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OutlineO Definition of Hyperlipidemia
O Epidemiology
O Clinical Aspects
O Treatment
O Effects of Exercise
O Exercise Testing
O Exercise Prescription
O Summary and Conclusion
O References
What is Hyperlipidemia?
Hyper- Lipid -Emia
Excess Fat A condition
of the blood
Hyperlipidemia is excessive amounts of
fatty substances in the blood (aka
Hyperlipemia).
Three Types of Lipids
OSimple Lipids
OCompound Lipids
ODerived Lipids
Simple Lipids
O Triacylglycerol aka Triglyceride
(storage form of fat; mostly adipose tissue)
O Saturated and Unsaturated Fats
O “Neutral Fats”
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Compound Lipids
O Simple Lipid + Phosphate = Phospholipid
O Lipid Bilayer of cell membranes
O Simple Lipid + CHO Group (Galactose) = Glycolipids
O Nerve cell membrane (esp. myelin sheath)
O Blood Lipids (Triglyceride, Phospholipid, or Cholesterol)
+ PRO (Apolipoprotein)
Lipoprotein
O 5 Types: Chylomicrons, VLDL, IDL, LDL, HDL
O Principle means for lipid transport in the blood
O Without this process, blood lipids would float to the top
LIPID + ANOTHER COMPOUND = COMPOUND LIPID
5 Kinds of
Lipoprotei
ns
Glycolipids
within
myelin
sheath of
nerve cell
Phospholipi
d Bilayer
Compound Lipids
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Derived LipidsO Substances derived from Simple and Compound
Lipids.O Cholesterol (most widely known, exists only in animal
tissue)O Exogenous Cholesterol
O Food Intake
O Endogenous CholesterolO Synthesized within the body
O 50-200 mg daily
O The body forms more cholesterol when SFA intake is high because SFA facilitates cholesterol synthesis in the liver.
O Serves many rolesO Helps synthesize hormones
O Component for bile
O Building of plasma membranes
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Lipoproteins
O Chylomicrons = Apolipoprotein + Exogenous
Triglyceride
O Synthesized in mucosa of intestine from dietary fat
O After fatty meal, blood is so full of chylomicrons that it
looks milky
LipoproteinsO Very-Low Density Lipoproteins (VLDL) =
Apolipoprotein + Endogenous Triglyceride (↑ %)
+ Cholesterol
O Synthesized in the liver
O Primary transport mechanism for endogenous
triglyceride to muscle and tissue when needed
Lipoproteins
O Intermediate Density Lipoproteins (IDL)
O Intermediate step in changing VLDL into LDL.
O Lipoprotein Lipase (enzyme) acts on VLDL to
change it into LDL
LipoproteinsO Low Density Lipoproteins (LDL)- “Bad” Cholesterol
O Principle carrier of cholesterol
O Greatest affinity for cells in arterial wall
O LDL oxidizes here, which causes damage and
narrowing to artery walls
Lipoproteins
O High Density Lipoproteins (HDL)- “Good” Cholesterol
O Reverse cholesterol transport
O Moves cholesterol from artery walls, back to the liver
where intestinal tract excretes it
LipoproteinsO Metabolism of lipoproteins is altered by:
O Gender
O Age
O Body Fat Distribution
O Dietary Composition
O Cigarette Smoking
O Certain Medications
O Genetics
O Physical Activity
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Types of HyperlipidemiaO Hyperlipidemia
O Elevated blood triglyceride and cholesterol
O HypertriglyceridemiaO Elevated triglyceride
O Exaggerated Postprandial LipemiaO Prolonged levels of triglyceride in the blood
O Fat’s version of hyperglycemia/diabetes
O HypercholesterolemiaO Elevated cholesterol
O High LDL-cholesterol AND/OR Low HDL-cholesterol
O Hyperlipoproteinemia or DyslipoproteinemiaO Elevated Lipoprotein concentrations
O Genetic abnormalities or secondary to underlying diseases (diabetes, kidney failure/disease, hypothyroidism, etc.)
Hyperlipidemic Blood
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Epidemiology
O Adults, age 20+, from 2005-2008
O 15% had HIGH total blood cholesterol levels
O Mean total blood cholesterol level for adults was
197.7 mg/dL
O Youth
O 20.3% had at least one abnormal lipid level (LDL,
HDL or Total Serum)
Symptoms
O There aren’t any symptoms due to
Hyperlipidemia itself, but there are
symptoms from the illnesses it may
cause, which include:
O Atherosclerosis
O Angina
O Heart Attack
O Stroke http://www.health.com/health/static/hw/media/me
dical/hw/h9991292_001.jpg
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edical/hw/h5551195.jpg
Laboratory Diagnosis
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Laboratory EvaluationsO Triglycerides
(milligrams/deciliter)
<150 Normal
150-199 Borderline High
200-499 High
≥500 Very High
O Total Cholesterol (mg/dL)
<200 Desirable
200-239 Borderline High
≥240 High
O LDL (mg/dL)
<100 Optimal
100-129 Near Optimal
130-159 Borderline High
≥190 Very High
O HDL (mg/dL)
Men <40, Women <50 Low
≥60 High
O Lipoprotein-a (mg/dL)
<30 Normal
Testing
O Cholesterol and triglyceride testing is done:
O As part of a routine physical exam
O To check someone’s response to medicines used to treat lipid disorders
O To help determine someone’s chance of having heart disease, especially if other risk factors are present
O If unusual symptoms are present, such as yellow fatty deposits in the skin (xanthomas), which may be caused by a rare genetic disease that causes very high cholesterol levels
Tests
O Types of tests include:
O HDL Test
O LDL Test
O Total Cholesterol Test
O Triglyceride Test
O Lipoprotein-a analysis
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ComplicationsO Possible Primary and Secondary
Complications of High Cholesterol
O Atherosclerosis
O Coronary Artery Disease
O Stroke
O Heart Attack (which can result in death)
O Possible Complications of High Triglyceride
O Pancreatitis
Treatment- Lifestyle
O Lose excess weight (even 5-10 lbs. can help)
O Eat heart-healthy foodsO Get <10% daily cals from SFA, replace with MUFA if necessary
O Eliminate Trans FatO Do not eat anything with “partially hydrogenated” oil on the
ingredients list
O Limit dietary cholesterol to <300 mg/day or <200 mg/day for those with heart disease
O Increase fiber intake
O Drink alcohol in moderationO If you already consume alcohol, then doing so in moderation may
increase HDL levels- but starting to drink just for this effect is not necessary
O Exercise regularly
O Don’t smoke
Treatment- DrugsO Statins-
O Block a substance the liver needs to make cholesterolO Hydroxymethylglutaryl-coenzyme A
reductase aka HMG-CoA reductaseinhibitors
O Allows liver to remove cholesterol
O Also may help the body reabsorb cholesterol from deposits on artery walls
O Examples: Lipitor, Lescol, and Altoprev
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Treatment- Drugs
O Bile-acid Binding Resins-
O Liver uses cholesterol to make bile acids
O These medications bind directly to bile
acids, causing the liver to use excess
cholesterol in order to synthesize more bile
O Examples: Prevalite, Welchol, and
Colestid
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Treatment- Drugs
O Cholesterol Absorption Inhibitors-
O Reduces blood cholesterol by limiting the
absorption of dietary cholesterol from the small
intestine before it is released into the blood
O Example: Zetia
O Zetia can be combined with any of the statin
drugs
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Treatment- DrugsO Fibrates-
O Decrease triglycerides by reducing the liver’s production of VLDL (contains mostly triglyceride) and speeding up the removal of triglyceride from the blood
O Examples: Lofibra, Lopid, and TriCor
O Niacin-
O Decreases triglycerides by limiting the liver’s ability to produce LDL and VLDL
O Prescription Niacin has least side-effects; OTC Niacin not effective and may damage liver
O Example: Niaspan
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Treatment- DrugsO Omega-3 Fatty Acid Supplements-
O Can help lower cholesterol and triglycerides
O Prescription supplements are available
O If taking OTC supplements, ask doctor first
O Example: Lovaza
O May be taken with other cholesterol lowering meds
O Side Effects of Cholesterol Lowering Medications
O Muscle pains
O Stomach pains
O Constipation
O Nausea
O Diarrheahttp://gripewaterforbabies.org/wp-
content/uploads/2010/08/side-effects.png
Treatment-Alternative Medicine
O Artichoke
O Barley
O Beta-sitosterolO Found in oral supplements & some margarines, such as
Promise Activ
O Blond psylliumO Metamucil
O Garlic
O Oat bran O Found in oatmeal
O SitostanolO Found in oral supplements & some margarines, such as
Benecol
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Effects on Ability to Exercise
O Dyslipidemia alone does not affect the exercise response
O Many times other conditions are prevalent, so those conditions must be considered
O People with excessively high levels of cholesterol should achieve medical management of dyslipidemia before beginning an exercise program on their own
O Supervised exercise is recommended
O All prescribed medications should be taken into account before testing or training
Effects of Medication on Exercise
O Muscle damage and toxicity (rhabdomyolosis)
may occur when combining statins with niacin
and fibrates
O Muscle discomfort is a side-effect of statin use
O Many of the prescribed medications can cause
muscle tenderness, weakness or pain
O Exercise may enhance/worsen all of these side
effects!
Acute Effects
O Total plasma cholesterol levels rise immediately post-exercise (≈24% increase), including LDL & HDL
O Due to changes in plasma volume which are a result of vigorous exercise
O Return to baseline within 60 minutes post-exercise
O Increases in HDL found about 48 hrs P.E.
O Decrease in plasma-triglyceride concentration
O Triglycerides form from excess calories; exercise reduces this
Chronic EffectsO Endurance exercise consistently lowers triglycerides
O Attributed to increases in skeletal muscle & adipose tissue lipoprotein lipase activity (enzyme for breakdown of triglyceride-rich lipoproteins)
O Reduction in postprandial lipemia
O Decrease in body fat lowers triglycerides
O Exercise increases size of LDL so they cannot get into linings of heart/blood vessels and cause damage
O Stimulates enzymes that help move LDL from the blood to the liver, where it is converted to bile and excreted.
O ↑ amounts of exercise = ↑ amounts LDL expelled
Exercise Testing
O If dyslipidemia is congenital and without symptoms, exercise testing can follow the usual guidelines for individuals at risk for CAD
O If dyslipidemia shows and signs/symptoms of comorbidities, testing should follow the recommendations for the particular disorder
O Primary objectives of testing are to:O Diagnose CAD
O Determine functional capacity
O Determine proper intensity range for aerobic exercise training
O Special Considerations for individuals with HyperlipidemiaO High risk of cardiac and arterial insufficiency
O Intravascular sludging and ischemia can result
Exercise TestingMethods Measures
Aerobic
• Cycle (ramp protocol 17 W/min;
staged protocol 25-50 W/3 min
stage)
• Treadmill (1-2 METs/3 min stage)
• 12-lead ECG,
HR
• BP, RPP
• RPE (6-20)
Endurance
• 6 min walk • Distance
Exercise Prescription
O Should complement dietary modifications and
lipid lowering medications
O Moderate intensity exercise (40-80% of VO2max)
O ≥5 days per week, 1-2 times per day (depending
on individual)
O Incorporates resistant training at 60-80% of 1RM
O Incorporates flexibility exercises to decrease risk
of injury
Summary
O Hyperlipidemia is an asymptomatic condition in
which there are elevated amounts of fatty
substances in the blood
O Triglycerides <150 mg/dL, Total Cholesterol <200
mg/dL, LDL <200 mg/dL, and HDL ≥60 mg/dL are
desirable
O Hyperlipidemia can lead to atherosclerosis, CAD,
stoke or MI
Summary
O Decreasing blood lipids requires lifestyle
modification (diet, exercise, weight loss and not
smoking) and possible prescription medication to
lower cholesterol or triglycerides in the blood
O Exercise testing for individuals w/o other
conditions can follow ACSM’s guidelines for
people who are at risk for CAD
O Exercise prescription should include moderate
intensity aerobic exercise training which has been
shown to decrease blood lipids
ReferencesO Chylomicron. (n.d.). In MedicineNet.com MedTerms Dictionary online. Retrieved
February 16, 2011, from http://www.medterms.com/script/main/art.asp?articlekey=11296
O Davis, S. (2008). Exercise to lower cholesterol. Retrieved February 16, 2011, from http://www.webmd.com/cholesterol-management/features/exercise-to-lower-cholesterol
O Dugdale, D.C. (2010). High blood cholesterol and triglycerides. Retrieved February 16, 2011, from http://www.nlm.nih.gov/medlineplus/ency/article/000403.htm
O Durstine, J.L., Moore, G.E., Painter, P.L., & Roberts, S.O. (2009). ACSM’s exercise management for persons with chronic diseases and disabilities (3rd ed.). Champaign, IL: Human Kinetics.
O -emia. (n.d.). Dictionary.com Unabridged. Retrieved February 16, 2011, from Dictionary.com website: http://dictionary.reference.com/browse/-emia
O George, D. (2009). The effects of exercise on cholesterol. Retrieved February 16, 2011, from http://www.livestrong.com/article/37736-effects-exercise-cholesterol/
O hyper. (n.d.). The American Heritage® Stedman's Medical Dictionary. Retrieved February 16, 2011, from Dictionary.com website: http://dictionary.reference.com/browse/hyper
O Krum, H., Conway, E.L., & Howes, L.G. (1991). Acute effects of exercise on plasma lipids, noradrenaline levels and plasma volume. Retrieved February 16, 2011, from http://www.ncbi.nlm.nih.gov/pubmed/1764814
O lipid. (n.d.). Dictionary.com Unabridged. Retrieved February 16, 2011, from Dictionary.com website: http://dictionary.reference.com/browse/lipid
ReferencesO Mayo Clinic Staff (2010). High cholesterol. Retrieved February 16, 2011, from
http://www.mayoclinic.com/health/high-blood-
cholesterol/DS00178/DSECTION=treatments-and-drugs
O McArdle, W.D., Katch, F.I., & Katch, V.L. (2006). Essentials of exercise physiology (3rd
ed.). Baltimore, MD: Lippincott Williams & Wilkins.
O Newell, L. (2010). Hyperlipidemia symptoms. Livestrong.com. Retrieved February 16,
2010, from http://www.livestrong.com/article/88420-hyperlipidemia-symptoms/
O Parks, R. (2009). Cholesterol management health center. Retrieved February 16,
2011, from http://www.webmd.com/cholesterol-management/cholesterol-and-
triglycerides-tests
O Surveys and Data Collection Systems (n.d.) In NHANES Selected Bibliography from
the Center for Disease Control. Retrieved February 16, 2011, from
http://wwwn.cdc.gov/nchs/nhanes/bibliography/Pubs.aspx?CatID=24&name=Hyperlipi
demia:%20prevalence%20and%20its%20correlates
O Zieve, D. (2010). Lipoprotein-a. Retrieved February 16, 2011, from
http://www.nlm.nih.gov/medlineplus/ency/article/007262.htm
Questions???
Arlena HarmonWSU, Spring 2011
Exercise Management for
Special Populations
Arlena.harmon@gmail.com
Maximal Cycle Ergometer ProtocolStage Speed
(rpm)
Resistanc
e (kg)
Workload Time O2 uptake *METs
1 60 2.5 900 kgm
(150 W)
2 2.1 L/min *8.8
2 60 3.0 1080 kgm
(180 W)
4 2.5 L/min *10.5
3 60 3.5 1260 kgm
(210 W)
6 2.9 L/min *12.1
4 60 4.0 1440 kgm
(240 W)
8 3.4 L/min *14.2
5 60 4.5 1620 kgm
(270 W)
10 3.8 L/min *15.9
6 60 5.0 1800 kgm
(300 W)
12 4.2 L/min *17.6
7 60 5.5 1980 kgm
(330 W)
14 4.6 L/min *19.3
For: normal risk *METs depend on
weight
Initial workload: 900 kgm (150 W), ↑ 180 kgm every 2 min (METs if wt=150
McArdle et al. Continuous
Recommended