Final Exam Tuesday, 6/5, 2 PM Closed book – Essay and MC/TF Determining Energy Needs – p – 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, ) – Biochemical assessments ( ) Iron status ( ) – Know markers (and their rationale) of iron status – Be able to interpret lab values Glucose (fasting & GTT) ( ) – principle & interpretation Lipoproteins & CHD ( ) – Assessment only, not treatment – CHD risk assessment using ATP III – Know cut points

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, TG Non-fasted blood sample – only TC and HDL-C usable – LDL-C = TC - HDL-C - (TG/5)

ATP III Classification of LDL- Cholesterol (mg/dl) LDL Cholesterol – < 100 optimal – near/above optimal – borderline high – high – >190very high

ATP III Classification of Total and HDL Cholesterol (mg/dl) Total Cholesterol – <200desirable – borderline high – >240high HDL Cholesterol – <40low (bad) – >60high(good)

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories  190 (160–189: LDL- lowering drug optional)  160<1600–1 Risk Factor 10-year risk 10–20%:  year risk <10%:  160  130< Risk Factors (10-year risk  20%)  130 (100–129: drug optional)  100<100 CHD or CHD Risk Equivalents (10-year risk >20%) LDL Level at Which to Consider Drug Therapy (mg/dL ) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Goal (mg/dL)Risk Category

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 10- year risk for CHD > 20%

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories  190 (160–189: LDL- lowering drug optional)  160<1600–1 Risk Factor 10-year risk 10–20%:  year risk <10%:  160  130< Risk Factors (10-year risk  20%)  130 (100–129: drug optional)  100<100 CHD or CHD Risk Equivalents (10-year risk >20%) LDL Level at Which to Consider Drug Therapy (mg/dL ) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Goal (mg/dL)Risk Category

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 – 1 o male relative < 55yrs – 1 o 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: – Palm III Operating System download at: – – includes other information from ATP III

Categories of Risk and LDL-C Goals

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories  190 (160–189: LDL- lowering drug optional)  160<1600–1 Risk Factor 10-year risk 10–20%:  year risk <10%:  160  130< Risk Factors (10-year risk  20%)  130 (100–129: drug optional)  100<100 CHD or CHD Risk Equivalents (10-year risk >20%) LDL Level at Which to Consider Drug Therapy (mg/dL ) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Goal (mg/dL)Risk Category

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

Reinforce reduction in saturated fat and cholesterol Consider adding plant stanols/sterols Increase fiber intake Consider referral to a dietitian Initiate Tx for Metabolic Syndrome Intensify weight management & physical activity Consider referral to a dietitian 6 wks Q 4-6 mo Emphasize reduction in saturated fat & cholesterol Encourage moderate physical activity Consider referral to a dietitian Visit I Begin Lifestyle Therapies Visit 2 Evaluate LDL response If LDL goal not achieved, intensify LDL-Lowering Tx Visit 3 Evaluate LDL response If LDL goal not achieved, consider adding drug Tx A Model of Steps in Therapeutic Lifestyle Changes (TLC) Monitor Adherence to TLC Visit N

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: (2002) NHANES III (8814 adults) Prevalence – 23.7% of adult population 47 million Americans – increases with age 6.7% of yr olds 43.5% of 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)

Who, me worry ???