©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Appendices for Disorders of Lipid Metabolism Toolkit
APPENDIX 1: Body Mass Index and Waist Circumference
APPENDIX 2: Determining Risk Level
APPENDIX 3: Metabolic Syndrome As A Target Of Therapy
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
APPENDIX 1: Body Mass Index and Waist Circumference
Body Mass Index (BMI):
BMI is the favored measure of excess weight to estimate relative risk of disease. BMI
correlates both with morbidity and mortality; the relative risk for CVH risk factors and
CVD incidence increases in a graded fashion with increasing BMI in all population
groups.
Calculating BMI is simple, rapid, inexpensive and can be applied generally to adults. For
BMI calculator, see http:www.nhlbisupport.com/bmi/
How to calculate BMI:
Metric conversion formula = weight (kg)/height (m)2
Non-metric conversion formula = [weight (pounds)/height (inches)2] x 703
Waist Circumference:
The presence of excess fat in the abdomen out of proportion to total body fat is an
independent predictor of risk factors and morbidity. Waist circumference is positively
correlated with abdominal fat content. It provides a clinically acceptable measurement for
assessing a patient’s abdominal fat content before and during weight loss treatment.
The sex-specific cutoffs can be used to identify increased relative risk for the
development of obesity-associated risk factors in most adults with a BMI of 25 to 34.9
kg/m2.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Measuring Tape Position for Waist (Abdominal) Circumference
From: National Heart, Lung and Blood Institute, Obesity Education Initiative Expert
Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults, The Evidence Report. Bethesda, Md: US Department
of Health and Human Services; 1998. NIH publication 98-4038.
“To obtain an accurate waist circumference measurement, patients should be standing in
only their underwear. A horizontal mark should be drawn just above the uppermost
lateral border of the right iliac crest, which should then be crossed with a vertical mark in
the midaxillary line. The measuring tape is placed in a horizontal plane around the
abdomen at the level of this marked point on the right side of the trunk. The plane of the
tape should be parallel to the floor, and the tape should be snug but not tight. The patient
should be advised to breathe normally when the measurement is taken.”
From: Wylie-Rosett J, Hark LA. Nutrition assessment for cardiovascular disease. In:
Carson JAS, Burke FM, Hark LA. eds. Cardiovascular Nutrition: Disease Prevention and
Management. Chicago, IL: American Dietetic Association, 2004.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Classification of Overweight and Obesity by BMI, Waist Circumference, and
Associated Disease Risk*
Disease Risk* Relative to Normal
Weight and Waist Circumference
BMI (kg/m2)
Men 102 cm
( 40 in.)
Men >102 cm
( >40 in.)
Women 88 cm
( 35 in.)
Women >88 cm
( >35 in.)
18.5
-----
-----
Normal+
18.5-24.9
-----
-----
Overweight
25.0-29.9
Increased
High
Obesity
30.0-34.9
I
High
Very High
35.0-39.9
II
Very High
Very High
III
Extremely High
Extremely High
Underweight
Extreme
Obesity
40
Obesity
Class
*Disease risk for type 2 diabetes, hypertension, and CVD.
+Increased waist circumference can also be a marker for increased risk even in persons of normal weight.
Source: From: National Heart, Lung and Blood Institute, Obesity Education Initiative
Expert Panel. Clinical Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults, The Evidence Report. Bethesda, Md: US Department
of Health and Human Services; 1998. NIH publication 98-4038. Available at:
http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4121.htm. Accessed February
22, 2006.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
APPENDIX 2: Determining Risk Level
In 2004, an update to ATP III was published that slightly modified the LDL cholesterol
goals and when drug therapy should be considered. The following table provides those
guidelines for use in identifying a patient’s LDL cholesterol goal.
ATP III LDL-C Goals and Cutpoints for TLC and Drug Therapy in Different Risk
Categories and Proposed Modifications Based on Recent Clinical Trial Evidence
Risk Category
LDL-C Goal
Initiate TLC
Consider Drug
Therapy**
High risk: CHD*
or CHD risk
equivalents† (10year risk >20%)
<100 mg/dL
(optional goal: <70
mg/dL)||
≥100 mg/dL#
≥100 mg/dL††
(<100 mg/dL:
consider drug
options)**
Moderately high
risk: 2+ risk
factors‡ (10-year
risk 10% to 20%)§§
<130 mg/dL¶
≥130 mg/dL#
≥130 mg/dL (100–
129 mg/dL;
consider drug
options)‡‡
Moderate risk:2+
risk factors‡ (10year risk <10%)§§
<130 mg/dL
≥130 mg/dL
≥160 mg/dL
Lower risk:0–1
risk factor§
<160 mg/dL
≥160 mg/dL
≥190 mg/dL (160–
189 mg/dL: LDLlowering drug
optional)
* CHD includes history of myocardial infarction, unstable angina, stable angina,
coronary artery procedures (angioplasty or bypass surgery), or evidence of clinically
significant myocardial ischemia.
† CHD risk equivalents include clinical manifestations of noncoronary forms of
atherosclerotic disease [peripheral arterial disease, abdominal aortic aneurysm, and
carotid artery disease (transient ischemic attacks or stroke of carotid origin or >50%
obstruction of a carotid artery)], diabetes, and 2+ risk factors with 10-year risk for hard
CHD >20%.
‡ Risk factors include cigarette smoking, hypertension (BP≥140/90 mm Hg or on
antihypertensive medication), low HDL cholesterol (<40 mg/dL), family history of
premature CHD (CHD in male first-degree relative <55 years of age; CHD in female
first-degree relative <65 years of age), and age (men≥45 years; women≥55 years).
§§ Electronic 10-year risk calculators are available at
http://www.nhlbi.nih.gov/guidelines/cholesterol.
§ Almost all people with zero or 1 risk factor have a 10-year risk <10%, and 10-year risk
assessment in people with zero or 1 risk factor is thus not necessary.
|| Very high risk favors the optional LDL-C goal of <70 mg/dL, and in patients with high
triglycerides, non-HDL-C <100 mg/dL.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
¶ Optional LDL-C goal <100 mg/dL.
# Any person at high risk or moderately high risk who has lifestyle-related risk factors
(e.g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic
syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors
regardless of LDL-C level.
** When LDL-lowering drug therapy is employed, it is advised that intensity of therapy
be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels.
†† If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug is a therapeutic
option on the basis of available clinical trial results. If a high-risk person has high
triglycerides or low HDL-C, combining a fibrate or nicotinic acid with an LDLlowering drug can be considered.
‡‡ For moderately high-risk persons, when LDL-C level is 100 to 129 mg/dL, at baseline
or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level
<100 mg/dL is a therapeutic option on the basis of available clinical trial results.
Recommendations Resulting from the Update to ATP III
Therapeutic lifestyle changes (TLC) remain an essential modality in clinical
management. TLC has the potential to reduce cardiovascular risk through several
mechanisms beyond LDL lowering.
 In high-risk persons, the recommended LDL-C goal is <100 mg/dL.
- An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available
clinical trial evidence, especially for patients at very high risk.
- If LDL-C is ≥100 mg/dL, an LDL-lowering drug is indicated simultaneously with
lifestyle changes.
- If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug to achieve
an LDL-C level <70 mg/dL is a therapeutic option on the basis of available clinical
trial evidence.
- If a high-risk person has high triglycerides or low HDL-C, consideration can be
given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When
triglycerides are ≥200 mg/dL, non-HDL-C is a secondary target of therapy, with a
goal 30 mg/dL higher than the identified LDL-C goal.
 For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the
recommended LDL-C goal is <130 mg/dL; an LDL-C goal <100 mg/dL is a
therapeutic option on the basis of available clinical trial evidence. When LDL-C level
is 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering
drug to achieve an LDL-C level <100 mg/dL is a therapeutic option on the basis of
available clinical trial evidence.
 Any person at high risk or moderately high risk who has lifestyle-related risk factors
(eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic
syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C
level.
 When LDL-lowering drug therapy is employed in high-risk or moderately high-risk
persons, it is advised that intensity of therapy be sufficient to achieve at least a 30%
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
to 40% reduction in LDL-C levels.
 For people in lower-risk categories, recent clinical trials do not modify the goals and
cutpoints of therapy.
Source of tables: Grundy SM, Cleeman JI, Merz CNB, Brewer HB, Clark LT,
Hunninghake DB, Pasternak RC, Smith SC, Stone NJ for the Coordinating Committee of
the National Cholesterol Education Program. Implications of recent clinical trials for the
National Cholesterol Education Program Adult Treatment Panel III guidelines.
Circulation. 2004;110:227-239.
To Calculate Risk Categories:
Estimate of 10-Year Risk for Men (Framingham Point Scores)
Age
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-9
-4
0
3
6
8
10
11
12
13
Points
Total
Cholesterol
<160
160-199
200-239
240-279
≥280
Points
Age 20-39
0
4
7
9
11
Age 40-49
0
3
5
6
8
Age 20-39
Age 40-49
0
0
Nonsmoker
8
5
Smoker
HDL (mg/dL)
>60
50-59
40-49
<40
Systolic BP (mmHg)
If Untreated
Age 50-59
0
2
3
4
5
Age 60-69
0
1
1
2
3
Age 70-79
0
0
0
1
1
Age 50-59
0
3
Points
-1
0
1
2
Age 60-69
0
1
Age 70-79
0
1
If Treated
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
<120
120-129
130-139
140-159
>160
0
0
1
1
2
Point Total
0
1
2
2
3
10-Year Risk
%
<1
1
1
1
1
1
2
2
3
4
5
6
8
10
12
16
20
25
≥30
<0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
≥17
Estimate of 10-Year Risk for Women (Framingham Point Scores)
Age
20-35
35-40
40-45
45-50
50-55
55-60
60-65
65-70
70-75
75-80
Points
-7
-3
0
3
6
8
10
12
14
16
Points
Total
Cholesterol
Age 20-39
Age 40-49
Age 50-59
Age 60-69
Age 70-79
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
<160
160-199
200-239
240-279
≥280
Points
Nonsmoker
Smoker
0
4
8
11
13
0
3
6
8
10
0
2
4
5
7
0
1
2
3
4
0
1
1
2
2
Age 20-39
0
9
Age 40-49
0
7
Age 50-59
0
4
Age 60-69
0
2
Age 70-79
0
1
HDL (mg/dL)
>60
50-59
40-49
<40
Systolic BP (mmHg)
If Untreated
<120
120-129
130-139
140-159
>160
Points
-1
0
1
2
If Treated
0
1
2
3
4
Point Total
<9
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
≥25
0
3
4
5
6
10-Year Risk
%
<1
1
1
1
1
2
2
3
4
5
6
8
11
14
17
22
27
≥30
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
Source: Summary of the Third Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III).
Washington, DC: US Dept of Health and Human Services, Public Health Service; 2001. NIH Pub
01-3670.
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
APPENDIX 3: Metabolic Syndrome as a Target of Therapy
Criteria for Clinical Diagnosis of Metabolic Syndrome
Measure (any 3 of 5 constitute diagnosis
of metabolic syndrome)
Elevated waist circumference*†
Categorical Cutpoints
≥102 cm (≥40 inches) in men
≥88 cm (≥35 inches) in women
Elevated triglycerides
≥150 mg/dL (1.7 mmol/L)
or
On drug treatment for elevated triglycerides‡
Reduced HDL-C
<40 mg/dL (1.03 mmol/L) in men
<50 mg/dL (1.3 mmol/L) in women
or
On drug treatment for reduced HDL-C‡
Elevated blood pressure
130 mm Hg systolic blood pressure
or
≥85 mm Hg diastolic blood pressure
or
On antihypertensive drug treatment in a
patient with a history of hypertension
Elevated fasting glucose
≥100 mg/dL
or
On drug treatment for elevated glucose
*To measure waist circumference, locate top of right iliac crest. Place a measuring tape
in a horizontal plane around abdomen at level of iliac crest. Before reading tape
measure, ensure that tape is snug but does not compress the skin and is parallel to floor.
Measurement is made at the end of a normal expiration.
†Some US adults of non-Asian origin (eg, white, black, Hispanic) with marginally
increased waist circumference (eg, 94-101 cm [37-39 inches] in men and 80-87 cm [3134 inches] in women) may have strong genetic contribution to insulin resistance and
should benefit from changes in lifestyle habits, similar to men with categorical increases
in waist circumference. Lower waist circumference cutpoint (eg, ≥90 cm [35 inches] in
men and ≥80 cm [31 inches] in women) appears to be appropriate for Asian Americans.
‡Fibrates and nicotinic acid are the most commonly used drugs for elevated TG and
©2006 American Dietetic Association
Disorders of Lipid Metabolism Toolkit
reduced HDL-C. Patients taking one of these drugs are presumed to have high TG and
low HDL.
From: Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA,
Gordon DJ, Krauss RM, Savage PJ, Smith SC, Spertus JA, Costa F. Diagnosis and
management of the metabolic syndrome: an American Heart Association/National Heart,
Lung, and Blood Institute scientific statement. Circulation. 2005;112: 112:2735-2752.