or more of the following:
• Abdominal Obesity
–
–
men > 40” waist circumference
women > 35” waist circumference
• Hypertriglyceridemia (>150 mg/dl)
• Low HDL
–
–
men < 40 mg/dl
women < 50 mg/dl
• Hypertension (>130/>85 mmHg)
• Hyperglycemia (> 110 mg/dl)
Prevalence of the Metabolic
Syndrome Among US Adults
JAMA 287:356-359 (2002)
• NHANES III (8814 adults)
• Prevalence
–
23.7% of adult population
•
–
increases with age
•
•
–
47 million Americans
6.7% of 20-29 yr olds
43.5% of 60-69 yr olds
overall, prevalence similar in men and women
•
•
African-American women 57% higher
Mexican-American women 26% higher
Management of Metabolic
Syndrome
• Control LDL-cholesterol
• Weight Control
–
–
enhances LDL-C lowering
reduces all risk factors of metabolic syndrome
• Physical Activity
–
–
–
–
–
reduces VLDL-TG
increases HDL-C
lowers LDL-C
lowers BP
reduces insulin resistance
ATP III Guidelines - Application
• Step 1
–
Determine lipoprotein levels
from fasted blood sample
• LDL-cholesterol
primary target of therapy
– Total cholesterol
– HDL-cholesterol
–
ATP III Guidelines - Application
• Step 2
–
Identify presence of clinical
atherosclerotic disease that
confer high risk
–
Clinical CHD
CHD risk equivalents
–
ATP III Guidelines - Application
• Step 3
–
•
•
•
•
•
Determine presence of major
risk factors (other than LDL)
cigarette smoking
hypertension or anti HPT meds
low HDL
family history
age
ATP III Guidelines - Application
• Step 4
–
–
If 2+ risk factors (other than LDL)
without CHD or CHD equivalent,
assess 10-year CHD risk
Framingham tables
• > 20% = CHD risk equivalent
ATP III Guidelines - Application
• Step 5
–
Determine risk category
•
•
•
CHD or CHD Risk Equivalent
2+ Risk Factors
1-1 Risk Factors
• Establish LDL goal
• Determine need for TLC based on LDL
• Determine level for drug consideration
ATP III Guidelines - Application
• Step 6
– Initiate
TLC if LDL is
above goal
• TLC diet
• Weight management
• Increase physical activity
ATP III Guidelines - Application
• Step 7
consider adding drug therapy if
LDL exceeds recommended levels
• Drugs + TLC simultaneously if CHD or
CHD equivalent
• Add drugs to TLC after 3 months for
other risk categories
–
ATP III Guidelines - Application
• Step 8
Identify metabolic syndrome and
treat, if present after 3 months
of TLC
• Clinical identification
–
abdominal obesity
– hypertriglyceridemia
– low HDL
– hypertension
– hyperglycemia
–
ATP III Guidelines - Application
• Step 8 (cont.)
• Treat underlying causes
weight management
– physical activity
–
• Treat risk factors if they persist
despite TLC
treat hypertension
– use asprin
– treat hypertriglyceridemia, low HDL
–
ATP III Guidelines - Application
• Step 9
–
•
•
•
•
•
Treat elevated triglycerides
primary aim is to reach LDL goals
intensify weight management
increase physical activity
consider TG lowering drugs
if TG > 500mg/dl, 1st lower TG to prevent
pancreatitis (VLFD)
ATP III Guidelines - Application
• Step 9 (cont.)
–
Treatment of low HDL
• first reach LDL goal
• intensify weight management and increase
physical activity
• consider drug treatment if TG normal
Thanks!
The End!
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Age
Points
Age
Points
20-34
-7
55-59
8
35-39
-3
60-64
10
40-44
0
65-69
12
45-49
3
70-74
14
50-54
6
75-79
16
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Total
Pts at age Pts at age Pts at age Pts at age Pts at age
Cholesterol
70-79
60-69
50-59
40-49
20-39
<160
0
0
0
0
0
160199
200239
240279
>280
4
3
2
1
1
8
6
4
2
1
11
8
5
3
2
13
10
7
4
2
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Pts at
age
20-39
Pts at
age
50-59
Pts at
age
60-69
Pts at
age
70-79
Nonsmoker
0
Pts at
age
40-49
Smoker
9
7
4
2
1
0
0
0
0
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
HDL-C (mg/dl)
Points
> 60
-1
50-59
0
40-49
1
< 40
2
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Systolic BP
If Untreated
If Treated
< 120
0
0
120-129
1
3
130-139
2
4
140-159
3
5
> 160
4
6
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Point
Total
<9
10-Year
Risk %
<1
Point
Total
13
10-Year
Risk %
2
9
1
14
2
10
1
15
3
11
1
16
4
12
1
17
5
Estimate of 10-Year Risk for
Women (Framingham Point Scores)
Point
Total
18
10-Year
Risk %
6
Point
Total
22
10-Year
Risk %
17
19
8
23
22
20
11
24
27
21
14
> 25
> 30
Who, me worry ???