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An FNP Clinician Guide will be presented for a 55 y.o. obese female with a history of severe scoliosis, chronic back pain, and a 35 pack-year history of smoking who was recently told she has high cholesterol. A primary care approach will be discussed to highlight the screening tests that would be offered, the screening organization, recommended immunizations, social determinants in this case, and health promotion and disease prevention measures.
Screening Tests
A complete cholesterol test, also known as lipid profile or lipid panel would be conducted. This blood test would determine the amount of cholesterol and triglycerides in the blood. Based on the levels of cholesterol in the blood, it would be possible to estimate the risk of developing heart diseases associated with the accumulation of plaques in arteries. This test determines the level of four components in the blood – total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides. HDL is commonly known as good cholesterol as it carries away LDL (bad cholesterol) thus allowing the arteries to remain open for free movement of blood. LDL causes the buildup of plaques in arteries thus reducing blood flow. Therefore, in this case, high levels of LDL and triglycerides are indicative of health problems.
Screening Organization and Management Guideline
The American Heart Association (AHA) is one of the organizations with guidelines for cholesterol management. AHA was formed on June 10, 1924, when a group of volunteering physicians and social workers met to come up with a way of dealing with heart disease, which was America’s number one killer disease. AHA was founded on the premise that scientific research could lead to the treatment, prevention, and cure of heart diseases. Therefore, initially, AHA was mainly composed of physicians and scientists. However, in 1948, the organization was reorganized to become a nationwide voluntary health organization made of both science and lay volunteers and professionals in various fields (AHA, 2021). Since then, the organization has grown both nationally and internationally, and currently, it has over 33 million volunteers seeking to improve heart health together with reducing mortality rates of cardiovascular diseases and stroke.
Therefore, the “My Cholesterol Guide” by the AHA was borne out of the vision of improving heart health because high levels of cholesterol are directly linked to the development of cardiovascular diseases. According to Jeong et al. (2018), the accumulation of LDL in the blood leads to a buildup of plaque in arteries and ultimately atherosclerosis, which is the main cause of heart diseases. Therefore, the total cholesterol test guide by the AHA was developed as a tool for predicting the risk of developing heart disease. This test is used in the decision-making process in determining the nature of treatment that could be used in the case of an individual at borderline or high risk. The guideline is comprehensive with treatment plans and lifestyle changes that individuals could make to improve their health and wellbeing by maintaining healthy cholesterol levels.
Immunizations
Currently, there are no immunizations against high-cholesterol. However, a vaccine is under development to mimic a condition that allows individuals to have low levels of cholesterol naturally. According to Crossey (2015), the vaccine would target proprotein convertase subtilisin/kexin type 9 (PCSK9), which is “a secretory protein that controls cholesterol homeostasis by enhancing endosomal and lysosomal degradation of the low-density lipoprotein receptor (LDL-R)” (p. 5747). In other words, this protein facilitates the body to break down receptors that cholesterol binds when being eliminated. Therefore, a vaccine would target this protein and stop it from functioning thus allowing the body to have low levels of cholesterol by minimizing accumulation.
Social Determinants
Social determinants of health are complex circumstances involving intangible factors and place-based conditions that affect an individual’s life. According to Islam (2019), social determinants are “conditions or circumstances in which people are born, grow, live, work, and age” (p. 1). These conditions are subject to socio-economic and political factors that shape the way people live. Cultural constructs are also part of social determinants of health. In this patient’s case, various social determinants could have affected her presentation and ability to become healthy. First, she is obese which could be due to social determinants such as low-income levels, lack of educational opportunities, unemployment, gender inequity and violence, racial segregation, food insecurity, early childhood experiences, physical environment, and lack of recreational and leisure opportunities among other related factors (Yusuf et al., 2020; Lakerveld & Mackenbach, 2017). Additionally, she has a 35 pack-year history of smoking, which could be due to various social determinants. For instance, individuals could resort to smoking as a way of dealing with stress caused by lack of employment and other related social issues. The patient also has severe scoliosis and chronic back pain, which could be directly linked to the aforementioned social determinants.
The patient’s severe scoliosis and chronic back pain could have contributed to her obesity because she might not be in a position to be physically active as part of leading a healthy lifestyle. Smoking could also have contributed significantly to her obesity and high cholesterol levels. According to Hallit et al. (2017), “A significant increase in total cholesterol and LDL-C is well shown in tobacco users, as compared to non-tobacco users…smokers have less favorable lipid profiles, even after accounting for current and lifetime smoking history and other CVD risk factors” (p. 269). Therefore, social determinants surrounding the patient’s obesity, scoliosis, chronic back pain, and smoking have contributed indirectly to her high levels of cholesterol.
The same factors also affect her ability to become healthy. For instance, as a way of dealing with obesity, lifestyle changes are needed and they include being physically active. However, she might not achieve this goal due to her scoliosis and chronic back pain. Additionally, she needs to quit smoking as part of her lifestyle change, but this might not be possible due to the lack of the necessary support systems as part of social determinants of health. For example, she might not be in a position to access quality care services due to a lack of financial capability and other related factors.
Health Promotion and Disease Prevention Recommendations
The patient has high levels of cholesterol and as part of intervention measures, she should start taking the appropriate drugs to lower the levels of LDL in the blood. The commonly used drugs include statins, selective cholesterol absorption inhibitors, resins, fibrates, and niacin. Omega-3 fatty acid medications could also be used to lower the levels of triglycerides. Additionally, prevention measures could be taken to prevent disease progression and promote health.
In this case, the patient is obese and thus she needs to take the necessary steps to address this problem. Dietary changes are paramount to ensure that she feeds on balanced and healthy foods. She should reduce the intake of saturated and trans fats. These fats are mainly found in animal products, coconut oil, palm oil, baked and fried foods. She should consume healthy fats (monounsaturated and polyunsaturated fats), which are mainly found in fish and plant-based foods. Regular exercise would also play a central role in weight loss. Given her condition of scoliosis and chronic back pain, she could resort to walking for at least 30 minutes a day before advancing to other exercises where possible. Clinical management of scoliosis and chronic back pain would play an important role in weight loss because they would create a desirable environment for physical exercise.
Additionally, she should quit smoking as an important step towards reducing the levels of cholesterol in her body. Various methods could be involved including nicotine replacement therapy and joining online stop-smoking programs for support. Quitting smoking is a long process that requires consistency and the resolve to overcome the craving for tobacco. Therefore, the patient should have goals that are intricately tied to her desire to lead a healthy lifestyle.
Conclusion
High cholesterol levels in the blood are the leading causes of cardiovascular diseases. The patient should undergo a total cholesterol test as part of screening to determine the levels of HDLs, LDLs, and triglycerides in her blood. The AHA offers a comprehensive guideline on how to conduct such screening. This guideline was created mainly to ensure that people are screened early enough to avoid the risks associated with cardiovascular diseases. This patient’s situation is subject to various social determinants of health that might have contributed to her scoliosis, smoking, chronic back pain, and obesity. Therefore, she needs to start medication coupled with lifestyle changes involving eating a balanced diet and quitting smoking to achieve the desired levels of blood cholesterol.
References
AHA. (2021). Our lifesaving history. Web.
Crossey, E., Amar, M., Sampson, M., Peabody, J., Schiller, J. T., Chackerian, B., & Remaley, A. T. (2015). A cholesterol-lowering VLP vaccine that targets PCSK9. Vaccine, 33(43), 5747–5755.
Hallit, S., Zoghbi, M., Hallit, R., Youssef, L., Costantine, R., Kheir, N., & Salameh, P. (2017). Effect of exclusive cigarette smoking and in combination with waterpipe smoking on lipoproteins. Journal of Epidemiology and Global Health, 7(4), 269–275.
Islam, M. M. (2019). Social determinants of health and related inequalities: Confusion and implications. Frontiers in Public Health, 7(11), 1-4.
Jeong, S. M., Choi, S., Kim, K., Kim, S. M., Lee, G., Park, S. Y., Kim, Y. Y., Son, J. S., Yun, J. M., & Park, S. M. (2018). Effect of change in total cholesterol levels on cardiovascular disease among young adults. Journal of the American Heart Association, 7(12), 1-17.
Lakerveld, J., & Mackenbach, J. (2017). The upstream determinants of adult obesity. Obesity Facts, 10(3), 216–222.
Yusuf, Z. I., Dongarwar, D., Yusuf, R. A., Bell, M., Harris, T., & Salihu, H. M. (2020). Social determinants of overweight and obesity among children in the United States. International Journal of MCH and AIDS, 9(1), 22–33.
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