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Name: Amanda Tome


NTD 610 Cardiovascular Case Study
You are running a comprehensive ‘wellness fair’ at a primarily African American church in your
community. One of the client’s you evaluate is RA. RA is a 50 year old female who requests a nutrition
assessment and has brought with her a copy of her medications and recent laboratory data.

You perform a basic physical assessment on RA to determine height, weight, waist/hip circumferences and
blood pressure. You also complete a basic interview and a 24-hour dietary recall. She does not follow any
particular diet, but has been trying to eat less processed and refined foods for the past month.

 Height 5’2”
 Weight 170#
 Waist Circumference 38 inches
 Hip Circumference 40 inches
 BP 160/94 mmHg
 Total Cholesterol 260 mg/dL
 HDL 32 mg/dL
 LDL 140 mg/dL
 Triglycerides 185 mg/dL
 Fasting plasma glucose (FPG) 95 mg/dL
 2-hr post prandial BG 180 mg/dL

OTHER: Non-smoker, walks for 45 minutes ~5 days per week for work due to lack of transportation
FAMILY HISTORY: 55 yo sister recently had a heart attack.
MEDS: Lopressor

24-HOUR RECALL
 Breakfast – 2 cups coffee with 2 TBSP half and half, 2 large eggs scrambled, 2 slices whole wheat
toast with 1 TBSP butter, medium banana.
 Lunch – 2 cups Campbell’s chicken noodle soup, 6 saltine crackers, half of a ham and cheese
sandwich on whole wheat bread (1 oz American cheese, 3 oz ham), 16 oz diet Pepsi.
 Snack – 2 medium chocolate chip cookies with 1 cup 2% milk.
 Dinner – 4 oz grilled chicken breast, 1 cup brown rice with ½ TBSP butter, ½ cup steamed broccoli,
1 small white dinner roll with ½ TBSP butter, 16 oz unsweetened iced tea.
 Snack – 1 medium brownie with 1 cup 2% milk.

1. Calculate or list the following and identify the category or risk level for each:
a) BMI
𝑤𝑒𝑖𝑔ℎ𝑡 (𝑙𝑏𝑠) 170 𝑙𝑏𝑠 170 𝑙𝑏𝑠
BMI = ℎ𝑒𝑖𝑔ℎ𝑡 2 (𝑐𝑚2 ) 𝑥 703 = 62𝑐𝑚2 𝑥 703 = 3844 𝑐𝑚2 𝑥 703 = 170/(62)2= 31.1 kg/m2
RA is classified as class I obese (Lee & Nieman, 2013-a).

b) Waist Circumference (WC)


38 in. (38 in. x 2.54 = 96.52 cm.)
In women, class I obesity and a WC > 35 in. indicates very high risk of disease (Lee & Nieman,
2013-a).

c) Waist to Hip Ratio (WHR)


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𝑤𝑎𝑖𝑠𝑡 𝑐𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒 38 𝑖𝑛.


WHR = = = 0.95
ℎ𝑖𝑝 𝑐𝑖𝑟𝑐𝑢𝑚𝑓𝑒𝑟𝑒𝑛𝑐𝑒 40 𝑖𝑛
RA has an increased risk for heart disease (Lee & Nieman, 2013-b)

d) Number of positive CHD risk factors, according to NCEP. List them. (Box 8.2, p. 258)
RA currently has four positive CHD risk factors (Lee & Nieman, 2013-c).
1. Elevated LDL-C; LDL-C > 130 mg/dL (RA’s LDL-C is 140 mg/dL)
2. Hypertension; BP ≥ 140/90 mmHg (RA’s BP is 160/94 mmHG) and RA is taking Lopressor,
an antihypertensive medication (Lopresor, n.d.)
3. Family history of CHD – RA’s 55 year old sister recently had a heart attack
4. Low HDL-C; HDL-C < 40 mg/dL (RA’s HDL-C is 32 mg/dL)

e) 10-year Risk (NHLBI website, http://cvdrisk.nhlbi.nih.gov/ or Table 8.4, pp. 264-265)


Risk-Prediction Score = age points + TC points + HDL-C points + smoking points + systolic BP
points = 6 + 5 + 2 + 0 + 6 = 19
 RA’s age (50 years) = 6 points
 TC (260 mg/dL = 5 points
 HDL-C (32 mg/dL) = 2 points
 Nonsmoker = 0 points
 Treated Systolic BP (160 mmHg) = 6 points
RA has risk-prediction score of 19, which indicates an 8% risk of developing CHD within the next 10
years (Lee & Nieman, 2013-d).

f) What is her Visceral Adiposity Index (VAI)? Formula can be found in research studies such as
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845052/. Show calculations.
𝑊𝐶 (𝑐𝑚) 𝑇𝐺 (𝑚𝑚𝑜𝑙/𝐿) 1.52
VAI = 36.58+(1.89 𝑥 𝐵𝑀𝐼 (𝑘𝑔/𝑚2)) 𝑥 𝑥 =
0.81 𝐻𝐷𝐿 (𝑚𝑚𝑜𝑙/𝐿)
96.52 𝑐𝑚 2.089 𝑚𝑚𝑜𝑙/𝐿 1.52
𝑥 𝑥 0.828 𝑚𝑚𝑜𝑙/𝐿 =4.79 (Amato & Giordano, 2014; Amato et al.,
36.58+(1.89 𝑥 31.1 𝑘𝑔/𝑚2 ) 0.81
2010).
 WC = 38 in x 2.54 = 96.52 cm.
 TG = 185 mg/dL / 88.57 = 2.089 mmol/L (Rugge et al., 2011)
 HDL = 32 mg/dL / 38.67 = 0.828 mmol/L (Rugge et al., 2011)
RA’s visceral adiposity index is 4.79. CHD and CVD risk factors significantly increase as VAI
increases. In the Amato et al. (2010) study, VAI was significantly associated with metabolic
syndrome factors, cardio events, and cerebrovascular events, with a moderate association for
individuals in the fourth quintile and a severe association for those in the fifth quintile. RA’s VAI of
4.79 would place her in the fifth quintile.

g) Does she have metabolic syndrome? List the risk factors.


(http://www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/About-Metabolic-
Syndrome_UCM_301920_Article.jsp)
RA has metabolic syndrome because she has four out of the five risk factors. (Sarcona, n.d.)
a. As a woman, a WC ≥ 35 in. (RA’s WC is 38 in.)
b. TG ≥ 150 mg/dL (RA’s TG is 185 mg/dL)
c. As a woman, HDL-C < 50 mg/dL (RA’s HDL-C is 32 mg/dL)
d. Blood pressure ≥ 130/85 mmHg and on drug treatment for hypertension (RA is taking the
antihypertensive medication Lopressor and her blood pressure is 160/94 mmHg)

h) Does she have normal glucose regulation? Pre-diabetes? Type 2 diabetes? (Box 8.8, p. 303;
check American Diabetes Association for pre-diabetes diagnostic values)
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No, RA does not have normal glucose regulation. Her fasting blood glucose is still within the
normal range, but her 2 hour postprandial blood glucose level is elevated above the normal range.
Diabetes is defined as having a fast blood glucose level ≥ 126 mg/dL, a 2-hour postprandial blood
glucose level ≥ 200 mg/dL, an A1c ≥ 6.5%, or a random blood glucose level ≥ 200 mg/dL (American
Diabetes Association [ADA], 2016).. Pre-diabetes is defined as having a fasting blood glucose level
between 100-125 mg/dL, a 2-hour postprandial blood glucose level between 140-199 mg/dL, or an
A1c between 5.7-6.4% (ADA, 2016). Because her postprandial blood glucose is between 140-199
mg/dL, RA has impaired glucose tolerance and pre-diabetes (ADA, 2016).

2. Describe in detail your assessment of RA’s health status and disease risk.
RA has a poor health status because she is classified as class I obese, has a waist circumference
greater than 35 in., hypertension, dyslipidemia, metabolic syndrome, and pre-diabetes. Furthermore, RA
has a high risk of developing CHD because she has four of the seven positive risk factors for CHD,
including hypertension, elevated LDL-C, low HDL-C, and a family history of premature CHD.
Although RA only has an 8% 10-year risk of developing CHD, her risk will increase as she ages and will
significantly increase if she develops Type 2 Diabetes Mellitus. Fortunately, RA is a non-smoker, is
currently under 55 years of age, and she walks for 45 minutes five days per week. Despite taking the
anti-hypertensive medication, Lopressor, RA’s blood pressure is still elevated and classified as Stage 2
hypertension because her systolic blood pressure is 160 mmHg (Lee & Nieman, 2013-e). RA also has an
extremely high VAI.

3. Choose at least 3 factors to focus on with RA


RA’s primary problems are insulin resistance, hypertension, and dyslipidemia. Therefore, I
would focus on implementing the TLC diet, increasing physical activity, and weight loss. The TLC diet
is the diet recommended diet for individuals with CHD or a risk of CHD and is mostly consistent with
the U.S. Dietary Guidelines although a few recommendations are altered to help improve lipid values.
The main features of the TLC diet are to consume less than 7% saturated fat, less than 200 mg. of dietary
cholesterol, 25-35% of total calories from total fat, up to 20% of total calories from monounsaturated fat,
50-60% of total calories from carbohydrates, 20-30 g. total fiber with 10-25 g. being soluble fiber, 15%
of total calories from protein, and to maintain energy balance (Lee & Nieman, 2013-f). The TLC diet
also recommends limiting sodium to less than 2,300 mg/day, and consumption of 3-5 servings/day of
vegetables and dry beans/peas, 2-4 servings/day of fruit, 2-3 servings/day of low-fat or non-fat dairy, 6-
11 servings/day of grains with an emphasis on whole-grain, 2 or fewer egg yolks per day, 5 or fewer
oz/day of lean meat, poultry, or fish, and nuts and oils based on calorie needs (National Cholesterol
Education Program [NCEP] & NHLBI Obesity Education Initiative, 2005). Decreasing saturated fat to
less than 7% of total calories can lower LDL-C by 8-10% and adding 5-10 g/day of soluble fiber can
reduce LDL-C by 3-5% and soluble fiber can help to slow cellular uptake of glucose (Mayo Clinic, 2015;
NCEP & NHLBI Obesity Education Initiative, 2005). Also, reducing sodium intake to less than 2,400
mg/day can lower systolic blood pressure by 2-8 mmHg (Lee & Nieman, 2013-f). To begin, I would
recommend that RA consume between 1350-1800 kcal/day which would result in weight maintenance or
up to 0.5 lb. weight loss per week, no more than 7% of total calories from saturated fat, 10-25 g/day
soluble fiber, less than 2,300 mg/day sodium, up to 20% of total calories from monounsaturated fat.

Moderate exercise, such as brisk walking for 30-45 minutes per day most days of the week can
lower blood pressure by 4-9 mmHg, improve insulin sensitivity, enhance cellular uptake of glucose,
improve lipid levels (Lee & Nieman, 2013-f). Moderate intensity exercise and resistance training are
beneficial for improving HDL-C whereas high-intensity exercise can decrease LDL-C, total cholesterol,
and triglycerides (Mann, Beedie, & Jimenez, 2014). Since RA already walks for 45 minutes per day
most days of the week, I would the level of intensity associated with that activity. If she is not walking at
a moderate intensity, I would recommend that she increase the intensity to a moderate intensity or if that
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is impractical because she does not want to perspire because walking is her mode of transportation, than I
would recommend adding moderate intensity physical activity until she is achieving at least 30 minutes
of moderate intensity physical activity most days of the week. Increasing RA’s physical activity will also
help her lose weight.

Weight loss is beneficial for lowering blood pressure, improving the effects of anti-hypertensive
mediations, increasing insulin sensitivity, and improving lipid levels by lowering total cholesterol, LDL-
C, and triglycerides and increasing HDL-C (Lee & Nieman, 2013-f). A 10 lb. weight loss can lower
LDL-C by 5-8% and a 10 kg weight loss can lower systolic blood pressure by 5-20 mmHg (Lee &
Nieman, 2013-f; NCEP & NHLBI Obesity Education Initiative, 2005). Furthermore, the Look-AHEAD
study found that a 5-10% weight loss improved glycemic control by lowering fasting blood glucose by
14 mg/dL and lowering Hb A1c by 0.4%, decreased both systolic and diastolic blood pressure by 5
mmHg, increased HDL-C by 5 mg/dL, and lower triglycerides by 40 mg/dL (Wing et al., 2011). The risk
of CHD mortality can be reduced by 4% by lowering blood pressure by 2 mmHg (Lee & Nieman, 2013-
f). Therefore, I would recommend a 5-10% weight loss for RA, which will be more likely to be achieved
by following the TLC diet and increasing her physical activity.

4. What type of nutritional advice would you give her? List specific recommendations that you would
make to help improve her health.
I would provide the following nutritional advice to RA:
 1350-1850 kcal/day
a. RMR = 9.99 x weight (kg) + 6.25 x height (cm) – 4.92 x age (yr) – 161 = 9.99 x 77.27 kg
+ 6.25 x 157.48 cm – 4.92 x 50 yr – 161 = 1349 kcal/day
b. RMR x activity factor (1.375) = 1349 kcal x 1.375 = 1855 kcal/day
c. For 0.5 lb. weight loss per week, subtract 500 kcal/day = 1855-500 = 1355 kcal/day
 Decrease saturated fat to less than 7% of total calories
a. Substitute butter with oils, such as olive or canola oil.
b. Substitute half & half for non-fat half & half
c. Substitute 2% milk with 1% or non-fat milk
d. Reduce consumption of baked goods
 Keep consumption of trans fat very low.
a. Reduce consumption of baked goods
 Decrease sodium to less than 2,300 mg/day
a. Reduce amount of processed foods
b. Choose low sodium soup, crackers, etc..
c. Reduce or eliminate intake of processed meat
 Increase total dietary fiber to 20-30 g/day and soluble fiber to 10-25 g/day
a. Increase whole-grains
b. Increase vegetable consumption
c. Eat oats, oatmeal, oat bran
d. Increase whole fruit consumption to 2-4 servings/day
e. Eat legumes, such as lentils and black, kidney, pinto, garbanzo, and white beans
 CHO consistent meals and 50% of total calories from carbohydrates
 Read label – a lot of processed foods contain high amounts of sodium, sugar, and saturated fat.
 Maintain portion control
 Increase consumption of monounsaturated fats
a. Eat olives, avocados
b. Eat olive, canola, and safflower oils
c. Eat nuts, such as almonds, hazelnuts
 Increase intake of omega-3 fatty acids
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a. Eat fatty fish such as salmon, trout, tuna,


b. Eat flax seed and flaxseed oil
c. Eat walnuts and sunflower seeds
d. Eat canola oil and soybean oils

5. According to the ATPIII Worksheet (all 9 steps), what would be her treatment goals?
Based on the ATP III Guidelines, RA’s primary treatment goal is to have a LDL-C < 130 mg/dL
through a TLC diet, weight management, and increased physical activity (NCEP, 2001). Since RA has
an 8% 10-year CHD risk and her LDL-C is less than 160 mg/dL, drug therapy is not recommended at this
time (NCEP, 2001). If RA still has metabolic syndrome after 3 months of TLC, the underlying causes of
metabolic syndrome, hypertension, elevated TG, and low HDL-C levels should be treated (NCEP, 2001).
The secondary treatment goals are to lower elevated triglycerides and increase low HDL-C levels by
reaching the LDL-C goal and by increasing weight management strategies and physical activity (NCEP,
2001). Although the ATP III does not establish specific goals for triglycerides or HDL-C, it can be
inferred that triglycerides should ideally be below 150 mg/dL and HDL-C should be above 40 mg/dL
because those are the thresholds to determine if treatment of those biomarkers is warranted.

A. Step 1: LDL-C is borderline high, TC is high, and HDL-C is low


B. Step 2: no CHD risk equivalents
C. Step 3: 3 Major risk factors (HTN, low HDL-C, and family history of premature CHD)
D. Step 4: <10% 10-year CHD risk
E. Step 5: Risk category is 2+ Risk Factors (10-year risk ≤ 20%)
a. LDL goal is < 130 mg/dL
b. LDL level at which to initiate therapeutic lifestyle changes (TLC) is ≥ 130 mg/dL
c. LDL level at which to consider drug therapy is ≥ 160 mg/dL
F. Step 6: Initiate TLC because LDL-C is 140 mg/dL which is greater than 130 mg/dL
G. Step 7: Drug therapy is not recommended at this time because LDL-C is less than 160 mg/dL
H. Step 8: Metabolic syndrome is present. Reassess after 3 months of TLC
I. Step 9: TG is borderline high. Treat elevated TG. HDL-C is low. Treat low HDL-C
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References:

Amato, M. C., & Giordano, C. (2014). Visceral adiposity index: An indicator of adipose tissue dysfunction.

International Journal of Endocrinology, 2014, p.1-7. doi:10.1155/2014/730827. Retrieved March 29,

2017 from https://www.hindawi.com/journals/ije/2014/730827/

Amato, M. C., Giordano, C., Galia, M., Criscimanna, A., Vitabile, S., Midiri, M., … Galluzzo, A. (2010).

Visceral adiposity index: A reliable indicator of visceral fat function associated with cardiometabolic

risk. Diabetes Care, 33(4), 920–922. doi: 10.2337/dc09-1825. Retrieved March 29, 2017 from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845052/

American Diabetes Association. (2016). Standards of medical care in diabetes—2016. Diabetes Care,

39(Suppl. 1), S1-S106. Retrieved March 29, 2017 from http://www.ndei.org/ADA-diabetes-

management-guidelines-diagnosis-A1C-testing.aspx.html

Lee, R. D., & Nieman, D. C. (2013-a). Classification of overweight and obesity by body mass index (BMI),

waist circumference, and associated disease risk in adults [Table]. In Nutritional assessment (6th ed.,

p. 183). New York, NY: McGraw-Hill.

Lee, R. D., & Nieman, D. C. (2013-b). Anthropometry. In Nutritional assessment (6th ed., pp. 166 – 218).

New York, NY: McGraw-Hill.

Lee, R. D., & Nieman, D. C. (2013-c). Major coronary heart disease risk factors other than LDL cholesterol

In Nutritional assessment (6th ed., p. 258). New York, NY: McGraw-Hill.

Lee, R. D., & Nieman, D. C. (2013-d). Estimating risk of CHD in the next 10 years, women. In Nutritional

assessment (6th ed., p. 265). New York, NY: McGraw-Hill.

Lee, R. D., & Nieman, D. C. (2013-e). Classification of blood pressure for persons age 18 years and older. In

Nutritional assessment (6th ed., p. 283). New York, NY: McGraw-Hill.

Lee, R. D., & Nieman, D. C. (2013-f). Nutritional assessment in disease prevention. In Nutritional

assessment (6th ed., p. 256-313). New York, NY: McGraw-Hill.


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Lopressor. (n.d.). Retrieved March 29, 2017 from https://www.drugs.com/cdi/lopressor.html

Mann, S., Beedie, C., & Jimenez, A. (2014). Differential effects of aerobic exercise, resistance training and

combined exercise modalities on cholesterol and the lipid profile: Review, synthesis and

recommendations. Sports Medicine, 44(2), 211–221. http://doi.org/10.1007/s40279-013-0110-5

Mayo Clinic. (2015). Dietary fiber: Essential for a healthy diet. Retrieved March 29, 2017 from

http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/fiber/art-20043983

National Cholesterol Education Program. (2001). ATP III guidelines at-a-glance quick desk reference.

Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute. Retrieved

March 29, 2017 from https://www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf

National Cholesterol Education Program & NHLBI Obesity Education Initiative. (2005). Your guide to

lowering your cholesterol with TLC. Bethesda, MD: National Institutes of Health, National Heart,

Lung, and Blood Institute. Retrieved March 29, 2017 from

https://www.nhlbi.nih.gov/files/docs/public/heart/chol_tlc.pdf

Rugge, B., Balshem, H., Sehgal, R., Relevo, R., Gorman, P., & Helfand, M. (2011). Appendix A of

Screening and treatment of subclinical hypothyroidism or hyperthyroidism. Comparative

Effectiveness Reviews, 24. Rockville, MD: DHHS, Agency for Healthcare Research and Quality.

Retrieved March 29, 2017 from https://www.ncbi.nlm.nih.gov/books/NBK83505/

Sarcona, A. (n.d.).Chapter 8 nutritional assessment in disease prevention: Part I [PowerPoint Slides].

Retrieved March 29, 2017 from

https://d2l.wcupa.edu/d2l/le/content/2169862/viewContent/13736902/View

Wing, R. R., Lang, W., Wadden, T. A., Safford, M., Knowler, W. C., Bertoni, A. G., … & Wagenknecht, L.

(2011). Benefits of modest weight loss in improving cardiovascular risk factors in overweight and

obese individuals with type 2 diabetes. Diabetes Care, 34(7), 1481-1486. doi: 10.2337/dc10-2415.
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Rubric
Sections Max Points Points Earned
Assessment of RA’s health status and disease risk 5
Appropriate nutritional advice 9
Appropriate nutritional recommendations to improve health 9
ATPIII treatment goals 7
Appropriate citations in the paper and separate reference page at the 2.5
end. Correct use of APA formatting.
Complete, neat, few grammar and spelling mistakes, correct sentence 2.5
structure, etc.
Total Points 35