Canes: Materials, Function, and Types

Canes: Materials, Function, and Types

• Canes come in various styles, sizes, and materials like glass, steel, and aluminum.
• Aluminum is favored for being lightweight and adjustable.
• They commonly feature vinyl grips and push-button length locks.
• Canes improve balance by widening the base of support.
• Some canes support partial weight-bearing.
• Use a cane when one upper limb provides sufficient support.
• When walking, hold the cane in the hand opposite the affected leg and move the cane together with the affected leg.
• Standard canes are lightweight, inexpensive, and custom-fitted if wooden but adjustable and more expensive if aluminum.
• Standard canes are used for balance issues like vestibular problems, vision problems, and sensory ataxia.
• Offset canes shift weight over the shaft for better support and allow occasional weight-bearing.
• Offset canes are suitable for mild to moderate joint pain, such as osteoarthritis.
• Quad canes feature a four-legged base to provide increased support and are beneficial for moderate to severe gait issues.
• Quad canes can stand upright alone, but can be awkward at faster gait speeds.
• Base size of quad canes can be adjusted according to the level of needed support and walking speed.
• Walk canes (hemi-walkers) are broad-based with a vertical handle and four legs to allow for continuous weight-bearing with one arm.
• Hemi-walkers are ideal for hemiparesis or major leg impairment.
• Specialty canes with folding seats or collapsible styles exist.
• The cane's fit and function should match the user's needs.

Selecting a Cane

• Choose a comfortable grip made of foam or ergonomic material.
• Use special grips for hand pain or weakness, and if numbness occurs, the grip may not be the right fit.
• Rubber tips offer floor traction.
• Tips should be soft and not worn; replace them every 5 years or when worn.
• Ensure proper replacements are used instead of glue.
• Adjustable canes are preferred.
• The cane's proper fit involves a 30-degree bend at the elbow, aligning the top of the cane with the wrist crease.
• Length should be from the wrist crease to the floor, adding 2–3 inches if over 70 inches or preferred.
• A cane that is too long is hard to lift, while one that is too short causes imbalance.

Using a Cane: Injury Considerations

• Those without injury can hold the cane in either hand based on comfort and move the cane with the opposite leg.
• If injured or disabled, hold the cane in the hand opposite the affected leg.
• Move the cane and affected leg together, then step with the unaffected leg.

EpiPen Auto Injector: Preparation and Administration

• Remove the EpiPen from the clear carrier tube.
• Flip open the yellow cap (EpiPen) or green cap (EpiPen Jr).
• Tip and slide the auto-injector out of the tube.
• Grasp the auto-injector in your fist with the orange tip pointing downward and remove the blue safety release by pulling straight up.
• Do not bend or twist the device during removal.
• Note that the needle comes out of the orange tip.
• Prevent accidental injection by keeping fingers, thumb, or hand away from the orange tip.
• Seek medical help immediately if accidental injection occurs.
• For young children, hold the leg firmly in place.
• Place the orange tip against the middle of the outer thigh (upper leg) at a 90-degree angle.
• Swing and push the auto-injector firmly until a click is heard.
• The click indicates the injection has started.
• Hold the injector in place for 3 seconds, then remove it from the thigh.
• The orange tip will extend to cover the needle.
• Do not reuse the device if the needle is visible.
• Massage the injection site for 10 seconds.

EpiPen Auto Injector: Emergency Help and Other Considerations

• Call 911 or go to the emergency room immediately after administering the injection.
• A second dose may be needed if symptoms persist or return.
• Bring the used auto-injector with you.
• Inform the healthcare provider that you received an epinephrine injection and where the injection was administered.
• Hand the used device to the provider for inspection and disposal.
• Request a refill if needed.

Walkers and Wheelchairs: Selection and Purpose

• Walkers increase the base of support, enhance lateral stability, and support patient weight.
• Disadvantages include difficulty maneuvering through doorways and tight spaces, reduced normal arm swing, may cause poor posture/back flexion, and is not suitable for stairs.
• Use a walker when there is a risk of falling, injury, or disability, and to provide balance and upright posture.
• Standard walkers have four rubber-tipped legs and are the most stable but require lifting before each step.
• They demand more attention and are useful for moderate to severe cerebellar ataxia and are not ideal for cognitively impaired patients.
• Front-wheeled walkers have two wheels in front, allow a faster gait, and are easier to use if there's difficulty lifting, but reduces stability.
• Front-wheeled walkers are suitable for frontal lobe gait disorders, Parkinson's, and moderate ataxia.
• Two-wheel walkers provide stability if weight-bearing is needed, prevent rolling away, and fold for car transport.
• Three/Four-wheeled walkers have brakes for downhill walking and a larger base of support.
• They should not be used for full weight bearing and are ideal for higher-functioning patients, including those with mild-moderate Parkinson's, cautious gait, and mild ataxia.
• They can have brakes, seats, and sturdy frames.
• Hemi walkers are for one-handed use and have a wide A-frame base for stability and are suitable for limited mobility/dexterity on one side.
• They feature foldable, compact storage and comfortable foam grip handles.

Walkers and Wheelchairs: Grips, Fitting. and Accessories

• Standard plastic grips may get slippery.
• Foam or soft covers provide more comfort.
• Larger grips are available for finger grasping issues.
• Grips must be secure.
• When fitting a walker, ensure a 30-degree elbow bend when holding grips.
• The top of the walker should align with the inside wrist crease, ensuring proper posture and reducing stress on shoulders/back.
• Walkers should be pushed forward, stepping into them with one leg, then the other, repeating the cycle.
• Stand inside the walker, not behind it, and avoid leaning forward or setting the height too high.
• Walker accessories include trays for carrying items, pouches for books/magazines, optional seats, and baskets.
• Comfort and practicality are important.
• Wheelchairs enhance mobility for those with spinal cord injury, arthritis, and active users.
• Wheelchairs act as interface between body and world and must be properly fitted.
• Manual wheelchairs are propelled by the user's arms, are lightweight, and energy-efficient.
• Powered wheelchairs are battery-operated, ideal for limited arm strength, and come in traditional, platform, Hoveround, and convertible models.
• Lightweight chairs range from 12-45 lbs in everyday lightweights.
• Sports lightweights were originally for sports, are now used daily.
• Standard chairs are heavy, metallic, difficult to maneuver, which require more effort to propel.
• Specialty chairs are for amputees, stroke survivors, and bariatric patients.
• Bariatric chairs feature a 22+ inch seat width and can be customized to user needs.
• Institutional/Nursing Home chairs are for residents needing mobility assistance, are inexpensive and less customizable.
• If independence is possible, opt for lightweight chairs.
• Child/Junior Chairs are designed for growth and environment.
• Growth kits allow size adjustment with custom colors and styles available.
• Scooters feature three/four-wheeled carts, are more maneuverable and discreet, propelled with bicycle-like steering, and may be less expensive than powered chairs.

Wheelchairs and Other Considerations

• Determine indoor/outdoor/transport use and involve therapists or experienced users when assessing level of need for wheelchair.
• Wheelchair funding sources are based on eligibility for medical or social support.
• Universal design promotes access for all, and equal access to public buildings and transportation.

Compression Stockings/Hose: Definition and Usage

• Specially fitted garments are designed to improve blood flow in the legs.
• Compression stockings are used to prevent or manage Deep Vein Thrombosis (DVT).
• Apply graduated compression: tightest at the ankle, and looser as they go up the leg.
• Compression stockings may be prescribed or recommended for relieving symptoms of existing DVT and preventing post-thrombotic syndrome.
• Compression stockings reduce the risk of developing DVT in high-risk patients
• Common risk factors for DVT include age >40, obesity, family or personal history of DVT, prolonged bed rest or reduced mobility, surgery (>30 min), especially involving legs/pelvis.
• Other risk factors for DVT include estrogen therapy and pregnancy and the postpartum period.
• 8-15 mmHg compression strength is classified as support wear and is indicated for mild swelling, tired/aching legs, and improved circulation.
• 15-20 mmHg compression strength is classified as medical Legwear and is indicated for minor varicosities, pregnancy-related swelling, DVT prevention.
• 20-30 mmHg compression strength is classified as medical Legwear (Rx) and is indicated for moderate-severe varicosities, post-surgery, edema, venous ulcers, and DVT prevention.
• 30-40 mmHg compression strength is classified as medical Legwear (Rx) and is indicated for severe varicosities, lymphatic edema, CVI, orthostatic hypotension.
• 40+ mmHg compression strength is classified as medical Legwear (Rx) and is indicated for severe edema, active ulcers, postphlebitic syndrome, and PTS management.
• They work by increasing tissue pressure, reducing fluid leakage, promoting capillary and lymphatic absorption, preventing overexpansion of superficial veins, and reducing pooling and enhancing venous return to the heart.
• The mechanism is not fully understood but is widely accepted to reduce swelling, improve circulation, and support vein function.

Compression Stockings/Hose: How To

• Support wear is based on shoe size or height and weight for pantyhose (8–15 mmHg, 12–16 mmHg).
• Medical compression stockings are based on leg circumferences.
• Measurements should be taken first thing in the morning before swelling occurs.
• Key measurements include ankle circumference, calf circumference, thigh circumference, hip circumference, and length from floor to knee crease.
• To put them on, insert hand into stocking to the heel, turn inside out to the heel pocket.
• Slide foot in carefully and align heel in pocket, gently ease the stocking up the leg, massage it up-do not pull.
• Position knee-high stockings below the knee, thigh-high stockings below the buttocks, and waist-high stockings with the body section at the waist and vertical seam in front.
• Do not roll down stockings-can restrict blood flow, avoid oils, ointments, lanolin—can damage elastic.
• Stay mobile: walk around, do foot/ankle exercises, and don't cross legs while sitting or lying.
• Measure and apply compression stockings in the morning before swelling and shower the night before, not the morning of.

Blood Pressure and Hypertension

• Normal blood pressure is below 120/80 mm Hg.
• Elevated: 120-129/< 80 mm Hg.
• Stage 1 hypertension: 130-139 or 80-89 mm Hg.
• Stage 2 hypertension: ≥ 140 or ≥ 90 mm Hg.
• Goals in general population < 60 years is SBP < 140 and DBP < 90 mm Hg, and age > 60 years is SBP < 150 and DBP < 90 mm Hg
• With CKD or diabetes: SBP < 140 and DBP < 90 mm Hg.
• Sequalae include stroke, heart disease, heart failure, peripheral artery disease, and abdominal aortic aneurysm.
• Stethoscope is used to listen for Korotkoff sounds during BP measurement.
• Sphygmomanometer is used to measure blood pressure and includes a cuff that inflates to constrict the arm and measure pressure.
• Korotkoff sounds are heard while taking BP, the first sound indicates systolic BP, and the disappearance of sound indicates diastolic BP.
• To take blood pressure, the patient must be seated with back supported, legs uncrossed, with their arm supported at heart level, and with the appropriate cuff size used.
• The patient should not consume any caffeine or smoke 30 minutes prior and should rest quietly for at least 5 minutes before measuring.
• Lifestyle interventions include weight loss, increased physical activity, a heart-healthy diet (DASH), moderation in alcohol intake, and reduced sodium intake.
• Orthostatic hypotension is a drop of ≥ 20 mm Hg SBP or ≥ 10 mm Hg DBP from lying to standing.
• Orthostatic hypotension is common in older adults and people with diabetes, can be caused by volume depletion and baroreflex dysfunction, and it is associated with falls and fractures.
• Assess by measuring BP lying and again within 3 minutes of standing.
• Normal heart rate is 60-100 bpm; Bradycardia: < 60 bpm; Tachycardia: > 100 bpm.
• To take heart rate, use your index and middle fingers to locate the pulse at the radial artery (wrist) and count for 30 seconds and multiply by 2 if regular or 60 seconds if irregular.

Respiration, Ophthalmic and Otic Meds, and Compression Stockings

• Normal respiration rate is 12-20 breaths per minute in adults.
• To measure respiration rate, count chest rises for 30 seconds and multiply by 2, being sure not to inform patient to avoid altered breathing.
• For ophthalmic medications: Wash hands before and after administration; Tilt head back, pull down lower eyelid to form pouch; Instill drop without touching eye with dropper. Gently press inner corner of eye for 1 minute; Wait ≥ 5 minutes between different drops; For ointments: apply thin strip to lower eyelid pouch, close eye and rotate.
• For otic medications, wash hands before and after administering them; warm bottle if cold, shake if suspension; Lie on side with affected ear up.
• For adults: pull ear up and back; for children: pull down and back; Instill drops, stay in position 3-5 minutes, and may use cotton plug to prevent leakage.
• Compression stockings help reduce swelling and improve circulation, as well as prevent blood clots.

EpiPen and Asthma

• EpiPen's purpose is emergency treatment for severe allergic reactions (anaphylaxis).
• Remove safety cap, press firmly against outer thigh at 90° angle until click is heard, hold in place for several seconds, and call 911 after use.
• Carry at all times if at risk, check expiration date, use through clothing if necessary, and seek immediate medical help after use.
• Asthma diagnosis is based on a history of typical respiratory symptoms that vary over time and in intensity and confirmed variable expiratory airflow limitation by testing.
• Symptoms include wheezing, shortness of breath, chest tightness, and cough.
• Spirometry or PEF testing before and after bronchodilator use helps confirm diagnosis.
• Reassess lung function and symptoms after starting ICS treatment to confirm asthma, if needed.

Asthma: Treatment and Inhalers

• Achieve symptom control, prevent exacerbations and hospitalizations, maintain normal activity levels (exercise), minimize medication side effects, and reduce long-term risk of airway damage and decline in lung function
• Spirometer is a tool to measure lung function.
• FEV1 is Forced Expiratory Volume in 1 second; key measurement in assessing airway obstruction and asthma severity.
• Metered Dose Inhaler (MDI) is portable, convenient, and delivers consistent medication dose but requires coordination of actuation and inhalation, and is commonly used incorrectly without training.
• Remove safety cap, press firmly against outer thigh at 90° angle until click is heard, hold in place for several seconds, and call 911 after use.
• Shake inhaler well before use, breathe out fully, place mouthpiece in mouth and press down on inhaler while breathing in slowly and deeply.
• Hold breath for 5–10 seconds, then exhale slowly; Wait 30-60 seconds between puffs if a second puff is needed.
• Demonstrate technique and have patient repeat; Use a spacer if coordination is difficult; Clean inhaler weekly; Check dose counter or keep track of usage.
• Spacers help deliver medication more effectively, reduce the need for coordination between actuation and inhalation, and decreases risk of oral side effects.
• Spacers are useful for children, elderly, and patients with difficulty using MDIs.
• Inhaler, shake MDI and insert into spacer, place mouthpiece between teeth and seal lips around it, press inhaler and inhale slowly and deeply, and hold breath, then exhale and repeat if needs.

Dry Powder Inhaler (DPI) and Peak Flow Meter

• Clean DPI regularly per manufacturer instructions.
• DPI is breath-activated, with no need for coordination.
• DPI is portable and multi-dose designs available but requires sufficient inspiratory effort and is not suitable for very young children or those with severe airflow limitation.
• Load dose per device instructions, breathe out fully away from device, inhale quickly and deeply through mouthpiece, and hold breath for 5–10 seconds, then exhale slowly.
• Demonstrate and review technique; Do not shake or exhale into device; Keep dry and store as instructed; Clean as recommended by manufacturer.
• Peak Flow Meter measures Peak Expiratory Flow (PEF); Helps monitor asthma control at home; Useful for detecting early signs of worsening asthma
• Green Zone: 80–100% of personal best, asthma is under control; Yellow Zone: 50-79%, caution and action needed; Red Zone: <50%, medical alert and immediate action required.
• Set meter to zero or lowest value; Stand up straight; Take a deep breath, place mouth on mouthpiece, and blow out as hard and fast as possible; Record value and repeat three times; Record highest value of the three attempts.

Diabetes: Blood Sugars, Insulin, and Home Monitoring

• Pre-prandial blood sugar normal values: 80-130 mg/dL
• Post-prandial blood sugar normal values : Less than 180 mg/dL (measured 2 hours after meals)
• Fasting blood sugar normal values: Normal: < 100 mg/dL; Prediabetes: 100-125 mg/dL; Diabetes: ≥ 126 mg/dL
• Clean injection site (typically abdomen, thigh, or upper arm). Pinch skin, insert needle at 90° angle (or 45° if thin); Inject insulin, hold for 5-10 seconds, remove and discard syringe properly. Syringes: Marked in units, typically 0–100 units; Pens: Dial the dose in units, accurate and easy to adjust.
• Prime pen (2 units), dial dose, clean site; Inject at 90° angle, press until full dose delivered; Hold in place for 5–10 seconds before removing
• Advantages of insulin: pens are more convenient and discreet than vials/syringes, allowing for Accurate dosing and provide Less injection pain for many patients
• Measure glucose levels continuously via a small sensor under the skin; Track trends and patterns in real-time or with synced devices; Alerts for high or low glucose values; Useful for patients with frequent hypo/hyperglycemia or insulin-dependent diabetes
• Patients test at times like pre-prandial, post-prandial, bedtime, exercise, or symptoms;

Glucose Monitoring and Monofilament Test

• When monitoring hyperglycemia, Symptoms include Polyuria, polydipsia, polyphagia; Fatigue, blurred vision, weight loss; Lethargy, hunger, infections
• When monitoring hypoglycemia, Symptoms include Shakiness, anxiety, sweating (diaphoresis); Dizziness, fatigue, hunger, blurred vision; Headache, nervousness, weakness
• Monofilament test uses a 10-g monofilament to touch areas of the foot (e.g. plantar surfaces of the big toe and metatarsals), where Patient indicates if pressure is felt
• The inability to feel the filament indicates loss of protective sensation, performed annually in patients with diabetes,
• Leads to neuropathy and an increased risk of foot ulcers and amputations

Pedal Pulses, Glucagon, and Cholesterol

• Why measure pedal pulses?: Assess peripheral circulation, Screen for peripheral artery disease (PAD)
• Dorsalis pedis location: top of the foot between first and second metatarsal bones
• Posterior tibial location: behind the medial malleolus (ankle bone)
• Glucagon Pen Purpose: Emergency treatment of severe hypoglycemia; When to use: When patient is unconscious, seizing, or unable to eat/drink
• How to use Glucagon Pen: Remove cap, insert needle into outer thigh; Press and hold for several seconds until dose is delivered; Turn patient on side (risk of nausea/vomiting)
• Counseling: Teach caregivers how to use it; Store at room temperature; Replace before expiration; Call 911 after administration
• Lipid testing involves a Fasting Lipid Panel (FLP) recommended every 5 years in adults ≥20 years and Preferred fasting for 9–12 hours before test
• Includes total cholesterol, LDL, HDL, and triglycerides where LDL is calculated, others measured directly
• CHD risk equivalents have the same risk level as coronary heart disease(Clinical CHD; Symptomatic carotid artery disease; Peripheral arterial disease; Abdominal aortic aneurysm; Diabetes mellitus)

Cholesterol: Risk Assessment

• Major risk factors include: Cigarette smoking, Hypertension (≥140/90 mm Hg or on therapy), Low HDL (<40 mg/dL)*, Family history of premature CHD (male <55 years, female <65 years), Age (men ≥45 years, women ≥55 years)
• *HDL ≥60 mg/dL is a negative risk factor and subtracts one from the total
• 0-1 risk factors are lower risk; 2+ risk factors are intermediate risk
• CHD or CHD equivalent is high risk as Risk calculators estimate 10-year CHD risk
• 20% = high risk; 10-20% = moderate risk; <10% = low risk
• LDL Goals: <100 mg/dL: optimal; 100-129 mg/dL: near/above optimal; 130-159 mg/dL: borderline high; 160-189 mg/dL: high; ≥190 mg/dL: very high
• Total Cholesterol goals: <200 mg/dL: desirable; 200-239 mg/dL: borderline high; ≥240 mg/dL: high
• HDL Goals :<40 mg/dL (men), <50 mg/dL (women): low; ≥60 mg/dL: high/desirable
• Lipid panel calculations: LDL + HDL + TG/5 = Total Cholesterol
• Risk calculators estimate 10-year risk of CHD using Framingham risk factors Used to guide intensity of lipid treatment.
• They're purpose is to Determine need for TLC or statin therapy, such that a Higher risk = more aggressive management
• Treatment for cholesterol - Scandinavian Simvastatin Survival Study (4S) Demonstrated that statin therapy reduces risk of heart attacks and mortality in CHD patients and Established statins as foundational treatment for high cholesterol

Cholesterol Treatment, Studies and Diet

• Therapeutic lifestyle changes (TLC) involves Diet: Reduce saturated fat and cholesterol intake, Increase soluble fiber intake, Eliminate trans fats, Favor monounsaturated fats (olive, peanut, canola oils), Include omega-3 fatty acids (e.g. salmon, mackerel)
• Exercise: At least 30 minutes most days of the week; Weight management: Maintain healthy weight or lose excess weight; Smoking cessation and Moderate alcohol intake if consumed
• Framingham Heart Study (Important to Know): began in 1948 with 5,209 adults (ages 30–62) Goal: to Identify factors contributing to CVD following every 2 years with exams and interviews, adding a Added 2nd gen (1971), 3rd gen (2002)
• Key findings include Major CVD risk factors: high BP, high cholesterol, smoking, obesity, diabetes, inactivity and that HDL, TG, age, gender, psychosocial issues also significant
• It led to Major CVD risk factors: high BP, high cholesterol, smoking, obesity, diabetes, inactivity as Over 1,200 publications ongoing research has Expanded to include stroke, dementia, osteoporosis, genetics.
• Led to modern concepts of risk factors and prevention strategies
• Lipid Management OverviewCholesterol, triglycerides, and phospholipids are major body lipids transported as lipoproteins (lipid-protein complexes) as lipid abnormalities predispose to coronary, cerebrovascular, peripheral arterial diseases wether elevated total and LDL, and reduced HDL, linked to coronary heart disease (CHD) with premature coronary atherosclerosis the main consequence of hyperlipidemia
• Guidelines Overview of ATP III (2001, updated 2004) provides hypercholesterolemia management standards with 2013 ACC/AHA guidelines introducing a new treatment approach while currently following 2019 ACC/AHA Guideline on Primary Prevention of Cardiovascular Disease
• Epideiology and Screening has cholesterol levels rise throughout life in both sexes and NHANES data that shows 50% of adults >20 yrs have total cholesterol ≥200 mg/dL however Only 12% on therapy, 1/3 aware they have hypercholesterolemia therefore fasting lipid profile (FLP) is recommended for adults ≥20 yrs at least once every 5 years to see total cholesterol, LDL, HDL, triglycerides measured (Non-fasting profile valid for total cholesterol and HDL only (FLP preferred after 9-12 hour fast)

Secondary Causes of Lipid Disorders and Treatment

• Secondary Causes of Dyslipidemia includes Hypercholesterolemia with Hypothyroidism, Chronic renal disease, Obstructive liver disease, and Anorexia nervosa alongside Drugs: progestins, thiazides, glucocorticoids, beta-blockers, isotretinoin, cyclosporine, and mirtazapine

• Hypertriglyceridemia is caused by Obesity, Diabetes mellitus, Lipodystrophy, and Sepsis with drugs that leads to Pregnacy and Acute hepatitis such as Alcohol, estrogens, beta-blockers, glucocorticoids, thiazides, mirtazapine, anabolic steroids

• ATP III Step 1: Lipid Classification : LDL Cholesterol (Primaryfocus) <100 Optimal , 100-129 Near/Above Optimal , 130-159 Borderline High, 160-189 High, ≥190 Very High. where Total Cholesterol: <200 Desirable 200-239 Borderline High ≥240 High & HDL <40 (Male), <50 (Female) Low ≥60 High/Desirable , Triglycerides: <150 Normal, 150-174 Borderline High, 175-499 High ≥500 Very High.

• ATP III Step 2: Assess for CHD Risk Equivalents with Symptomatic carotid artery disease, Peripheral arterial disease, Abdominal aortic aneurysm, Diabetes mellitus

• ATP III Step 3: Major Risk Factors is Hypertension (≥140/90 mmHg or on antihypertensives), Cigarette smoking, Low HDL cholesterol (<40 mg/dL), Family history of premature CHD Male 1st degree relative <55 yrs Female 1st degree relative <65 yrs , Age Men/women & HDL ≥60 mg/dL is a negative risk factor (subtracts 1 risk)

• ATP III Step 4: Assessing 10-Year CHD Risk with 20% = CHD Risk and 10-20% = Moderate risk alongside a low risk with less than 10%. Be sure that risk calculators for that is like the Framingham Risk Score

• ATP III Step 6: Initiate Therapeutic Lifestyle Changes (TLC) if LDL Above Goal where TLC is always first step which includes , Diet , Increased physical activity and Weight loss as well as weight gain

• Statins is a form of add drug therapy and can lower ldl and hdl

• Treatment of Low HDL (<40 mg/dL) involves Weight management, Increased physical activity, Avoid trans fats, alcohol and Use monounsaturated fats alongside eating fish high in omega-3

• If TG <200 & you have CHD/CHD then consider nicotinic acid or fibrates