P. Therapeutic Lifestyle Change

objective

Initiate lifestyle modification.

background

In 2002, the National Cholesterol Education Program (NCEP) Expert Panel on Deletection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) recommended Therapeutic Lifestyle Change (TLC) is a clinically focused, multifactorial approach to reducing risk for CVD.  Components of TLC include: promoting reduced intakes of saturated fat and cholesterol, adding therapeutic dietary components for enhancing LDL-C lowering (plant stanols/sterols and soluble fiber), weight reduction, and an increase in physical activity.  TLC is indicated in all patients with dyslipidemia and represents a shift from the two-step dietary approach recommended in the second report of the Adult Treatment Panel.  The Step 1 diet, recommending dietary cholesterol intake of less than 300 mg/day and saturated fat intake of 8-10 percent of total calories, has now become the general recommendation for a healthy diet.  The Step II diet, recommending cholesterol intake of less than 200 mg/day and saturated fat intake of less than 7 percent of total calories has become the basis for the current TLC dietary recommendations.

The priority of treatment for reducing CAD risk remains focused on LDL-C reduction.  Once a patient’s LDL-C goal has been achieved, management of metabolic syndrome and other lipid abnormalities may be emphasized.  At any and every stage of dietary therapy, effective dietary modification will be facilitated by consultation with a registered dietitian or other qualified nutritionist for Medical Nutrition Therapy (MNT).

recommendations

For secondary prevention of recurrent CVD events, non-pharmacologic therapy is always indicated, but should not delay appropriate pharmacotherapy.

For primary prevention of CVD, emphasis on TLC is an important component and is effective in reducing CVD risk by lowering LDL-C and blood pressure.  Ample time should be given (3-6 months) for patients to improve their LDL-C and total lipid profile prior to starting lipid-lowering medication.  Patients failing primary clinician efforts may benefit from MNT provided by a registered dietitian or other qualified nutritionist (see Appendix C, Medical Nutrition Therapy).

discussion

TLC is provided in a step-wise approach focused on initiating TLC components and followed by subsequent evaluation of the effect on LDL-C and moving to intensify MNT as indicated

Figure 2: Step Wise Care Approach (NCEP ATP-III, 2002)