Disorders of Lipid Metabolism

DLM: Executive Summary of Recommendations (2005)

Disorders of Lipid Metabolism (2005) Evidence-Based Nutrition Practice Guideline

Executive Summary of Recommendations

Below are the major recommendations, and ratings for the Disorders of Lipid Metabolism (2005) Evidence-Based Nutrition Practice Guideline. Click here to view the Guideline Overview. More detail, including the evidence analysis supporting these recommendations, is available on this website to ADA members and subscribers under  Major Recommendations.

To see a description of the ADA Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence) click here

Medical Nutrition Therapy

DLM: Referral to a Registered Dietitian for Medical Nutrition Therapy (MNT) 2005

DLM: MNT and Referral to a Registered Dietitian

Referral to a registered dietitian for Medical Nutrition Therapy (MNT) is recommended whenever an individual has an abnormal lipid profile, based on ATPIII Risk category and LDL-C goals, or has CHD. A planned initial visit lasting from 45-90 minutes and at least two to six planned follow-up visits (30-60 minutes each, with an RD) can lead to improved dietary pattern; improved lipid profile; reduced plasma total cholesterol, LDL-C, and triglycerides; and improved weight status.

Strong, Conditional

DLM: MNT Number and Duration of Visits

The number and duration of visits in the course of Medical Nutrition Therapy will need to be greater if the client is in a higher risk category, if there is a large number of Therapeutic Lifestyle Changes (TLC) that need to be made, and if the individual is not motivated to make TLC changes. Increasing the number of visits and length of time spent with a dietitian can improve serum lipid levels and CVD risk.

Fair, Conditional

DLM: Lipid-Lowering Medication Re-evaluation

Re-evaluate the dosage and necessity of lipid-lowering medications throughout the course of Medical Nutrition Therapy. Medical Nutrition Therapy may successfully improve the lipid levels to the point where medication doses can be lowered or discontinued.

Fair, Imperative


Energy Balance

 DLM: Body Mass Index, Waist Circumference or Waist-to-Hip Ratio (WHR) 2005

 DLM: Body Mass Index , Waist Circumference and Waist to Hip Ratio

In addition to BMI, use waist circumference or waist to hip ratio (WHR) to assess obesity and CVD risk. BMI alone is not a good predictor of CVD risk in persons over 65 years old. Increases in waist circumference, WHR, and BMI are associated with CHD events and CVD mortality.

Strong, Imperative

Macronutrients: Fat

 DLM: Major Dietary Fat Components 2005

DLM: Major Fat Components and a Cardioprotective Diet


The cardioprotective dietary pattern should be tailored to the individual's needs to provide a fat intake of 25-35% of calories, <7% of calories from saturated fat and trans-fatty acids, and <200 mg cholesterol per day. This dietary pattern can lower LDL-cholesterol up to 16% and decrease risk of CHD.

Strong, Imperative

DLM: Saturated and Trans-fatty Acids and a Cardioprotective Diet

The cardioprotective dietary pattern should be as low as possible in saturated and trans fatty acids and less than 7% of calories. For individuals at their appropriate body weight without elevated LDL-cholesterol or triglyceride levels and with normal HDL-cholesterol levels, saturated fatty acid calories could be replaced by unsaturated fat and/or complex carbohydrate. Replacing saturated fats with mono- and polyunsaturated fat lowers LDL-cholesterol, without lowering HDL-cholesterol or increasing triglycerides, although the ideal replacement percentages are unclear. Research is needed on how best to titrate these recommendations.

Strong, Imperative

DLM: Trans-Fatty Acid Intake 2005

DLM: Trans-fatty Acid Intake


Trans-fatty acids consumption should be as low as possible. A cardioprotective dietary pattern should contain less than 7% of calories from saturated fat and trans-fatty acids. Trans-fatty acids raise total cholesterol and LDL-C and may decrease HDL-C, thereby increasing the TC/HDL-C and LDL-C/HDL-C ratios. Increasing trans-fatty acid intake increases risk of CHD events.

Strong, Imperative

DLM: Omega-3 Fatty Acids 2005

DLM: Omega-3 Food Sources

If consistent with patient preference and not contraindicated by risks or harms, omega-3 fatty acids, preferably from both marine and plant sources, should be included in a cardioprotective diet. Consuming dietary sources of omega-3 fatty acids from fish [two 4oz servings of fish per week (preferably fatty fish such as mackerel, salmon, herring, trout, sardines, or tuna)] and plant-based foods of 1.5g alpha-linolenic acids (1 Tbs canola or walnut oil, 0.5 Tbs ground flax seed, <1 tsp flaxseed oil) are recommended. Consumption of increased omega-3 fatty acids is associated with a decreased risk of death from cardiac events and non-fatal MIs. Some fatty fish can be high in methylmercury and should be limited, according to the FDA.

Fair, Conditional

DLM: Omega-3 Supplements

If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention.

Fair, Conditional




 DLM: Carbohydrates and Protein, Including Dietary Fiber 2005

 DLM: Carbohydrates and Protein in the Cardioprotective Diet


The cardioprotective dietary pattern should be as low as possible in saturated and trans fatty acids and less than 7% of calories. Saturated fatty acid and trans-fatty acid calories may be replaced by unsaturated fatty acids, complex carbohydrates and protein. However, studies to determine the ideal percentages of these macronutrients as replacements for saturated fat are needed.

Strong, Imperative

 DLM: Fiber in the Cardioprotective Diet


Include foods containing 25 to 30 grams of fiber per day, with special emphasis on soluble fiber sources (7 to 13 grams), as part of a cardioprotective diet. Foods rich in soluble fiber include: fruits, vegetables and whole grains, especially high-fiber cereals, oatmeal, beans and prunes. Risk factors associated with CHD (blood pressure, lipoprotein subclasses and particle sizes, insulin resistance, and post-prandial glucose) and CVD (fatal and non-fatal MI and stroke) are decreased as dietary fiber intake increases. Diets high in total and soluble fiber, as part of a cardioprotective diet, can further reduce TC by 2 to 3% and LDL up to 7%.

Strong, Imperative

Specific Foods

DLM: Plant Stanols and Sterols 2005

DLM: Plant Stanols and Sterols


If consistent with patient preference and not contraindicated by risks or harms, then plant sterol and stanol ester enriched foods consumed two or three times per day, for a total consumption of two or three grams per day, may be used in addition to a cardioprotective diet to further lower TC by 4 to 11% and LDL-C by 7 to 15%. For maximal effectiveness, foods containing plant sterols and stanols (spreads, juices, yogurts) should be eaten with other foods. To prevent weight gain, isocalorically substitute stanol- and sterol-enriched foods for other foods. Plant stanols and plant sterols are effective in people taking statin drugs. As part of a cardioprotective diet, foods rich in carotenoids and fat-soluble vitamins, such as fruits, vegetables, whole grains and nuts are encouraged when sterols and stanols are consumed.

Strong, Conditional

DLM: Soy Protein 2005

DLM: Soy Protein


If consistent with patient preference and not contraindicated by risks/harms, then soy (e.g., isolated soy protein, textured soy, tofu) may be included as part of a cardioprotective diet. Consuming 26-50g of soy protein per day in place of animal protein can reduce TC by 0-20% and LDL-C by 4-24%. Evidence is insufficient to establish a beneficial role of isoflavones as an independent component.

Fair, Conditional

DLM: Nuts and CHD 2005

DLM: Nuts and CHD

If consistent with patient preference and not contraindicated by risks or harms, then nuts (walnuts, almonds, peanuts, macadamia, pistachios, and pecans) may be isocalorically incorporated into a cardioprotective dietary pattern. Consuming five ounces of nuts per week is associated with a reduced risk of CHD. Because of their beneficial fatty acid profile as well as other nutritional components, nuts may be incorporated into a cardioprotective dietary pattern low in saturated fat and cholesterol to reduce TC by 4-21% and LDL-C by 6-29%.

Fair, Conditional

DLM: Alcohol Intake 2005

DLM: Alcohol Intake

Current evidence does not justify encouraging those who do not drink alcohol to start doing so. If a patient currently drinks alcohol, and if not contraindicated, then a maximum of one drink per day for women and up to two drinks per day for men may be incorporated into a cardioprotective dietary pattern with meals within recommended calorie levels. This level of alcohol consumption has been demonstrated to be associated with a reduced risk of CVD.

There is no evidence that one type of alcohol is better than another.

Fair, Conditional






 DLM: Antioxidants (Vitamin E, Vitamin C, Beta-Carotene) and Coronary Heart Disease (CHD) 2005

 DLM: Antioxidants and a Cardioprotective Diet

Antioxidant-rich foods such as fruits, vegetables, whole grains and nuts containing Vitamin E, vitamin C and B-carotene (and other carotenoids), have been shown to be associated with reduced disease risk. These foods should be specifically planned into a cardioprotective dietary pattern.

Fair, Imperative

DLM: CVD and Vitamin E, Vitamin C and B-carotene Supplements

Dietary sources of vitamin E, vitamin C, and B-carotene are encouraged. Supplements of these antioxidants have shown no protection for CVD events or mortality, therefore doses greater than the RDA of these nutrients should not be recommended.

Strong, Imperative

DLM: Supplemental vitamins, CVD and smoking

Supplemental vitamin E, vitamin C, B-carotene, and selenium should not be taken with a Simvastatin/Niacin drug combination. Supplemental B-carotene cannot be recommended in individuals with a smoking habit. Research indicates that in these situations there is an increased risk.

Fair, Imperative

DLM: Homocysteine, Folate, or Vitamin B6 or B12 and Prevention of Coronary Heart Disease (CHD) 2005

DLM: Homocysteine, Folate, Vitamin B6, Vitamin B12 and CHD

Folate, vitamin B6, and vitamin B12 should be planned into the cardioprotective dietary pattern to meet the DRI. If an individual has high serum homocysteine levels (usually greater than 13 umol/L), these B vitamins may lower serum homocysteine levels by 17-34%.

Fair, Imperative

DLM: Homocysteine and Supplemental B12 and CHD

Supplemental folate, given alone or in combination with B6 and B12 may or may not be beneficial. If a patient with CVD is taking supplemental B vitamins to lower homocysteine, then registered dietitians may decide to discuss the evidence for supplemental B vitamin and CVD events. Research has shown that after six months to two years, supplemental folate and B-vitamins did not reduce the risk for coronary events. Consultation with the patient's physician is warranted.

Weak, Conditional

DLM: Coenzyme Q10 2005

DLM: Coenzyme Q10 and Disorders of Lipid Metabolism

If a patient is taking coenzyme Q10 supplements, then the practitioner may discuss the lack of evidence for the association of Q10 and CHD events. Research is inconclusive regarding the relationshiip between co-Q10 and risk of disease.

Insufficient Evidence, Conditional

Behavior/Physical Activity


DLM: Physical Activity and Coronary Heart Disease (CHD) 2005

DLM: Physical Activity and CHD


Moderate intensity physical activity (e.g., brisk walking, swimming laps, bicycling) should be incorporated for at least 30 minutes most, if not all, days of the week, if not contraindicated. Many individuals will have to start slowly and increase gradually to achieve goals. Moderately intense physical activity reduces the risk of CVD events, decreases LDL-C and triglyerides, and increases HDL-C.

Strong, Imperative

Corollary Health Issues

DLM: Hypertension 2005

DLM: Hypertension

A cardioprotective dietary pattern such as the DASH diet,  should be planned to include 9 to 12 servings of fruits and vegetables, 2 to 3 servings of low-fat dairy products, less than 2.3g sodium, weight loss if necessary, and increased physical activity (moderate intensity 3 times per week) if individuals also need to lower their blood pressure. Following this type of lifestyle change has been demonstrated to lower systolic blood pressure by at least 4 to 12mmHg.

Strong, Imperative

DLM: Metabolic Syndrome 2005

DLM: Metabolic Syndrome

A calorie-controlled cardioprotective dietary pattern that avoids extremes in carbohydrate and fat intake, limits refined sugar and alcohol, and includes physical activity at a moderate-intensity level for at least 30 minutes on most (preferably all) days of the week, should be used for individuals with metabolic syndrome. Weight loss of 7 to 10% of body weight should be encouraged if indicated. These lifestyle changes improve risk factors of metabolic syndrome.

Fair, Imperative