LESSON PLAN

I. HEADING
Instructors:
Course: Bachelor of Science in Medical Laboratory Sciences - 2nd Year
Time allotted: 30 minutes

II. TOPIC
Total Cholesterol

III. RATIONALE AND BACKGROUND

The concept of lipids was introduced during the course of biochemistry and the students were expected to
understand the molecular structure and properties of lipids, as well as the different metabolic pathways, enzymes, and
chemical processes involved in lipids. The purpose of this lesson is to further develop the understanding of the students about
lipids, specifically cholesterol physiology and metabolism in the human body. Laboratory tests used to assess total
cholesterol in the body will be introduced to the students, along with the principles and procedures behind the given tests.
Reference ranges for total cholesterol will also be discussed and relate the given values to its clinical significance.
Providing the lesson about total cholesterol is essential to the students as future medical laboratory scientists (MLS)
since it is one of the analytes being tested in the clinical chemistry section of a laboratory. Understanding the concepts of
tests, reference values, and its clinical significance about this analyte will help the students to fulfill their roles as MLS in the
future.

IV. LESSON OBJECTIVE

● To provide relevant information about Total Cholesterol to emphasize its function to the human body.
● Explain the laboratory diagnosis, clinical significance, and the purpose of Total Cholesterol.
● To explain and describe different assays of Cholesterol

V. LIST OF MATERIALS/RESOURCES
Audiovisual Materials
● Powerpoint presentation
References
● Bishop, M. L., Fody, E. P., & Schoeff, L. E. (2018). Clinical chemistry: Principles, techniques, and correlations
(8th ed.). Jones & Bartlett Publishers.
● Burtis, C. A., Ashwood, E. R., & Bruns, D. E. (2008). Tietz fundamentals of clinical chemistry (6th ed.). Saunders.

VI. PROCEDURES
A. INTRODUCTION/MOTIVATION
The first instructor will provide some fun facts about cholesterol that will serve as the foundation for the
students and to develop meaningful relationships with the students. The instructors will encourage the students to
take down notes to help them keep track during the discussion.
B. LESSON BODY
Description
Cholesterol, a steroid alcohol (27 carbon atoms arranged in a tetracyclic sterane ring system, with a C-H sidechain)
is a key membrane component of all cells. It is relatively hydrophobic, however, it contains a polar hydroxyl (OH)
group on its a-ring, thus making it amphipathic, which accounts for its ability to insert into cell membranes.

Despite having a bad reputation as a high-risk factor for cardiovascular diseases, cholesterol is an essential
component of all animal cells. It is an integral part of the cell membrane, providing fluidity and participating in a
number of cellular processes. Cholesterol also serves as a precursor for production of bile, steroid hormones, and
vitamin D.

While the body can obtain cholesterol from food, many cells synthesize their own endogenous cholesterol. Cellular
production of cholesterol is under negative feedback control. Low levels of intracellular cholesterol induce its own
production, while high cholesterol levels inhibit it.
Cholesterol with other lipids is transported in blood plasma within large particles known as lipoproteins (an
assembly of lipids and proteins). These are classified based on their density, because lipids are lighter than proteins,
particles that contain more lipids are larger in size but have a lower in density and vice versa. Different types of
lipoproteins have different sets of proteins on their surface. These proteins serve as "address tags", determining the
destination, and hence, function. Low-density lipoprotein (LDL), carries cholesterol from the liver to other tissues,
while high-density lipoprotein (HDL) returns excess cholesterol to the liver.

Major events in cholesterol metabolism include:

● Dietary cholesterol is absorbed in the intestine and carried via blood circulation to the liver.
● ‌The liver packages its cholesterol pool
● ‌A combination of endogenous and dietary, together with triglycerides into particles of very low-density
lipoprotein (VLDL)
● ‌VLDL travels in the bloodstream to other organs
● ‌During circulation, muscle and adipose tissues extract triglycerides from VLDL, turning it into LDL
● ‌Peripheral cells take up LDL by endocytosis, using LDL receptors

Cholesterol is used in cell membrane and other functions:

● Excess cholesterol is exported from the cells and delivered to HDL, to be returned to the liver in a process
called reverse cholesterol transport
● ‌The liver uses cholesterol to produce bile, which is then secreted to the intestine, where it helps break down
fats.
● ‌Part of this bile is excreted in feces, the rest is recycled back to the liver.

LDL has the highest cholesterol content and is the major carrier of cholesterol in the blood. High-levels of LDL in
the blood are associated with cholesterol plaque buildup and cardiovascular diseases.
Clinical Significance
Increased concentration of analyte/electrolyte (2 Clinical Correlation)
●
Reference Range for Total Cholesterol

(Bishop et al., 2018) (Burtis et al., 2008)

140 - 200 mg/dL ● >200 mg/dL = desirable

● 200-239 mg/dL = borderline high
● >240 mg/dL = high
● Dyslipidemia is the term used to describe diseases associated with abnormal lipid concentrations. The
diseases can be caused due to genetic abnormalities, environmental or lifestyle imbalances, or develop
secondarily from other diseases.
● Dyslipidemias can be subdivided into two major categories: hyperlipoproteinemias, which are diseases with
increased lipoprotein levels, and hypolipoproteinemias, which are associated with decreased levels of
lipoproteins. The diseases associated with the abnormal serum lipids may be due to malfunctions in the
synthesis, transport, or catabolism of lipoproteins.
● In hyperlipoproteinemia, it can be subdivided into hypercholesterolemia, hypertriglyceridemia, and
combined hyperlipidemia. Hypercholesterolemia is the lipid abnormality that is most closely linked to heart
disease. One form of the disease is called familial hypercholesterolemia (FH).
● Familial Hypercholesterolemia (FH)
➢ It is a genetic abnormality, where:
■ Homozygotes for FH can have a total cholesterol concentration of 800 - 1,000 mg/dL
■ Heterozygotes for FH have total cholesterol concentration of 300 - 600 mg/dL
➢ In FH, both homozygotes and heterozygotes have elevated levels of cholesterol and can be
primarily associated with an increase in LDL-C.
➢ Affected individuals normally synthesize intracellular cholesterol, however, they lack, or are
deficient in active LDL receptors due to gene defects.
➢ It may also be due to defects in two auxiliary proteins, ARH-1 and Psk9, which are involved in
either the internalization or processing of the LDL receptor, however it is less common to cause
FH.
➢ Mutations in the LDL receptor and Psk9 are inherited in autosomal co-dominant pattern, while
ARH-1 defects are autosomal recessive.
➢ What happens in FH is due to insufficient receptors that are responsible for binding LDL and
transferring the cholesterol into the cells, LDL starts to build up in the circulation and results in
deposition in the skin, tendons, and arteries causing atherosclerosis. Cells, on the other hand,
synthesize cholesterol intracellularly at an increased rate in order to compensate for the lack of
cholesterol needed in the cell membrane and hormone production.
➢ Patients affected with FH often present hypercholesterolemia at birth and persist throughout life.
Xanthomas also appear but earlier in homozygotes than heterozygotes. If it is left untreated, death
from myocardial infarction generally occurs to homozygotes before the end of the second or third
decade of life.
● Dysbetalipoproteinemia (Type III Hyperlipoproteinemia)
➢ Individuals affected by this disease have a total cholesterol value of 200 - 300 mg/dL
➢ It results from the accumulation of remnants of cholesterol-rich VLDL and chylomicron due to a
defect in its catabolism.
➢ The defect in the catabolism of the VLDL and chylomicron remnants is associated with the
presence of a relatively rare form of apo E, called apo E2/2.
➢ Apo E is present on the surface of lipoprotein remnant particles and it interacts with the hepatic E
receptor and facilitates the removal of the remnants.
➢ In the case of dysbetalipoproteinemia, the apo E2/2 cannot bind with the hepatic E receptor and
the remnant particles, rich in cholesterol, accumulate in the body.
➢ The most distinctive clinical feature of this disease is the presence of palmar xanthomas, which are
yellow fat deposits in the creases of the palms.

Decreased Concentration (2 Clinical Correlation)

Malnutrition

Malnutrition refers to a condition where the body doesn't receive sufficient nutrients, including proteins, fats,
carbohydrates, vitamins, and minerals, to maintain optimal health and function. This deficiency can arise due to
inadequate intake of food, poor absorption of nutrients, or excessive loss of nutrients.

Cholesterol is a crucial lipid that serves various functions in the body, such as forming cell membranes, aiding in the
production of hormones, and contributing to bile production for digestion. The body synthesizes cholesterol
primarily in the liver, and its levels are influenced by factors like diet, genetics, and overall health.

Several factors can contribute to a decrease in total cholesterol levels:

Altered Lipid Metabolism
 ➢ Malnutrition can disrupt the normal metabolic processes, including the metabolism of lipids. When the
body is deprived of essential nutrients, it may prioritize energy conservation and essential functions,
leading to a decrease in the synthesis of cholesterol.
Liver Dysfunction:
➢ The liver plays a central role in cholesterol metabolism. It synthesizes cholesterol and regulates its release
into the bloodstream. Malnutrition-induced liver dysfunction can impair these processes, resulting in
reduced cholesterol production and secretion.
Protein Deficiency
➢ Proteins are vital for various physiological functions, including the transport of lipids in the blood. Protein
deficiency can lead to a decrease in lipoprotein synthesis, affecting the transport of cholesterol in the
bloodstream.
Hormonal Changes
➢ Malnutrition can disrupt the balance of hormones involved in lipid metabolism. For example, insulin
resistance, which can occur in malnourished individuals, may influence cholesterol levels.

Hepatitis C Virus (HCV)

Hepatitis C is a viral infection caused by the hepatitis C virus (HCV), primarily affecting the liver. While the main
focus of hepatitis C is often on its impact on the liver, it can have systemic effects on the body, including alterations
in lipid metabolism, which may contribute to a decrease in total cholesterol levels.

Liver Inflammation and Damage

➢ Hepatitis C primarily targets liver cells, leading to inflammation and damage to the liver tissue. The liver
plays a central role in cholesterol metabolism, including synthesizing and regulating cholesterol levels in
the blood. When the liver is inflamed or damaged, its ability to perform these functions can be
compromised.
Impaired Synthesis of Lipoproteins
➢ The liver is responsible for producing lipoproteins, which are complexes of lipids (including cholesterol)
and proteins. These lipoproteins, such as very low-density lipoprotein (VLDL) and low-density lipoprotein
(LDL), transport cholesterol through the bloodstream. Hepatitis C can disrupt the synthesis and secretion of
these lipoproteins, leading to lower circulating cholesterol levels.
Altered Lipid Metabolism
➢ Chronic hepatitis C infection can affect lipid metabolism by influencing the expression of genes involved in
cholesterol regulation. The virus may interfere with the normal pathways of cholesterol synthesis and
transport.
Impact on Apolipoproteins
➢ Apolipoproteins are proteins that combine with lipids to form lipoproteins. Hepatitis C infection has been
associated with changes in the levels and function of apolipoproteins, further contributing to lipid
metabolism and cholesterol transport disruptions.
Association with Steatosis
➢ Hepatitis C infection is sometimes linked with the development of steatosis, a condition characterized by
fat accumulation in liver cells. This fatty infiltration can affect the liver's overall function, including its role
in cholesterol metabolism.

Methods
Cholesterol Assay
- Also known as the ‘Lipid Panel’ or ‘Lipid Profile’
- It is a blood test that measures the amount of cholesterol in the blood. It helps determine and evaluate the
heart's health since excess cholesterol is a risk factor for cardiovascular health concerns.
A complete cholesterol test measure these four types of fats in your blood:
A. Total cholesterol
- The total amount of cholesterol that’s circulating in your blood.
- Formula: HDL + LDL + 20% triglycerides = total cholesterol
B. Low density lipoprotein (LDL)
- ‘Bad Cholesterol’
- Excess LDL contributes to the buildup of plaques that lead to atherosclerosis, which reduces blood
flow and can cause heart attack or aneurysm.
C. High density lipoprotein (HDL)
- ‘Good Cholesterol’
- It helps carry away LDL cholesterol, which allows the arteries to open and regulate blood flow.
D. Triglycerides
- A type of fat in the blood
- Hypertriglyceridemia (too many triglycerides) causes atherosclerosis & other diseases.

Case Study
- Ms.Aguedan is a 30-years old woman, who works as an office manager presented to the clinic for a routine
health checkup. She reported no significant family history of cardiovascular diseases, but Ms. Aguedan has
a sedentary lifestyle and a diet rich in processed foods. Upon conducting lipid profile tests, it was observed
that Ms.Aguedan’s total cholesterol levels were elevated, measuring 250 mg/dl.
 Lifestyle Analysis
1. Dietary Habits: Ms. Aguedan’s diet mainly consisted of processed foods, high in saturated and trans fats. Fast
food, sugary snacks, and red meat were common components of her meals.
2. Physical Activity: Her sedentary job required long hours of sitting at a desk, and she rarely engaged in regular
physical exercise.
3. Stress Levels:Work-related stress and lack of sufficient stress management practices were noted as contributing
factors.

Intervention
1. Dietary Changes: A registered dietitian worked with Ms. Aguedan to create a heart-healthy diet plan. This
involved incorporating more fruits, vegetables, whole grains, and lean proteins while reducing the intake of saturated and
trans fats.
2. Exercise Routine: A personalized exercise plan, including both aerobic activities and strength training, was
developed to improve cardiovascular fitness and assist in weight management.
3. Stress Management: Techniques such as mindfulness meditation and regular breaks during work hours were
introduced to help manage stress levels.

Conclusion:
This case study highlights the impact of lifestyle changes on managing total cholesterol. Through a comprehensive
approach involving dietary modifications, regular exercise, and stress management, Mr. Smith achieved a significant
improvement in his lipid profile. This emphasizes the importance of personalized interventions and ongoing monitoring in
promoting cardiovascular health.

C. LESSON CLOSURE
1. Provide an ice-breaker activity which will serve as the summary of the lesson. Students will be asked
questions related to the discussion and assess what they have gained from the lesson.
2. Ask the students if there are any questions or concerns about the lesson
3. Inform the students that a short assessment will be given next meeting

VII. EVALUATION

A. Student Assessment
The instructors will provide an individual short quiz that will serve as their assessment to measure and determine
how much the students have gained learning. The score of the short examination will be up to ten points. Most
students should get fifty-five percent of the perfect score, which will be based on the analysis and evaluation of the
score results. The results will act as evidence of the teaching effectiveness of the instructors.

Short Quiz Questionnaires

Instruction: Write True if the statement is true; otherwise, False.

1. FALSE (formation). Emulsification is a process solubilizing cholesterol which involves destruction of

mixed micelles.
2. FALSE (Third stage). Second stage occurs in the endoplasmic reticulum, with many intermediate
products bound to a carrier protein.
3. TRUE. In hyperlipoproteinemia, it can be subdivided into hypercholesterolemia, hypertriglyceridemia, and
combined hyperlipidemia.
4. FALSE (Dyslipidemia). Low density lipoprotein is the term used to describe diseases associated with
abnormal lipid concentrations.
5. FALSE (Dysbetalipoproteinemia). Familial Hypercholesterolemia results from the accumulation of
remnants of cholesterol-rich VLDL and chylomicron due to a defect in its catabolism.
6. TRUE. Low density lipoprotein is also called Bad cholesterol.
7. FALSE (HDL). Triglycerides helps carry away LDL cholesterol, which allows the arteries to open and
regulate blood flow.
8. FALSE (Liver). Hepatitis C primarily targets kidney cells, leading to inflammation and damage to the liver
tissue.
9. TRUE. The cholesterol assay also known as Lipid Profile.
10. FALSE (high). >240 mg/dL is considered to be a desirable reference range of the concentration of analyte.

B. Self-evaluation
1. Strengths of this Lesson:
- The learning session will empower the cognitive skills of the students by cultivating their skills in
remembering since some contents of the topic have been introduced to them in Biochemistry;
- Some information was added during the discussion, which brings new learning discoveries for
students, which can be applied once they become professional health workers.
- The students are capable of understanding the reference range, functions, and clinical significance
of Total Cholesterol and determining its cholesterol assays.

2. Weaknesses of this Lesson that requires improvement:

- The instructors' capabilities to manage their time wisely since the given time is minimal and more
not likely to be enough to discuss all the relevant information regarding Total Cholesterol.
- The presentation would be more effective for the students and help them understand conveniently
if the instructors provided a video demonstration of some cholesterol assays.