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ASSESSMENT
Mr. Miller is a 39-year-old male with a primary diagnosis of hyperlipidemia. Mr. Miller works
from home in medical equipment sales but travels frequently for work, 3 days out of the week to nearby
cities. He has a family history of cardiovascular disease, with his father having his first heart attack at 48
years old and his brother dying from a heart attack one year ago. He reports that his family is intolerant of
statins with myalgia as a side effect and therefore does not take prescription medication for cardiovascular
disease. The patient’s anthropometric data was recorded at a recent medical appointment as well as a lipid
Anthropometrics
Mr. Miller’s anthropometric data were recorded in Table 1. His BMI according to his height and
weight of 175.3cm and 93.2kg records his BMI at 30.2 which is obese according to the BMI guidelines.
For his height and gender, his ideal body weight (IDW) would be 70.7kg. The IDW is calculated with the
following equation:
Since Mr. Miller is obese, the adjusted body weight is used to calculate a more accurate measurement.
The adjusted body weight is used for making clinical recommendations for patients that are overweight or
obese.
For men, high-risk waist circumference is above 40 inches, which is associated with an increased
risk for type 2 diabetes, dyslipidemia, hypertension, and CVD. Waist circumference is more indicative of
risk for obesity-related disease because it measures abdominal fat, and in obese patients with metabolic
conditions, waist circumference changes can be predictors of changes in CVD risk factors. 1
Mr. Miller’s waist circumference is recorded at 42 inches, increasing his risk of CVD. In one
study, the obesity in the study population was associated with higher levels of CVD risk factors including
fasting glucose, triglycerides, LDL-cholesterol, uric acid, hs-CRP, increased SBP, however only
abdominal obesity was significantly associated with clinical CVD. The study concluded that waist
circumference provides additional information about risk stratification, thus proving that waist
circumference is an important indicator of CVD and important to take note of when doing an assessment. 2
Weight gain in a certain period of time is also associated with increased risk for CVD.Mr. Miller
gained 14.2kg over the course of 7 years, and evidence shows that changes in weight alter cardiac
structure and function according to one study called the Dallas Heart Study. Participants underwent body
weight assessment and other anthropometrics and then were recorded again 7 years later. 41% of
participants had an increase of >5% or more were associated with increases in left ventricular mass, wall
thickness, and concentricity. The study concluded that weight management is necessary to prevent
changes in adiposity that could eventually lead to heart failure over time. 3
Anthropometrics Value
Height 175.3 cm
Weight 93.2 kg
Weight (2013) 79 kg
BMI 30.3
Family history
Mr. Miller has a family history of cardiovascular disease (CVD) among male relatives in his
family. This increases his risk of CVD according to health research and data analysis. According to one
study published by the Canadian Family Physician, siblings of patients have an increased 40% risk while
children whose parents have premature CVD have a 60-75% increased risk. The study also found that
there was an increased risk of myocardial infarction by 1.7 times if one parent had myocardial infarction,
and increases by 2.4 times if the parents had myocardial infarction before the age of 50. In Mr. Miller’s
case, his brother suffered a fatal myocardial infarction and his father had a heart attack at age 48, thus Mr.
Miller’s risk is increased for cardiovascular disease and myocardial infarction due to the family history. 4
Biochemical data
The biochemical data from the lipid panel shows that Mr. Miller has high total cholesterol,
triglycerides, LDL, and apoB. Mr. Miller’s triglycerides are 207 and a healthy triglyceride range is 150
mg/dL and below. The cause of high triglycerides would be from eating a diet high in simple sugars, fat,
and excessive alcohol. In this case, the total cholesterol does not provide a lot of information because it is
a sum of LDL and HDL, it is more important to look at the LDL and HDL levels independently. Mr.
Miller’s LDL cholesterol was high, which is linked to a greater risk of heart and blood vessel disease. The
goal for Mr. Miller should be less than 100 mg/dL due to having high risk of heart disease. Included in
this lipid panel was also a test of apolipoprotein B, which is a major protein found in cholesterol. This
lipoprotein is one of the most important agents of atherosclerosis of the blood vessels causing
cardiovascular disease. The apoB levels indicate that there small, dense LDLs in the blood. Lowering the
Lipid panel
+ (539.6 x height [m]) }For a 39-year old sedentary male with Mr. Miller’s height and weight, his EER is
calculated at 2722 kcal to maintain energy balance. However, Mr. Miller is classified as obese according
to his waist circumference and BMI so his goal should be to eat fewer calories than his EER in order to
lose weight to lower his risk for cardiovascular disease. To lose one pound per week, the caloric intake
goal should be 500 calories fewer than EER. In Mr. Miller’s case, he should be consuming 2222 kcals per
week to be in a negative energy balance to lose weight. The other nutrient goals are shown below in Table
5 to compare his diet recall and his goal intakes for each nutrient.
The main nutrients of concern in the case to lower cardiovascular risk include saturated fat intake
and sodium. In his diet recall, Mr. Miller consumed 122g of fat, including 32g of saturated fat. In any
person’s diet, calories from saturated fat should be less than 10% but to lower cardiovascular risk, it
should be less than 7% .6 The foods in Mr. Miller’s diet contributing most to overall fat content would be
the Panera Italian Combo, goldfish, and Planters honey peanuts. Although the Planters peanuts are filled
with health unsaturated fats, Mr. Miller’s portion size is double the serving size and contributes to
excessive caloric intake. Another concern is the high sodium in his diet, which increases blood pressure
and cardiovascular risk. According to one study, excessive sodium intake has negative effects other than
hypertension as well, and a reduction in sodium shows evidence in improved endothelial functioning,
Mr. Miller is often traveling, eating out, and eating catered and highly processed foods at
meetings. These choices are high in sodium and fat, and the lack of home-cooked meals results in an
excessive amount of calories. Mr. Miller does not consume fruits and vegetables on a daily basis
according to his diet recall, and his portion sizes are much higher than they should be. Due to the
excessive caloric intake of 666 calories, his macronutrients are higher in the number of grams than what
the recommended goals are, but Miller’s macronutrients are in the acceptable ranges overall. However,
the carbohydrate choices come from simple carbs such as added sugars, white bread, and white rice rather
than whole grains, fruits, and vegetables. Mr. Miller consumes some high-quality protein such as chicken
breast, but low-quality protein in the highly processed deli meats he has on sandwiches for lunch. Mr.
Miller is still consuming an excessive amount of protein, eating a serving size of chicken that is double
than recommended. Lastly, Mr. Miller is consuming a low fiber diet. An increase in fiber would result in
increased satiety to help hunger cues more in balance and prevent overconsumption. Mr. Miller is also
taking a men’s multivitamin and niacin supplement, which does not seem to be helping his cholesterol.
Total Cal Total CHO Total Fat Total PRO Total Fiber
Coffee 2 0 0 0 0
Lunch
Water 0 0 0 0 0
Goldfish 509 73 18 15 0
Dinner
Broccoli 40 3 3 2 2
Supplement Dose
Niacin 500mg
DIAGNOSIS
Excessive saturated fat and energy intake related to high consumption of processed foods and
INTERVENTION
To address the familial history of cardiovascular disease, Mr. Miller should start on medication.
Mr. Miller has noted that he has a family history of intolerance to statins that results in myalgia. Statins
are the primary medication to address hyperlipidemia and are the first line of defense that practitioners
use to address hyperlipidemia. To ease Mr. Miller’s anxiety about starting on a statin in fear of statin-
induced myopathy, Mr. Miller can undergo a StatinSmart test. This test analyzes saliva for a gene called
SLCO1B1 that is linked to statin-induced myopathy. This test would be clinically relevant due to a family
history of statin-induced myopathy. This way, Mr. Miller can have more reassurance about starting on a
statin to reduce his LDL cholesterol levels. If Mr. Miller has two normal versions of the SLCO1B1 gene,
he is not at risk for myopathy.8 If Mr. Miller does have 2 copies of the gene and it would not result in
myopathy, a common statin medication for him to try would be atorvastatin at 10mg daily. If Mr. Miller
does not have 2 copies of the gene and could be at risk for statin-induced myopathy, an alternative to
statins would be a bile acid-binding resin such as cholestyramine. 9 A barrier to this change could be
bloodwork for Mr. Miller would be his busy schedule with work, as he is often traveling and may not try
to make time for medical appointments. Luckily, LabCorp is open starting at 6am and Mr. Miller would
be able to get a blood draw before work. Another barrier would be his hesitance of starting medication,
however, hopefully, his anxiety would be relieved with the statin-induced myopathy genetic testing.
Mr. Miller needs to address his diet regarding fruit and vegetable intake. He is consuming an
excess of 666 calories which is causing him to gain weight. His diet is high in fat and sodium which is
contributing to his risk of cardiovascular disease. To start out, Mr. Miller should work to increase his
fiber consumption to between 30g - 38g per day. High fiber foods include fruits, vegetables, and whole
grains. More specifically, realistic changes to increase fiber could be buying Fiber-One bars, oatmeal,
broccoli, and lentils. If Mr. Miller increases his fiber consumption, he will also be increasing his fruit and
vegetable consumption which is currently very low. He will also be helping to lower his LDL cholesterol
levels because fiber binds to LDL cholesterol in the small intestine and prevents them from entering the
bloodstream and other parts of the body. To help Mr. Miller understand high fiber foods, he should have
education on how to read a food label and use a website such as Spark People to figure out the number of
grams of fiber in foods that do not have labels, such as fruits and vegetables. Some simple swaps in his
current diet could be to swap white rice for brown rice, and whole wheat bread instead of ciabatta bread.
Mr. Miller has family support that will help him to achieve this goal. His family is most likely eating a
more healthful diet than he is since his food is mostly eaten out of the home. With support from his
Another part of his diet that needs to be addressed is his saturated fat intake. Mr. Miller is
consuming 32g of saturated fat and this is important to address because it contributes to his
cardiovascular disease risk and is responsible for 9% of his caloric intake. However, since Mr. Miller’s
caloric intake is much greater than it should be, if he was consuming the calories calculated for his EER,
his saturated fat consumption would be 11% of his caloric consumption. Saturated fats should be replaced
with unsaturated fats such as olive oil. In one study, saturated fat was reduced and replaced by vegetable
oil rich in polyunsaturated fats that showed a 29% reduction in major coronary events. 10 Mr. Miller should
aim to avoid snacks such as cookies and Goldfish, lower red meat intake, and choose options such as
yogurt, wheat toast, or tuna salad dip with vegetables. Mr. Millter should try to reduce his saturated intake
to 7%. A barrier to this intervention would be Mr. Miller’s environmental factors of his career’s lifestyle.
He is often on the road, traveling, and looking for quick snacks or eating meals that the catering provides.
If he packs his lunch and avoids temptations to eat the catered meals, this will help him to achieve his
goals.
MONITORING/EVALUATION
To monitor the first intervention, Mr. Miller should have repeat bloodwork every few months to
analyze blood lipid levels. A lipid panel should be completed to assess total cholesterol, triglycerides,
LDL, and apoB lipid levels since those were the abnormal results from his first lipid panel. Major changes
start to occur in cholesterol levels after 2-4 weeks of starting medication. Healthy cholesterol ranges that
would show improvement would be total cholesterol under 200 mg/dL, triglycerides under 150 mg/dL,
LDL below 130 mg/dL, and apoB below 100 mg/dL. It would be unrealistic for Mr. Miller to have perfect
cholesterol levels only 4 weeks after starting medication, so a proper plan could be to have blood work 4
weeks after medication and a long term goal of reassessing blood work 8 weeks and 16 after that to
continue monitoring his cholesterol levels to ensure that the medication is still working properly. A long
term goal would be to see a decrease in his cholesterol to healthy levels as shown in the reference ranges
of Table 2.
To monitor and evaluate Mr. Miller’s fiber intake the dietitian can evaluate the number of grams
of fiber he is eating if he is consistently using Spark People. Additionally, knowledge of high fiber foods
will show that he is making more of a conscious effort to consume high fiber foods. Periodic analysis of
24-hour diet recalls will determine if he is meeting a fiber goal of 30g - 38g. An increase in fiber and an
increase in satiety would also help Mr. Miller to lose weight. To monitor his weight loss, his height,
weight, and BMI could be assessed. A more accurate measurement to assess Mr. Miller’s weight loss
would be to do a body fat composition test at the start of his weight loss and consistently monitor it
throughout to ensure that he is losing mostly fat and not only muscle. Mr. Miller should aim to lose 1
pound per week, so a realistic goal would be to lose 8 pounds in 8 weeks after the start of his nutrition
counseling. A long term goal of Mr. Miller’s should be to get his weight down to his adjusted bodyweight
To monitor and evaluate Mr. Miller’s reduction in saturated fats, his diet-recall should be
analyzed. A lower-fat diet will cut out some of the processed foods such as cookies, crackers, and eat lean
protein sources such as fish and poultry rather than red meat. A realistic way to analyze his saturated fat
intake would be to monitor diet recall as well as weight loss. If Mr. Miller is reducing saturated fat intake
and reducing caloric intake overall, his weight would indicate the consumption of lower-fat foods as well.
Mr. Miller’s lipid panel results would also indicate that he is not lowering his cholesterol levels through
diet. Therefore, another way to monitor his intervention of lowering saturated fat intake would be to look
at his lipid-panel. His lipid panel should be analyzed 8 weeks after the start of his lifestyle changes and
SUMMARY
Overall, Mr. Miller’s diet is poor and could be greatly improved with nutrition counseling. His
diet is high in saturated fat and sodium and he is not consuming fruits and vegetables. Mr. Miller’s
prognosis is positive given his history of physical exercise and weight from 2013. Mr. Miller is
emotionally motivated to make a change due to his brother’s fatal myocardial infarction and his other
family history of cardiovascular disease. He understands if he does not make a change, he will be led
down a similar path and he is worried about leaving his family behind if something were to happen. With
his family’s support, his prognosis for reducing his cholesterol and losing weight is good.
References