Biochemical Case Study Dyslipidemia

Objectives:
Identify cardiac risk factors for coronary artery disease in obese patients without known
disease.
Describe other physical examination findings and screening and laboratory
measurements relevant in a patient with disorders of lipid metabolism.
Describe the science-based nutritional and lifestyle recommendations for patients with
disorders of lipid metabolism.
JT is a a 52-year-old Puerto Rican man who consults a new physician for a routine physical
examination because his employer recently changed their health insurance plan. He has not
seen a physician for the past 3 years.
Past Hx No prior Hx of hospitalization or chronic illness. He is not taking any medications
or over-the-counter dietary or herbal supplements and he has no know food allergies (NKA).
Family Hx positive for heart disease. Father had a fatal heart attack at age 54. Fathers
brother had a heart attack at age 55. JTs uncle is currently being treated for
hypercholesterolemia. No family Hx of hypertension, diabetes, or obesity.
Social Hx JT works as an accountant and reports a high stress level both at work and at
home. His work commitments do not allow him much free time so he frequently orders lunch
in and eats at his desk. He has a 45 minute commute home. JT feels too tired to exercise. Over
the past 3 years he has experienced a 12 pound weight gain. JT attributes this to his sedentary,
high-stress lifestyle, and to dining out with clients on average 2-3 nights per week. JT is a nonsmoker. He drinks a 20 ounce cup of regular coffee every morning and two alcoholic
beverages every evening. JT is married with one daughter in college.
Dietary Intake: Using the 24-hr recall method, JTs physician obtained the following
information about his typical diet.
Breakfast (office)
Bagel 1 large (4 oz)
Cream cheese (2 Tbsp)
Coffee (20 oz)
Half-andhalf (2 oz.)

Lunch
Pizza w cheese (2 slices)
Soda (12 oz)
Snack
Jelly beans (1 oz)

Dinner (restaurant)
Hamburger 6 oz
Bun 1 large
French fries (1 cup)
Vanilla ice cream (1 c)
Beer (24 oz)

Total kcals 1798

Approximate macronutrient distribution: Carbs/Protein/Fat 55%, 13.8%, 20%

Physical Examination
Temperature, heart rate, respirations: all normal
Blood pressure: 139/88 mm Hg
Height 510
Current Weight 212 lb
Weight two years ago: 200 lbs
BMI 30.5

Waist circumference: 42 inches

Exam:
General Obese male in no acute distress
Remainder of physical exam was normal and unremarkable
Laboratory Data 12 hour fasting
Pts values
Normal
Lipid profile: Total Cholesterol 260 mg/dl
desirable < 200 mg/dl
HDL-C 32 mg/dl
desirable > 40 mg/dl
LDL-C 158 mg/dl
desirable < 130 mg/dl
Triglycerides 350 mg/dl
desirable < 150 mg/dl
CRP 4.5 mg/L
< 3.0 mg/L
Homocysteine: 8 mol/L
<12 mol/L
Lp(a): 11 mg/dL
<20 mg/dL
Plasma glucose: 95 mg/dl
70-99 mg/dl
Framingham point score: 10 year risk for Coronary Heart Disease 13%
Case Questions
1. How should JTs lipid profile, waist circumference, and blood pressure be interpreted,
based on the ATP III Guidelines? Does he meet the criteria for metabolic syndrome?
JTs total cholesterol, triglycerides, and LDL-C are high. His HDL-C is below 40mg/dL so it is
considered a major risk factor for heart disease. His waist circumference puts him in between
the 50th and 75th percentiles, just above the mean. His systolic blood pressure is below the risk
but his diastolic blood pressure is above the risk factor. Because he meets more than three of
the criteria, JT can be considered to have metabolic syndrome.
2. Why would the Dr. recommend lab tests for CRP, Homocysteine and Lp(a)?
CRP is highly sensitive. His CRP is above the desired level so there may be possible
inflammation and potential risk for atherosclerosis and thrombosis. A higher homocysteine
level would indicate platelet aggregation, inflammation or other dysfunctions with the
endothelial linings of his blood vessels. It is important to make sure it is in the desired range.
Lp(a) above 20mg/dL is associated with increased risks of myocardial infarctions and agina
pectoris so it, too, is important to check if it is in the desired range.

3. What are the recommended lipid goals for JTs dyslipidemia?

JT should get his LDL-C below 100mg/dL and blood pressure <140/<80 mmHg.

4. Is JTs current nutrient intake within the recommended guidelines of the ATP III
Therapeutic Lifestyle Changes (TLC) diet?
Saturated fats and dietary cholesterol are most likely above 7% and 200mg, respectively. Total
fat is below the desired range. JT is also consuming little, to no poly- or monounsaturated fats
in his diet, as shown in the 24-hr recall. For the other macronutrients, carbohydrates are in the
desired range, whereas the protein may be slightly under the desired 15%. JT is also barely,
consuming fiber because of the lack of whole foods in his diet.

5. Should JT receive lipid lowering medication at this time?

Since JT is above the age of 40 years with multiple risk factors for cardiovascular disease, he
should be treated with Statin therapy to lower his lipid values to desired values.