Medical Nutrition Therapy (MNT) is an initial, effective, and low-cost approach to the management of patients with hypercholesterolemia (McGehee et al., 1995). MNT is the clinical nutrition assessment and the provision of appropriate nutrition therapy by a registered dietitian or nutrition professional. A primary care clinician should refer the patient for MNT. It has demonstrated effectiveness for many diagnoses and has shown to be associated with a decrease in utilization of health services (The Cost of Covering MNT under TRICARE, 1998).

MNT includes review and analysis of a patient's medical and dietary history, lab values, and anthropometric values. It is the provision of appropriate nutrition therapy, to include skills training for the patient, diet modification and outcomes-based counseling. The benefits of MNT are lowered morbidity and progress towards positive health outcomes (DCCT, 1993; Sikand et al., 1996; Sikand et al., 1997).

MNT can lead to significant decrease in total cholesterol, LDL-C and TG (Sikand et al., 1998; Shaffer & Wexler, 1996; Shenberger et al., 1992). In one study, 34 of 67 patients receiving MNT avoided use of lipid medications, at an annual cost savings of $60,561; this study demonstrated significant serum cholesterol reduction and health care dollar savings with just three or four individualized MNT visits.

Often patients have multiple medical conditions, each with specific dietary recommendations. MNT is an inexpensive and safe intervention (McGehee et al., 1995; Brannon et al., 1997; Stinnett et al., 1996; Tosteson, et al., 1997; Sheills et al., 1999; Splett, 1996). MNT teaches patients how to incorporate appropriate foods into their current eating patterns, and how to make long-term diet changes. MNT integrates information on food, nutrients, and meal preparation-consistent with cultural background, socioeconomic status, and desired clinical outcomes-to provide appropriate care (Medical Nutritional Therapy, 1998).

Dietary change can significantly reduce total cholesterol and LDL-C, and when part of an intensive lifestyle change program, can slow the progression and may actually reverse the disease process (Haskell et al, 1994; Ornish et al., 1990). MNT is an intrinsic component of clinical practice and a shared responsibility of the health care team. In the current managed care environment, we must provide optimal health outcomes in the most economical way.

The MNT Protocol for Dyslipidemia recommends three to four sessions, of 30 to 60 minutes in length.

ADDITIONAL INFORMATION:  The following guidelines are provided to assist those who do not have access to nutrition professionals for MNT.

The primary focus of diet therapy for the prevention and treatment of hypercholesterolemia is to progressively lower saturated fatty acids (SFAs) and cholesterol at an energy level that facilitates optimal weight management (See Table for Step I and Step II diets). Other diet modifications may be necessary for particular patient subgroups.

1. Consumption of a diet in accordance with the NCEP/AHA guidelines, starting with a Step I diet. In some individuals, a Step II diet may be indicated, (NIH Consensus Conference, 1993). For hypertriglyceridemia, the proportion of carbohydrate to fat is controversial. However, the effect is attenuated in the context of weight reduction and with the incorporation of high fiber foods, (Tillotson et al. 1997; NIH Consensus Conference, 1993).



2. Complex carbohydrate and fiber should be emphasized while restricting simple carbohydrate, (NIH Consensus Conference, 1993).



3. Weight reduction: Often weight loss can significantly decrease plasma lipids and increase HDL-C levels, (NIH Consensus Conference, 1993; NCEP II, 1993).



4. Restriction of alcohol: Small amounts can result in fluctuations in serum triglycerides and should therefore be restricted at least on a trial basis, (NCEP II, 1993).

^a Often this guideline is misinterpreted to mean that each (single) food item should be less than 30 percent fat. The guideline applies to total calories eaten over several days. Applying the 30 percent rule to single food items would exclude many appropriate food choices. Although Step I and Step II diets are frequently referenced as initial therapies, individualization based on nutritional assessment, BMI, co-morbidities, lifestyle and lipid reduction goal is essential for appropriate care. Patients eat foods, not nutrients. The MNT prescriptions must be translated into foods to be meaningful for patients (see patient education references).

It is important to provide ongoing support and reinforcement to patients undertaking significant dietary changes. This can take several forms, including follow-up visits, telephone calls, and postcards. It is important to encourage patients through the plateaus and regressions that occur as a normal part of efforts at long-term change (USDHHS, Clinician's Handbook, 1998).

Examples of foods to choose or decrease for the NCEP Step I and Step II Diets

Food Group	Choose	Decrease
Lean meat, poultry, and fish 5-6 ounces per day	Beef, pork, lamb – lean cuts well trimmed before cooking Poultry w/o skin Fish, shellfish Processed meats prepared from lean meats, e.g., lean ham, lean frankfurters, lean meat with soy protein or carrageen	Regular hamburger, fatty cuts of beef, spare ribs, organ meats Poultry with skin, fried chicken Fried fish, fried shellfish Regular luncheon meat (bologna, salami, sausage, frankfurters)
Eggs 4 egg yolks per week, Step I 2 egg yolks per week, Step II	Egg whites, cholesterol-free egg whites	Egg yolks (if more than the recommended); includes eggs used in baking and cooking
Low-fat dairy products	Milk – skim ½% or 1% fat (fluid, powdered, evaporated, buttermilk) Yogurt – non-fat or low-fat yogurt or yogurt beverages	Whole milk, regular yogurt (fluid, evaporated, condensed), 2% milk, imitation milk Whole milk yogurt
Dairy products	Cheese – low-fat natural or processed cheese Low-fat or nonfat varieties, e.g., cottage cheese-low-fat, nonfat, or dry curd 0% to 2%) Frozen dairy dessert – ice milk, frozen yogurt (low-fat or nonfat) Low-fat coffee creamer Low-fat or nonfat sour cream	Regular cheeses (American blue, Brie, cheddar, Colby, Edam, Monterey Jack, whole-milk mozzarella, Parmesan , Swiss), cream cheese, Neufchatel cheese Cottage cheese (4% milkfat) Ice cream Cream, half & half, whipping cream Non-dairy creamer, whipped topping, sour cream
Fats and Oils 6-8 teaspoons per day	Unsaturated oils – safflower, sunflower, corn, soybean, cottonseed, canola, olive, peanut Margarines – made from unsaturated oils listed above, especially soft or liquid forms Salad dressings – made with unsaturated oils, low-fat or fat-free Seeds and nuts – peanut butter, other nut butters Cocoa powder	Coconut oil, palm kernel oil, palm oil Butter, lard, shortening, bacon fat, hard margarine Dressings – made with egg yolk, cheese, sour cream, whole milk Coconut Milk chocolate
Breads and cereals	Breads – whole-grain bread, English muffins, bagels, buns, corn or flour tortilla Cereal – oat, wheat, corn, multi-grain Pasta Rice Dry beans and peas Crackers, low-fat – animal type, graham, soda crackers, breadsticks, melba toast Homemade baked goods using unsaturated oil, skim or 1% milk, and egg substitute – quick breads, biscuits, cornbread muffins, bran muffins, pancakes, waffles	Bread in which eggs, fat, and/or butter are a major ingredient; croissants Most granolas High-fat crackers Commercial baked pastries, muffins, biscuits
Soups	Reduced – or low-fat and reduced sodium varieties, e.g., chicken or beef noodle, minestrone, tomato, vegetable, potato, reduced-fat soups made with skim milk	Soup containing whole milk, cream, meat fat, poultry fat, or poultry skin
Vegetables 3-5 servings per day	Fresh, frozen, or canned, without added fat or sauce	Vegetables fried or prepared with butter, cheese, or cheese sauce
Fruits 2-4 servings per day	Fruit – fresh, frozen, canned or dried Fruit juice – fresh, frozen or canned	Fried fruit or fruit served with butter or cream sauce
Sweets and modified fat desserts Use cautiously if weight loss is recommended or with hypertriglyceridemia	Beverages – fruit – fruit-flavored drinks, lemonade, fruit punch Sweets – sugar, syrup, honey, jam, preserves, candy made without added fat (candy corn, gumdrops, hard candy), fruit flavored gelatin Frozen dessert – low-fat and nonfat yogurt, ice milk, sherbet, sorbet, fruit ice, popsicles Cookies, cake, pie, pudding – prepared with egg whites, egg substitutes, skim milk or 1% milk, and unsaturated oil or margarine; ginger snaps, fig and other fruit bar cookies, fat-free cookies, angel food cake	Candy made with milk chocolate, coconut oil, palm kernel oil, palm oil Ice cream and frozen treats made with ice cream Commercial baked pies, cakes, doughnuts, high-fat cookies, cream pies

Consumers and health care professionals alike are increasingly interested in the use of functional foods (nutritious foods that contain specific ingredients that aid with specific physiological functions). Consumers are interested in non-pharmacologic ways to prevent diseases. Below is a summary of the more recognized nutrients, their potential benefits, and practical application.

Nutrients with Strong Supportive Clinical Evidence

Specific Food	Potential Benefit	Concerns	Practical Advice
Fish Oil and Fish Oil Supplements*	TG levels Effects on other lipids variable Protective against CVD thrombus formation	Monitor if on anticoagulant therapy Fish oil capsules may contribute to vitamins A and D toxicity Some preparations lack vitamin E; concern for oxidation Capsules expensive	Eat fish at least once a week, especially varieties high in n-3 fatty acids (salmon, sardines, mackerel)
Plant Sterols and Stanols	Shown to LDL 10-20%		Include plant stanol ester foods into daily diet, substituted for foods of similar fat content