A 55-year-old white woman with no symptoms presented for a routine annual physical examination. She was a housewife with 2 children and was married to a school teacher. She looked well and was fluent and engaging. She had a history of chronic allergic rhinitis, which was managed with nasal steroids and desensitization in the past.

The patient had been overweight for more than 10 years, with a body mass index (BMI) ranging from 25 to 27 kg/m². She also had prehypertension, with previous blood pressures ranging from 110/70 mm Hg to 130/85 mm Hg during the previous 10 years. She had no prior operations and took acetaminophen on rare occasion. She also had no known allergies. She did not smoke and consumed 1 to 2 glasses of wine with dinner 2 to 3 days per week.

The patient's father died from coronary heart disease at the age of 69. Her mother was well at age 76. The patient had 2 younger brothers who were well. She walked 3 to 6 miles daily without difficulty and swam twice a week. Results of breast cancer screening 5 years earlier were negative. She had gained approximately 10 to 15 pounds over the past 5 to 10 years. Previous testing showed the following values: total cholesterol, 236 mg/dL; high-density lipoprotein (HDL) cholesterol, 38 mg/dL; and total cholesterol/HDL cholesterol ratio, 6.2. The patient's diet was varied, with no added salt, and she ate most meals at home.

Results of the physical examination showed a blood pressure of 135/83 mm Hg, a resting heart rate of 63 beats/minute, a weight of 179 pounds, and a BMI of 27.4 kg/m². Results of the head, eyes, ears, nose, and throat examination were normal. The patient's lungs were clear on auscultation. Her heart rate was regular, with no murmurs, rubs, or gallops, and she had no jugular venous distension. There were no carotid, femoral, or abdominal bruits. Results of examination of the abdomen, genitourinary system, and extremities were normal.

The patient was concerned about her risk of cardiovascular disease because of her family history, prehypertension, and body weight. Therefore, she recently started a weight-loss program and took up swimming. She successfully reduced her total and saturated fat intake. She was worried about her intake of too many high-sugar or high-carbohydrate products, which she was using to replace her fat intake. She sought advice on her diet.