What is the treatment plan for a 17-year-old with hypercholesterolemia (elevated total cholesterol), hypertriglyceridemia (elevated triglycerides), normal high-density lipoprotein (HDL) cholesterol, and elevated low-density lipoprotein (LDL) cholesterol?

Treatment Plan for a 17-Year-Old with Borderline Dyslipidemia

Begin with intensive lifestyle modifications for 6 months, focusing on dietary changes and daily physical activity, then reassess lipid levels before considering pharmacologic therapy.

Initial Assessment

Your 17-year-old patient has:

• Total cholesterol: 211 mg/dL (borderline-high; normal <200 mg/dL) 1
• LDL cholesterol: 116 mg/dL (acceptable; <130 mg/dL is the threshold for intervention) 1
• HDL cholesterol: 76 mg/dL (excellent; well above the minimum of >35 mg/dL) 1
• Triglycerides: 106 mg/dL (normal; <150 mg/dL is optimal) 1

This lipid profile does NOT currently meet criteria for statin therapy, as the LDL cholesterol is below 130 mg/dL and there are no other high-risk features described 1.

First-Line Treatment: Intensive Lifestyle Modifications (6-Month Trial)

Dietary Interventions

Implement medical nutrition therapy with the following specific parameters 1, 2:

• Limit total fat to 25-30% of total daily calories 1, 2
• Restrict saturated fat to <7% of total calories 1, 2
• Limit dietary cholesterol to <200 mg/day 1, 2
• Completely eliminate trans fats 1, 2
• Increase soluble fiber intake: Use the formula (age in years + 5-10 grams), which for a 17-year-old equals 22-27 grams daily, approaching the adult goal of 25 grams 1
• Eliminate all sugar-sweetened beverages 3
• Increase dietary omega-3 fatty acids 1, 3
• Increase consumption of fresh fruits and vegetables 4

Physical Activity Requirements

The cornerstone intervention for adolescents differs from adult guidelines 4:

• Mandate at least 60 minutes daily of moderate-to-vigorous physical activity 4, 3
• Limit sedentary screen time to no more than 2 hours per day 4, 3
• Focus on activities that can be sustained long-term rather than short-term intensive programs 4
• Emphasize that higher volumes of exercise produce incrementally greater HDL improvements, with statistical significance typically reached at caloric expenditure levels of 1200-1600 kcal per week 4

Weight Management (If Applicable)

• If the patient is overweight or obese (BMI ≥85th percentile), implement a family-centered behavioral management approach for weight control 1, 3
• Weight management should target all family members who are overweight 1

Monitoring and Follow-Up

Recheck the complete fasting lipid profile after 6 months of consistent lifestyle modifications 1, 3, 2:

• If LDL cholesterol remains <130 mg/dL, continue lifestyle modifications and recheck annually 1
• If LDL cholesterol rises to ≥130 mg/dL despite 6 months of dietary intervention, proceed to pharmacologic therapy 1, 2

Screen for other cardiovascular risk factors and metabolic syndrome components 3:

• Blood pressure measurement 1
• Fasting glucose and HbA1c 3
• Assessment for diabetes, smoking, or family history of premature cardiovascular disease 1

When Pharmacologic Therapy Would Be Indicated

Statin therapy should be initiated if 1, 2:

• LDL cholesterol remains >130 mg/dL after 6 months of dietary intervention, with a goal of LDL <100 mg/dL 1, 2
• LDL cholesterol ≥190 mg/dL (regardless of other risk factors) 1, 5
• LDL cholesterol ≥160 mg/dL with positive family history of premature CVD or ≥2 other CVD risk factors 1, 6

Statins are approved for children aged ≥10 years 1, and this patient at age 17 meets the age requirement.

Critical Contraindication

For females of childbearing potential, discuss reliable contraception before initiating statin therapy due to teratogenic effects 1, 2. Statins are absolutely contraindicated in pregnancy, and prevention of unplanned pregnancies is paramount 1, 2.

Common Pitfalls to Avoid

• Do not initiate statin therapy prematurely when LDL cholesterol is <130 mg/dL without additional high-risk features 1
• Do not underestimate the importance of the 6-month lifestyle modification trial before considering pharmacotherapy 1, 2
• Do not fail to assess and address family history of premature cardiovascular disease, as this significantly influences treatment decisions 1
• Do not neglect annual lipid screening once treatment is initiated 1