Case 1

Mark’s recent blood cholesterol levels: total cholesterol 275 mg/dL, HDL= 35 mg/dL, TG=350
mg/dL, LDL=220 mg/dL. His breakfast, lunch, and dinner are listed below.

Breakfast Lunch Dinner Snack

Cheddar and bacon Salad (iceburg Beef, Cashews, & Almonds

omelet lettuce) with ham, Vegetable Stir-fry Pretzels
½ avocado tomatoes, cheddar with sesame oil Dried cranberries
3 sausage links cheese, ranch White rice 2 beers
2 pieces of toast (1 dressing Chocolate cake
oz. each) with butter 16 oz Soda Ice cream
8 ounces of apple 1.5 oz French fries Red wine
juice Banana
16 ounces of black
coffee

1.
What dietary approaches could Mark take to improve his cholesterol and triglycerides?
Explain the mechanisms by which these changes will reduce his cardiovascular disease risk.
Mediterranean diet. More fruits and vegetables in his diet, decrease simple sugar intake,
moderate his alcohol intake, consume more MUFAs and PUFAs in place of saturated and trans
fats, increase foods with fiber, antioxidants, and phytosterols.

The polyphenols in the diet will reduce cholesterol absorption in the small intestine.

2. Identify specific foods that should be reduced in his diet to improve his LDL-C. Why did
you make this recommendation?
Sausage, bacon, butter.
To improve a his LDL-C he needs to consume a dietary pattern that emphasizes intake of
vegetables, fruits, and whole grains, includes low-fat dairy products, poultry, fish, legumes,
nontropical vegetable oils, and nuts; and limits intake of sweets, sugar-sweetened beverages,
and red meats. These foods above do not fit in this dietary pattern because they have a high
sugar content, saturated fat content, or are a red meat.
Nutrient: saturated fat, trans fat is focused on for LDL (bacon, sausage, butter) reduce these.
 3. Identify specific foods that should be reduced in his diet to improve his TG. Why did you
make this recommendation?
Limit Soda, apple juice, chocolate cake, icecream, white rice.
Soda should be reduced as limiting and replacing simple sugars with MUFAs and PUFAs and
protein sources will lower TG levels. Additionally, reducing the amount of beer that is drunk in a
day will reduce TG levels as well.

Nutrient: simple sugars

Losing weight is also important to improve TG.

4. Recommend specific foods that could be added to his diet. Why did you make the
recommendation?
Some foods that Mark could add to his diet include fish, more vegetables and fruits, grains,
nuts, and various nontropical vegetable oils. The fish provide omega-3 fatty acid, fruits and
vegetables are great sources of fiber and provide some phytosterols, unrefined vegetable oils
provide lots of phytosterols, and nuts and grains provide some as well.

Nutrient: increase phytosterols and fiber (phytosterols reduce cholesterol absorption because
they are similar in shape to cholesterols, they react with the LXR receptor, this reduces the
absorption of the cholesterol) (fiber captures nutrients and pulls bile acids with it, bile acids are
the only way to excrete cholesterol, fiber increases fat excretion)

5. What other lifestyle recommendation do you have to help Mark reduce his risk of CVD?
Why did you make this recommendation?
Increase physical activity and promote weight loss if he is obese or weight management.
Physical activity should be 40 minutes a day interval training for at least 8 weeks.
Increase HDL with exercise and red wine (maybe depends on genetic factors in an individual, if
you’re under 40 NEVER DRINK ALCOHOL!!!)
Nuts: high in phytosterols and monopoly-unsaturated fats, when consuming proteins we are
reducing saturated fat (butter, bacon, sausage) increase unsaturated fat!

Case 2
Kelly’s blood lipids were measured: total cholesterol=250 mg/dL; HDL=45 mg/dL; and TG 400
mg/dL.

1. Calculate her LDL cholesterol.

Total = HDL + LDL + (TG/5)
250= 45 + LDL + (400/5)
250-125=125
LDL=125

2. What is the LDL-cholesterol recommendation?

a. Why?
< 100 is optimal, 100-129 is normal. Cholesterol can not be degraded once it is
synthesized or absorbed into the body so it leads to plaque build up in the arteries. As
LDL-C builds up it oxidizes and we want to reduce oxidation with Vitamin C and Vitamin
E.

3. If she currently gets 20% of her total calories from saturated fat and she reduces
it to 7%, what would be the reduction in her total cholesterol?
202-168.2 = 33.8 mg/dl decrease in total cholesterol
150 + 2.6 x 20% = 202
150 + 2.6 x 7% = 168.2

4. What dietary approaches can she institute to reduce her LDL-C?

She should look to limit her intake of trans fats and saturated fats, as both are
contributors to the raising of blood cholesterol levels

We want to reduce trans fat and saturated fat and increase antioxidants

a. Discuss the mechanism of the dietary recommendations.

Mechanism: Reducing oxidation so that it can interact with its receptor to reduce
circulation of apoB. As it continues to be oxidized and in circulation, the
cholesterol builds up in concentration as plaque in the arteries.

LDL is made in the liver (we don’t consume it, it is synthesized)

5. What dietary and lifestyle approaches can be used to reduce her TG?

Weight loss, reduction in simple sugars, and refined grains. Consume alcohol moderately or not
at all.
 In terms of diet, moderating alcohol intake, replacing simple and added sugars and refined
grains with MUFAs, PUFAs and protein will lower TG. Replacing 10% of calories from
carbohydrates with 10% of calories from protein will lower TG levels. Also replacing 10% of
calories from carbohydrates with 10% of calories from unsaturated fats will lower TG levels.

6. What lifestyle approaches can be used to increase her HDL?

High-intensity interval training for 8 weeks will increase HDL. Moderate

7. What medications can be used to reduce her blood cholesterol? Discuss how these
medications work.

HMG CoA reductase inhibitors (statins), bile acid sequestrants, fibric acid derivatives, probucol,
and nicotinic acid can be used to lower blood cholesterol. Statins inhibit HMG CoA reductase
which is the rate limiting enzyme in cholesterol synthesis. Bile acid sequestrants bind to charged
bile acids, inhibiting cholesterol absorption. Fibric acid derivatives degrade VLDL and lower its
production while also increasing production of apoA-I, leading to higher HDL levels. Probucol
degrades LDL and can inhibit cholesterol absorption and synthesis. Nicotinic acid inhibits
hormone sensitive lipase which reduces breakdown of TGs to free fatty acids and thus the
transport of those to the liver. This reduces TG synthesis, which inhibits VLDL secretion and thus
the production of LDL.

Case 3
Max is 75 inches tall and weighs 300 lbs. His blood pressure is 155/98. His breakfast, lunch, and
dinner are listed below.

Breakfast Lunch Snack Dinner

Cocoa Puffs cereal Pepperoni Pizza Chips 1 cup chicken

4 ounces of whole 16 oz fruit punch 12 oz soda noodle soup
milk 1 cup of side salad 8 oz salmon
1 medium apple (spinach, tomato, ½ cup of broccoli
16 ounces of black cucumber, carrots + 8 oz water
coffee ranch dressing) 24 oz beer
 1. Identify specific foods that should be reduced in his diet to improve his blood
pressure.

Pepperoni pizza, chips, and chicken noodle soup should be reduced to improve blood pressure.

2. Identify specific foods that should be increased in his diet to improve his blood
pressure.
Apples, salad, salmon, broccoli, chicken.

3. Recommend specific foods that could be added to his diet. Are there any specific
substitutions that could be made?

Vegetables and fruits, whole grains, low-fat dairy, fish, legumes. He could substitute
whole milk for 2% milk, replace chips with nuts, and replace the cereal with granola.

4. Explain how these foods in this diet may improve blood pressure. Discuss the
nutrients that you are focusing on and why.

These foods would help improve his blood pressure because they are high in
magnesium, calcium, potassium, and they are low in sodium. These all fit into the DASH diet,
which strives to limit sodium intake to under 1500 mg a day (the goal intake for those with
hypertension) while increasing Ca, K, and Mg intake.

5. Make specific exercise recommendations to help improve Max’s blood pressure.

Engage in regular physical activity. At least 30 minutes per day most days of week.

Case 4
Sarah is a 60-year-old female. She is 68 inches tall and weighs 240 lbs. Her blood pressure is
158/88.

1. What dietary approach could Sarah take to improve her blood pressure?

Follow DASH diet- rich in fruits, vegetables, and low fat dairy produces with a reduced content
of saturated and total fat
 2. Make 1-day menu that follows the DASH diet.

Breakfast Lunch Snack Dinner

- Low fat yogurt -mediterranean -almonds -salmon

- Blueberries bowl(chicken, -fruit cup -brown rice
cucumbers, -broccoli
tomatoes, red onion, -water
lettuce, tzatziki
sauce)
-water

3. What other lifestyle recommendation do you have to help Sarah reduce her
blood pressure?

Engage in regular physical activity. At least 30 minutes a day, most days of week. Maintain
normal body weight. Limit alcohol consumption to no more than 1 drink a day.

4. What complications may develop if Sarah does not control her disease? Explain
how these complications manifest.

High blood pressure can lead to complications including-stroke, cognitive impairment,

hypertensive retinopathy, myocardial infarction, heart failure, renal failure, and
peripheral vascular disease.
 Increased blood pressure and extra abdominal fat lead to resistance in the blood vessels,
increased artery stiffness, and other stresses on the body's organs which can lead to
these complications.

5. What medications can be used to reduce her blood pressure?

a. Discuss how these medications work.
b. Which of these medications is potassium wasting? Why?

Diuretics inhibit reabsorption of sodium in the kidneys and specifically thiazide and loop
diuretics are potassium wasting. This is due to the inhibition of the Na-Cl cotransporter TNC in
thiazide and loop diuretics which increases potassium loss, or wasting.
Renin-angiotensin-aldosterone system inhibitors inhibit ACE which lowers the conversion of
angiotensin I to angiotensin II. This leads to less vasoconstriction, less water and sodium
reabsorption and increases in vasodilation, leading to lower blood pressure. Beta blockers lower
the effect of adrenaline which leads to a slower heart rate and a heart beating with less force.
Thus blood pressure is lowered. Calcium channel blockers inhibit calcium from entering the cells
of the heart and arteries which allows for vasodilation and lower blood pressure.