Case Study 1:
A 55-year old female

Case Study 1: A-55 year old female patient, normal weight

Cardiovascular disease risk factors identified:

  • Hypercholesterolaemia (serum total cholesterol 228 mg/dl
    (5.9 mmol/l), elevated, LDL-cholesterol 174 mg/dl (4.5 mmol/l),
  • Age 55 years
  • Smoker
  • Elevated blood pressure, despite medication (145/95 mmHg)
  • Father died of an acute myocardial infarction at the age of
    45 years


According to the EAS and ESC guidelines for the management of
dyslipidaemia, lifestyle changes together with statin treatment should be considered. Patient was reluctant to start medication, so a three step approach was undertaken.

Patient was referred to clinical nutritionist to start dietary changes. The clinical nutritionist evaluated her diet, using a 3-day dietary recall of her eating habits. Results indicated that total amount of cholesterol and fat intake were according to recommendations, but patient was consuming:

  • Too much saturated fatty acids/day, mainly from butter and fatty cheese
  • Too little fibre/day

Otherwise the dietary habits were according to the general recommendations. Changes recommended by the clinical nutritionist included:

  • Replacing butter with vegetable oil- based margarine


40% on bread, and using vegetable oils in cooking / adding them to salad dressing

  • Replacing white bread with wholemeal bread

After 2 months’ follow up, the patient’s serum and LDL-cholesterol values had lowered as demonstrated below, and HDL-cholesterol and serum triglyceride concentrations remained within the reference values.

  • Serum total cholesterol 216 mg/dl (5.9 mmol/l), a 5% reduction
  • LDL-cholesterol 154 mg/dl (4.2 mmol/l) , an 11% reduction

However, the patient’s serum total and LDL-cholesterol concentrations were still too high, since an LDL-cholesterol goal of less than 100 mg/dl (2.7 mmol/l) should be considered, in respect of the patient’s moderate risk for developing of cardiovascular disease. The patient still refused to consider drug therapy.

The patient was advised to change their vegetable-oil based margarine to plant sterol or plant stanol containing margarine so that 2 g of plant sterols or stanols were consumed daily. Otherwise, the patient continued the diet recommended by the clinical nutritionist.

After 2 months’ follow up, the patient’s serum total cholesterol concentration was 194 mg/dl (5.3 mmol/l), and LDL-cholesterol concentration was 135 mg/dl (3.7 mmol/l), so that the total reduction from baseline with dietary changes including daily consumption of plant sterol or plant stanol products were as follows:

  • Serum total cholesterol : -34 mg/dl (0.9 mmol/l), a 15% reduction
  • LDL-cholesterol: -39 mg/dl (1.0 mmol/l), a 22% reduction

Despite impressive results via dietary intervention, the patient was still not reaching their lipid target, so combining statin therapy with her new dietary habits was considered.

Statin treatment is added to dietary changes. Since LDL-cholesterol levels are now lower than they were previously at baseline, a smaller statin dose is needed. This compares to the higher statin dose that would have been required starting with high baseline values (before dietary changes).