©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Disorders of Lipid Metabolism Toolkit
Overview
The American Dietetic Association’s Disorders of Lipid Metabolism Evidence-Based
Nutrition Practice Guideline incorporates systemically reviewed scientific evidence for
the treatment of lipid metabolism disorders, which can result in abnormal lipid levels, and
accompanying health issues such as hypertension, and metabolic syndrome. The
Guideline defines evidence-based recommendations, which guides the food and nutrition
practice decisions and reduces the variability in practice of the Registered Dietitian.
The Disorders of Lipid Metabolism Evidence-Based Nutrition Practice Guideline can be
accessed online in the Evidence Analysis Library at www.adaevidencelibrary.com.
The Disorders of Lipid Metabolism Toolkit contains the Medical Nutrition Therapy
(MNT) protocol and documentation forms that can be used for the application of the
Guideline. This set of companion documents focuses on ADA’s Nutrition Care Process,
which consists of the assessment, diagnosis, intervention, monitoring, and evaluation of
lipid metabolism disorders in adults 19 years of age and older. The primary goal of MNT
is to provide a dietary pattern that supports improvement in lipid levels and risk factor
management of cardiovascular disease. National evidence-based guidelines recommend
nutrition therapy as the first line therapy for management of dyslipidemia.1 The
Disorders of Lipid Metabolism Toolkit integrates the medical, nutritional, and behavioral
components of the Nutrition Care Process. The Disorders of Lipid Metabolism EvidenceBased Nutrition Practice Guideline and Toolkit together are the revision of ADA’s MNT
Evidence-Based Guides for Practice on Hyperlipidemia, 2001.
Dyslipidemia is a term used to describe abnormal lipid levels, which can include a high
blood level of total cholesterol, elevated LDL cholesterol (low-density lipoprotein), and
triglyceride level, and a decreased HDL-cholesterol (high-density lipoprotein) level.
Dyslipidemia is a recognized independent risk factor for atherosclerotic diseases
including coronary heart disease (CHD). The relationship of blood lipid levels of total
and LDL cholesterol subsequent to CHD events has been documented in several major
observational and randomized controlled trials.1,2,3 An increasing body of evidence has
linked dyslipidemias to the occurrence of stroke.4 Evidence is also accumulating that risk
for CHD can be reduced beyond LDL-lowering therapy by modification of other risk
factors.
One potential secondary target of therapy is the metabolic syndrome, which represents a
constellation of lipid and non-lipid risk factors of metabolic origin. ATP III recognizes
metabolic syndrome as a secondary target of risk reduction therapy and is included in this
toolkit.1 ATP III has introduced a new secondary target of therapy, non-HDL-C, in
patients with elevated triglycerides (>200 mg/dL).3
Scientific evidence strongly supports the effectiveness of MNT as a means to manage
dyslipidemia and reduce risk factors associated with cardiovascular disease.1 Studies
indicate that a reduction in total serum cholesterol, LDL-cholesterol levels, and drug
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
therapy increases with the level of time spent with the registered dietitian. Evidence
supports the need for two to six visits with the registered dietitian to achieve optimal
outcomes.1,5,6,7 Population groups, medical conditions, or coexisting diagnoses, where the
Disorders of Lipid Metabolism evidence-based nutrition practice guidelines may be
indicated include:
 Coronary heart disease
 Cerebral vascular disease
 Peripheral vascular disease
 Familial or combined hyperlipidemia, hypertriglyceridemia, hypercholesterolemia,
hypoalphalipoproteinemia
 Metabolic syndrome
 Diabetes mellitus
 History of cardiovascular disease and dyslipidemia in first degree relatives
 Hypertension
 Myocardial infarction
 Obesity and smoking
Cardiovascular disease is the leading cause of death and a major contributor to health
care utilization.2 According to data compiled by the American Heart Association (2005),
the cost of cardiovascular diseases in 2005 was estimated at $393.5 billion.8
The nutrition prescription goes beyond the realm of fat intake, integrating the use of food
sources providing key nutrients that have demonstrated improvement in lipid
management and cardiovascular disease outcomes. In addition, the registered dietitian
plays an active role in assisting the interdisciplinary team in designing the optimal
nutrition prescription that coincides with pharmacotherapy when necessary. The
nutrition prescription and nutrition outcomes monitors are based on disease severity and
comorbid conditions. Based on the client’s treatment plan and comorbid conditions,
other nutrition toolkits such as Hypertension, and Type 2 Diabetes Mellitus may need to
be combined as part of optimal treatment.
Included in the Disorders of Lipid Metabolism Toolkit are the following documents:
Medical Nutrition Therapy Protocol for Implementing Disorders of Lipid
Metabolism Evidence-Based Guideline: a set of steps that define the level, content, and
frequency of nutrition care that is appropriate for Disorders of Lipid Metabolism within
an ambulatory setting, based on the Nutrition Care Process.
 Summary Page: includes the recommended encounters for medical nutrition
therapy, and provides a summary of outcomes assessment factors, expected
outcomes, and ideal values for MNT, ideal values are based on scientific
evidence with the evidence strength indicated (Grade I – good/strong, Grade II
– fair, Grade III – limited/weak, Grade IV- expert opinion, Grade V – grade
not assignable).
 Flowchart: an overview of the process that includes the timeline and a brief
description of how to conduct each client encounter organized by assessment,
diagnosis, intervention, evaluation, and monitoring.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit

Encounter Process: a detailed set of instructions for each client encounter
organized by assessment, diagnosis, intervention, evaluation, and monitoring;
specifically describes suggested clinical and nutritional data to obtain, related
nutrition diagnoses, pertinent nutrition education, and the outcomes to
measure and evaluate. Document may be used to train and orient new staff or
students.
Sample Referral form: a one-page form for physicians to complete in order to justify
the need for medical nutrition therapy and give the practitioner a brief health history on
the client.
Nutrition Progress Notes (initial and follow-up): documentation forms for the paper or
electronic medical record, uses narrative notation to be used at each encounter, that are
specific to disorders of lipid metabolism. Forms should be used in coordination with
ADA’s Nutrition Diagnosis: A Critical Step in the Nutrition Care Process, 2006
(http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/career_912_ENU_HTML.htm).
Progress note forms may be adapted to meet specific needs of the facility or dietitian.
Sample Case Studies: client cases that illustrate the use of the Initial and Follow-up
Nutrition Progress Notes, using the nutrition care process, while highlighting clients with
lipid metabolism disorders.
Outcomes Monitoring Forms: individual and aggregate forms which, allow the
monitoring of client and population outcomes; used to document client progress at each
encounter or a population’s progress over time, in order to guide the treatment process
and evaluate the need for future MNT.
Client Education Resources: a list of resources available through ADA for client
education, highlighting those found in the Nutrition Care Manual (NCM); several
food/nutrient-specific handouts related to Disorders of Lipid Metabolism, the Toolkit
resources have not duplicated any client education found in the NCM, but may be used in
combination with these resources; an Agreement for Care, which can be used to outline
the goals and expectations of nutrition therapy and the dietitian’s role for the client,
encourages collaboration between dietitian and client in determining client goals for
nutrition therapy.
Appendices: includes guidelines for assessing overweight and obesity, ATP III LDL-C
goals and cut-points for TLC and drug therapy, Framingham risk scoring system, and
criteria for diagnosing metabolic syndrome.
In summary, this toolkit provides practitioners with guidance in applying the Disorders of
Lipid Metabolism Evidence-Based Nutrition Practice Guidelines in the provision of
Medical Nutrition Therapy to their clients. The materials incorporate use of the Nutrition
Care Process with case studies illustrating pertinent nutrition diagnoses. Used in
conjunction with the online Evidence Analysis Library, these tools enable dietetic
practitioners to individualize a nutrition plan based on the current state of science, client
values, clinical judgment, and monitoring of outcomes.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
References:
1. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults. Washington, DC: US Dept of Health and Human
Services, Public Health Service; 2001. NIH Pub 01-3095.
2. Institute of Medicine, Committee on Nutrition Services for Medicare Beneficiaries.
The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating
Coverage of Nutrition Services for the Medicare Population. Washington, DC:
National Academy Press, 2000.
3. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB,
Pasternak RC, Smith SC Jr, Stone NJ, for the National Heart, Lung, and Blood
Institute; American College of Cardiology Foundation; and American Heart
Association. Implications of recent clinical trials for the National Cholesterol
Education Program Adult Treatment Panel III guidelines. Circulation. 2004; 110:
227–239.
4. Ross SD, Allen IA, Connelly JE. Clinical outcomes in statin treatment trials: a metaanalysis. Arch Intern Med. 1999;159:1793-1802.
5. Sikand G, Kashyap ML, Wong ND, Hsu JC. Dietitian intervention improves lipid
values and saves medication costs in men with combined hyperlipidemia and a
history of niacin noncompliance. J Am Diet Assoc. 2000; 100:218-224.
6. McGehee MM, Johnson EQ, Rasmussen HM, Sahyoun N, Lynch MM, Carey M,
Massachusetts Dietetic Association. 1995. Benefits and costs of medical nutrition
therapy by registered dietitians for patients with hypercholesterolemia. J Am Diet
Assoc. 1995; 95:1041-1043.
7. Dalgard C, Thuroe A, Haastrup B, Haghfelt T, Stender S. Saturated fat intake is
reduced in patients with ischemic heart disease 1 year after comprehensive counseling
but not after brief counseling. J Am Diet Assoc. 2001; 101:1420-1424.
8. American Heart Association. Heart Disease and Stroke Statistics-2005 Update.
Dallas, TX: American Heart Association; 2005. Available at:
http://www.americanheart.org/downloadable/heart/1105390918119HDSStats2005Up
date.pdf. Accessed February 10, 2006.