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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

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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

  • Glucose (fasting & GTT) (303-307)

    • principle & interpretation

  • Lipoproteins & CHD (262-272)

    • 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

    • 100-129near/above optimal

    • 130-159borderline high

    • 160-189high

    • >190very high


ATP III Classification of Total and HDL Cholesterol (mg/dl)

  • Total Cholesterol

    • <200desirable

    • 200-239borderline high

    • >240high

  • HDL Cholesterol

    • <40low (bad)

    • >60high(good)


Risk Category

LDL Goal(mg/dL)

LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)

LDL Level at Which to ConsiderDrug Therapy (mg/dL)

CHD or CHD Risk Equivalents(10-year risk >20%)

<100

100

130 (100–129: drug optional)

2+ Risk Factors (10-year risk 20%)

<130

130

10-year risk 10–20%: 130

10-year risk <10%: 160

0–1 Risk Factor

<160

160

190 (160–189: LDL-lowering drug optional)

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories


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%


Risk Category

LDL Goal(mg/dL)

LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)

LDL Level at Which to ConsiderDrug Therapy (mg/dL)

CHD or CHD Risk Equivalents(10-year risk >20%)

<100

100

130 (100–129: drug optional)

2+ Risk Factors (10-year risk 20%)

<130

130

10-year risk 10–20%: 130

10-year risk <10%: 160

0–1 Risk Factor

<160

160

190 (160–189: LDL-lowering drug optional)

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories


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 RiskFramingham 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)

LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)

LDL Level at Which to ConsiderDrug Therapy (mg/dL)

CHD or CHD Risk Equivalents(10-year risk >20%)

<100

100

130 (100–129: drug optional)

2+ Risk Factors (10-year risk 20%)

<130

130

10-year risk 10–20%: 130

10-year risk <10%: 160

0–1 Risk Factor

<160

160

190 (160–189: LDL-lowering drug optional)

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories


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


Visit 3

Visit 2

Evaluate LDLresponse

If LDL goal notachieved, consideradding drug Tx

Evaluate LDLresponse

If LDL goal notachieved, intensifyLDL-Lowering Tx

Visit I

Begin LifestyleTherapies

A Model of Steps in Therapeutic Lifestyle Changes (TLC)

Visit N

6 wks

6 wks

Q 4-6 mo

MonitorAdherenceto TLC

  • Emphasizereduction insaturated fat &cholesterol

  • Encouragemoderate physicalactivity

  • Consider referral toa dietitian

  • Reinforce reductionin saturated fat andcholesterol

  • Consider addingplant stanols/sterols

  • Increase fiber intake

  • Consider referral toa dietitian

  • Initiate Tx forMetabolicSyndrome

  • Intensify weightmanagement &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 AdultsJAMA 287:356-359 (2002)

  • NHANES III (8814 adults)

  • Prevalence

    • 23.7% of adult population

      • 47 million Americans

    • increases with age

      • 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)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Estimate of 10-Year Risk for Women (Framingham Point Scores)


Who, me worry ???


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