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Final Exam

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

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  1. 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

  2. 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

  3. 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

  4. 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

  5. National Cholesterol Education Program (NCEP) • Children’s Treatment Panel • 1991 • ATP II • 1993 • reaffirmed ATP I • secondary prevention of CHD

  6. 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

  7. 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)

  8. ATP III Classification of LDL- Cholesterol (mg/dl) • LDL Cholesterol • < 100 optimal • 100-129 near/above optimal • 130-159 borderline high • 160-189 high • >190 very high

  9. ATP III Classification of Total and HDL Cholesterol (mg/dl) • Total Cholesterol • <200 desirable • 200-239 borderline high • >240 high • HDL Cholesterol • <40 low (bad) • >60 high(good)

  10. 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

  11. 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%

  12. 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

  13. 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

  14. 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

  15. 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

  16. Categories of Risk and LDL-C Goals

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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)

  23. 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

  24. 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

  25. ATP III Guidelines - Application • Step 1 • Determine lipoprotein levels from fasted blood sample • LDL-cholesterol • primary target of therapy • Total cholesterol • HDL-cholesterol

  26. ATP III Guidelines - Application • Step 2 • Identify presence of clinical atherosclerotic disease that confer high risk • Clinical CHD • CHD risk equivalents

  27. 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

  28. 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

  29. 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

  30. ATP III Guidelines - Application • Step 6 • Initiate TLC if LDL is above goal • TLC diet • Weight management • Increase physical activity

  31. 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

  32. 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

  33. 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

  34. 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)

  35. 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

  36. Thanks!The End!

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

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

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

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

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

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

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

  44. Who, me worry ???

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